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FREE Resource to Evaluate MHL Programming from the MHLC

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FREE Resource to Evaluate MHL Programming from the MHLC

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The Mental Health Literacy Collaborative

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MHL Evaluation Tool — The Mental Health Literacy Collaborative

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The Mental Health Literacy Collaborative

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As you can see in our name, the core value of the MHLC is collaboration.

Our values are in support of this central tenet.

We have mission-driven clarity of purpose. We treat people with respect and empathy. We embrace diversity of thought to enhance our understanding and impact. We seek equity in our relationships and actions. We strive for innovative solutions and resilience in the face of challenges. We are accountable for our commitments.

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About Us - The Mental Health Literacy Collaborative

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As you can see in our name, the core value of the MHLC is collaboration. Our values are in support of this central tenet. We have mission-driven clarity of purpose. We treat people with respect and empathy. We embrace diversity of thought to enhance our understanding and impact.

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This guest post comes to us from Annie Slease, chief executive officer of The Mental Health Literacy Collaborative. MHLC is a nonpartisan, nonprofit organization focused on mental health literacy education in schools and communities. All views expressed in this post are those of the author.

Schools can be ideal settings to address youth mental health needs, yet they struggle to provide effective services. According to the National Center for Education Statistics, 96% of public schools reported providing student mental health services, but only 56% agreed that they could provide these services to all students effectively. These schools cited large caseloads, workforce strains and lack of funding as the top three barriers.

School mental health services may include more than clinical services. Research shows that universal mental health education programs can improve knowledge, attitudes and help-seeking. New York passed the first legislation requiring this education for K-12 students in 2016. According to a recent policy scan, more than half of the U.S. now has similar policies by statute, regulation, legislation or learning standards. These policies vary significantly with differences in specificity, resources, intended audience, scope and clarity of education content, standards development, parent removal options and requirement conditions.

Despite the number of states embracing these policies, implementation issues exist. Following New York's landmark law, an audit in 2022 revealed opportunities for improvement, including the recommendation to develop evaluation criteria to ensure adherence to the law. These results are not surprising since mental health education had not been part of K-12 or pre-service curricula and has no national guidance.

These policies try to address the youth mental health crisis through promotion, prevention and early intervention but only benefit students and families when implemented effectively. So, how can policymakers ensure their intentions meet the mark?

First, mental health education policies need clear expectations.
What Information Could Be Taught?
Mental health literacy offers an evidence-based, four-component framework for mental health education that can be adapted to developmentally and culturally appropriate levels. This includes understanding how to:

Foster and maintain positive mental health.

Recognize common mental health disorders and treatments.

Seek help for yourself and others.

Reduce stigma.

Policies could include the components of mental health literacy to offer a clearer path for K-12 implementation. This helps distinguish mental health education learning goals from the goals of social and emotional learning. While mental health literacy includes the four-component framework mentioned above, social and emotional learning addresses these five areas: self-awareness, self-management, social awareness, relationship skills, and responsible decision-making, according to the Collaborative for Academic, Social, and Emotional Learning. Mental health literacy and social and emotional learning are related much like math and science; they complement one another and may have overlapping goals, but they are distinct in how they function.
Who Will Deliver This Education? How Will They Be Prepared?
Often, mental health education mandates fall on school mental health clinicians. Not only does this further strain an understaffed workforce, but it also overlooks what is needed for any quality education: expertise in teaching. Educators can teach about mental health effectively, but they need content knowledge, confidence and support.

Policies could require and support foundational mental health literacy training for pre-service educators and for educators seeking state teaching certification. For example, Mental Health Literacy Aware for Educators from MHLC provides foundational mental health literacy information in a 60-minute, asynchronous format; early data shows an increase of over 80% in educator confidence about mental health literacy.
How Will the Content Be Selected, Implemented and Evaluated?
Unfunded mandates pose significant barriers. Because K-12 education has not historically included mental health in curricula, schools need funding for quality training, selection and purchase of materials, resources and guidance for program evaluation, and ongoing leadership support.

Policies could allocate these essential funds and establish and fund new mental health education leadership roles. Policymakers could also expand access to funding that allows more school mental health dollars to be used for universal, Tier 1 mental health education.

With effective policies in place, schools will be better equipped to help youth thrive.

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Implementing Mental Health Education in States

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Schools can be ideal settings to address youth mental health needs, yet they struggle to provide effective services. According to the National Center for

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National Alliance on Mental Illness (NAMI)

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NAMI’s School Mental Health Education Map

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The United States is going through a well-documented and ongoing youth mental health crisis, with high rates of suicidal ideation, hopelessness and depression. Mental health conditions typically start during childhood, adolescence or young adulthood. More than 1 in 7 U.S. youth ages 6-17 experience a mental health disorder each year. When mental health conditions are […]

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We can all help prevent suicide. The 988 Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States.

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The 988 Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week in the United States. We're committed to improving crisis services and advancing suicide prevention by empowering individuals, advancing professional best practices, and building awareness.

About The Lifeline

Anyone could be struggling with suicide. Find more specific resources below.

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First, you'll hear an automated message featuring additional options while your call is routed to your local 988 Lifeline network crisis center.

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Skip to main content We can all help prevent suicide. The 988 Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States. 988 ¡Los servicios de texto y chat de 988 Lifeline ya están disponibles en español!

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Crisis Text Line | Text HOME To 741741 free, 24/7 Crisis Counseling

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Crisis Text Line provides free, 24/7 support via text message. We're here for everything: anxiety, depression, suicide, school. Text HOME to 741741.

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The Mental Health Literacy Collaborative

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MHL Interstate Workgroup — The Mental Health Literacy Collaborative

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“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” — Margaret Mead The MHLC is launching an MHL Interstate Workgroup to facilitate connections and collaboration between states as they navigate how to succ

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The Mental Health Literacy Collaborative

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Young Adult Council — The Mental Health Literacy Collaborative

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Our Young Adult Advocacy Council is starting soon!

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Parents are more worried than teens about teen mental health. Both groups – especially parents – partly blame social media. But teens also see benefits.

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How Accurate is Mental Health Advice on TikTok?

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How accurate is mental health advice on TikTok? Discover how many influencers have relevant qualifications, and why they can be misleading.

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Toward Mental Health Literacy Education in U.S. School Communities: A National Collaborative for Research, Policy, and Practice

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Youth mental health needs have worsened following COVID-19. Rising demand for school mental health services is straining capacity. Several states have added policies requiring mental health educati…

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Qualitative Evaluation of the Impact of a School Mental Health Literacy Curriculum on Student-Teacher Relationships - PubMed

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Mental health literacy (MHL) programs, which aim to improve knowledge, reduce stigma and promote help-seeking behavior, are a promising approach to meeting the growing mental and behavioral health needs of youth. This study aimed to understand the relational impacts of a MHL curriculum on students a …

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About Mental Health Instruction.org

This website is a non-commercial endeavor to help bring Mental Health Education to schools across the United States and beyond. As a society, we have now agreed physical health and mental health are not separate within healthcare and efforts are underway to bring parity between the two healthcare realms. With that, we seek to bring the same parity to education and create a world where Physical Health and Mental Health curricula are taught hand in hand.

Our Vision

Where every struggling youth is surrounded by peers equipped with a supportive and effective knowledge base

That all youth are equipped with comprehensive knowledge and resources in Mental Health.

To realize the rapid reduction and eventual elimination of Stigma, a reduction of suicide ideation and a speedier track to seeking care.

To enable a future where every struggling youth is surrounded by peers equipped with a supportive and effective knowledge base.

Our Mission

Providing schools with quick reference resources to mental health education

Offering implementation plans specific to each listing in aiding smooth, clear execution of curricula and program choices.

To provide a free library for all school staff that have interest in bringing Mental Health Education into their school.

Creating a comprehensive library that includes all mental health resources, ie. Social Emotional Learning, Mental Health Literacy, Substance Use Disorder education, Suicide Prevention programs and emerging Social Media & Mental Health programs.

Our Partnership

A non-profit endeavor of Chad's Legacy Project with the support of the UW SMART Center

Chad's Legacy Project values the expertise of the University of Washington SMART Center and it's role as our educational expertise within this effort to aid teachers across the United States.

sponsors & acknowledgements

Thank You to Our Sponsors

This project could not be possible without our valued supporters. MentalHealthInstruction.org is committed to remaining a non-commercial endeavor. We seek to aid in making Mental Health Education widely and easily available to any school; urban, rural, resource-rich as well as under-served. We are eternally grateful to our past sponsors and invite you to consider sponsoring the ongoing efforts to grow and maintain this library.

Become a Sponsor

for program developers

Submit a Program or Curriculum

If you represent a curriculum as a program developer and you would like to submit for inclusion into the library please contact us to request a program survey from the University of Washington SMART Center and we will begin efforts to add yours to MentalHealthInstruction.org

Request a Survey

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This website is a non-commercial endeavor to help bring Mental Health Education to schools across the United States and beyond.

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An Action Guide for School and District Leaders

At a Glance

Schools are prioritizing students' mental health, and there are many tools and resources to choose from. CDC created this action guide as a place to start. It can help school and district leaders build on what they are already doing to promote students' mental health and find new strategies to fill in gaps.

The action guide describes six in-school strategies that are proven to promote and support mental health and well-being. For each strategy, the guide also describes approaches, or specific ways to put the strategy into action, and examples of evidence-based policies, programs, and practices.

Audience

School and district leaders of kindergarten through 12th-grade schools (K-12), including principals and leaders of student support teams.

Goal

Provide school and district leaders with strategies, approaches, and practices that can improve students' mental health.

CDC has identified six school-based strategies and associated approaches that can help prevent mental health problems and promote positive behavioral and mental health of students.

Multitiered Systems Of Support

Multitiered Systems of Support (MTSS) are used by many schools and districts to support different levels of students' needs. The strategies in this action guide can align with schools' existing MTSS to enhance the work schools have already started.

Why Schools?

Schools help promote the mental health and well-being of students through education, prevention, and early intervention efforts. They provide an opportunity to reach a large number of youth with strategies that can lessen the impact of negative experiences and improve students' health and well-being.

Schools can establish safe and supportive environments.

Schools can connect students to caring adults and encourage positive peer relationships.

Schools can give students mental health support and link them and their families to community behavioral and mental health services.

Schools that promote student mental health and well-being can improve classroom behavior, school engagement, and peer relationships. These factors are connected to academic success.

Additional Resources

Some of the strategies and approaches in this action guide may also improve other important health outcomes, such as experiences of violence and suicide. CDC has several Resources for Action for preventing violence.

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Promoting Mental Health and Well-Being in Schools

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Learn more about promoting student mental health and well-being in schools in CDC's action guide for school leaders.

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PDF Promoting Mental Health and Wellbeing in Schools: An Action Guide for School and District Leaders

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PDF Promoting Mental Health and Wellbeing in Schools: An Action Guide for School and District Leaders

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Recently, the US Surgeon General issued an advisory regarding an epidemic of loneliness and isolation throughout the country. In addition, the National Institute of Mental Health has acknowledged that nearly half of all adolescents in the United States will experience some form of mental health disorder over the course of their lifetime. There is a current mental health crisis amongst youth taking shape throughout the nation.

As literacy specialists, we understand the value of bringing diverse works of literature into the classroom. As Rudine Sims Bishop shared, books serve as mirrors, windows, and sliding glass doors. And while we often consider the ways in which books offer a glimpse into diverse experiences and identities of others, we must be sure to include literature that speaks to diversity with regard to mental health and mental health challenges.

Teachers can support students' social and emotional development by providing students access to a wide array of books that not only engage student interests, identities, and experiences, but also invite readers into the interests, identities, and experiences of others. Not only can such works help students to see they are not alone, but they can open the door to an empathetic understanding and battle stigma surrounding mental illness.
Following, we share our recommended "Top 10" adolescent titles featuring mental health themes to jumpstart your summer reading list.
This lyric novel is perfect for all ages, but we can see it appealing to struggling middle grade readers, as it explores the relationship between a 12-year-old boy (Trace Reynolds) and his older brother, Will. When Will suffers a traumatic brain injury, the family is left with a very different Will (one who is depressed and angry), and it takes all of their strength to make things right by being honest with each other and even themselves.

Want a book that rips out your heart and slowly weaves you a new one? This beautiful book has it all: the trauma of loss, the danger of revenge, unexpected friends (even an intergenerational friendship), grief group meetings (many of them), an epic kiss, and a road trip to Elvis's Graceland.

Characters have the power to draw us in and make us feel things we may not have felt in some time. June Bug and Ziggy are two such characters. Readers will be drawn in as these thoughtful characters navigate the harsh realities of loss and parental mental health challenges while finding joy in everyday life.

Joanna Ho delivers a powerful, hopeful YA debut. Through the narration of May, a Chinese Taiwanese American high schooler, the author explores the possible perils of being silent in the face of significant loss.

This amazing, uplifting debut novel is filled with humor while also providing readers a glimpse into the mind of a middle school girl as she learns about the complicated science of the brain (mental health) and also the sometimes joyful/sometimes sorrowful matters of the heart.

In this lyric novel, Lerner spotlights the all-too-often hidden truths of body image and its impact on male adolescents. Told through the drawings and commentary of a middle school boy's notebook, the protagonist shares his journey toward self-acceptance.

Ab(solutley) Normal: Short Stories that Smash Mental Health Stereotypes (Nora Shalaway Carpenter and Rocky Callen, Editors)

This anthology, filled with a variety of writing genres crafted by middle and YA authors, is the perfect addition to any classroom library. The best part? Each author shares a hopeful, personal reflection related to their own challenges of living with mental health issues.

Baron's book will immediately transport readers to the summer of 1989 as 12-year-old Etan navigates his tumultuous life while meeting and befriending Malia, a young girl who also fears sharing her story. This work of magical realism will enchant and encourage readers in understanding that one's circumstance does not define one's self.

Told through personal journal entries of 12-year-old Riley as she resides in an eating disorder treatment facility, this narrative has the power to strike a chord for anyone who has ever felt they weren't quite "good enough." This is a story that offers hope through ongoing progress, personal strength, and advocacy.

With all the humor and cleverness of Jason Reynolds comes this partly-graphic novel about Portico Reeves, self-proclaimed superhero of keeping those around him safe. Reynolds, as usual, addresses kids' feelings of being overwhelmed with great care, concern, and a good dose of humor.
Professional text suggestions
Whether you're just beginning your journey into mental-health-themed YA literature or seeking additional instructional ideas to add to your collection of strategies, we have two suggested professional titles to add to your collection.

This professional text features chapters coauthored by literacy experts and mental health specialists. Each chapter gives attention to pre-reading, during reading, and after-reading strategies for integrating select middle level and young adult novels into the ELA classroom context. Readers will gain valuable insight into text suggestions for the classroom, as well as instructional strategies that address literacy instruction and mental health literacy education.

This professional text provides readers insight into mental illnesses featured in the Diagnostic and statistical manual of mental disorders (DSM-5) alongside a variety of young adult novels that feature the designated mental illness. The provided appendix features suggestions for integrating titles into the classroom space.
A quick word of consideration for the classroom
Despite teachers' understanding of the value in classroom libraries and diverse books, recent policies and state-wide laws are making it increasingly challenging for teachers to provide access to select titles within the classroom. It may be beneficial to brainstorm means of embedding literature into your curriculum through whole class, small group, or independent reading opportunities, as well as identifying ways of encouraging student reading while being mindful of their reader identities, experiences, and mental health needs. Not every book is the right fit for every reader, and no student owes us their story. Providing student choice and voice in text selection, and maintaining open communication with caregivers can be a powerful tool in developing a curriculum that gives attention to mental health while remaining aware of the needs of our readers.
Dr. Brooke Eisenbach is an associate professor at Lesley University and former middle level teacher of English language arts and young adult literature (YAL). She is a former member of the NCTE Middle Level Section Steering Committee. Dr. Susan Densmore-James is an associate professor at the University of West Florida and the director of the Emerald Coast National Writing Project at UWF. She is known as The Book Dealer for her work with middle grades and young adult literature (YAL). It is the policy of NCTE in all publications, including the Literacy & NCTE blog, to provide a forum for the open discussion of ideas concerning the content and the teaching of English and the language arts. Publicity accorded to any particular point of view does not imply endorsement by the Executive Committee, the Board of Directors, the staff, or the membership at large, except in announcements of policy, where such endorsement is clearly specified.

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Mental Health Themes and the ELA Classroom: A Guide for Your Summer Reading

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Mental Health Themes and the ELA Classroom: A Guide for Your Summer Reading

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" Energy rightly applied and directed will accomplish anything."
-Nellie Bly, investigative reporter

Essential Question

How does investigative journalism bring awareness to problems and help support reform efforts?

Overview

In this case study, you will analyze primary sources on the mental health reform movement of the mid-nineteenth century, which was spearheaded by Dorothea Dix. Hospitals were overcrowded, provided little training for nurses, and lacked translators for many of the poor immigrants who were wrongly committed in the first place. Medical knowledge of how to care for those with mental health issues still had far to go.

In addition, you will examine primary sources about the young journalist Nellie Bly who was given the assignment to go undercover as a patient inside the notorious New York City Lunatic Asylum on Blackwell's Island in New York.

The term "lunatic asylum" was used in the 1800s but dropped out of the medical lexicon by the end of the century and is seen as a derogatory term today.

To complete her assignment, Bly feigned mental illness at a women's boardinghouse and was soon committed to Blackwell's. Within days of her release, Bly published her exposé in the newspaper the New York World. In it, she described the hospital's inhumane living conditions and the staff's cruel treatment of their patients. Her work led to government reforms and was an early example of a new type of reporting called investigative journalism.

Context

Throughout the 1700s in colonial America, the treatment of people with mental illness was almost always barbaric. Many mentally ill individuals were placed in prisons-often chained to the walls-and lacked appropriate clothing for the season. While some families took responsibility for their mentally ill relatives, many more would hide them in attics or sheds in order to avoid embarrassment. In the 1770s, facilities began to be built for the mentally ill but still were not designed to help patients get better, since most mentally ill people were seen as incurable.

The 1800s ushered in reforms in mental health, including the construction of asylums, as patients were no longer seen as having moral failings but rather treatable medical conditions. These reforms coincided with other humanitarian efforts focused on temperance, women's rights, penal reform, and the abolition of slavery.

New Pennsylvania Hospital for the Insane, building, Pa. Stereograph showing the Pennsylvania Hospital for the Insane under construction, with many workers posing in foreground. ca. 1859. Library of Congress

Fenced-in walkways of the Richardson Olmsted Complex, the 1870 Buffalo State Asylum for the Insane, Buffalo, New York. Photograph by Carol M. Highsmith, 2018. Library of Congress

In the 1840s, Dorothea Dix led the reform movement for mental health and advocated for the "moral treatment" of individuals, for example that patients should no longer be kept in shackles or straitjackets. Dix successfully lobbied state legislatures and Congress for the construction of public hospitals for the mentally ill.

As is typical at many large institutions, problems began to develop inside the hospitals that arose. Dix blamed much of the problem on poor administrative leadership and a lack of funding, which led to overcrowding and poor care. Newspaper reports exposed the inhumane conditions inside these hospitals, taken from accounts by former patients or family members. However, most journalists were forbidden to see what was actually going on inside for themselves.

"Behind Asylum Bars" by Nellie Bly. The New York World. Oct. 17, 1887. Permission has been granted for educational purposes only courtesy of NYU Digital Library Services.

One notable exception was twenty-four-year-old Nellie Bly. In 1887, Bly was able to get herself committed to the asylum on Blackwell's Island, an overcrowded, state-run mental institution. Shortly upon her release, she wrote a groundbreaking piece for the newspaper the New York World about her experience. Bly's exposé won her instant notoriety and helped to bring widespread attention to the problem.

Discuss the following questions:

1. How was mental health treated in the 1800s compared to the 1700s?

2. What contribution did Dorothea Dix make on advancing mental health treatment? Why were her accomplishments important?

3. Describe the unusual way Nellie Bly found out what life was like in an asylum. Do you feel this was an ethical way to get a story? Why or why not?

Journalists

The newspaper business was very competitive in the late nineteenth century, especially in big cities. Publishers and editors sought out sensational stories of poor urban conditions to increase circulation. If reform and improvement came about in the process, so much the better. One reporter sought more than the sensational and was one of the first to develop a form of reporting known as investigative journalism.

Elizabeth Jane Cochran, a.k.a. Nellie Bly, was one of fourteen siblings growing up in Pittsburgh, Pennsylvania. Early in life, she was compelled to speak truth to power when she testified on her mother's behalf against an abusive stepfather. Later, she studied to become a teacher, one of the few professions open to women at the time, but dropped out due to lack of funds.

At age twenty, Bly read a newspaper column in the Pittsburgh Dispatch entitled "What Girls Are Good For" that argued womens' value was only in birthing children and keeping house. Incensed, Elizabeth wrote a letter in response, pointing out the article's negative representation of women. The managing editor of the Dispatch was so impressed that he printed her rebuttal letter and offered her a full-time job.

After a series of Bly's investigative articles on female sweatshop workers received several complaints from factory owners, she was reassigned to the Society pages. Bly soon became dissatisfied with her new assignment and traveled to New York City, where she got a job writing for the New York World.

In one of her first assignments, Bly had herself committed to the New York City Lunatic Asylum on Blackwell's Island. There she experienced the filthy conditions and abusive treatment firsthand. She interviewed patients who were committed after only a brief examination. Many of these people were immigrants who didn't speak English.

In 1887, the New York World published a series of articles that were later compiled into a book, Ten Days in a Mad-House. The articles caused a major sensation, prompting city officials to implement reforms and bringing Bly lasting fame.

Not long after Bly's exposé, a group of journalists who came to be known as muckrakers began reporting on issues of social injustice in an in-depth way that connected to the public on an emotional level. (Be sure to check out the case study on the Muckrakers to learn more.)

Discuss the following questions:

1. Why do you think circulation increased when nineteenth-century newspapers printed sensational stories about poor urban conditions?

2. What does the story about how Nellie Bly got the job at the Pittsburgh Dispatch tell you about her personality and ambition?

3. What does Bly's reporting from the "Mad-House" tell you about society's attitudes toward mental health and ethnic prejudice at the time?

Newspapers like the Sun wrote their own stories about the "mad woman" known as Nellie Brown whose identity remained a mystery to authorities. The Sun's editors were not pleased to learn that the woman was in fact a reporter for their rival paper. Oct. 14, 1887. Library of Congress

News Format

During the late nineteenth century, the newspaper business became not only "big business" but highly competitive and sensational as publishers battled for increased circulation to grow their advertising revenue. Some newspapers printed yellow journalism, exaggerated stories with sensational headlines. Bly worked for Joseph Pulitzer's New York World, which became one of the most famous examples of yellow journalism but also published hard-hitting, investigative articles.

Newspapers like the World also engaged in "stunt journalism"-or "immersive journalism"-in which reporters like Bly embedded themselves into the subject of their story. The result is a deep look into the inner workings of business and government. The stories often revealed the dangerous living and working conditions in tenement housing and factories. The writing was vividly descriptive and condemning, but oftentimes told only one side of the story. Stunt journalists were sometimes criticized when their experience affected them so much that their stories lost objectivity.

Discuss the following questions:

1. What is meant by "investigative journalism"? What are some examples of this today?

2. Why was "investigative journalism" sometimes called "stunt journalism"?

3. What was some of the criticism of investigative journalism at this time?

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" Energy rightly applied and directed will accomplish anything." -Nellie Bly, investigative reporter How does investigative journalism bring awareness to problems and help support reform efforts? In this case study, you will analyze primary sources on the mental health reform movement of the mid-nineteenth century, which was spearheaded by Dorothea Dix.

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​In 2020, according to the National Institute of Mental Health, suicide was the second leading cause of death for children ages 10-14, and young adults, ages 18-25, were reported to have the highest rates of serious mental illness and mental health concerns compared to adults ( Duszynski-Goodman & Henderson, 2024). In response to the growing numbers of teens facing mental health issues, many school districts have incorporated Mental Health Literacy (MHL) into the curriculum and now require teacher training on mental health awareness and early detection. According to Claire Goodfellow ( 2022), MHL was first developed in Australia in 1997 and incorporated into the curriculum to destigmatize mental health issues and to enhance youth's belief in seeking out help as an effective action. Since the early establishment of MHL which was originally designed to inform "knowledge and beliefs about mental disorders," the scholarship regarding MHL has expanded to incorporate four major components: 1) to maintain positive mental health; 2) to identify and understand disorders and treatment; 3) to reduce the stigma of mental health issues and seek out help; and 4) to supply essential resources for support and seeking help ( Eisenback & Frydman, 2003, p. 2). While MHL is often supported with resources, such as the Center for Disease Control and Prevention's Action Guide for School and District Leaders ( 2023), there is less literature available that directs teachers' inclusion of MHL in conversation with curriculum, learning outcomes, and state standards.

​What is clear, however, is that one major element of the success of MHL in schools is the role of a teacher who is committed to incorporating its components ( Eisenbach & Frydman, 2023). There is no disagreement that MHL is important and should be included in the curriculum, as education can "open dialogue and break the stigma associated with mental illness" ( Eisenbach & Frydman, 2023, p. 2). However, when it comes to MHL, teachers may rightfully feel pressure when incorporating content outside of their area of expertise and/or may cross into unfamiliar territory being placed in the role of a counselor or psychologist. Despite these potential challenges, we follow Esenbach and Frydman ( 2023), feeling that "excluding such topics is a disservice to student learning" (p. 2) and noting the import of building collaborations with qualified school personnel to broach such topics in the classroom.

As educators of literature, we believe that stories, especially those crafted in YAL, have the power to transform the lives of readers. Outside of our own opinions and love for YAL, research has shown that the inclusion of YAL can promote empathy ( Sherr & Beise, 2015) and has the potential to create change or inform social perceptions ( Ginsberg & Glenn, 2019). According to Eisenbach and Frydman ( 2023), narratives have the power to change personal beliefs and attitudes regarding the world, and conversations cultivating MHL can "educate readers on the truths of mental illness while challenging stigma and providing a safe space for exploration and discussion" (p. 2). Literature can facilitate these discussions in a multitude of ways. As a mirror ( Bishop, 1990), readers can see themselves reflected in the readings in meaningful ways and even help inform their own feelings or situations when they may not have the understanding or the words to name and discuss their situation on their own. It gives readers agency in discussions of their own well-being. According to Goodfellow ( 2022), over half of the teens involved in a UK survey expressed "that they did not seek help for poor mental health, because they didn't understand what it was that they were going through" (para. 6). Literature as a mirror may also help a reader identify that there is a need to seek out help in relation to character portrayal, diagnosis, or depictions of mental distress presented in the text.

​As a window ( Bishop, 1990), depictions can inform readers who do not experience mental health issues about the realities of mental illness. And, as a sliding glass door (Bishop, 1990), students may be able to experience empathy for characters whose lives are different from their own, asking students to walk through a narrative understanding what someone who is different from them may feel. Webber and Agiro ( 2019) remind us that "inducing empathy toward a person belonging to a stigmatized group not only improves attitudes toward the whole group, but also increases the chance that those positive attitudes will prompt actions to benefit that group" (p. 2). Falter (2022) cautions us to take the idea of empathy with YAL a step further and offers a "critical empathy framework" for reading that "moves beyond mere identification with others and perspective taking, and understands that social, cultural, and historical elements are always at play and complicate our ability to feel and think with another fully" (p. 24). In what follows, we describe our approaches to inviting students' mental health literacies into our classrooms through a focal text.

​The assigned reading for this unit was introduced to students a week in advance with content warnings ( Appleman, 2022) and students were given the option of choosing between two texts depicting mental illness so as to offer a space for choice and self-determination. In preparation for the unit, students also received information for seeking help for themselves, both at the institution and state levels. They were offered statistics regarding teens' mental health, reported by the CDC (2024) which informed them that 1 in 5 young adults have a mental health issue and that many go unreported. They were asked to discuss the content with their peers and determine how they wished to proceed with the unit in terms of text choice. Below we focus on one of the choice texts, The Words We Keep (2022) by Erin Stewart.

​ Focal Text: The Words We Keep
The Words We Keep (Stewart, 2022) follows two sisters through their intense struggles with mental illness. Lily, the younger sister, has anxiety and desires to live a "normal" life. Lily's story begins as her sister Alice returns home from a treatment program where she was diagnosed and medicated for bipolar disorder. Lily remembers Alice's traumatic suicide attempt and sees the burden of her diagnosis on the family, especially her father, but she sees even more how different Alice is after she returns. Alice doesn't have her previous flair, and her personality is muted. She no longer dons her brightly colored clothing or has eccentric plans or enthusiasm. Instead, Alice is withdrawn and distant. Under close supervision of their father, Alice is not allowed to be alone; all sharp objects have been hidden; and there is a tension in their home as the family supports and navigates Alice's diagnosis. In the midst of Alice's mental health crisis, Lily feels like she has to be perfect. She spends most of her time worried about getting into college and being the model daughter to support her sister and family. This exacerbates her anxiety throughout the text and even though she meets Micah, a new student at her school (who also attended the same treatment center as her sister), she feels alone. Throughout the novel, Lily uses art as a way of expressing the 'words we keep' inside, hidden, and private. As her school poetry project unfolds, Lily finds that she is not alone in her experiences. Lily, Alice, and Micah journey through the unknowns of mental health issues and face the stigmas surrounding mental health to find that their journey together is what matters most. This exceptional novel is raw and descriptive of what mental illness can look like in multiple forms-through Lily's anxiety, Micah's depression, and Alice's bipolar disorder.

​​ Reading with Students
Students' reading of this novel was divided into two sections, with half the novel assigned per class meeting. During the halfway mark, students reported that: they loved the text and couldn't put it down, had completed the novel already, or felt that the content was so vividly descriptive that they had to take multiple breaks and were behind schedule. Some students shared that the novel was graphic and brought up their own experiences with trauma, but they felt that the content was accurate in its portrayal. Even though they knew that everyone experiences mental health related issues differently, the students shared that they enjoyed the accuracy of the text based on their own understanding of the elements within the novel. While some expressed that the novel was difficult to read, each student did successfully complete the reading and stated that while it brought up hard issues, they were important topics to discuss in the classroom. They understood that mental health issues impact a large portion of the population and expect that they will encounter people in their lives and in their future classrooms who are in crisis. The students appreciated the additional resources delivered with the unit. Some students, interested in writing a novel themselves, went on to have further discussions of mental health representations and the need for more accuracy to fight against stigmas of mental health. Some students identified with having anxiety and resonated with the depictions of Lily feeling like she needed to be perfect. Others understood the realities of bipolar disorder. Ultimately, students repeatedly expressed that while the text might be difficult to read, it facilitated healthy conversations about mental health, representation, stigma, and access to resources.

​The students' responses all point to the myriad ways that YAL dealing with mental health can promote honest conversation and connection. Our students experienced the text as a reflection of their own struggles, while others learned more about aspects they had not experienced, such as the effects of medication. Still others noted being transformed by the narrative, especially as it reflected the impact of mental health on family members and how sometimes surrounding a person with love is not enough when they need professional help.

In the novel, Stewart (2022) expertly depicts the dynamics of friendship, family, and romance. We drew on several discussion questions to solicit their connections of these themes alongside mental health, reminding students throughout that they were not expected to disclose any personal information unless they chose to, which many did. We prodded them to deeply consider the parents' roles, asking: How did Lily's father miss the signs that his daughter was struggling? And, how was Lily's stepmom helpful (and not) to her stepdaughters? To help students see the damaging effects of Lily keeping secrets, we asked: How did Lily think she was helping Alice? And, to unpack the stigmas in the text, we asked students to locate microaggressions and aggressions expressed at school as well as how the students at the party reacted to Alice's episode toward the end of the novel, which resulted in social media postings. Our readers delved into how social media can contribute to declined mental health, especially through cyberbullying. With our final assigned social action projects (Boyd, 2017; Boyd & Darragh, 2019), we extended the opportunity to students to act on their knowledge gleaned from the text. In almost every semester that students have completed the projects in this course, multiple groups choose to focus on mental health, raising awareness of campus resources, building websites, or hosting movie viewings and critical conversations. Using The Words We Keep as a springboard, a recent group constructed a website to give students quick and easy access to mental health resources on campus. Using flyers to advertise this website, the group focused on preventative mental health and wellness, advocating for the importance of caring for your mental health even when you feel "fine." The flyers created were bright and colorful, depicting mental health awareness as positive. They heralded the power in knowing oneself and provided resources for improving mental health wellness as well as resources for mental health crises. Using a QR code, the group reported that they advertised in private spaces, such as bathrooms on campus as well as on public information boards and received multiple visitors to their website.

​​ Integrating Mental Health Literacy
As noted above, MHL has expanded to incorporate four major components: 1) to maintain positive mental health; 2) to identify and understand disorders and treatment; 3) to reduce the stigma of mental health issues and seek out help; and 4) to supply essential resources for support and seeking help ( Eisenback & Frydman, 2003, p. 2). Our unit attempted to address these elements through reading, research, and discussion. We provided resources at the outset of the unit and offered data on the prevalence of mental health issues, definitions of various types of diagnoses, and practices for establishing mental well-being. As also mentioned above, we focused extensively on the authenticity of the narrative and how Stewart's (2022) representation revealed and debunked common stigmas. Olan and Richmond (2023) write, "many texts featuring characters with mental illness include authors' language and descriptions which perpetuate stigma via the readers' positioning of the characters through a deficit narrative model ... In YAL, for example, this could mean characters with mental illness are written as not having effective relationships, not fitting in, experiencing violence/harassment, being positioned as victims, experiencing social isolation, or having negative futures" (p. 22). We asked students how The Words We Keep worked against such tropes.

​One caution, however, that we ourselves experienced (and our students worried about for their future classrooms) was being placed in the role of a counselor. Because we work with college students, we realize we are uniquely positioned with resources and support at the university. For secondary teachers, we encourage the use of Eisenbach and Frydman's ( 2024) model in which middle grades teachers "consulted with the school's social support staff on content and delivery" (p. 7), collaborating with professionals who can "clarify misconceptions, fill in knowledge gaps for the teacher, and provide resources to deepen teachers' understandings" (p. 11). We don't-and shouldn't-do this work alone. Many resources exist to guide us in selecting texts with authentic depictions of mental health, educating ourselves, and working with those trained to provide mental health instruction (e.g. Anti-Defamation League, 2013; Eisenbach & Frydman, 2024; Olan & Richmond, 2023). A few other points to note are that we did offer student choice in the texts, allowing students to select a mental health related option of interest to them since "MHL interventions need to be developmentally appropriate and applied within the most suitable developmental context" (Kutcher, Wei, & Coniglio, 2016, p. 154). Finally, we embedded the text amongst others and within a focus on ELA curriculum and texts, rather than as an added entity for study solely on mental health.

​Thus, despite the fears that we, as teachers, may experience surrounding working with mental health, we echo scholars before us who have argued that ignoring sensitive topics only perpetuates suffering in silence or in ignorance surrounding conditions, and we feel it is imperative to incorporate novels like The Words We Keep and MHL into our ELA classrooms. We seek to support our students and to engage them with meaningful literature, and we believe we can accomplish these through units such as that which we have described.

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Drawing on Young Adult Literature to Facilitate Mental Health Literacy: Reading The Words We Keep with Pre-Service Teachers

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School Mental Health Report Card | Inseparable

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No one’s worst day should keep them from living their best life. School Mental Health: Policies to Improve Student Wellbeing Recent data show investments in school-based mental health supports are having a positive impact on our youth. There is still more to be done to ensure every child’s school has effective programs in place that […]

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Strengthening Youth Mental Health: A Governor's Playbook

Even before the pandemic turned the world upside down, our young people were struggling with a mental health crisis that has only grown more serious in recent years. Yet we have reason to feel optimistic that we can reverse these trends and help our children.

Over the past year, we have spent countless hours meeting with those on the front lines of this crisis, and we have seen innovative approaches, thoughtful programs, and effective models across the country. Together, they form the basis of this playbook that states, policymakers, and stakeholders can use to address youth mental health challenges.

These are issues that impact every community - urban, suburban, and rural, east, west, north, and south. There are no geographic boundaries or political party lines. As Governors, one of our most important and sacred responsibilities is protecting the health and well-being of our state's children. Mental health is just as important as physical health, and while many are unfamiliar with the signs and symptoms of mental illness, we're encouraged by the extensive efforts taking place across the country to raise awareness and reduce stigma. As more and more people know it's okay to say they're not okay, we know we're seeing significant progress.

But this crisis is too deep and complex for any state or organization to solve on its own. It requires partnership from everyone, especially the folks on-the-ground in our communities - young people, parents, caregivers, educators as well as business, community, and faith-based leaders to work together. The pages of this playbook contain examples of successful policies and initiatives that use this all-hands approach to address youth mental health needs, and it is our hope that more states will implement similar policies.

We want to extend our deepest thanks to everyone who shared their expertise in helping to create this playbook. We are especially grateful to those who shared their lived experience. Throughout my year as Chair, this Initiative has honored the need to listen to youth voices and perspectives to collaboratively find more effective ways to meet the mental health needs of our youth.

Our kids deserve better, and we can do better. It will not be easy, but this playbook offers a path to ensuring young people can get the help they need when they need it. Together, we can help our youth and our communities heal.
- New Jersey Governor Phil Murphy, NGA Chair

If you or someone you know is having thoughts of suicide or experiencing a mental health or substance use crisis, 988 provides 24/7 connection to confidential support. There is Hope. Just call or text 988 or chat 988lifeline.org

Executive Summary
(Download/Print)
Across the country, on social media, in pop culture, around kitchen tables and in state capitols, the focus on youth mental health has become increasingly common. Governors and policymakers at all levels of government and on both sides of the aisle are continuing to seek to make positive impacts on youth mental well-being and the systems that support young people. As Chair of the National Governors Association (NGA), New Jersey Governor Phil Murphy sought to harness the bipartisan efforts and national focus on youth mental health and made Strengthening Youth Mental Health the focus of his year-long NGA Chair's Initiative. The Strengthening Youth Mental Health Initiative brought together close to 500 people, including youth, Governors and other experts, in four convenings held across the country to discuss the current state of youth mental health systems and advance best practices and implementable, impactful solutions for states. Strengthening Youth Mental Health: A Governor's Playbook is a culmination of those discussions as well as more than 50 learning calls with national experts.

The Playbook is intended to serve as a tool for states to further impactful policy solutions that strengthen youth mental health. Nationally, the current state of youth mental health is often labeled as a crisis - youth have not been provided the tools and resources they need to thrive, young people often do not know where to go to begin to understand their mental health needs and they face a mental health care system that is often inaccessible and unaffordable when they do need it. Young people are not alone in their efforts to support their own mental and emotional health. Parents, caregivers, educators, peers and other youth-facing adults want to support the mental well-being of the youth in their lives but face similar barriers to understanding what they need and how to help them. The Playbook provides states with actionable solutions to address each of these concerns.

The Strengthening Youth Mental Health Initiative consists of four pillars that address the core challenges to a system that supports youth and helps their mental well-being. Altogether, the four pillars address the continuum of youth mental health, helping states to address the needs of youth in crisis today, while ensuring that systems focus on holistically supporting youth mental well-being to help future generations succeed. The four pillars are:

1. Addressing prevention and building resilience: Supporting youth with the necessary tools to respond to stressors and challenges, reducing the risk of mental health conditions, and proactively identifying and managing existing conditions to prevent crises.

2. Increasing awareness and reducing stigma: Promoting awareness of mental health knowledge and resources, and decreasing the social, self and structural stigma around youth mental health challenges.

3. Ensuring access and affordability of quality treatment and care: Removing the barriers to care, including unaffordable costs, lack of insurance coverage and a depleted workforce to ensure that high-quality, trauma-informed and culturally relevant care is accessible to youth in appropriate places, spaces and timeframes to meet their needs.

4. Training and supporting caregivers and educators: Expanding training and supports so that those caring for and interacting with youth daily have the understanding and tools to identify mental health needs to access relevant supports.

The opportunities noted in the Playbook are not exhaustive of all potential actions that Governors can take to address youth mental health in their states, but are instead a representative collection of replicable, implementable and impactful solutions that are already underway across the country. The ultimate goal of the Playbook is to help Governors understand the best practices and ideal status of youth mental health systems and then to provide examples and context for how to adapt and implement them in their states.

Further, the Playbook recognizes there is a vast diversity of youth identities and experiences that interact with mental health outcomes in unique ways. The Strengthening Youth Mental Health Initiative deliberately does not define an age range or limit the focus of policy opportunities to specific types of youth to empower Governors to determine the target audiences for the mental health programs in their states across their unique backgrounds, experiences and stages of life.

Finally, while the Playbook can be utilized as a standalone resource, it is not the only support available to states in conjunction with this effort. The Playbook represents the culmination of Governor Murphy's Chair's Initiative, but the Strengthening Youth Mental Health effort will continue on beyond his time as NGA Chair. In addition to the representative sampling of state efforts included in the Playbook, a more comprehensive database of Governor's collective efforts can be found at: www.nga.org/youthmentalhealth. The NGA and Strengthening Youth Mental Health partners also remain accessible for technical assistance for implementation of the Playbook 's recommendations as well as guidance on additional efforts Governors can pursue to Strengthen Youth Mental Health in their states across the country.

Introduction

The United States has a widely recognized youth mental health crisis. Data released by the Centers for Disease Control and Prevention ( CDC) show the continuation of a 10-year rise in young people's mental health challenges. In 2021, more than 40% of students felt persistently sad or hopeless, and for teenage girls, this number was nearly 60%. More than 20% of all students and nearly 50% of LGBTQ+ students seriously considered attempting suicide. The CDC also reports an increase in suicide rates among younger Americans in 2021, with a 37% increase in the suicide rate for Black youth aged 10 to 24. American Indian or Alaska Native youth continued to have the highest suicide rates for youth aged 10 to 24 at 36.3 deaths per 100,000 persons in 2021.

However, the crisis does not need to go unsolved. While historically mental health support, including innovative treatment and dedicated funding, has been targeted towards adults, addressing youth mental health and well-being is increasingly front and center for states. In 2022, more than 30 Governors highlighted mental health as a major priority in their State of the State or Budget Addresses. Recognizing rising youth mental health needs and the unique position of Governors to advance solutions, as Chair of the National Governor's Association, New Jersey Governor Phil Murphy selected Strengthening Youth Mental Health as the 2022-2023 NGA Chair's Initiative for cross-state engagement and collaboration on relevant solutions. The Chair's Initiative brings together Governors, their advisors, youth voices and leaders across the public and private sectors to advance impactful programs, policies and partnerships that can be tailored to state-specific contexts.

The vision for Strengthening Youth Mental Health is to build equitable and integrated youth mental health systems that promote individual, family and community well-being, and are informed by lived experience. Achieving this vision is enabled through four pillars, with distinct but interconnected themes:

1. Addressing prevention and building resilience: Supporting youth with the necessary tools to respond to stressors and challenges, reducing the risk of mental health conditions, and proactively identifying and managing existing conditions to prevent crises.

2. Increasing awareness and reducing stigma: Promoting awareness of mental health knowledge and resources, and decreasing the social, self and structural stigma around youth mental health challenges.

3. Ensuring access and affordability of quality treatment and care: Removing the barriers to care, including unaffordable costs, lack of insurance coverage and a depleted workforce to ensure that high-quality, trauma-informed and culturally relevant care is accessible to youth in appropriate places, spaces and timeframes to meet their needs.

4. Training and supporting caregivers and educators: Expanding training and supports so that those caring for and interacting with youth daily have the understanding and tools to identify mental health needs to access relevant supports.

Progress in each of these pillars is supported by key levers Governors and other state leaders can use to drive change:

Setting the agenda: Clearly identifying priorities, empowering state agencies to act, and endorsing relevant organizations and their initiatives to set the "tone from the top."

Allocating funding: Appropriating sufficient funds to youth mental health, leveraging federal funding sources effectively and exploring innovative funding approaches with private sector organizations and philanthropies.

Supporting legislation: Directing legislative platforms towards key issues, introducing supportive legislative proposals and advancing relevant policies.

Orchestrating stakeholders: Employing strategies including cross-sector coalition building and working groups, allocating responsibilities to stakeholders and identifying leaders to drive alignment throughout state systems to better coordinate resources across disparate structures.

Historically, agencies that cover public health or child welfare have often been the primary drivers of statewide youth mental health agendas. However, impactful solutions to strengthen youth mental health often require a systems approach and benefit from cross-agency coordination and leadership, including but not limited to education, insurance regulators, social safety net programs, workforce boards, juvenile justice systems, human services and Medicaid agencies, many of which were not developed and designed to address the unique and specific needs of youth. Families often interact with multiple systems in a state, and coordination between these systems can be critical to getting families the help they need. A successful youth mental health agenda often starts with building momentum out of youth-facing state systems. Governors can champion and commit to a unified statewide strategy, compel agencies to come together to solve problems, braid and blend funding, remove administrative barriers and share information with the goal of improving family well-being.

The 2022-2023 NGA Chair's Initiative held four roundtable discussions - one per pillar - across the country, from October 2022 to May 2023. Across the four roundtables, more than 14 state representatives were joined by over 400 community leaders, academic experts and representatives from partner organizations and funders. In total, more than 60 organizations were represented throughout the Initiative. The key takeaways from these discussions were supported through over 50 learning calls with other relevant organizations and individuals and an in-depth landscape analysis of states' and territories' activities to strengthen youth mental health.

A Governor's Playbook is the culmination of the 2022-2023 NGA Chair's Initiative: Strengthening Youth Mental Health and focuses on actionable ways to improve youth mental health and ensure that resources, innovation and attention are directed towards children and youth. The publication is organized according to the four pillars of the initiative. Each pillar is supported by a set of priorities, or focus areas, which can be enabled through opportunities: specific action itemsfor Governors and state leaders and state spotlights to highlight states' policies and programs.

The youth mental health landscape is complicated and nuanced and no solution can be representative of every child or youth's unique experience. The Playbook recognizes the disparate outcomes experienced by youth of diverse identities, communities and environments, including youth of color, LGBTQ+ youth, multi-system youth, youth from families with low incomes and youth with co-occurring disorders, including substance use. The Playbook also covers solutions across all ages, from early relational health to transition-age programs. The National Governors Association supports Governors' efforts to strengthen the mental health of all youth in their states, including youth across all backgrounds, experiences and stages of life.

Not all examples will be relevant for all states, due to differing priorities and populations, but A Governor's Playbook aims to support state policymakers in navigating the youth mental health landscape and to inspire cross-state and cross-sector collaboration by amplifying the work already being done across the country. The examples selected for this Playbook highlight different responses to the youth mental health crisis and were selected to illustrate some of the innovative and impactful initiatives across a range of states and territories. These examples are not intended to be exhaustive; many states are doing incredible work in youth mental health. To learn about additional state programs and examples, please see the online resource below. The highlighted examples in this Playbook aim to prompt more discussion on ways to advance progress.

Pillar 1: Addressing Prevention and Building Resilience

The mental health and well-being of a young person is affected by a mix of biological, psychological and environmental circumstances. Due to the ways in which these often intersect, preventing mental health issues is complex; however, by focusing on building resilience in youth, we can increase their ability to maintain or return to mental well-being when faced with stress or adversity and reduce the likelihood of engaging in unhealthy or damaging behaviors. States can foster mental well-being and reduce the risk of mental health challenges by focusing upstream on the root causes of youth mental health issues, supporting early identification of mental health conditions through screening and strengthening response systems to prevent suicide and other crises.

Priority: Prioritize upstream interventions

Prevention is better than cure. States have several opportunities to prevent mental or behavioral health conditions from developing or deteriorating, potentially avoiding harm to youth and strain on state services and resources. As Mental Health America notes, we are learning more about the "critical points in brain development and life experiences that increase the risk for or provide protection against the development of mental health disorders." These critical points occur from infancy to adolescence and span across the different aspects of a young person's life. To address youth mental health suitably, we need to start with early and holistic interventions.
Opportunity: Provide access to support services and early intervention for infant and early childhood mental health (IECMH)
Although significant focus is often on older children and adolescents, 16% of children aged two to eight years have a diagnosed mental, behavioral or developmental disorder, according the CDC. Many mental health challenges can be traced back to a child's formative years. Mental health starts before birth, and investments that support IECMH often prevent the need for more costly interventions at a later age.

The majority of states are taking action on IECMH. Governors and state leaders can provide supports and resources to parents and caregivers, clinicians and child care providers looking for help to promote babies' and toddler's mental well-being or cope with mental health challenges. Prevention strategies for IECMH are only the beginning of supporting our youngest children's mental well-being; states and territories can also incorporate IECMH practices into their Medicaid plans, allow for IECMH screenings in diverse settings and pay for quality family relational treatment. Several states have also expanded home visiting programs to connect mental health needs and promote well-being for both children and their caregivers. For example:

In 2022, Colorado's Department of Human Services launched an Early Childhood Mental Health Support Line to connect caregivers of children under age six with mental health resources.

New Mexico's Infant and Early Childhood Mental Health Services focuses on addressing the transmission of intergenerational trauma from parents to infants and shares resources including an infant mental health child parent psychotherapy provider directory.

The U.S. Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program supports 23 evidence-based home visiting programs in all 50 states, five territories and the District of Columbia. MIECHV programs in part support maternal mental health and the physical, social and emotional development of infants and young children from birth or during pregnancy, depending on the program. Oregonand New Jerseyare the first two states in the nation to establish statewide universal home visiting programs that offer a nurse home visit to every family with a newborn at no cost to the family utilizing the Family Connects model.

The U.S. Substance Use and Mental Health Services Administration (SAMHSA) also has a Center of Excellence for Infant and Early Childhood Mental Health Consultation that provides funding and technical assistance to community partners, states, territories and tribal partners.

According to the National Center for Children in Poverty, more than 43 states use Medicaid to cover social-emotional screening of young children. More than 25 states allow for social-emotional screening to take place in some sort of a nonmedical setting, like in the home, within early intervention services, or within an early care and education program.

Opportunity: Address the social drivers of youth mental health issues

Social drivers of health, including income, access to education, health care, nutrition and safe housing, as well as repercussions related to discrimination and violence, are some of the leading causes of disparities in health and general well-being outcomes. Youth mental health challenges do not occur in a vacuum. According to the National Institute of Health, youth from homes with low socioeconomic status (SES) are twice as likely to suffer from mental health problems as those from homes with high SES.

State leaders can incorporate the needs young people have for healthy and thriving lives in their youth mental health efforts. Examples include:

It is important to note that social drivers of health impact the experience and outcomes of youth across all systems. According to the 2019 National Academies The Promise of Adolescence report, children of color and of lower socioeconomic status experience lower rates of academic proficiency and higher rates of child welfare involvement, and such environmental factors can contribute to poor mental health outcomes. The report highlights potential factors that may contribute to disparities, including differences in family income, institutional response to adolescents by schools or the health system, or prejudicial or discriminatory attitudes or behavior on the part of adults in youth-facing systems. To address the social drivers of health comprehensively as a vehicle to prevent youth mental health concerns, Governors can drive progress in reducing these disparities holistically across all state systems.
Opportunity: Implement youth-focused trauma-informed practices
According to the CDC, over 60% of adults experience at least one adverse childhood experience (ACE) by age 18, including emotional, physical or sexual abuse; emotional or physical neglect; household challenges such as substance abuse or the incarceration of a family member; or environmental challenges such as discrimination. The number and severity of ACEs a child faces have a strong correlation to mental health issues. Governors and other state leaders can ensure training throughout youth-serving systems in trauma-informed practices to cater to youth who have experienced ACEs or toxic stress and can consider strategies to include families in their efforts to mitigate the occurrence of ACEs and improve family well-being. Further, states can promote positive childhood experiences, including community-building, to encourage strong social connections, a protective factor that contributes to mental and emotional well-being.

States have been advancing these efforts in unique ways. For example, Puerto Rico has prioritized training all clinical service providers on trauma-informed care practices and created four new regional Treatment Centers for Children and Youth to provide trauma-informed out-patient treatment for mental health and substance use to serve the four regions of the island. A powerful advocate for the reduction of ACEs, Oklahoma First Lady Sarah Stitt launched Hope Rising Oklahoma, a program that offers coaching and training for community-based organizations around building resilience, striving for well-being and fostering hope.

The NGA has supported state efforts on ACEs and trauma, including a multi-state technical assistance project on which it partnered with the National Academy for State Health Policy (NASHP), culminating in State Actions to Prevent and Mitigate Adverse Childhood Experiences. Following this initiative, the State Trauma and Resilience Network (Connecticut, Delaware, Hawai'i, Maryland, New Jersey, New York, North Carolina, Pennsylvania, Virginia, Wisconsin and Wyoming) was formed to share best-practices advancingstatewide, multi-agency and cross-sector efforts to address ACEs, trauma and resilience holistically in their states. Some examples from these states include Delaware, where Governor John Carney signed an executive order in 2018 to make Delaware a trauma-informed state, including training state employees on ACEs.In Pennsylvania, HEAL PA, a coalition of state agency representatives and community stakeholders, supported enactment of a bill requiring future legislation to consider childhood trauma.
Opportunity: Support the development of healthy school climates
The role of schools in youth mental health is not limited to what is taught in the classroom; schools should be a safe, supportive learning environment for all young people. Healthy school climates contribute to youth mental well-being by creating safe spaces for young people to share their feelings and ask for help from educators and/or their peers. As reflected in recent data from the Civil Rights Data Collection, youth of color are overrepresented in a number of data points; Black youth accounted for almost 40% of suspensions in schools but only 15% of public school enrollment. Youth struggling with their mental health or well-being can sometimes "act out" in schools, and ending disparities in suspensions, expulsions and incidences of bullying can help to promote supportive school environments.

An important first step can be understanding students' experiences at school through data collection and analysis; for example, Colorado's Healthy Kids Survey and Healthy Schools Smart Source is an annual survey of K through 12 students, to provide a more complete picture of youth and school health for over 70% of schools.

States can further support positive school climates and student success in different ways, such as:

Wyoming's Positive School Climate Grant, which provides school districts up to $9,000 to acquire and operate evidence-based programs to reduce school bullying and increase positive school culture and climate. Proposed outcomes must be quantified by using one metric and how that metric changed over time (e.g., discipline referrals, fights).

Oklahoma's State Department of Education, which released a Model Bullying Policy template to be used by school districts to develop anti-bullying policies in line with state statutes.

Priority: Champion the advancement of life skills education

Youth face everyday stressors that can negatively impact their mental health if they do not have the necessary tools to manage them. One way to build resilience is through teaching life skills in schools and community programs. The definition of life skills can vary according to each state's priorities, but traditionally comprises competencies such as self-regulation, problem-solving, interpersonal communication and adaptability that enable youth to navigate life's challenges. According to the WHO Life Skills Education Schools Handbook, there is increasing evidence that learning life skills plays a vital role in the prevention and management of non-communicable diseases, including mental health conditions.
Opportunity: Support the development and implementation of school-based life skills curricula
According to Child Trends, in 2019, 31 states and territories had laws and regulations enabling life skills education to be taught in schools, with just under half mandating their inclusion. However, according to education publisher McGraw-Hill, only 22% of educators currently feel very prepared to teach life skills in classrooms, necessitating additional funding and professional learning opportunities for educators to implement teaching life skills in the classroom successfully.

States are addressing this in different ways:

Arkansas's G.U.I.D.E. for Life curriculum, based on the principles of Growth, Understanding, Interactions, Decisions and Empathy, was collaboratively developed by 96 educators across 74 schools and 44 districts.

The implementation of Florida's Resiliency Education Standards, adopted by the state Board of Education in 2023, is supported by $21 million in dedicated funding to create and share resiliency curriculums including civic and character education with parents and educators.

Michigan's investment in Transforming Research into Action to Improve the Lives of Students (TRAILS) aims to deliver resilience-focused lessons in classrooms. Since the start of the COVID-19 pandemic, TRAILS has seen a 1,000% increase in attendance of educators and counselors at school staff trainings.

Opportunity: Advocate for the role of life skills education through public campaigns and partnerships with relevant organizations
Governors and other state leaders are in a unique position to use their platforms to advocate for age-appropriate life skills education in schools, sharing experiences from their work or personal lives on the importance of teaching coping mechanisms from a young age. Public support from state leaders can go a long way to normalizing life skills education in schools. And states do not have to do this alone; partnerships with organizations, including non-profits and academic institutions, can help to craft relevant, impactful materials.

New Hampshire Governor Chris Sununu implemented the Jesse Lewis Choose Love Movement curriculum in schools, containing evidence-based life skills strategies designed by an associated nonprofit.

Healthy Minds, Thriving Kids curriculum, a comprehensive set of video and print life skills resources in both English and Spanish, disseminated to over 70,000 California educators in 2022.

annual Governors' Summit on Innovative Education, and in 2021, the summit featured a keynote address by Dr. Stuart Ablon, the director of Think:Kids in the Department of Psychiatry at Massachusetts General Hospital, who emphasized that youth "lack skill, not will" when it comes to these life skills.

Opportunity: Encourage the teaching of practical life skills in out-of-school settings
Many valuable life skills are taught outside the classroom environment through sports, extracurricular activities or community engagement. According to the National Alliance on Mental Illness (NAMI), volunteering improves mental health; it is a way to build connections to reduce loneliness, develop self-esteem, reduce stress and find purpose. Maryland is a stand-out example of state leaders encouraging community involvement and is the only state which includes service-learning experiences as a condition of graduation. Since the class of 1997, approximately four million service hours have been provided to the community. Maryland Governor Wes Moore has also recently created the Department of Service and Civic Innovation to implement the country's first state-run service-year option for high school graduates in Maryland and to encourage graduates to pursue civic options.

Priority: Implement mental health screening in relevant settings

According to the Substance Abuse and Mental Health Services Administration ( SAMHSA), approximately half of all lifetime mental health conditions begin before age 14; however, they regularly go untreated for years. To attend to these challenges sooner, the United States Preventative Services Task Force recommends, and the American Academy of Pediatrics endorses, conducting screenings for anxiety from age eight and major screening for depressive disorder or suicide risk from age 12. These screenings are often part of a child's wellness check-up; however, not all children access or receive these services from a medical provider. Universally available, age-appropriate mental health screening for young people is an important secondary prevention mechanism. It can accelerate the detection and diagnosis of mental health conditions and enable earlier connection to care that helps prevent progression to more serious illness. Governors and other state leaders can consider how to implement school- and community-based mental health screenings on a statewide basis to provide access outside of clinical settings.
Opportunity: Allocate funding for mental health screenings in schools and other community settings
School-based screenings for physical health conditions, including hearing and vision loss, have long been accepted to address gaps in care. This should be the case for mental health conditions as well; however, according to the Kaiser Family Foundation, just one third of schools provide services that include mental health screenings for all students. Screenings in schools also offer the opportunity to assess school climate, overall well-being, and metrics of connectedness and belonging, both of which are predictive of student mental health and academic success as discussed above. Support for screenings also allows states to begin to focus on the connection between screening and services, ensuring that schools and community organizations have the resources they need to connect youth to quality care post-screening.

Multiple states have enacted legislation allowing school districts and/or individual schools to provide mental health screening to students, including: Colorado, Iowa, New Jersey and Utah. Other states' legislation requires that these screenings are provided, including Illinois.

National Center for Children in Poverty, more than 43 states use Medicaid to cover social-emotional screening of young children. More than 25 states allow for social-emotional screenings to take place in some sort of a nonmedical setting, like in the home, in a foster home, within early intervention services, or within an early care and education program.
Opportunity: Ensure mental health screenings reach high-risk populations
Youth from certain backgrounds are more likely to experience negative mental health outcomes. According to studies cited by Mental Health America, 65-70% of youth in the juvenile justice system have a diagnosable mental health condition. As stated by the National Conference of State Legislatures, as of 2019, up to 80% of youth in foster care experience significant mental health issues, drastically higher than the general population. Governors and state leaders have especially consequential influence over the mental health screening and services provided to youth involved in state systems, including justice involved youth, foster youth and youth with disabilities. Universally available mental health screenings should be prioritized for these populations to ensure coordinated statewide connection to care.

States are addressing this need. For example, Minnesota's Children's Mental Health Screening grant, launched in 2022 by the Minnesota Department of Human Services, provides funding to counties and tribes across the state to conduct children's mental health screenings, targeting children ages three months to 17 years in Child Protective Services or ages 10 to 17 in the juvenile justice system. Currently, data is being collected in the Minnesota Social Service Information System to evaluate the impact of the grant and determine how much funding the awardees receive based on their reach.

High-risk populations are not limited to system-involved youth. In Montana, Governor Greg Gianforte announced a $2.1 million grant to fund free optional mental health and substance use screenings for all schools and same-day care for students flagged as being high risk for suicide. Of youth screened, nearly eight percent were identified with a recent high risk of future suicide, and of these at-risk students, 99.5% received same day follow up care by licensed clinicians.

Priority: Invest in crisis prevention and Response

A robust and multi-faceted crisis response system, with the requisite tools, processes and training for first responders, is a key component of crisis de-escalation and suicide prevention. The 988 Suicide and Crisis Lifeline, launched nationally in July 2022, forms an integral part of the crisis response frontline; however, Kaiser Family Foundation analysis shows that 988 in-state answer rates varied widely, ranging from a low of 51% to a high of 98%. This emphasizes the need for states to further integrate 988 into their larger youth mental health landscape to build a strong crisis response system with "someone to call," "someone to respond" and "somewhere to go," composing a comprehensive suicide and crisis prevention plan, including mobile response teams and community-based centers.
Opportunity: Allocate funding to ensure the 988 Suicide and Crisis Lifeline can effectively meet the needs of youth
State leaders can ensure that their local 988 systems have specific practices and training to respond to the unique needs of young callers. For example, in its 988 Implementation Plan published in 2022, Mississippiallocated $500,000 in SAMHSA grants and state appropriations to a Crisis Stabilization Unit for children and youth, including enhanced data collection and monitoring approaches for children at risk, and to develop an up-to-date referral approach to address the unique needs of the youth population.

States can also focus on underserved youth. Legislation enacted by Washington in 2021 requires its Crisis Improvement Strategy Committee to consider the unique needs of youth, including American Indian, Alaska Native and LGBTQ+ youth, and in 2022, Alaskawas awarded a SAMHSA grant to target 988 messaging to at-risk youth.
Opportunity: Build mobile and community-based youth mental health crisis response and stabilization services
Crisis response systems that are embedded in the communities in which youth live, work and play are a critical component of a robust continuum of care. Mobile crisis response teams of trained clinicians that can be deployed to a young person's home, school or other community location help stabilize youth and prevent hospitalization and incarceration and keep youth from harming themselves or others. Strong mobile crisis systems can further provide training for providers on youth-specific engagement strategies, highlight evidence-based models of care and facilitate connection to local providers. Over the past couple decades, states have been advancing these systems, particularly for youth.

Multiple states have statewide youth-specific mobile crisis programs. To highlight the outcomes of a few:

Connecticut's Department of Children and Families contracts with clinics throughout the state to provide no-cost statewide Mobile Crisis Intervention Services for youth under 18 years in-home and at school. Outcome reports have linked the crisis service to a 22% reduction in emergency department use, a reduction in student arrests by 40%, and higher functioning among youth after intervention.

Oklahoma's Youth Crisis Mobile Response is an integral component of Oklahoma's youth suicide prevention effort, providing rapid mobile mental health services including crisis stabilization, counseling, and connection to follow-up services. Oklahoma has diverted 78% of youth from inpatient care, had fewer calls to the police, a reduction in Medicaid costs, and a positive change in youth behavior and functioning.

Nevada's Youth Mobile Crisis Program provided 86% of youth with a safety plan, resulting in 92% of youth avoiding emergency stays four months post-response.

Opportunity: Implement state-wide suicide prevention plans throughout health care delivery systems and schools
There are central tenets to youth suicide prevention that can be adopted universally throughout the country, but it is also important for state leaders to consider their state's diverse populations, specific youth needs, and unique state assets and partners to tailor prevention plans to their state's youth. Relevant system stakeholders, including youth, need to be convened to develop and implement state-wide suicide prevention plans.

Nebraska's Suicide Prevention Plan, developed in partnership with The Kim Foundation in 2022, includes survey findings from over 500 diverse stakeholders from focus groups and online surveys. Once state-wide suicide prevention plans have been developed, state leaders can share guidance with counties and school districts on how best to implement them.

New York's Guide for Suicide Prevention in New York Schools provides best practices and resources for schools to implement suicide reduction through three tiers of universal, targeted and individualized interventions.

Launched in 2020, Ohio's Zero Suicide Pediatric Initiative is a partnership between the Department of Mental Health and Addiction Services, the Cardinal Health Foundation and the Children's Hospital Association to provide training to hospitals on evidence-based and promising practices for suicide prevention.

Pillar 2: Increasing Awareness and Reducing Stigma

Mental health is front and center for today's youth. By the end of 2022, TikTok videos with #mentalhealth had more than 45 billion views. According to the recent U.S. Surgeon General's Advisory on Social Media and Youth Mental Health, adolescents have been increasingly turning to social media for mental health advice, which can be both a safe space to find community as well as a source of harmful or misleading information. The number and diversity of mental health resources can be overwhelming as young people may not know where to turn for support and help. Additionally, individual, environmental or societal stigma can prevent youth from reaching out for assistance. A lack of understanding around the causes and symptoms of mental health can create stigma within youth and families, isolating youth who need help. Reducing stigma entails a whole family approach, and parents of youth with mental health concerns may also carry stigma or shame themselves. Increasing awareness of emotional well-being strategies and the spectrum of mental health needs improves our collective understanding and encourages young people and their families to seek information, recognize symptoms, learn about potential interventions and treatment, and access appropriate supports. Awareness can be promoted by educating young people and communities on mental health, promoting accurate and practical information and resources, and sharing personal stories of lived experience.

The existing leaders in this space are often youth themselves, and Governors can leverage the lived experience of youth to develop and improve policy that accurately reflects their needs. Younger generations are more comfortable talking about mental health than ever before, and Governors have the opportunity to build systems that are responsive to their concerns.

Priority: Include mental health education in school curriculums

Education helps to normalize mental health challenges and conditions that youth may experience. Including mental health as part of the school curriculum can help to standardize the level and type of content taught, and to ensure that it is age- and context-appropriate. Studies in the U.S. and Canada have shown that introducing mental health curriculum significantly predicted increases in positive attitudes toward mental health and reduced stigma.

Opportunity: Provide guidance and oversight for mental health curricula taught in schools
In 2018, New York and Virginia were the first two states to require mental health education in schools. Although some states encourage mental health curricula, the majority of states today have mandated it in either statute or regulations. For example, in 2019, Maine enacted legislation that requires mental health curriculum for K-12 that includes instruction in mental health and the relationship between physical and mental health to reduce the stigma associated with mental illness. Mandates are very important but should be supported with guidance and oversight from state leaders to ensure effective mental health education is taking place.

For example, New York's School Mental Health Resource and Training Center helps schools to comply with its law by providing a Mental Health Education Readiness Guide to evaluate existing curriculum content as well as lesson plans. To assess the implementation of mental health curricula in schools, the New York State Comptroller performed an audit of school districts, finding variation in the materials between districts and the need for a formal mechanism to monitor implementation going forward. South Carolina's Department of Education provides materials and standards for mental health curricula from seventhgrade onwards.
Opportunity: Orchestrate partnerships with state and academic groups to develop mental health curricula material
One way that states can support curricula implementation is through creating partnerships to develop robust materials. This can alleviate the pressure on school administrators to develop material themselves and help to promote age-appropriate and consistent quality across school districts. States can do this in different ways:

Massachusetts's Comprehensive Health Curriculum Framework was revised in 2019. The state Department of Education worked on this revision with a multidisciplinary committee in partnership with the Massachusetts Department of Elementary and Secondary Education, the Massachusetts School Psychologists Association and the Massachusetts School Counselors Association.

A Utah law enacted in 2022 requires the development of a youth behavioral health curriculum by the Education Department in conjunction with the University of Utah's Huntsman Mental Health Institute. The multi-year program will draw on expertise from psychologists and trained educators at the Huntsman Institute to help students manage their mental and emotional health into adulthood. Utah dedicated $600,000 to develop and disseminate the curriculum to elementary and secondary schools in the state.

Priority: Reduce stigma through promoting dialogue and creating safe spaces

Compared to previous generations, young people today are much more open to talking about their mental health and want to play an active role in reducing the social, self and structural stigma surrounding their mental and emotional health. However, youth mental health stigma is a reality across different settings. Within the home, a cultural disconnect or generational divide can make it difficult to talk about mental health, and outside the home, misconceptions continue to pervade attitudes in schools and colleges, places of worship and workplaces. There is a lot that state leaders can do to promote acceptance of mental health challenges and conditions, encourage young people to talk about them, and create avenues - digital or in person - for youth to turn to when they need help.
Opportunity: Invest in anti-stigma campaigns to reach youth populations through diverse and inclusive messaging
Research from Tulane University showed that 90% of teenagers who are taking psychiatric medications displayed at least one of the three measured stigma themes: secrecy, shame and limiting social interaction. Effective anti-stigma campaigns incorporate the lived expertise of the youth they serve to build culturally relevant programs that address the realities of the communities in the state. States regularly launch anti-stigma campaigns, for example:

Georgia's 2022 #FreeYourFeels campaign encourages youth to share their real feelings online, and Tennessee's educational website shares information about the different types of stigma and the importance of confronting it.

Ohio's "Life is Better With You Here" campaign aims to reduce the high suicide rate of Black youth with pop-up events established in communities and colleges.

Opportunity: Champion the use of digital tools as safe spaces to enable students to report mental health issues and be connected to help
Adolescents may feel more comfortable sharing their mental health issues, or those of their peers, anonymously in digital spaces. State leaders can consider developing and supporting digital tools for use in schools; importantly, apps need to be integrated into the system of care so that youth's concerns are taken seriously and, if appropriate, they can be connected to clinical help. Further, states can periodically monitor and evaluate outcomes from these platforms to determine which digital tools are most effective in reaching youth and connecting them to the right services and supports for their needs.

Colorado's iMatter program, established in 2021 through legislation that initially appropriated $9 million in state funding, includes an online screening tool for youth up to age 21, provides up to six free virtual therapist visits, and has successfully engaged youth and delivered services.

In 2019, when serving as attorney general, Pennsylvania Governor Josh Shapiro launched Pennsylvania's Safe2Say Something, a $1.6m partnership funded by the State and Sandy Hook Promise. Although built for the purpose of reporting possible threats of school violence, approximately 75% of the first 100,000 tips have been about mental health issues. More than 26,000 tips were received in the 2021-2022 school year, an increase of 140% year over year.

Utah's SafeUT app connects students, parents/guardians and educators with licensed counsellors from the University of Utah's Huntsman Mental Health Institute to share any crisis or concern 24/7. Funded by the state and developed via a public-private partnership, over 95% of all Utah K-12 schools and universities have been enrolled in SafeUT with over 880,000 students having access to the app. From 2021 to 2022, SafeUT received over 25,000 total chats and tips along with one million back and forth chat messages.

Priority: Meaningfully include youth and community voices

Listening to the lived experience of youth and their communities and engaging them in policy development enables more relevant action from Governors and other state leaders. Community-based organizations are often well-trusted and have a deep knowledge of the needs of the people they serve and knowledge of how best to address them.
Opportunity: Include young people in the development of youth mental health programs and policies
Those with lived experience of mental health problems should have a real seat at the table, not only when problems are being discussed, but also when programs are being designed and decisions made. Many states and territories have a youth council:

Vermont's State Youth Council advises the Governor and general assembly on issues including mental health, education, equity and climate change. Maryland's Youth Advisory Council also jointly advises the Governor and state legislature. Arizona's Governor's Youth Commission has five workgroups dedicated to distracted driving, domestic violence, mental health, education and substance use. American Samoa's Youth Council meets monthly and serves as the voice of youth to the government.

Valuing the expertise that comes from lived experience, state leaders can look to reimburse youth for their contribution. For example, Nebraska's Student Advisory Board of the Behavioral Health Education Center has established paid leadership opportunities for students of color pursing a degree in behavioral health to contribute their perspectives on state health care policies.

Opportunity: Consider diverse perspectives from youth-focused community organizations
It is important to ensure that community organizations have a seat at the table on advisory and other committees to incorporate their valuable perspective. Funding the work of existing community-based organizations' youth mental health efforts is another way to drive impact; solutions to the youth mental health crisis exist within communities, and there is a lot that state leaders can do to elevate them.

Pillar 3: Ensuring Access and Affordability of Quality Treatment and Care

According to recent data from the CDC, 15% of children aged 5 to 17 had received mental health treatment within the past year. On average, according to the National Alliance on Mental Illness, it takes 11 years after the onset of mental health symptoms for individuals to receive treatment, and access and affordability challenges contribute significantly to this delay. Ensuring access requires public and private coverage across the continuum of quality youth mental health services, treatment and care to be available where and when required (with appropriate treatment pathways and referral loops), sufficient capacity for inpatient, outpatient and intermediate services in brick-and-mortar settings and in staff, and the use of telehealth and digital tools where appropriate to increase convenience and minimize wait times. Increasing affordability means that young people in need receive treatment regardless of insurance coverage and acuity, means there is parity between benefits and coverage for physical and mental health, and means reimbursement approaches incentivize appropriate and high-quality care. High-quality care is also enabled by integrated systems with well-coordinated handover points.

It is important to note that this pillar focuses on access to quality care. For the purpose of this Playbook, high-quality care is care that effectively meets the needs of each youth, as determined by the youth, their family and their care team. Governors and state leaders have the opportunity to identify and prioritize high-quality care within their states by listening to the voices of youth, families, providers and community leaders, and by collecting data on key metrics to assess the outcomes of care strategies and the value they offer to families.

Priority: Champion mental health care coverage and parity

Accessibility of mental health care is often related to the affordability of that care. Medicaid agencies and commercial insurers play a critical role in increasing access to and parity for mental health care, but gaps remain due to insufficient reimbursement rates across public and commercial insurance and high out-of-pocket costs. High out-of-pocket costs for treatment can add to the burden for families struggling with mental health concerns, made worse for those who are uninsured or underinsured. However, robust access to affordable care cannot exist without a sufficient pipeline of youth-focused mental health workers as addressed in another priority.
Opportunity: Bolster Medicaid and CHIP coverage for and access to mental health care for eligible young people
Medicaid is vital to the health and wellness of young people and covers 35 million children across the country, over 40% of its entire enrollee population. By expanding Medicaid to cover a full range of medically necessary services from prevention to crisis care, states can supplement and amplify their investments in youth mental health. Encouraging provider acceptance of Medicaid through increasing reimbursement rates for mental health services is particularly important for vulnerable youth.

Multiple states have enacted Medicaid State Plan Amendments to allow schools to bill for all medically necessary services provided to Medicaid-enrolled students, including all treatments required under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) mandate. The EPSDT mandate requires states to provide comprehensive health care services to children and adolescents who are eligible for Medicaid. Personal care services, transportation and applied behavioral analysis can be billed to Medicaid in a school-based setting as needed. Recent federal guidance from the Center for Medicare and Medicaid Services (CMS) provides new flexibility to cover a range of school-based mental health providers increasing access to mental health care services.

The Healthy Schools Campaign provides information on the multiple states that have enacted Medicaid State Plan Amendments to allow schools to bill for all medically necessary services provided to Medicaid-enrolled students, including all treatments required by the EPSDT Program.

Another barrier to care can be the requirement to have a formal mental health diagnosis in order for services to be covered. If certain criteria are met, Californiaand Massachusetts allow youth to access Medicaid mental health services without requiring a diagnosis, thereby reducing stigma and other barriers to youth getting therapeutic support.

Throughout this Playbook, several state programs that leverage Medicaid funding in innovative ways are highlighted. The landscape and needs of each state are different, and Governors have the opportunity to encourage state agencies to leverage Medicaid to best fit their state's needs.

Opportunity: Enforce parity from payors for physical and mental health services
According to Mental Health America, 1.2 million youth covered under private insurance do not have coverage for mental health care. This is despite federal legislation passed in 1996 (the Mental Health Parity Act) and 2008 (Mental Health Parity and Addiction Equity Act) that requires insurers to cover mental health and substance use disorder benefits under the same terms as physical health benefits, following which 37 states have enacted laws codifying similar requirements at the state level. A report from the Council of State Governments highlights leading states' efforts to shape coverage, provide a model for federal legislation, facilitate implementation of federal laws and ensure insurance market compliance. However, challenges still exist with compliance efforts on parity. States can encourage federal regulators to allow states to lead in ensuring plan compliance with mental health parity laws and implement state-level legislation and regulation to drive parity. Robust mental health agendas rely on partnerships within and outside of the public sector, and Governors have the opportunity to build collaborative partnerships with health insurance organizations to create a statewide vision on strengthening youth mental health.

New York's State Office of Mental Health Parity Compliance Toolkit supports the understanding of mental health and substance use disorder parity among insurers, providers and consumers by providing definitions and resources surrounding the Mental Health Parity and Addiction Equity Act in state context. New York State has also conducted rigorous analyses of Medicaid managed care plans' parity compliance.

Texas'sHB 2595, signed into law in 2021, created a parity complaint portal with basic tracking and reporting features to ensure an enrollee's complaint can be filed and followed up on, and requires annual reporting of parity metrics.

Arizona's Jake's Law prohibits insurance companies from denying coverage for services covered by a plan because they are delivered in an educational setting, created the Children's Behavioral Health Services Fund and provided $8 million for behavioral health services for children who are uninsured or underinsured. It also requires health plans to submit parity compliance analyses to the state.

Massachusetts legislation enacted in 2020 requires coverage for same day care, specifically prohibiting insurers from denying coverage for mental health services and primary care services solely because they were delivered on the same day in the same facility.

Priority: Grow and diversify the mental health workforce

The national shortage of youth mental health professionals across all specialties, credentials and geographic regions continues to impede access for youth to treatment and care. According to a policy brief from the University of Michigan School of Public Health, the U.S. needs more than 28,000 additional child and adolescent psychologists by 2030, an increase of over 25% of today's workforce. These shortages particularly impact intensive outpatient programs or specialized care, rural communities and low-income urban areas.
Opportunity: Expand pathways and entry points into the youth mental health field
The NGA Center for Best Practices is working with over 20 states in the Next Gen Healthcare Workforce Project and Knowledge Exchange Network to strengthen and expand the next generation of healthcare workers, including for mental health. Young people in high school and college can be educated and inspired to follow a career in mental health, both clinical and non-clinical, but action is also needed to support these career paths through programs including loan repayment models and apprenticeship opportunities, notably to incentivize service provision in under-resourced areas.

Many states are testing out different approaches to incentivize and develop the mental health workforce of the future:

Michigan's student mental health apprenticeship retention and training (SMART) internship grant program provides a $25 per hour stipend (up to $15,000 annually) for psychologists-in-training during their field education in public schools.

Oregon's Mental Health Emergency Act diversity initiatives provide incentives to retain BIPOC and rural behavioral health providers and encourage them to practice in underserved areas to help eliminate health disparities.

Georgia's Transformative Experiential Training grant aims to place a gender-, racially- and ethnically diverse group of trainees in a hub-and-spoke model to link interdisciplinary specialist teams virtually to serve high need areas.

Loan repayment is also an impactful lever. Behavioral health professionals in New Jersey can have up to $150,000 of their student loan balance paid off in exchange for six years' work at an approved community provider, and those who primarily work with children and adolescents can receive supplemental grants up to $30,000. Texas's and North Dakota's loan repayment programsalso encourage mental health professionals to practice in provider shortage areas.
Opportunity: Review licensing regulations and requirements for mental health professionals to reduce barriers to practice
According to the American Academy of Child and Adolescent Psychiatrists, child and adolescent psychiatrists are unevenly distributed across the map. Ratios per 100,000 children range by state from four to 65, with a national average of 14, compared to the required 47. Exacerbating this uneven distribution are administrative burdens that mental health professionals face in obtaining licenses to practice within their state and especially across states, limiting their ability to provide care to youth in need. Cross-state practice is particularly important for military families and college students who often move across state lines as well as for youth of color seeking a mental health professional who looks like them.

Minnesota legislation enacted in 2022 establishes a workgroup including mental health providers from diverse cultural communities and representatives from graduate programs to identify barriers to licensure, collect data on the number of individuals graduating but not passing licensing exams and develop recommendations for creating alternative pathways for licensure in mental health professions.

The Psychology Interjurisdictional Compact (PSYPACT) is another interstate compact designed to facilitate the practice of telepsychology and the temporary in-person, face-to-face practice of psychology across state boundaries, with 39 current effective state members.

Opportunity: Train pediatric primary care physicians to provide youth mental health care and support linkages to specialty care providers to amplify reach
Integrated care models for youth mental health care can help to mitigate the shortage of specialist clinical providers and provide patients with more coordinated care. Increasing the competency and capacity of primary care providers (PCPs) on youth mental health, notably screening and early identification, enabling the co-location of both mental and physical health services and connecting PCPs with psychiatrists, psychologists and other behavioral health professionals are ways that states can better equip PCPs to respond as appropriate to the significant number of young people in need. States can also expand consult lines to support primary care providers with mental health screening, treatment plan development and prescribing.

New York's Project TEACH provides training to providers who treat children and adolescents to assess, treat and manage mild-to-moderate mental health concerns.

Washington provides grants to primary care practices serving children and youth to establish behavioral health integration, including training, technology support, physical space modifications and recruitment of behavioral health professionals.

Oklahoma's Project ECHO is a hub-and-spoke model that educates local providers about providing pediatric mental health care, often in under-served areas. A specialist team disseminates best practices through case-based learning and upskills PCPs through guided practice.

Missouri'sChild Psychiatry Access Project (MO-CPAP) connects PCPs to mental health coordinators or child and adolescent psychologists. Among the 400 enrolled PCPs, nearly all reported improved patient care, and all said that they would use the service again if needed. In 2022, MO-CPAP expanded to schools.

The U.S. Health Resources and Services Administration (HRSA) has a Pediatric Mental Health Care Access Program that provides funding and technical assistance to states, regions, territories and tribal partners to support providers working with children in primary care practices, schools, emergency departments and other settings to help children with mental health conditions.

Opportunity: Diversify the pipeline of youth mental health professionals to better reflect the communities in which they operate
According to 2021 data from the American Psychological Association, about 81% of the U.S. psychology workforce is white. Although this share is decreasing, the workforce lacks adequate representation of people of color, LGBTQ+ people and people with disabilities. The demand for diverse mental health professionals - notably those with a youth focus - far outstrips the supply, and there are often long waitlists for people in need to see a psychologist or psychiatrist who shares their cultural background and lived experience.

Massachusetts'sMental Health Workforce Pipeline Pilot Programaims to foster a culturally, ethnically and linguistically diverse behavioral health workforce. In 2022, legislation was enacted requiring the State Board of Professional Counselors and Therapists, the State Board of Examiners of Psychologists and the State Board of Social Work Examiners to have at least three members who are from underrepresented communities. Colorado's new Behavioral Health Administration created a multi-faceted plan to increase and diversify the behavioral health workforce through funding appropriated from the American Rescue Plan Act. The agency is designed to be the single entity responsible for driving coordination and collaboration across state agencies to address behavioral health needs.
Opportunity: Require mental health professionals to complete cultural competency trainings
Cultural competency training is especially important when considering that a person's perception of mental health, including stigma, is often influenced by their cultural identity and social value. According to the American Psychological Association, nine states mandate psychologists to complete a course in equity, diversity and inclusion as part of their continuing education requirements. A number of states have cultural competency training requirements for a broader set of clinicians, including:
Opportunity: Fund peer-support models for youth mental health
Peer support models have gained significant traction nationally, and adolescent brains are especially responsive to peer influence, which can be highly beneficial in terms of youth mental health if teenagers' peers have been trained to support. Children and adolescents are also often more likely to take their concerns to a friend than an adult. Governors can help equip youth with the tools to offer protective and effective support to their peers.

According to SAMHSA, 49 states have established certification for peer support specialists.California and New York legislation allow certified youth peer support services to be reimbursed through Medicaid. North Carolinalaunched NC Voices Amplified in 2022 to provide training, technical assistance and other resources for an expanding workforce of family and youth peer support providers across the state. Georgia's Certified Peer Specialist - Youth designation is a young adult between the ages of 18 and 30 certified by the Department of Behavioral Health and Developmental Disabilities who has lived experience of either a mental health condition and/or substance use disorder as a youth and is practicing recovery as related to that condition. Wisconsinhas over 200 schools with student-led peer support wellness programs.

Priority: Break down barriers to access for youth and families

Today's youth mental and behavioral health landscape is fragmented and uncoordinated, and young people and their families are forced to be extremely resilient and resourceful to access care. Even when services are available, access challenges including finding transportation and balancing competing needs can delay receiving treatment. Practices such as prohibiting payment for medical and mental health services on the same day for the same patient fragment care and impede integrating medical and mental health care. Strong community- and school-based systems, with accessible patient pathways, can prevent escalation that would require utilization of crisis and/or inpatient services.
Opportunity: Ensure clear entry points, case management, and handovers within the youth mental health system
A significant driver of the youth mental health crisis is the complexity of the system, which often creates insurmountable challenges for families seeking treatment for their children who are at risk of "falling through the cracks" when shifting from one acuity level to another. Lack of communication between mental health systems and schools and primary or specialty care physicians may hinder effective post-acute care and result in potentially preventable readmissions.

Illinois's Children's Behavioral Health Transformation Initiative launched in 2022. It recommended the development of a centralized "Care Portal" as a resource for families to seek cross-agency mental health services. It also recommended conducting regular data reviews to inform capacity adjustments (i.e., number of psychiatrists or counselors needed in an area) and implementing resource referral technology for increased patient access.
Opportunity: Support the use of telehealth in relevant settings
Building the capacity and infrastructure for mental health services can be a challenge. The systems that enable advancements in digital mental healthcare have not kept up with the surging demand for care, and innovation can be blocked by a lack of infrastructure or burdensome and outdated regulations. Telehealth can be a powerful tool to provide culturally-representative, affordable and stable care. Access to telehealth offers unique benefits to transient youth, like college students, those in military families, the foster care system or in rural and underserved areas. Telehealth can be leveraged in home- and community-based services and can also be a critical tool for schools. According to the Institute of Education Sciences, in 2022, 17% of public schools had implemented some form of telehealth services, a number that is expected to grow as more students seek mental health services post-pandemic.

Texas provides telehealth and telemedicine services in schools through the Texas Child Health Access Through Telemedicine (TCHATT) program and to primary care providers through the Child Psychiatry Access Network (CPAN).

New Jersey dedicated $26 million in funds from the American Rescue Plan Act to support access to mental health care for college students, including $10 million for a statewide tele-mental health partnership with Uwill to provide all students at all public and independent institutions with a public mission in the state with access telehealth services for free.

South Dakota released guidance on how school districts can integrate free telehealth services in schools through a partnership with the Department of Social Services and the state's Community Mental Health Centers. South Dakota's Juvenile Justice Reinvestment Initiative offers family-based therapy, aggression replacement training, and substance abuse treatment through telehealth for justice involved youth.

Mississippi is providing access to school telehealth services statewide starting August 2023 through a $18 million telehealth grant approved by the Mississippi Department of Education for University of Mississippi Medical Center.

Pennsylvania has entered into a $3 million one-year contract with Kooth, a digital mental health platform, to provide free telehealth services to 30 school districts across the state.

Wisconsin Governor Tony Evers awarded $2.5 million in American Rescue Plan Act funding to five organizations to increase access to child telepsychiatry services

Opportunity: Create and support youth centers that provide mental health services in their communities
Children and adolescents often rely on clubs, organizations, sports teams and safe spaces within their communities to go to after school. These spaces can be highly suitable to provide appropriate mental health supports, such as counselling, and to connect youth to care in more acute situations.

Priority: Provide mental health services in schools to meet youth where they are

There is an opportunity to meet children where they are: in school, for seven hours a day, five days a week. Established and often well-trusted relationships between schools, families and community-based organizations can facilitate appropriate resources and services. Data from the U.S. Department of Education shows that 96% of all public schools reported offering at least one type of mental health service. However, according to Effective School Solutions, only 40% of school administrators said they were highly confident to tackle mental health challenges.
Opportunity: Increase the number of school-based mental health providers
Research has shown that embedding mental health services into schools reduces the stigma of accessing services, increases mental health care utilization and improves overall youth mental well-being. States are focusing on increasing the number of mental health professionals within schools. For example:

Delaware established a three-year phased approach to reach a ratio of one full-time school counselor or social worker for every 250 students and one full-time school psychologist for every 700 students in grades K through eight.

New Mexico has a five-year plan to hire over 400 school-based mental health providers in public schools, with a strong focus on addressing equity gaps in mental health options for Indigenous students and those who live in rural areas.

U.S. Department of Education is supporting states' efforts to expand school-based mental health providers through $188 million in funding from the Bipartisan Safer Communities Act.

Opportunity: Build capacity through school-linked partnerships with community providers
Schools cannot do this alone; they need administrative support and capacity expansion through connection to community-based services. These strategies can be employed not in place of outpatient or clinical care, but alongside it, to build a robust scale of services.

Alabama addresses this "top down," requiring a school mental health service coordinator in every school district, to set up mental health awareness events, hold small group sessions with students and connect families with professional mental health services.

Kansas's Mental Health Intervention Team program links local education authorities with community mental health centers and provides a system of payments and outcomes data reporting through the State Department of Education. Outcomes from the pilot year indicated over 1,700 students served through the program and improvements in academics, attendance, behavior and overall school climate.

Georgia'sAPEX program is a partnership between community mental health providers and local school districts to provide mental health services for K-12 students. The program has provided first-time mental health services to approximately 14,000 students.

Pillar 4: Training and Supporting Caregivers and Educators

Caregivers and educators play a vital role in supporting young people's mental well-being by observing warning signs of mental health challenges and conditions and steering young people to care before crisis point is reached. However, they cannot do this unsupported. Youth-facing adults need to be trained to recognize symptoms and appropriately react in a supportive manner. Currently, there is significant variation in mental health literacy across caregivers and educators who face difficulty with their own mental and emotional health management, especially after the COVID-19 pandemic. The country is also simultaneously experiencing increased rates of educator burnout. An ideal target state is one in which all caregivers and educators are empowered to appropriately support young people with their mental health needs, workplace accommodations, community support, accessible and affordable care for themselves, and relevant in-home, in-community, and in-classroom services.

Priority: Provide resources and services to empower and involve caregivers

Parents and guardians play a fundamental role in developing their children's mental well-being and supporting them when they are facing challenges. Caregivers know their children best but can use help to understand how to talk to their children about mental health, recognize and respond to changes in behavior at home, and what to do about them. Caregivers also face significant barriers when navigating the complex mental health system to secure care for their child. In a study investigating perceived barriers to access to youth mental health care, parents commonly reported lack of information and issues with health care professionals taking them seriously or referring them to specialized supports.
Opportunity: Share and expand supports to help caregivers manage their children's youth mental health challenges
Eighty-five percent of parents in the U.S. are worried about depression negatively impacting the lives of their teenage children according to research done in 2022 by the Kaiser Family Foundation. Having a child with a youth mental health challenge can be stigmatizing due to misconceptions and caregivers can benefit greatly from peer support from those who have been through similar experiences.

Montana's Department of Public Health and Human Services distributed $1 million in innovation grants to engage family members of youth served through the state children's mental health system and who are facing out-of-home placement. The funds focused on improving the engagement, involvement, and capacity of families to provide for the care and support of their child following any out-of-home placement as well as improving ways to engage family members in community- and home-based care to prevent the need for out-of-home placement.

The District ofColumbia's Parent Support program launched in 2019 and includes a monthly online support group offered via video call in English and Spanish. There is also a mental health hotline for parents to speak with licensed clinicians for immediate support to discuss coping strategies, address crisis situations and resolve family stressors. The program also has a bilingual on-demand video library. In 2021 alone, this group provided webinars to approximately 2,000 individuals and 2,500 outreach services to individuals and created a website of English and Spanish resources for parents to use to support their well-being.

Ken t ucky's Family to Family Health Information Resource Centers offer mental health support through health consultants, with peer liaisons available for conversation and support in accessing services including formal support groups.

Louisiana's Be Engaged Birth-12 Framework provides a roadmap for effective engagement between schools and caregivers, highlighting family engagement opportunities throughout a child's progression from early childhood through high school.

In late 2022, the West Virginia Department of Health and Human Resources Kids Thrive Collaborative launched weekly virtual sessions for parents and caregivers of children to share information on community-based mental and behavioral health services.

Opportunity: Create holistic systems of care that include culturally relevant wraparound support for caregivers and integrate caregivers in mental health care to improve youth outcomes
Caregivers need information and support, but they also need effective and holistic systems of care that include them in the care and treatment journey. Systems of care help families navigate this journey without expecting them to "quarterback" it. Multiple states have an integrated system of care to support this, for example:

New Jersey's Children System of Care (CSOC) offers care for all youth in New Jersey aged 5 to 21, at no cost to the family, regardless of insurance status or income. Funded through a combination of Medicaid, state funding and family insurance when available, CSOC includes care management organizations that holistically help families identify needed care and family support organizations that act as peer supports for parents. Care provided for youth includes in-community, in-home, and out-of-home treatment and support, including Mobile Response and Stabilization Services and respite care for families with youth with intellectual and developmental disabilities. Evaluation data has shown that 93% of families receiving CSOC services have a better understanding of their youth's needs, and 94% feel better able to navigate and manage their youth's mental health needs.

Idaho's system of care, Youth Empowerment Services (YES), includes a Child and Family Team that partners with a family and youth to create a coordinated care plan across all health providers in the youth's community. Eighty-three percent of parents state that the program empowered their family as the main decision-makers about care and 76% said providers were acting in a beneficial manner for youth. Youth receiving court-ordered mental health services has decreased by 48% in Idaho since the launch of YES.

States can fund evidence-based training centers to ensure caregivers and families have the proper skills to deliver quality care that is safe. In Maryland, the Maryland Coalition of Families provides robust training opportunities for parents and caregivers to support their navigation of the mental health services and advocacy for an improved system of care.

Priority: Equip educators and communities to support youth mental health
Young people are in day-to-day contact with various people outside their families who can play a critical role in their mental health. Educators are key youth-serving adults due to the frequency of interaction with their students, but the "village" includes faith leaders, sports coaches and a host of others who have regular contact and connection with children. Educators and community leaders are often the first lines of defense in recognizing the symptoms of mental health challenges in youth and can play a pivotal role in supporting their mental well-being and connecting them to care.
Opportunity: Equip educators to recognize warning signs of mental health challenges in their classrooms
Early identification of mental health challenges is not only key to preventing mental health decline and crisis among youth; behavioral issues in the classroom or poor academic performance often stem from or are otherwise connected to students' mental health. By equipping educators and other school staff to identify mental health needs, state leaders can help improve academic achievement, classroom environments, and both student and educator success and well-being. For example:

North Dakota's Department of Health and Human Services' Behavioral Health Division has made online, role-playing simulation technology available to help school personnel recognize signs of distress and models conversations for approaching students and discussing concerns, as well as making referrals for both parents and students to appropriate resources.

Rhode Island, enacted legislation in 2021 that requires the Department of Education to adopt rules and regulations supporting annual suicide prevention and training for public school personnel, including educators, administrators, custodians, lunch personnel, substitutes, nurses and coaching staff (including volunteers).

In South Dakota,all educators and education professionals are required to participate in a minimum of one hour of suicide awareness and prevention training. The state Board of Education identifies evidence-based resources that fulfill suicide awareness and prevention training requirements and make these lists available to school districts.

Opportunity: Provide resources for educators to support their own mental health needs and cope with burnout
Educators are often exhausted and underprepared to support students' mental health, especially in the era following the COVID-19 pandemic, while also coping with their own stressors. An early 2021 survey by the RAND Corp. found that educators are almost twice as likely to experience frequent job-related stress and nearly three times as likely to experience symptoms of depression than the general population. Educators need support to manage their own mental health so that they have the capacity to help their students to do the same. Some states have done this through legislation:

Illinois law enacted in 2022 requires all school districts to include mental health as part of their current negotiated sick days for full-time employees of the district. Two days are currently allowed, but more may be permitted with a note from a mental health professional.

States can also support educators through providing resources. As of 2023,Hawai'iprovides free mental health resources for stress, anxiety and depression via a confidential, clinically-validated app based on the principles of cognitive behavioral therapy, mindfulness and meditation. The app provides resources such as daily mood tracking, guided journeys, coping tools, meditations, progress assessments and the ability to reach out to an anonymous community of peers for support.

Opportunity: Support faith- and community-based mental health training and programs
Every young person affected by mental health challenges should be surrounded by a community that cares. According to SAMHSA, many people turn to trusted leaders in their communities before they turn to mental health professionals. Recognizing this, the U.S. Department of Health and Human Services' Center for Faith-based and Neighborhood Partnerships published a guide on youth mental health and well-being in faith and community settings. Faith leaders should be equipped through training and resources to play a positive role in reducing the stigma around mental health in their communities and helping young people to navigate care.

States can empower faith leaders in different ways. One example is Missouri's Bridges to Care and Recovery program, which aims to mobilize churches in St. Louis's African-American faith community to support behavioral health assessment, treatment and recovery. "Church engagement" requires congregants to complete 19 hours of training to receive the designation of "behavioral health friendly" church, with monthly meetings and further trainings for ongoing support. "Wellness champions" are also supported through the program; these are faith-based volunteers who have completed at least 14 hours of training and have made a commitment to reduce the stigma of mental health conditions.

Way Forward and Supporting Next Steps

Despite the challenges that lie ahead to reverse the downward trajectory of youth mental health and strengthen the complex systems across the country, significant progress has already been made by states to identify and implement solutions that make a difference in the quality of young people's lives and those of their families and wider communities.

When developing the framework for the 2022-2023 Chair's Initiative, New Jersey Governor Phil Murphy identified four themes that became the pillars of the work: addressing prevention and building resilience, increasing awareness and reducing stigma, ensuring access and affordability of quality treatment and care, and training and supporting caregivers and educators. These pillars represent a comprehensive effort to capture the urgency and scope of this issue. Strengthening Mental Health: A Governor's Playbook is the culmination of the 2022-2023 NGA Chair's Initiative, but the policy, advocacy and program work of a multitude of public and private sector organizations will need to continue and adjust to changing circumstances for years to come. Governors have the opportunity to protect and cultivate the wellness of youth in their state and build a stronger path to a healthy future.

This Playbook offers a set of emerging best practices across the four pillars, though it does not, as it cannot, represent all of the innovations that states are spearheading around youth mental health. Strong mental health agendas incorporate and elevate the voice of youth, and valuing their lived expertise is critical to create a system that reflects their needs. The data speak for themselves; children and youth of all ages are struggling, and some are hurting worse than others. Each youth's journey with their mental health and well-being is unique, and each state has its own landscape and priorities. Governors have the opportunity to devote time, attention and resources to develop supports for youth of all needs - saving the lives of our most vulnerable youth and championing a holistic system around mental wellness.

The current concerns around youth mental health may seem daunting, but there is so much hope. Innovators driving meaningful change in youth mental health are already embedded in schools, leading advocacy and community organizations, serving as health care providers, steering insurance organizations, celebrating their high school graduations and leading states as Governors. The National Governors Association and Governor Murphy are grateful to have connected with many of them in the development of this Playbook and will continue to elevate their invaluable expertise.

The goal of this Playbook is to offer a starting point for Governors to implement change in their own states; these pillars only stand if we build something to support them. If a Governor's office is interested in any of the priorities, opportunities or examples highlighted above, they can visit the NGA website for additional state examples and resources from the Chair's Initiative thought partners. Policymakers can also reach out to the NGA team for support. The National Governors Association exists to serve the needs of all 55 Governors in the states and territories, and NGA looks forward to supporting the states' work to strengthen youth mental health and wellness for years to come.

Acknowledgements

The National Governors Association and Governor Murphy would like to thank the funders, partners, thought leaders and organizations that contributed to the Chair's Initiative and this publication and volunteered time to take learning calls, speak at events, and offer clarifying and valuable policy insight. All of those who joined in the four convenings and spoke on panels and in roundtable discussions provided incredible perspectives to the Governors and advisors in the room and altogether made this Playbook possible. They are some of the brightest changemakers in youth mental health, and the NGA, Governor Murphy and the project team are incredibly grateful for their time and remain in admiration of their work.

Accenture

AHIP

Amazon

American Psychological Association

Annie E. Casey Foundation

Boston Consulting Group

Biogen

Blue Cross Blue Shield Association

Children's Hospital Association

CVS Health

Deloitte

Elevance Health

Effective School Solutions

Everytown for Gun Safety

Funders for Adolescent Science Translation

Gilead

Inseparable

Johnson & Johnson

Kaiser Permanente

Kennedy Forum

March of Dimes

Maximus

McKinsey

Mental Health America

Merck

Meta

Organon

Penner Family Foundation

Perigee Fund

Pfizer

Philips

Pritzker Children's Initiative

Robert Wood Johnson Foundation

Sanofi

Walmart

Western Governors University

W.K. Kellogg Foundation

Project Team

Timothy Blute, Director for the NGA Center for Best Practices

Jordan Hynes, Director of the Children and Families program at the NGA Center for Best Practices

Jessica Kirchner, Policy Analyst for the Children and Families program at the NGA Center for Best Practices

Brianna Keys, Senior Policy Advisor, Office of New Jersey Governor Phil Murphy

Laura Console, Senior Policy Advisor, Office of New Jersey Governor Phil Murphy

Alex Hermann, Director of Federal Affairs, Office of New Jersey Governor Phil Murphy

Colleen Desmond, Managing Director and Partner, Boston Consulting Group

Dr. Jonathan Lim M.D., Managing Director and Partner, Boston Consulting Group

Jessica Bester, Project Leader, Boston Consulting Group

Strengthening Youth Mental Health: Training And Supporting Caregivers And Educators

In response to rising rates of mental health distress among young people, NGA Chair New Jersey Governor Phil Murphy introduced his NGA Chair's Initiative last July. Through the Strengthening Youth Mental Health initiative, Governors from across the nation are collaborating to develop bipartisan solutions.

The fourth and final roundtable of the National Governors Association 2022-2023 Chair's Initiative on Strengthening Youth Mental Health was held in Philadelphia, Pennsylvania, on May 18, 2023. NGA Chair New Jersey Governor Phil Murphy and First Lady Tammy Murphy were joined by Pennsylvania Governor Josh Shapiro and First Lady Lori Shapiro, Delaware Governor John Carney and state representatives from Louisiana, New Jersey, Pennsylvania, and Virginia. Conversation centered on the role states can play to enable and equip a wide range of caregivers and educators with training and tools to support youth mental health.

The roundtable opened with a conversation with Goldie Hawn, Academy Award winning actress and founder and CEO of the Hawn Foundation. The Hawn Foundation's signature program, MindUP, aims to help children and their families better understand the brain science behind resiliency and develop tools to manage emotions and stress. Ms. Hawn spoke on the importance of teaching youth that they can have agency over their mental health and providing them the tools to do so.

State Policy Solutions Discussed At The Roundtable Include:

Educator And Community Training And Support

To expand youth support structures, Governors and state leaders can implement policies and programs to:

Offer culturally competent trainings for a range of school staff and youth-facing adults on how to identify and respond to risk factors and warning signs of earlier mental health and substance use disorders

Build awareness around available care and resources for youth facing adults

Implement trauma-informed and culturally competent approaches within spaces like schools, after-school organizations, extra-curricular activities and sports teams

Coordinate sustainable funding for school-based mental health supports, including leveraging federal funds, such as Medicaid

Create evidence-based guidance and standards for the design and implementation of youth mental health services within schools, using multi-tiered systems of support (MTSS) as a framework

Support educators' ability to address their own mental health challenges and avoid burnout by investing in mental health resources and benefits for staff members

Ensure faith leaders, out-of-school programs, sports coaches and other youth-facing adults have a voice in policymaking conversations

Create relationships with and elevate the voices of "wellness champions" within faith-based and other communities

Incorporate youth peer support models by creating youth peer support specialist certifications and adding-on youth and young adult training for current certified peer support specialists who support young people

Grow the school mental health workforce by implementing licensing changes to target key shortages and introducing or expanding school mental health professional pipeline programs

Caring For The Caregivers

States can empower caregivers by:

Dedicating funding for trusted, community-based organizations that offer parent and caregiver peer support programs

Creating regional task forces to address workforce incentives and collaboration with community providers

Upholding the testimony of caregivers and including their expertise and experiences in policymaking conversations

Reducing administrative barriers within state systems to support whole-child and whole-family treatment approaches that include parental mental health care and peer supports

Engaging youth in leadership positions, such as a Governor's Commission or advisory boards that have authority to address issues important to youth and provide recommendations directly to the Governor and leaders in the agencies

Maximizing regulatory flexibilities, available technology and licensing changes to enable tele-mental health care to lessen logistical burdens for families

Developing a comprehensive system of care that offers wraparound supports for youth and families with complex needs and respite care to reduce caregiver burnout

Explore including system navigation, peer supports and caregiver resources in Medicaid managed care contracts

Governors Lead Roundtable on Access and Affordability of Care

During a two-day roundtable event in Detroit, held April 19-20, 2023, Governor Murphy and Michigan Governor Gretchen Whitmer held discussions with First Spouses, private sector leaders, and policy and subject matter experts focused on the role of states in ensuring access and affordability of quality youth mental health treatment and care. New Jersey First Lady Tammy Murphy, North Carolina First Lady Kristin Cooper and North Dakota First Lady Kathryn Burgum spoke at the event, which also focused on expanding access and quality of care for maternal and infant health.

"Every single kid deserves to have their mental health supported. As governors, we're committed to ensuring that the young people in our states - and every state - can access the mental health support they need to thrive."Governor Phil Murphy and Governor Gretchen Whitmer (Detroit News)

State Policy Solutions Discussed At The Roundtable Include:

2023 NGA Winter Meeting

NGA Chair New Jersey Governor Phil Murphy opened the the 2023 NGA Winter Meeting with a plenary session on Strengthening Youth Mental Health. In response to rising rates of mental health distress among young people, Governor Murphy first introduced his NGA Chair's Initiative in July of 2022. Through the Strengthening Youth Mental Health initiative, Governors from across the nation are collaborating to develop bipartisan, state solutions. Governor Murphy and Utah Governor Spencer Cox provided opening remarks before turning the discussion over to moderator Dr. Alfiee Breland-Noble, Founder, The AAKOMA Project.

The panel, consisting of Governor Murphy, U.S. Surgeon General Vivek Murthy, Dr. Richard Besser, CEO, Robert Wood Johnson Foundation, Reina Chiang, a college student and founder of the nonprofit, "u matter apparel," and First Lady Tammy Murphy discussed elevating and expanding the national conversation around youth mental health and the close link between youth mental health and maternal and infant health. Watch the full session.

"As leaders, one of the most important and sacred responsibilities is protecting the health and well-being of our kids, and for far too long, mental health and well-being of our young people has been overlooked, and the consequences are impossible to miss. From small towns to big cities, America's youth mental health crisis is playing out in homes, schools, hospitals and beyond."Governor Phil Murphy

Governor Murphy and Governor Polis Join Forces To Tackle Youth Mental Health Crisis

The second roundtable of the 2022-2023 NGA Chair's Initiative: Strengthening Youth Mental Health was held on January 24-25, 2023, in Santa Monica, California. During the two-day roundtable, NGA Chair New Jersey Governor Phil Murphy and Colorado Governor Jared Polis held discussions with parents, physicians, pediatric psychologists, educators, policymakers and other mental health experts. Over the two days, roundtable discussions unpacked the Initiative's second pillar focusing on themes of building a foundation of diversity and equity in addressing stigma, reducing the stigma of mental health and seeking help, and increasing awareness around youth mental health.

Compared to previous generations, young people today are much more open to talking about mental health and want to play an active role in reducing the stigma surrounding mental health challenges to promote mental wellbeing. Throughout the convening, the young leaders in attendance shared impassioned stories of both their own mental health struggles and the many ways in which youth are organizing to break the stigma. Despite this progress, stigma continues to be a major barrier to young people reaching out for help. Although half of mental health disorders begin by age 14, treatment is often delayed by a decade or more as youth and their families grapple with feelings of fear and shame. Stigma is a reality across different settings: cultural disconnects or generational divides within the home can make it difficult to talk about mental health, and misconceptions continue to pervade attitudes in educational settings, places of worship, and workplaces. Bias, conscious or unconscious, within the healthcare system, can also have a stigmatizing effect on those who need respect, understanding, and support from providers.

Solutions To Break The Stigma And Support The Conversation Around Mental Health

Governors can increase awareness and reduce stigma by supporting:

Existing community-based mental health organizations' awareness-building efforts: Ensuring funding and other resources get to organizations with deep knowledge of their communities' mental health challenges

Targeted anti-stigma campaigns with a focus on storytelling: Developing efforts driven and co-designed by young people, that reach young people on social media, and are focused on diverse populations, including youth of color and Indigenous youth, LGBTQIA+ youth, youth involved in the foster care system, etc. Governors can also humanize mental health by using their platforms to share their personal journeys with mental health

School mental health curriculums: Growing capacity for mental health literacy for youth and their families by implementing age-appropriate awareness of the spectrum of mental health, bolster mental wellbeing, and encourage youth to seek help, as well as adopting family engagement plans and public-private partnerships to tap into the knowledge and support of thought leaders in the private or nonprofit sector

Suicide stigma reduction: Normalizing discussing suicide and suicidal ideation, making them less "scary" and unbroachable topics by training youth peers, as well as the adults who live and work with youth, on appropriate and compassionate responses to someone who is experiencing intrusive thoughts can help to reduce the silence around suicide

Sensitivity training for adults interacting with youth: Enabling sufficient support, care, and treatment for youth experiencing mental health challenges through bias, sensitivity, and cultural responsiveness training for healthcare professionals, educators, and others

The power of peer networks: Recognizing a recent Active Minds survey that found that 67% of young adults first tell a friend they are feeling suicidal before telling anyone else - supporting the development of a diverse mental health workforce of peer supporters and community health workers to complement a workforce that is able to provide culturally competent care when and where families need it at the level that is needed; including through trainings on mental health identification and crisis management

Crisis services that meet youth where they are: Protecting young people's privacy and enabling trust through innovative services such as anonymous text lines or apps and in building youth-specific crisis response systems including home-crisis models

Delivery systems improvements to promote trust and safety: Addressing the experience patients have when they seek care after breaking the stigma of seeking help, including addressing the trust gap between patients and the health care system

Increased awareness of people working in programs that support the well-being needs of youth: increasing awareness of youth mental health among all state systems and agencies that touch the lives of youth and their families, including public health staff, human services staff, youth employment systems, out of school time staff, justice, or housing and child welfare systems

Safe and supportive school environments: Implementing mental health awareness and stigma-reducing tools in schools such as anti-bullying measures and adding information on seeking mental health (988) to student IDs, utilizing yearly school climate improvements surveys to understand current youth needs; incorporating trained peers into campus programming; and considering alternatives to exclusionary discipline

governors and states meet on prevention and resilience in youth mental health

On October 18-19, 2022, in Salt Lake City, Utah, National Governors Association (NGA) Chair New Jersey Governor Phil Murphy and NGA Vice Chair Utah Governor Spencer Cox held the first of four roundtables to discuss the 2022-2023 NGA Chair's Initiative: Strengthening Youth Mental Health. A strong state contingent was represented, including Alabama, Arkansas, Minnesota, New Mexico, and Pennsylvania. States were joined by over fifty community leaders, academic experts, and representatives from partner organizations and funders.

The convening centered on practical solutions for the first of the initiative's four pillars: prevention and resilience building. Discussions forged connections across the public and private sectors, shared best practices across states and territories to amplify their impact, and aligned on ways that Governors can further support youth mental health.

Key themes on prevention and resilience were unpacked across three discussions that centered the voices of those with first-hand experience of youth mental health from different perspectives; focused on applying the brain and behavioral science of resiliency, specifically to provide opportunities to build and rebuild mental health in youth; and oriented the group towards practical and implementable solutions. Credentials spanning academia, government, business, and community service were interwoven with personal stories of delegates' lived experience.

Despite the immense challenge, the roundtable discussion coalesced around hope: evidence shows that prevention and resilience building in childhood and adolescence can fundamentally change the trajectory of a child and family's life. Given supportive environments and the right skillset, the effects of adverse childhood experiences (ACEs) and exposure to toxic stress can be successfully managed to prevent mental health challenges from developing or worsening. Strengthening youth mental health, starting with prevention and a focus on resilience, needs to be a key priority within all levels of government, and across all sectors of society.

About the Initiative

Governor Phil Murphy's 2022-2023 Chair's Initiative is focused on four key pillars to address youth mental health:
Addressing Prevention and Resilience Building

Providing youth with the supports and tools necessary to cope with stressors and challenges, helping them to thrive and reduce likelihood of engaging in unhealthy or damaging behaviors.

Increasing Awareness and Reducing Stigma

Promoting awareness of mental health resources and foundational mental health knowledge by expanding easy access points to education, helplines and state services.

Insuring Access and Affordability of Quality Treatment and Care

Addressing the barriers that prevent youth from accessing care including ensuring high quality care is available in the places, spaces, and timeframes that youth want and need, and that costs and lack of insurance coverage do not prevent access.

Training and Supporting Caregivers and Teachers

Examining not just the core issues around youth mental health, but also considering the impacts of youth mental health challenges, including the tie-in to academic recovery.

Expanding existing training and supports so that those caring for and interacting with youth daily have the tools and understanding to identify mental health needs and how to facilitate access to supports for youth

Improving Maternal and Infant Health

In addition, First Lady Tammy Murphy is leading an effort focused on maternal and infant health (MIH). This has been a significant area of focus in New Jersey throughout the Murphy Administration and this effort seeks to elevate and expand the conversation around maternal and infant health nationwide.

The four pillars of this effort are:

Centering Women's Voices in MIH Policy - This area focuses on the importance of integrating the voices of mothers and women of color in the policymaking process, making sure they have a seat at the table before the table is even built.

Improving and Utilizing Maternal and Infant Health Data - Improving data systems by incorporating qualitative data on maternal health experiences, linking state data and increasing accessibility to data to improve accountability.

Expanding Access and Quality of Care - Identifying ways for states to ensure citizens have access to high quality maternal and infant care, including various MIH Medicaid policies that states can look to implement.

Elevating Innovative MIH Polices, Programs and Technologies - Identify and highlight innovative and novel approaches to MIH policy, including highlighting effective programs and examining the role of technology to improve MIH outcomes.

2022 Summer Meeting

Insights - Youth Mental Health & Maternal and Infant Health

NGA has collated a variety of resources from stakeholders to assist Governors and their staff with strengthening youth mental health, and improving maternal and infant health. These resources leverage the expertise of NGA partners to provide insights to assist with delivering specific program areas and cross-program tools and best practices.

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Elevance Health

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Strengthening Youth Mental Health - National Governors Association

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The United States faces a nationwide youth mental health crisis. The time is right and the need has never been more apparent to discuss proven and innovative solutions for states.

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To address this growing youth mental health crisis, states can leverage schools as a touchpoint for promotion of mental health to avoid problems from developing, as well as early intervention and treatment to meet needs when they do arise. The sections below analyze (1) prevention and mental health promotion options for states with a focus on mental health in schools, (2) early intervention and treatment integrated into schools, and (3) youth empowerment to drive cultural shifts in schools.

A. Prevention and Promotion: Mental Health Education & Social-Emotional Learning

Mental health education in K-12 classrooms often includes both social-emotional learning and mental health literacy, with younger grades beginning with social-emotional learning and mental health literacy included in health education classes for older students.
MENTAL HEALTH EDUCATION AND MENTAL HEALTH LITERACY
Mental health literacy curriculum is designed to be provided to all students and often includes information about mental health conditions, wellness skills, and how to seek help. Australian researchers have demonstrated that people, particularly students, who receive mental health education are more likely to recognize and seek help for the symptoms of a mental health challenge. The researchers coined the term mental health literacy, which is, they explain, an extension of health literacy and is defined as "knowledge and beliefs about mental disorders which aid their recognition, management or prevention." There are several studies indicating that mental health education generates positive, meaningful outcomes. For example, a recent meta-review of effective suicide prevention strategies concluded that educating high school students with a mental health curriculum was one of the few policies that was proven to reduce suicide attempts and suicidal ideation.18 A randomized controlled study of a suicide education program provided to diverse technical high school students showed students who received the intervention were 64% less likely to report a suicide attempt after three months than those in the control group.

Another study compared states with school mental health policies to those lacking these policies. States that mandate more mental health policies in public schools overall have significantly lower adolescent and young adult suicide and substance abuse rates, but one subset of policies was particularly impactful. State-mandated school-based mental health centers, social-emotional curricula, and school professional development in suicide prevention were all associated with significantly lower adolescent and young adult suicide and substance abuse rates.

Surveys consistently show that youth are aware of their own mental health challenges and those of their peers, and as such, are interested in mental health education. A 2019 study by the Pew Research Center found that anxiety and depression top the list of challenges teens see among their peers. In a survey of teens ages 13-17, 70% said that anxiety and depression were major problems among themselves and their peers, outranking other significant social problems such as bullying, substance use, teen pregnancy, and even poverty. This finding suggests that because teens themselves recognize their own mental health challenges, they may be more motivated to learn about mental health in order to increase their own ability to recognize signs and symptoms and to get help.
SOCIAL AND EMOTIONAL LEARNING
According to the Collaborative for Social and Emotional Learning (CASEL), SEL is the process through which all young people and adults acquire and apply the knowledge, skills, and attitudes to develop healthy identities, manage emotions and achieve personal and collective goals, feel and show empathy for others, establish and maintain supportive relationships, and make responsible and caring decisions. SEL can include both classroom curricular content and approaches to classroom management, such as rules that reinforce positive behaviors. More recently, trainings have become available to ensure that SEL activities are unbiased and culturally responsive for students and educators of racially and ethnically varied backgrounds.

Two meta-analyses of studies of social-emotional learning interventions found significant improvements for students. The first study, in 2011, found that compared to controls, students demonstrated enhanced skills, attitudes, and positive social behaviors following intervention and fewer conduct problems and had lower levels of emotional distress. Academic performance was significantly improved by 11% in the subset of studies measuring this outcome. A 2017 follow-up study found that gains endured over time and social and emotional learning interventions had an effect on promoting positive outcomes, such as improving skills, positive attitudes, prosocial behavior, and academic performance and avoiding negative outcomes, including conduct problems, emotional distress, and substance use. These gains were achieved across racially and socioeconomically diverse student populations.
POLICY OPTIONS FOR ADVANCING MENTAL HEALTH EDUCATION
Part IV of this report offers a lengthy case study of policy change in New York State for mental health education in schools. In addition to New York State, there are several other states that have laws or regulations requiring mental health education, and in the coming years, more will likely be added. It is expected that the federal government will begin providing more technical assistance and guidelines to improve mental health literacy in schools. States have taken similar strategies specific to social and emotional learning as well. Ideally, these approaches will be combined with school-wide integration of services, as described in subsequent sections. Youth leadership has been critical to these efforts.

Many of these laws build upon existing curriculum and requirements. For example, Virginia's statute (HB 1604) adds the following language after the state code's general support for physical and health education in the schools:

Such health instruction shall incorporate standards that recognize the multiple dimensions of health by including mental health and the relationship of physical and mental health so as to enhance student understanding, attitudes, and behavior that promote health, well-being, and human dignity.

YOUTH EMPOWERMENT
Angela Wallace of Massachusetts

Angela Wallace of Massachusetts discusses her experience as a Black female student in a racially homogenous school district in Massachusetts and why she was driven to speak out about her challenges regardless of shame and bias. Angela has provided expert witness testimony for the Massachusetts Legislative Committee on Mental Health and Substance Use Recovery in favor of mental health education legislation.

The bill further provides that the State board of education will review and update the health standards of learning for students in grades nine and 10 to include mental health education and requires the state to consult a wide array of stakeholders in developing the new standards, including providers, the state mental health agency, and advocacy and peer organizations.

Importantly, Virginia's process was entirely youth-led. Students who were aware of the New York law secured sponsors in the Virginia legislature and advocated for the bill. They approached Virginia State Senator, Creigh Deeds, who sponsored the bill. Senator Deeds had a son who died by suicide after being denied psychiatric services in 2013. Finding a very motivated and well-positioned sponsor was a key factor in moving the bill forward.

Just as in New York, getting a law passed was only the first step toward progress. Advocacy organizations highlighted the students' success and worked with the board of education to spur the agency to prioritize conducting the required review and update of the standards. Unlike New York's law, the Virginia statute does not include funding for a technical assistance center, which has hampered widespread implementation and tracking of progress. In Virginia, advocates and policymakers have continued to build on the student education requirement and a bill to require teacher training passed in 2020.

In Florida, the state board of education voted to require every Florida public school to provide students in grades 6-12 at least five hours of mental health instruction. The board specified both the number of hours and the general content of the instruction. The instruction must include: awareness of signs and symptoms; process for getting or seeking help for themselves or others; awareness of resources (i.e., Fortify Florida app and the National Suicide Prevention Hotline: 1-800-273-8255); and what to do or say to peers struggling with mental health disorders.

This requirement was championed by First Lady Casey DeSantis as part of her Hope for Healing Florida, an initiative to promote mental health and avoid addiction. Again, having a high-profile sponsor for the initiative was very helpful. With respect to the new education requirement, the First Lady said:

Ron and I have traveled the state and have heard from many families who voice concern about the struggles that adversely affect so many of our children. We know that 50% of all mental illness cases begin by age 14, so we are being proactive in our commitment to provide our kids with the necessary tools to see them through their successes and challenges. Providing mental health instruction is another important step forward in supporting our families.

In Florida, mental health education is one of several components addressing school-based mental health and resiliency. The Hope for Healing initiative has also included partnering with the state's athletic teams to promote resiliency and create a peer-to-peer student mentoring program.

Although the shooting at Marjorie Stoneman Douglas High School increased statewide awareness of the need for mental health education and supports in Florida, it also has led to an over-reliance on law enforcement, requiring every school to have an armed staff member or a law enforcement officer. This has resulted in higher rates of arrests, especially for students of color.26 Focusing on mental health and wellness instead of safety is critical to ensuring equity in state reforms.

In Appendix C of this report is a state-by-state chart with every state and its respective current mental health curriculum requirements. CASEL also offers resources on state efforts related to SEL.

In addition to these strategies, the Every Student Succeeds Act (ESSA) gives states new flexibility in administering federal grants for schools that serve low-income families and allows for greater focus on student health and well-being. This also gives advocates additional opportunities to advance mental health in schools. For example, ESSA gives states flexibility in selecting a "non-academic" indicator of school success to track, which can include a measure related to student mental health. ESSA also allows some of the school funding and professional development dollars to go toward student well-being, opening the door to funding programs and staff training in mental health education in schools. Advocates can work with their state departments of education to ensure that their ESSA plans promote student mental health and well-being. More information is available in this issue brief.

After the COVID-19 pandemic, the American Rescue Plan Act (ARPA) creates other opportunities. ARPA offered over $200 billion in additional investment in K-12 public education, with a specific requirement that some of these funds must respond to students' academic, social, and emotional needs. Advocates can work with state departments of education that are administering these programs to ensure that these funds go toward building the necessary infrastructure and training to integrate mental health education in schools.
Lessons Learned From State Policy Efforts Seeking Mental Health Education Requirements

Build on what exists. Review the state-by-state chart to see where your state is and see what you can add to what you already have regarding health curriculum requirements. Try to increase coverage to K-12 students but at a minimum cover 6-12. Include a technical assistance center to implement the requirement or as a stand-alone if the curriculum requirement is not moving forward.

Empower youth leadership because they can powerfully articulate the need for this legislation and reach legislators in their districts.

Find a high profile, motivated, and effective sponsor in the legislature or executive branch because that can be very impactful.

Be vigilant with implementation. Getting a bill passed is only the first step. So if your state has any requirements, find out if they are being implemented. Ensure that equity is considered in all aspects of implementation.

Leverage student education requirements to have a more holistic approach, either through technical assistance and training or more comprehensive initiatives for programs such as peer support or staff training. Ensure equity within reform efforts through a wellness and mental health focus.

B. Early Intervention and Treatment: School-Based Mental Health Services

Mental health education is a universal intervention, but schools must be able to respond when students reach out for help. An adequate response includes school mental health personnel, who can provide early interventions and coordinate care, as well as treatment professionals, who can be part of a school-based health center, a community partner, or other arrangements. These different levels of response are often referred to as Multi-Tiered Systems of Support (MTSS), with Tier 1 addressing universal needs, Tier 2 for students at risk or in need of early intervention, and Tier 3 for students who need individualized treatment and support for mental health and substance use conditions.30 School personnel are generally involved in all tiers, and community providers may provide general education in Tier 1 but more likely provide services in Tiers 2 and 3.

In 2019, the ACLU released a comprehensive report detailing the lack of school mental health personnel using data provided by the Department of Education and noted that 14 million students were in schools with a police officer, but no counselor, nurse, school psychologist, or social worker. Over 90% of schools failed to meet professional standards for school counselors. The report noted that low-income students and students of color are more likely to get their mental health services at school and are disproportionately harmed by the low ratio of school personnel. The report also noted the importance of school-based mental health centers and the ability of students to access services on site. With COVID-19, there continues to be a strong interest in telehealth, and financing remains a critical need to support school-based personnel and community treatment options.

We found several effective state policy strategies for advancing school-based mental health services, including laws or policies setting ratios of students to school personnel, Medicaid policy approaches, using telehealth to provide school-based services, and policy proposals improving school-based mental health services from community providers. Note that, across all of these approaches, federal relief funds from ARPA offer new opportunities, including additional funding for schools to integrate mental health services, to purchase telehealth equipment, to provide training for school staff, and to fund mental health services that could be integrated within schools.
LAWS OR POLICIES SETTING RATIOS OF STUDENTS TO SCHOOL PERSONNEL
There are statutes and board of education policies at the state level setting ratios of students to school personnel. Policy analysts studying counselor ratios and state policy initiatives have concluded, "the relationship between these policy levers and a state's median school counselor ratio is striking. For instance, of the seven states with the highest median ratios (least access), none have mandated a maximum student-to-counselor ratio. Conversely, of the six states with the lowest median ratios (greatest access), all either have a mandated student-to-counselor ratio or a recommended ratio with dedicated state funding to help support counselor access."

Improving school ratios is another area where students have provided leadership. In one district, the advocacy of a group of students doubled the number of school mental health professionals through testimony designed to ensure that the allocation of new resources to the district was spent to promote mental health.

Advocates seeking to understand their state requirements can review the ACLU report and the American School Counselor Association's list of state-by-state legislation and mandates. For a better understanding of equity and school counselor ratios, this fact sheet provides information on the 38 states that are failing to provide adequate counselors for their students of color and low-income students and has specific steps for advocates to address these shortfalls.33 The National Association for College Admission Counseling has developed maps at the school district level with 2015-2016 data for school counselors.

YOUTH EMPOWERMENT
Melanie Zhou of Colorado

Melanie Zhou of Colorado discusses the burden of experiencing a classmate die by suicide. This motivated her to push for student representation on the board of education and to advocate for funding to address the mental health needs of students in her school district. She successfully advocated for millions of dollars in funding for mental health professionals and subsequently founded a mental health student healing group.

Some of the most favorable ratios in the state bills are in Colorado and Virginia. In 2019, Colorado passed a statute creating a pilot program in 10 schools to achieve a ratio of 250 students per mental health professional and evaluate the results on the students' physical and mental health. In 2020, Virginia passed a statute lowering the ratios of school counselors to 1:325 for K-12 beginning in the 2021-2022 school year. The state has progressively worked to lower the ratios, and advocates may want to look at their state policies over time. In addition, counselors can spend much of their time in administrative duties, and Arkansas passed a bill to limit such work to 10% of the time and specify the student contact activities that counselors should be doing.

There is much work to be done, particularly for schools serving children of color and low-income students. According to the ACLU report, more than 67,000 schools lacked any social worker, and more than 24,000 schools (25%) reported having no counselor on staff. In addition, 43% of public school students were enrolled in a school that did not have a school psychologist.
MEDICAID POLICY APPROACHES
In 2014, the Centers for Medicare and Medicaid Services (CMS) reversed longstanding policy and issued a letter to State Medicaid Directors allowing states to bill for school services for any Medicaid eligible child, not just those who had an Individualized Education Plan (IEP) and had qualified for services under the Individuals with Disabilities Education Act (IDEA). In 2019, CMS and the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a joint informational bulletin offering additional guidance to states on how to bill for school services if they chose to do so.

To date, 14 states have chosen to take advantage of the ability to bill Medicaid beyond IEPs, and several others are in progress. These states are listed in a state policy dashboard in Appendix E. Some states have specifically enacted legislation to enhance mental health benefits, and advocates can find details on state efforts in this report from the Healthy Schools Campaign. Michigan, for example, passed SB 149, appropriating $30 million to pay for school mental health professionals and an additional $1.3 million for the state to issue a state plan amendment to CMS to be able to draw down more Medicaid dollars for mental health services. The relevant provision read:

Sec. 31n. (1) From the school mental health and support services fund money appropriated in section 11, there is allocated for 2018-2019 for the purposes of this section an amount not to exceed $30,000,000.00, and from the general fund money appropriated in section 11, there is allocated for 2018-2019 for the purposes of this section an amount not to exceed $1,300,000.00. Not later than February 15, 2019, the department and the department of health and human services shall establish a program to distribute this funding to add licensed behavioral health providers for general education pupils and shall seek federal Medicaid match funding for all eligible mental health and support services.

Early results show significant increases in behavioral health staff. As of May 2021, the Michigan state team working on this initiative reported behavioral staff increased from 1,738 to 2,975, a 71.17% increase. In addition, reimbursement also significantly increased by $6.17 million from Medicaid expansion. This Michigan case study provides additional details for states seeking to make similar changes.
USING TELEHEALTH TO PROVIDE SCHOOL-BASED SERVICES
In addition to expanding funding for Medicaid, some states have expanded access to services by specifically adopting Medicaid policies indicating that schools can be an originating site for telehealth. According to a Spring 2021 report from the Center for Connected Health Policy, 27 states and the District of Columbia expressly have policies allowing schools to be originating sites, although sometimes restrictions apply. These states are listed in Appendix E.

According to the Center's analysis, "the most common modality allowed in schools is live video, and only four states allow a store-and-forward modality to be used (NC, NM, OK, and GA). Eleven of these states require parent informed consent for a minor to participate." Services vary from state to state, but the most common services are therapy services, which include mental health therapy as well as speech, occupational, and physical therapy.

Texas has maximized the use of telehealth to provide school-based mental health services. In 2019, the state legislature passed Senate Bill 11, creating the Texas Child Mental Health Care Consortium, a collaboration of the state's higher education institutions, nonprofits, and service providers. The Texas Higher Education Coordinating Board was the administrative agency tasked with receiving and appropriating the funds for Consortium initiatives.

One of the initiatives relevant to school-based mental health was the Texas Child Health Access Through Telemedicine (TCHATT) program. This program is built on existing telehealth programs in the state, including a consultative pediatric mental health access program funded in part by Health Resources and Services Administration (HRSA) and operating in many states. The team includes licensed professional counselors, licensed clinical social workers, a child psychologist, licensed vocational nurse, child psychiatrists, and community health workers. They collaborate to assess, refer, and treat students, who can receive up to four sessions from the program at no charge to families.

Key elements of the program include a partnership between the team and schools, the provision of counseling services and telepsychiatry to students, and guidance to school professionals in assessing, supporting, and referring students.

As of October 15, 2020, 96 school districts in Texas were actively involved with TCHATT, covering 1,124 schools and a total student population of 842,422. It is anticipated that the total number of covered students will expand to 1.33 million once the memoranda of understanding in progress are fully executed. Funding for the fiscal year 2020 and 2021 is approximately $37 million. The program is too new to have outcomes, but anticipated data may include numbers reached, number of services, satisfaction, reduced mental health needs, reduced school absences, and improved graduation rates.
POLICY PROPOSALS IMPROVING SCHOOL-BASED MENTAL HEALTH SERVICES FROM COMMUNITY PROVIDERS
One of the most effective policy changes has been state grant programs that provide school-based mental health services through partnerships between community providers and schools. These programs eliminate the need for transportation, parents having to take off work, wait times, and other barriers. Youth are also more likely to complete treatment in schools compared to other settings.42

These programs have demonstrated very positive effects on access and other outcomes, such as graduation rates and academic achievement. For example, the 2018 Kansas legislature passed a statute creating a pilot program that they have continued to fund at increased levels. The Mental Health Intervention Team (MHIT) pilot program began with nine school districts and provided resources for school-based mental health liaisons and for case managers and therapists at the community mental health centers (CMHCs). The local education authority and the community mental health centers entered into memorandums of agreement, and the Kansas State Department of Education created the payment mechanism and the database to track outcomes. Creating the database within the state agency saved resources and allowed for customization to meet the program's needs.

A summary report from the Kansas State Department of Education at the end of the first fiscal year stated:

At the end of fiscal 2019, over 1700 students were receiving CMHC services through the MHIT project, including 212 foster students. Overall improvement was shown in academics, attendance, and behavior in many of the students. Feedback from families, students, and teachers was positive, and families appreciated the convenience of the school-based partnership with the local CMHC. Students appeared to understand their personal issues and how to effectively change their own behavior. Teachers and school staff also reported fewer disruptions in the classroom which improved the school climate.

REDUCING DISPARITIES
Bernadeia Johnson of Minnesota

As superintendent of Minneapolis Public Schools, Bernadeia Johnson intentionally set out to improve access to mental health services through schools, especially for underserved BIPOC students. By spearheading an initiative with community stakeholders and education leaders, she successfully secured additional supports for marginalized students and families to receive mental health services and supports on school campuses, where they were most likely to benefit from it.

The program tracks outcomes, and results from the past two years indicate similar positive outcomes. Approximately two-thirds of children improved their attendance, and over half improved internalized behaviors; roughly 60% improved their academic performance, and approximately 70% improved external behaviors. Given the positive early outcomes, the legislature has continued to invest in the program. For the 2020-2021 school year, 56 school districts and 212 schools are participating in the mental health intervention team program.

Minnesota has one of the oldest school-linked programs in statute, first passed and funded by the 2007 legislature. Over the years, the program has expanded substantially to cover more schools and has increased its focus on evidence-based practices such as trauma-focused cognitive behavioral therapy. Advocates in Minnesota credit the educational community for the expansion, noting that school superintendents and teachers have been some of the most vocal advocates for the program at the legislature because they have seen the impact on their schools and communities.

Under the program, the Department of Human Services, not the state education agency, distributes grant funds to local community mental health agencies to "offer mental health services in schools, including assessment, treatment and care coordination, teacher consultation, and school-wide trainings." These community mental health agencies bill both public and private insurers for clinical services so that the grant funds are used for students who do not have health coverage or are underinsured. Funds can also be used to pay for the services that are not typically reimbursable, such as in-service training and outreach to families and communities. Funds can also be used for equipment, connection charges, on-site coordination, and other expenses to set up telehealth programs. Advocates and providers worked to address the bidding process to ensure more consistency in funding from year to year for community mental health agencies.

Importantly, the program has been effective in meeting the needs of children who had previously been underserved. Almost half of the children (47%) had not received mental health services before they were provided care under the school-linked program. This percentage was even higher for children of color, and 58% of children of color had not received any mental health services before participating in the program. School-linked programs can begin to narrow the access gaps for mental health care for children of color. Of the children newly identified, half of those were children with serious emotional disturbance, indicating that many children with very high needs are not identified without school-linked programs.

One of the recent recommendations for improving the program included youth leadership and voice. Stakeholders recommended utilizing the Minnesota Youth Council or another youth advisory process "to review implementation practices, methods, and barriers to school-linked programs to gain youth perspective on successful access to services. Actively involving young people in a consultation process can create an opportunity to get reliable information about young people's needs and everyday experiences accessing mental health services." The Minnesota Youth Council Committee was created by Minn.Stat. 124D.957, to provide advice and recommendations to the legislature and the governor.
Lessons Learned From School Policies Increasing Access to School-Based Mental Health Services

Seek sustainable funding for community mental health providers. Medicaid policies should encourage payment, and private insurers should be required to pay their fair share of school services, allowing state grant funds and other resources to be used for training and services for children who lack insurance or are underinsured. Telehealth should be permissible as a way to reach students more easily. Resources should go directly to the community mental health providers rather than the schools for the funding areas related to services.

Measure outcomes to support expansion of the program. In both Kansas and Minnesota, strong outcomes led to increased funding and more schools covered. The Kansas Department of Education developed a database to ensure adequate tracking of key outcomes.

Design programs to increase access to mental health care and address inequity. In Texas, the TCHATT program is reaching children in parts of Texas that lack mental health providers and is providing immediate access to care in crisis situations. The Kansas MHIT program included children in the foster care system as a key target for the program. Minnesota data indicated that over half of the children served had not received mental health services prior to the school program, and almost 60% of children of color had not received any services before participating in the program.

Engage beneficiaries of the legislation in advocating for the program. In Minnesota, education stakeholders have been particularly effective in reaching out to their legislators to increase funding to allow expansion of the program to more schools.

Ensure youth have a key role in advocacy and implementation of the program. In Minnesota, a stakeholder group evaluating the school-linked program recommended an existing Youth Advisory Council or other similar body provide ongoing input into implementation.

C. Youth Empowerment: Driving School Culture Change

Youth empowerment is a key strategy for effective state school mental health policy. With respect to New York and Virginia mental health education legislation, young people were key advocates with the legislature, and for the Virginia bill, they were the driving force behind the legislation. This youth involvement ensures that the policy will be effective and tailored to meet the current needs of young people. Youth-led initiatives are also very responsive to the immediate needs of young people and reflect policies that they believe are going to help. Youth empowerment can play a crucial role. Given the opportunity, young people are able and have the desire to provide school administrators, public health officials, and legislators a clear idea of what interventions they need right now to improve their mental health and well-being.

The fastest, most efficacious, and most equity-focused way to meet the needs of young people is to give them the space and the encouragement to ask for what they need. Youth-led initiatives are better suited to address and reflect the needs of LGBTQ+ students and students of color. For example, advocates for LGBTQ+ youth have noted that youth-led activities better incorporate and reflect their needs because traditional evidence-based strategies are based on aggregate data that often leaves out the needs of those students.

According to Mental Health America's 2020 Young People's Mental Health Report, when surveyed on the top three things that young people felt would be most helpful to their mental health, high school students (ages 14-18) reported that learning how to support their own mental health in their daily lives (48% of respondents) access to mental health professionals (53%), and mental health breaks and absences as part of school and work (53%) were most important. In this report, we have already addressed mental health education and increasing access to mental health services in schools. The last of the three areas that young people have identified as being important to improving their mental health is the concept of excused absences for mental/behavioral health, also known as mental health sick days. The data shows that high school students (ages 14-18) feel that being able to take a break to care for their mental health is equally as important as having access to mental health professionals (tied for the top survey response as mentioned above).
OREGON AND OTHER STATES
Not only is it clear that young people care deeply about excused absences for mental health, they are also taking action to implement these policies. In Oregon, for example, a group of teen mental health advocates was the driving force behind the passage of HB 2191, the 2019 bill that expanded Oregon's excused school absence policy to include mental and behavioral health as a valid reason for an excused absence. The group of students, including Hailey Hardcastle (view her TED Talk here) and Derek Evans, partnered with Providence Health and Services, a major health system in the state, and advocated for the Oregon legislature to pass the bill in response to the youth mental health crisis facing the state.

Just as many of the mental health education laws build upon a state's current health education policy, excused absence laws can also amend existing policy. Oregon state law already had a section on excused absences, so HB 2191 added the phrase "including the mental or behavioral health of the pupil" in order to include mental health-related absences in the law. It is important to note that the new bill did not actually change the number of excused absences a student can take in a given period of time. In Oregon, students are permitted no more than five excused absences per three-month term. Now, as a result of the passage of HB 2191, students can access these five excused absences per term for physical or mental health.

The language for the bill was drafted by Students for a Healthy Oregon (a group of approximately 30 students) with the help of a lobbyist for Providence. The bill was introduced in January of 2019, signed into law by the governor in June of that same year, with an effective date of one month later (July 2019). Importantly, the bill had no fiscal impact. From introduction to enactment, the bill took only six months and cost zero dollars.

Other states followed closely behind Oregon, passing similar legislation often driven by young advocates within their respective states. Other states that have passed legislation regarding excused absences for mental/behavioral health include Colorado, Maine, Utah, and Virginia. States with legislative movement on excused absences for mental health are listed in Appendix E.
HOW TO ENCOURAGE YOUTH INVOLVEMENT:
Oregon, Colorado, and other states with youth-led advocacy efforts for mental health excused absences provide a model for how to encourage and support youth involvement in mental health advocacy. In Oregon, a group of students formed a coalition known as Students for a Healthy Oregon. The partnership between these students and Providence is an excellent example of how adults can support youth empowerment in mental health advocacy. Students drove the entire process from the conception of the idea to the bill to the writing to the introduction and advocacy for its passage. Providence supported these students by providing training and resources that helped the students be successful. For example, a lobbyist from Providence worked with the students to produce legislative language that addressed the students' issues. Experienced advocates at Providence helped to train small groups of students about the rules and procedures for meeting with state legislators, as well as aided in developing talking points for how to tell their individual stories and prepare for difficult questions and arguments. Robin Henderson, PsyD, Chief Executive of Behavioral Health at Providence, explained, "students completely led the 'what,' while Providence supported them with the 'how.'"

This has repeatedly been a successful strategy - empowering young people to lead the effort with support from health or advocacy organizations when needed. Advocacy organizations and others interested in helping young people advocate for what they need can support youth advocacy efforts by actively seeking out young people who are already doing the work and offering guidance or resources as needed, rather than trying to recruit young people to advocate for the organization's existing agenda. This allows young people to be empowered to create the changes they truly want to see in their communities. A framework entitled Hart's Ladder of Participation was created for UNICEF and shows the pathway to greater empowerment and engagement of youth. UNICEF also has created an extensive toolkit to guide youth advocacy.

Another key part of encouraging youth advocacy is to give all young people, not just leaders or members of youth councils, etc., the opportunity to have their voices heard. Mental Health America's Young People's Mental Health Report is a good example of how to amplify the voices and ideas of young people in a way that is approachable not just to natural leaders but also to those who may still be actively struggling with mental health concerns. MHA surveyed just under 2,000 young people between the ages of 14 and 24 about what they believe would make a positive difference in their mental health. Surveys and reports like this that ask not just what the problems are but how young people want to see them solved can play a key role in encouraging youth advocacy.

Another example of widespread input is The YouthScan Project, a program created by the organization Youth Roots, which teaches young people the skills they need to gather relevant data in their communities that can then be used for policy development. Programs like these are incredibly helpful for gathering up-to-date, relevant information and can help to elevate the voices and ideas of young people whose voices might not be heard through more traditional data collection methods.
Lessons Learned From Policy Initiatives to Allow Excused Absences for Mental Health:

Empower youth leadership. In Oregon, Students for a Heathy Oregon led the effort from conception of the idea to writing the bill to testifying and were driving the change.

Support young people by providing training and resources on the state and local processes and how to use these procedures successfully to change policy. Providence provided assistance with bill drafting and helped prepare the students for questions they might be asked when they testified.

Incorporate ways to hear the voices of all young people, not just leaders or members of councils. MHA surveyed thousands of young people about what they believe would make a difference.

Involve young people in gathering data in their local communities to inform public policy. The Youthscan Project is one example of a program that empowers young people to gather relevant data that can be used to inform public policy.

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Addressing the Youth Mental Health Crisis: The Urgent Need for More Education, Services, and Supports

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To address this growing youth mental health crisis, states can leverage schools as a touchpoint for promotion of mental health to avoid problems from developing, as well as early intervention and treatment to meet needs when they do arise.

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Language matters in mental health. The words we use shape how we see the world-and ourselves. The words we choose and the meanings we attach to them influence our decisions, beliefs, and well-being. We have a choice in the words we use to describe ourselves, others, and the world around us.

The Hogg Foundation for Mental Health recommends we start by talking with others about the words they prefer. Affirming the preferences of the person you are referring to is always going to be the best way to go.

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Mark Twain

Neither "person-first" or "identity-first" is always right or always wrong. Language is complicated and always changing. Whether a term is acceptable or not depends on your audience, whose experience you are trying to capture, and a person's own preference.

Effective communication starts with respect. We better promote mental health when we show respect for people from different cultures, backgrounds, or life experiences. When we practice inclusion, we improve our communication.

Once you develop greater awareness, knowledge, and skills about the culture of mental health, you may be surprised at how often hurtful language and labels are used in everyday conversation.

How do we respectfully talk to someone about mental health conditions?

Do we use person-first or identity-first language?

What are the cultural impacts of the words we choose?

We're sharing this updated mental health resource to help answer these questions. We can all do better in understanding the power of the language we use and how language matters. Please download and share this PDF.
Download PDF
For more tips, tools, and opportunities on mental health issues, follow us:
Facebook | Instagram | LinkedIn | Twitter | YouTube

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Language Matters in Mental Health | Hogg Foundation for Mental Health

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Language matters in mental health. Our words have a powerful effect on people living with mental health conditions.

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Without the infrastructure necessary to connect needed resources for mental health care, pediatric emergency departments across the country are filling up with kids in crisis. "The Wait to Nowhere: When a Crisis Goes Untreated" reveals an unspeakable reality: children living in the ER for days, weeks and even months at a time, awaiting dedicated care. This film explores the issue and touches on solutions. True stories are told by those living this nightmare, including hospitals that are caught up in a failed system, while lawmakers help lay out a plan to address the crisis before even more children's lives are lost.

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Ending the Youth Mental Health Crisis | Speak Our Minds

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Speak Our Minds is focused on creating a comprehensive system for youth mental health care. Together we can end the youth mental health crisis

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Congressman August Pfluger Introduces EARLY Minds Act to Address Youth Mental Health Crisis

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People experiencing a mental health, substance use or suicide crisis deserve to receive a mental health response. We can reimagine our crisis response.

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The premise behind Find Your Anchor is that each person needs an anchor. "Establish an anchor - a dependable, stable, secure base that you can hold on to, one that keeps you firmly planted, no matter what winds or storms may come." Find Your Anchor doesn't assume to be the anchor, or have all the answers, rather, it sets out to create a community of anchors, all with the help of some little blue boxes.

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The premise behind Find Your Anchor is that each person needs an anchor. "Establish an anchor - a dependable, stable, secure base that you can hold on to, one that keeps you firmly planted, no matter what winds or storms may come."

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Modern Family Clip - 60 Second Stigma Example

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Modern Family Clip - 60 Second Stigma Example

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Modern Family - Sneak Peek from "Halloween 3: Awesomeland"

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Lucy opened her psychiatric booth 62 years ago today in a Peanuts strip published on March 27, 1959! The psychiatric services of Lucy are sought by many in the Peanuts Gang for a mere 5 cents. 
⁠...

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DE Mental Health Literacy Resources to support Mental Health Literacy and required educational programming Delaware adopted the CDC definition for Mental Health to ground the work with House Bill 301.
“Mental health includes our emotional, psychological, and social wellbeing. It affects how we think, feel, and act. It also helps determine how

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Mental Health Education - (CA Health Ed Framework)

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​​​​​​“It is inarguable that we are in the midst of a mental health crisis in California. Even before the pandemic, the rate of students struggling with mental health problems such as depression has steadily risen over the years. Now isolated from their family and friends, students are suffering even more. Mental health is just as important as physical health and it is unfortunate that we neglect it in our curriculum. By educating kids from a young age, we can bring these issues out of the shadows and end the stigma and taboo surrounding the discussion of mental health.”

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Wisconsin Department of Public Instruction

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Stigma Reduction

One aspect of mental health literacy is being able to recognize and minimize stigmatizing ideas, beliefs, and actions about mental health. Mental health stigma includes stereotypes, prejudice, and discrimination against people with mental health challenges. Mental health stigma can keep students from receiving needed services and supports to address mental health challenges. The Stigma Reduction Toolkit includes lessons that can be used with secondary students in a variety of settings, caregiver engagement materials, and a discussion guide for educators to examine their own stigmatizing beliefs and behaviors. Together, these toolkit materials can promote a resilient, hopeful, and inclusive school-community for all affected by mental health challenges.

Students can learn to recognize signs and symptoms that a friend is in trouble, understand that not all secrets should be kept, how to support another student to seek the help they need, and to understand their own needs to promote wellness. Review the classroom curriculum and other resources. Suicide Prevention Education is a legal responsibility of schools in Wisconsin. Find out more about DPI's full day Youth Suicide Prevention Workshop.

Youth Mental Health First Aid

Youth Mental Health First Aid is one of Wisconsin DPI's spotlighted trainings on mental health. Youth Mental Health First Aid is designed to teach parents, family members, caregivers, teachers, school staff, peers, neighbors, health and human services workers, and other caring citizens how to help an adolescent (age 12-18) who is experiencing a mental health or addictions challenge or is in crisis. Young people interested in helping other youth also can attend. Youth Mental Health First Aid is primarily designed for adults who regularly interact with young people. Contact the Wisconsin Safe & Healthy Schools Training and Technical Assistance Center for more information about attending or scheduling a Youth Mental Health First Aid Training.

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Mental Health Literacy and Wellness Education

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Literacy and Wellness Students must be exposed to practices that promote high level wellness, mentally as well as physically. Stigma Reduction One aspect of mental health literacy is being able to recognize and minimize stigmatizing ideas, beliefs, and actions about mental health. Mental health stigma includes stereotypes, prejudice, and discrimination against people with mental health challenges.

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Supporting Mental Health for Maine's Students:

Like physical health, positive mental health promotes success in life. As defined by the Centers for Disease Control and Prevention (CDC), "mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood."

In schools, we prioritize three critical and inter-related components of mental health: social (how we relate to others), emotional (how we feel), and behavioral (how we act) supports to promote overall well-being.

Prioritize Wellness for Every Maine Student

While schools and districts are faced with significant educational and developmental priorities for many children and students associated with the pandemic, there is a need for balanced programming that supports learning, while also supporting their social, emotional, and behavioral adjustment.

The following modules can be incorporated into existing Social Emotional Learning, School Counseling, and Health programs as well as part of an overall MTSS approach that prioritizes stress reduction through mental and physical wellness routines that include daily opportunities for movement, mindfulness activities, and any additional calming routines to promote self-regulation (e.g., lights off, music, breathing, drawing). Supporting students in establishing these routines promote resilience and health among children who have experienced trauma, reduce stress and negative behaviors while increasing health and focus.

Promote Mental Health Literacy and Reduce Stigma

Given increased mental health needs associated with the pandemic and social challenges, there is an urgent need to improve access to mental health support by reducing barriers, changing attitudes and perceptions about mental health, and eliminating discriminatory practices that harm students with mental health challenges.

The goal is to eliminate stigma associated with seeking mental health support. These resources can be part of a way to develop understanding and awareness of mental health (e.g., thoughts, feelings and actions that promote success in life, or developing capacity of the child or student to form close relationships, manage and express emotions, and explore the environment and learn) and improve mental health literacy.

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Supporting Mental Health for Maine's Students: Like physical health, positive mental health promotes success in life. As defined by the Centers for Disease Control and Prevention (CDC), "mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act.

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The Behavioral and Mental Health team in the Office of Student and Family Support (SFS) works to help ensure that schools and districts build internal capacity to meet the social emotional and behavioral and mental health needs of their students, families and staff as well as develop their capacity to build partnerships with community-based providers.

Professional Development
Spotlight on Social Emotional Learning (SEL) and Mental Health Enhancing Systems of Student Support Professional Learning Communities (PLC):
The Department, is pleased to offer a series of professional learning communities (PLCs) that offer educators guidance and support on building comprehensive school mental health systems that address the holistic needs of students, in partnership with:

The full menu, schedule and registration information for the PLCs planned for school year 2023-2024 can be found at Spotlight on SEL MH.
Additional related PD offerings:

Lighthouse Wellness and Health Education Consulting, Inc, will offer a series of free professional learning opportunities for school and district personnel covering topics related to Cultivating Well-Being, Physical Education & Physical Activity, and Youth Mental Health First Aid.

Youth Mental Health First Aid: The Department has partnered with Walker Therapeutic & Educational Programs, Lighthouse Wellness and Health Education Consulting, Pinnacle Partnerships, and others to offer Youth Mental Health First Aid (YMHFA) training. The training helps teachers, other school staff, parents, and others who interact with youth to recognize and support students ages 6-18 who may be experiencing mental health or substance use challenges. The training also helps adults know how to refer students to mental health services. As everyone continues to navigate the impacts and challenges of the pandemic, it is likely that adults are seeing more students who report and show changes in mood as well as more intense feelings of anxiety and stress.

Though school mental health professionals may find this training helpful, the intended audience is individuals without mental health training who work or interact with young people. School districts may request up to two free trainings for up to 60 members of their staff and community. Participating districts will also be eligible for technical assistance to develop follow-up systems and resources for integrating this training into multi-tiered systems for student support. Request sessions here.

Collaborative Improvement and Innovation Network (CoIIN): During school years 2020-2021 and 2021-2022 the Department, in partnership with the Massachusetts School Mental Health Consortium (MASMHC), engaged with selected districts in a learning collaborative facilitated by the National Center for School Mental Health. The initiative included professional development, technical assistance, and ongoing coaching to pilot practices to support the establishment of comprehensive school mental health systems. Participating Districts - Fiscal Year (FY) 2022: Agawam, Haverhill, King Phillip, Monomoy Regional & Waltham. FY2021: Belchertown, Berkshire Hills Regional, Boston Renaissance Charter Public, Burlington, New Bedford, and Randolph

What is a Comprehensive School Mental Health System (CSMHS)?

A Comprehensive School Mental Health System (CSMHS) is defined as school-district-community-family partnerships that provide a continuum of evidence-based mental health services to support students, families, and the school community.

A CSMHS:

Provides a full array of tiered mental health services

Includes a variety of collaborative partnerships

Uses evidence-based services and supports

Department Resources

Supporting Students' Social Emotional Learning, Behavioral & Mental Health, and Wellness Grant - The SEL/ MH grant is funded through state line items and with additional federal funding from the Elementary and Secondary School Emergency Funds (ESSER). This grant program supports Massachusetts public school districts and communities to adapt, expand, or strengthen multi-tiered systems of support to respond to the social-emotional and behavioral health needs of students, families, and educators and to build strong partnerships with community-based mental health agencies and/or providers.

This grant aims to build capacity of school districts, charter schools, and educational collaboratives to do the following:

develop comprehensive, integrated multi-tiered systems for student, family, and educator social-emotional and/or mental health supports; and

build sustainable infrastructure to facilitate integrated coordination between school students, family, and community-based services and/or providers.

In FY2022, seventy-three (73) school districts and collaboratives were awarded grants and are eligible for continued funding pending appropriation in FY2023 and FY2024.

The competitive FY2023 Supporting SEL & Mental Health Grant SEL/MH Grant is open to Massachusetts public school districts (including charter schools) that were not recipients of a FY2022 Fund Codes 613-311-332 SEL & MH Grant .

Holistic Support and Enrichment, SEL, Health and Safety Newsletter - The Department periodically shares updates and offerings related to holistic supports and enrichment, including efforts to help strengthen social emotional competencies, health, and safety. You can sign-up & see past issues for this and other Department newsletters.

Family Engagement - The primary goal of family engagement is to facilitate shared responsibility that contributes to the healthy development, learning, and growth of children - from the earliest ages into young adulthood. Family engagement builds relationships between students, families, educators, and the community. These relationships over time develop into meaningful partnerships rooted in the strengths and assets of all.

Multi-Tiered Systems of Support (MTSS) - A Multi-Tiered Systems of Support (MTSS) is a framework for how school districts can build the necessary systems to ensure that each and every student receives a high-quality educational experience. It is designed to support schools with proactively identifying and addressing the strengths and needs of all students by optimizing data-driven decision-making, progress monitoring, and the use of evidence-based supports and strategies with increasing intensity to sustain student growth. In 2018, Massachusetts updated its MTSS Blueprint to reflect the most current research and enhance the user experience. For example, the current blueprint more explicitly focuses on equitable access and universal design for learning (UDL) and fully integrates social emotional, behavioral, and academic learning.

Promoting Student Engagement, Learning, Wellbeing and Safety - School Year 2021-2022 (Released Summer 2021) : ( Power Point slides / eLearning Module) The Department is providing this document to support district efforts to promote the wellbeing of students families and school staff. This document includes guidance previously released by DESE, as well as new and updated resources to help districts develop, strengthen, and implement comprehensive systems for engaging with students and their families, connecting students and families with additional supports they may need, and promoting student safety. This document also includes racial equity and cultural responsiveness considerations to support districts in ensuring the wellbeing of all our students.

MA Tools for Schools is a clearinghouse from the Department of resources to support sustainable school improvement in Massachusetts.

Other State Resources

National Resources

Contact

Chris Pond , Behavioral Health and Mental Health Specialist

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massachusetts department of elementary and secondary education

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Massachusetts Department of Elementary and Secondary Education

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Mental and Behavioral Health and Wellness Supports

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The goal of the Massachusetts public K-12 education system is to prepare all students for success after high school. Massachusetts public school students are leading the nation in reading and math and are at the top internationally in reading, science, and math according to the national NAEP and international PISA assessments.

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Annie Slease | Mental Health Literacy and the Power of Language

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The Gap in Mental Health Education That Could Save Lives

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Greater mental health literacy can help prevent problems before they manifest and ensure that people receive the help they need and deserve.

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Annie Slease created the Mental Health Literacy Collaborative to help communities better understand mental health. She hopes to expand her work to include Indigenous communities.

"The Mental Health Literacy Collaborative is a national nonpartisan nonprofit, and it's focused on an evidence-based framework called mental health literacy. We bring that framework to schools and communities," Slease said. "We teach how they can use it to build knowledge and confidence about mental health."

Slease, a Wano family descendant, grew up in Oklahoma. She was a classroom teacher for 25 years, taught middle school English and even directed school musicals.

"In those years, I was also raising two children. My older child at 18 developed significant psychiatric symptoms, but I didn't recognize them and neither did my child. My child had just graduated high school, but there was no mental health education in that high school. We were both unaware of what was going on until it got very, very serious," she said.

Slease began writing an anonymous blog to help process her feelings. She wasn't ready to share her name due to the stigma involved in mental health. Other people began to read it and connect with her story. Eventually, the support she received helped her feel confident to share her identity. After she did, she connected with mental health advocates in her area.

"I got involved with NAMI, the National Alliance on Mental Illness," she said. "Ultimately, I realized that anybody can teach English and anybody can direct musicals. But when you've been impacted the way our family was, I felt like I had a story to tell that could really make a big difference," she said.

Slease helped pass a law in her home state of Delaware that requires mental health education for kindergarten to grade 12. But the passage of the law was just the beginning. Without the infrastructure to carry it out, she said, a law may not be effective. She realized that teachers needed support to be able to teach about mental health.

"Educators, just like me, may never have learned about mental health. To require us to teach it, it's a big ask. (MHLC) is sitting in that intersection. We help empower educators and leaders to understand mental health literacy so that they can not only know it for themselves, they can help others learn it at the right pace in the right developmental and cultural fashion that they need it," Slease said.
The framework
Mental health literacy has four components, Slease said. The first component is understanding how to foster and maintain positive mental health.

"With or without a mental health diagnosis, you still should know how to take care of your mental health," she said.

The second component is understanding common disorders and their treatment.
"Just like we understand very general information about diabetes, and we understand that something like insulin can help, we should understand that there are mental health disorders and there are treatments for those," Slease said.

The third component is understanding how to seek help effectively, whether for yourself or a loved one.

"When we talk about that, we're not talking about only a crisis like I described in my household. I didn't have the knowledge to help my child early. But if I had mental health literacy, I would have known how to get help much earlier and it would have been a much easier process to seek treatment for my child," she said.

The fourth component is understanding stigma and how to reduce it. Stigma is a primary barrier to care, Slease said. Stigma is the way society thinks negatively about mental health.

"We don't understand it and we often have judgmental thoughts about it. And we make people feel inadequate or shameful about these real health conditions. That keeps people from getting the help they need," she said.
Breaking stigmas
To break through those misconceptions surrounding mental health, language shapes perceptions.

"If we could dissuade people from conflating the idea of mental health as a mental illness, because they're not the same thing. We're going to say that this person has a health condition, just like any other health condition," she said.

Slease believes it could take a generation to shift the conversation, but starting the process begins with our youngest community members.

"By starting it at our very youngest ages, they can grow up understanding this reality in a much more inclusive way. It can be done, but it's not going to happen overnight, and it's not going to be one school program or school assembly once a year," Slease said. "It's got to be a belief system. It's got to start at the very youngest ages and be embedded into the fabric of the community. When my granddaughter goes to school and learns about her eyes, her lungs and her heart, she will also learn about her mind. Every child deserves that knowledge."
Tailoring services to needs
Slease said the framework can be adapted to support Indigenous communities that have specific needs.

"When we're dealing with generational trauma, generation after generation, that really becomes an issue that can become problematic in communities. Trauma is a primary risk factor for developing a mental health condition. Indigenous groups, as well as other marginalized groups, face higher rates of mental health and substance use disorders. But that doesn't mean that treatments aren't possible," she said.

According to a 2022 report from the Substance Abuse and Mental Health Services Administration, 19.6% of Native American adults experienced mental illness the previous year.

Slease said treatment options need to serve populations appropriately and avoid a one-size-fits-all approach. Mental health literacy can be adapted to serve communities appropriately.

"We can bring mental health literacy into a community space through the voice of people who are (Indigenous), people who do understand what those challenges look like, and how we can talk about them safely and inclusively," Slease said. "That's what mental health literacy is meant to do. It's meant to be an adapted framework that serves communities where they are through the perspectives and voices of members of those communities."

Partnerships are an important way of helping to spread awareness, she said. MHLC works with various organizations who have a greater understanding of their community and its needs. From nonprofits to public education, to the Clinton Global Initiative, their list of partners is growing.

"This work is all about relationships. We are bringing them the mental health literacy framework, but we're not making it land on them. We're helping them develop plans and strategies to make it work in their spaces. And we're continuing to develop new projects so that those communities and those various partners can use mental health literacy to elevate their own work," she said.

By working with universities who educate future teachers, MHLC plans to reach Indigenous students who will be taught by those teachers one day.

"We've developed a one-hour training called MHL Aware. We're bringing it to 30,000 pre-service educators during their college years. When they enter their teaching professions, they already know mental health literacy and they're bringing it into wherever they're going to work," she said. "If we could offer that to students in universities in and around Oklahoma, who will ultimately serve Indigenous students, that is how we bring mental health literacy into communities effectively. We can find those university partners and offer that training to students at no cost."

Support for the training is available through the Clinton Global Initiative's Commitment to Action.

"Our CGI project is open to all colleges and universities but because of my Potawatomi heritage and connection to Oklahoma, I personally hope to reach education students in and around the state."
Long term goals
MHLC is available to work with any tribal organization, whether education or health care related.

Slease hopes to make mental health literacy something that people don't think of as a program. It becomes part of a community's knowledge base and in turn, she said, helps ease the burden on crisis care systems and mental health providers. She envisions a time when people see mental health as part of their overall health.

"When mental health literacy is embedded in the fabric of these communities, we're going to see suicide rates go down. We're going to see overdose rates go down. It will be when people recognize mental health as part of health. Individuals who are talking about their own health conditions openly and not with shame," she said. "I'm not ashamed to tell you that I wear contacts, or I couldn't see to drive. But people are ashamed to talk about seeing a therapist. They're ashamed to talk about taking medication or receiving inpatient treatment for substance use disorder. That shouldn't cause people shame."

"We just need to have the information, and we need to understand it at a level that it becomes inherently our knowledge. That's why the framework is so important. It needs to come out of voices that are trusted in each community. My dream in Indigenous communities is not that I'm teaching it, it's that I'm talking to trusted leaders in these spaces and we're talking about it and we're breaking it down and they're adapting it to meet their community's needs most appropriately."

To learn more, visit the Mental Health Literacy Collaborative website at themhlc.org.

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Mental health literacy offered to local communities

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Tribal member Annie Slease created the Mental Health Literacy Collaborative to help communities better understand mental health. She hopes to expand her work to include Indigenous communities.

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The Mental Health Literacy Collaborative

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Preventing Crisis: Mental Health Literacy and Why It’s Essential (Ep. 88)

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Podcast Episode · Schizophrenia: Three Moms in the Trenches · 04/17/2024 · 52m

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Shareable Flyer with QR code to YA Toolkit

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Shareable Flyer with QR code to YA Toolkit

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What Is Mental Health Literacy in Schools? A Guide for K-12 District Leaders | eLuma

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Find out how enhancing mental health literacy in schools can lead to better support for students facing mental health challenges.

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Inseparable - The Workforce Report: Bridging the Mental Health Care Gap

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Inseparable - The Workforce Report: Bridging the Mental Health Care Gap

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The Mental Health Literacy Collaborative

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CGI Commitment to Action — The Mental Health Literacy Collaborative

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Learn about our 2024 Commitment to Action with the Clinton Global Initiative

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Mental Health Literacy (MHL) Aware for Educators is a 60-minute training (with an optional certificate) that addresses professional, personal, and community needs for knowledge, language, and confidence around the topic of mental health. This training is the first step in guiding people to successfully integrate MHL into the fabric of their school community.

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MHL Aware Discussion Facilitator Application

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MHL Aware Discussion Facilitator Application

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Apply here: https://tinyurl.com/Aware-Facilitator-App