Addressing youth mental health through school-based services

The number of US children struggling with mental health challenges has hit historic highs. In 2023, four in ten high school students reported experiencing persistent feelings of sadness or hopelessness, and two in ten students seriously considered attempting suicide. For youth, nearly all indicators of poor mental health and suicidal thoughts and behaviors worsened from 2013 to 2023.¹Youth Risk Behavior Survey data summary & trends report: 2013–2023, US Centers for Disease Control and Prevention, August 6, 2024. Despite this, about 50 percent of youths with a mental health condition do not receive needed treatment or counseling from a mental health professional.²Daniel G. Whitney and Mark D. Peterson, “US national and state-level prevalence of mental health disorders and disparities of mental health care use in children,” JAMA Pediatrics, February 2019, Volume 173, Number 4. Obstacles to getting an appointment, cost issues, and a lack of services were the primary reasons children did not receive care for mental health.³Julie Fang Meng and Eileen Wiznitzer, “Factors associated with not receiving mental health services among children with a mental disorder in early childhood in the United States, 2021–2022,” Preventing Chronic Disease: Public Health Research, Practice, and Policy, October 10, 2024, Volume 21.

Schools have an opportunity to make a difference. District leaders consider student mental health to be a top priority (see sidebar “K–12 district funding and spending dynamics”). Yet research has shown that schools currently lack the staff coverage, access to licensed mental health professionals, and funding to effectively provide mental health services.⁴Nirmita Panchal, Cynthia Cox, and Robin Rudowitz, “The landscape of school-based mental health services,” KFF, September 9, 2022. To better support students’ mental health, both states and school districts could consider how to prioritize evidence-based interventions and determine how to sustainably fund them.

Our research and experience suggest that leaders of state and local agencies—such as state educational agencies, local educational agencies, state Medicaid agencies, and departments of health—could take six actions to make a lasting difference in school-based services and the mental health of students. These include offering comprehensive services, cultivating community partnerships, building up the mental health workforce, establishing a clear governance structure, implementing integrated data systems, and securing sustainable funding.

Offering comprehensive school-based services

Schools have already proved to be an important part of the continuum of care: Half of children aged 12 to 17 who receive mental health services receive at least some of that care in educational settings.⁵Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration, September 2020. There is an opportunity to sustain and expand comprehensive school-based services to support children and youths where they are. These include the following:

• upstream services and supports such as promotion of wellness, including social and emotional learning⁶For examples of evidence-based social and emotional learning interventions, see CASEL’s website.
• prevention (for example, brief screening for depression) and education related to mental health⁷For example, these could include school-based prevention interventions for opioid use disorder and cannabis use disorder as well as interventions for alcohol use harm reduction. For more, see Joe Markiewicz, Kim Swanberg, and Martin Weis, “Awareness, education, and collaboration: Promising school-based opioid prevention approaches,” Substance Abuse and Mental Health Services Administration, 2018; Preventing marijuana use among youth, Substance Abuse and Mental Health Services Administration, 2021; and “School health and Alcohol Harm Reduction Project,” National Drug Research Institute, updated on December 19, 2023.
• safe and healthy use of social media⁸In 2023, the Office of the Surgeon General issued an advisory calling attention to growing concerns about the effects of social media on youth mental health. For more, see “Social media and youth mental health,” US Surgeon General, 2023. The McKinsey Health Institute also recently completed research on the mixed impacts of social media use on Gen Z. For more, see Erica Coe, Andrew Doy, Kana Enomoto, and Cheryl Healy, “Gen Z mental health: The impact of tech and social media,” McKinsey Health Institute, April 28, 2023. The not-for-profit Common Sense provides digital citizenship lesson plans for use in schools that address an array of digital literacy topics, including media balance and well-being.
• early identification and intervention, such as brief interventions for anxiety and bullying
• treatment that reflects the full continuum of care for mental health needs, including higher acuity, which may be provided by community partners⁹“What is PBIS?,” Positive Behavioral Interventions & Supports, accessed February 18, 2025.
• provision of family supports and services to caregivers for the benefit of the child

Data has shown that youths with serious emotional disturbance are two times more likely to drop out of school than those with other disabilities.¹⁰“OSEP fast facts: Children identified with emotional disturbance,” Individuals with Disabilities Education Act, May 6, 2020. Proactively identifying students with mental health needs prior to intervention may improve outcomes,¹¹Scaling coordinated specialty care for first-episode psychosis: Insights from a national impact model, National Alliance on Mental Illness, November 2024. save on costs, and increase school attendance.¹²Lisa B. Dixon et al., “Transforming the treatment of schizophrenia in the United States: The RAISE Initiative,” Annual Review of Clinical Psychology, January 12, 2018, Volume 14. For example, some schools have successfully implemented an evidence-based school intervention called the Good Behavior Game, a team- and classroom-based behavior management strategy.¹³For more, see Good Behavior Game at American Institutes for Research. Teachers and other school staff who have used this intervention have created classroom environments that are more supportive for students with mental health needs, leading to fewer classroom disruptions.

To address the needs of all students, comprehensive care includes an array of research- and evidence-based practices along the continuum of care, such as universal mental health screenings,¹⁴See, for example, “School mental health quality guide: Screening,” School Health Assessment and Performance Evaluation System, 2023. social-emotional learning,¹⁵See Second Step for examples of programming. and interventions that target student mental health challenges and positively affect academic outcomes (such as the Brief Intervention Strategy for School Clinicians and Cognitive Behavioral Intervention for Trauma in Schools).¹⁶For more, see the website of The Center for Safe and Resilient Schools. State agencies could also consider providing incentives and resources to help districts support the mental health needs of school staff; doing so has been shown to positively affect the mental health of students.¹⁷Advancing comprehensive school mental health systems: Guidance from the field, National Center for School Mental Health, September 2019; Every young heart and mind: Schools as centers of wellness, Mental Health Services Oversight & Accountability Commission, October 7, 2020. These interventions could address stress, burnout, anxiety, and secondary trauma among school staff.¹⁸Lindsey Phillips, “A closer look at the mental health provider shortage,” Counseling Today, May 2023.

Multiple state agencies (including state education, health, and Medicaid agencies) have released guidance and provided funding and technical support to help districts adopt comprehensive mental health services in schools. For example, the state educational agencies of Wisconsin and Colorado released frameworks for school-based mental health services, and Michigan launched a technical-assistance center to support state agencies in implementing comprehensive care models.¹⁹Advancing comprehensive school mental health systems: Guidance from the field, National Center for School Mental Health, September 2019.

Cultivating strong community partnerships

Comprehensive services, from prevention to targeted supports, are most effective when schools partner with local communities to understand community needs and build upon existing community assets. Young people thrive when they live in healthy, inclusive communities that augment protective factors that are vital to increasing resilience and well-being.²⁰“Protective factors,” National Center on Safe Supportive Learning Environments, accessed on February 18, 2025. Conversely, mental health conditions may be exacerbated by challenging living conditions, such as housing insecurity. Community partnerships could be a conduit to a more holistic, wraparound support system by connecting schools with a broader set of social services and community-based resources (such as housing, transportation, and family supports), thus reducing the burden on schools and individual student households.

Community partnerships may include collaborating with family- and youth-based organizations such as Sesame Workshop (for preschool-aged children who have experienced trauma), Federation for Families, Community Anti-Drug Coalitions of America, and Youth MOVE. Partnerships could also involve faith-based or recreational organizations that offer mentorship and social supports, or they could include physical-health providers such as outpatient clinics, federally qualified health centers, primary care and pediatric practices, and hospitals. These partnerships can increase the volume and types of mental health services available for students both within and outside the school building.²¹Advancing comprehensive school mental health systems: Guidance from the field, National Center for School Mental Health, September 2019. School districts could consider telehealth-based partnerships to bring accessible and remote services to regions where transportation to a physical location is a barrier to care.²²Preliminary evidence suggests telehealth services may be as feasible, acceptable, sustainable, and effective as in-person services. For example, one study found a significant concordance between video and in-person evaluations and no meaningful difference in satisfaction in the use of telehealth with children and adolescents. Nicole E. Gloff et al., “Telemental health for children and adolescents,” International Review of Psychiatry, 2015, Volume 27, Number 6.

State agencies could consider establishing or enhancing existing state and local children’s cabinets.²³For more, see “Children’s Cabinet Networks,” Forum for Youth Investment, accessed on February 18, 2025. These collaborative networks are made up of children’s health advocates, peers, and young adults with lived experiences; government officials; and private sector or not-for-profit leaders. They offer a broad platform for sharing knowledge, capabilities, and resources and foster a deep sense of accountability from a governance and policy standpoint. As of 2019, 27 states have stood up children’s cabinets (or similar structures), with 30 percent of those cabinets embedded in the governor’s office.²⁴“Building and empowering impactful children’s cabinets,” National Governors Association, March 8, 2024. For example, Maryland’s Children’s Cabinet prioritizes interventions and supports to address adverse childhood experiences, prevent out-of-state placements through stronger interagency collaboration, address youth homelessness, and more.²⁵“Maryland Children’s Cabinet three-year plan (2021–2023),” Maryland Governor’s Office of Crime Prevention and Policy, 2021.

Building a robust, diverse, and well-trained mental health workforce

School systems cannot wait for broader mental health workforce shortages to be resolved. Actions can be taken now to mitigate shortages—including expanding coaching and peer support, upskilling existing staff, and expanding telehealth services. It may be possible to attract additional talent to the field by reforming complex licensure and education requirements, increasing compensation, and recognizing and funding the full array of mental health professionals. Peer support specialists, community health workers, mental health coaches, and school-based mental health coordinators can expand the diversity and availability of services and interventions for mild to moderate conditions while freeing up capacity for licensed clinicians to address more severe or complex conditions. In addition, research suggests that students are open to, and want, peer support. For example, in a 2020 Mental Health America survey, 44 percent of youths aged 14 to 18 responded that support from other young people would be most helpful for their mental health,²⁶Young people’s mental health in 2020: Hope, advocacy, and action for the future, Mental Health America, 2020. highlighting an opportunity to increase peer support specialists.

States could also consider opportunities to train and upskill new or existing school-based staff who play meaningful roles in fostering student well-being. For example, educating and training teachers, coaches, and administrative staff about mental health and substance use disorders may increase referrals to screening, supports, and services.

Last, some states may consider expanding telehealth supports and services in schools by embracing relevant technologies and removing barriers to telehealth reimbursements in school-based settings. Doing so could potentially address shortages in school psychologist and other clinician roles, reduce wait times to see a professional, and allow schools to reach a broader group of students.²⁷Preliminary evidence suggests telehealth services may be as feasible, acceptable, sustainable, and effective as in-person services. For example, one study found a significant concordance between video and in-person evaluations and no meaningful difference in satisfaction in the use of telehealth with children and adolescents. Nicole E. Gloff et al., “Telemental health for children and adolescents,” International Review of Psychiatry, 2015, Volume 27, Number 6.

Several states have already begun taking these types of actions. For example, in 2021, California launched the Children and Youth Behavioral Health Initiative (CYBHI), a more than $4 billion effort to enhance, expand, and redesign the systems that support mental health for children and youths. In addition, CYBHI expands the number of mental health training opportunities across the state, builds out a new “wellness coach” role, and provides trauma-informed training for all educators.²⁸“CYBHI for Schools,” CYBHI, May 3, 2024.

Establishing a clear governance and accountability structure

Achieving effective and continuous delivery of comprehensive services within schools requires collaborative efforts among essential systems concerned with child welfare, such as community-based organizations, service providers, and other state agencies responsible for mental health, education, justice, child welfare, housing, and social services. Too often, these systems operate in silos, limiting the potential for impact because of uncoordinated efforts in funding, data sharing, stakeholder engagement, accountability, and decision-making.

States may benefit from creating a more coordinated central governing structure that prioritizes the health of children and youths and has regular touchpoints. The governance structures could be formalized and fully funded. In addition, roles and responsibilities can be delineated across relevant community and system stakeholders—including educators, pediatricians, psychiatrists, school psychologists, counselors, social workers, and agency leaders—in the mental health journey.

A core aspect of this structure is including the voices of youths and families with lived experiences as part of the decision-making process (see sidebar “Guiding principles to support the six actions”).

Implementing integrated data systems

Data can be a powerful tool for driving equitable, systemic change by providing a comprehensive view of the landscape of school-based mental health needs, resources, providers, and outcomes. It can be used to identify areas of focus based on disparate student needs, such as suicidality among female or LGBTQ+ students or anxiety rates among Black boys. Data can then be used to map those needs to available resources, such as the number of children’s mental health professionals or the number of clinicians trained in culturally relevant care to serve Tribal youths. Following this mapping, the data can be used to identify gaps in treatment—for instance, if a particular district has insufficient staff trained in trauma-informed care. Data’s potential impact on mental health outcomes is evident in crisis-counseling hotlines that use machine learning to identify individuals most at risk for suicidal ideation or self-harm and move them to the front of the queue.²⁹Brian Resnick, “How data scientists are using AI for suicide prevention,” Vox, June 9, 2018.

Strategic use of data can help drive continuous quality improvement across services by allowing states to track outcomes and assess impact across a variety of health indicators, such as changes in students’ academic performance, rates of depression, and substance use. It can also be used to help streamline care and sustain funding across systems and providers, as seen in the data collection efforts by System of Care grantees of the Substance Abuse and Mental Health Services Administration, now the Administration for a Healthy America.³⁰“System of Care,” NTTAC Mental Health, accessed June 3, 2025 Data related to child and youth mental health outcomes are collected at regular intervals to help grant makers, community members, providers, and system leaders understand the impact of those grants on improving child and youth health. Similarly, state agencies could collect data to help clarify student needs and guide policy toward better outcomes or use available data from school districts, public health agencies, or partnerships with university research departments.

States will need to ensure alignment with data privacy laws such as HIPAA and FERPA,³¹The Health Insurance Portability and Accountability Act and the Family Educational Rights and Privacy Act. including consent from youths and families to share their data. Through appropriate and transparent data-sharing agreements, states could consider integrating data about mental health, substance use, or school climate into state reporting and accountability systems (for example, school report cards as required by the Every Student Succeeds Act and reports by state or local grant programs). And they could potentially work with other agencies focused on children and youths, such as those involved in child welfare and juvenile justice, to set benchmarks and common goals to track progress toward better K–12 outcomes.³²Advancing comprehensive school mental health systems: Guidance from the field, National Center for School Mental Health, September 2019.

Securing flexible and diversified funding mechanisms

All the above recommendations fall flat without the funding to make them possible. With ESSER funding now expired and future federal funding uncertain, states are at an inflection point. Alternative funding mechanisms, such as insurance reimbursement, may be needed to sustain and enhance school-based mental health services.

Insurance reimbursement

In 2023, the Centers for Medicare & Medicaid Services (CMS) released updated guidance to states to facilitate reimbursement for healthcare services provided in school-based settings.³³“Delivering service in school-based settings: A comprehensive guide to Medicaid services and administrative claiming,” CMS, May 18, 2023. This guidance builds on prior efforts to facilitate reimbursement, such as the 2014 CMS guidance allowing states to pay for medically necessary services for any student eligible for Medicaid,³⁴“SMD# 14-006, Re: Medicaid payment for services provided without charge (free care),” CMS, December 15, 2014. regardless of whether those services are identified in an individualized education program or individualized family service plan.

States could also consider opportunities to expand private insurance and Medicaid participation in the reimbursement of school-based services and look to other states for inspiration. In California, for example, CYBHI established a first-of-its-kind multipayer fee schedule program³⁵“California moves to transform the behavioral health delivery system—are payers and providers ready?,” Foley & Lardner, October 31, 2022. to make it easier for children and families to receive outpatient services and support for mental health and substance use disorder when, where, and how they need them. This program allows local educational agencies and public institutions of higher education to receive reimbursement for services carried out in schools. Since its inception, more than 3.6 million students and more than 500 local educational agencies have enrolled in the program.³⁶“Children and Youth Behavioral Health Initiative Fee Schedule program,” California Department of Health Care Services, accessed on May 20, 2025. In addition to accessing federal and private insurance dollars, states could identify creative ways to pool existing public dollars, including blending multiple funding streams and directing them toward school mental health supports and services.³⁷Alyssa Rafa et al., State funding for student mental health, Education Commission of the States, March 2021.

Other funding

State educational agencies could also consider providing technical assistance to school districts to help them access grant programs administered at the state level. For example, the Bipartisan Safer Communities Act of 2022 provides more than $1 billion in funding over five years to support schools in addressing youth mental health needs, including funding to expand the school-based mental health workforce.³⁸Bipartisan Safer Communities Act, Pub. L. No. 117-159, 136 Stat. 1313. And Certified Community Behavioral Health Clinics ensure access for all individuals in need of mental health services through a comprehensive and coordinated array of services at the community level, including in partnership with schools.³⁹“Certified Community Behavioral Health Clinics (CCBHCs),” Substance Abuse and Mental Health Services Administration, April 24, 2023.

The United States is experiencing a youth mental health crisis. While all states are addressing this crisis in some capacity, significant opportunities for greater impact remain in each of the six actions described above.

By meeting kids and youths where they are, evidence-based services in schools can promote mental health, help prevent mental illness, and provide early intervention. Beyond that, these services can improve students’ academic performance⁴⁰“Comprehensive school-based mental and behavioral health services and school psychologists,” National Association of School Psychologists, 2021. and social relationships⁴¹Blair Wriston, Nancy Duchesneau, and Manny Zapata, “How mental health supports impact students’ social, emotional, and academic development (SEAD),” The Education Trust, September 2023. and equip them with tools for mental well-being that they can use throughout their lives.