What we can learn from New Hampshire's response to youth mental health needs

Mental health among children and adolescents has long been a concern in the United States. However, the COVID-19 pandemic intensified social isolation, economic stress, and disruptions to everyday routines and support systems, all of which contributed to the increase in mental health issues among young people.

Data from the Centers for Disease Control and Prevention showed that the number of children and adolescents seeking emergency help for mental health issues rose by 20-30% in 2020.¹ Citing an uptick in ER visits and alarming upsurges in depression, anxiety, grief from the loss of a caregiver, and suicidality in K-12 populations, the American Academy of Pediatrics declared a state of emergency in children's mental health.²

While we are still uncovering the full, long-term impact of the pandemic, educators, parents, and therapists agree that the pandemic profoundly upended the mental health landscape for young people. Academic and social setbacks, grief, and financial insecurity all contributed to the increase in mental health issues during the pandemic — and unfortunately, too many kids fail to get help before their burden and unmet needs lead them to emergency circumstances.

Before the pandemic, New Hampshire (NH) started to organize state resources toward a comprehensive program to tackle increased mental health needs among children and families. In June 2021, the Comprehensive Assessment for Treatment (CAT) program was launched as part of an intensive redesign of the state's behavioral health services and in alignment with NH's System of Care Law, RSA 135-F.³

The NH System of Care Transformation initiative makes resources more accessible, effective, and aligned with best practices. The CAT program provides a conflict-free assessment to all children and youth in the state with more intense service needs to determine whether they need residential treatment and, if so, the appropriate service setting to meet their needs. In addition, the CAT program works with multiple state agencies within the System of Care, including child protection, juvenile justice, courts, and community providers, as well as care management entities, local school districts, hospitals, and substance use disorder providers. The program uses the Child and Adolescent Needs and Strengths (CANS) instrument to help determine the required level of services and protective factors and set treatment goals.

CAT program

By identifying the clinical needs and strengths of the youth and providing a conflict-free assessment process, the program aims to provide a comprehensive report and recommendation, which helps to guide the child and family team.

The program starts with referrals from the New Hampshire Department of Health and Human Services' Division of Children, Youth, and Families (DCYF), Bureau for Children's Behavioral Health, or the department's contractors. When a child requires services beyond what is currently offered in the community and a different level of care is indicated, Care Management Entities, DCYF, and other designated service providers within the Children's System of Care work together to determine the necessity of residential treatment and create a personalized recommendation for the child's care.

The assessment process involves close collaboration with the child, parent/guardian, referral source, and related partners in the child's life. The assessor employs the evidence-based CANS instrument and clinical questions to recommend the appropriate level of care and identify goals and protective factors. The consistent longitudinal data generated by this method is analyzed by Maximus, the state's private sector assessment provider, and the Department, to identify areas for continuous enhancement of services to meet the needs of the population being assessed.

The CAT assessment also includes a module on caregiver needs and strengths which helps to identify areas where the child's family may require additional support. Moreover, the CAT program provides data analysis and tools to help identify trends in the needs of both the child and family, such as substance abuse and disordered eating, as well as informs the state on where there may need to be additional programming or supports developed within the System of Care.

CAT program performance: Pulling in all stakeholders to deliver better outcomes for children

A core objective of the CAT program and New Hampshire's System of Care redesign is to provide the right level of services in the most appropriate setting. In the first year of operation, the CAT program has recorded a significant reduction in the number of children referred to the highest level of care by utilizing all available community resources and guiding youth to the most appropriate setting for care.

A second core objective is to accommodate referrals from the community — from a parent, teacher, or community therapist — rather than solely from the courts. Promisingly, over 20% of referrals in the first year came from the community, ensuring these children could access vital services without requiring court intervention or DCYF involvement. A third core objective of this redesign is to shorten the time a child may spend in higher levels of care, such as a hospital setting. The CAT provides expedited assessments for New Hampshire to ensure a youth's time in these settings is reduced, and they can move to the appropriate setting for services as quickly as possible.

Moreover, New Hampshire designed CAT to fit into a constant service-array evaluation. As a result, the state continually uses program data to identify not only what services are needed, but where they are needed. Capturing this information provides a powerful tool to drive policy and service delivery decisions.

Conclusion

The COVID-19 pandemic accelerated and exacerbated the gaps in getting American children and adolescents the mental health supports they need, leading to an unprecedented and historic crisis for an entire generation of young people. While much work is still necessary to fully address the children's mental health crisis, New Hampshire's CAT program, in conjunction with the entire System of Care development, provides a promising model for other states to follow.

By leveraging public and private sector partnerships, employing data-driven strategies, and dismantling barriers between stakeholder agencies, states can deliver a comprehensive and coordinated response to the mental health needs of children and families. Through collaboration between public-private partnerships, communities, and families, we can help increase access to the care and support children need to thrive. 

Resources

[1] Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1675–1680. DOI: https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm?s_cid=mm6945a3_w 

[2] AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/

[3] New Hampshire Title X Public Health. Chapter 135-F: System of Care for Children's Mental Health. https://gencourt.state.nh.us/rsa/html/X/135-F/135-F-mrg.htm