Our School of Thought
How Schools Can Help Address the Adolescent Mental Health Crisis
Despite increased attention, an influx of institutional investment, and digital health innovation, the current state of adolescent mental health remains in crisis. Leveraging our school systems, where adolescents spend the majority of their time, is a logical path to scaling care. Able Partners is excited to announce our investment in Cartwheel, a virtual care platform partnering with students, families, and school districts to tackle the mental health crisis in K-12 schools.
- The state of mental health among adolescents has been deteriorating over the last several decades, well before the COVID-19 pandemic, and was officially declared a “devastating” crisis last year by the U.S. Surgeon General in a rare public advisory.
- The adolescent population is currently drastically underserved by traditional treatment options (e.g. talk therapy, medication, and inpatient care) due to the lack of care infrastructure and an ongoing shortage of clinicians, even despite the rise of telehealth facilitating scaled care and helping to partially mitigate the supply challenges.
- Schools play an instrumental role in adolescents’ everyday lives and as a result, have an opportunity to help enable earlier intervention if they are equipped with mental health care infrastructure and trained resources that allow them to partner with families to improve outcomes.
The need for mental health treatment options tailored specifically to adolescents has never been more pronounced. In a survey of nationally representative high school students conducted in the first half of 2021, the CDC found that nearly half of the students reported they persistently felt sad or hopeless during the previous twelve months, while more than a third reported they experienced poor mental health — including stress, anxiety, and depression — during the pandemic. More alarming, 47% of LGBTQ+ students had “seriously considered committing suicide,” compared to 20% of students on average, driven by stigma, trauma, and bullying.¹ Among all 10 to 24 year-olds, suicide is now the second leading cause of death in the United States² where data suggests, “1 in 5 young women (and 1 in 10 young men) experience a clinical episode of major depression before age 25.”³ While the pandemic brought attention to the mental health crisis, it shouldn’t be ignored that the state of adolescents’ mental health has been deteriorating since the late 2000s. While the causes aren’t concretely understood, research points to increasing academic pressure, lifestyle changes, and the rise of social media as being contributing factors,⁴ only made worse by the acceleration of puberty onset before the brain has fully developed to self-regulate emotional responses.⁵
Investors have begun to take notice, recognizing the need for mental health solutions designed for this age demographic. Funding for digital behavioral health tools for children and teenagers reached $919 million in 2021, more than double the amount raised in 2020, but that only accounted for less than 20% of the year’s total mental health tech sector funding.⁶
Despite the increase in funding and proliferation of digital tools, applications and services, the supply has not been able to keep up with the growing demand for mental health care. Both the lack of existing infrastructure in the school system and the shortage of care providers have challenged the supply side:
- Schools lack the necessary infrastructure: Ideally, schools should operate within a framework known as Multi-Tiered Systems of Support (MTSS), and to their credit, some already do. MTSS is designed to address students’ varying degree of needs through three tiers of escalating behavioral and academic support. The framework calls for teachers to spearhead Tier 1 interventions that are more preventative in nature. The most common example is through Social Emotional Learning (SEL) classroom activities such as journal prompts, arts and crafts, and mindfulness exercises where students learn how to understand emotions, connect with others, and make decisions. A sub-set of the school population identified as being at-risk, or experiencing mental health difficulties, is then escalated to Tiers 2 and 3, where diagnosis and treatment occur. However, the practical implementation and execution of the MTSS framework is still nascent. Schools are grossly understaffed, mental health literacy training for teachers is lacking, and some stigma still exists around talking about mental health in schools. Despite increased reliance on teachers to fill the gap in school-based mental health care, a recent study published in Psychology in the Schools found that the vast majority of teachers surveyed have had zero or very few trainings on student mental health.⁷
- There are not enough care providers: Less than 20% of adolescents struggling with mental health issues are adequately treated and three-quarters of those that are seeking treatment rely on help from schools, which have historically lacked resources.⁸ According to the U.S. Department of Education, only two states meet the American School Counselor Association (ASCA)’s recommended student-to-counselor ratio of 250 to 1, with a national average ratio of 415 to 1 as of the 2020–2021 school year.⁹ In fact, less than half of states mandate a school counselor for grades K to 8, and only 30 states require one for grades 9 to 12, where a third of those mandating a school counselor do not provide schools with state funding.¹⁰ Furthermore, school counselors across the nation often do not have clinical licenses. Without these licenses, school counselors cannot bill Medicaid and private insurance for the care they provide which often precludes schools from recouping federal funds. Outside of the education system, there has been an ongoing national shortage of youth and adolescent psychiatrists, leading to extremely long waitlists for inpatient and outpatient care both in person and virtually.¹¹ There are currently only 25% of the recommended number of psychiatrists per one hundred thousand children, and 7 out of 10 U.S. counties do not have a child psychiatrist at all.¹² These pain points are only further magnified in rural communities where it is a struggle to both recruit school counselors and access providers outside of the education system for referrals.
In response to the dramatic need for providers, the regulatory landscape has shifted to expand psychiatry residency slots, accelerate private partnerships, and allocate funding to school-based resources. Legislation passed in 2020 increased the number of Medicare-supported residency slots for the first time in decades and in the last few years the number of psychiatry residents rose 21%.¹³ It is encouraging to see federal policy expand mental health resources in schools to reduce the reliance on outside clinical providers. Additionally, there has been an increase in federal funding directed at school-based care as part of the American Rescue Plan, which allocated more than $160 billion to Elementary and Secondary School Emergency Relief (ESSER) and Higher Education Emergency Relief Fund (HEERF). To help schools sustain mental health professional roles, the Department of Health and Human Services is working to make Medicaid reimbursement easier. President Biden’s fiscal 2023 budget also proposes “$1 billion to help schools hire additional counselors and school psychologists and other health professionals.”¹⁴
Ultimately, at the root of the adolescent mental health crisis are systemic flaws that will not be solved by the existing system. At Able Partners, we believe generational change will come from improved policy and fundamental societal shifts, but until then, we are hopeful that private sector innovation can help augment existing school systems by addressing the need for infrastructure and additional providers. This will allow schools to play a significant role in identification and intervention on the front lines, which students are beginning to expect.¹⁵ Research has shown that students are 21 times more likely to visit school-based health centers than community providers¹⁶ and are therefore more likely to seek, and be receptive to, mental health services when they are available in schools.¹⁷
We are excited to partner with Cartwheel, which will serve as a critical part of the solution to bolster schools’ infrastructure and ease the shortage of clinical providers. Not only does Cartwheel provide students and families with direct clinical mental health care, but Cartwheel also partners with school staff to strengthen MTSS through professional development and skill-building workshops. By offering the tools to help schools become self-sufficient at the ground level, and the clinical resources to combat care fragmentation, Cartwheel is imagining a world where 100% of adolescents have access to the care they need — when they need it — and so are we.
¹CDC, Adolescent Behaviors and Experiences Survey (ABES)
²CDC, Facts about Suicide
³American Psychological Association, U.S. Youth are in a Mental Health Crisis — We Must Invest in Their Care
⁴The New York Times, Teens in Distress Are Swamping Pediatricians
⁵The New York Times, A Teen’s Journey Into the Internet’s Darkness and Back Again
⁶The Morning Consult, Digital Mental Health Startups for Kids Are Raking in Cash, New Data Shows. It Won’t Be Enough to Fix the Crisis
⁷Psychology in the Schools, Teachers’ Experiences with K-12 Students’ Mental Health
⁸The Wall Street Journal, We Need Mental Health Services for Schools
⁹American School Counselor Association, School Counselor Roles & Ratios
¹⁰American School Counselor Association, State School Counseling Mandates & Legislation
¹¹The New York Times, Our Children are Suffering. We Must Help Them
¹²Pediatrics Nationwide, Beyond A Bigger Workforce: Addressing the Shortage of Child and Adolescent Psychiatrists
¹³Association of American Medical Colleges, A Growing Psychiatrist Shortage and an Enormous Demand for Mental Health Services
¹⁴The White House, President Biden to Announce Strategy to Address Our National Mental Health Crisis, as Part of Unity Agenda in His First State of the Union
¹⁵National Alliance on Mental Illness, NAMI/Ipsos Poll: Teens Struggling with Their Mental Health, but Parents and Schools Can Help
¹⁶American Psychological Association, Schools Expand Mental Health Care
¹⁷National Association of School Psychologists, The Importance of School Mental Health Services 2016