I just finished my signature assignment for my Master of Public Health course which focuses on mental health care in children in California. I am passionate about mental health and wellbeing in adolescents especially in light of the COVID-19 pandemic. More must be done for our children to provide access to adequate mental and behavioral health services!

Healthy People 2020 Logic Model- Children’s Mental Health

A logic model assists in planning, implementing, developing, and evaluating public health measures and programs (Centers for Disease Control and Prevention [CDC], 2021a). This model will focus on reducing the proportion of persons who experience major depressive episodes (MDEs). It will be focused specifically on adolescent mental health.  Youth mental health has become an increasing concern, especially burdened by social isolation brought on by the COVID-19 pandemic. Nearly 1 in 5 of children are diagnosed with a mental/emotional health or behavioral disorder in the United States (CDC, 2020b).

With this intervention, Healthy People 2020 strives to deliver competent mental health care that is community centered, holistic, and equitable. Building upon such a measure improves correlation to proportion of adults with mental health disorders who receive treatment and is diagnosed and discussed at higher rates when depression screening tools are utilized more widely by primary care providers. The logic model that will evaluate Healthy People 2020’s measures to improve adolescent mental health, consisting of the following components: process- inputs, activities, and outputs outcomes- short, intermediate, and long; assumptions; and contextual factors. This paper will serve as an evaluation guide through discussion of all the parts of the logic model to plan, implement, and assess the delivery system and policies of adolescent mental health measures in California.

Process

Inputs

Inputs make up the resources that go into a logic model; they can include financial resources, in-kind stakeholders, and staffing resources that are delegated towards the program (CDC 2021a, p. 6). According to the CDC (2020b), many families cannot access mental health services for their children near their homes and must travel long distances or be placed on waitlists to establish care. Mental health providers are within short supply, especially in rural areas (CDC, 2020b). In California, Medi-Cal is responsible for providing mental health services for youth by county or local health jurisdiction; schools are also required to provide special education mental health services to children.  (California State Legislature, 2021).

Presented in the 2021-2022 budget are the following strategies and monies to address the state’s lack of coordinated mental health strategy.  California’s Mental Health Services Act (MHSA) was voted into the state budget in 2004, which allots $2 million for state mental health service services by placing a 1% income tax on annual salaries over $1 million (California State Legislature, 2021). Medi-Cal reimbursements also fund vital mental health resources within schools. Governor Gavin Newsome has approved, “$25 million ongoing in Proposition 98 matching Funds for County Children’s Mental Health Projects,” and, “provides $25 Million One-time to expand County‑School Partnership Grant Program,” (California State Legislature, 2021, para. 5) Additionally, the California legislature (2021) provided for $50 million to establish a County‑School Partnership Grant Program in the 2018-2019 budget (para. 4). The “Mental Health Services Oversight and Accountability Commission (OAC)—a state agency created by Prop 63,” administers grants every 4 years- which, by August 2020- established ten new grants to current county-school partnerships and eight new partnerships, also totaling 20 partnerships left unfunded in $80 million (California State Legislature, 2021, para. 4). Through each of these funding sources, schools can choose to hire private professionals, “contract with county mental health departments or outside contractors, establish on‑site school‑based health centers, or use a combination of approaches” (California State Legislature, 2021, para. 1). All these personnel resources are funded by Med-Cal reimbursable dollars (California State Legislature, 2021).

Activities

            Improving access to youth mental health is supported by the CDC’s 1 in 5 project efforts. Children statistically benefit from earlier diagnosis and intervention; however, “only about 20% of children with mental, emotional, or behavioral disorders receive care from a specialized mental health care provider,” (Centers for Disease Control and Prevention, 2020, para. 1). Activities within this logic model are actions and plans taken to meet the goals of the Healthy People 2020 mental health initiatives (CDC, 2020b). Grant funding from the 2018-2019 $50 million dollar budget supported school-county partnerships by bolstering, at a minimum, “school‑based mental health services, suicide prevention services, dropout prevention services, support for students needing ongoing services, and outreach to vulnerable youth,” (California State Legislature, 2021 para 4.) Of funds contained within the MHSA, counties must provide a variety of mental health services to children of all ages (California State Legislature, 2021) These “programs provide a broad range of mental health services, including prevention and early intervention services, as well as full‑range mental health services for students with serious emotional disturbances not covered by health plans,” (California Legislature, 2021, para. 1). These are only just a few of the interventions and activities implemented to improve children’s access to mental health services. More work needs to be done to match children and families with providers and services that meet their mental/emotional, psychosocial, and behavioral health needs.

Outputs

            Outputs are the results of the actions taken discussed within the activities section; state-level programs, activities and interventions taken funded by the inputs to the program, for example determine children’s mental health output framework (CDC, 2020). Through the county-school partnership, children can receive mental-health services related directly to their educational level. This allows an increase school and didactic interventions while children attend school. Coordinating efforts is more cost effective as it provides early diagnosis, treatment, and intervention. Families may not have outside time to seek mental health services for their children; therefore, connected fragmented services offers children to function at an optimal psychosocial level. Expanding access to mental health services in schools allows for children to thrive while in school.

            Governor Gavin Newsome’s current matched proposal is vague and cumbersome, which hinders access to care due to the ambiguity of which the law is written. There are a lack of measurable objective listed in the $50 million mental health grant. Each grant must be approved and administered by the California Department of Education (CDE) instead of directly applying funding to counties’ OAC boards. Counties may not know how to apply for specific grant funding, which may affect services in the following ways: lack of increased spending on children’s mental health services; unlikely immediate increase in services; competition for funding by existing school-county partnerships; unmatched number of projects likely to receive funds; and most importantly, “expanded services may not be sustainable without matching funds,” potentially limiting access to future funds (California State Legislature, 2021, para 7). The California State Legislature (2021) seeks to make clear the existing language in the governor’s proposal, which would allow county-school partnerships to expand and become approved at an expedited pace.

A statewide effort to clarify how schools and counties should specifically coordinate efforts to offer services on a continuum. Addressing this gap between connecting children’s’ diagnoses (such as attention deficit disorder and hyperactivity disorder [ADD & ADHD]; anxiety and depression; Tourette’s syndrome, and childhood disruptive behavior syndrome) and matching them to appropriate providers bridges a lack of organization of services and programs offered.  Additionally, there is a need to address children’s’ mental health in rural areas and lack of policies addressing children’s’ mental health care in emergency departments (EDs) (CDC, 2020b). EDs are often overutilized, undertrained and used as a last resort to deal with mental health crises. Coordination effort throughout the state are necessary to address lapses in services across educational and developmental lines. Ongoing support to referrals according to appropriate facilities and programs allows children to access appropriate care.

Outcomes

Behavioral and developmental care outcomes are important in understanding and bridging the gap in children’s’ mental health services, especially in rural areas (Kelleher and Gardener, 2017). These outcomes are achieved by connecting services and may be measured by short-term, intermediate, and long-term expected results (CDC, 2021a).

                  Recording statistics on youth suicide rates is important in understanding the context of mental health services accessed and received in California. In 2007, adjusted by age to the year 2000 standard population, the baseline data on every 100,000 members of the population was 11.3 suicides (U.S. Department of Health and Human Services, 2020, para 10). “The target is 10.2 suicides, based on a target-setting method of 10 percent improvement,” (HHS, 2020a, para 1). By comparison, adolescent suicide attempts that required medical attention measured in grades 9-12 by sex was 2.4 % combined, 1.5% male, and 3.1% female, with a 2020 target of 1.7% (HHS, 2020a, para 2).  The breakdown of adolescent suicide attempts that needed medical attention (grades 9-12) by demographics were as follows in 2017: 2.4% total, 3.1% American Indian or Alaskan Natives, 3.0% Asian only, 2.1% Native Hawaiian or other Pacific Islander only, 4.0% 2 or more races, 2.8% Hispanic or Latino, 3.4% Black or African American only (not Hispanic or Latino), and 1.9% White only (not Hispanic or Latino). At baseline, 1.9% of suicides occurred in 2009, with a target rate of 1.7% (HHS, 2020a, para. 3).

                   By assessing depressive episodes, number of children receiving care, and suicide attempts, we can observe that there is a failure of the current mental health system. More work must be done to educate providers, develop robust mental health policies, and make lasting impact. Improving access to care is necessary to meet children’s’ mental health target goals for Healthy People 2020.

Short-term Outcomes

                  The COVID-19 pandemic and state mandatory quarantines have pushed many school systems to cut mental health services offered to youth within their home. Children who would be regularly accessing these services cannot do so at the same level with distance education enforcements. The short-term effects of limited mental health services can be better understood by examining depression screening rates.

                  Short term-outcomes of depression screenings measure depressive symptoms over a period of 7 days. Over the past year, COVID-19 survey questions presented by the U.S. Census Bureau Pulse survey measured depressive episodes by symptoms over a period of 7 days.  More households by proportion reported experiencing depressive symptoms, scoring 2 and 3 (sometimes or often experiencing depressive symptoms in the past 7 days) more often overall than in recent years (CDC, 2020a). The results of the screening tool show that anxiety and depression disorders are exacerbated by social isolation brought on by the pandemic. Short term outcomes of using this depression screening are educating more providers on how to use depression screening tools, increasing physician knowledge on depressive symptoms in adolescents, and increasing physician knowledge on warning signs for adolescent suicide attempts.

Intermediate Outcomes

The school-county partnership also seeks to address improving intermediate outcomes of existing mental health programs in California. A recent report out of EdSource cites California as receiving an “F” in educational interventions concerning mental health. The report recommendations match with the current California legislature recommendations of increasing spending on mental health resources in schools; increased funding for districts would allow hiring of more behavioral health personnel within the county-school partnerships. Increased funding for mental health professionals such as psychologists, nurses, social workers, and counselors helps to bridge the gap in delivering appropriate care and services to children care in mental, emotional, and behavioral health in the state (Jones 2020). The county-school mental health programs in the state are also fragmented, lacking in rural areas, and are competitive for funding that go towards grant programs. Appropriate intermediate actions to improve outcomes in California children’s’ mental health include deploying more mental health providers to rural areas, continuing funding for the governor’s proposed mental health grant program, and clearing up legislation so grant funding is easier to access for county-school programs.

Long-term Outcomes

            Long-term outcomes to improve children’s mental health care in California can be measured by the proportion of children aged 4-17 receiving mental health or behavioral care. In 2018, children with mental health problems receiving treatment by sex was 75.8% total, 75.7% male, and 69.8% female. The baseline in 2009 was 68.9% of children receiving mental health care. The target percentage, based upon a 10% improvement increase, is 75.8%. In 2018, the percentage of children aged 4-17 receiving mental health care by ethnicity was as follows: was 73.3% total, 62.8% Hispanic or Latino, and 79.2% White (not Hispanic or Latino), with a baseline of 75.8% (HHS, 2020a, para, 7). Clearly, improving access to care improves the number of children who are appropriately diagnosed with and receiving mental health services. Specifically, increasing mental health programs for children of minority descent, who are affected by limited services and higher suicide attempt rates than children of White descent, is needed to ensure mental health programs provide impactful, long-term, and effective care across the spectrum. Decreasing suicide rates and increasing overall percent of children receiving mental health treatments are the goal for creating impactful mental health services.

                                                                   Assumptions

           Assumptions are the predictions and beliefs cast upon a logic model. This allows for the theory evaluating the resources and programs involved to develop based upon best practice, common sense, and past experiences (CDC, 2020).  If children are supported in their early development, diagnosed early, and receive an ongoing spectrum of support by linked county-school resources, mental health measures will improve, and children will be able to be supported in their diagnoses and treatment into adulthood. The HHS (2020b) supports these findings presented by the Community Preventive Services Task Force, which recommends mental health legislation that secures financial resources and, “increase appropriate utilization of mental health services for people with mental health conditions,” (para. 1). Legislation needs to increase access to care to increase diagnosis rates, decrease prevalence of poor mental health and reduce suicide rates. This is supported by increasing mental health coverage and increasing financial resources that are allocated towards improving mental health (HHS, 2020b). Overall, legislation enacted at the state level that partners with local health jurisdictions and schools has proven to be effective.

Contextual Factors

         Contextual factors are those which exist externally that influence the program or intervention; they are outside forces which stakeholders may have little or no control of (CDC, 2020a). Contextual factors in implementing youth mental health are “illness and treatment representations, disease management, and health outcomes” (Höhn, Metzner., Waldeck, & Glattacker, 2020, para 1). Youth with chronic mental illnesses may not have access to care due to lack of insurance coverage or their families may live too far to regularly access vital mental health resources (CDC, 2020b). Despite these barriers to care Höhn, Metzner., Waldeck, & Glattacker (2020) show that youth with chronic illnesses have better outcomes with early rehabilitation, identification of gaps in services, and increasing the spectrum of mental health and behavioral services offered.

Conclusion

This logic model has evaluated the efficacy and availability of mental, emotional, and behavioral health services to children in California. Data from Healthy People 2020 Mental Health and Mental Illness was used to develop and assess interventions to improve mental health care. The proportion of youth that access mental health services has greatly increased in the last 10 years; however, percentage of suicide attempts that require medical care in grades 9-12 have not yet met their target rate. These measures indicate a gap in mental health services, including diagnosis through depression screenings for example and improving policies to address mental health crises in the ED. Providers must be better equipped to recognize signs of mental distress and appropriately recommend mental health services that best suit children diagnosed with a mental or behavioral disturbance. Moreover, improving the state’s county-school program allows for more personnel to be hired and more grant funding to be accessed to improve and create programs across the developmental spectrum. Clearing up on legislation will allow fragmented services to be linked and meet children’s’ needs appropriately without pulling them out of school. Securing finances for mental health legislation is vital to ensure families can equitably access appropriate services despite barriers to care such as living far from appropriate services and not having adequate coverage for their children’s mental health needs. Ultimately, supporting mental health uniformity legislation will aid in bridging these gaps and ensure equal access to care for all.

References

California State Legislature. (2021a, February 12). The 2021–22 Budget: School Mental Health. https://lao.ca.gov/Publications/Report/4368
            Centers for Disease Control and Prevention. (2020a). Mental health – household pulse survey – COVID-19. National Center for Health Statistics. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

Centers for Disease Control and Prevention. (2021b). Evaluation guide: Developing and using a logic model. State Heart Disease and Stroke Prevention Evaluation Guide. https://www.cdc.gov/dhdsp/docs/logic_model.pdf

 Centers for Disease Control and Prevention. (2020b, June 15). Improving Access to Children’s Mental Health Care | CDC. https://www.cdc.gov/childrensmentalhealth/access.html#:%7E:text=Nearly%201%20in%205%20children,from%20early%20diagnosis%20and%20treatment.

Höhn, C., Metzner, G., Waldeck, E., & Glattacker, M. (2020). Contextual factors of self-regulation in children and adolescents with chronic diseases – a qualitative analysis. BMC Public Health, 20(1), 1. https://doi.org/10.1186/s12889-020-10056-1

Jones, C. (2020, January 28). Children’s mental health a cause for concern in report on California youth policies. EdSource. https://edsource.org/2020/childrens-mental-health-a-cause-for-concern-in-report-on-california-youth-policies/623070
          

  Kelleher, K. J ., & Gardner, W. (2017). Out of Sight, Out of Mind — Behavioral and Developmental Care for Rural Children. New England Journal of Medicine, 376(14), 1301–1303. https://doi.org/10.1056/nejmp1700713

Turnock, Bernard J. (2016).  Essentials of public health (3^rd ed.). [VitalSource Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/978124087901.

US Department of Health and Human Services. (2020a, October 8). Mental Health and Mental Disorders | Healthy People 2020. Mental Health and Mental Disorders- Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders/national-snapshot

U.S. Department of Health and Human Services. (2020b). Mental health and mental illness: Mental health benefits legislation | healthy people 2020. Healthy People 2020. https://www.healthypeople.gov/2020/tools-resources/evidence-based-resource/mental-health-and-mental-illness-mental-health-benefits-legislation