Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

The Community Schoolyards project is an initiative that aims to transform asphalt schoolyards into green spaces that can serve as public parks and outdoor recreation areas for urban communities. The project is based on the idea that schoolyards are a valuable but underutilized resource that can benefit students, families, and neighbors, such as improving health, education, equity, and climate resilience.[1]

According to Trust for Public Land, parks are essential for healthy, equitable communities, but across America, 100 million people - including 28 million children, do not have a park close to home. This means they miss out on the physical, mental, and social benefits of spending time in nature. In our biggest cities, communities of color have access to 44 percent less park space than majority white communities.[2] This creates environmental injustices and health disparities that affect people’s quality of life and well-being. Nationwide, 36 percent of public school students attend school in heat islands, which negatively impacts cognitive development and can cause heat stress in children.[2] A growing body of research also connects extreme heat – which is even worse in urban heat islands – to increases in attempted and completed suicides, depression, substance use, and hospitalizations for mental health conditions.[3]

Gaps in park access and the effects of urban heat islands can be addressed by turning existing public schoolyards into vibrant, shared outdoor spaces that benefit the entire community. American public schools own a combined two million acres of land with much of it remaining closed to the public outside of school hours. If every public schoolyard in the U.S. functioned as a shared outdoor space, 20 million more people, including over 5 million children, would have access to a park within a 10-minute walk of home.[2] This would significantly improve the quality of life and well-being of millions of Americans, especially those who live in underserved communities.Green schoolyards can provide multiple benefits for students and communities, such as improving physical and mental health, enhancing academic performance and attendance, increasing prosocial behavior, reducing crime and violence, and mitigating urban heat islands and stormwater runoff.[2][4] Access to green spaces in childhood has also been shown to protect against the development of many mental health disorders in adolescence and adulthood. One of the most significant benefits is psychological restoration, which can help prevent stress-related issues, depression, and mood disorders.[5]The ORLP grant program is a nationally competitive program funded through the Land and Water Conservation Fund (LWCF). The program targets grant assistance to urban areas with little or no access to publicly available outdoor recreation spaces.[6] The program is administered by the NPS and is an ideal mechanism for codifying the Community Schoolyards initiative at the federal level. The program aligns with the goals and objectives of the initiative by prioritizing projects that create new or reinvigorate parks in economically disadvantaged areas.

Children’s mental health is a critical issue that affects millions of families in the United States. According to the American Academy of Pediatrics, more than 14 million children and adolescents in the United States have a diagnosable mental health condition.[1] Using data from the 2016 National Survey on Children’s Health, researchers at the University of Michigan also found that only half of children with mental health conditions were receiving treatment.[2] Moreover, the COVID-19 pandemic has exacerbated the mental health crisis among children, with increased rates of anxiety, depression, and substance use disorders.[3] Many communities lack enough options for children’s mental health treatment, and often children do not receive the care they need, which can lead to more severe mental health problems. Consequently, children’s hospitals are seeing more children in crisis who are “boarding,” or waiting in hospitals (often emergency departments) for suitable care placements to open up.[4]

The Strengthen Kids’ Mental Health Now Act would improve access and quality of mental health care for children and adolescents by increasing community-based provider rates for pediatric mental health services. The bill would also improve state implementation of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), a Medicaid coverage requirement that provides comprehensive and preventive health care services for children under age 21, to improve accessibility to pediatric mental health and substance use services that EPSDT guarantees, but often fails to deliver.[5]

The legislation also identifies the regulatory and legal hurdles that prevent providers from increasing their ability to provide pediatric mental health services and encourages existing flexibilities states can use to broaden mental health services, while creating a new Health Resources and Services Administration (HRSA) grant program to improve community-based pediatric mental health services and help communities implement or develop new programs and policies that suit the mental health needs of children and adolescents. Additionally, the bill aims to establish a new HRSA workforce grant program that focuses on strengthening the pediatric mental health workforce, through more training for the current workforce and focused investment in the recruitment, retention, and diversity of future pediatric mental health professionals. Finally, the bill proposes to create a HRSA program that aims to enhance vital pediatric mental health infrastructure and expand our national ability to deliver suitable care for children with more intensive treatment needs.[5]

Domestic and sexual violence have damaging long-term mental health effects on both mothers and their children. About 20 percent of people who survive IPV experience new mental health disorders as a result of the abuse, including major depressive disorder, post-traumatic stress disorder, generalized anxiety disorder, and a wide range of substance use disorders (SUDs).[1] Tragically, more than 50 percent of female homicide victims are killed due to some type of IPV.

Congress should pass the Protect Moms from Domestic Violence Act, which would address IPV during pregnancy by requiring the Department of Health and Human Services to study maternal mortality and morbidity due to IPV, with recommendations on best practices for reducing maternal mortality due to IPV. The bill would also require the National Academy of Medicine to study whether various forms of violence increase the risk of suicide, SUDs, and drug overdose among pregnant and postpartum people. Finally, the bill would provide grants to nonprofit and community-based organizations to improve maternal and child outcomes of IPV victims.[2]

School “zero-tolerance” policies, many of which were imposed in the 1990s, for discipline encourage a strict approach, increasing the number of expulsions and suspensions for actions ranging from possessing weapons or drugs to fighting and swearing.[2][3] However, research has shown that zero-tolerance punishment is ineffective in changing student behavior and that proactively engaging students has more productive and cost-effective outcomes than punitive actions.[1][2][3][4][5]

SEL and executive function programs have proven to be an effective means for positively influencing student behaviors.[3][5] SEL programs, like the Responsive Classroom approach to teaching, engage students in developing academic, social, and emotional skills in a safe and responsive learning environment.[6] Executive function training programs like ACTIVATE improve cognitive function for children with attention deficit hyperactivity disorder (ADHD), autism, or other learning disorders.[7] Using Federal Title I education funds, schools should replace zero-tolerance policies with SEL and executive function training programs.[1]

Peer support programming for youth and young people can effectively provide mental health support outside of traditional healthcare systems and can support culture change within healthcare systems. It is a trauma-informed practice recognized by SAMHSA that can help youth and young people manage their physical and mental health, build support networks, and engage in services.[1] Peer support is a priority outlined in President Biden’s 2022 Presidential Unity Agenda, and SAMHSA has issued National Model Standards for Peer Support Certification for local, state, federal, and tribal partners. [2][3]

Peer support is a Medicaid-covered service in over 45 states and reimbursable by the Veterans Administration. In 2013, CMS and SAMHSA issued an Informational Bulletin providing guidance to states on how to establish peer support services as a Medicaid benefit for children, youth, and young adults with “significant behavioral health conditions.” [4] Still, Medicaid funding for youth peer support is commonly funded under state Medicaid waivers, limiting available funding to a small percentage of high-need youth.[5] School-based health centers that are designated federally qualified health centers can also receive increased federal matching funds for providing Medicaid-approved mental health services like youth peer support but often express confusion about how to seek those funds. Similarly, school districts are often not familiar with how to properly bill Medicaid for peer support services – either provided by the school or by a peer hired by the school, community mental health center or provider, or other school-linked community organizations.[5] The Bipartisan Safer Communities Act invests in school-based services through Elementary and Secondary Education Act grants. However, it is unclear that youth peer support may be implemented with this funding.[6]

CMS and the DOE should ensure schools and states are aware that youth peer support programs may be implemented and expanded and should provide guidance to states on billing for peer services. CMS should update its administrative claiming guide with information about claiming and billing for youth peer support, with additional guidance on the topics of parental consent and alignment with provider requirements. CMS should also issue clarifying guidance that people under 18 years old can be provided peer support by another person under the age of 18. Guidance should discuss both Medicaid reimbursement pathways through managed care organizations and Medicaid fee-for-service reimbursement. CMS and SAMHSA should additionally offer learning collaboratives and technical assistance to states on peer support implementation and billing best practices and offer learning communities.[5]

Schools play a vital role in preventing, identifying early, and addressing students’ mental health and substance use challenges, especially in the wake of the COVID-19 pandemic. However, many schools lack adequate resources and staff to provide effective and accessible MH/SUD services and supports.[1]

The ASSIST Act would establish a new grant program at the Department of Health and Human Services to help schools and school-based health centers hire and retain qualified MH/SUD providers, such as counselors, social workers, psychologists, and psychiatrists. The ASSIST Act would also permanently increase the federal government’s share of Medicaid reimbursement of school-based services, including MH/SUD care, to 90 percent.[2] This would help states sustainably increase the rate of pay for school-based providers, which would help reduce provider shortages and turnover. A higher Medicaid reimbursement rate would also reduce the administrative burden on schools and states to claim Medicaid reimbursement for school-based services.

By passing the ASSIST Act, Congress can make a significant investment in the mental health and well-being of our nation’s students. School-based MH/SUD care can improve access to care, allow for early identification and treatment of MH/SUD challenges, reduce stigma and discrimination, and promote academic achievement and positive youth development.[3] The ASSIST Act would help ensure that every student has access to the behavioral health services they need to thrive.