Boosting youth mental health access

Throughout her 25 years as a school social worker, Michelle Vollan can't recall a period when the number of acute youth mental health situations requiring hospitalization was as high as it was post-Covid. 

Vollan has seen anxiety issues increasing, and along with that, attendance concerns and drops in grades for those affected. On the most severe end of the spectrum, thoughts of suicide and self harm have increased leading to cases of psychiatric hospitalization. 

And while a spike two years ago which led to 25 psychiatric hospitalizations at the Bismarck middle school she works at has leveled off, she said, the overall situation remains a concern. 

"I think, just from my experience, it's drastically increased," Vollan said, adding that hospitalizations have halved in the current school year. "However, I think there are as many kids that are suffering with anxiety, depression, that inability to cope ... those numbers have not dropped." 

Schools were never meant to be the front line for addressing youth mental health challenges, but that's what they've often become. 

"North Dakota has a mental health crisis that we're in the midst of, and our state is legally obligated to serve children that would have what they call serious emotional disorders or disturbance," said Carlotta McCleary, executive director of the North Dakota Federation of Families for Children's Mental Health. 

McCleary said around 18,000 youth in the state are in need of treatment for severe mental health issues, but few are getting the full support they need with continuous ongoing services. 

According to numbers her organization gathered through open records requests, only 73 youth were treated through the state's human service centers two years ago. Those numbers jumped to 966 during the 2023-2024 fiscal year, but are still far away from really meeting the population's needs.

"We're serving so few kids," McCleary said. "Where does that pressure go? It goes to our schools."

McCleary also said there's been increases in youth dealing with severe anxiety, which leads to snowballing impacts with attendance and grades to more acute situations. 

"We know that the kids who attend school do better. Their outcomes are better. If they can be at school, on time and attend and not have attendance issues, their outcomes are better," McCleary said. "Kids with anxiety have a great deal of difficulty, sometimes going to school and getting to school on time because of the anxiety." 

Left untreated, some youth brush up against the juvenile justice system and later, the adult criminal justice system. According to the most recent figures from the Division of Juvenile Services, 74% of the youth coming through the system have issues with mental health. 

System-wide approaches 

Two programs currently being rolled out across the state could begin addressing gaps in access, however, McCleary said. This includes a $3 million federal grant for implementing a System of Care system for youth from birth to 21 years of age in two regions of the state as well as a program for transitioning all clinics in the state to become Certified Community Behavioral Health Clinics (CCBHCs). 

"I do believe it's going to make a difference," Vollan said of the programs. 

System of Care is being put into place in the Lake Region Human Service Center around Devils Lake, which includes both the Spirit Lake and Turtle Mountain reservations, and in the West Central Human Service Center centered on Bismarck and including the MHA Nation and parts of Standing Rock reservations. 

Implementing this stems from a 2018 behavioral health study ordered by the legislature to research strengths and gaps in youth behavioral health services, said Katie Houle, clinical administrator in the behavioral health division at the Department of Health and Human Services (DHHS). 

System of Care is a set of philosophies and values, said Houle, that streamline and coordinate care for individuals and families dealing with mental health challenge by breaking down barriers between services preventing adequate care. 

Too often youth with a mental health crisis can feel like a "hot potato," Houle said, "being sent to different places and spaces and not feeling they are getting the services they need." 

Schools, inpatient and outpatient therapists, the juvenile justice system all have their own ways of addressing and interacting with youth, so anchoring them all in a system wide approach that includes the wider family and community is essential to building a better service climate, she said. 

"It's really going to take strategic planning and partnerships across juvenile justice, child welfare, schools, both public and private behavioral health services, and most importantly, thinking about how we work with our family organizations and youth that have these issues," Houle said. 

The second program being developed, and part of a longer term process, has been to identify clinics to begin transitioning to CCBHCs in the state with a goal to eventually transition all eight regions to this certification, said Daniel Cramer, clinical director of behavioral health clinics at DHHS. 

North Central Human Service Center in Minot was the first site identified to actively work towards CCBHC status, Cramer said. Northwest Human Service Center in Williston and Badlands Human Service Center in Dickinson are now additionally working towards becoming a CCBHC. 

Cramer said this involves prioritizing care coordination and includes hiring behavioral health liaisons at each clinic to establish key relationships with community partners, as well as care coordinators to provide targeted care management. 

Certified clinics would be required to have crisis services available 24/7, develop comprehensive services so individuals do not have to coordinate this themselves through a variety of providers, and to assist those in need in navigating the variety of care they need. 

"That's what we're all moving towards," Cramer said. "How we can open our door more broadly for those in need, and then assure that when the need is sought out and/or identified, that we're working with all of our partners to build up to meet that need."

Bringing back wraparound 

Vollan said the state system for addressing mental health issues had a broader framework called "wraparound" where it seemed easier to identify what needs and options were available not only for youth in a mental health crisis but also their wider family.

That approach fell away over time and treatments and options have become increasingly siloed. 

"When we did wraparound, like back in the day, it truly was this is your team, how do we talk through what supports not only our kids needs, but our parents, the siblings, all of those other pieces that you look at," Vollan said. "It just left a lot of our families with the question, what do we do? Where do we go when my child is having a crisis?"

Houle said the DHHS has developed a contract with the National Wraparound Implementation Center to assess where North Dakota's system is at and how it could be reintroduced. This includes specific measures on engaging with families and developing cross system plans where one person is holding each member of the team – wrapping around a child – responsible. 

"A lot of parents and caregivers of children with complex needs are burnt out, experiencing really severe caregiver stress, all of those types of things," Houle said.

This could include engaging mentors, faith communities, coaches and other relatives to provide an embrace of support. 

"In an ideal system I feel like wraparound and other types of care coordination will work alongside clinical treatment services to make sure the right children are getting into the right place at the right time," Houle said. 

Other wider systems of support could also include meeting underlying issues of instability and stress including addressing poverty, lack of access to transportation, as well as food and housing insecurity, Houle said. 

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