Education and Public Health: Supporting Youth Through COVID-19 and Beyond

October 15, 2020|3:05 p.m.| ASTHO Staff

Toxic stress contributes to a variety of negative outcomes for children. And unfortunately, COVID-19 has increased the likelihood of children experiencing childhood trauma, adverse childhood experiences (ACEs), and toxic stress. States and territories should have programmatic, and policy mechanisms to both prevent and mitigate the lifelong effects. A CDC Vital Signs Report found that preventing or mitigating ACEs could reduce depressive disorder by 44%, smoking by 33%, and unemployment by 15%.

Schools, as critical pillars to a community, provide an important avenue for preventing and mitigating ACEs, even with the challenges of a pandemic. They are essential to promoting a shared risk and protective factor (SRPF) approach to foster resilience. Schools—and specifically the teacher-child relationship—can mitigate the long-term effects of trauma by supporting the social and emotional health of students, especially as families may be experiencing social isolation, increased anxiety, and other stressors due to COVID-19.

School connectedness—teacher-child closeness that can moderate early childhood adversity and education outcomes—reduces the risk for mental health issues, substance use, and school dropout. As schools weigh the benefits and burdens of activities to maximize student wellness, schools may need to consider reinstating school activities based on a continuum of risk of COVID-19 spread from lowest risk (e.g., virtual teaching methods) to highest risk (e.g., in-person only with no protection/hygiene protocols).

Public health and education sectors should collaborate to address the health needs of youth in a holistic manner, as state and territorial health agency population health goals align with the priorities for the education sector to address children’s behavioral health. The SRPF framework aligns with the Whole School, Whole Community, Whole Child model, which the education sector uses to improve students’ cognitive, physical, social, and emotional development. Both frameworks depend on stakeholder engagement, policy development, evaluation, and can be tailored to a jurisdiction’s unique needs.

Preventing Risk Factors: Trauma-Informed Schools
Creating supportive social and emotional school climates can come from both encouraging skills-building programs and building trauma-informed schools. Trauma-informed schools require cross-sector collaborations between education, health sectors, and community organizations to create safe and supportive school environments. It can also allow youth to learn and develop skills such as self-regulation, self-awareness, and control that can promote resilience in challenging situations. State policies can encourage local school districts to integrate social and emotional learning programs, focusing on developing individual students’ skills and knowledge to manage emotions, relationships, and make healthy decisions. While there is an increased risk of experiencing trauma due to the COVID-19 pandemic, jurisdictions can continue to build upon their important steps in creating spaces where children can cultivate resiliency.

Trauma-informed schools also increase school staff mental health literacy through training to improve mental health knowledge, mental health promotion and resilience, reducing stigma, and understanding how to connect students to resources. Washington state has promoted trauma-informed schools since 2014 when the state legislature required social and emotional learning benchmarks for all public schools. In 2017 the legislature passed the “Summer Step-Up Act” (HB 1518) that required creating a workgroup to guide programming for schools on positive school climates.

An innovative practice to improve school health professional training on behavioral health is to include training as part of licensure requirements. In 2020, Virginia enacted companion bills (HB 894, SB 619) requiring teacher training programs to have a curriculum on positive behavioral interventions, crisis prevention and de-escalation, and requiring existing teachers to complete training for licensure renewal. Colorado also enacted HB 20-1128 requiring all teachers, special services providers, principals, and administrators to complete at least 10 hours of training on supportive learning environments as part of their licensure requirements. Teacher connection is still a pivotal access point to children during COVID-19 as teachers are the most likely school staff member to interact with children daily in virtual school settings, and states should consider strategies to improve teacher mental health literacy.

Mitigating Risk Factors: School-Based Health Services
Though a supportive social and emotional climate reduces behavioral health risk factors for students, there still must be a way to deliver health resources for students who have already experienced trauma or a behavioral health episode. In 2014, the Centers for Medicare and Medicaid Services (CMS) clarified a policy that prohibited reimbursement for services when those services are available to all students. Known as the “free care” policy reversal, this allows reimbursement for Medicaid school-based services, increasing access to physical and behavioral health services. Also, it advances health equity by providing increased reimbursement for school districts that serve higher percentages of Medicaid-enrolled students.

Many states had written the “free care” reimbursement prohibition into state law, so lawmakers had to remove restrictions in their state Medicaid plan by submitting a State Plan Amendment to CMS. As of Aug. 31, 2020, 13 states have approved state amendment plans by CMS, allowing them to expand school-based health services. In Michigan, a 2018 bill (SB 149) allocated $31 million to provide behavioral health services in schools. It directed the Michigan Department of Health and Human Services to submit a state plan amendment to CMS by collaborating with the Michigan Department of Education. Michigan expanded Medicaid reimbursement to cover all medically necessary services delivered to students through the Early, Periodic, Screening, Diagnosis benefit, and also expanded covered providers to include physician assistants, certified nurse specialists, marriage and family therapists, behavior analysts, school social workers, and school psychologists.

During COVID-19, it is especially important for students to continue to access youth-friendly health services as behavioral health cases continue to increase. COVID-19 has shown that schools are major providers of food, social connection, and health care, and administrators have stepped up to support children through the pandemic. In March, the Ohio Departments of Medicaid and Mental Health and Addiction Services issued an emergency rule allowing school-based providers to bill Medicaid for telehealth services. Oregon also released guidance for school-based providers to provide care through telehealth, with a special focus on maintaining student privacy.

Schools must be equipped to both prevent and mitigate the effects of trauma. Given the alignment between the Whole School, Whole Community, Whole Child Model and the Shared Risk and Protective Factor framework, public health and education sectors have an opportunity to collaborate on and promote protective policies for youth. Supporting youth early in life can lead to a reduction of ACEs and the promotion of resiliency, decreasing the likelihood that they will experience adverse outcomes later in life.


Ioana Ungureanu is a senior analyst of public and behavioral health Integration at ASTHO
Victoria Pless, MPH, is a senior analyst of social and behavioral health at ASTHO
Jessica Lyons, MPH, is a senior analyst of social and behavioral health at ASTHO