[Senate Hearing 118-202]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-202

                    WHY ARE SO MANY AMERICAN YOUTH 
                       IN A MENTAL HEALTH CRISIS?
                     EXPLORING CAUSES AND SOLUTIONS

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                                   ON

 EXAMINING THE AMERICAN YOUTH MENTAL HEALTH CRISIS, FOCUSING ON CAUSES 
                             AND SOLUTIONS
                               __________

                              JUNE 8, 2023
                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                

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                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                 BERNIE SANDERS (I), Vermont, Chairman
PATTY MURRAY, Washington             BILL CASSIDY, M.D., Louisiana, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  LISA MURKOWSKI, Alaska
MAGGIE HASSAN, New Hampshire         MIKE BRAUN, Indiana
TINA SMITH, Minnesota                ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            MITT ROMNEY, Utah
JOHN HICKENLOOPER, Colorado          TOMMY TUBERVILLE, Alabama
ED MARKEY, Massachusetts             MARKWAYNE MULLIN, Oklahoma
                                     TED BUDD, North Carolina

                Warren Gunnels, Majority Staff Director
              Bill Dauster, Majority Deputy Staff Director
                Amanda Lincoln, Minority Staff Director
           Danielle Janowski, Minority Deputy Staff Director

                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                         THURSDAY, JUNE 8, 2023

                                                                   Page

                           Committee Members

Sanders, Hon. Bernie, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1
Cassidy, Hon. Bill, Ranking Member, U.S. Senator from the State 
  of Louisiana, Opening statement................................     3

                           Witnesses--Panel I

Murthy, Vivek H., Vice Admiral, U.S. Surgeon General, U.S. 
  Department of Health and Human Services, Washington, DC........     5
    Prepared statement...........................................     7
Neas, Katherine, Deputy Assistant Secretary, Office of Special 
  Education and Rehabilitative Services, U.S. Department of 
  Education, Washington, DC......................................    13
    Prepared statement...........................................    15
    Summary statement............................................    19

                          Witnesses--Panel II

Russell-Tucker, Charlene M., Commissioner, Connecticut State 
  Department of Education, Hartford, CT..........................    45
    Prepared statement...........................................    47
    Summary statement............................................    57
Osofsky, Joy, Dr., Professor of Pediatrics, Psychiatry, and 
  Public Health, Head of Division of Pediatric Mental Health, at 
  Louisiana State University Health Sciences Center, New Orleans, 
  LA.............................................................    59
    Prepared statement...........................................    60
    Summary statement............................................    64
Garcia, Joshua, Dr., Superintendent, Tacoma Public Schools, 
  Washington, Tacoma, WA.........................................    65
    Prepared statement...........................................    67
    Summary statement............................................    70

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
Sanders, Hon. Bernie:
    American Occupational Therapy Association Statement for the 
      Record.....................................................    80
    Child and Adolescent Mental Health Coalition Statement for 
      the Record.................................................    82
    National Education Association Statement for the Record......    84
    The American Association of Child and Adolescent Psychiatry 
      Statement for the Record...................................    85
    2023 National Survey Key Findings............................    89
Budd, Hon. Ted:
    Letter to NIH................................................    90
    No One Knows How Many L.G.B.T.Q. Americans Die by Suicide. 
      The New York Times.........................................    93

 
                     WHY ARE SO MANY AMERICAN YOUTH
                       IN A MENTAL HEALTH CRISIS?
                     EXPLORING CAUSES AND SOLUTIONS

                         Thursday, June 8, 2023

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:01 a.m., in 
room 430, Dirksen Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Committee, presiding.

    Present: Senators Sanders [presiding], Casey, Baldwin, 
Murphy, Kaine, Hassan, Smith, Markey, Cassidy, Murkowski, 
Braun, Marshall, Romney, Tuberville, and Budd.

                  OPENING STATEMENT OF SENATOR SANDERS

    The Chair. The Senate Committee on Health, Education, 
Labor, and Pensions will come to order. And we are delighted to 
welcome our panelists that we are going to hear from in a few 
minutes.

    But let me begin by telling everybody what they already 
know, and that is it is no great secret that in America today 
we have a mental health crisis, and the crisis has been 
exacerbated by the horrific COVID pandemic which we have 
experienced.

    This is a crisis that has hit all of us, but I think 
especially the younger generation. In America today, 40 percent 
of parents report being either very or extremely worried that 
their child is struggling with anxiety or depression.

    According to a recent survey by the Centers for Disease 
Control, nearly one out of every three teenagers in America 
reported that the state of their mental health was poor. Two 
out of every five teenagers felt persistently sad or hopeless, 
and tragically, one out of every five teenagers in our Country 
has seriously considered suicide.

    How frightening is that? Tragically, suicide was the second 
leading cause of death for young people between the ages of 10 
and 14, and it was the third leading cause of death among 
teenagers. All of us understand that the pandemic has had a 
huge and lasting impact on the mental health and well-being of 
our Country and our young people.

    Let us never forget, and sometimes it is easy to forget, we 
remember the million people who died during the pandemic. But 
over 200,000 children, often children of color by the way, lost 
one or both of their parents to COVID.

    Think about the impact that had on their lives. Further, 
and I think we are going to hear more about this later, our 
kids have become less connected humanly to each other, and this 
is kind of a new phenomenon.

    Dr. Murthy has written about this, and I am sure will be 
speaking about it this morning. Instead of building trusting 
healthy, and strong relationships with their friends, their 
teachers, their mentors, an increasing number of kids are 
turning to their phones and social media to feel connected.

    What type of impact does social media have on the mental 
health of our Nation's youth? That is an issue that we have got 
to really explore at great length as a Nation. According to a 
recent study, 32 percent of teen girls said that when they felt 
bad about their bodies, Instagram made them feel worse.

    More than 40 percent of Instagram users who reported 
feeling unattractive said the feeling began on Instagram. About 
25 percent of teenagers who reported feeling not good enough, 
inadequate, said it started on Instagram. But we are not here 
to single out Instagram alone, certainly, and I am sure that 
the same can be said about other social media platforms.

    Let's be clear, and something I think this Committee in the 
months ahead will get into, we are up against some of the best 
minds in the world who keep coming up with new ways to get 
teenagers addicted, addicted to their websites in order to sell 
them more products and make more money, and that is what we are 
going to have to address.

    But it is not just social media, as dangerous as that may 
be. Kids in Vermont, and I have been around to a lot of high 
schools and some community colleges in my state, but around 
this country as well, worry about the kind of future that 
awaits them.

    They wonder if their political leaders in this country and 
around the world will address climate change, or whether the 
world that they and their kids will grow up in will be 
increasingly unhealthy and uninhabitable.

    I really do wonder, walking here today through the smog and 
the smoke that Washington, DC. is experiencing right now, the 
horror in New York City, yes, it is a bad day, but you wonder 
what impact it has on the kids who wonder, is this the future--
and what that does to them psychologically.

    Yesterday on another issue, I had the occasion to meet with 
people who came to the Capitol who lost loved ones as a result 
of gun violence in schools. And I was stunned, in Vermont, 
where kids worry, when we were young, you went to school. It 
was a safe haven.

    Now they really wonder that some terrible thing might 
happen. And when we talk about the anxieties facing young 
people, we can't ignore economics. Everything being equal, if 
we don't get our act together, the young people will have a 
lower standard of living than their parents.

    Right now, some 60 percent of our people are struggling 
paycheck to paycheck. So, all I would say is the pandemic has 
exacerbated a bad situation. It is there. As political leaders 
in this country, it is our job to address it. Senator Cassidy, 
the mic is yours.

                  OPENING STATEMENT OF SENATOR CASSIDY

    Senator Cassidy. Thank you, Mr. Chairman. Everybody here 
knows a fellow American struggling with mental health issues. 
Everybody watching knows, school closures, isolation from the 
COVID-19 pandemic exacerbated, almost concentrated this among 
those who are younger.

    According to the CDC, from 2021 to 2022, the percent of 
teenagers feeling sad or hopeless increased from 37 percent to 
42 percent. Those seriously considering suicide, seriously 
considered suicide, goes from 19 percent to 22. To say it is 
troubling is to kind of not have an adequate adjective.

    This is terrible. The goal of this hearing is how do we 
improve access to quality mental health care for young people? 
Now, we must highlight that Congress has done a lot in recent 
years to improve mental health care and access for children and 
all Americans. We have walked this ground.

    We need to see what our recent work has accomplished, need 
to measure its effectiveness, and then to figure out what gaps 
remain. Now, just for context, we have know this for decades, 
the Nation's mental health system was dysfunctional, under-
resourced, not getting crucial services to Americans facing 
mental health issues, especially those in underserved areas. I 
worked in a hospital for the uninsured and the under-insured 
for 25 years.

    I worked with this. Now, before I go on, let me give a 
shout out to Senator Chris Murphy. He and I in 2015 led the 
Mental Health Reform Act, an historic bill that overhauled our 
mental health system to increase access to quality mental 
health care for all Americans.

    I remember Chris at that time saying, Bill, there are some 
things we agree on, a lot of them, and a few that we disagree. 
Let's focus on that which we agree and leave the other for 
another day.

    By that, we did something which Lamar Alexander, then the 
Chair of this Committee, said he didn't think two freshmen 
Senators could do. There is both an insult and a praise in 
there.

    [Laughter.]

    Senator Cassidy. But we accomplished it. And Lamar went on 
to say it was the most profound--the most profound reform of 
mental health law in the previous 30 years. He and I were both 
honored. Now, we teamed up again this past year to reauthorize 
this and to reform it to better address the needs of Americans.

    We increased funding for mental health block grants to 
better serve children at risk for serious mental illness, 
expanded tele-mental health care, and promoted the integration 
of mental health providers into primary care, increased mental 
health workforce programs, focusing on treating children and 
underserved populations, and I could go on.

    Now, additionally, and again I am going to give a shout out 
to Murphy once more, in response to the tragedy in Uvalde, 
Congress passed the bipartisan Safer Community Act, which 
invested billions of dollars so that every child and every 
American had access to mental health care no matter whether 
they are in a pediatrician's office, their school, an emergency 
room, or a community health center.

    Chris was the lead on that, I had the privilege to work 
with them, but Congress passed it. The legislation invested 
$8.6 billion to expand certified community behavioral health 
clinics to all 50 states, offering 24/7 crisis intervention 
services, outpatient mental health, and substance abuse 
services, case management, increasing access to primary care 
for Americans, especially those who are lower income and 
uninsured.

    It provided $2 billion for school based mental health 
treatment, to train school personnel to better help students 
through a crisis, to increase care for children suffering from 
trauma, to fund prevention programs, to decrease bullying and 
violence in schools, and much more.

    Additionally, the Safer Communities Act instructing the 
Department of Education and the Department of Health and Human 
Services, both represented here today, to improve guidance to 
schools, particularly those in local--excuse me, in small or 
rural communities, to more easily build Medicaid for school 
based mental health services. And we will talk and hear more 
about that during the first panel.

    I am proud of the work that Congress put into this 
legislation and signed into law, and these achievements show 
that there is a strong bipartisan support for addressing youth 
mental health issues.

    But, and I say this all the time at home, these grants and 
programs only make a difference if state and local Government 
are aware of them, and apply, and show local leadership in 
order to participate. We need this local leadership to use 
these resources to make sure the assistance reaches those who 
need it most.

    What we can't do is pretend that Congress hasn't done 
anything and that we must start anew. That, sweeping the debt 
clean, so to speak, in our minds, not acknowledging the basis 
upon which we build will create duplicate, inefficient 
programs, wasting dollars and wasting effort.

    By the way, the Chair, just echoing the Chair, made the 
point, and I agree wholeheartedly, as you might guess, that the 
resources Congress appropriates should not be wasted. Now, 
Congress can't solve this on its own. Throwing money at an 
issue without accountability is not the solution.

    There has to be complete buy in from the executive, from 
states, local Government, tribal leaders, and community 
organizations, among others, to make sure these programs work 
as Congress intended. There is, however, existing legislation 
up for reauthorization that requires attention.

    As I mentioned in last week's hearing, the Committee has 
nine health care reauthorizations are waiting for programs that 
expire in September. One of these is the Support Act which 
helps individuals dealing with substance abuse disorder and 
increases support services for children suffering from trauma.

    There are more than 50 individual provisions in the Support 
Act that fall in this Committee's jurisdiction. The fact that 
the Committee has 2 months left to reauthorize the programs and 
we have not formally considered bipartisan text, let alone 
marked them up, is concerning. I reiterate that reauthorizing 
the Support Act and these eight other health related bills on 
time, bipartisan must be the Committee's top priority.

    As Ranking Member of the Committee, improving our Federal 
programs so they are more effective and having greater reach is 
crucial. So let me finish by saying I look forward to hearing 
from our witnesses as to how we can better address the mental 
health crisis to make sure that more young people have access 
to quality mental health and that the resources already 
allocated are used effectively.

    Thank you, I yield.

    The Chair. Thank you, Senator Cassidy. Now we are going to 
hear from our witnesses. And our first witness will be Vice-
Admiral Vivek Murthy, who is the Surgeon General of the United 
States of America.

    In my view, Dr. Vivek has done an extraordinary job in 
talking about the mental health crisis and the crisis of 
loneliness and many, many other issues. Dr. Vivek, thanks very 
much for being with us.

    STATEMENT OF VICE ADMIRAL VIVEK H. MURTHY, U.S. SURGEON 
    GENERAL, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                         WASHINGTON, DC

    Admiral Murthy. Thank you so much, Chairman Sanders. And 
thank you so much, Ranking Member Cassidy, for your leadership 
as well on issues related to mental health. To all the Members 
of the Committee who are here today, I am Dr. Vivek Murthy.

    I have the privilege of serving as Surgeon General and as 
Vice Admiral of the U.S. Public Health Service Commission 
Corps, but I am most importantly here, as a father of two young 
children who is concerned about their future and the future of 
kids across America.

    I am here to speak about what I believe is the defining 
public health issue of our time, and that is a youth mental 
health crisis. It now threatens the foundation for health and 
well-being for millions of our children.

    In 2021, more than two in five high school students, 
including almost 60 percent of girls and 70 percent of LGBTQ 
youth, reported feeling persistently sad or hopeless. Nearly 
one in five high school students reported making a suicide 
plan, and this followed a 57 percent increase in the suicide 
rate among young people in the decade prior to the pandemic.

    In response to this crisis, in December 2021, I issued a 
Surgeon General's advisory on protecting youth mental health, 
and I did this to call our Nation's attention to this urgent 
issue and to the need to act.

    Over the last 2 years, I am grateful that Congress, on a 
bipartisan basis, and the Biden administration have made 
unprecedented investments to strengthen the mental health care 
system and to connect more youth to care.

    These investments have already started to help children and 
families. But as all of you know, we have much more to do. Last 
month, my office released two new Surgeon General's advisories, 
and one on our epidemic of loneliness and isolation, and the 
other on social media and youth mental health.

    Together, they explore two important drivers of the youth 
mental health crisis. Regarding loneliness and isolation, we 
now understand that social disconnection is both exceedingly 
common and profoundly consequential.

    About one in two adults are reporting measurable levels of 
loneliness, and social disconnection is associated with an 
increased risk of not only depression, anxiety, and suicide, 
but also heart disease, dementia, stroke, and premature death.

    The loneliness epidemic has hit young people particularly 
hard, and they have the highest rates of loneliness across age 
groups. The time young people, ages 15 through 24, spend in-
person with friends declined by more than 50 percent from 2003 
to 2019.

    Furthermore, there has been a decline in participation over 
the last half century in community organizations that have 
traditionally brought us together, including faith 
organizations and recreational leagues.

    Second though, I am increasingly concerned about the 
harmful impact that social media is having on youth mental 
health. Despite near universal users' inadequate evidence to 
conclude that social media is sufficiently safe for our kids, 
and while social media may provide some benefits for some 
children, there is a growing body of research associating 
social media use with potential harms.

    This is especially concerning during adolescence, which is 
a highly sensitive period of brain development for kids and 
when they are particularly susceptible to peer comparison. The 
data show that youth who spend more than 3 hours a day on 
social media face double the risk of experiencing symptoms of 
depression and anxiety.

    This is deeply worrisome because on average, teenagers are 
spending 3.5 hours a day on social media. And excessive social 
media use can also disrupt activities that are essential for 
healthy development, like physical activity, sleep, and in-
person interactions. For example, a third of adolescents are 
telling us that they stay up until midnight or later on 
weeknights in front of their screens, and much of that is, in 
fact, social media use.

    In addition, too often kids on social media are exposed to 
extreme, inappropriate, and harmful content. Indeed, nearly 
half of adolescents are saying that social media now makes them 
feel worse about their bodies. Now, two other drivers of youth 
mental health crisis that I just want to note briefly.

    One is trauma, which has become all too common in young 
people's lives, particularly from violence and abuse, and the 
loss of loved ones to incarceration, addiction, and death. When 
young people go through such adverse childhood experiences, we 
know it has a negative impact on their mental and physical 
health.

    Additionally, for many young people, their confidence in 
the future has been undermined by the serious challenges they 
are set to inherit, from economic inequality, and climate 
change, to racism, and gun violence.

    This is what they say to me time and time again when I meet 
with young people around the country. The bottom line is our 
kids can't afford to wait longer for us to address the youth 
mental health crisis.

    We have to expand our efforts to ensure every child has 
access to high quality, affordable, culturally competent mental 
health care. But we also must tackle the root causes by 
addressing the potential harms of social media through age 
appropriate health and safety standards and data transparency 
requirements, by investing in school based programs that equip 
children with the tools to manage their emotions, adversity, 
and their mental health, by addressing trauma, particularly 
violence, and by embarking on a generational effort to rebuild 
social connection and community in America.

    Finally, we can all play a role in addressing the ongoing 
shame and stigma that still surround mental health and prevent 
young people for asking from help. Now, our obligation, finally 
to act is not just medical, it is moral.

    It is about fulfilling our most sacred responsibility to 
care for our children and to secure a better future for them. I 
thank you for giving this critical issue the attention and the 
action it deserves, and I look forward to your questions.

    [The prepared statement of Mr. Murthy follows:]

                 prepared statement of vivek h. murthy
    Chairman Sanders, Ranking Member Cassidy, Members of the Committee. 
I'm Dr. Vivek Murthy, and I have the privilege of serving as Surgeon 
General of the United States; as Vice Admiral in the United States 
Public Health Service Commissioned Corps; and, most importantly, as the 
father of two young children, a 5-year-old girl and a 6-year-old boy. 
They are the primary reason I am grateful for this opportunity to speak 
with you today.

    Over the next few years, both of my children will enter an 
important stage of their education and development, where they'll learn 
how to build friendships, deal with adversity, and develop the values 
that will guide them throughout their lives. They and millions of their 
peers will start down the path to adulthood. Each path will be 
different. All will be filled with challenges along the way.

    It's these challenges that I want to talk about today. I'm deeply 
concerned, as a parent and as a doctor, that many of the obstacles that 
this generation of young people face are unprecedented, and uniquely 
hard to navigate. The resulting impact on the mental health of millions 
of our children has been devastating.

    In 2021, more than 2 in 5 high school students reported feeling 
persistently sad or hopeless almost every day for at least 2 weeks in a 
row--so much so that they stopped their regular activities. \1\ This is 
an increase of 14 percent from 2019 and 50 percent from the previous 
decade. We also know that, in 2021, nearly 1 in 5 high school students 
reported making a suicide plan, a 13 percent increase from 2019. \2\ 
And, within these numbers, we know that disparities exist. For example, 
nearly 60 percent of high school girls reported persistent feelings of 
sadness or hopelessness--a figure that was double the share of boys and 
the highest in a decade. \3\ Students who identified as lesbian, gay, 
bisexual, questioning, or another non-heterosexual identity were 
approximately two times more likely than their heterosexual peers to 
experience persistent feelings of sadness or hopelessness too (69 
percent vs 35 percent). \4\ And also, in 2021, 3.7 percent of youth 
ages 12-17 had both a Major Depressive Episode (MDE) and a substance 
use disorder (SUD). \5\
---------------------------------------------------------------------------
    \1\  Centers for Disease Control and Prevention. (2023). Youth Risk 
Behavior Surveillance Data Summary and Trends Report: 2011-2021. 
Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS-
Data-Summary-Trends-Report2023-508.pdf.
    \2\  Id.
    \3\  Id. at 1.
    \4\  Id. at 1.
    \5\  Substance Abuse and Mental Health Services Administration. 
(2022). Key substance use and mental health indicators in the United 
States: Results from the 2021 National Survey on Drug Use and Health 
(HHS Publication No. PEP22-07-01-005, NSDUH Series H-57). Center for 
Behavioral Health Statistics and Quality, Substance Abuse and Mental 
Health Services Administration. https://www.samhsa.gov/data/report/
2021-nsduh-annual-national-report.

    The pandemic exacerbated this problem, but these challenges started 
well before the pandemic began and have many other contributing 
factors. From 2011 to 2015, youth psychiatric visits to emergency 
departments for depression, anxiety, and behavioral challenges 
increased by 28 percent. \6\ And between 2007 and 2018, suicide rates 
among youth ages 10-24 increased by 57%--a total of 65,026 young people 
lost. \7\
---------------------------------------------------------------------------
    \6\  Kalb, L. G., Stapp, E. K., Ballard, E. D., Holingue, C., 
Keefer, A., & Riley, A. (2019). Trends in Psychiatric Emergency 
Department Visits Among Youth and Young Adults in the US. Pediatrics, 
143(4), e20182192. https://doi.org/10.1542/peds.2018-2192.
    \7\  Curtin, S. C. (2020). State suicide rates among adolescents 
and young adults aged 10-24: United States, 2000-2018. National Vital 
Statistics Reports; 69:11. Hyattsville, MD: National Center for Health 
Statistics.

    Many mental health challenges first emerge early in life--half of 
all lifetime mental health issues begin by age 14, and 75 percent begin 
by age 24. \8\ We need to do more to give young people and their 
families the tools to prevent and treat these mental health challenges. 
The average delay between the onset of mental health symptoms and 
treatment is 11 years--11 long, isolating, confusing, and painful 
years. \9\
---------------------------------------------------------------------------
    \8\  Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, 
K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset 
distributions of DSM-IV disorders in the National Comorbidity Survey 
Replication. Archives of general psychiatry, 62(6), 593-602. https://
doi.org/10.1001/archpsyc.62.6.593.

    \9\  Wang, P. S., Berglund, P. A., Olfson, M., & Kessler, R. C. 
(2004). Delays in initial treatment contact after first onset of a 
mental disorder. Health services research, 39(2), 393-415. https://
doi.org/10.1111/j.1475-6773.2004.00234.x.

    We have the opportunity, the responsibility, and--as evidenced 
through my travels across the country and my conversations with many of 
you--the desire to address the youth mental health crisis in America. 
In 2021, I released The Surgeon General's Advisory on Protecting Youth 
Mental Health, which outlines the policy, institutional, and individual 
changes it will take to treat and prevent mental health challenges. 
Just last month, my office released two new advisories. First on Our 
Epidemic of Loneliness and Isolation: The U.S. Surgeon General's 
Advisory on the Healing Effects of Social Connection and Community. And 
second, The U.S. Surgeon General's Advisory on Social Media and Youth 
Mental Health. Together, these Advisories explore what's contributing 
---------------------------------------------------------------------------
to the mental health crisis among youth and how to address it.

    One of the key barriers to addressing mental health is the stubborn 
and pervasive stigmatization of mental health that tells people they 
should be ashamed if they are struggling with depression, anxiety, 
stress, or loneliness. It's isolating and further separates people 
experiencing mental health challenges from their loved ones and from 
sources of support. This stigmatization prevents kids from seeking help 
and receiving the long-term recovery supports they need.

    I felt that stigma myself, growing up in Miami as a child who 
didn't look the same as the other kids, and who too often was bullied 
and called racial slurs by classmates who told me I didn't belong. Not 
surprisingly, that left me feeling lonely and anxious about going to 
school--and I felt a deep sense of shame as well. Like it was somehow 
entirely my fault that I was hurting. Even though I knew my family 
loved me unconditionally, the embarrassment I felt prevented me from 
asking them for help.

    Even when children are able to summon the courage to ask for help, 
we do not always have sufficient resources to meet their needs. I am 
grateful that, in recent years, Congress and the Biden administration 
have made unprecedented investments in expanding access to mental 
health care and treatment for kids. In 2022, President Biden announced 
his Unity Agenda for the Nation--calling on us all to work together to 
tackle the mental health crisis, particularly for our youth. He 
released a comprehensive strategy to transform how we understand, treat 
and integrate mental health in America. And, already several actions 
have been taken to strengthen system capacity and connect more youth to 
care, including unprecedented investments to increase access to school-
based mental health services with a focus on high-need school 
districts; to harness technology to bring virtual mental health 
services to where young people are; and to increase the number of peer 
support workers across the country. And historic investments have been 
made to enhance crisis response through the 988 Suicide and Crisis 
Lifeline to ensure that anyone experiencing a mental health crisis 
receives faster access to mental health services and trained mental 
health professionals. Significant investments have also been made to 
expand proven models of care like Certified Community Behavioral Health 
Centers (CCBHC) to provide comprehensive behavioral health care--
including crisis care--to the most vulnerable Americans regardless of 
their ability to pay.

    These are tremendous steps and many children now have access to 
care that they didn't previously have. However, more action is needed 
to help the millions who still lack adequate access. This means 
training providers, expanding peer support programs, enabling 
widespread use of technology to provide remote care, integrating 
behavioral health care with primary care and other settings, and 
strengthening and enforcing health insurance parity laws to ensure that 
insurers do their part to provide fair, equitable access to mental 
health services.

    In addition to investment in treatment, it's crucial we do more to 
address the root causes of the youth mental health crisis. Today, I'd 
like to highlight three drivers that impact the mental health of 
today's kids and that I am particularly concerned about: loneliness, 
the impact of social media, and profound concerns about the state of 
the world.

    First, increasing rates of loneliness. Across many measures, 
Americans appear to be becoming less socially connected over time. This 
is a problem that preceded the COVID-19 pandemic, though it certainly 
worsened for many people over the last 3 years. Social networks have 
been getting smaller, and levels of social participation have been 
declining. For example, objective measures of social exposure obtained 
from 2003-2020 find that social isolation, measured by the average time 
spent alone, increased from 2003 (285-minutes/day, 142.5-hours/month) 
to 2019 (309-minutes/day, 154.5-hours/month) and continued to increase 
in 2020 (333-minutes/day, 166.5-hours/month). \10\ This represents an 
increase of 24 hours per month spent alone. At the same time, social 
participation across several types of relationships has steadily 
declined. For instance, the amount of time respondents engaged with 
friends socially in--person decreased from 2003 (60-minutes/day, 30-
hours/month) to 2020 (20-minutes/day, 10-hours/month). \11\ This 
represents a decrease of 20 hours per month spent engaging with 
friends. This decline in total time spent in-person with friends was 
starkest for young people ages 15 to 24. For this age group, time spent 
in-person with friends has declined by nearly 50% over the last two 
decades, from roughly 150 minutes per day in 2003 to less than 70 
minutes per day in 2019. \12\ This is concerning because, for children 
and adolescents, loneliness and social isolation in childhood increases 
the risk of depression and anxiety both in the short-term and well into 
the future (up to 9 years later). \13\
---------------------------------------------------------------------------
    \10\  Kannan, V. D., & Veazie, P. J. (2022). US trends in social 
isolation, social engagement, and companionship--nationally and by age, 
sex, race/ethnicity, family income, and work hours, 2003-2020. SSM--
population health, 21, 101331. https://doi.org/10.1016/
j.ssmph.2022.101331.
    \11\  Id.
    \12\  Id. at 9.
    \13\  Loades, M. E., Chatburn, E., Higson-Sweeney, N., Reynolds, 
S., Shafran, R., Brigden, A., Linney, C., McManus, M. N., Borwick, C., 
& Crawley, E. (2020). Rapid Systematic Review: The Impact of Social 
Isolation and Loneliness on the Mental Health of Children and 
Adolescents in the Context of COVID-19. Journal of the American Academy 
of Child and Adolescent Psychiatry, 59(11), 1218-1239.e3. https://
doi.org/10.1016/j.jaac.2020.05.009.

    Second, as discussed in the recent U.S. Surgeon General's Advisory 
on Social Media and Youth Mental Health, we have reason to be concerned 
about the impact of social media \14\ use on youth mental health. 
Social media use by youth is nearly universal. Up to 95 percent of 
youth ages 13-17 report using a social media platform, with more than a 
third saying they use social media ``almost constantly.'' \15\ Although 
age 13 is commonly the required minimum age used by social media 
platforms in the U.S., nearly 40 percent of children ages 8-12 use 
social media. \16\ Despite this widespread use among children and 
adolescents, there is insufficient evidence to conclude that social 
media is sufficiently safe for kids. Instead, there is a growing body 
of data associating social media use with potential harms to kids. 
There are also widespread concerns among parents and caregivers, young 
people, health care experts, and others about the impact of social 
media on youth mental health.
---------------------------------------------------------------------------
    \14\  The definition of social media has been highly debated over 
the past few decades. As a result, there isn't a single, widely 
accepted scholarly definition of social media. (Aichner et al., 2021) 
The definition may vary from the cited research in this document based 
on the methods used in each study. In making conclusions and 
recommendations, this document regards social media as ``internet-based 
channels that allow users to opportunistically interact and selectively 
self-present, either in real-time or asynchronously, with both broad 
and narrow audiences who derive value from user-generated content and 
the perception of interaction with others.'' (Carr & Hayes, 2015). For 
the purposes of this product, we did not include studies specific to 
online gaming or e-sports. Aichner, T., Grunfelder, M., Maurer, O., & 
Jegeni, D. (2021). Twenty-Five Years of Social Media: A Review of 
Social Media Applications and Definitions from 1994 to 2019. 
Cyberpsychology, Behavior And Social Networking, 24(4), 215-222. 
https://doi.org/10.1089/cyber.2020.0134; Carr, C. T., & Hayes, R. A. 
(2015). Social Media: Defining, Developing, and Divining. Atlantic 
Journal of Communication, 23:1, 46-65. https://doi.org/10.1080/
15456870.2015.972282.
    \15\  Vogels, E., Gelles-Watnick, R. & Massarat, N. (2022). Teens, 
Social Media and Technology 2022. Pew Research Center: Internet, 
Science & Tech. United States of America. Retrieved from https://
www.pewresearch.org/internet/2022/08/10/teens-social-media-and-
technology2022/.
    \16\  Rideout, V., Peebles, A., Mann, S., & Robb, M. B. (2022). 
Common Sense Census: Media use by tweens and teens, 2021. San 
Francisco, CA: Common Sense. Retrieved from https://
www.commonsensemedia.org/sites/default/files/research/report/8-18-
census-integrated-report-final-web-0.pdf.

    While social media may have benefits for some children and 
adolescents, such as serving as a source of connection, information, 
and support, especially for youth who are often marginalized, we must 
acknowledge and better understand the growing body of research about 
potential harms associated with social media use and urgently take 
action to create safe and healthy digital environments--ones that 
minimize harm and safeguard children's and adolescents' mental health 
and well-being while also maximizing the potential benefits of social 
---------------------------------------------------------------------------
media on health and well-being.

    We are especially concerned about social media use among children 
because adolescence represents a highly sensitive period of brain 
development that can make young people more vulnerable to harms from 
social media. During this period, we know that young people are more 
prone to engage in risk-taking behaviors, their overall well-being (in 
terms of mood, physical health, etc.) fluctuates the most, and mental 
health challenges begin to emerge. We also know that, in early 
adolescence, when identities and sense of self-worth are forming, brain 
development is especially susceptible to social pressures, peer 
opinions, and peer comparison. As such, adolescents may experience 
heightened emotional sensitivity to the communicative and interactive 
nature of social media.

    Social media platforms may contribute to youth mental health 
concerns in a number of ways. Excessive social media use can disrupt 
activities that are essential for healthy youth development like 
physical activity and sleep and reduce time for positive in-person 
activities. The content on social media platforms can reinforce 
negative behaviors like online harassment, abuse, exploitation, and 
exclusion, perpetuate body dissatisfaction and social comparison, and 
undermine the safe and supportive environments kids need to thrive. 
Research suggests that social media use can be excessive and 
problematic for some kids; that children and adolescents on social 
media are commonly exposed to extreme, inappropriate, and harmful 
content. The research also shows that those who spend more than 3 hours 
a day on social media face double the risk of experiencing poor mental 
health outcomes, such as symptoms of depression and anxiety. \17\ This 
is deeply concerning as a survey of teenagers showed that, on average, 
they spend 3.5 hours a day on social media, with one in four spending 5 
or more hours per day and one in seven spending 7 or more hours per day 
on social media. \18\ Over half of teenagers report that it would be 
hard to give up social media, and on a typical weekday, nearly one in 
three adolescents report using screens (most commonly social media) 
until midnight or later. \19\, \20\
---------------------------------------------------------------------------
    \17\  Riehm, K. E., Feder, K. A., Tormohlen, K. N., Crum, R. M., 
Young, A. S., Green, K. M., Pacek, L. R., La Flair, L. N., & Mojtabai, 
R. (2019). Associations Between Time Spent Using Social Media and 
Internalizing and Externalizing Problems Among US Youth. JAMA 
psychiatry, 76(12), 1266-1273. https://doi.org/10.1001/
jamapsychiatry.2019.2325.
    \18\  Miech, R. A., Johnston, L. D., Bachman, J. G., O'Malley, P. 
M., Schulenberg, J. E., and Patrick, M. E. (2022). Monitoring the 
Future: A Continuing Study of American Youth (8th-and 10th-Grade 
Surveys), 2021. Inter-university Consortium for Political and Social 
Research [distributor]. https://doi.org/10.3886/ICPSR38502.v1
    \19\  Id. at 14.
    \20\  Bickham, D.S., Hunt, E., Bediou, B., & Rich, M. (2022). 
Adolescent Media Use: Attitudes, Effects, and Online Experiences. 
Boston, MA: Boston Children's Hospital Digital Wellness Lab. Retrieved 
from https://digitalwellnesslab.org/wp-content/uploads/Pulse-Survey-
Adolescent-Attitudes-Effects-and-Experiences.pdf.

    When asked about the impact of social media on their body image, 
nearly half (46 percent) of adolescents ages 13-17 said social media 
makes them feel worse, 40 percent said it makes them feel neither 
better nor worse, and 14 percent said it makes them feel better. \21\
---------------------------------------------------------------------------
    \21\  Id.

    This increase in social media use may also contribute to the 
bombardment of messages that undermine this generation's sense of self-
worth--messages that tell our kids with greater frequency and volume 
than ever before that they're not good-looking enough, not popular 
---------------------------------------------------------------------------
enough, not smart enough, not rich enough.

    Third, many young people are grappling with challenges that impact 
their present-day experience and the world they'll inherit, including 
economic inequality, climate change, racial injustice, discrimination 
against individuals who identify as LGBTQI+, the opioid epidemic, and 
gun violence. And they feel progress is too slow. The COVID-19 pandemic 
further exacerbated the stresses young people already faced. As of 
December 2022, more than 275,000 children lost a primary or secondary 
caregiver due to COVID-19 and many more worried about losing loved ones 
who fell sick. \22\ With the support of Congress, the Administration 
has taken actions to support this population of youth who have been 
affected by COVID-19 and other disasters, such as the Children and 
Youth Resilience Prize Challenge which will fund innovative community-
led solutions to promote resilience in children and adolescents. 
Millions of children experienced increased food insecurity, 
instability, and economic stress at home, and were isolated from 
friends and family during an extraordinarily stressful period. The 
collective impact of these challenges and the absence of a clear, 
unified path to progress has undermined young people's confidence in 
the future that awaits them.
---------------------------------------------------------------------------
    \22\  Imperial College London. (14 February, 2022). Global 
Orphanhood estimates real time calculator. Imperial College London. 
Retrieved from https://imperialcollegelondon.github.io/orphanhood-
calculator/#/country/United%20States%20of%20America.

    It is imperative that we act now. Our children do not have the 
---------------------------------------------------------------------------
luxury of time--their childhoods and developments are happening now.

    Out of the many recommendations in the recent Surgeon General's 
Advisories, I'd like to highlight four overarching recommendations 
today:

    First, ensuring that every child has access to high-quality, 
affordable, and culturally competent mental health care. To do this, we 
must make sure that children are enrolled in health coverage--far too 
many children in our Country are eligible for coverage under Medicaid 
and the Children's Health Insurance Program, but aren't enrolled. We 
need to do better here, especially as pandemic-era provisions to 
support coverage have come to an end, which could leave gaps in 
coverage for countless families and children. \23\ We also need to 
expand our mental health workforce, from clinical psychologists, school 
counselors, and psychiatrists, to recovery coaches and peer 
specialists--and that includes making sure these professionals can 
serve in, and provide services at, schools. We have too few providers 
to meet the growing demand. And we need to make sure that care is 
delivered at the right place and time, whether that's in health care 
settings like primary care practices, or community-based settings like 
schools, and whether it's in person or through telehealth. The 
Departments of Education and Health and Human Services are 
collaborating to help make it easier for schools to file Medicaid 
claims for crucial mental and physical school-based health services, 
with potential to unlock additional supports for millions more students 
nation-wide. This is on top of the from the American Rescue Plan 
Elementary and Secondary School Emergency Relief Fund and the 
Bipartisan Safer Communities Act that we know states and schools 
districts are already using to provide more counselors, other mental 
health providers, and nurses in schools. More than 14,000 new mental 
health professionals--including school psychologists, counselors, and 
social workers--are projected to be placed in U.S. schools. \24\ Those 
funds, coupled with Medicaid funding, are available now to help meet 
our young peoples' critical mental health needs.
---------------------------------------------------------------------------
    \23\  Centers for Medicare & Medicaid Services. (n.d.). Unwinding 
and Returning to Regular Operations after COVID-19. Retrieved from 
https://www.Medicaid.gov/resources-for-states/coronavirus-disease-2019-
covid-19/unwinding-and-returning-regular-operations-after-covid-19/
index.html.
    \24\  U.S. Department of Education. (15, May 2023). Press Release: 
Biden-Harris Administration Announces Nearly $100 Million in Continued 
Support for Mental Health and Student Wellness Through Bipartisan Safer 
Communities Act. Retrieved from https://www.ed.gov/news/press-releases/
today-biden-harris-administration-announcing-more-95-million-awards-
across-35-states-increase-access-school-based-mental-health-services-
and-strengthen-pipeline-mental-health-professionals-high-needs-school-
districts-t.

    Second, focusing on prevention, by investing in school-and 
community-based prevention, promotion, and early intervention programs 
that have been shown to improve the mental health and emotional well-
being of children at low cost and high benefit. Every dollar we spend 
on prevention represents multiple dollars we won't have to spend on 
treatment--in fact, one study estimated that investment in early 
prevention offered a fourfold return down the line. \25\ We've seen the 
extraordinary potential of certain strategies and programs--Project 
AWARE and What Works in Schools, for example, which help communities 
develop a sustainable infrastructure for school-based mental health 
programs and services. The recent Surgeon General's Advisory on Our 
Epidemic of Loneliness and Isolation lays out a set of recommendations 
for schools, including developing a strategic plan for school 
connectedness, building social connection into health curricula, 
implementing socially based educational techniques such as cooperative 
learning projects, and creating supportive school environments that 
foster belonging.
---------------------------------------------------------------------------
    \25\  Karoly, L.A., Greenwood, P.W., Everingham, S.S., Houb, J.S., 
Kilburn, M.R., Rydell, C.P., Sanders, M.R., & Chiesa, J. (1998). 
Investing in Our Children: What We Know and Don't Know About the Costs 
and Benefits of Early Childhood Interventions.

    These programs support families, teaching parents how to recognize 
challenges as they emerge, find available resources, and offer support 
and care. They also give kids tools to manage their emotions in healthy 
ways, build supportive relationships, and get help when they need it. 
We need to invest in scaling these programs, and programs like them, 
across the country. And that must go hand-in-hand with continuing to 
advance comprehensive public health approaches such as preventing 
adverse childhood experiences, promoting positive childhood 
experiences, and addressing the systemic economic and social barriers, 
like safety, housing, food, and economic insecurity, that contribute to 
and create the conditions for poor mental health for young people, 
families, and caregivers. \26\
---------------------------------------------------------------------------
    \26\  Centers for Disease Control and Prevention. (22 September, 
2022). Preventing Adverse Childhood Experiences: Data to Action 
(PACE:D2A). Retrieved from https://www.cdc.gov/violenceprevention/aces/
preventingace-datatoaction.html.

    Third, we need to take action now to protect children against the 
potential harms of social media. The recent Surgeon General's Advisory 
on Social Media and Youth Mental Health describes the current evidence 
on the impacts of social media on the mental health of children and 
adolescents. It details how there are critical gaps to understanding 
the full extent of mental health risks posed by social media--including 
a lack of evidence that social media is sufficiently safe for children 
and adolescents. There are critical steps policymakers can take to 
address the complex issues related to social media use and protect 
youth from the risk of harm, including by strengthening safety 
protections, developing age-appropriate health and safety standards, 
limiting access in ways that make social media safer for children of 
all ages, requiring platforms to better protect children's privacy, 
supporting digital and media literacy curricula within schools and in 
academic standards, and supporting research on both the benefits and 
harms of social media use. The Administration has taken actions to help 
us fill critical knowledge gaps such as the establishment of the 
National Center of Excellence on Social Media and Mental Wellness, 
which will develop and disseminate information, guidance, and training 
on the impact--including risks and benefits--of social media use on 
children and young people and examine clinical and social interventions 
that can be used to prevent and mitigate the risks. It's crucial that 
these platforms are designed to maximize the benefits and minimize the 
harms to the mental health of our youth and with the health and well-
---------------------------------------------------------------------------
being of all users, especially children, in mind.

    The final recommendation I will highlight today concerns individual 
and community engagement to cultivate a culture of connection--a 
culture in which we prioritize cultivating healthy relationships with 
family, friends, neighbors, coworkers, and community members. A strong 
culture of connection shapes not only our individual experience but 
also how we design our school and work environments and the investments 
we make in community organizations that bring us together. Such a 
culture rests on core values of kindness, respect, service, and 
commitment to one another. As leaders, parents, friends, and fellow 
Americans, it is up to us to build this culture by reflecting these 
core values through our actions, our words, and our example. We can do 
it by investing in local-level programs, policies, and physical 
elements of a community that facilitate bringing people together, by 
reaching out to people in our lives who are having a hard time to offer 
our support, by choosing to understand someone's intention and choosing 
not to demonize them because of our differences, and by sharing our own 
stories and struggles with mental health, recognizing that there is 
great power in our authenticity and vulnerability.

    A nation with a strong culture of connection is one where people 
feel a sense of community and belonging, where people recognize that we 
are defined not by our differences and disagreements but by the hopes 
we share for our kids, our community, and our Country.

    I look forward to discussing these recommendations and 
possibilities with you today. Mitigating this crisis is urgent, but it 
will take a bipartisan, all-of-society coalition of governments, 
community organizations, employers, technology and social companies, 
schools and health care systems, and young people and their families 
alike. I thank you for recognizing this, and for your shared commitment 
to action.

    Our obligation to act is not just medical--it's moral. It's not 
only about saving lives. It's about fulfilling our sacred obligation--
to care for our children and secure a better future for them. 
Throughout our history, progress has been born in the wake of tragedy. 
I'm eager to partner with you to make it happen again.

    Thank you for having me, and for giving this critical issue the 
attention it needs and deserves.
                                 ______
                                 
    The Chair. Let me turn to Senator Cassidy, who will 
introduce our next witness.

    Senator Cassidy. It is an honor to introduce Mrs. Katherine 
Neas, Deputy Assistant Secretary of the Office of Special 
Education and Rehabilitative Services at the U.S. Department of 
Education.

    In her role, Mrs. Neas works to improve the educational and 
employment outcomes for students with disabilities. Today, she 
will discuss the Department's broader work to support the 
mental well-being of all students. Mrs. Neas.

STATEMENT OF KATHERINE NEAS, DEPUTY ASSISTANT SECRETARY, OFFICE 
    OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES, U.S. 
            DEPARTMENT OF EDUCATION, WASHINGTON, DC

    Ms. Neas. Chairman Sanders, Ranking Member Cassidy, and 
distinguished Members of the Committee, thank you for the 
opportunity to share the Department of Education's work on 
youth mental health and promising interventions.

    The Youth Risks Behavioral Survey, released this past 
February by the Centers for Disease Control and Prevention, 
conveyed alarming findings of the prevalence of mental health 
or substance use disorder among our Nation's youth.

    The report advances the critical need for schools to expand 
school based services and to connect youth and families to 
community based sources of care. Simply put, schools are a 
gateway to needed services that otherwise might be inaccessible 
to many young people. The report also emphasizes the 
responsibility of schools to ensure that all learning occurs in 
a safe and supportive environment.

    The Department's work is focused on three top priorities, 
increasing the skill and knowledge of existing school personnel 
to support the mental health needs of students, increasing the 
supply of mental health professionals who can work with 
students, and increasing funding through the Medicaid program 
to support school health services, including mental health 
services.

    One year ago, Congress provided new funding under the 
bipartisan Safer Communities Act that significantly bolstered 
Federal, state, and local efforts to address student mental 
health needs. I am pleased to provide you with an update of our 
work to implement this law.

    Last September, the Department awarded $1 billion to state 
educational agencies to competitively award sub-grants to high 
needs school districts for activities to support safe and 
healthy students. This Stronger Connections Grant Program will 
support school districts to develop, implement, and evaluate 
comprehensive programs and activities that foster safe, 
healthy, supportive, and drug free environments that support 
student academic achievement.

    The bipartisan Safer Communities Act also provided $1 
billion over 5 years to be equally divided across two programs 
to increase the supply of school based mental health service 
providers. The response to these two grants has been 
enthusiastic. Under the school based mental health services 
grant, 12 states and the District of Columbia and 229 school 
districts across 41 states submitted applications.

    The Department was able to fund nine states, the District 
of Columbia, and 94 school districts across 31 states. Under 
the Mental Health Services Professional Demonstration Grant 
Program, 266 school districts applied, and the Department was 
able to find 160 grants.

    To support this $280 million of Federal support across 264 
grantees that will train 14,000, sorry, school based mental 
health professionals, the Department will fund a mental Health 
Personnel Technical Assistance Center later this year.

    This past January, the Department awarded $86 million in 
grants to local communities through the Promise Neighborhood 
and the Full Service Community Schools Program. The bipartisan 
Safer Communities Act also directed the Departments of Health 
and Human Services in collaboration with the Department of 
Education to issue guidance to increase access to school based 
health services to children enrolled in Medicaid and the 
Children's Health Insurance Program.

    This guidance was released on May 18th of this year. 
Medicaid and CHIP provide health coverage to more than half of 
America's children, roughly 41 million children. These programs 
are administered by state according to Federal requirements.

    Children are eligible based on family income or unique 
health care needs, such as having a disability or a serious 
mental illness, or if they are in foster care. Under Medicaid's 
Early Periodic Screening Diagnostics and Treatment Program, 
eligible children can receive comprehensive primary health, 
mental health, and behavioral health services.

    Medicaid enrolled children who need services in school can 
fall into two categories, eligible children who need general 
health care services and students with disabilities who receive 
services under the Individuals with Disabilities Education Act.

    In 2021, schools receive nearly $6 billion in total 
payments for school based health care to Medicaid students. 
Schools also received about $14 billion in Federal IDEA 
funding. In 2014, the Centers for Medicare and Medicaid 
Services issued a letter to state Medicaid directors clarifying 
reimbursable services in a school based setting.

    The CMS letter explained that schools can seek payment for 
all Medicare covered services provided to all students enrolled 
in Medicaid, not just for students with disabilities. As of May 
2023, 21 states have used this policy to expand their school 
based Medicaid programs. Most states use these funds to hire 
and sustain essential personnel who can deliver or facilitate 
the delivery of health and mental health services.

    As you can see, the Department is actively engaging in 
efforts to address the mental health crisis facing our Nation's 
youth. We are committed to ensuring that students' needs are 
met, that they are ready to learn, and that they have the full 
access to learning opportunities. Thank you for the opportunity 
to be here, and I look forward to answer your questions.

    [The prepared statement of Ms. Neas follows:]

                  prepared statement of katherine neas
    Chairman Sanders, Ranking Member Cassidy, and distinguished Members 
of the Committee, thank you for the opportunity to share the Department 
of Education's (Department's) work to meet the needs of the 49.5 
million students enrolled in public schools across the country and the 
25.3 million students enrolled in colleges and universities.

    While I serve as the Department's Deputy Assistant Secretary for 
the Office of Special Education and Rehabilitative Services, mental 
health is a deep personal and professional area of interest to me, and 
a priority issue across the Department. Mental health affects the well-
being of every student, educator, school, and community in America; and 
the Department is committed to creating the conditions for all students 
to thrive academically and personally.

    The National Survey on Drug Use and Health released in January by 
the Substance Abuse and Mental Health Services Administration and the 
Youth Risk Behavioral Survey released this past February by the Centers 
for Disease Control and Prevention (CDC) conveyed alarming findings of 
the prevalence of mental health or substance use disorders, or co-
occurrence of both among our Nation's youth. \1\ The Youth Risk 
Behavioral Survey also included recommendations on how schools can be 
part of the solution. The report advances the critical need for schools 
to expand school-based services and to connect youth and families to 
community-based sources of care. Simply put, schools are a gateway to 
needed services for many young people. As trusted community partners, 
schools can provide critical behavioral and mental health services 
directly or establish referral systems to connect those in need to 
community sources of care that might otherwise be inaccessible. The 
report also emphasized the responsibility of schools to ensure that all 
learning occurs in a safe and supportive environment.

    \1\  Centers for Disease Control and Prevention, Youth Risk 
Behavior Survey: Data Summary and Trends Report 2011-2021, https://
www.cdc.gov/healthyyouth/data/yrbs/yrbs-data-summary-and-trends.htm.

    The Kaiser Family Foundation highlights several factors that limit 
schools' current ability to effectively provide mental health services 
to students. \2\ These factors include insufficient mental health 
professional staff coverage; inadequate access to licensed mental 
health professionals; inadequate funding; concerns about reactions from 
parents; requirements that schools pay for the services, and a lack of 
community support for providing services.
---------------------------------------------------------------------------
    \2\  Nirmita Panchal, Cynthia Cox, Robin Rudowitz, ``The Landscape 
of School-Based Mental Health Services,'' Kaiser family Foundation, 
September 6, 2022, https://www.kff.org/other/issue-brief/the-landscape-
of-school-based-mental-health-services/.

    We know the COVID-19 pandemic exacerbated certain pre-existing 
challenges to student wellness and academic success, and the ongoing 
impacts of the pandemic continue to hinder some state and local 
recovery efforts. \3\ Moreover, suicide was the second leading cause of 
death among people age 20-34. \4\ Additionally, college students who 
experience basic needs insecurity experience significantly higher rates 
of depression, anxiety, and suicidal ideation, planning, or attempt. 
\5\ The Department embraces the opportunity to reflect on what we have 
learned and move forward with a renewed energy to support the field in 
accelerating learning and supporting the mental health of preschool to 
postsecondary students and school personnel.
---------------------------------------------------------------------------
    \3\  U.S. Department of Education. ``Education in a Pandemic: 
Disparate Impacts of COVID-19 on America's Students.'' Retrieved from: 
https://www..ed.gov/about/offices/list/ocr/docs/20210608-impacts-of-
covid19.pdf.
    \4\  Centers for Disease Control and Prevention. Facts About 
Suicide. https://www.cdc.gov/suicide/facts/index.html.
    \5\  Katharine M. Broton, Milad Mohebali, Mitchell D. Lingo. Basic 
Needs Insecurity and Mental Health: Community College Students' Dual 
Challenges and Use of Social Support. 2022. https://
journals.sagepub.com/doi/abs/10.1177/00915521221111460.

    The Department is actively engaged in efforts to accelerate 
recovery. These efforts have been supported by historic investments 
that continue to raise the bar so students can recover academically and 
access critical supports for their mental health and well-being. 
Raising the bar means recognizing that our Nation already has what it 
takes to continue leading the world--if we deliver a comprehensive, 
rigorous education for every student; boldly improve conditions for 
learning; and ensure every student has a pathway to multilingualism and 
to college and careers. When the bar is raised in education, all our 
Nation's students will build the skills to succeed inside and outside 
of school. Our students will reach new heights in the classroom, in 
their careers, and in their enriched lives and communities, making a 
---------------------------------------------------------------------------
positive difference in the world, for generations to come.

    While the work is far from over, I am pleased to share what is 
underway.
                   Department of Education Priorities
    The Department's work aligns with the President's Unity Agenda, the 
CDC and the Kaiser Family Foundation findings and is focused on three 
top priorities: (1) increasing the skills and knowledge of existing 
school personnel to support the mental health needs of students; (2) 
increasing the supply of mental health professionals who can work with 
students; and (3) increasing funding through the Medicaid program to 
support school health services, including mental health services.

    One year ago, Congress provided new funding under the Bipartisan 
Safer Communities Act (BSCA) that significantly bolstered Federal, 
state, and local efforts to address student mental health needs. I am 
pleased to provide you with an update on our work to implement this 
legislation.

             Funding of School Based Mental Health Services

    Through BSCA, the Department received four categories of funding, 
reflecting a comprehensive approach to supporting States, Local 
Educational Agencies (LEAs), and schools in creating safe and healthy 
learning environments.

    This includes:

          $1 billion through Title IV, Part A of the Elementary 
        and Secondary Education Act of 1965 (ESEA) to enable State 
        Educational Agencies (SEAs) to competitively award subgrants to 
        high-need LEAs for activities to support safe and healthy 
        students under ESEA section 4108. The Department has designated 
        this component of BSCA the Stronger Connections Grant Program. 
        States are in the process of running Stronger Connections grant 
        competitions. ESEA section 4108 allows funds to be used to 
        ``develop, implement, and evaluate comprehensive programs and 
        activities'' that foster safe, healthy, supportive, and drug-
        free environments that support student academic achievement. 
        Therefore, Stronger Connections funds may be used to hire 
        professionals who are necessary to implementing such programs.

          An additional $50 million in formula funding for the 
        21st Century Community Learning Centers, which provides 
        academic enrichment opportunities to students during non-school 
        hours.

          $500 million for competitively awarded School-Based 
        Mental Health (SBMH) Services Grants designed to increase the 
        number of credentialed school-based mental health services 
        providers delivering school-based mental health services to 
        students.

          $500 million for competitively awarded Mental Health 
        Services Professionals (MHSP) Demonstration Grants to support 
        innovative partnerships involving states, school districts, and 
        institutions of higher education (IHEs) to train and increase 
        the number and diversity of high-quality school-based mental 
        health services providers available to address shortages of 
        such providers in schools within high-need districts. Nearly 
        half of the new MHSP awardees included a partnership with a 
        Minority Serving Institution, Historically Black Colleges or 
        Universities or Tribal Colleges.

          $280 million across 264 projects projected to train 
        approximately 14,000 school-based mental health professionals.

          $86 million in grants to local communities awarded in 
        December 2022. Under the Promise Neighborhood Grants, six 
        communities received $23 million to provide coordinated support 
        services and programs to students from low-income backgrounds 
        at every stage of their education from early childhood through 
        their careers. These grants will also focus on preventing and 
        reducing community violence that too often impacts low-income 
        communities. Under the Full-Service Community Schools program, 
        $63 million in new awards went to 42 LEAs, non-profits, and 
        IHEs across 18 states, the District of Columbia, and Puerto 
        Rico.

    To support grantees funded under the SBMH and MHSP grant programs, 
later this year, the Department will fund a first of its kind school-
based mental health professional development technical assistance 
center. This center will provide support and resources to grantees, 
help ensure accurate data-collection and reporting to gauge progress, 
and disseminate best practices in credentialing, recruiting, training 
and developing, and retaining school-based mental health services 
providers. This will include best practices for establishing and 
sustaining partnerships with IHEs to create and provide innovative 
high-quality training and credentialing options and maintain a robust 
pipeline of school-based mental health services providers.

    IHEs have also worked creatively on the ground to utilize funding 
from the Higher Education Emergency Relief Fund to address mental 
health at colleges and universities around the country. \6\
---------------------------------------------------------------------------
    \6\  U.S. Department of Education. Using Higher Education Emergency 
Relief Fund (HEERF) Institutional. Portion Grant Funds to Meet the 
Mental Health and Substance Use Disorder Needs of Students. May 19, 
2022. https://www..ed.gov/about/offices/list/ope/
heerfmentalhealthfaqs.pdf.

---------------------------------------------------------------------------
    Some examples include:

          North Carolina Central University created a suicide 
        prevention coordinating committee. The committee has worked to 
        develop on-campus resources and a suicide response plan.

          The University System of Georgia created a system-
        wide task force to develop a comprehensive plan for long-term 
        solutions to address mental health challenges and provide 
        mental health services at their institutions.

          The University of Alabama provided centers for 
        students from underserved or marginalized groups and 
        communities, open for all students, including a Safe Zone for 
        LGBTQ+ students, a Collegiate Recovery and Intervention 
        Services Center for students with substance use disorders, and 
        a Women and Gender Resource Center for students who are 
        survivors of violence.

          Lac Courte Oreilles Ojibwe College in Wisconsin 
        partnered with a mental health platform to allow all students 
        and faculty on-demand, 24/7 access to counselors.
   Interagency Collaboration and Capacity Expansion Through Medicaid
    BSCA also directed the Department of Health and Human Services, in 
collaboration with the Department of Education to issue guidance to 
state Medicaid agencies, LEAs, and school-based entities to support the 
delivery of medical assistance to Medicaid and the Children's Health 
Insurance Program (CHIP) beneficiaries in school-based settings. This 
guidance, Delivering Services in School-Based Settings: A Comprehensive 
Guide to Medicaid Services and Administrative Claiming was released on 
May 18, 2023. \7\
---------------------------------------------------------------------------
    \7\  The Centers for Medicare and Medicaid Services, Delivering 
Services in School-Based Settings, 2023, https://www.Medicaid.gov/
Medicaid/financial-management/downloads/sbs-guide-Medicaid-services-
administrative-claiming.pdf.

    Medicaid and CHIP provide health coverage to millions of people 
living with disabilities and low-income families, children, pregnant 
individuals, adults, and seniors, including over half of American 
children (57 percent = 41.9 million children enrolled in Medicaid and 
CHIP / 73.1 million children in the U.S.). \8\ These programs are 
administered by states, according to Federal requirements. Children are 
eligible based on their family income or unique health care needs (such 
as a disability or serious mental illness), or if they are in foster 
care. Under Medicaid's Early Periodic Screening, Diagnostic and 
Treatment (EPSDT) benefit, eligible children under age 21 should 
receive comprehensive physical health, mental health and behavioral 
health services. \9\
---------------------------------------------------------------------------
    \8\  The Centers for Medicare and Medicaid Services, Delivering 
Services in School-Based Settings, 2023, https://www.Medicaid.gov/
Medicaid/financial-management/downloads/sbs-guide-Medicaid-services-
administrative-claiming.pdf.
    \9\  The Centers for Medicare & Medicaid Services, CMCS 
Informational Bulletin: Information on School-Based Services in 
Medicaid: Funding, Documentation and Expanding Services, August 18, 
2022, https://www.Medicaid.gov/Federal-policy-guidance/downloads/
sbscib081820222.pdf.

    Medicaid-enrolled children who need services in school can fall 
into two categories: eligible students who need general health care 
services and students with disabilities who receive special education 
services under the Individuals with Disabilities Education Act (IDEA). 
School-based services delivered to children with disabilities are at no 
cost to their families. The Medicaid Budget and Expenditure System 
(MBES) expenditures reports for 2021 show more than $5.98 billion in 
total computable payments for school-based health care services to 
Medicaid students. Schools also received $14.1 billion in Federal IDEA 
funding in 2023. \10\
---------------------------------------------------------------------------
    \10\  The Centers for Medicare and Medicaid Services, Delivering 
Services in School-Based Settings, 2023, https://www.Medicaid.gov/
Medicaid/financial-management/downloads/sbs-guide-Medicaid-services-
administrative-claiming.pdf.
    \11\  Healthy Schools Campaign, ``State Data on Medicaid-Eligible 
School Health Services and Providers,'' https://
healthystudentspromisingfutures.org/map-school-Medicaid-programs/.

    Medicaid can support schools to sustain essential services for 
eligible students. \11\ In 2014, the Centers for Medicare & Medicaid 
Services (CMS) issued a letter to State Medicaid Directors clarifying 
reimbursable services in a school-based setting. The CMS letter 
explained that schools can seek payment for all Medicaid-covered 
services provided to all students enrolled in Medicaid. \12\ As of May 
2023, 214 states have used this policy to expand their school-based 
Medicaid programs. Most states use these funds to hire and sustain 
essential personnel who can delivery or facilitate the delivery of 
health and mental health services. The actual amount of additional 
Medicaid funding varies across school districts based on a wide variety 
of factors, including: (1) the number of students who are eligible for 
Medicaid in a district; (2) the unique needs of each child with a 
disability; and (3) State Medicaid payment rates;
---------------------------------------------------------------------------
    \12\  Centers for Medicare & Medicaid Services, SMD# 14-006 
Medicaid Payment for Services Provided without Charge (Free Care) 
https://www.Medicaid.gov/Federal-policy-guidance/downloads/smd-
Medicaid-payment-for-services-provided-without-charge-free-care.pdf.

    Here are a few examples of how states have leveraged this 
opportunity to date to leverage Medicaid payments to hire key staff to 
---------------------------------------------------------------------------
provide essential health and mental health services to youth:

          Louisiana was the first state to expand its program, 
        focusing solely on school nursing services. The State's 
        financial analysis showed a 35 percent increase in Federal 
        revenue. The program was such a success that the State did a 
        second school Medicaid expansion to include all eligible 
        providers and services. \13\
---------------------------------------------------------------------------
    \13\  https://healthystudentspromisingfutures.org/state-successes/
examples/.

          Colorado ran a pilot project to better understand the 
        financial impact of expanding its program. The state began by 
        examining the impact of adding additional Medicaid eligible 
        providers and, with the inclusion of additional school 
        behavioral providers, estimated an increase of around $8 
        million, Michigan expanded its program to allow claiming for 
        all Medicaid-enrolled students and added a number of additional 
        providers, including masters-level school psychologists and 
        behavioral health analysts. Billing for masters-level school 
        psychologists alone is projected to lead to an increase of $14 
---------------------------------------------------------------------------
        million to the school system.

          Voices for Georgia's Children estimates that 
        Georgia's pending expansion to allow claiming and payment for 
        school nurses would bring in an additional $48.6 million in 
        Federal revenue to the school-based Medicaid program.

                               Conclusion
    The Department's mission is ``to promote student achievement and 
preparation for global competitiveness by fostering educational 
excellence and ensuring equal access.'' This mission is urgent now more 
than ever as members of the educational community work together to 
address the learning gaps and increased mental health needs, fueled by 
the pandemic, that affected all students, particularly students from 
historically underserved groups.

    As described above, we are actively engaging in efforts to 
accelerate recovery. We note throughout this testimony how the 
Department prioritizes work to address the mental health crisis facing 
our Nation's youth. We are committed to ensuring that students' needs 
are met, that they are ready to learn, and that they have full access 
to learning opportunities.

    Thank you, I look forward to answering your questions.
                                 ______
                                 
                 [summary statement of katherine neas]
    Mental health affects the well-being of every student, educator, 
school, and community in America; and the Department is committed to 
creating the conditions for all students to thrive academically and 
personally. The Department's work is focused on three top priorities: 
(1) increasing the skills and knowledge of existing school personnel to 
support the mental health needs of students; (2) increasing the supply 
of mental health professionals who can work with students; and (3) 
increasing funding through the Medicaid program to support school 
health services, including mental health services. The Department also 
is engaged in robust delivery of technical assistance through funded 
technical assistance centers.

    One year ago, Congress provided new funding under the Bipartisan 
Safer Communities Act (BSCA) that significantly bolstered Federal, 
state, and local efforts to address student mental health needs. Here 
is an update on our work to implement this legislation.

          $1 billion through Title IV, Part A of the Elementary 
        and Secondary Education Act of 1965 (ESEA) to enable State 
        Educational Agencies (SEAs) to competitively award subgrants to 
        high-need LEAs for activities to support safe and healthy 
        students under ESEA section 4108. The Department has designated 
        this component of BSCA the Stronger Connections Grant Program. 
        States are in the process of running Stronger Connections grant 
        competitions. ESEA section 4108 allows funds to be used to 
        ``develop, implement, and evaluate comprehensive programs and 
        activities'' that foster safe, healthy, supportive, and drug-
        free environments that support student academic achievement.

          $280 million across 264 projects projected to train 
        approximately 13,500 school-based mental health professionals 
        and hire approximately 14,000 more under the School-Based 
        Mental Health Services Grant and the Mental Health Services 
        Professionals Grants.

          $86 million in grants to local communities under the 
        Promise Neighborhood Grants and the Full-Service Community 
        Schools program.

          A new competition for a mental health professional 
        development technical assistance center is underway. services 
        providers.

          BSCA also directed the Department of Health and Human 
        Services, in collaboration with the Department of Education to 
        issue guidance to State Medicaid agencies, LEAs, and school-
        based entities to support the delivery of medical assistance to 
        Medicaid and the Children's Health Insurance Program 
        beneficiaries in school-based settings. This guidance, 
        Delivering Services in School-Based Settings: A Comprehensive 
        Guide to Medicaid Services and Administrative Claiming was 
        released on May 18, 2023. \1\
---------------------------------------------------------------------------
    \1\  Medicaid, Medicaid and School Based Services: Overview of 
Medicaid and School-Based Services, May 18, 2023, https://
www.Medicaid.gov/resources-for-states/Medicaid-state-technical-
assistance/Medicaid-and-school-based-services/index.html.

        Additional Resources from the US Department of Education
    Bipartisan Safer Communities Act--Office of Elementary and 
Secondary Education

    Safe and Supportive Schools--Office of Elementary and Secondary 
Education

    Center to Improve Social and Emotional Learning and School Safety--
Office of Elementary and Secondary Education

    Supporting Child and Student Social Emotional Behavioral and Mental 
Health

    Medicaid School Based Services information

    www.ed.gov/raisethebar
                                 ______
                                 
    The Chair. Mrs. Neas, thank you very much. Let me start off 
with Dr. Murthy. Senator Cassidy mentioned what is true, that 
the Congress has taken some action. But I will tell you, as I 
go around Vermont and talk to teachers and principals, they 
tell me they need more help.

    In your judgment, do we have at this moment the kind of 
mental health infrastructure, from psychiatrists, the social 
workers, the counselors that this country needs?

    Admiral Murthy. Well, thank you, Senator. And I do 
appreciate the significant historic investments that have been 
made over the last few years. I think they have helped, but we 
do need more to help build the infrastructure.

    When we think about care, for example, mental health care, 
there are several pieces of the infrastructure that still need 
to be expanded. No. 1 is the mental health workforce itself.

    I am talking here not only about psychologists and 
psychiatrists and others in the traditional mental health 
delivery model, but I am also thinking about peer support 
models and others, which we know can help kids, and we need to 
think more broadly about that workforce.

    The Chair. Let me ask you this, we have talked a lot about 
the problems. Talk about some of the solutions. Are there 
communities or schools in America that are doing something that 
is effective in addressing the crisis we are talking about?

    Admiral Murthy. The good news is that there are successful 
models around the country. Many of them do not know about each 
other and hence are not learning from each other, and we have 
to invest in studying and scaling them.

    But a few that I will mention. One is the Becoming a Man 
Program, which has been a very powerful program, started in 
Chicago and now spread to some other cities, which has worked 
in high schools with helping young people, essentially be 
sources of support to one another, and it has been able to 
demonstrate actual benefits in trials that were run by the 
University of Chicago.

    We also know the Afterschool Matters Program has been 
another one, which has brought community organizations together 
to be with kids and provide the mentorship, support, and safe 
spaces to play and learn after school. And that has also 
demonstrated positive benefits.

    The Chair. Let me ask you this, because you have written 
about this. What is--you write about loneliness, and yet people 
spend half their lives on these things. What is the difference, 
in your judgment, between human interactivity and activity on 
social media, and how does that impact the well-being of 
Americans?

    Admiral Murthy. Well, Senator, this has been an important 
point of concern for me. There is no substitute for in-person 
interaction. As human beings, we evolved over thousands of 
years to perceive not just the content of what someone says, 
but also interpret their body language, to sense nonverbal 
cues.

    We take all of that in, and that contributes to a rich 
human interaction. When you strip a lot of that away, you lose 
richness, you lose quality of connection. That is not to say 
there is never a place for texting or for online connection.

    But what I worry about is that the balance has shifted 
dramatically toward online connection and away from in-person 
connection, particularly for our kids. But the other concern, 
Senator, is not only what kids are missing out on as a result 
of social media, but what they are being exposed to on social 
media.

    We--I talk to parents all over the country who--and to kids 
as well, who say that they are exposed to content that is 
violent and sexual in nature, that they are often bullied and 
harassed online. Six out of ten adolescent girls are telling us 
that they have been approached by strangers on social media in 
ways that have made them feel uncomfortable.

    These are--I am concerned both about what is not happening 
as a result of social media in our kids' lives, but also about 
some of the toxic effects of what they are being exposed to.

    The Chair. Mrs. Neas, you spoke about the impact that 
Medicaid is having on providing services to kids who 
desperately need it. We are now, as a result of the end of the 
pandemic and the cessation of the funding,--the many billions 
of dollars we put into funds and increasing Medicaid,--what 
impact will hundreds of thousands of millions of people losing 
their Medicaid have on mental health in this country?

    Ms. Neas. Senator, thank you for that question. The work 
that we have done with the Department of Health and Human 
Services to make it easier for schools to access the Medicaid 
program for school based services is one that we are very proud 
of because we think it is going to make it easier for schools 
to hire and sustain necessary people.

    At the same time, we have been working hand in glove with 
the Department to get word out to our school leaders about this 
time of re-enrollment and hoping that those children who have 
to re-enroll in Medicaid are found eligible.

    That those that are found not eligible can be directed to 
another source of insurance. But it is something that I think 
the Administration is very concerned about and wanting to do 
everything we can to make sure that children who are eligible 
can stay on the program.

    The Chair. But is it a concern that if hundreds of 
thousands of millions of families lose their Medicaid, it is 
going to make it harder for people to get the mental health 
services they need?

    Ms. Neas. Without question, sir.

    The Chair. Senator Cassidy.

    Senator Cassidy. Although I am tempted not to because my 
fellow Southerner did not wear a seersucker today, I am going 
to defer to Senator Tuberville.

    [Laughter.]

    Senator Tuberville. I have got two suits, I just forgot.

    [Laughter.]

    Senator Tuberville. Thank you, Mr. Chairman, for having 
this hearing. I spent 35 years with the youth of this country 
as a coach, educator, and this is not just a crisis that we 
have, mental health, it is an emergency. We got huge problems. 
This is probably the biggest problem we have in this country. 
It is getting worse every day.

    I saw it change in just a short period of time. The No. 1 
commodity that we have in this country is not gold and silver, 
it is our young people, and we are destroying them, and we are 
sitting back and watching it happen. I have seen prescription 
drugs take over our youth, especially a lot of kids that I work 
with.

    We have ruined the nuclear family, and that is where a lot 
of this has got to come from. I counted up yesterday 32 mental 
health programs that we have in this country--32. We spend tens 
of billions of dollars. We are not making any progress. We are 
going the opposite way. We have all kinds of addiction.

    I talked to a sheriff last week in Montgomery, Alabama, and 
he said, coach, I had never heard the word fentanyl till 2 
years ago. Now, that is 95 percent of the drugs that we have in 
our schools and on the streets. The biggest drug we got is this 
right here. We all got it. There is not a person in here that 
doesn't have one of these.

    I am guilty like everybody else, and I stay on it. I think 
everything on it is true, but it is not. But our young kids 
think that it is. That is the problem, and we have got to get 
control of that. And a lot of it, that is what we are talking 
about here today, is loneliness. And we can agree on some of 
that.

    We have a program in Alabama that is called Harsha that our 
state mental health Department is running through our 
children's hospital. It works to connect interested primary 
providers with mental health specialists across the state and 
operates a sort of a command center at the hospital in 
Birmingham. Kids experiencing these--all the issues that they 
have, they are connected with providers that are close to them, 
whether it is rural or inner city.

    Money for this particular program has tripled in the last 
year in the bipartisan Safer Communities Act. Now, I will tell 
you this. We can afford a lot of things around here, but we 
cannot not afford to fund mental health.

    We can't. We have to be able to afford it and through 
situations like this. So, Dr. Murphy, are we tracking the 
successes and failures of the rest of the billions of dollars 
that we spend, or we track?

    Are we tracking that, where it is working? Have you got 
people that are doing that in your line of work, that is 
helping us track the money going in? Is that money helping to 
the degree where we can see success?

    Admiral Murthy. Well, thanks, Senator, and I wish I could 
circle, underscore, star so much of what you just said, because 
you are right on and you are right that the most important task 
that we have is our kids, and we have got to do more to protect 
them.

    I also agree with you that when we do put funds toward a 
cause, it is important to know, is it actually working? Is it 
delivering the benefit? And, while our office, the Surgeon 
General does not conduct evaluation trials, that is not what we 
are a resourced to do, we do have colleagues across the 
Department of Health and Human Services, at NIH and at SAMHSA, 
who do conduct evaluations of programs so that we understand 
what is working, who it is working for, and what more--what is 
missing.

    But I think, Senator, to pick up on something else you said 
here as well. I think--and I like the program you mentioned in 
Alabama in terms of the concept of building a network and an 
infrastructure so that primary care doctors in particular and 
others aren't trying to manage all this on their own.

    Programs like the Pediatric Mental Health Access Program, 
for example, have been very helpful in making sure that those 
primary care doctors can get expertise, mental health 
expertise, into the clinic when a patient is there, and we do 
need more programs like that.

    But I don't think that we will be able to keep up with the 
sheer disturbing trends that we are seeing in terms of 
increased mental health concerns unless we simultaneously 
attack some of these root causes.

    You mentioned our devices, and particular for young people, 
social media has become, I worry for too many of them, a 
contributor, an important contributor to their mental health 
strains. I also spent a lot of time with student athletes when 
I travel around the country, do roundtables specifically with 
student athletes.

    Many of them tell me that not only are they having a hard 
time sometimes getting help, some of them have incredibly 
supportive coaches and administrations. Others do not. I had 
one football player who told me that after having serious 
thoughts of taking his own life, he approached his coach and 
said--and it took a lot of courage for him when he admitted to 
his coach what was going on and asked for help.

    But as a response from the coach as well if that is how you 
are feeling, maybe this program is not for you. You should 
consider going to another university. And he was heartbroken. 
Now, thankfully, that is not the response that most kids get, 
but we still have more to do in terms of making sure kids get 
the help they need.

    But if we can focus on making social media safer for our 
kids, if we can focus on rebuilding the social connection and 
community that our kids need, families are a key part of that, 
faith institutions are a key part of that, other community 
organizations like YMCA, boys and girls clubs, these are all 
play vital roles in helping connect kids to each other, 
families to each other, but participation in them, Senator, has 
been declining for a half a century, and it is leaving people 
lonely, isolated, and in greater risk for mental illness.

    Senator Tuberville. Thank you. And one thing I would like 
to say, I know we are over a little bit here, Mr. Chairman, but 
we have, unfortunately, people in this country that are born 
with a mental health problem, and we are trying to treat them 
with a lot of prescription drugs. And I think that is fine to a 
certain degree.

    Sometimes we are overprescribing. But the problem is we are 
creating more mental health problems now than we are having 
young people born with mental health problems. And I think we 
all have to understand that. If we will start understanding 
that I think we can understand the problems that we have to 
overcome.

    Because if we don't do this now, we are going to lose the 
country that we all grew up in, because mental health is the 
No. 1 problem in this country, the No. 1 problem, and we have 
to--because it leads to everything else. Leads to so many 
things in this country that are negative. So, thank you. Thank 
you for your answer. Thank you. Mr. Chairman.

    The Chair. Senator Casey.

    Senator Casey. Mr. Chairman, thanks for having this 
hearing. I want to thank you and the Ranking Member for 
convening us. And I want to thank both of our witnesses for 
their testimony and their public service.

    I wanted to start with Deputy Assistant Secretary Neas to 
talk about bullying and harassment, one aspect of this larger 
challenge. I think we can all agree that children deserve to go 
to school without any fear or intimidation.

    But as we know, far too often bullying and harassment 
affects so many children and can have very serious consequences 
for the mental health that stay with them for the rest of their 
lives, and it undermines their ability to achieve academically.

    We know that these issues are especially prevalent among 
students with disabilities, LGBTQ+ students, students of color, 
and students who are either in high school or elementary 
school, girls and young women.

    To support the well-being of all students, I have 
introduced multiple times now the Safe Schools Improvement Act, 
which would require school districts to adopt codes of conduct 
that explicitly and transparently prohibit bullying and 
harassment based upon race, color, national origin, sex, 
disability, sexual orientation, gender identity, and religion, 
very much consistent with our civil rights statutes.

    The bill would ensure that school districts take proactive 
action to support the safety and inclusion of all children. And 
Deputy Assistant Secretary, what is the value of universal 
prevention strategies such as legislation like I just outlined, 
in supporting mental health and academic achievement of every 
student?

    [Technical problems.]

    Ms. Neas. Is that better? Here we go, sorry. Thank you for 
that question. The Department has partnered with the Department 
of Health and Human Services on a website called 
stopbullying.gov, which includes resources for schools to do 
exactly what you are saying.

    I think one of the reasons we are so proud of the 
bipartisan Safer Communities Act and the work we are doing to 
increase the supply of mental health professionals who are in 
school is to make those things real. It is important to have 
the culture of a school be conducive to learning and safe for 
everyone.

    We want to have those resources in schools and available to 
schools so that they can actually act on it. So, I couldn't 
agree with you more. The need for us to address the bullying, 
particularly of vulnerable kids, kids with disabilities, kids 
who may have uncertainty at home. We want school to be that 
safe place where they always know that there is somebody there 
who has their back.

    Senator Casey. Thank you. I wanted to move to a question 
for Dr. Murthy. One of the many pieces of data that you cite in 
your testimony--and I am looking at page one of your written 
testimony, it just kind of leaps off the page, and I am just 
reading a pertinent part here, ``in 2021, nearly one in five 
high school students reported making a suicide plan.''

    Hard to comprehend those numbers, one in five high school 
students. And I wanted to not just focus on those high school 
years, but what happens afterwards as well. And because if that 
is the circumstance in high school, we can only imagine what 
that means down the road.

    This challenge that we are all talking about here today 
predated obviously the pandemic but was made much worse by it. 
I am citing here the Kaiser Family Foundation, showing that 
half of young adults, ages 18 to 24, reported anxiety and 
depression symptoms this year, 2023--half of young adults.

    Despite these rising needs, many institutions of higher 
education are poorly equipped to handle the mental health needs 
of students. I have introduced the Higher Education Mental 
Health Act, along with Senator Kaine.

    The legislation promotes collaboration among educators, 
students, parents, advocates, and communities to study the 
mental health concerns facing college students. How can 
institutions of higher education better support students who 
are struggling with mental health today?

    Admiral Murthy. Well, thank you, Senator. And I appreciate 
your leadership on this issue, and with your proposed 
legislation. I think higher--institutions of higher learning 
have a huge role to play.

    First of all, they are aware a lot of young people are, and 
we better bring the care to where people are. They can help to 
change culture by starting conversation addressing stigma. They 
can increase access to mental health services on campus and 
through telehealth to make it easy for kids to get care. But 
they can also invest in building the kind of connection and 
community that we know is vital to the mental health of 
children.

    It doesn't just happen by throwing kids in a room and 
saying, hey, mingle and build connection. It turns out a little 
bit of structure, along with a little bit of time, can help 
kids actually build the relationships that they want. And 
finally, let's just keep in mind, many kids don't have what we 
might assume are just basic tools for managing emotions, 
building strong, healthy relationships.

    Many of them may not have gotten that. And so, we have got 
to recognize that. And it is why I think programs that focus on 
building social skills and an emotional development so kids can 
manage their emotions and understand the emotions of others are 
really vital. That is a life skill. That, to me, is just as 
important as learning how to read or write.

    Senator Casey. Thanks very much.

    The Chair. Senator Cassidy.

    Senator Cassidy. I defer to Senator Budd.

    Senator Budd. Thank you, Senator. And thank you, Chair. And 
thank you both for being here today. So, I sent a letter to NIH 
back on May 9th asking why taxpayer dollars were spent on a 
study entitled, Psychological Functioning in Transgender Youth 
After Two Years on Hormones, in which two participants 
tragically committed suicide. So, I am still waiting for a 
response from NIH on that letter, and I, Chairman, I ask for 
unanimous consent that I can submit my letter for the record.

    The Chair. Without objection----

    [The following information can be found on page 90 in 
Additional Material:]

    Senator Budd. Thank you. Now, the researchers, they 
concluded that the study was a success, but they admitted also 
that they couldn't show that cross-sex hormones improved the 
psychosocial functioning for minors. So clearly, it looks like 
this was a real waste of taxpayer dollars.

    Even worse than that, it led or contributed to the suicide 
of two youth. So, Dr. Murthy, considering what I understand is 
your past support for providing cross-sex hormones to children, 
can you explain whether you think spending more taxpayer 
dollars on research into transgender procedures on minors will 
actually help children with the mental issues that we are 
discussing today?

    Admiral Murthy. Well, thanks, Senator Budd, for that 
question. While I was not directly involved in this study, and 
I am not familiar with it----

    Senator Budd. I understand----

    Admiral Murthy [continuing]. What I will say is that it is 
important for us to study what measures may help improve the 
mental health and well-being of transgender youth, because what 
we see clearly in the data is that as disturbing as these rates 
of anxiety, depression, and suicide are, they are actually 
disproportionately higher among LGBTQ youth, particularly 
transgender youth.

    Studies that look to understand what interventions that 
work to address those psychosocial concerns I do think are 
important because this is a community that is struggling.

    Senator Budd. Thank you. A follow-up to that. Are you 
concerned about causing sterility and infertility in children 
who receive these cross-sex hormones, and about the negative 
long term impacts of these medical interventions on their 
mental health?

    Admiral Murthy. Well, Senator, I think whenever you have a 
medical intervention, it is vital to study both the short and 
long term impacts on physical and mental health. And I think 
that is where an investment of resources is needed.

    Senator Budd. Just to clarify, you said you would be 
concerned about the long term and short term impacts of these 
medical interventions on their health, their mental health?

    Admiral Murthy. Well, I think it is important for us to 
understand what those are through research, sir. So that is 
what I am saying. And I think that this is a space where, this 
is obviously a very complex area, and what we need to do here 
is what we do in other areas of medicine, which is to look to 
experts who have expertise in this area to put together the 
kind of guidelines that clinicians can then look at, and then 
make the best decision for patients based on that, or 
individual circumstance, just like we do in other areas of 
medicine.

    Senator Budd. Thank you. And I would just hope that the 
medical community and their research would be very cautious 
here. I mean, we have seen an NIH study which contributed to 
the suicide of two individuals, so please be careful, is the 
message. I want to shift gears just a little bit back to social 
media.

    We know that children are being bombarded every day by 
unhealthy information on social media. Millions of children are 
suffering, as we have talked about, from anxiety and 
depression, and loneliness, because of the addictive content on 
social media.

    There is an advisory, I think, that you issued on social 
media and youth mental health, and it discussed the increased 
use of social media by kids. So, to what extent, Dr. Murthy, do 
you agree that social media is damaging to the mental well-
being of children? And how do you believe that we should 
address this?

    Admiral Murthy. Well, thanks for that, Senator. And my 
concern here is not just the Surgeon General, sir, it is as a 
doctor and as a parent. I have a five and 6 year old child--
children, and my daughter is five. She is in preschool. And she 
came home a couple of weeks ago and asked my wife and me if she 
could post a picture on social media. She didn't have a social 
media account.

    We have never talked to her about social media, yet all of 
her friends are talking about this. And I do believe that while 
there are some kids who get benefits from their use of social 
media in terms of opportunities to interact with others, in 
terms of the opportunity to find a community online, whereas 
they may not have one in person, I do worry that for many 
children the effects are in fact harmful and are contributing 
to the depression and the anxiety that we see among many young 
people, as well as issues with body image. In terms of what we 
can do, I think there is a lot we can do.

    Ultimately, this isn't all about what Government can do. I 
think there is an important role, a critical role for parents 
here and for kids themselves. But I think what parents need is 
some support and help. And by establishing safety standards for 
social media that help protect kids from exposure to harmful 
content, and from harassment and bullying, and from features 
that seek to manipulate them into excessive use, I do think 
that we can help parents.

    We also need, as policymakers, I think there is also a role 
to require data transparency here. And researchers around the 
country, Senator, tell me that they have had a hard time 
getting the data from companies to fully understand the extent 
of the impact of social media.

    I will just say this, Senator, when our child--when our 
children get old enough to drive a car, or when they are small 
like mine were a few years ago and we needed to get a car seat 
for them, we don't tell parents, go inspect the tires yourself, 
check out the engine, make sure the frame is adequately strong, 
because we know that not all parents have the expertise to do 
this.

    They rely on us establishing standards and then enforcing 
those with manufacturers. These are incredibly complex 
platforms that are rapidly evolving, fundamentally changing how 
our kids see themselves and interact with the world, and 
parents need help here to interpret and understand their 
safety.

    Senator Budd. Good. Thank you both.

    The Chair. Thank you.

    Senator Murphy.

    Senator Murphy. Thank you very much, Mr. Chairman. Thank 
you for holding this very important hearing. I am so proud of 
this Congress and many on this Committee for passing the 
bipartisan Safer Communities Act, and I am glad to get an 
update today on how that money is being impactful to help our 
kids. It is part of a trend. We are spending more money today 
on mental health than ever before.

    We have gone from about $155 billion in 2010 to $238 
billion in 2020, and it is still not enough. But I think this 
hearing is so important because I think we have come to the 
conclusion that unless you get at the root causes of 
unhappiness and isolation and loneliness, there is almost no 
amount of money that can make up for that inattention.

    Dr. Murthy, I wanted to continue this conversation about 
social media, in part because I think it is the most immediate 
public policy concern that this Congress can tackle, and 
because I think there is easy agreement between Republicans and 
Democrats, but not because I think it is the whole story.

    I think, frankly, we probably spend more time than we 
should talking about this narrow but very important problem 
that our kids are facing. But I think we can do something about 
it, so let's not lose the opportunity. I know the 
Administration hasn't endorsed any specific policy proposals, 
but just give us your take on which direction we should head.

    Senator Schatz, and Cotton, and Britt, and I have a piece 
of legislation that says, you have got to do age verification 
and make sure that you can't get on before you are 13. You 
can't use algorithm boosting on younger kids, and parents have 
to have a say.

    Other legislation says you should have a standard that 
applies to social media companies so that they are only putting 
healthy content online. As you look at the sort of cornucopia 
of policy options that Congress is looking at here, what 
direction would you point us in to best protect our kids?

    What are the tactics that the social media companies are 
using that are most disturbing to you? And I will just give you 
maybe the statistic that is most worrying to me. There is a 
recent study that shows within 2 minutes of establishing a 
TikTok account, a teenager can be fed information glorifying 
suicide.

    Within 4 minutes of establishing a TikTok account, a 
teenager can be sent content celebrating eating disorders. That 
is how quickly really damaging, really dangerous content can 
get to kids who are in crisis, who are in trouble. And it just 
compels us, in this Congress, to do something about it. So, 
give us a little bit of advice.

    Admiral Murthy. Well, thanks, Senator. And I just want to 
also appreciate your leadership on the issue of loneliness and 
isolation. It has been an honor to work together with you on 
addressing this. And I agree with you that there are multiple 
drivers of the mental health crisis. Social media is one of 
them, and I agree it is an important one for us to address.

    A few things I would say in terms of avenues of focus on, 
recognizing that social media has been around for almost two 
decades. During that time, there has been a lot of evolution in 
the platforms, a lot of different ways in which it is affecting 
our kids' lives. And so there is actually a lot to do here if 
we truly want to make them safe.

    I think one certainly is around enforcement concerning age. 
Many platforms established 13 as the age at which kids can use 
social media. By the way, that is not based on health grounds, 
the age of 13.

    Although many people think it is. But it--40 percent of 
kids 8 through 12 are on social media. So whatever rules the 
platforms have in place are very poorly enforced. I think the 
second area is we need to protect the privacy, data privacy of 
kids. Kids at this point do not have sufficient control over 
their data, neither do their parents.

    This data is often used in direct ads to them, and other 
content is driven by the algorithms. We need to give kids and 
parents control over that data. The third is actually around 
data transparency. Companies are not fully disclosing the data 
they have about the health impacts of their platforms to our 
kids, to kids, to parents, to researchers, and to the public at 
large.

    This is what researchers tell us all the time. And without 
that transparency, we don't even know the full extent of the 
problem and which kids are more most affected, and so it is 
hard to target interventions. But finally, I would say when it 
comes to safety standards, this is a place where I do think we 
can build models off of other products where we establish 
safety standards.

    Whether it is for cars, car seats, medication, baby 
formula, whatever you want to consider as a parallel, but the 
bottom line is, we need to have standards that push companies 
to assure us and to be able to demonstrate through data that 
they are not exposing our kids to harmful content, that they 
are not in fact allowing kids to be bullied and harassed 
online, particularly by strangers, and also that they are not 
promoting the use of features that lead to excessive use.

    We know that kids are in a vulnerable stage here of 
development and they are particularly susceptible to some of 
these features. We can't have companies taking advantage of 
those. So, these are some areas that I think are essential for.

    I would be happy to work with you and other Members of this 
Committee as you develop legislation around this, because I 
think this can't come soon enough.

    Senator Murphy. I appreciate our partnership. I appreciate 
your guidance to this Committee. The only thing we cannot 
afford to do is to stand pat. There is a consensus here that we 
can find with your help. Thank you very much, Mr. Chairman.

    The Chair. Thank you.

    Senator Cassidy.

    Senator Cassidy. I defer to the sartorially splendid, Dr. 
Marshall.

    Senator Marshall. Well, thank you, Senator Cassidy. And 
thank you, Chairman Sanders. We have to stop the hemorrhaging. 
We have to stop the hemorrhaging. When a patient comes to the 
emergency room when they are bleeding out, we don't start 
pumping blood into them. The first thing we have to do is stop 
the bleeding. Most of our solutions today seem to be pumping 
more blood into people.

    We got to go back and start over. The greatest health care 
mistake the NIH and CDC ever did was locking our youth out of 
schools, and that has launched this mental health epidemic that 
we have. Irrefutable damage to our children's mental health, 
and I hope the CDC will own that someday.

    Instead of our children talking to their friends, their 
colleagues, their teachers, their coaches, they talk to social 
media. That became their best friend. So how do we stop that 
hemorrhaging? I think we have to go back and think about, I 
look at social media today it is worse than pornography.

    My young sons were exposed to pornography when they were 
very young because of social media, and I think the addictive 
pressures coming from social media today are worse than 
pornography. And just like we had to set parameters around 
pornography, we need to do the same thing with social media.

    I wish we didn't have to. I think we need to start over on 
what the solutions are. Dr. Murthy, would you support some type 
of an electronic Surgeon General's warning on a statement on 
mental health and the impact of social media?

    Admiral Murthy. Well, thank you, Senator Marshall. And it 
is always good to be here with a fellow clinician as well. I 
know you have seen this from different angles.

    I do worry about social media, as you do, and what I have 
tried to actually do in the advisory we just issued 2 weeks ago 
was to put in writing clear as day what our concerning was. Our 
concern was about social media, and to issue that warning to 
the American public.

    I don't think it is the last thing, though, that we need to 
do. I think it is a start.

    Senator Marshall. Much like when I was growing up, we put a 
Surgeon General's warning on tobacco. And it had an impact. I 
think, when we put a Surgeon General's warning on alcohol for 
pregnant women, it has an impact. Are you willing to use your 
bully pulpit and say, we need a Surgeon General's warning on 
what is the biggest threat to our youth right now when it comes 
to their health.

    This is the No. 1 threat to our children's health right 
now. It is not cancer. It is not osteoporosis. It is not a 
whole lot of things. This is the No. 1 threat. Are you willing 
to use your pulpit and put your reputation on the line and say, 
we need a Surgeon General's warning on social media for youth?

    Admiral Murthy. Well, Senator, I do think it would be 
appropriate to have a warning on social media to warn parents 
and kids. And if Congress is willing to provide the legislative 
or regulatory authority to put that label on, then I would 
certainly be willing to partner.

    Senator Marshall. Does it take legislation for you to put 
that label on? I don't know the answer to that.

    Admiral Murthy. Yes, it takes either a legislative or 
regulatory authority to do that.

    Senator Marshall. Okay. Another issue I want to talk about 
are--is fentanyl or drug cartels, that they are selling fake 
Adderall. This, of course, laced with fentanyl. You are well 
aware of this. And they are using social media.

    Of course, the top buyers are children. Senator Shaheen and 
I wrote legislation with leaders on the Judiciary Committee to 
hold social media companies accountable for illegal drug sales 
happening on their platforms.

    Does this have the support--it does have the support of the 
White House and the DOJ and would love to add your continued 
efforts with this. Any comments on that?

    Admiral Murthy. I want to highlight the word you use, 
accountability, because there has been an utter lack of that 
when it comes to how we have been addressing the impact of 
social media on our kids.

    What you mentioned, which is the use--the platform is being 
used to expose our kids to drugs and other harmful content is 
one example of that. So yes, I would support measures to ensure 
there was more accountability for the platforms.

    Senator Marshall. Okay. The last thing we need to do is go 
back and study this and form committees and pray about this. We 
know social media is preying on our youth. We know it as surely 
as alcohol causes infant problems for moms as well. We know it. 
We don't need to study this more.

    As black and white as you can make this, what would be your 
recommendations to stop this from happening? What--if you 
were--if you owned the social media company, why wouldn't you 
take the responsibility yourselves? Why does it take an act of 
Congress to do the right damn thing? What would you recommend 
that they do?

    Admiral Murthy. Well, do you mean this company 
specifically?

    Senator Marshall. Yes.

    Admiral Murthy. Yes. So, what I laid out on the advisory is 
a series of checks for the tech companies specifically. One is 
to apply age appropriate design to their platform, so they are 
not exposing young kids to harmful content.

    Second is to be transparent with their health impacts and 
the data that they are collecting that--so everybody can see 
how these platforms are impacting our kids' health. But the 
truth is, Senator, these social media platforms have been 
around for nearly 20 years. If we are going to just rely on 
them to fix this problem, I think we are waiting for something 
that is not going to happen.

    Because while they have made some efforts to put safety 
measures in place, it is not nearly enough, and it is not 
happening nearly fast enough.

    Senator Marshall. Greed is a horrible thing. Using greed to 
take advantage of our youth is a horrible thing. I just call on 
the social media companies to take self-accountability and to 
do something about this. Don't wait for Congress to do it. They 
know what the right thing is to do. They are taking advantage 
of our youth. They are poisoning our youth. They are killing 
our youth.

    Admiral Murthy. Senator, I would just say, when you and I 
have practiced medicine and we have prescribed medicines to 
people, to patients, we have been able to generally tell them 
what the evidence is if something works or doesn't work, and 
what the evidence is around safety.

    I think it is very reasonable for us to expect a company to 
demonstrate similar data to us, so that parents like we can 
take that into account as we make decisions for our kids on 
when to start using social media and whether or not to even use 
it.

    The Chair. Senator Kaine.

    Senator Kaine. Thank you, Mr. Chair. And to our witnesses, 
what an important hearing. And my colleagues have asked a lot 
of good questions that I was thinking about asking, but I have 
decided I would like to just take my time to speak to any young 
person that is watching this hearing, here in the room, or 
watching it live, or maybe watching it streamed.

    Young people feeling depressed about the future of the 
world, feeling hopeless has many causes, but to some degree you 
probably feel that way because you think adults have let you 
down, climate change, gun violence--a couple people were killed 
in my hometown at a high school graduation the other day.

    Both my kids graduated from that building. My wife and I 
both spoke in that building. That is where we do all the 
graduations in Richmond. So, I think young people's part of 
this sense of hopelessness is this feeling that adults have let 
us down, whether it is on climate, or guns, or political 
polarization, or kids getting kicked around by adults for 
political purposes if they are marginalized.

    I look in my own life, I have a Social Security card now, 
but I look at my own life to can I even remember what it was 
like to be a 5 to 18 year old? And I want to tell you, I had 
the same feeling when I was 5 to 18, that the adults in the 
world were letting us down. I came home from kindergarten in 
November 1963.

    I saw my mother crying for the first time in front of the 
television because JFK had been assassinated. I picked up the 
newspaper in April 1968 and the news of RFK--of MLK being 
assassinated. And then in June of 1968, RFK being assassinated. 
You saw protests about the Vietnam War.

    You saw protests about civil rights issues. I was 16 when 
our President was forced to resign because of corruption. So, 
my formative life from 5 to 16 was a time of chaos. War, 
nuclear weapons, drills in the classroom.

    It was a time of chaos and there was a palpable feeling 
that I had, and that a lot of my friends had, that the adults 
in the world were letting us down. And that was a creator of 
confusion and anxiety and even depression.

    We weren't so open about talking about mental health and 
mental health stresses then, but I could just remember that 
feeling. But what I want to say to young people watching, and 
Dr. Murthy, your focus on loneliness and isolation really gets 
at something really important, young people have the power--
young people have the power to change the reality if you link 
arms and band together, and to reduce some of the things that 
might make you feel hopeless or depressed right now.

    Because in all of that confusion, I saw young people a 
little older than me, I wasn't into it, but I saw young people 
protesting against the war and helping lead to its end. I saw 
young people in the civil rights movement helping battle to get 
voting rights done and civil rights laws passed.

    I saw young people who are now eligible to vote at age 18, 
becoming deeply engaged in events that led to improvements, 
that led to a Congress willing to hold the President 
accountable for impeachable behavior, forcing his resignation.

    The lesson that I learned from 5 to 16 was the adults were 
screwing a lot of things up, and if we waited for adults to 
solve those things, we would wait for a very long time. But 
when the young high schoolers and college kids that I was 
looking up to as a younger person linked arms and said, well, 
we are not going to just wait for adults to fix it, we are 
going to get engaged, when young people do that, young people 
change the direction of the country.

    I guess what I would just like to say to any young person 
watching this is you might not think you have the power to 
change the conditions that you find depressing. I think an 
awful lot of young--well, I am not even on up to vote yet, or 
what does one vote matter the system is rigged so that we don't 
matter.

    Our history shows the opposite. Things get worse when young 
people don't engage. Things get better when young people do 
engage. And not only do they get better in society, but the 
therapeutic value of linking arms with colleagues to battle for 
improvements in climate or reductions in gun violence, that 
very act of forming community among young people has a positive 
impact not only on society but on one's sense of well-being. 
You have a purpose on the table right before you.

    If you look at us and you think we are not responsive to 
you, you can link arms and you can change the world and feel a 
lot better about the world that you are living in. So, with 
that, Mr. Chair, I yield back.

    The Chair. Thank you, Senator Kaine.

    Senator Cassidy.

    Senator Cassidy. Thank you, Mr. Chair. In Senator Sanders, 
opening questions of Dr. Murthy, he suggested, yes, we have 
done a lot, but we need to do more. But Mrs. Neas, you made it 
clear that we were actually on a trajectory to do more. Yes, we 
have put in these programs. For example, you mentioned in your 
testimony a school in Louisiana that has very successfully 
instituted a Medicaid based clinic for those with mental 
health.

    Now there is another one opening. And presumably there will 
be another, and another, and another. So sometimes it is the 
potential of that which is being realized, which is more 
important to allowed to be realized, than creating a whole new 
program.

    I say that, though, my question is, are my assumptions 
correct, that the programs that we put in place, for example, 
to help schools use Medicaid to pay for services, is that 
increasing in terms of its implementation, and do you suspect 
that it will continue to increase?

    Ms. Neas. Senator, thank you so much for that question. And 
we certainly hope that with this Medicaid guide and a new 
technical assistance center that will be announced shortly, 
that we are going to make it easier for more and more school 
districts to figure out how to access Medicaid so they can, in 
fact, do just the things that you are talking about. We have 
seen a number of great examples across the country of 
partnerships. We were just in Delaware----

    Senator Cassidy. Let me stop, because I understand you have 
got these examples, but are you getting--what I am really 
asking is, do you have the interest being shown to expand upon 
these examples to make this even more widely used?

    Ms. Neas. Absolutely.

    Senator Cassidy. The potential is being realized. And I 
think that is the point I want to emphasize.

    Ms. Neas. Yes, sir.

    Senator Cassidy. Now, let me speak to something which 
perhaps is not being realized, and maybe you can speak to it 
directly. But in the bipartisan Safer Communities Act passing 
because of Republican support, there was $1 billion for funding 
physical safety of schools. In one says we are trying to 
address the front end.

    How do we keep kids from having a problem? But we are also 
trying to address the back end. If a kid does have a problem 
and comes in and tries to commit violence or someone else does. 
And as far as I know, the rules to tell schools districts how 
to implement physical hardening of their schools has only been 
promulgated into three different states.

    Why have those rules not been promulgated? Okay, this is 
what is allowed to physically harden your school in case there 
is somebody who attempts to commit violence. Why have those not 
been promulgated to all 50 states?

    Ms. Neas. Senator, thank you for that question. The 
Stronger Connections Grant that we released the funds to states 
last September and states are--we are doing listening sessions 
with key stakeholders on what kinds of things they wanted to 
use those funds for.

    Our guidance that was put out in November, and again 
revised this past March, does help schools understand what are 
allowable activities. What we are hearing from----

    Senator Cassidy. Let me stop you, again to being specific 
with my question----

    Ms. Neas. Yes, sir.

    Senator Cassidy. I was called by my state Superintendent 
that they were being told that they could not use the money to 
physically harden the school. I spoke with the Secretary, and 
he said he would correct that. But I am told, maybe I am wrong, 
that the correction that says that schools may use the money, 
as is Congress intended by the way----

    Ms. Neas. Correct.

    Senator Cassidy [continuing]. To physically harden was only 
promulgated with three states, Louisiana being one of them. Is 
that--am I correct in that or am I wrong?

    Ms. Neas. Senator, I am not aware of--my understanding is, 
from what we have heard from states, that they have used these 
funds for things to increase the physical security of schools.

    Senator Cassidy. Now, that is different from hardening. So, 
if I can ask, can you get back with me on the particulars of 
that most updated information?

    Ms. Neas. Yes, sir, I would be happy to do that.

    Senator Cassidy. Next. It has been suggested several times 
that there are things which subject children to ridicule that 
can otherwise make them prone to these episodes of depression, 
etcetera. I am very concerned about the issue of dyslexia.

    I think anyone that as a child stands up that can't read in 
front of a class and is ridiculed because she can't read 
understands that pain. Now, there is a lot of money put out in 
these bills to help school districts do catch up learning. And 
I mentioned dyslexics because they are particularly vulnerable.

    Here is an article, though, from The Times from 3 days ago. 
Schools receive billions in stimulus funds that may not be 
doing enough. Pandemic aid was supposed to help students 
recover from learning loss, but results have been mixed. And it 
points out that there was little guidance given to schools 
beyond, you shall spend 20 percent of it.

    There are some schools that have put in very good programs, 
small, focused learning, and others that apparently have not. 
Any comments on that? And specifically, what can Congress--
knowing the money is about to run out, but what can we do now 
to try and get schools to use best practices as opposed to just 
frittering dollars away?

    Ms. Neas. Right. Senator, one of the key elements of the 
Federal special education law is child find. And one of the 
things that states have struggled with that we are working very 
closely with them on to address is making sure they are 
identifying and serving any eligible child. And certainly, 
students who have dyslexia are among those kids that we want--
--

    Senator Cassidy. I get that but there are best practices. 
It does not appear as if they are universally adopted.

    Ms. Neas. That is correct, sir. We are--and we are working 
on specific guidance on these specific issues so that states 
can fully understand what their responsibilities are, so they 
can make, so that we can have a different situation.

    Senator Cassidy. Okay.

    The Chair. Senator Hassan.

    Senator Hassan. Thank you very much, Mr. Chairman, Ranking 
Member for this hearing. Thanks to our witnesses not only for 
being here today, but for the work that you do. And I just want 
to start by following-up a little bit on what Senator Kaine was 
talking about.

    I think we all have been hearing from constituents about 
concerns about mental health, in particular children's mental 
health. I will tell you that in the spring of 2021, when 
schools in New Hampshire began to reopen more fully, I went and 
visited in one of my local school districts with a mix of 
students, and teachers, and administrators. Students from first 
grade all the way through high school.

    I was struck toward the end of the discussion when we had 
been talking about how kids were doing, how their families were 
doing, what the schedule in school felt like. Did they feel 
that they were keeping up with their learning?

    How the year had been, when a girl who must have been about 
ten turned to me and said, so, Senator, what are you doing 
about mental health? And I had been kind of dancing around it. 
I am from a generation where we didn't talk about mental health 
in the same way we talked about so-called physical health.

    Then recently, another one of my constituents, Loreley, who 
is 18 years old, raised awareness about mental health because 
she was driving with a friend 1 day and the friend had a panic 
attack, and Loreley didn't know what to do.

    Now Loreley is working to help students get that kind of 
understanding for mental health first aid--what can kids do to 
help each other in these moments where they need to be 
supported and until they can get professional help.

    I also want to encourage young people to know that when you 
speak up, your representatives hear it, and we are doing our 
best to listen, and we are trying to make progress. And I want 
to ask a couple of questions to our witnesses about some of the 
progress we have made.

    Sometimes it doesn't seem enough, fast enough, but it is 
really important to understand the building blocks that maybe 
are in place. So let me start with a question to Dr. Murthy. I 
really enjoyed our discussion, doctor, in my office yesterday, 
and my team appreciated it very much, too.

    Last year, my colleague, Senator Ernst and I, led something 
called the Stand Up Act, which was passed into law. And it is a 
law that helps ensure that schools are using suicide prevention 
policies that are actually evidence based. So, Dr. Murthy, why 
is it important for schools to adopt policies that are evidence 
based?

    Senator Cassidy was just talking about our schools using 
the resources we are giving them in the right way. Why is it 
important that they are evidence-based, especially given the 
increased mental health risks that our youth face from social 
media?

    Admiral Murthy. Well, thank you, Senator. And Loreley's 
story will remain with me, and I have something I want to say 
about that at the end. But specifically, to your question, 
having evidence based practices is important because sometimes, 
even with the best of intentions, our programs may not have the 
desired effect, either in terms of the extent of impact, or in 
terms of who they are impacting.

    They may leave certain people behind. The only way we 
really know that is to study them. The other piece is that 
sometimes when we study programs well, we realize that there 
may be unintended consequences of those programs. They may help 
in some areas and actually harm in others.

    That is the whole point of studying these programs and then 
making sure that people know what the evidence tells us so that 
the program, when they do finally invest resources, time, and 
effort, they can do it in programs that we have greater 
confidence will actually help.

    Senator Hassan. Yes. Good. So let me then ask a question to 
you, Mrs. Neas. This is another example coming out of New 
Hampshire. Our University of New Hampshire and Manchester 
School District, which is our biggest school district in New 
Hampshire, they are leveraging funds from the bipartisan Safer 
Communities Act to train and place 80 graduate students 
studying social work in high school--in high needs schools--
high schools, and elementary, and middle schools.

    These graduate students will benefit from a yearlong 
internship with on the job training while public school 
students receive needed services. So, Mrs. Neas, in addition to 
this innovative example from my state, what other innovative 
local solutions are you seeing school districts deploy to 
address the school mental health personnel shortage?

    Ms. Neas. Senator, one of my favorite questions. We have 
seen some really innovative things across the country. We were 
just in a school in Delaware where the children's hospital runs 
a clinic that is on the campus of the school.

    The majority of these children in this elementary school 
are homeless and live in nearby shelters. The year before the 
clinic was on staff, they had more than 1,000 instances of this 
disruptive behavior that resulted in suspensions. The first 
year of the center, that 1,000 number went down to 100, and now 
there are virtually none.

    It is a great partnership. The children's hospital staffs 
it, does all the billing, and the school provides the physical 
space. What the principal said to me, I said, what keeps you up 
at night? And he said, learning loss. He said, we have got the 
support for kids and the teachers don't have to be both 
therapist and teacher.

    Senator Hassan. Right.

    Ms. Neas. That the staff there help teachers figure out how 
to get through the day to support kids so that they are 
emotionally Okay and learning. And I think that is one of the 
greatest things that we are seeing, is that partnership between 
educators and mental health providers on behalf of children, 
where children are.

    Senator Hassan. Well, thank you very much. Thank you, Mr. 
Chair, for your indulgence. I have some other questions, too, 
including the importance of providing services in summer 
programs and summer camps, which is something I think I will 
follow-up with our witnesses on.

    Last, again, to the young people watching, this hearing 
probably wouldn't be happening if young people hadn't been 
speaking up, so thank you all very much for that.

    The Chair. Senator Smith.

    Senator Smith. Thank you, Chairman Sanders and Ranking 
Member Cassidy. And thanks so much to both of you for being 
here. So, when I was in--a sophomore in college, I was really 
struggling.

    I, thanks to my roommate who recognized some of the signals 
and signs of somebody who is dealing with depression, she 
suggested that I go to a school counselor at my university. And 
man, that made a huge difference.

    I don't think I would have done that on my own, and I can 
see now that I was struggling also in high school, but having 
access to that care in my school setting made a huge difference 
because the barriers and the stigma that I would have 
experienced were sort of stripped away.

    I share this story often, especially with young people, 
because I can see them kind of go, finally somebody is being 
real about this with me. This is one of the reasons why I have 
been so focused on expanding access to school based care.

    Ms. Neas, I am really excited about the support that we 
have put behind school based services. I have heard from places 
in Minnesota where we are doing this, especially in places, 
this is something I have been working on, helping schools 
partner with community based organizations to get those 
services in schools.

    It makes a huge difference. But here is the thing. In 
Minnesota--and Minnesotans we are go getters. All of this 
money. Three higher education institutions focus on training. 
That is fantastic. One school district has pursued this so far. 
So can you talk to us just a little bit about--because I have 
this feeling that we are sort of constantly putting grant 
opportunities in front of school districts.

    Some of them, especially rural districts, just do not have 
the capacity to even know about these opportunities, let alone 
act on them. Could you talk a little bit about that issue, and 
how we are putting resources out there that is actually not 
that accessible to a lot of schools?

    Ms. Neas. Absolutely. And thank you very much for that 
question. And we hear that all the time about capacities, 
especially small districts not able to write for these 
opportunities. It is one of the many motivators to our Medicaid 
work.

    Senator Smith. Right.

    Ms. Neas. Where we are really trying hard to make it 
possible for people that are in schools to work with their 
Medicaid agencies so that--we know we have got lots of kids.

    Half the kids in our public schools----

    Senator Smith. Right.

    Ms. Neas. Are eligible for Medicaid. If we can help schools 
figure out how to recoup some of those payments----

    Senator Smith. Exactly.

    Ms. Neas. They can sustain things. They don't have to write 
a grant.

    Again, we know that with the 21 states that have access to 
free care rule, that they are--that is resulting in an almost 
$6 billion of revenue to schools for services they want to 
provide. And that is to me, how do--we need the more people, 
and the people--we need to train more people.

    Senator Smith. Yes.

    Ms. Neas. We need to train more people. And that is 
something that you can do with grants. But I want this to be 
sustainable for the long term----

    Senator Smith [continuing]. They need sustainable funding. 
Yes, exactly----

    Ms. Neas. For small school districts to not be left out of 
that. That is really what we hope TA center and the guidance 
and in our efforts to shine a light on this opportunity, that 
we can have more of that happen.

    Senator Smith. Let me just ask for clarification. How many 
states did you say are participating in this right now?

    Ms. Neas. 21.

    Senator Smith. 21. So only--less than half of the states 
are participating. And that is a decision essentially of the 
Governor and the legislature. So, this is another problem we 
have, Mr. Chairman, is that in some places there is 
opportunity, in some places there are not based on the 
calculations that state leaders have. Vice Admiral Murthy--I am 
used to calling you Vivek, so----

    [Laughter.]

    Senator Smith. You and I have had some really terrific 
conversations. I am so grateful for your leadership on issues 
of social isolation, both for our elders, as well as for young 
people.

    Now, I have had people say to me, Tina, like, you can't 
legislate away loneliness, but you have done research that 
really shows how we can think about this as a social 
determinant of people's health, and that can make a huge 
difference. Could you just speak briefly to that, because I 
think it is really important.

    Admiral Murthy. Absolutely. And I think, I agree that you 
can't legislate away loneliness, but I don't think that is the 
solution here.

    Senator Smith. Right.

    Admiral Murthy. But I think there are steps Government can 
take to help support community organizations, to invest in 
research, to understand more deeply the drivers and solutions 
of loneliness.

    But we also need community organizations, families, 
individuals to recognize that this is an important priority for 
all of us. I worry that we have become a lonely and 
disconnected nation, and that has massive consequences for our 
mental health, for our physical health, for economic 
prosperity, for our ability to pull together in the face of 
adversity, whether that is a pandemic or another hardship.

    For all of those reasons, I believe that addressing 
loneliness is a strategic and critical priority for our 
Country. It is something I think we can do, and the people who 
give me the most faith that we can do that are young people.

    Because when I talk to them around the country, they are 
not waiting for others to step in, they are building programs 
at their schools to help connect one another. They are reaching 
out to support each other.

    They are talking more openly about mental health and issues 
like loneliness than any prior generation. And I think their 
leadership is going to be vital in us addressing this 
challenge.

    Senator Smith. Thank you. Thank you so much, Mr. Chair.

    The Chair. Thank you.

    Senator Murkowski.

    Senator Murkowski. Thank you, Mr. Chairman. And thank you 
for the hearing this morning. I think it is somewhat telling 
that with everything that is happening this morning, there is a 
significant overflow room just down the hall.

    I have been back and forth between a couple of different 
committee hearings this morning and there continues to be a 
line of young people, of young people trying to get into this 
Committee hearing. And so, I stopped and talked to them. Why 
are you standing in this line today? Why is it important to 
you?

    One of the young men said, it is personally important to 
me. I am curious to know, as a--apparently as a young 
immigrant, the intersection, the services that are available 
for those in--from other areas. Another one indicated that she 
was interested in education, but she wanted to understand more 
how people who had adverse incidents in their lives as young 
kids as she had, what more support could be provided in 
schools? Young people are paying attention to this as an issue.

    They are paying attention to what we as legislators do. And 
I have listened to some of my colleagues, and yes, we can't 
legislate loneliness going away. It is hard enough to; how do 
you legislate against bullying? How do we do the reach out? I 
appreciated your comments to Senator Tuberville when he 
mentioned that as a coach he interacted directly with these 
young people.

    Your comment that you sat down at roundtables with 
students, particularly student athletes. What more are we doing 
to ask young people what the solutions are? We had a hearing in 
this--in the HELP Committee last year on youth mental health. 
We invited an extraordinary young Alaskan by the name of Claire 
Rainier.

    I think Claire at the time was 19. She gave testimony and 
presented the youth perspective and what she had done as one 
individual that had gone through real crisis, what she had done 
within her school community to engage more.

    I remember Claire's story and how strong she was in sharing 
that with us. But what are we doing to ask the young people 
what we can do to help? And I will throw that out to you, 
Surgeon General.

    Admiral Murthy. Well, thanks so much, Senator----

    Senator Murkowski. I understand you are coming to Alaska 
soon, and I hope those conversations are going to take place.

    Admiral Murthy. I am. Thank you. Yes, I am really looking 
forward to it. And it is actually relevant, like when I first 
came to Alaska, when you and I met there in 2016, that was an 
opportunity.

    We did a lot of roundtables, including with young people. 
And the goal there was to really understand how they are being 
impacted by substance use disorders, and more broadly by 
behavioral health concerns.

    To involve young people, to answer your question, I think 
there are a few things we have to do and that we are doing more 
and more. No. 1 is we have got to bring young people to the 
table to understand and hear their concerns and go to where 
they are.

    That is part of what my office has been doing, is having 
roundtables with young people in communities across the 
country. The second thing we have to do----

    Senator Murkowski. Can I just stop you there?

    Admiral Murthy. Of course.

    Senator Murkowski. Because it takes extraordinary strength 
for a young person to say, no, I am going--I want to be part of 
this public dialog and engagement.

    The ones that are really hurting are the ones that are just 
struggling to get up out of bed that morning, much less go to a 
roundtable. How do we get them?

    Admiral Murthy. That is exactly right. And that is why what 
we are also doing is recognizing that it is not easy for 
everyone to come to those tables, to be open. It is easier 
often when they are doing that with folks they know with 
trusted institutions, trusted organizations.

    We are also working with faith organizations, with 
universities, and others to help them pull roundtables and 
other such listening sessions together with young people to 
create opportunities for them to give input that don't 
necessarily involve showing up at a roundtable--that may 
involve more commenting on a survey or share their input 
anonymously.

    We want to create as many channels as possible for young 
people to be heard on this. And then using that input, we are 
encouraging mayors as well as the institutions I mentioned to 
then formulate their plans.

    My belief is that if we want to do something that is going 
to help young people here, we need them at the table throughout 
the process, before we developed a solution, as we work on 
execution, and when we do evaluation to understand whether it 
is working or not. And that is what we are encouraging 
localities to do, from Mayors to non-Governmental organizations 
like YMCAs, educational institutions, and others.

    But, Senator, it is not--I will just say this, it is not 
easy to do this, right. It takes time, effort, and focus, and 
continued attention. The easiest thing is just to go into a 
closed room and come up with your own solutions and try to 
implement them, but I just don't think that is what is going to 
get us the best result here.

    Senator Murkowski. Agreed. Recognize that we just need to 
be doing more to be inclusive of these young people. I am going 
to have a question for the record for you, Mrs. Neas.

    This is relating to the fact that of the bipartisan Safer 
Communities Act funding through the mental health services 
grant, professional demonstration grant programs, apparently 
only 17 percent of these grants were awarded to rural 
districts.

    I am trying to understand what more we can be doing to make 
sure that these grant resources are going out to all areas of 
the country, including rural. Thank you, Mr. Chairman.

    The Chair. Thank you very much.

    Senator Baldwin.

    Senator Baldwin. Thank you, Mr. Chairman. In June, we 
celebrate pride. It is a time for folks to gather and lift up 
and celebrate LGBTQ Americans, the movement for the fight for 
equality. And we also reflect upon the challenges.

    There is an intersection of our conversation here. It has 
already come up a little bit that with the mental health crisis 
that kids are facing, from data last year, 45 percent of LGBTQ 
youth reported that they had considered attempting suicide--45 
percent. Youth who live in communities that are not 
particularly accepting or families that aren't particularly 
accepting report higher rates of attempting suicide.

    I am just going to note, and maybe we can introduce it for 
the record, there was an article last weekend in the New York 
Times about death investigations and the fact that we don't 
have complete--after suicides, we don't have complete 
information, because oftentimes they don't ask the question 
about sexual orientation or gender identity.

    But in Utah, they are. And it was a fascinating piece that 
we should have as a part of the record, because that is data 
that we are lacking. But at the same time, we are celebrating 
pride month, we are witnessing in America a staggering number 
of pieces of legislation at the state level that are described 
as anti-LGBTQ bills. I--491 reported so far this year. At the 
state and local level, school board level, we see a lot of 
additional activity.

    I don't have any numbers on that. I don't know who is 
aggregating those. But it is rampant. And I wonder, again, what 
the impact of that is on mental health of members of the LGBTQ 
community. Now, I want to get to a question.

    We are talking about offering support in schools, but I 
want to also think of other gateways where people come in and 
get help. I was proud to co-sponsor the bill that brought us 
the 9-8-8 suicide prevention hotline, and it was made--it was--
became operational last summer.

    There is the ability with that technology to provide more 
customized service. I know the first thing people are asked, 
are you a veteran? And if so, you will get your mental health 
services, if you choose, from the VA.

    But we, along with Susan Collins, we have provided funding 
for a pilot program in 9-8-8 for offering specialized support 
for people who call, text, or chat on 9-8-8 who are identifying 
as LGBTQ. So, how do we use we have school board--or sorry, 
school based mental health in some cases, but how do we use a 
gateway like 9-8-8 to provide better support for, in 
particular, our LGBTQ population?

    Admiral Murthy. Senator, first, just thank you for your 
leadership on 9-8-8. As it is a topic that I talk about often 
when I travel around the country, and I can't tell you how many 
faces I have seen turn from worry to look of relief when they 
know that there is some help actually available immediately 
when they or their child have a crisis. So, thank you for that. 
It is already making a difference.

    I do want to say, specifically with LGBTQ youth, I agree 
with you that we need to look for more ways to ensure that they 
know help is available for them. I think schools are a natural 
place. I think 9-8-8 is a place where early on, if we can 
signal to young people that this is a place where you can get 
assistance, where people will understand your unique 
circumstance and your background, I do think that is essential.

    I also think that, and I say this just as a doctor and as a 
father, I believe that every child deserves to know they 
matter, regardless of what their background is. The reason my 
parents came to America many years ago was because they wanted 
my sister and me to grow up in a country where we knew that 
just because we had a different color of our skin or our name 
sounded funny or a background was different, it didn't mean 
that we mattered any less than any other child. And that is a 
value we aspire to as a country.

    We may not always have gotten there, but I think that is a 
place where we need to do more when it comes to making LGBTQ 
youth feel that they do matter, that they are valued. And too 
many of them tell me often that they don't feel that way. They 
often feel left out or bullied or attacked.

    Finally, I would just urge leaders, whether they are 
elected leaders, whether they are leaders in the community, to 
include LGBTQ youth at the table when they are listening to 
what communities have to say, and to specifically reach out to 
them to understand their perspective and their life experience.

    I have just learned as a doctor over the years who has had 
the privilege of sitting with patients and with very different 
backgrounds, and listening and learning to them, that there is 
nothing that replaces face to face contact with people, 
listening to someone's story, and it shifts how we think about 
issues.

    I think that could not be more important now because too 
many of our LGBTQ youth are struggling, and you see it in the 
suicide rates. And to me, that is in--a five alarm fire that we 
are dealing with.

    Senator Baldwin. Yes. Thank you. Mr. Chairman, I have 
several questions for the record, since I have run out of time, 
but I thank our witnesses.

    The Chair. Thank you very much, Senator Baldwin. And let me 
thank the panelists for what I think is an extraordinarily 
interesting hearing on a subject that I think everybody here 
recognizes is of enormous consequences to this country.

    I just want to take a few seconds to make this point. I 
think we are all proud of the accomplishments that we have 
made, and we wanted to help them. But there is another reality, 
and I want you to tell me what I am missing here, if I am 
missing anything.

    If 85 million Americans are uninsured or underinsured, and 
if we have a scarcity of mental health providers in this 
country, am I missing something in suggesting that for tens of 
millions of people--I know people call my office.

    I am sure they call other offices. My husband is in 
desperate shape. I can't find the help. We can't afford the 
help. And on top of that, correct me if I am wrong, but I think 
it as a result of the ending of the public health emergency, 
some 17 million people are going to be dropped from the 
Medicaid rolls. Is that correct, Mrs. Neas? Is that correct?

    Ms. Neas. I am not--I know that it is a large number, sir. 
I am not exactly----

    The Chair. The point is, yes, we want to take pride in what 
we have accomplished, but let's not kid ourselves. We have got 
to move dramatically if we are serious about protecting the 
mental health and helping people in this country. There is a 
lot of work that has to be done. So, with--Okay. Yes, Senator 
Cassidy. Well, let me just, with that--all right, give the mic 
to Senator Cassidy.

    Senator Cassidy. A lot of great things said today. In my 
closing, 30 seconds, I want to emphasize three things. Senator 
Kaine is speaking about how young people can be the drivers of 
change. Senator Murkowski is speaking about how folks are lined 
up and they are all young.

    Looking at the audience here, you are young, and I suspect 
those watching on TV are young. And Dr. Murthy saying that we 
can't leave it up to Government, but we also have to have 
individual action.

    I guess my appeal is all the young people who rightly have 
a concern about this, you are the ones who can introduce people 
to this hotline set up by Senator Baldwin. You are the ones 
that can advise, as Senator Smith was advised, to go seek help.

    We can only do so much. You are going to do a heck of a lot 
more than we. So, I just finish by echoing wonderful comments 
from my colleagues.

    The Chair. All right. To the witnesses, thank you very, 
very much. This is the end of our first panel. We are going to 
be going to our second panel in a moment. Thank you. Thank you 
all very much for being here, and we are going to continue this 
discussion on this issue of enormous concern to the American 
people.

    I--Senator Murphy was going to introduce Charlene Russell-
Tucker, but unfortunately, he is detained. So let me begin by 
introducing her. And that is, Mrs. Russell-Tucker was appointed 
Commissioner of the Connecticut Department of Education in 
2021.

    Previously, she served as Chief Operating Officer and 
Division Chief for the Department's Office of Student Supports 
and Organizational Effectiveness. Mrs. Russell-Tucker, thank so 
much for being with us.

    STATEMENT OF CHARLENE M. RUSSELL-TUCKER, COMMISSIONER, 
    CONNECTICUT STATE DEPARTMENT OF EDUCATION, HARTFORD, CT

    Ms. Russell-Tucker. Thank you. Good morning, Chairman 
Sanders, Ranking Member Cassidy, and Members of the Senate 
Committee on Health, Education, Labor, and Pensions. I am 
Charlene Russell-Tucker, Commissioner of Education in 
Connecticut. I am honored to share critical information 
regarding the youth mental health crisis and Connecticut's 
response to support the needs of our students.

    My big audacious goal is to ensure every Connecticut school 
has a coordinated and sustainable system of care to provide 
comprehensive behavioral and mental health support and services 
to all students and school staff. As Surgeon General Murthy 
mentioned and a survey of Connecticut high school students 
confirms, our students face unprecedented mental health 
challenges.

    Too many of our students reported having felt sad or 
hopeless, and that their mental health was not good most or all 
of the time. Most concerning is that 14 percent said they had 
seriously considered suicide, and 6 percent actually attempted 
suicide. These data highlight the immense need to address 
student wellness and underscore the urgency for action at 
Federal, state, and local levels.

    Effective solutions require teams of stakeholders, 
including policymakers, community leaders, parents and 
families, educators and students. I like to say, it can't be 
about them without them.

    The Commissioners Roundtable for Family and Community 
Engagement and Education is a diverse constituent group of 
stakeholders, representing school staff, advocates, parents and 
guardians, community leaders, and students to advise me on 
policy and programmatic priorities.

    Connecticut's Student Voice for Change Program allows high 
school students to propose projects utilizing state ESSER 
funds. Notably, 80 percent of student proposals focused on 
mental health, using their voice to advocate for mental health 
supports for their peers. They spoke and we are listening.

    Our ESSER funded behavioral health pilot established a 
system of coordinated care for schools in seven districts. One 
pilot school district identified 250 students at risk of 
suicide and was able to provide critical and immediate 
responses. Our state's mobile crisis intervention services 
deliver a range of crisis response and stabilization services 
to youth and families.

    Simply call in 2-1-1, or now 9-8-8, immediately dispatches 
clinicians to schools or anywhere a child is in crisis. The 
Surgeon General report on the epidemic of loneliness reinforces 
the importance of school attendance and engagement.

    Our Governor's Learner Engagement and Attendance Program is 
a research based home visit initiative that improves 
attendance, feelings of belonging, and family, school 
relationships. Additionally, we invested $33 million in ESSER 
and ARP funding in a multi-year summer enrichment grant 
program, prioritizing communities disproportionately impacted 
by the pandemic.

    Programs place a strong focus on peer relationships, 
wellness, and academic acceleration during the summer. In the 
first year, this program connected more than 108,000 students 
with enrichment opportunities. The Department invested $2.2 
million in ESSER funds for innovation grants to support new 
partners in underserved communities in designing innovative, 
high quality afterschool programs to address students' academic 
and mental health needs.

    Mental health is a bipartisan state priority, including 
addressing workforce shortages. Governor Lamont and our General 
Assembly directed $100 million for multi-agency mental health 
initiatives, including $28 million for mental health 
professionals in schools. Multi-state agencies are working 
together to expand the ranks of clinicians to meet increasing 
mental health needs.

    Additionally, the school districts are leveraging over $183 
million of local ESSER funds for student and staff well-being. 
We are committed to funding and sustaining what works. We also 
invested ESSER funds to establish a groundbreaking 
collaborative that brings together teams of university 
researchers to conduct rigorous evaluations of the many new 
programs and initiatives that are underway in our state to 
ensure programs and investments are achieving results.

    Thank you for modeling bipartisan national discourse that 
will lead to enhanced access to needed services, and 
ultimately, improve academic access, supports, and outcomes for 
young people. Thank you very much. I am happy to take your 
questions.

    [The prepared statement of Ms. Russell-Tucker follows:]
            prepared statement of charlene m. russell-tucker
    Good morning. Chair Sanders, Ranking Member Cassidy, Committee 
Members, thank you for having me here today.

    My name is Charlene Russell-Tucker, and I am the Commissioner of 
Education in Connecticut. I am honored to appear before you all today 
to represent our great state and share critical information regarding 
the youth mental health crisis, its impact on learning, and the 
interventions, policies and initiatives Connecticut implemented before, 
during and after the pandemic to support the emotional, mental, 
physical, and behavioral health needs of our students. Many of the 
interventions that I am discussing today align with what I call my 
``Big Audacious Goal,'' which is to ensure every Connecticut school has 
a coordinated and sustainable system of care for all K-12 schools to 
provide comprehensive behavioral and mental health supports and 
services to students and staff.

    As mentioned by Surgeon General Murthy earlier today, Connecticut, 
like the rest of the country, is experiencing an unprecedented need for 
mental, physical, and behavioral health supports among young adults and 
adolescents--likely stemming from and exacerbated by isolation and 
loneliness caused by the pandemic and its after-effects, as well as a 
lack of meaningful connection due to this isolation. Concurrently, 
consistent with national trends, Connecticut is experiencing a shortage 
of mental health professionals. Despite these challenges, Connecticut 
is leveraging substantial Federal and state resources to build a 
scalable system of supports to address our students' mental, physical, 
and emotional health through prevention and early intervention 
services, as well as just-in-time crisis support. Sound mental health 
is foundational to learning and ultimately all aspects of human 
development; therefore, we must continue to develop, evaluate, and 
provide resources to support these efforts.

    Connecticut prioritized student mental health alongside academic 
recovery when investing the more than $1.7 billion that has been 
allocated to our state under the Elementary and Secondary Schools 
Emergency Relief (ESSER) Fund. On behalf of the State of Connecticut, 
we are very appreciative for Congress's critical support. The 
priorities we established for these funds at both the state and 
district levels included supporting learning acceleration and academic 
renewal, ensuring safe and healthy schools during and post pandemic, 
technology enhancements, and family and community engagement. We knew, 
however, that none of these investments would be successful if we did 
not first implement a system of supports for students' physical, 
social, emotional, and mental wellness, which is why we included this 
funding priority as well. Districts responded by earmarking over $183 
million for supporting student and staff wellness through hiring 
additional staff, providing professional learning and technical 
assistance, and partnering with external partners for the provision of 
referral services, enhanced counseling, and care coordination. 
Additionally, this is also why the Connecticut General Assembly and 
Gov. Ned Lamont, in a bipartisan effort, allocated over $100 million in 
the 2022 legislative session to support mental health statewide, of 
which $28 million was earmarked for the Connecticut State Department of 
Education (CSDE) to create grant programs to support the hiring of 
school mental health professionals.
                       The Connecticut Landscape

    Connecticut has a beautifully diverse student body of more than 
half a million students. Across 205 districts, we have over 1,500 
schools and more than 110,000 school staff devoted to helping our 
students thrive.

    Looking more closely at our student population, more than half of 
students identify as nonwhite; 42.4 percent are eligible for free or 
reduced-price meals, 17.1 percent are students with disabilities, and 
9.7 percent are English/multilingual learners with more than 145 spoken 
languages.

    Results from the Connecticut School Health Survey, modeled after 
the Centers for Disease Control and Prevention (CDC) Youth Risk 
Behavior Survey, indicated that feelings of sadness and hopelessness in 
high school students have increased steadily over time, reaching a new 
high during the COVID-19 pandemic. In the 2021 survey, 35.6 percent of 
Connecticut high school students reported having felt sad or hopeless, 
28.5 percent reported that their mental health was not good most or all 
the time. Most concerning in the survey results, is that 14.1 percent 
said they had seriously considered attempting suicide and 5.9 percent 
had actually attempted suicide.

    The survey found that mental health issues are more common among 
female students, with 47.6 percent of female students reporting 
feelings of sadness or hopelessness compared to 24.2 percent of male 
students and 40.5 percent of female students saying their mental health 
was not good most or all of the time compared to 16.4 percent of male 
students. Suicidality in females was also much more pronounced, with 
19.8 percent of female students verses 8.7 percent of male students 
seriously considering attempting suicide and 8.8 percent of female 
students verses 3.3 percent of male students actually attempting 
suicide. These data highlight the immense need to address student 
wellness and underscore the need for action at all levels--Federal, 
state, and local--to protect our students' mental health.

               Stakeholder Involvement and Collaboration

    I want to lead with what makes Connecticut unique--what in 
Connecticut is referred to as ``The Connecticut Difference.'' This is 
our longstanding focus on best-in-class collaboration, working 
together, and listening to one another, in search of common ground for 
the sake of our students.

    With almost every policy or initiative, including supporting the 
mental, physical, and behavioral health needs of our students, 
Connecticut prioritizes engagement with our various partners and 
stakeholders--the Office of the Governor, the State Board of Education, 
state agencies, educators and administrators, families, students, 
advocates, policymakers, local health officials, and more--as often as 
possible to develop and implement our policies. Policies designed 
without hearing different perspectives, and without our constituents' 
input and feedback, are not likely to produce the intended and needed 
results.

    We are staunchly committed to ensuring that family, student, and 
community voices are included in our decision-making processes. I like 
to say, ``It can't be about them without them.'' We cannot actively 
gauge the impacts of isolation and the pandemic on our students' mental 
health without understanding their perspectives.

    In Connecticut, we strongly affirm these voices, particularly when 
they indicate severe mental health concerns, suicidality, or other 
harmful thoughts because these challenges negatively impact students' 
overall well-being and, therefore, their ability to learn. We believe 
that part of addressing student learning and academic needs is the 
provision of mental and behavioral supports. A quote from yesteryear 
still rings true today--there is no curriculum brilliant enough to 
compensate for a hungry stomach or a distracted mind.

    Listed below are structures that the CSDE has in place that are 
foundational to engaging stakeholders in driving our mental and 
behavioral health policies, practices, and initiatives.
    1. Commissioner's Roundtable on Family and Community Engagement
        In 2017, recognizing the critical importance of family and 
        community voice, I developed and implemented the Commissioner's 
        Roundtable for Family and Community Engagement in Education, 
        which is a diverse constituent group of education stakeholders 
        representing school and district staff, advocacy organizations, 
        parents and guardians, community members, and students, who 
        advise the Commissioner of Education regarding policy and 
        programmatic priorities. The Roundtable meets quarterly to 
        bring authentic parent and community voice to CSDE products and 
        initiatives; communicate state-level initiatives with families 
        and communities; recommend effective practices to increase 
        successful school and district engagement with families; and 
        provide strategies to empower families in supporting their 
        children's education. The Roundtable has informed many of our 
        mental, physical, and behavioral health initiatives through 
        active deliberation and discussions. This group developed the 
        Connecticut Framework for Family and Community Engagement, 
        which defined family engagement as ``a full, equal, and 
        equitable partnership among families, educators, and community 
        partners to promote children's learning and development form 
        birth through college and career.''
                       2. AccelerateCT Taskforce
        AccelerateCT Education Taskforce was launched to develop a 
        statewide education recovery and acceleration framework and 
        programming for students across the state beginning with 
        enhanced learning and enrichment opportunities. The Taskforce 
        is made up of over 30 members representing every aspect of 
        education and focuses on six key areas: learning acceleration; 
        academic renewal and student enrichment; family and community 
        connections; social, emotional, and mental health of students 
        and school staff; leveraging technology to accelerate student 
        learning; building safe and healthy schools; and summer 
        enrichment. As noted, mental health is a core component of the 
        Taskforce's priorities, consistent with our statewide approach.
                   3. School Discipline Collaborative
        Understanding that students sometimes do not feel welcomed and 
        valued in school and that exclusion from school impacts 
        students' overall behavioral health and learning, I formed the 
        Connecticut School Discipline Collaborative. The Collaborative 
        advises the Commissioner of Education and State Board of 
        Education on strategies for transforming school discipline to 
        reduce the overall and disproportionate use of exclusionary 
        discipline. Members reflect a diverse range of expertise in the 
        fields of school administration, teaching and learning, public 
        policy and legislation, education law, youth development and 
        children's advocacy, family and student engagement, and 
        community leadership.
                       4. Voice4Change Initiative
        In November 2021, the CSDE launched Voice4Change, the first 
        statewide student participatory budgeting initiative in the 
        country, to give students a direct say in how a portion of the 
        $1.5 million of ESSER funding should be spent across 
        Connecticut schools. Using the same five investment priorities 
        set forth for districts, students crafted and voted on 
        proposals for projects or supports they desired in their school 
        community. More than 80 percent of winning proposals addressed 
        the need for more supports for student social, emotional, and 
        mental health. Students also saw what worked during the 
        pandemic--best practices they wanted to make permanent in their 
        school going forward like a mental health first aid team 
        available to students, peer mediation, afterschool programming 
        focused on stress reduction, and creative and innovative 
        learning environments such as outdoor classrooms.

    In addition to the structures described above, the CSDE works 
closely with our member associations in Connecticut to gain feedback 
from the field, drive policy development and implementation, discuss 
resource access and allocation, and receive advice on how the CSDE can 
support our schools. These organizations include the Connecticut 
Association of Public School Superintendents, the Connecticut 
Association of Boards of Education, and the Connecticut Association of 
Schools, which represents school principals and vice principals. The 
CSDE also routinely engages with our teachers' unions as well as 
associations representing school nurses, counselors, social workers, 
and psychologists, paraeducators, and child nutrition program 
directors. This collaborative approach is necessary in building 
effective policy and positively supports the whole child.
 Initiatives and Programs Supporting the Social, Emotional, and Mental 
                  Health Needs of Students and Staff:

    I am privileged to live in a state where education receives robust 
bipartisan support from the legislature. Last session, Connecticut 
lawmakers passed the most comprehensive mental health bills in the 
state's history--including grants for schools to hire staff to support 
student well-being, bolstering the Governor's home-visiting initiative, 
increasing summer programs' capacity to support the mental health of 
their campers, and more.

    The pandemic brought keen attention to the necessity of addressing 
the social, emotional, and mental health needs of our students and 
school staff. While Connecticut has a longstanding history with this 
work, COVID-19 significantly increased the demand for mental health 
services and supports--both in the number of students needing support 
as well as the severity and complexity of those needs.

    Connecticut has prioritized the allocation of human and financial 
resources toward addressing the comprehensive health needs of our 
students, encompassing their emotional, mental, physical, and 
behavioral well-being. Throughout the pandemic, the state implemented a 
range of interventions and policies that not only catered to immediate 
challenges but also considered prevention strategies and long-term 
support. By prioritizing the whole child, Connecticut has paved the way 
for promising practices that can serve as valuable examples for other 
regions across the Nation seeking to enhance their educational systems 
and ensure the overall well-being of their student populations. The 
following outline some of our most impactful initiatives and programs:
             1. Statewide Behavioral Health Landscape Scan
        The CSDE commenced a statewide behavioral health landscape scan 
        in September 2020 to provide insight into emerging concerns and 
        trends related to the well-being of students in K-12 schools 
        across Connecticut. This was the first step in providing a 
        systematic collection of data to identify needs and enhance 
        existing efforts related to supporting the mental health and 
        well-being of our students.
                 2. Connecticut Behavioral Health Pilot
        State level ESSER funding has afforded the CSDE the opportunity 
        to support resources to fully fund the Connecticut Behavioral 
        Health Pilot. Currently, our Behavioral Health Pilot is 
        underway in seven districts in partnership with community-based 
        behavioral health partners to assess their mental health 
        support needs.

        The CSDE identified districts of various demographics--from 
        large urban districts, medium sized suburban districts and 
        small rural districts--to participate in the pilot program to 
        implement targeted supports based on needs identified from the 
        landscape scan and focus group discussions. The specific needs 
        and gaps in service will drive the development and 
        implementation of these systems of care. The pilots will then 
        inform plans to scale these systems statewide for 
        implementation in similarly situated Connecticut districts. 
        Robust needs assessments are being conducted in each district 
        to document the mental health system components that exist 
        within each district and assess the comprehensiveness of those 
        systems. These data are driving the prioritization of quality 
        improvement efforts and will set into motion systems to track 
        improvements throughout implementation.

        Specifically, the district-level assessments examined the 
        efficacy of districts' behavioral and mental health systems by 
        analyzing current and existing programming, as well as human 
        and fiscal capital. This process will help to determine the 
        appropriate, scalable interventions, which will depend on the 
        capacity and resources--both internal and community-based--in 
        each community. Solutions may include increased staffing and 
        service provision; opportunities for training, professional 
        development, technical assistance, and coaching; external 
        referral systems of care through partnerships with mental 
        health providers and primary care facilities; and streamlined 
        and shortened referral processes. These combined efforts will 
        ensure students' emotional well-being, which can support 
        consistent school attendance, engagement, and academic success. 
        All relevant school district staff will then receive adequate 
        trainings and demonstrate increased knowledge in both content 
        and referral processes and systems, which will help to reduce 
        both the total number of student visits to local emergency 
        departments for behavioral health crises and reduce the rates 
        of exclusionary discipline and absenteeism.

        The early results of the pilot are already evident. Districts 
        have established priorities and identified community partners 
        to support them. One district realized that it needed more 
        universal mental health assessment capacity. They have 
        subsequently created a liaison position between the school and 
        the community provider to identify students needing a higher 
        level of support. Through their assessment, one of our larger 
        districts identified that over 250 out of their 4,000 students 
        reported having attempted suicide. The district quickly 
        developed partnerships with community providers and created a 
        student response team to address pressing mental health needs.
            3. Grants to Support Mental Health Professionals
        In a bipartisan effort, the Connecticut General Assembly 
        directed $28 million in American Rescue Plan Act (ARPA) funding 
        across three different grants to support mental health 
        professionals in schools. The legislature directed $5 million 
        toward a School Mental Health Workers grant program to assist 
        Connecticut local and regional school districts in hiring and 
        retaining additional school social workers, school 
        psychologists, school counselors, school nurses, and licensed 
        marriage and family therapists. An additional $15 million was 
        directed to support a School Mental Health Specialist grant 
        program to assist school districts in hiring and retaining 
        additional school social workers, school psychologists, trauma 
        specialists, behavior technicians, board certified behavior 
        analysts, school counselors, licensed professional counselors, 
        and licensed marriage and family therapists. Over 70 clinicians 
        have been or will be hired through these grants to support 
        students through three school years. Last, the legislature 
        directed $8 million to a Summer Mental Health grant program to 
        support the delivery of mental health services for students 
        when school is not in session. Funding is available to school 
        districts, operators of youth camps and other summer programs.

        These grants, funded entirely through Federal ARPA dollars, are 
        essential for local efforts to adequately address the needs of 
        children and youth. The CSDE understands the critical need to 
        maintain these positions and the vital services they provide 
        for our students, and districts will require new mechanisms and 
        resources to retain these essential staff when the ARPA funding 
        expires. The CSDE is looking at opportunities under Medicaid to 
        sustain this critical investment.
                   4. Summer Enrichment Grant Program
        Connecticut has invested $33 million in ESSER and ARPA funding 
        toward a multi-year Summer Enrichment Grant program, initiated 
        in summer 2021. The program was created in an effort to connect 
        K-12 students whose education may have been negatively impacted 
        by the pandemic with low or no-cost, high-quality enrichment 
        opportunities when they are out of school during the summer 
        months, including at summer camps, childcare centers, and other 
        similar programs, with a priority for those in communities that 
        were disproportionately impacted by the pandemic.

        Programs place a strong focus on social-emotional, physical, 
        and mental health; academic acceleration, intellectual growth, 
        and exploration; and student-peer relationships during the 
        summer months. This investment also enables summer camps to 
        hire additional staff such as behavioral specialists or other 
        personnel to serve more students. An evaluation of the 2021 
        program concluded that the initiative successfully connected 
        more than 108,000 Connecticut students with summertime 
        enrichment opportunities that year. An evaluation of the 2022 
        program will be released soon.
                         5. After-School Grants
        In 2022, the CSDE released $2.2 million in ESSER funding to 
        support after-school Innovation Grants for underserved 
        communities to address the academic, social, emotional, and 
        mental health needs of students, especially for those who have 
        been disproportionately affected by COVID-19. Innovation Grants 
        enabled smaller towns, districts, and non-profit organizations 
        to create innovative after-school programs. This was an 
        addition to $8.7 million used to expand and enhance 
        Connecticut's existing after-school programs, for a total 
        combined funding of $10.9 million.

        The Innovation Grants focused on creating new after-school 
        programs to reach underserved target populations while building 
        districts' capacity through the assistance of local and 
        community partnerships. This grant provided successful 
        applicants with the necessary funding to design and implement 
        new, high-quality after-school programs that address the 
        academic, social, emotional, and mental health needs of 
        students across the state.
        6. Deveraux Student Strengths Assessment System (DESSA)
        Through ESSER funding, the CSDE implemented the DESSA System. 
        The DESSA is a strength-based observation tool that teachers 
        use to capture how frequently they have observed a student 
        demonstrating positive behaviors (e.g., getting along with 
        others, taking turns, considering different opinions, active 
        listening, etc.) rather than inappropriate behaviors. Focusing 
        on strengths can build students' self-efficacy and help them 
        persevere when they face difficulties and challenges in the 
        classroom and the school environment. This helps teachers 
        better support their students in feeling, confident, 
        successful, engaged in learning and connected to school. Close 
        to half of Connecticut school districts are participating in 
        the DESSA System.

        Following the first year of implementation, half of students 
        were already demonstrating positive growth in pro-social 
        competence and behavior. Our high school students are invited 
        to participate in the DESSA Student Self-Report (SSR), which 
        engages students in reflecting on their own strengths and 
        empowers them to steer their learning in a way that aligns with 
        their needs. The SSR is a student self-rating that delivers 
        real-time results and immediate strategies to incorporate 
        student voice and choice in learning, which has a significant 
        impact on learner engagement, motivation, and achievement.

        Supporting the well-being of our K-12 administrators, educators 
        and staff is also vital for them to be able to ensure student 
        growth and success. This initiative is a pilot program designed 
        to help educators give their best to students while also caring 
        for themselves. It includes a comprehensive set of research-
        based resources that provide educators with professional 
        development tools, self-assessments, personal development 
        plans, self-directed strategies, and teaching practices.
7. Components of Social, Emotional, and Intellectual Habits for Grades 
                                  K-12
        The CSDE has developed the Components of Social, Emotional, and 
        Intellectual Habits for Grades K-12. This guidance represents 
        the knowledge, skills, and habits that form an essential 
        blueprint for students' well-being and equip every student with 
        the knowledge and skills necessary to succeed in college, 
        careers, and civic life. While attention to core academic 
        subjects remains important, positive habits set the stage for 
        all future learning, promoting intrapersonal, interpersonal, 
        and cognitive competence. This guidance provides grade-specific 
        competencies for districts and schools to integrate into 
        academic content areas so that students will learn and model 
        essential life habits. Some examples of the competencies 
        include: (1) Acknowledging and welcoming constructive feedback 
        from others that challenges and builds resilience and 
        identifies strengths and areas for growth and (2) demonstrating 
        critical thinking skills when solving problems or making 
        decisions, recognizing there may be more than one perspective 
        or solution to the problem.
                  8. Leveraging Medicaid Reimbursement
        The CSDE's partnership and collaboration regarding leveraging 
        Medicaid reimbursement began with the Connecticut Department of 
        Social Services (CTDSS) prior to the pandemic due to the 
        existing challenges of providing healthcare supports to all 
        students in Connecticut. The current patchwork of Medicaid, 
        private coverage, SAMHSA, local and state educational authority 
        funding makes it very challenging to implement consistent, 
        evidence-based, sustainable and comprehensive systems within 
        schools. Current medical models in which reimbursement is 
        provided based on individual student clinical services do not 
        allow for a systems approach to meeting the needs of all 
        students. Schools and school districts do not have the capacity 
        or expertise to bill as medical providers or manage complex 
        grants, and districts with the greatest needs often have the 
        least capacity in this regard. Eligible students currently 
        receive coverage and care through Medicaid via the Medicaid 
        School Based Child Health Program (administered by the CT DSS). 
        This program allows school districts to seek federal Medicaid 
        reimbursement for many Medicaid-covered services, such as 
        assessment, audiology, clinical diagnostic laboratory, medical, 
        mentalhealth, nursing, occupational therapy, physical therapy, 
        respiratory care, speech/language, and optometric services. 
        Districts may also pursue federal reimbursement for 
        administrative activities which support provided Medicaid 
        health services. Currently 118 of Connecticut's 205 school 
        districts are enrolled in the Medicaid School Based Health 
        Program. Medicaid covers roughly 250,000 young people (ages 5-
        17) in the state of Connecticut. Prior to the pandemic, the 
        CSDE was in active communication with the CTDSS on how to 
        leverage Medicaid reimbursement for students. With the new 
        Centers for Medicare and Medicaid Services guidelines, CT DSS 
        is actively looking into two options to streamline Medicaid 
        coverage and reimbursement. These are (1) School Based Child 
        Health (the district is the provider and biller) and (2) School 
        Based Health Center (private health care provider embedded in 
        the school). The partnership between the CSDE and CT DSS will 
        actively work to ensure that schools and school districts can 
        leverage these added resources and that a robust plan is in 
        place to ensure the greatest number of students possible are 
        eligible for Medicaid. In addition, the sustainability of 
        funding a robust professional mental health work force within 
        schools is tied to our ability to leverage Medicaid funds for 
        students. As mentioned above, we also see Medicaid as a tool to 
        sustain some of the impactful work enabled by ESSER funds once 
        those funds are no longer available.
               9. Bipartisan Safer Communities Act (BSCA)
        Connecticut received $9.12 million in federal BSCA funding to 
        create a Stronger Connections Grant. These grants are 
        competitive subgrants that SEAs can provide to high-needs LEAs 
        to fund a broad range of activities including school-based 
        mental health services, early identification of mental health 
        issues, substance use prevention, trauma-informed care, and 
        appropriate referrals to support services, which may be 
        provided by school-based mental health service providers or in 
        partnership with a public or private mental and behavioral 
        health providers.

        Our Request for Proposals (RFP) will be released this month and 
        will reflect feedback provided from our many stakeholders. It 
        must be noted that this timeline to release the Bipartisan 
        Safer Communities Act RFP is purposeful following the awarding 
        of the robust $28 million in School Mental Health Grants 
        mentioned above. This allows for the CSDE, as well as school 
        districts, to be strategic in first planning for the use of 
        existing ESSER funding to support student mental health and 
        then determining the gaps in resources that can be supported by 
        the School Mental Health Grants. This will ensure that BSCA 
        funds will be strategically utilized to support the most 
        pressing needs.
                    10. School Based Health Centers
        Connecticut's School-Based Health Centers (SBHCs) are 
        comprehensive primary health care facilities licensed as 
        outpatient clinics or hospital satellites. SBHCs are 
        intentionally located in schools where students have 
        historically experienced health care access disparities and are 
        often publicly insured, underinsured, or uninsured. Multi-
        disciplinary teams of pediatric and adolescent health 
        specialists staff the health centers, including nurse 
        practitioners, physician assistants, social workers, physicians 
        and in some cases, dentists and dental hygienists. SBHCs 
        provide all levels of care for students including medical 
        services and mental health services. Connecticut currently 
        funds 90 SBHCs and efforts are underway to expand that number 
        in areas and schools not currently served by an existing SBHC 
        or other health care center.
                11. Mobile Crisis Intervention Services
        Mobile Crisis Intervention Services is an initiative developed 
        and administered by the Connecticut Department of Children and 
        Families (CT DCF), the state's child welfare and behavioral 
        health agency. Accessible by simply calling 2-1-1, or 9-8-8, 
        Mobile Crisis providers deliver a range of crisis response and 
        stabilization services to children, youth, their families and 
        caregivers. Mobile Crisis providers are experts in meeting the 
        complex needs of students experiencing psychological or 
        behavioral issues. Districts in Connecticut are required to 
        contract with community-based Mobile Crisis providers to 
        respond to schools and families when students are in crisis. As 
        a result of the pandemic, Connecticut invested an additional 
        $8.6 million in ARPA funding for an annual total of $19 million 
        to ensure access 24 hours per day, 7 days per week, 365 days 
        per year. In the event of a psychiatric emergency, a trained 
        screener will, within 15 minutes, facilitate direct contact 
        with a licensed Mobile Crisis staff member or other emergency 
        service as necessary. The trained screener will connect the 
        caller real-time with a clinician during the call and the 
        clinician can respond in person to the caller's location within 
        45 minutes if needed.

        Initiatives to Support Healthcare Workforce Development

    As stated, Connecticut is not immune to shortages of mental and 
behavioral health staff. As a result, a concerted cross-agency effort 
to recruit and retain a quality behavioral and mental health workforce 
is underway in Connecticut.
   1. Connecticut Office of Workforce Strategies (CT OWS) Initiatives
        The Connecticut Office of Workforce Strategy (CT OWS) has 
        several workforce initiatives related to healthcare career 
        pathways. While these programs are not focused specifically on 
        school-based practitioners, they are geared toward increasing 
        the number of clinical workers in the state. The education and 
        training provided these programs will increase the supply of 
        clinical healthcare workers entering schools as school-based 
        practitioners. Many of these projects have stemmed from inter-
        agency collaborative efforts, including between the CSDE, CT 
        State Colleges and Universities (CSCU), and CT OWS.

                (a) One such program is the CT Health Horizons, which 
                CT OWS launched with $35 million in state ARPA funds. 
                The goal of this program is to increase the number of 
                graduates from the nursing and social work program 
                (prioritizing the MSW degree, which is the precursor to 
                becoming a Licensed Clinical Social Worker, the most 
                in-demand position in behavioral health), with a focus 
                on diversifying the workforce. Grants will soon be 
                available to address three areas: (1) Tuition Support 
                to incentivize low-income and minority students to 
                enter accelerated and cost-effective nursing and social 
                work programs, (2) Increase faculty to expand seat 
                capacity and train an influx of nursing and social work 
                students, and (3) Promote employer-driven innovation 
                programs to support entrance into high-demand careers 
                in nursing and social work. Grants were provided to 
                independent colleges and universities that coordinated 
                efforts to increase access to accelerated nursing and 
                mental health programs. Students are enrolling in 
                programs that start fall semester 2023.

                (b) In addition, CT OWS has invested $11.6 million in 
                two CareerConneCT grants focusing on health care 
                training. The Academy for Human Service Training (AHST) 
                is a 15-week comprehensive classroom and hands-on 
                training opportunity for roles in Community and Social 
                Services/Human Services; Case Managers, Direct Support 
                Professionals, Psychiatric Aides, Recovery Assistants, 
                etc. The Health CareerX Academy is designed to support 
                the scaling of the Southwest Healthcare Career Academy 
                statewide to train individuals in entry-level 
                healthcare roles.

                (c) An OWS legislatively mandated report is 
                recommending a plan to work with high schools across 
                the state to develop and strengthen pathways that 
                encourage students to pursue careers in healthcare.
    2. Connecticut Department of Public Health (CT DPH) Initiatives
        Similar to the CT OWS, the CT DPH has recognized the pressing 
        need to bolster its mental health workforce to effectively 
        address the growing demand for mental health services. In 
        response to this imperative, the state has embarked on a series 
        of robust public health initiatives aimed at increasing the 
        number of mental health professionals.

                (a) In 2022, CT DPH joined the Psychology 
                Interjurisdictional Compact (PSYPACT) designed to 
                facilitate the practice of tele-psychology and the 
                temporary in-person, face-to-face practice of 
                psychology across state boundaries. The Interstate 
                Medical Licensure Compact is an agreement among 
                participating U.S. states and territories to work 
                together to significantly streamline the licensing 
                process for physicians who want to practice in multiple 
                states. It offers a voluntary, expedited pathway to 
                licensure for physicians who qualify.

                (b) In 2022, the Connecticut General Assembly passed 
                two public acts providing DPH resources to strengthen 
                the mental and behavioral healthcare workforce in 
                Connecticut, to include:

                        (i) PA 22-81 encourages pediatric offices to 
                        integrate behavioral health into their 
                        practices. This is accomplished through a new 
                        grant program to provide pediatric offices with 
                        a 50 percent match for costs associated with 
                        paying the salaries of licensed social workers 
                        providing counseling and other services to 
                        children receiving primary health care from 
                        such providers.

                        (ii) PA 22-47 increases the number of child and 
                        adolescent psychiatrists available in the state 
                        to provide services to school-aged children. 
                        This is accomplished by the establishment of 
                        child and adolescent psychiatrist grant program 
                        to provide incentive grants to employers for 
                        recruiting, hiring, and retaining child and 
                        adolescent psychiatrists.
                   Focus on Attendance and Engagement
    With any discussion on mental and behavioral health supports, it is 
critical to include the importance of student attendance and engagement 
in school. Attendance is a precursor to engagement which is a precursor 
to learning. When students regularly attend school, they have access to 
not only in-person relationships with their peers but also to critical 
social and emotional supports. Therefore, the CSDE has placed a 
significant focus on improving attendance. Two practices the CSDE 
implemented to decrease chronic absenteeism include:
                      1. Increased Data Collection
    Beginning with the 2020-21 school year, the CSDE rolled out two new 
data collections--weekly collection of learning models (e.g., in-
person, hybrid, or remote) and enrollment, as well as expanding the 
collection of student attendance from yearly to monthly, to allow us to 
make data-informed decisions in real time to focus resources on student 
engagement and participation.
        2. The Learner Engagement and Attendance Program (LEAP)
    The state's response to this data collection was the Governor's 
Learner Engagement and Attendance Program, or LEAP, which was announced 
in April 2021. Underway in 15 high-needs districts, LEAP is the CSDE's 
research-based, relational home visiting model proven to increase 
student attendance and family engagement. Home visitors establish 
relationships with families and students and connect them with school 
and community resources, including behavioral health resources as 
needed.

    As of December 2021, nearly 7,000 students across the 15 LEAP 
school districts had received more than 12,000 contacts from home 
visitor staff to encourage and support increased student attendance in 
school. Thanks to financial commitments of our legislature, this 
program will continue.

    LEAP, by design, is supportive and creates trusting, relationship-
based partnerships with parents. This helps parents resolve barriers to 
attendance and other life stressors. The Center for Connecticut 
Education Research Collaboration's (CCERC) evaluation of the LEAP 
program found that home visitors and families noted eight main benefits 
of LEAP including:

          Improved family school relationships

          Increased student attendance

          Increased student achievement

          Increased feelings of belonging

          Increased access to resources for families

          Increased expectations of accountability

          Greater gratitude and appreciation

    CCERC conducted the largest, most robust study ever completed of a 
home visit program. The research shows that when implemented with 
fidelity, the LEAP model has a positive impact on students and 
families.

    The results of the quantitative analysis indicated the following 
findings:

          Visits that were made in-person had more impact than 
        virtual visits or phone calls.

          One month after the initial home visit, participating 
        students showed a 4 percentage point increase in attendance.

          Six months after the visit showed a 10 percentage 
        point increase in attendance among pre-K to grade 5.

          Six months after the visit showed a 20 percentage 
        point increase in attendance among grades 6-12.

              Evaluating Effectiveness and Sustainability

    Scientifically researching and evaluating the effectiveness of the 
referenced initiatives, programs and investments is at the heart of our 
strategy in Connecticut. ESSER funds were used to establish the first-
of-its-kind research collaborative we call the Connecticut COVID-19 
Education Research Collaborative (CCERC). CCERC is a research 
partnership between the CSDE and public and private institutions of 
higher education across Connecticut that works collaboratively on 
program evaluations. Given the value of the research collaboration 
beyond COVID-19 research efforts, it was recently rebranded as the 
Center for Connecticut Education Research Collaboration (CCERC), 
keeping the same acronym, and continuing this partnership well after 
the COVID-19 pandemic.

    The rebranded CCERC's mission is to address pressing issues in the 
state's public schools through high quality evaluation and research 
that leverages the expertise of researchers from different institutions 
possessing varied methodological expertise and content knowledge. 
District and school leaders across our state are critical partners in 
this work. Many of the projects require an in-depth review of local 
policies and practices, especially when there have been large 
investments in the area of study. These important evaluation studies 
require district cooperation with researchers.

    In addition to evaluation studies released on LEAP, summer 
enrichment, and remote learning, nine additional projects are underway 
and include the behavioral health pilot, identifying effective and 
equitable socio-emotional supports for students and educators, equity 
in academic recovery, and more.

    CCERC demonstrates the CSDE's commitment to programmatic 
accountability and sustainability, building evidence on the 
effectiveness of its interventions and knowing what works. As the end 
of the ESSER funding approaches, Connecticut will have the strength of 
results to fund and sustain what works.
                        Policy Recommendations:
    As we gather here today to address pressing youth mental health 
challenges, I would like to draw your attention to a set of policy 
recommendations below that I believe warrants your consideration.
   1. Allocate Resources for State and Local Evidence-Based Program 
                               Evaluation
        Program evaluation initiatives such as CCERC provide an 
        objective and evidence-based assessment of the efficacy of 
        educational programs, allowing policymakers, educators, and 
        administrators to make informed decisions. These evaluations 
        help identify strengths and weaknesses in funded programs/
        initiatives, measure impact on student outcomes, and pinpoint 
        areas for improvement. By understanding what works and what 
        does not, states and school districts can better direct 
        resources to strategies that have a proven track record of 
        success, ultimately benefiting students, educators and 
        communities. As Congress considers reauthorizing the Education 
        Sciences Reform Act, I encourage you to help states build 
        capacity to evaluate program effectiveness and support 
        effective uses of limited resources.
2. Provide Funding for the Continuation of Prevention and Intervention 
                              Initiatives
        By the end of 2024, states and school districts will have fully 
        invested the Federal education funding that Congress provided 
        under three relief packages to mitigate COVID-19 and address 
        its lasting impacts upon student achievement and well-being. In 
        2024, the end of this funding will significantly limit schools' 
        ability to access the resources and supports students and 
        communities need to recover from the ongoing effects of the 
        pandemic. Moving forward, we are committed to effective uses of 
        more limited funds but also encourage Congress to make 
        additional investments in K-12 education to ensure that we can 
        continue to meet the needs of students and families.
         3. Support Educators' Focus on Student Physical Health
        Student physical health is a critical factor in youth 
        development and overall health and needs to be part of the 
        package of supports for students. Childhood obesity is again on 
        the rise along with increased sedentary habits in our Nation's 
        youth. Diminished physical health, especially in underserved 
        populations is a doorway to other issues and concerns, 
        including mental and behavioral health, potentially leading to 
        negative impacts on overall health and well-being. Programs and 
        services to support physical fitness and wellness, as well as 
        expansion of the Federal child nutrition programs for all 
        students, are foundational to lifelong health and success.
        4. Incentivize Collaboration Between Federal Agencies [
        Federal agencies need to coordinate to leverage different entry 
        points to mental health support so that, regardless of the 
        agency that has a high touch with a family, any one of them are 
        able to provide entry into supports for children and students 
        experiencing trauma and struggling with access to services and 
        care. Such collaboration is critical to address the Social 
        Determinants of Mental Health. Augmenting traditional 
        behavioral health services with additional health-enhancing 
        supports and positive youth development opportunities has the 
        power to develop well-rounded students with the knowledge, 
        skills and confidence to support their lifelong wellness and 
        success. Such opportunities include: focused investments 
        targeting protective factors; providing for basic needs such as 
        stable housing; supporting comprehensive wraparound supports 
        for emerging adults; providing innovative education 
        opportunities outside of school that focus on building skills 
        and confidence; providing opportunities for employment or 
        training; and, providing access to mentors with lived 
        experience in behavioral health, juvenile justice, and child 
        welfare systems.

    As Connecticut's Commissioner of Education, I am greatly 
appreciative for the invitation to be part of this national discourse 
to share what Connecticut has done to support youth mental health and 
to describe potentially scalable initiatives to inform Federal 
investments and policies. Addressing non-academic barriers to learning 
will serve to improve educational attainment. Your willingness to model 
transparent bipartisan national discourse such as this will lead to 
enhanced access to needed services and ultimately improved academic 
supports and outcomes for our young people, and I appreciate these 
efforts. I am part of a strong, nationwide network of state 
commissioners working together with the Council of Chief State School 
Officers, and I can guarantee you no two stories are alike. What I can 
surely guarantee you is that we all collectively wake up every morning 
with our students and their families, educators, and school staff at 
the forefront of our minds, because it is when our schools are 
supported our students achieve more, our communities achieve more, and 
together--we all achieve more.

    We must use this moment to think holistically across all levels of 
government about the continuum of supports necessary for our students 
and nation to thrive.

    Finally, none of the practices and initiatives that I bring from 
our great state would be possible without the leadership of our 
Governor, our sister agencies, the excellent staff at the CSDE, our 
State Board of Education, our school district superintendents, 
administrators, educators and staff, our policymakers, and the many 
education partners in our state. That truly is the Connecticut 
Difference!

    Chair Sanders, Ranking Member Cassidy, and HELP Committee Members, 
thank you once again for the opportunity to share Connecticut's story 
with you today.
                                 ______
                                 
           [summary statement of charlene m. russell-tucker]
    The social isolation and stress of the COVID-19 Pandemic 
exacerbated existing mental health challenges facing our youth and also 
exposed gaps in the behavioral and mental health care system. This is 
evident from the results of the Connecticut School Health Survey, which 
indicated that feelings of sadness and hopelessness in high school 
students reached a new high in the fall of 2021. The Connecticut 
Department of Education (CSDE) built on existing systems and leveraged 
new funding to address this critical need in our students.
               Stakeholder Involvement and Collaboration
    Stakeholder engagement is a pillar of Connecticut's response to 
addressing mental health concerns in students. The Commissioner's 
Roundtable for Family and Community Engagement in Education represents 
a diverse constituent group of education stakeholders representing 
school and district staff, advocacy organizations, parents and 
guardians, community members, and students, to advise the Commissioner 
of Education regarding policy and programmatic priorities. 
Voice4Change, the first statewide student participatory budgeting 
initiative in the country, gave students a direct say in how a small 
portion of state set-aside ESSER funding should be spent across 
Connecticut schools. Students overwhelmingly voted for projects that 
supported student and staff mental health. The AccelerateCT Education 
Taskforce was launched in 2021 to develop a statewide education 
recovery and acceleration framework and programming for students across 
the state beginning with enhanced learning and enrichment 
opportunities, which included a focus on social, emotional, and mental 
well-being. Engaging associations representing school superintendents, 
principals, teachers, nurses, counselors, social workers and others are 
also part of Connecticut's play book for success.
 Supporting the Social, Emotional, and Mental Health Needs of Students 
                               and Staff
    Connecticut created programs and rolled out grants to strategically 
build the infrastructure to support schools and students. Efforts 
include: $183 million district ESSER funding prioritized for mental 
health; $28 million in school mental health personnel grants; $35 
million after-school and summer enrichment grants; the school 
behavioral health pilot program; expansion of Mobile Crisis 
Intervention Services; School Based Health Center expansion plans; 
guidance and systems to support positive growth in pro-social 
competence and behavior in students.
        Initiatives to Support Healthcare Workforce Development
    Key initiatives spearheaded by the CSDE's partnerships with other 
state agencies include workforce grants and training programs for 
mental health professionals to increasing the number of social workers 
and psychologists for school-aged children including $35 million to 
support students in nursing and social work programs, and funding 
incentive programs for employers of clinicians to strengthen the mental 
and behavioral healthcare workforce.
                   Focus on Attendance and Engagement
    The CSDE understands the power and importance of real-time 
evaluation data. Increasing the collection of attendance data from 
yearly to monthly allowed the CSDE to address root causes of chronic 
absence and disengagement in real time. These data points led to the 
development of the Governor's Learner Engagement and Attendance Program 
(LEAP). LEAP is the CSDE's research-based, relational home visiting 
model proven to significantly increase student attendance and family 
engagement.
              Evaluating Effectiveness and Sustainability
    A commitment to evaluation is at the heart of our strategy in 
Connecticut. Data-driven decisionmaking is key to informed and 
effective policymaking. To that end, the CSDE invested a portion of our 
ESSER funds to establish the first-of-its-kind, research collaborative 
called the Connecticut COVID-19 Education Research Collaborative 
(CCERC). Recently rebranded as the Center for Connecticut Education 
Research Collaboration, CCERC is a research partnership between the 
CSDE and institutions of higher education across Connecticut. This 
research center allows the CSDE to leverage the strong collaboration 
that exists in our state to scientifically research and evaluate the 
effectiveness of our initiatives and investments.
                         Policy Recommendations
    The policy recommendations in this testimony for consideration to 
support youth mental health include: allocate resources for state and 
local evidence-based program evaluation; provide funding for the 
continuation of prevention and intervention initiatives; support a 
focus on student physical health; and incentivize collaboration between 
Federal agencies.
                                 ______
                                 
    The Chair. Thank you very much. We are going to jump over 
Dr. Garcia for a second. We are to go to Dr. Joy Osofsky, who 
will be introduced by Senator Cassidy.

    Senator Cassidy. It is a joy to introduce Dr. Joy Osofsky. 
She is the head of pediatric mental health at LSU Medical 
School, a developmental psychologist, and a national leader in 
early childhood development. I have learned a lot from Dr. 
Osofsky.

    She is who taught me that you can actually begin picking up 
separation disorder from day zero. It was just amazing to me. 
And she was very influential in what Chris Murphy and I did, at 
least my part of the mental health reform bill of 2016, so I 
owe a lot to her.

    She has expertise in trauma informed care, helped many 
Louisiana families recover from Hurricane Katrina, and apply 
that expertise during the COVID-19 pandemic. She received 
numerous awards and recognition for her work. Dr. Osofsky, 
thank you for being here.

STATEMENT OF JOY OSOFSKY, PROFESSOR OF PEDIATRICS, PSYCHIATRY, 
AND PUBLIC HEALTH, HEAD OF DIVISION OF PEDIATRIC MENTAL HEALTH, 
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER, NEW ORLEANS, 
                               LA

    Dr. Osofsky. Thank you very much, Senator Cassidy, for the 
invitation, and Senator Sanders. I very much appreciate being 
here.

    One of the things that I want to say in introducing my 
testimony is how important the opportunity has been for me, 
actually together with my husband who is a psychiatrist, to be 
able to consult with Senator Cassidy on mental health issues, 
to identify and support community and state agencies that work 
individually and collaboratively in supporting the mental 
health needs of children and families, including cross-state 
efforts.

    We started this in 2016. We have been pleased to support 
his efforts to increase mental health support in schools and in 
communities. And we didn't talk earlier as much about 
communities, and I think we need to integrate that in the 
conversation we have now.

    Bipartisan Safer Communities Act and Support Act would 
expand community based behavioral health services and access to 
mental health care services in schools and communities in both 
rural and urban areas. And we know in rural areas, it is much 
harder to access mental health services in general.

    The Act would provide funding also for the National Child 
Traumatic Stress Network to improve trauma informed training, 
treatment, and services for children, adolescents, and families 
who have experienced trauma. I have been fortunate enough to 
work with the National Child Traumatic Stress Network being 
funded since 2003, to develop mental health collaboration with 
schools and communities.

    Our latest effort, and I think one that is really very much 
reflective of the direction of the National Child Traumatic 
Stress Network is going, has been to not just work in one 
community, but develop regional coalitions so that we spread 
the work that we do and the efforts that each of us make in 
working with children who have been traumatized in different 
ways and experienced trauma, to be able to share that knowledge 
with other communities.

    For example, and I actually happened to be quite fortunate 
during the COVID pandemic, we had a center within the National 
Child Traumatic Stress Network that just ended, a terrorism and 
disaster coalition for child and family resilience.

    Through that coalition, we built regional relationships 
across states, one in the Gulf South, where we already had 
relationships due to the disasters, Hurricane Katrina and the 
Gulf oil spill, but then in the Northeast region of the United 
States, across five states.

    The regional coalitions are composed of people from all 
different backgrounds, state agencies, education agencies, 
stakeholders in the community, people who are involved in 
policy, we have some politicians involved, so that we were able 
to share information across the different groups for much 
better preparedness, as we share information, response, and 
then recovery when a disaster of any type occurs.

    Not just a natural or technological disaster, but also a 
terrorist attack or a shooting that has occurred in a 
community, or a shooting that has occurred in schools, that we 
can share information and have immediate response to those 
situations. I really feel about the work of the National Child 
Traumatic Stress Network speaks to some of the issues that have 
already come up in terms of integrating across community 
innovative ways to provide mental health services in ways that 
would be quite acceptable.

    The other thing that I want to bring up that has not been 
discussed is the importance of how to support resilience--how 
to support resilience in children, and how to support 
resilience in families. Certainly, we have seen families being 
pressed immeasurably during the COVID pandemic. What I call it 
is an indefinite information.

    Everything changed all the time, indefinite uncertainty. We 
didn't know what was going to happen from 1 day to the next. 
How can a family come together and how can a school system or a 
community come together when you don't know how things are 
going to change from day to day? And the issue came off of how 
to communicate, and I think that is why there has been so much 
excess use of social media as a way to connect.

    We were told we couldn't be around people, so how can 
children relate to their friends? And how can one have a sense 
of family, if you can't see people and relate to them? So, I 
think that it is really very important for us to think about 
how to establish connections across families and connections 
across communities.

    One of them, I will give you--I see I am just about out of 
time. I was going to give you a brief example how we brought 
together families and children after Hurricane Katrina on some 
of the cruise ships that housed people who did not have 
housing. And how we work together, including mental health, as 
a way of just being there.

    That is something that we have to think about. Also, it is 
supporting parents to be able just be there and listen to their 
children and give support to parents to be able to do that. 
Thank you very much.

    [The prepared statement of Dr. Osofsky follows:]
                   prepared statement of joy osofsky
    Since 2016, we have had the opportunity to work with Senator 
Cassidy to identify and support community and state agencies that can 
work individually and collaboratively in supporting the mental health 
needs of children and families including cross-state efforts. We have 
been pleased to support his efforts to increase mental health support 
in schools and communities. The Bipartisan Safe Communities Act and 
SUPPORT Act would expand community based behavioral health services and 
access to mental health care services in schools and communities in 
both rural and urban areas. This Act would also provide funding for the 
National Child Traumatic Stress Network to improve trauma informed 
training, treatment, and services for children, adolescents, and 
families who have experienced trauma.
                       Effects of Trauma on Youth
    Youth are exposed to trauma in many ways, for example, experiencing 
abuse and neglect, exposure to domestic violence, substance use, and 
community violence. Youth are also exposed to natural and technological 
disasters and, in the past 3 years, to the COVID-19 pandemic with its 
many effects on children and families, including parental and caregiver 
loss. There is much evidence that exposure to trauma affects 
development in different ways. For very young children, exposure to 
abuse and neglect can impact on their brain development. For all 
children, their cognitive, social, and emotional development can be 
affected by abuse and neglect (Center for the Developing Child at 
Harvard, 2023). Many studies have shown that children who are exposed 
to adverse life experiences (ACEs) early in their lives are at 
significant risk for developing serious and long-term problems, both 
medical and psychological, later in development. Trauma-informed and 
trauma-responsive interventions and evidence-based mental health 
treatments have been developed to help youth who have been exposed to 
trauma. It is crucial to recognize that recovery from trauma and 
development of resilience with meaningful, consistent relationships 
which means that parent and caregiver availability and support, in 
addition to mental health services, will help children and adolescents 
recovery from trauma exposure and also support resilience (Masten, 
2021). The COVID-19 pandemic has contributed to increased risk of 
mental health problems for several reasons. Children of all ages, 
including adolescents, are likely to develop well with consistency in 
their schedules, positive relationships with a parent or caregiver in a 
supportive environment, and, as they grow older, consistent peer 
relationships. Few of these positive supports for youth development 
were in place during the COVID -19 pandemic.
  The Mental Health Impact of Natural and Technological Disasters on 
                Youth Compared to the COVID-19 Pandemic
    While the psychological and social impact of the COVID-19 pandemic 
shares some similarities to natural and technological disasters, there 
are also major differences that need to be considered related to the 
mental health impact on youth, having contributed significantly to the 
increase in anxiety, depression, and other mental health disorders. 
Unlike the COVID-19 pandemic, natural disasters commonly impact on 
designated regions of a city, community, state, or country, allowing 
those not impacted to be available to help with recovery. A second 
difference is that it is often possible to predict, with some 
variations, the duration of natural and technological disasters; 
however, with the COVID-19 pandemic, there has been much uncertainty 
about the duration and, therefore, the recovery process. Third, and 
perhaps most important, is that recovery from natural and technological 
disasters is helped to a great extent by supportive in-person 
relationships that have been unavailable during COVID-19. Psychological 
and social well-being has been affected significantly by ``stay at 
home'' orders, social distancing, and other safety precautions needed 
to contain the pandemic that preclude social relationships. Further, 
the psychological and social impact is influenced by fears of becoming 
sick as well as having to cope with friends and family being sick and 
dying mostly alone from COVID-19. Youth have reported that they often 
worried about going to school when they opened being fearful of 
bringing COVID back to a parent or other caregiver in the family. 
Recent data has shown that intrafamilial spread is often due to 
apparently well children. The number of fatalities from COVID-19 also 
has taken a toll on psychological well-being. Following Hurricane 
Katrina, Louisiana experienced an estimated 1,700-2,200 fatalities. In 
contrast, as of May 2020, there were already more than 2,281 fatalities 
in Louisiana from COVID-19 (NOLA.com, 2020) and in 2023, a total of 
18,835 deaths which was 1 in 247 residents. The death rate for the 
African American population is 2.65 times the rate for all other 
groups. As with many major disasters, socioeconomic difficulties and 
preexisting health conditions are contributing to racial disparities in 
COVID-19. The mental health repercussions following disasters like 
Hurricane Katrina have been significant with both adults and children 
reporting high incidences of depression, anxiety, posttraumatic stress 
disorder, and substance abuse that went down slowly over time with 
growing family and community stability. This outcome has not been the 
case with COVID-19. Rather there have been reports of increases in 
anxiety, depression, substance use, and an exacerbation of previous 
mental health problems. Early in the pandemic, crisis counseling 
(Psychological First Aid), as is offered with disasters, was provided 
remotely. However, generally, there were limited clinical services and 
outreach support for individuals and families dealing with the stresses 
of temporary or permanent layoffs, decline in income, having to provide 
remote learning for children, and worries about illness and possible 
death. Mental health support also emphasizes the importance of 
establishing new routines and schedules for daily life including a 
schedule for youth to get up in the morning, have breakfast and go to 
school. During COVID, both youth and families experienced continual 
uncertainty about school, work, virtual schooling, homework, meals, 
self-care for parents, and time with children not only for virtual 
schoolwork, but also for positive play or conversation. The new 
routines also needed to include virtual ways to maintain friendships 
and family relationships using telephone or social media if available. 
While systematic reporting has been hampered with Stay-at-Home orders, 
concerns were raised, but not fully substantiated, about possible 
increases in child abuse and domestic violence with perpetrators and 
victims living in close quarters. Additional stress was contributed by 
family members becoming ill with COVID and not being able to be with 
loved ones when they were severely ill or dying from the virus. 
Further, youth experienced death of a parent, grandparent, or caregiver 
being taken to the hospital or leaving in an ambulance when sick with 
COVID never to return. For all children, this experience has been 
traumatic and, for younger children, confusing and difficult for them 
to understand. Clinically, we have heard many reports of young children 
continuing to stand at the window of their homes waiting for a parent 
to return. And with such losses, the remaining caregivers have had to 
find ways to support the children while also grieving themselves. The 
issue of inequities with COVID-19 is striking. In Louisiana, African 
Americans represent 32.7 percent of the population but account for 70 
percent of the deaths from COVID-19. These figures for Louisiana have 
been repeated across the United States with a much higher incidence of 
illness and death from COVID for Black/African Americans, Latino, 
Native Americans, Alaska Natives, Pacific Islanders among the many 
groups heavily impacted. This figure and inequities are likely related 
to having less access to care. Further, limited health care, which has 
contributed to a higher percentage of underlying conditions such as 
heart disease, hypertension, diabetes, and respiratory problems, places 
these individuals at higher risk if they become sick with COVID-19. The 
only conclusion to be drawn is that the COVID-19 pandemic is an 
unmitigated disaster in many ways comparable but worse than 
traditionally defined disasters such as hurricanes, earthquakes, 
tornadoes, and fires. Natural and technological disasters disrupt the 
essential consistencies in children's environments that are important 
for positive development. However, in most cases, substitute support 
can be established relatively quickly. However, the COVID-19 pandemic 
was different requiring a prolonged lockdown and social distancing 
requirements that should have been called physical distancing for 
safety so that social interactions that are so important for youth 
development would continue to occur, even if done virtually. Many young 
children could not really understand what happened and why their lives 
had changed from going to day care, preschool, or school to being 
isolated at home. For youth and adolescents of health care providers, 
they were often confused about why could they not see or hug their 
mother or father when they came home from work. Why could they not see 
or visit their grandparents who played such an important part in their 
lives? Also, the role of parents and caregivers in supporting their 
children is very important. If a parent is available to listen to their 
child, it can be extremely helpful even before mental health support 
may be available. A study done by Sesame Workshop during the pandemic 
that asked children to answer questions about their experiences during 
COVID, found that most children said that their parents would take care 
of them and keep them safe and secure.

    Youth and parents were continually living with ``indefinite 
uncertainty'' with schools, including preschools, being closed and then 
opened and closed again if there was spread of COVID. Further, the 
pandemic exposed inequities as for many families, virtual schooling was 
not possible with parents needing to work and limited access to 
internet and the technology needed for virtual schooling. This 
constantly changing environment interfered for children and adolescents 
with many of the important components for positive development 
including consistent peer relationships. The Rapid Assessment of 
Pandemic Impact on Development Early Childhood Survey, that was 
designed to collect essential information from households and families 
of young children during COVID, indicated that the level of emotional 
distress in households for both parents and children was related to the 
number of material hardships encountered. Further, they found that 
financial and material hardships contribute to caregiver distress that 
impacts on child distress. Virtual schooling with little support may 
have added to the stress for both youth and parents contributing to 
mental health symptoms.

    Youth mental health has been impacted by the ``indefinite 
uncertainty'' as a result of the pandemic with inconsistencies in 
schedules, feelings of isolation and anxiety with schools being closed, 
and an inability to be with friends. While virtual communication was 
possible for many youth, having to depend totally on this type of 
interaction may have also contributed to feelings of isolation and 
anxiety. Given that ideally for positive youth development, the use of 
social media, both content shared with friends and time spent, should 
be monitored by parents. During the pandemic, both children and parents 
depended more on virtual communication to interact with friends and 
family members. While some use of social media is reasonable for 
development. Unfortunately many youth and also their parents became 
more dependent on this method of communication and sharing during the 
pandemic. On the one hand, youth likely felt less isolated using social 
media; however, it could also have led to their feeling more isolated 
if they saw others interacting more with peers than they were doing. 
The main point is that use of social media for youth of any age should 
be monitored carefully by parents or caregivers which was made more 
difficult during COVID when this became a main way for youth to 
communicate and to receive education.
   Integrating Mental Health Support in School and Community Settings
    Following Hurricane Katrina, we had the opportunity to develop an 
innovative community-academic partnership program in a temporary 
building with school personnel, all of whom had lost their homes and 
now their schools, the former principals and teachers collaborated with 
our mental health team to encourage high school students to take a 
leadership role in recovery by helping older citizens and younger 
children come back to school and the community. The youth in the 
``Young Leadership Program'' who were mainly higher risk adolescents 
felt responsibility for leadership in the recovery giving them a sense 
of purpose and also helped other students and their community--giving 
them a sense of purpose. Other youth leadership programs were being 
planned for high-risk students when the COVID-19 pandemic closed 
schools.

    From extensive school and community-based experiences in providing 
mental health supports following Hurricane Katrina and the Deepwater 
Horizon Oil Spill, our team learned about the importance of delivering 
mental health supports and services in collaboration with schools and 
community groups. In several of the rural parishes where few mental 
health supports are available, we also collaborated with community 
clinics to bring more mental health support for youth. Further, and not 
unexpectedly, we also learned about the importance of providing trauma-
informed training for school personnel including teachers, counselors, 
nurses, other school staff, and administrators most of whom were also 
impacted personally by the disasters. To be supportive of students who 
experience trauma, it is important for school personnel to understand 
the impact of trauma and how it may be affecting the students. In this 
relationship-based approach, the students can feel understood and heal 
from trauma. The training and support for schools also includes 
information about vicarious traumatization and compassion fatigue in 
trying to support children who have also experienced trauma. The 
situation has been similar with the COVID-19 pandemic from survey 
research with teachers, childcare providers, and administrators who 
have experienced due to illness and loss in their families, the 
pressures of doing virtual schooling, and their concerns related to re-
opening schools and possible illness. Many of the teachers reported 
being concerned that it would be difficult for them to provide the 
support that the youth needed while also teaching them. Emphasis on 
these recommendations also comes from a recent experience shared by a 
psychologist who worked closely with us during our NCTSN grants 
supporting students in school settings. He shared with me that he 
walked into the school where he provides services and learned that two 
students had been shot and killed they day before. There was no 
supportive work done for the students or the teachers whether or not 
they knew the boys as all attended the same school. There are 
strategies that have been established to support schools, students, 
teachers, and staff when a student has been traumatically injured. It 
was hard for us to imagine the feelings at the school with no 
intervention and supportive work being done. Trauma-informed 
interventions and support should be in place for all students, 
teachers, staff, and families when needed.

    To deliver mental health services most effectively in school 
settings, collaboration with school personnel is important especially 
with counselors and nurses whom the youth see if they are having 
problems. Unfortunately, there are many schools across the country that 
have no school counselors. In the work of our team after natural 
disasters, we learned the importance of school personnel being 
``trauma-informed,'' in order to recognize that behaviors like anxiety, 
irritability, or symptoms like stomach aches may reflect the child or 
adolescent's anxiety related to exposure to trauma. After Hurricane 
Katrina and the Deepwater Horizon Oil Spill, our team worked 
collaboratively with schools to obtain parental consent, which is 
required for mental health services for youth, to provide services at 
the school setting. It also provides an opportunity to also meet and 
work with the parents.
 Providing Mental Health Support in Collaboration with Community Groups
    Not only partnering with schools in delivery of mental health 
services, but also collaborating with community groups where children 
may come for recreation or after school activities may be a place to 
identify increased anxiety or depression in youth and provide support. 
Trauma-informed community programs can play an important role in 
identifying and helping with mental health and substance use problems 
earlier. We have had experience with a successful community program in 
New Orleans, Son of a Saint, started 11 years ago by an innovative 
young man who lost his father, a New Orleans Saints player, due to 
natural causes when he was 3 years old. While his mother was very 
devoted, he found the teenage years difficult without having a father 
and was determined after he finished his education to start a program 
for adolescents. Boys ages 10-12, who had lost their fathers to 
violence or incarceration. Ninety percent of the youth are minorities 
and 80 percent are Black. While there are some mental health services 
provided for the program, most of the support is done by mentors who 
are well trained to provide ongoing support for the youth and 
adolescents, including the important encouragement of a consistent 
relationship. Since the beginning of the program, all have graduated 
high school, many have gone on to college, and none have had problems 
with the law.
                               References
    Center for the Developinng Child at Harvard--https://
developingchild.harvard.edu/.

    Fisher, et al (2023) Rapid Survey-https://rapidsurvey3years.com/.

    Kaiser Family Foundation (2022) Recent trends in mental health and 
substance use concerns among adolescentshttps://www.kff.org/
coronavirus-covid-19/issue-brief/recent-trends-in-mental-health-and-
substance-use-concerns-among-adolescents/.

    Masten, A. (2021) Resilience of children in disasters: A 
multisystemic perspective. International Journal of Psychology, 56, 1-
11. DOI:10.1002/ijop.12737.

    Osofsky, J.D., Osofsky, H.D., Mamon, L.Y. (2020). Psychological and 
social impact of COVID-19. Psychological Trauma: Theory, Research, 
Practice, and Policy. Advance online publication. http://dx.doi.org/
10.1037/tra0000656.

    Osofsky, J.D. and Osofsky, H.J. (2020). Hurricane Katrina and the 
Gulf Oil Spill: Lessons Learned about Short and Long-term Effects. 
International Journal of Psychology,DOI: 10.1002/ijop.12729.

    Osofsky, H., Osofsky, J., Hansel, T., Lawrason, Speier, A. (2018) 
Youth Leadership Program https://muse.jhu.edu/article/692848/pdf.

    Sesame Workshop https://sesameworkshop.org/our-work/impact-areas/
covid-response/.
                                 ______
                                 
                   [summary statement of joy osofsky]
    Since 2016, we have had the opportunity to work with Senator 
Cassidy to identify and support community and state agencies that can 
work individually and collaboratively in supporting the mental health 
needs of children and families including cross-state efforts. We have 
been pleased to continue to support his efforts to increase mental 
health support in schools and communities in urban and rural areas to 
help youth and families.

    In my written testimony, I review and provide some important 
references for this work:

        1. The Effects of Trauma on Youth including ways to support 
        resilience following trauma exposure. Children of all ages, 
        including those exposed to trauma, are likely to develop well 
        with consistency in their schedules, positive relationships 
        with a parent or caregiver in a supportive environment.

        2. Mental health impact of natural and technological disasters 
        on youth compared to the COVID-19 pandemic.

        Natural disasters are often more predictable and are time 
        limited. The COVID-19 pandemic has been marked by indefinite 
        uncertainty. Recovery from disasters is helped by supportive 
        in-person relationships. Mental health support following 
        natural disasters is helped by supportive in-person 
        relationships. Mental health support following natural 
        disasters can be provided in schools and community settings.

        With COVID-19, in order to limit spread of the virus, lockdowns 
        and social distancing was imposed with no in-person contact. 
        Schools that are important for recovery following disasters 
        were closed during the pandemic with much stress imposed on 
        families, particularly those with fewer resources having to 
        work and do virtual schooling. Family stress after natural 
        disasters is helped with community support. With COVID-19, 
        increased financial and other family stress due to lockdown 
        contributed to child stress. Both parents and youth depend on 
        social media to maintain contact with family, friends and 
        peers. Difficult to set suggested limits on use of social media 
        with COVID-19. Inequities were apparent with both natural 
        disasters and the pandemic. Inequities were even more 
        pronounced with serious illness from COVID-19

        3. Integrating Mental Health Support in Schools and Community 
        Settings.

        Mental health services in collaboration with schools worked 
        well in providing support for youth of all ages. Trauma-
        informed training and support in preparation for or following 
        disasters for teachers, administrators, and other school staff 
        to help them be more sensitive to students, especially given 
        vicarious trauma and compassion fatigue.

        4. Providing mental health collaboration with community groups 
        and school collaborations will be very helpful in supporting 
        youth mental health following the COVID-19 pandemic. Additional 
        initiatives in school and community settings following 
        disasters were helpful for high-risk youth with an illustrative 
        example provided.
                                 ______
                                 
    The Chair. Thank you. Our next witness is Dr. Joshua 
Garcia. Dr. Garcia is the Superintendent of the Tacoma, 
Washington School District. He previously served as Deputy 
Superintendent, Assistant Superintendent, High School 
Principal, Assistant Principal, Athletic Director, and Teacher. 
Other than that, not much. All right.

    [Laughter.]

    The Chair. Thanks very much for being with us, Dr. Garcia.

   STATEMENT OF JOSHUA GARCIA, SUPERINTENDENT, TACOMA PUBLIC 
                      SCHOOLS, TACOMA, WA

    Dr. Garcia. Chairman Sanders, Ranking Member Cassidy, and 
Members of the Committee, I am a proud Superintendent of the 
Tacoma school district and honored to share the viewpoint of 
superintendents for this important hearing focused on mental 
health of our Nation's youth, and to speak with you about what 
we have observed, what we have been doing, and what we might do 
together to curb the youth mental health crisis in America.

    Tacoma is fully committed to each of our students being 
safe, engaged, supported, healthy, and challenged. We recognize 
mental health impacts us all. Mental health includes our 
emotional, psychological, and social well-being. It affects how 
we think and act. It helps us determine how we handle stress, 
relate to others, and make healthy choices.

    During a highly critical phase of development, the lack of 
support and comprehensive approaches are significantly 
impacting our students' ability to grow socially, emotionally, 
and their academic development. Tacoma Public Schools, more 
than 28,000 students represent 170 tribes and ethnicities.

    Over 2,000 of our students qualify as homeless. Over 55 
percent of our students qualify as low income. And over 15 
percent qualify for special education students. In the 2011 and 
2012 school year, each of our high schools was labeled as a 
dropout factory. We were in a dire state, and we needed a new 
approach.

    We started the Tacoma Whole Child Initiative, an 
intentional action plan that recognizes students are learning 
24 hours a day, 7 days a week. Fast forward to 2022, 90.2 
percent of our students graduate in 4 years. 86.7 percent of 
our high schools take college level classes. This year alone, 
over 12,000 participants in kindergarten through eighth grade 
have engaged in after school activity, and a record number of 
high school students are participating in paid job experience.

    Tacoma has been able to make big strides to improve 
outcomes, but we know the challenges our students are facing 
are only growing. In the last year, our students, Tony, Angel, 
Brielle, Isiah, Marco, DJ, Wyatt, Xavier, Larry, and Iyana have 
been shot in our community. Our students have to survive human 
trafficking, battle homelessness, drug abuse, physical and 
mental abuse, and social media harassment and bullying.

    Although these may not be new challenges to us as a nation, 
the speed of the incidences and the traumatic stress are only 
increasing. Like you and I, students are being bombarded with 
images, news events, daily experiences of trauma, and hate and 
stress.

    Unlike us, they are doing this without fully developed 
brains, coping skills, or access to preventative and 
therapeutic services. In 2021, 13,239 of our 10th graders in 
our states made a plan for suicide. As you heard, Washington 
State is not unique. Our students are facing tremendous 
challenges and schools can't do this work alone.

    Through the Tacoma Whole Child Initiative, we have moved 
away from episodic events to sustainable practices across our 
buildings and our community. They are focused on three 
elements, prevention strategies, response strategies, and 
therapeutic services. Our prevention strategies.

    Each of our schools develop an intentional plan to support 
social emotional learning. They contextualize each plan at each 
school site. Our students are engaged in physical and mental 
wellness supports during the day and in the afterschool 
ecosystem. We do this with the Beyond the Bell and Club B, 
which uses a shared business model, common mental health 
supports, community assets, and align funding with over 70 
partners.

    Our system of positive behavioral supports ensure students 
understand schoolwide expectation, fostering stability and 
reinforcing healthy mental health habits. We also provide a 
safe space for our students to build belonging during evening 
and non-school hours. Our responsive strategies.

    We have invested in professional development focused on 
trauma sensitive practice. We support and train facilitate 
restorative practice that bring voice with intentional healing 
and understanding. And we also provide tiered supports, 
focusing on target intensive support for students at risk. 
Using ESSER and U.S. Department of Education grants, we were 
able to invest in therapeutic supports.

    During a robust prevention and strategy, TPS is not able to 
alone meet the needs. To meet this challenge, we are 
implementing an ambitious plan to increase the ratio of 
students to mental health providers. Here are a few things I 
encourage us to think about doing together. Expand on the 
bipartisan Safe Communities Act. I know budget decisions are 
tough, but with the message students are telling us, we just--
we have to listen to.

    Pay for health care services with health care dollars to 
ensure Medicaid access. Incentivize the health care industry to 
formalize partners with schools, prioritizing youth first. 
Build on categorical funding opportunities.

    Increase flexibility with the support for the Carl Perkins 
and Department of Labor grants to build hope. Require states to 
match your investment. Has Tacoma done everything we could? Not 
yet. Tacoma is learning, responding, and making a difference.

    We have evidence. We know that through engagement, tiered 
supports, and shared strategies, our students are being more 
successful dealing with their individual emotions and stresses, 
developing their social awareness, and working academically at 
all times.

    Finally, America's schools and individual communities can't 
do this alone. We must work in partnership, and we know that it 
is not easy. There are egos, turf battles, and frustrations. 
However, we are truly better together.

    We may not be united on everything, but our future is with 
us now, and we must be united in our commitment to serving 
youth first. Thank you.

    [The prepared statement of Dr. Garcia follows:]
                  prepared statement of joshua garcia
    Good morning, Chairman Sanders, Ranking Member Cassidy and Members 
of the Committee.

    My name is Josh Garcia, and I am the proud Superintendent of the 
Tacoma School District. I am honored to share the viewpoint of school 
superintendents for this important hearing focused on the mental health 
of our Nation's youth and to speak with you today what we have 
observed, what we have been doing in Tacoma Public Schools and what we 
might do together to support the youth mental health crisis in America.

    What do we want for every child in America? A simple question that 
has a complex and nuanced response. As one school district, we're 
thinking and working to take action every day. We are fully committed 
to each of our kids being safe, engaged, supported, healthy and 
challenged. We recognize mental health impacts us all, students, staff, 
and community. Mental health includes our emotional, psychological, and 
social well-being. It affects how we think, feel, and act. It also 
helps determine how we handle stress, relate to others, and make 
healthy choices. The need for this hearing is more critical than ever.

    As we know, the human brain is developing during the K-12 
experience. At the most impactful phase in human development, the lack 
of support and comprehensive approaches are significantly impacting our 
students' ability to grow their social, emotional, and academic 
development.

    1. Tacoma--

    For those that don't know our beautiful community, Tacoma WA is an 
urban port city that is diverse. Our Tacoma Public Schools represent 
more than 28,000 students representing over 170 tribes and ethnicities. 
Over 2,000 of our students qualify as homeless, over 55 percent qualify 
as low income, and over 15 percent receive special education services.

    In the 2011-2012 school year, each of our high schools was labeled 
as drop out factory by U.S. News and World Report. We were in a dire 
state, and we needed a new approach. We started the Tacoma Whole Child 
Initiative, which is an intentional action plan that recognizes that 
students are learning 24 hours a day, 7 days a week. It's a recognition 
that focusing all our community energy on solely transforming the 
student experience during schools is a bad model, when schools only 
have students one-third of the time. We knew we had to transform 
schools and leverage the other two-thirds of the time to truly make 
gains and provide the supports necessary to reach our desired academic 
and mental health goals.

    Fast Forward to 2022, 90.2 percent of our students graduate in 4 
years. 86.7 percent of high school students take college level classes. 
We have record numbers of students engaged in extra-curricular 
activities and athletics. This year alone over 12,000 participants in 
K-8 have been engaged in after school activities, STEM, fitness, arts 
and more. A record number of High School students are participating in 
paid job experiences through work-based learning and Jobs 253. Tacoma 
has been able to make big strides to improve student outcomes. But we 
know that the challenges our students are facing are only growing. Our 
kids are in pain--in our own homes, neighborhoods, cities, states and 
in our own Nation. We need a united response.

    2. Mental Health Youth Crisis

    Everyday our students face the challenges that are ripping our 
great nation apart. In the last year, 10 of our students--Tony, Angel, 
Brielle, Isiah, Marco, DJ, Wyatt, Xavier, Larry, and Iyana--have been 
shot, our students have had to attempt to survive human trafficking, 
battle homelessness, drug abuse, physical and mental abuse, and social 
media harassment and bullying. If we pause and read the news, we will 
see that our students are like many American youth in the trauma they 
face daily. Although these may not be new challenges for us as a 
Nation, the speed of the incidents and the traumatic stress are more 
intense than ever.

    Like you and I, our students are relentlessly being bombarded with 
images, news events and daily experiences of trauma and stress. Unlike 
you and I, they are doing this without fully developed brains, coping 
skills and access to preventive and therapeutic services. This repeated 
attack on the human brain is putting our youth on high alert, which 
brings us all here today.

    In 2021, 72 percent of our 10th graders reported feeling anxious, 
nervous or on edge regularly (68 percent across the state) and 60 
percent reported not being able to stop worrying (55 percent across the 
state).

    17 percent of our 10th graders made a suicide plan in the last year 
compared to 15.6 percent across the state. This translates into 13,239 
students in our state making a plan to commit suicide.

    Unfortunately, it is hard to imagine that 10th grade kids in 
Washington are unique. That same data would show the number is higher 
in 8th grade (16.2 percent of 85, 819) = 13,902.

    3. How Tacoma Faces These Challenges Head On

    The challenges our students and schools face are tremendous, and 
schools can't do this work alone! Communities, states, and our great 
nation need sustainable action plans that are functional, continuous, 
and comprehensive. We must all acknowledge our responsibility without 
blame. Through the Tacoma Whole Child Initiative, we have moved away 
from episodic events to sustainable practices across our school 
buildings. Our sustainable practices related to supporting whole child 
to improve student outcomes are focused on three elements: prevention 
strategies, response strategies, and therapeutic supports.

    Prevention Strategies:

    In Tacoma we have an intentional plan to support social emotional 
learning defined at the local level: each of our schools has developed 
their own social emotional learning plan and publishes it annually to 
ensure feedback from families and community stakeholders.

    We also make sure our students are engaged in solid physical and 
mental wellness supports during the school day as well as in the 
afterschool ecosystem. Locally we do this with Beyond the Bell and Club 
Beyond which serves over 12,000 participants using a shared business 
model, common mental health supports, accessing community assets and 
aligned funding with over 70 partners. Through our shared signature 
strategies, we make sure students are greeted warmly, which builds a 
sense of belonging, and we focus on relationship building through 
strategies like, ``circles'' (building community, empathy and equitable 
story telling) and ``emotion checks'' (fostering self-regulation and 
understanding of others).

    Our system of positive behavioral supports ensures students 
understand--school wide expectations to foster stability, encourage 
positive expectations and outcomes and reinforce healthy mental health 
habits.

    We also provide a safe place for students to build belonging during 
the evening; Tacoma has launched 12 summer sites across town where 
teens can belong, break bread, and have equitable access to safe 
environments.

    Responsive Strategies:

    We have invested in professional development focused on trauma 
sensitive practices.

    We support, train, and facilitate restorative practices that bring 
voice with the intention of healing and understanding for all 
participants.

    We also provide tiered supports--focusing on targeted support for 
some students (check in, check out) and intensive supports (students at 
risk of harming self or others).

    Therapeutic Supports:

    Using Federal ESSER funding and U.S. Department of Education grants 
we were able to invest in therapeutic supports. We have learned that we 
must build partnerships and be honest about what our schools can and 
can't do for our students. We have 10 healthcare partners that are 
providing site based mental health supports to our students to keep 
them engaged in school and learning alongside their peers.

    How can we move forward together:

    Expanding on the lessons we have learned and successes we have had 
in Tacoma to date, I would encourage Congress to do the following:

        (1) Continue to expand on your work with Bipartisan Safer 
        Communities Act. I know that budget decisions are difficult and 
        there is never enough. However, it would be foolish for us all 
        to ignore the signs are youth are sending us. If we don't 
        invest now, our costs will be 10 times what they are now in the 
        future. In particular, the School-Based Mental Health Services 
        Grant and the Mental Health Service Professional Demonstration 
        (MHSP) grants will help districts train and retain desperately 
        needed school mental health professionals.

        (2) Pay for healthcare services with healthcare dollars by 
        ensuring every district can bill Medicaid for the healthcare 
        services delivered to Medicaid eligible students, so we can 
        focus our local education funding on other supportive programs 
        and services.

        (3) Incentivize the Health Care Industry to have formalized 
        partnership with public schools to serve youth with Mental 
        Health Supports. We need to bring therapeutic services to our 
        youth and continue to find ways to support growth in the 
        workforce.

        (4) Build on categorical funding opportunities like Title IV of 
        ESEA and consider new targeted support specifically for mental 
        health programs and services and require states to match 
        Federal investments. This will allow smaller communities to 
        have sustainable resources for their students.

        (5) Provide flexibility through the Carl Perkins Grant and 
        Department of Labor Grants to support paid youth job 
        experiences and required financial literacy, building a sense a 
        hope for the future.

    Gratitude

    Has Tacoma done everything we could, far from it! Tacoma is trying, 
learning, responding, and making a difference, we have evidence. We 
know that through engagement, tiered supports, and shared strategies, 
our students are being more successful dealing with their individual 
emotions and stresses, developing their social awareness and its impact 
on others. They are making responsible decisions for their future and 
building relationship skills. We are seeing students give back, feel 
seen, fostering their own sense of belonging, and working academically 
at all time high levels.

    America's public schools and our beautifully unique communities 
can't respond to the mental health needs in isolation. In Tacoma, we 
work in partnership and that is not easy, there are egos, turf battles 
and frustrations. However, we recognize that we are better together, 
that we may not be united on everything, but our future is with us now 
and we must be united in our commitment to serving youth first. 
Personally, and professionally, I am grateful for your willingness to 
do more and better. I know that out of the 27,141 Washington students 
who reported the made a plan to commit suicide, 751 of those students 
are in our city. I challenge us all to know how many youth are in 
crisis in our own communities.

    Thank you!

    References:

    Data Dashboard--Healthy Youth Survey (askhys.net)

    Report Card--Washington State Report Card (ospi.k12.wa.us)
                                 ______
                                 
                  [summary statement of joshua garcia]
    Tacoma is an urban port city that is diverse, with more than 28,000 
students representing over 170 tribes and ethnicities. Over 2,000 of 
our students qualify as homeless, over 55 percent qualify as low 
income, and over 15 percent receive special education services. In the 
2011-2012 school year, each of our high schools was labeled as drop out 
factory by U.S. News and World Report. We were in a dire state, and we 
needed a new approach. We started the Tacoma Whole Child Initiative, an 
intentional action plan that recognizes that students are learning 24 
hours a day, 7 days a week. Fast Forward to 2022, 90 percent of our 
students graduate in 4 years and 87 percent of high school students 
take college level classes. But we know that the challenges our 
students are facing are only growing. Our kids are in pain and we need 
a united response. Everyday our students face the challenges that are 
ripping our great nation apart. In the last year, 10 of our students 
have been shot, our students have had to attempt to survive human 
trafficking, battle homelessness, drug, physical, and mental abuse, and 
social media harassment and bullying. In 2021, 72 percent of our 10th 
graders reported feeling anxious, nervous or on edge regularly and 60 
percent reported not being able to stop worrying. 17 percent of our 
10th graders made a suicide plan in the last year. This translates into 
13,239 students in our State making a plan to commit suicide.

    Our sustainable practices related to supporting whole child to 
improve student outcomes are focused on three elements: prevention 
strategies, response strategies, and therapeutic supports. In Tacoma 
each of our schools has developed their own social emotional learning 
plan and publishes it annually to ensure feedback from families and 
community stakeholders. Our system of positive behavioral supports 
ensures students understand--school wide expectations to foster 
stability, encourage positive expectations and outcomes and reinforce 
healthy mental health habits. We also provide a safe place for students 
to build belonging during the evening with 12 summer sites where teens 
can belong, break bread, and have equitable access to safe 
environments. We have invested in professional development focused on 
trauma sensitive and restorative practices that bring voice with the 
intention of healing and understanding.

    Expanding on the lessons we have learned and successes we have had 
in Tacoma to date, I would encourage Congress to (1) continue to expand 
on your work with Bipartisan Safer Communities Act. In particular, the 
School-Based Mental Health Services Grant and the Mental Health Service 
Professional Demonstration grants; (2) ensure every district can bill 
Medicaid for the healthcare services delivered; (3) incentivize the 
Health Care Industry to have formalized partnership with public schools 
to serve youth; (4) increase funding for Title IV of ESEA; and (5) 
Provide flexibility through the Carl Perkins Grant and Department of 
Labor Grants to support paid youth job experiences and required 
financial literacy.

    We know that through engagement, tiered supports, and shared 
strategies, our students are being more successful dealing with their 
individual emotions and stresses, developing their social awareness and 
its impact on others. They are making responsible decisions for their 
future and building relationship skills. We are seeing students give 
back, feel seen, fostering their own sense of belonging, and working 
academically at all time high levels. America's public schools and our 
beautifully unique communities can't respond to the mental health needs 
in isolation. In Tacoma, we work in partnership and that is not easy. 
However, we recognize that we are better together, that we may not be 
united on everything, but our future is with us now and we must be 
united in our commitment to serving youth first.
                                 ______
                                 
    The Chair. Thank you very much. Let me begin the 
questioning. Mrs. Russell-Tucker, you mentioned the importance 
of afterschool and summer programs.

    I think one of the things we all agree on is that we are 
going to have to do a lot of treatment, but on the other hand, 
we are going to have to give young people a lot of positive 
community based activity.

    Can you talk a little bit about the impact that increased 
funding for summer and afterschool programs has had in 
Connecticut?

    Ms. Russell-Tucker. Thank you, Senator. Really important 
for--I appreciate that question, because it is such an 
important piece of the work that we have been doing. Under ARP 
ESSER fund, or ESSER funding, that we received $11 million for 
some enrichment, and we immediately put that to work. And our 
state stepped up and added more funding for the subsequent 
summers.

    We are now up to $33 million of state investment around 
summer enrichment. We are able, in that space--the first summer 
was to really try to get students back together, back with 
their peers, back in that environment, allowing them to work 
with sometimes behavioral--behavior therapists in that space 
while they are having a really good time with each other, 
right.

    It is enrichment, which is so important. And so, we have 
been able now, we have also evaluated the impact of that 
reimbursement. As I mentioned in my testimony of our 108,000 
students we served that first summer, we are now into summer 
No. 3, and we are evaluating it rigorously to make sure we know 
what is happening and so that we can----

    The Chair. Let me guess that you would like Congress to 
continue that kind of funding. Is that a good guess?

    Ms. Russell-Tucker. [continuing]. Exactly. Fund what works, 
right. That is one way of thinking about sustainability. Same 
is true for our after school program that we also we see 
funding to support.

    The Chair. We significantly expanded those programs in the 
American Rescue Plan.

    Ms. Russell-Tucker. Yes, absolutely. And so, it is 
important that we are funding what works, and that is why I am 
so proud that we are evaluating the impact of those 
investments.

    The Chair. Okay. Dr. Garcia, I want you to pick up on that. 
Again, we want to treat the millions of young people who are 
struggling, but we also want to challenge them. We want to 
bring them together.

    We want to have proactive activities. It sounds to me like 
in Tacoma, you are challenging young people. You are trying to 
provide job opportunities, among other things. Talk about the 
importance of treating young people with respect and allowing 
them to use their energies in productive ways.

    Dr. Garcia. Thank you, Senator. I think it is important 
that each community has the opportunity to define what respect, 
responsible, and safe looks like, and that is what our social 
emotional learning plans do. They bring voice, student voice to 
that conversation. They bring staff voice to that conversation. 
And they bring family voice. Each of our plans is published, 
so----

    The Chair. Young people are involved in the development of 
those plans?

    Dr. Garcia. Absolutely. Absolutely. And they define what it 
looks like in each location, right. Respect looks a little 
differently in a classroom than it does in a lunchroom, right. 
There are different settings. It looks different than in your 
neighborhood.

    We have to build community through a common language, and 
that is important. We bring respect, and how does that look in 
the afterschool world? How do we hear their voice and what are 
the activities that they want to participate in?

    It is very much an intentional effort to bring community 
together to define that, but those common words are across all 
the town.

    The Chair. I am gathering that the empowerment of young 
people, giving them a voice in the community, has a positive 
impact on mental health, among other things.

    Dr. Garcia. We bring voices in several ways, and we also 
hear from students. Students have asked me, they have said, 
Josh, stop asking us our opinions and bringing others to ask 
our opinions if the adults aren't going to do anything.

    That is a really important message. So, we bring voice 
through empathy interviews. We bring data around positive 
interactions. We have student voice at our board meetings. We--
students will vote with their feet, if you will.

    The increased activities in extracurricular activities, not 
what the adults want to offer, but what do they want to 
participate in. They have also told us they don't want to be 
engaged in the business model. They want to know the activity 
of that. We survey their interest regularly.

    The Chair. Okay. Let me ask Dr. Osofsky a question. You use 
the term indefinite uncertainty. What impact you walk through 
the streets of Washington this morning, you breathe the air, 
which is a result of terrible fires in Canada. Young people 
worry about climate change.

    We have heard discussions, Senator Kaine mentioned, on 
school, gun violence in the school. Kids worry about gun 
violence. Families all over the country are struggling 
economically. Louisiana, Vermont.

    What impact does all of that and more have in indefinite 
uncertainty about worrying what the future is going to look for 
these young people, whether there will be a decent future, from 
an environmental point of view, from an economic point of view, 
from a violence free point of view? What impact is that having 
on the lives of young people?

    Dr. Osofsky. I really appreciate you are asking that 
question because this is something that I struggle with and a 
lot of us struggle with, us in the mental health world. What 
children need, of all ages growing up, is they need to have 
schedules. They need to have routines. They need to know what 
is expected.

    For example, having a schedule of knowing they get up in 
the morning and they go to school, and who is going to pick 
them up at school, or where they are going to go and what their 
activity might be. And what happened, unfortunately, with the 
COVID pandemic is that changed continually.

    One of the things that we recommended is set a new 
schedule, have the children involved with setting the schedule 
so there is something predictable for them. But it went on for 
a very long time in that way. We also tried to support the 
parents, too, because parents were having--didn't have a 
schedule either.

    Instead of getting up, and if they went to work, going to 
work and doing whatever, they were having to balance that with 
educating their children virtually, if they were fortunate to 
have the internet and the equipment that is needed to do that. 
And every day that changed as well for them.

    The other thing that is very important for the young people 
is their peers at every age. For the younger children, being 
able to play with them and get to know them. For the older 
children, we know that it gets more complicated in adolescence 
and that kind of thing, which as I mentioned, contributes to 
some of the extensive use of social media.

    It is very, very important now that schools are open again 
for there to be that kind of schedule and things that parents 
can count on and children can count on to be able to move 
forward. I also wanted to make a comment on the involvement of 
youth.

    We found that to be extremely helpful after there was so 
much destruction with Hurricane Katrina, that there were a lot 
of teenagers who were on the streets because there was nothing 
there for them to do with themselves. They couldn't--there were 
no activities. So, we involved them with recovery.

    The teachers, who also didn't have classrooms and schools, 
they involved with recovery, so that the teenagers, instead of 
being in trouble, were able to contribute in positive ways.

    The Chair. Thank you very much. My time is long expired. 
Senator Braun, or Senator Cassidy? Senator Cassidy.

    Senator Cassidy. Dr. Osofsky, in some schools, they are 
limiting information sharing between parents and teachers, 
effectively cutting parents out of their child's life. What 
does your research say about the role of parents when students 
are going through traumatic experiences?

    Dr. Osofsky. That is such an important issue that you bring 
up, Senator Cassidy, because we know the important role that 
parents play for children, to be there, for them to listen, to 
advise them, and to be very much a part of their life.

    One of the studies that was done during COVID by Sesame 
Workshop sent out information to families, different 
backgrounds, racial groups, and asked them to have their 
children talk about what is important to them during COVID and 
what is going to help them. And the No. 1 issue was their 
parents.

    Their parents were the hero. The parent was going to keep 
them safe, and that was so important to them. And also, from a 
mental health point of view, if parents are available, can be 
emotionally available, like say to not just be there and listen 
to the children, and be involved with their activities, that is 
going to be very important.

    They will know when things are happening sometimes before 
the school will know, but obviously that collaboration is very 
important. But parents play a key role in mental health, in 
supporting the mental health of their children.

    Senator Cassidy. In the bipartisan Safer Communities Act, 
there are significant dollars put forward for tele-mental 
health. Does that work equally well for adolescents? Is there a 
role for that to be used in school health settings?

    Dr. Osofsky. We found tele-mental health to be very helpful 
and it does work well generally for adolescents. They kind of 
like that. They are more used to being on the screen than 
others are, and it is a way to stay in contact.

    We are very pleased that they allowed a lot of mental 
health work to be done using telehealth during the pandemic 
because it was a way that we were able to stay in touch and 
help people. For younger children, it can be a little bit 
challenging.

    They may want to go press a button or something like that, 
but we found it to be very successful in working with teenagers 
related to telehealth, and I hope that opportunity will 
continue as a way to reach them.

    Senator Cassidy. I keep asking questions I don't know the 
answer to, but hearing you speak today, it suddenly occurred to 
me that the people that decided to lock down our economy, who 
had the noble goal of limiting death but of course ended up 
increasing isolation, did they actually have children, 
psychiatrists, psychologists involved in their deliberations to 
do a cost benefit ratio, if you will, a risk benefit ratio of 
if we lock down, we are going to have X amount happen because 
of isolation, as much as that was foreseeable? Do you know that 
process? I don't, I am asking.

    Dr. Osofsky. Yes. I don't know for sure about that process 
either. Certainly, we were communicating, a number of us, and 
talking about it. And I recall almost every time I did an 
interview, I specifically recall an interview with an NPR 
reporter who had two children at home, and he took 15 minutes 
before he did the interview to talk to me about how can I 
support my children under the circumstance.

    They can't see their grandparents. The holiday was coming. 
It was a very important part of their lives. So, the tele--
telecommunication was really helpful. But I am not sure, 
Senator Cassidy, whether they did consult----

    Senator Cassidy. But what I am hearing from you is 
actually, it wasn't an imponderable. It was actually 
predictable that when the children were isolated, that they 
would have some of the problems that we now see. Is that a fair 
statement?

    Dr. Osofsky. I think it is. I think in families, it is very 
clear in families where they have more resources, for example, 
where they could work remotely, where they could get help, 
where they could set up separate learning areas for a few kids. 
Where they consist in kids that wouldn't have to be afraid of 
COVID.

    I know many families with resources who were able to do 
that. But for families with fewer resources, it was going to 
set up an ongoing problem, including learning over time and 
catching up where many of these children had problems to begin 
with.

    Senator Cassidy. Last, when I FaceTime with my 8 year old 
grandson, almost nine, he has got like 3 minutes for me, then 
he's gone. I say that because you mentioning that tele-mental 
health actually works.

    But as the younger child, they want to hit a button. At 
what point does it begin to work? Because we will be asked to 
support these programs in schools of various ages. At what 
point does it begin to work, and at what point--or is it just a 
little boy who has got ADD? Like a squirrel, squirrel, 
squirrel.

    Dr. Osofsky. Yes, I think certainly with what we call 
latency in children. Children about 8 years old and older, as 
we found with the earlier--that they were able to pay attention 
better when we did something----

    Senator Cassidy. Boys, girls difference or the same?

    Dr. Osofsky. Sorry--?

    Senator Cassidy. Boy and girl----

    Dr. Osofsky. Oh, I didn't--we didn't see differences 
between boys and girls, but we found the earlier work, at that 
age and older, seemed to be going pretty well. But on the other 
hand, we provided mental health services for younger children, 
but again, that was in person. I think it is the really little 
ones.

    As you know, we work with very young children like under 
the age of five that may have more difficulty with that. But 
again, if the parent is with them and working with them, and it 
is really a combination. It is not just the mental health 
person dealing with a three or 4 year old, it is working with 
the parent together.

    A dyadic work, and then the parent learns how to support 
the child. We are finding now in mental health in general, even 
in person, but certainly virtual, that involving parents, even 
with teenagers, with older children, is very important as a way 
to support them.

    Senator Cassidy. Thank you.

    The Chair. Thank you.

    Senator Markey.

    Senator Markey. Thank you, Mr. Chairman, before I begin my 
questions, I want to address and make a comment about the 
health of trans youth, reiterating some of what Senator Baldwin 
mentioned earlier.

    In the past 6 months, state legislators have passed 75 
bills discriminating against LGBTQ Americans and blocking 
access to gender affirming care. Drag shows have been attacked, 
hospitals providing gender affirming care are receiving bomb 
threats, and local clinics are installing security systems.

    Human Rights Campaign declared a national state of 
emergency for LGBTQ Americans, and the discriminatory actions 
and statements by elected officials at every level of 
Government are fueling the fire and making the youth mental 
health crisis worse. Passing bills into law is a tough process.

    What is easy is giving people the freedom to be themselves. 
What is easy is not using hate fueled rhetoric on trans kids to 
score cheap political points. And we need to do this, 
especially during pride week, to identify this as a huge 
problem in our Country. So, I want to turn to other issues that 
obviously the Surgeon General was addressing. But you are on 
the front lines. One in three teenage girls contemplated 
suicide last year. One in ten teenage girls attempted suicide 
last year.

    One in five LGBTQ youth attempted suicide last year--one in 
five LGBTQ youth attempted suicide last year. So, this is a 
real crisis, and we know that it is totally exacerbated by big 
tech and the role that they are playing in the lives of these 
children in our Country, because it is just unregulated in 
terms of what it can do to teenagers in our society. No 
protections, no safeguards.

    They collect an avalanche of personal information, and they 
use it up to send back an endless stream of toxic content into 
the minds of young people in our society. And the results are 
clear. More money for big tech, more pain for kids and 
teenagers in our Country. And we know that it is Instagram. We 
know that it is--we know that it is Facebook. We know that it 
is TikTok.

    We have to take action to pass a comprehensive law. We know 
that it is Disney. We know that it is Paramount. They are 
collecting information and sending it right back in a form that 
advances the financial interests of these companies. So, my 
question to you is, Ranking Member Cassidy and I have 
introduced a piece of legislation that would create an online 
privacy bill of rights for teenagers in America.

    There is a law on the books right now for 12 and under, but 
there is no law for a 13 year old girl with bulimia or anorexia 
from being targeted by these companies with information that 
actually worsen the situation. So here is what the legislation 
would do. Just would love to get your comments on it.

    One, the bill would ban targeted ads to children and teens. 
Two, it would establish a youth marketing and privacy division 
at the Federal Trade Commission. And three, it would limit the 
collection of children and teens' personal information.

    It would actually say to parents, you have a right to say 
to the companies, erase this stuff that you have gathered about 
my child. Do you think that is necessary? Would you support 
legislation to accomplish that goal, so that the parents and 
the kids have protections against big tech?

    Ms. Russell-Tucker. Well, thank you, Senator, for the 
background and information that you have just shared. And it is 
so important, I think, critically, recognizing the impacts of 
all of this on our youth, that we are really paying close 
attention.

    I really believe hearing the voices, so having youth voices 
as a part of what is proposed, which is what we try to do in 
Connecticut. Hear from all the voices, including our families. 
Inform ultimately the impact, right, of the proposal being 
made. And so, we will really be looking at that very closely to 
get a sense of all that is being proposed, but anything that we 
can do----

    Senator Markey. But in general, do you believe that teens 
and children need an online privacy bill of rights?

    Ms. Russell-Tucker. No, I believe that.

    Senator Markey. Thank you. Yes, sir.

    Dr. Garcia. Thank you, Senator. Yes, I do. I also was 
struck by the comments earlier this morning, and I don't know 
if we are using the tools to our advantage. The data would tell 
us that when kids are talking about suicide, that we could 
inform them right there online and require companies to give 
them suicide information. If they are struggling with food, we 
could require those companies to push that information to them 
as well to curb that support as well.

    Senator Markey. What about upfront just putting the 
preventative action in place?

    Dr. Garcia. Yes, Senator.

    Senator Markey. That way the kids and the parents have a 
bill of rights so that the kid isn't targeted, that exacerbates 
the situation, so that they do become excessively depressed and 
contemplate suicide. Do we need those protections put in place?

    Dr. Garcia. I have three teenagers and I would say yes, 
please.

    Senator Markey. Okay, yes. And doctor?

    Dr. Osofsky. Yes, I would agree with my with two other 
panelists here. One of the things I was thinking about, but it 
doesn't in any way negate what I just said that I agree with 
that. We also know that for many of these youth, that is how 
they make relationships, too. And so, if there was a way that 
we would be able to help support them in some way, at the same 
time that we are protecting them, I think it would be very 
important.

    Senator Markey. Yes, I would say that we are in a crisis. 
We hear it today, we know that big tech plays a big role in 
creating this amongst kids. So, we are urgently in need of 
passing comprehensive legislation in my opinion.

    AI that we are discussing right now is just algorithms on 
steroids. But we already have algorithms on steroids by big 
companies who target children in our Country. We have to put 
the protections in place.

    If we can't do that, we are never going to be able to deal 
with the consequences for AI on steroids. If we can't protect 
children, we are not going to be able to protect our society. 
Thank you, Mr. Chairman.

    The Chair. Thank you.

    Senator Braun.

    Senator Braun. Thank you, Mr. Chairman. Senator Kaine asked 
Dr. Osofsky about parents' role. I am going to turn to Mrs. 
Russell Tucker. I served on a school board many years ago, 
didn't have the issues I think that we now contend with. It is 
a lot different now than then. Parents were always the primary 
stakeholder on almost any issue.

    Generally, it ended up being a disciplinary one, not what 
we deal with currently. In your testimony, you list in terms of 
on the mental health issue, the stakeholders, the Office of the 
Governor, and the State Board of Education, state agencies, 
educators, administrators, families, students, advocates, 
policymakers, local health officials, and more.

    I tried to tease out of Secretary Cardona on who the main 
stakeholders should be in our own kids' education and could not 
get parents out of his mouth the first time. After the Virginia 
election and it was made an issue there, he did begrudgingly 
say that parents should be a stakeholder, not the primary.

    When we are talking about mental health, there is a list of 
a lot of, and I believe sometimes that village doesn't need to 
be consulted, but I would think that in any of these issues, 
the parents ought to be the primary and everything else 
ancillary.

    By the way, you stated that. Would you agree with parents 
being the primary, all these other ancillary, or do you have a 
different way of saying what you are meaning what you said 
there?

    Ms. Russell-Tucker. Thank you, Senator. And I have long, if 
you saw from my testimony, as you mentioned, recognized the 
value and importance of parent voice in everything that we do 
in education. It is really important that they are at the 
table.

    They are a stakeholder. And the family engagement 
roundtable that I mentioned is doing just that. As a matter of 
fact, they have worked together through their voices to define 
what family engagement means in Connecticut.

    They truly are very important. And every time we have a 
chance to do any program, any policy, that their voices are 
actually are there at the table so we can understand, hear from 
them, and hear their perspectives. Because it really--so they 
are key stakeholders----

    Senator Braun. Are they consulted first in any navigation 
through a mental health issue in terms of getting with them 
first, are they just part of the group?

    Ms. Russell-Tucker. They are very much important about the 
health of their children. And so, I know for a lot of the 
initiatives that we have in the state, they are consulted and 
provide consent for services that is being provided. And so, in 
that case of health, I think it is very important that they are 
very much key and there to make decisions, to help to make 
decisions around their children.

    Senator Braun. Thank you. And Dr. Garcia, briefly on that 
topic.

    Dr. Garcia. Yes. They are very much a part of the process. 
At certain ages in Washington State, students can access 
services without family consent.

    Senator Braun. Would you say they are the primary, not just 
part of it?

    Dr. Garcia. I don't think it is a simple answer because I 
have experiences as families are in different spots. And so 
there is a recognition that I have, is that some families are 
not in a place where they are able to be at the table for work, 
social issues, a variety of things. And so, as a school system, 
it is not a luxury of one----

    Senator Braun. But whenever possible and able to, you would 
probably consider them the primary.

    Dr. Garcia. We engage them. Yes.

    Senator Braun. Another question, over the years, we have 
spent billions on the issue, and I would like each panelist, we 
have got about a minute and a half left here, do you think we 
have implemented what we have already put in the law and the 
money that we have devoted to it properly?

    Do you think that has been done in a way that would justify 
more? Do we need to do better at that? And where does the state 
fit in terms of maybe being able to do that better? We will 
start with Mrs. Russell Tucker. Give it about 30, 40 seconds, 
and move on down the panel.

    Ms. Russell-Tucker. Really important that we are 
continually evaluating so we know what works. We implement, but 
we must know the results and the impact. And so, at the state 
level, we have done that. You can see that in my testimony in 
making sure that we are indeed doing that. So, we can tell you 
what works, so we can actually talk about sustainability.

    Senator Braun. Yes or no, have the Federal programs and 
everything we have sent your way, do you think we have 
implemented that as good as it needs to be?

    Ms. Russell-Tucker. I think there is always room for 
improvement.

    Senator Braun. Thank you. And Dr. Garcia.

    Dr. Garcia. In my testimony, I ask that you work with 
states to require them to match your investments. My rural 
colleagues--let me know that categorical funding, direct 
streams are important, and competing for grants are oftentimes 
problematic alone. And so, I would encourage us to think about 
how we can do direct spend through categorical investments to 
build on sustainability.

    Dr. Osofsky. Yes, I believe very strongly that the 
investment, at least one program that I am involved with, and 
that is the National Child Traumatic Stress Network, has been 
extremely helpful because we focus on trauma.

    We have been talking about trauma. How to help children. 
And there has also been creative ways to spread what we have 
learned and also address the issues that we are concerned about 
with children. So that money has been very well spent.

    Senator Braun. Thank you.

    The Chair. Thank you, Senator Braun. That concludes our 
hearing today. And I want to thank all three of our witnesses 
for their excellent presentations. For any Senators who wish to 
ask additional questions, questions for the record will be due 
in 10 business days, June 23rd at 5.00 p.m.

    Finally, I ask unanimous consent to enter into the record 
five statements from stakeholders outlining their youth mental 
health priorities, and that will take place.

    [The following information can be found on page 80 in 
Additional Material:]

    The Chair. The Committee stands adjourned. Thanks.

                          ADDITIONAL MATERIAL

         American Occupational Therapy Association,
                                                  aota.org.
                                                      June 8, 2023,
Hon. Bernie Sanders, Chairman,
Hon. Bill Cassidy, Ranking Member,
U.S. Senate Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC.

    RE: Why Are So Many American Youth in a Mental Health Crisis? 
Exploring Causes and Solutions

    Dear Chairman Sanders and Ranking Member Cassidy:

    The American Occupational Therapy Association (AOTA) greatly 
appreciates the Senate Health, Education, Labor, and Pensions 
Committee's hearing on the youth mental health crisis. We are pleased 
to provide testimony and resources in support of this hearing.
                               Background
    AOTA is the national professional association representing the 
interests of more than 244,500 occupational therapists, occupational 
therapy assistants, and students of occupational therapy across the 
Nation. The practice of occupational therapy is science-driven, 
evidence-based, and enables people of all ages to live life to its 
fullest by promoting health and minimizing the functional effects of 
illness, injury, and disability.

    Occupational therapy (OT) is a vital component of a complete mental 
health team to address the youth mental health crisis. Roughly one 
third of the profession are already working with children in a range of 
settings, such as schools, pediatric outpatient clinics, and hospitals. 
OT practitioners focus on an individual's ability to engage in day-to-
day activities to maximize independence, function, and performance. 
They are trained to identify how factors such as the environment, 
cognition, and sensory processing support or hinder recovery and 
participation.

                  A History and Scope in Mental Health

    The profession was founded in public psychiatric hospitals over a 
century ago, based on the observation that a person's ability to engage 
in their desired roles, routines, and activities, could dramatically 
affect their mental health and overall well-being. Today, occupational 
therapy practitioners still focus on an individual's ability to engage 
in day-to-day activities.

    For decades, OT was a core part of the interdisciplinary mental 
health services. With the call for deinstitutionalization of 
individuals with mental illness, which culminated in the 1963 Community 
Mental Health Act, occupational therapists and occupational therapy 
assistants began working in community mental health. However, the role 
of occupational therapy in working with those with behavioral health 
disorders has declined, despite OT's focus on the promotion of 
functional skills and independence.

    One of the barriers to providing the services they are trained to 
provide, is a lack of clear and complete understanding of the 
profession and what they are allowed to provide by law. This barrier 
has created the misconception OT mental health services aren't eligible 
for reimbursement. However, statute in all 50 states and the District 
of Columbia, the explicitly allows OT practitioners to provide 
interventions and procedures for the development, remediation, or 
compensation of cognitive, psychosocial, or psychological deficits.

    Occupational therapists have been included in imperative 
legislation to combat workforce shortages in mental and behavioral 
health, addressing chronic pain, and expansion of community mental 
health services. The Federal Government recognizes occupational therapy 
as a valued part of the behavioral health workforce. Occupational 
therapy services provided to a beneficiary with a mental health 
diagnosis have long been reimbursable under Medicare.

    Occupational therapy is included under the staffing suggestions for 
Certified Community Behavioral Health Centers, a Medicaid demonstration 
program. In 2016 occupational therapy education programs were made 
eligible to receive Behavioral Health Workforce Educations Training 
Grants, and since 2018, the Health Resources Service Administration 
(HRSA) has included occupational therapy among the professions making 
up the behavioral health workforce.
                  School and Community-Based Settings
    AOTA believes the schools are the most effective setting to provide 
basic and universal mental health support. Children spend a vast 
majority of their time outside of the home in schools, where they have 
access to a range of specialized instructional support personnel (SISP) 
who work in mental health, such as occupational therapists, 
psychologists, social workers, and counselors.

    Academic success is critical, but schools must be equipped to 
address children's social, emotional, and behavioral needs in order to 
make it possible for them to learn in the classroom. These needs and 
their educational progress cannot be minimized or separated. This 
emphasized by research that demonstrates the relationship between 
improved mental health and improved outcomes for students. Occupational 
therapy uses activity or occupation-based interventions to enable 
students to achieve their potential by increasing their functional 
skills for better participation in school and later in adult life, as 
well as to minimize the effects of disabilities.

    As part of a larger treatment plan, occupational therapy 
practitioners help persons with schizophrenia, bipolar disorder, and 
major clinical depression, regain, build, or maintain skills that are 
essential to independent functioning, health, and well-being. In 
particular, occupational therapy practitioners are able to assist 
individuals with the cognitive impairments commonly associated with 
serious mental disorders that impact independent function, and 
compromise speech, memory, attention, and executive decision-making of 
all kinds.
                      Indiana: The National Model
    The State of Indiana should be the national model for coverage of 
mental health OT services. In September 2021, the Indiana Health 
Coverage Programs (IHCP) issued a bulletin clarifying coverage of 
occupational therapy services for eligible IHCP persons. The IHCP 
supported including occupational therapists on a substance use disorder 
(SUD) or behavioral health treatment team when the occupational 
therapists provide services within their scope of state licensure.

    In addition, the IHCP guidance specifies that when occupational 
therapy is delivered to patients with mental illnesses or addiction 
treatment disorders, the scope of occupational therapy includes 
``services that are provided to promote health and wellness, prevent 
disability, preserve functional capabilities, prevent barriers for 
occupational performance from occurring, and enable or improve 
performance in everyday activities.'' The agency noted that the scope 
of occupational therapy practice allows for the provision of 
psychosocial interventions, and the IHCP supported including 
occupational therapy in the treatment plan of members receiving mental 
health care and addiction treatment services.
                               Conclusion
    As is well known, there is a documented shortage of mental health 
professionals in America with at least 152 million Americans living in 
a mental health professional shortage area. While occupational therapy 
practitioners continue to provide services in multiple mental and 
behavioral health settings, such as acute care hospitals and Certified 
Community Behavioral Health Centers, they remain an under-utilized part 
of this workforce. The profession is already well positioned to support 
efforts to address the youth mental health crisis. In early 2023, two 
occupational therapy programs received funding to strengthen the mental 
health workforce pipeline from the Department of Education's Mental 
Health Service Professional Grant Program.

    AOTA strongly urges the Committee to build on past successes 
broadening OT's visibility with regards to mental health services and 
prioritize methods to promote the inclusion of occupational therapy in 
future policy discussions.

    Thank you for the opportunity to provide these comments. AOTA 
stands ready to provide any additional information you need and to 
collaborate on any efforts in this area. Please contact Abe Saffer if 
you have questions or need additional information.

            Sincerely,
                                                Abe Saffer,
                     MPM American Occupational Therapy Association.
                                 ______
                                 
 prepared statement of the child and adolescent mental health coalition
    On behalf of our organizations, which are leading members of the 
Child and Adolescent Mental Health Coalition (CAMH), \1\ we commend the 
Senate Health, Education, Labor, and Pensions Committee for holding a 
hearing on youth mental health. We thank you for your bipartisan 
commitment to addressing the youth mental health crisis and look 
forward to working with you to ensure that Congress crafts legislation 
that addresses the full continuum of child and adolescent mental health 
needs.
---------------------------------------------------------------------------
    \1\  CAMH is a coalition of organizations dedicated to promoting 
the mental health and well-being of infants, children, adolescents, and 
young adults. Our organizations reflect a diversity of viewpoints and 
expertise, ranging from clinical providers to school-based services to 
suicide prevention organizations and others. As a coalition, we seek to 
advance a robust mental health safety net, inclusive of programs, 
supportive payment models, and infrastructure, that provide the full 
continuum of mental health care, in a manner that facilitates easy and 
prompt access to services. Our coalition has prepared a set of core 
principles, available here. Our full coalition consists of over 30 
organizations; entities specifically endorsing this statement are 
specified at the conclusion of this statement.

    In October 2021, the American Academy of Pediatrics, the American 
Academy of Child and Adolescent Psychiatry, and the Children's Hospital 
Association declared a national emergency in child and adolescent 
mental health. Since then, important work has been done to address the 
mental and behavioral health needs of the Nation's youth, but it is not 
enough. Suicide is the second leading cause of death for youth ages 10-
18 in the United States. \2\ In 2021, 42 percent of high school 
students reported feeling persistently sad or hopeless, and 29 percent 
reported experiencing poor mental health. \3\ Additionally, 20.1 
percent of youth ages 12-17 had a major depressive episode in the past 
year, compared to only 15.7 percent of youth in 2019. \4\ We urge 
Congress to make new dedicated investments that are designed to support 
a full range pediatric mental and behavioral health services and to 
grow the pediatric mental health workforce to deliver this essential 
care, across settings.
---------------------------------------------------------------------------
    \2\  National Vital Statistics System. Leading Causes of Death, 
United States. Centers for Disease Control and Prevention; 2020 https:/
/wisqars.cdc.gov/data/lcd/home.

    \3\  Youth Risk Behavior Survey Data Summary & Trends Report, 2011-
2021. Centers for Disease Control and Prevention; 2023. https://
www.cdc.gov/healthyyouth/data/yrbs/yrbs-data-summary-and-trends.htm.

    \4\  Substance Abuse and Mental Health Services Administration. Key 
Substance Use and Mental Health Indicators in the United States: 
Results from the 2019 National Survey on Drug Use and Health. US 
Department of Health and Human Services; 2020. https://www.samhsa.gov/
data/report/2019-nsduh-annual-national-report; Substance Abuse and 
Mental Health Services Administration. Key Substance Use and Mental 
Health Indicators in the United States: Results from the 2021 National 
Survey on Drug Use and Health. US Department of Health and Human 
Services; 2023. https://www.samhsa.gov/data/report/2021-nsduh-annual-
national-report.

    The experiences and needs of children and adolescents are different 
from those of adults, and the system and funding must be designed to 
address their needs across the continuum of mental health care 
services, from promotion and prevention to early identification, 
intervention and treatment, to care for children and youth in crisis. 
To support this continuum of care, new dedicated investments in 
pediatric health care services and infrastructure are vital, including 
to grow the pediatric behavioral health workforce. It is clear that 
current Federal programs and investments are not sufficient, as 
currently structured and funded, to alleviate the national emergency in 
children's mental health and to ensure that children's mental health 
needs are prioritized, identified, and addressed with timely, high-
---------------------------------------------------------------------------
quality care.

    By some estimates, as many as 19 percent of children have mental 
health symptoms that impair their functioning without meeting criteria 
for a disorder. Programs and funding that are limited to children with 
serious emotional disturbance (SED) miss a key opportunity to support 
early prevention and early intervention. Our organizations were pleased 
to see a prevention set-aside within the Community Mental Health 
Services Block Grant for early identification and early intervention in 
the Mental Health Reform Authorization Act of 2022. A similar provision 
to allow Community Mental Health Services Block Grant funds to be used 
for prevention and early intervention passed the House in H.R. 7666, 
Restoring Hope for Mental Health and Well-Being Act of 2022. We were 
disappointed that these provisions which would enable the Community 
Mental Health Services Block Grant to better meet children's needs did 
not become law last Congress. Children urgently need access to 
prevention and early intervention services to improve outcomes and 
prevent worsening conditions.

    The Community Mental Health Services Block Grant is SAMHSA's 
primary investment in community mental health services, yet children's 
mental health needs continue to be insufficiently met by this program. 
A set aside for prevention and early intervention would allow states to 
fund programs that provide help upstream to people who have not been 
diagnosed with SED or Serious Mental Illness (SMI). Research shows that 
early intervention and prevention activities can mitigate, or in some 
cases, prevent the incidence of mental health conditions. With a 
prevention and early intervention set-aside in place, the block grant 
would allow flexibility for states to determine what prevention and 
early intervention programs are needed in their communities and fund 
those initiatives. This can include mental health literacy programs, 
outreach programs, and integrated services in primary care and school 
settings that reach underserved communities.

    We strongly support a 5 percent set aside for the Community Mental 
Health Services Block Grant targeted for prevention and early 
intervention to begin addressing these needs not currently met with 
these funds. We encourage a greater emphasis on addressing the mental 
health needs of children, including young children and children who do 
not have a diagnosis or who have a mental health condition that is not 
considered an SED. Congress must make targeted investments in expanding 
the availability of a full spectrum of mental health care for children 
and the critical infrastructure to support these services. While this 
set aside is a good first step, it is unlikely to be enough to 
facilitate the expansion needed to meet children's mental health needs 
across settings and across the continuum of mental health service 
levels.

    CAMH has identified nine priority areas and offers the following 
policy solutions that, if enacted, will help to increase access to 
quality pediatric mental health care. For more information, please see 
the CAMH Principles:

    Prevention, Early Identification, and Early Intervention

          Roughly half of lifetime cases of mental illness 
        begin by age 14 and almost three-quarters begin by age 24. \5\
---------------------------------------------------------------------------
    \5\  Kessler RC, Berglund P, Demler O et al. Lifetime prevalence 
and age-of-onset distributions of DSM-IV disorders in the National 
Comorbidity Survey Replication. Arch Gen Psychiatry; 2005; 62(6):593-
602. Doi:10.1001/archpsyc.62.6.593.

          Congress should ensure new and existing Federal 
        investments in mental health are tailored to include prevention 
---------------------------------------------------------------------------
        and early intervention services.

    School-Based Mental Health

          School-based mental health services help ensure 
        children receive screenings and care.

          Congress should increase resources and financing 
        mechanisms available to schools for mental health services.

    Integration of Mental and Behavioral Health into Pediatric Primary 
Care

          Primary care is where most families access care and 
        where identification, initial assessment, and care of mental 
        health conditions in children often occur.

          Congress should support models of co-location or 
        integration of mental health providers in all pediatric primary 
        care settings.

    Child and Adolescent Mental and Behavioral Health Workforce

          There is a dire shortage of practitioners 
        specializing in mental and behavioral health to care for 
        infants, children, adolescents, and young adults.

          A nationwide cross-sector strategy to expand the 
        supply, diversity, and distribution of the behavioral health 
        workforce, along with appropriate payment for pediatric mental 
        health services, must be developed and implemented.

    Insurance Coverage and Payment

          Even when covered by Medicaid, CHIP, or private 
        insurance, children's access to timely, quality mental health 
        care is often limited by high costs.

          Barriers to care like carve-outs, same day billing 
        restrictions, inadequate payment rates for mental and 
        behavioral health services, and lack of payment for emerging 
        conditions that do not yet have a diagnosis should be 
        addressed.
    Mental Health Parity

          There is a persistent need to improve oversight and 
        compliance with the requirements of the Paul Wellstone and Pete 
        Domenici Mental Health Parity and Addiction Equity Act 
        (MHPAEA).

          Congress should expand MHPAEA to children in Medicaid 
        fee-for-service arrangements and ensure meaningful compliance 
        and enforcement.

    Telehealth

          Telehealth utilization has surged in the past few 
        years, offering an efficient way to support youth in rural, 
        underserved, and low-income communities who continue to face 
        the most barriers to care.

          Congress should ensure that telehealth continues to 
        be a part of a comprehensive set of care options available to 
        children with mental and behavioral health needs.

    Infants, Children, and Adolescents in Crisis

      Providers are witnessing an alarming number of children 
and adolescents in behavioral health crisis, with emergency departments 
seeing increases in suicidal ideation and self-harm.

          Congress should designate funding specifically 
        intended to target youth crisis care needs, including 
        consistent and sufficient funding for 988 and to support access 
        to step-down programs.

    Justice-Involved Youth

          The prevalence of mental health disorders among 
        justice-involved youth ranges from 50 percent-75 percent.

          Congress should invest in incarceration diversion 
        programs, including specialized mental health and substance use 
        programs.

    We thank the Senate Health, Education, Labor, and Pensions 
Committee for your continued attention to child and adolescent mental 
health and the critical roles of child serving professionals within 
both education and health care. More action is needed now to end the 
national emergency in child and adolescent mental health and ensure 
children and families can access the mental health services and support 
they need.

    American Academy of Pediatrics. American Academy of Child and 
Adolesecent Psichiatry. American Foundation for Suicide Prevention. 
Children's Hospital Association.
                                 ______
                                 
                    NATIONAL EDUCATION ASSOCIATION,
                                            Washington, DC,
                                                      June 7, 2023.
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC.

    Dear Senator:

    On behalf of our 3 million members and the 50 million students they 
serve, we would like to submit the following comments for the record of 
tomorrow's hearing, ``Why Are So Many American Youth in a Mental Health 
Crisis? Exploring Causes and Solutions.'' This is a vital topic as 
students and families emerge from the COVID-19 pandemic. We embrace 
public dialog on mental healthcare for our Nation's students.

    Our youth are in crisis. According to the Centers for Disease 
Control and Prevention (CDC), more than a third (37 percent) of high 
school students reported experiencing poor mental health during the 
pandemic, and 44 percent reported feeling persistently sad or hopeless 
during the past year. In addition, more than 1 in 5 students (22 
percent) seriously considered attempting suicide and 1 in 10 (10 
percent) attempted suicide. Suicide attempts occurred more often among 
Black students than students from other groups, and increased among 
Black and White students from 2011 to 2021.

    We are pleased that Congress responded to this crisis through the 
Bipartisan Safer Communities Act, creating and funding two programs 
that begin to address these needs. We urge continued support for the:

          Mental Health Service Professional Demonstration 
        Grant Program that provides competitive grants to support a 
        strong pipeline into the mental health profession, including 
        innovative partnerships to prepare qualified school-based 
        mental health service providers for employment in schools.

          School-Based Mental Health (SBMH) Services Grant 
        Program that provides competitive grants to states and school 
        districts to increase the number of qualified mental health 
        service providers delivering school-based mental health 
        services to students in local educational agencies with 
        demonstrated need.

    In addition, we urge continued support for the Full-Service 
Community Schools Program that meets the unique needs of the locations 
they serve by engaging with parents, students, and the community. 
Through this grant program, student and family needs are assessed, and 
programs developed and opportunities created in partnership with 
students, families, and community members to meet those needs. A 
critical aspect of these opportunities is the ability to help youth and 
their families access mental health services and supports.

    We know that the programs cited above are not the only programs to 
address the mental health and overall health of students, and that we 
must continue to partner to address the crisis facing young people 
today. NEA and its members stand ready to work with you to do so.

    We thank you for holding this hearing and giving us the opportunity 
to submit these comments.

            Sincerely,
                                                 Marc Egan,
                                  Director of Government Relations.
                                 ______
                                 
prepared statement of the american association of child and adolescent 
                               psychiatry
    On behalf of the American Association of Child and Adolescent 
Psychiatry (AACAP), we thank the Committee for hosting this hearing and 
for the opportunity to submit testimony on why so many American youth 
are in a mental health crisis and to offer AACAP's recommendations on 
causes we should consider and solutions that can make a difference.

    AACAP represents over 10,000 child and adolescent psychiatrists and 
trainees all of whom grasp the gravity of our Nation's pediatric mental 
health crisis and continue to respond to it. Our members work in every 
child-facing system of care: in urban and rural communities and from 
hospitals to schools.

    AACAP, along with the American Academy of Pediatrics and the 
Children's Hospital Association, have declared a national state of 
emergency in children's mental health. \1\ While there are many factors 
that contribute to poor access to pediatric behavioral health care, we 
emphasize the impact the insufficient behavioral health workforce has 
had and continues to have on access to care and note the importance of 
ensuring equity, diversity, and inclusion. Along these lines, we 
recommend policy solutions toward addressing this crisis.
---------------------------------------------------------------------------
    \1\  Pediatricians, CAPs, and Children's Hospitals Declare National 
Emergency (aacap.org)
---------------------------------------------------------------------------
                               Background
    There has been a silent pediatric mental health pandemic building 
for decades, disproportionately impacting minoritized groups including 
racial, ethnic, and gender diverse youth, and those living in poverty. 
The social disruptions and fear and grief caused by the COVID-19 
pandemic turned the world upside down for all children, especially 
those vulnerable to mental illness and substance use disorders.

    Rates of childhood mental health concerns and suicide rose steadily 
between 2010 and 2020 and by 2018, suicide was the second leading cause 
of death for youth ages 10-24. The pandemic intensified this crisis: 
across the country we have witnessed dramatic increases in Emergency 
Department visits for all mental health emergencies, including 
suspected suicide attempts.

    The pandemic struck at the safety and stability of families. 
According to the National Institutes of Health, more than 140,000 
children in the United States lost a primary and/or secondary 
caregiver, with youth of color disproportionately impacted. Child and 
adolescent psychiatrists are caring for young people with soaring rates 
of depression, anxiety, trauma, loneliness, and suicidality. We must 
identify strategies to meet these challenges through state, local and 
national approaches to improve access to care. We must work as a 
community to address mental health awareness, prevention, and 
treatment.

    The Declaration of a National State of Emergency in Children's 
Mental Health outlined the following shared recommendations for how we 
address the crisis we face (in no order of priority):

          Increase Federal funding dedicated to ensuring all 
        families and children, from infancy through adolescence, can 
        access evidence-based mental health screening, diagnosis, and 
        treatment to appropriately address their mental health needs, 
        with particular emphasis on meeting the needs of under-
        resourced populations.

          Address regulatory challenges to improve access to 
        technology to assure continued availability of telemedicine to 
        provide mental health care to all populations.

          Increase implementation and sustainable funding of 
        effective models of school-based mental health care, including 
        clinical strategies and models for payment.

          Accelerate adoption of effective and financially 
        sustainable models of integrated mental health care in primary 
        care pediatrics, including clinical strategies and models for 
        payment.

          Strengthen emerging efforts to reduce the risk of 
        suicide in children and adolescents through prevention programs 
        in schools, primary care, and community settings.

          Address the ongoing challenges of the acute care 
        needs of children and adolescents, including shortage of beds 
        and emergency room boarding by expanding access to step-down 
        programs from inpatient units, short-stay stabilization units, 
        and community-based response teams.

          Fully fund comprehensive, community-based systems of 
        care that connect families in need of behavioral health 
        services and support for their child with evidence-based 
        interventions in their home, community, or school.

          Promote and pay for trauma-informed care services 
        that support relational health and family resilience.

          Accelerate strategies to address longstanding 
        workforce challenges in child mental health, including 
        innovative training programs, loan repayment, and intensified 
        efforts to recruit underrepresented populations into mental 
        health professions as well as attention to the impact that the 
        public health crisis has had on the well-being of health 
        professionals.

          Advance policies that ensure compliance with and 
        enforcement of mental health parity laws.
               Policy Actions for Committee Consideration

   Access to Specialty Care and the Child and Adolescent Psychiatry 
                               Workforce

    To increase access, we can extend the reach of the child and 
adolescent psychiatry workforce by supporting primary care providers 
and school-based providers in identifying, assessing, and stabilizing 
children with pediatric behavioral health disorders and then escalating 
to specialty behavioral healthcare when a patient's needs require a 
higher level of care.

        1. Support child psychiatry consultation programs

    Pediatric Mental Healthcare Access (PMHCA) consultation programs, 
run through the Maternal and Child Health Bureau (MCHB) at the Health 
Resources and Services Administration (HRSA), school-based mental 
health care, and integrated behavioral health and primary care models, 
connect patients to behavioral health care.

    These consultation programs, commonly called child psychiatry 
access programs (CPAPs), have been implemented in most states across 
the country, and are funded through HRSA grants, state funding, or 
institutional funding, or a combination of these funding resources, yet 
some states with large rural and underserved areas have not yet 
developed such programs. \2\ Pediatricians utilize CPAPs in their state 
to consult with child and adolescent psychiatrists about treatment 
options for the children and youth they see who may need mental and 
behavioral health care. Research has shown that the use of CPAPs 
significantly improves outcomes for the patients who receive integrated 
medical and behavioral health care through this model compared to 
treatment as usual. \3\ AACAP encourages the Committee to support 
replication of the CPAP program in every state.
---------------------------------------------------------------------------
    \2\  Map--NNCPAP National Network of Child Psychiatry Access 
Programs.
    \3\  Integrated Medical-Behavioral Care Compared With Usual Primary 
Care for Child and Adolescent Behavioral Health: A Meta-analysis--
PubMed (nih.gov).

    AACAP is grateful for recent congressional investments in these 
programs and urges the Committee to continue to support these resources 
and promote state and provider adoption to ensure these models are 
sustainable. We must meet children where they are and eliminate 
---------------------------------------------------------------------------
additional barriers.

        2. Support integrated care arrangements

    Integrating behavioral healthcare, including child and adolescent 
psychiatry, into primary care practices facilitates primary care 
provider's in accessing real time, immediate support for behavioral and 
mental health issues that present during patient visits. AACAP 
encourages the Committee to support integrated care arrangements, like 
the collaborative care model, that support pediatric practice 
engagement with child and adolescent psychiatrists.

        3. Build a pipeline of child and adolescent psychiatrists

    Before the COVID-19 pandemic, the workforce shortage of child and 
adolescent psychiatrists was significant, and this shortage continues. 
As physician subspecialists who conduct 4 years of medical school, 
complete a medical residency in psychiatry and complete a residency 
fellowship in child and adolescent psychiatry, the training is 
extensive and costly. AACAP recommends the following strategies for 
supporting a pipeline of child and adolescent psychiatrists:

          Support targeted student loan repayment programs--S. 
        462, the ``Mental Health Professionals Workforce Shortage Loan 
        Repayment Act of 2023,'' sponsored by Committee Members 
        Senators Tina Smith, Lisa Murkowski, and Maggie Hassan, would 
        repay up to $250,000 in eligible student loan debt for mental 
        health professionals who work in mental health professional 
        shortage areas.

          Support efforts to defer student loan payments on an 
        interest-free basis during training--S. 704, the ``Resident 
        Education Deferred Interest (REDI) Act,'' would allow borrowers 
        to qualify for interest-free deferment on their student loans 
        while serving in a medical residency program.

        4. Advocate for mental health parity--coverage and payment

    We must support mental health parity to ensure mental health is on 
equal footing with physical health and surgical care. Lack of medical 
coverage and poor reimbursement for mental health care are 
disincentives to recruiting medical students into child and adolescent 
psychiatry and building robust psychiatric services for children. Lack 
of parity contributes to limited in-network psychiatry access, longer 
wait times for children and youth, and higher expenses for patients who 
are often forced to go out of their insurance networks to find any 
care. Full parity in insurance coverage and reimbursement rates for 
mental health and substance use treatment across insurance plans would 
support children's access to high quality and timely mental health 
care.

    The Paul Wellstone and Pete Domenici Mental Health Parity and 
Addiction Equity Act of 2008 (MHPAEA) aims to ensure that insurance 
coverage for mental health and addiction treatment is no more 
restrictive than insurance coverage for other medical care. This goal 
needs to be realized to tackle mental health access issues. AACAP 
appreciates the authorization of state parity assistance grants in the 
2023 Consolidated Appropriations Act, as well as the sunsetting of the 
non-government health plan opt-out of MHPAEA. AACAP respectfully asks 
Congress to fund the state parity assistance grants.

    AACAP urges the Committee to support granting the Department of 
Labor authority to levy civil monetary penalties on ERISA plans found 
out of compliance with MHPAEA. In addition, the Committee should 
encourage more technical assistance to state regulators to ensure 
health plans are complying with MHPAEA.

    AACAP also recommends that insurance regulators require health 
plans to use nationally recognized service intensity technological 
tools developed by professional medical organizations in making medical 
necessity determinations. With respect to children and adolescents, 
service intensity instruments such as the Child and Adolescent Service 
Intensity Instrument \4\ and the Early Childhood Service Intensity 
Instrument, \5\ are standardized assessment tools that provide 
determinations of the appropriate level of mental, behavioral, 
substance use, or other service needed by a particular child or 
adolescent and his or her family.
---------------------------------------------------------------------------
    \4\  CASII (aacap.org)
    \5\  ECSII (aacap.org)

        5. Build a behavioral health workforce that represents 
---------------------------------------------------------------------------
        communities being served

    The current pediatric mental health care system does not 
sufficiently serve the needs of all of our communities. The COVID-19 
pandemic amplified pre-existing mental health disparities in 
minoritized children and adolescents, including gaps in access to high 
quality mental health care. To truly bridge the gap in all children's 
access to mental health and substance use disorder care, we need a 
behavioral health workforce that understands and identifies with their 
patient's experiences, language, and background. We can do this by 
investing in the recruitment, training, and broader distribution of a 
more diverse and representative workforce through the workforce 
programs supported by HRSA and the Substance Abuse and Mental Health 
Services Administration (SAMHSA). Physicians who speak the same 
language as their patients and can identify with their patient's life 
experiences are best equipped to overcome stigma and gain the trust of 
their providers. AACAP encourage Congress to support programs that 
improve health equity by training a racially and ethnically diverse 
pediatric behavioral health workforce through scholarship, tuition 
assistance, and professional development opportunities.

    We hope to work with the Committee to advance these priorities to 
improve existing programs and create new models to address the series 
crisis in children's mental health care.
                                 ______
                                 
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                 CONGRESS OF THE UNITED STATES,
                                            Washington, DC,
                                                       May 9, 2023.
The Hon. Lawrence Tabak,
Acting Director, National Institutes of Health,
9000 Rockville Pike,
Bethesda, MD.
    Dear Dr. Tabak:

    We write today with grave concerns regarding a study funded by the 
National Institutes of Health (NIH) in which two young people 
tragically died by suicide.

    The study, titled ``Psychosocial Functioning in Transgender Youth 
after 2 Years of Hormones,'' evaluated the psychosocial effects of 
cross-sex hormones on ``transgender and nonbinary youth.'' \1\ In this 
study, researchers examined young people between the ages of 12 and 20 
who identify as transgender and were given cross-sex hormones. Of the 
315 subjects, 240 were minors. \2\
---------------------------------------------------------------------------
    \1\  https://doi.org/10.1056/nejmoa2206297.
    \2\  Ibid.

    Notably, the four clinics and some of the researchers who conducted 
this experiment are outspoken advocates for conducting gender 
transition interventions on children. In a video it later removed from 
its YouTube channel, Boston Children's Hospital, one of the clinics 
involved, went as far as to claim that children can know their gender 
identity ``from the womb.'' \3\ Johanna Olson, a co-author of this 
paper, told CNN in 2014, ``We're definitely in the middle of a gender 
revolution and it's exciting.'' \4\ This same researcher later received 
a Federal grant for a study in which she altered protocol to allow 
children as young as 8 years old to receive cross-sex hormones. \5\
---------------------------------------------------------------------------
    \3\  https://first-heritage-foundation.s3.amazonaws.com/live-files/
2023/01/230130-DNH-NEJM-Response.pdf.
    \4\  https://www.cnn.com/2014/06/27/living/transgender-youth-pride-
march/index.html.
    \5\  https://docs.wixstatic.com/ugd/3f4f51-
a929d049f7fb46c7a72c4c86ba43869a.pdf.

    During this study, two young people died by suicide and 11 reported 
suicidal ideation. \6\ Rather than shutting the study down after such 
serious adverse events, the researchers published their paper, 
concluding that the study was a success because cross-sex hormones had 
altered subjects' physical appearance and improved psychosocial 
functioning. \7\ However, the researchers admitted that they were not 
able to properly establish causality between the administration of 
cross-sex hormones and improved psychosocial functioning because their 
study lacked a control group. \8\
---------------------------------------------------------------------------
    \6\  https://doi.org/10.1056/nejmoa2206297.
    \7\  Ibid.
    \8\  Ibid.

    Despite glaring shortfalls, this government-funded research is 
already being used to further the fallacy that chemically transitioning 
children is safe and effective. \9\ It is alarming that vulnerable 
young people died by suicide while participating in a taxpayer-funded 
study that will almost certainly inflict devastating physical harm on 
those who participated. Twenty-four participants in this study received 
cross-sex hormones after puberty suppression or ``in early puberty'' 
and are likely sterile as a result. \10\ Further, participants are now 
at increased risk for cardiovascular disease, blood clotting, and a 
host of other complications. \11\
---------------------------------------------------------------------------
    \9\  https://www.nbcnews.com/nbc-out/out-health-and-wellness/
hormone-therapy-improves-mental-health-transgender-youths-new-study-fi-
rcna66306; https://abcnews.go.com/Health/gender-affirming-care-trans-
youth-improves-mental-health/story?id=96510337; https://
www.washingtonpost.com/business/trans-teens-benefit-from-gender-
affirming-care/2023/01/20/955f807c-98bd-11ed-a173-61e055ec24ef-
story.html.
    \10\  https://doi.org/10.2147/AHMT.S110859.
    \11\  https://pubmed.ncbi.nlm.nih.gov/36238954/.

    Research shows that gender dysphoria in minors often resolves as 
they progress through puberty--completely undermining the idea that 
children should have their bodies permanently altered to match their 
changing identities. \12\ Despite overwhelming evidence that chemically 
transitioning children is not safe, the NIH plans to give more than 
$10.6 million to experiment on children and adolescents through 2026. 
\13\ We are deeply concerned about your agency's use of taxpayer 
dollars to advance experiments on children who will be irreversibly 
harmed by radical gender ideology.
---------------------------------------------------------------------------
    \12\  https://www.dovepress.com/getfile.php?fileID=40774.
    \13\  http://gendersanity.org/documents/NIH-funding-from-progress-
report-12-15-21.pdf.

    We request your full and complete response to each question below 
no later than June 9, 2023. Please provide a separate response to each 
---------------------------------------------------------------------------
question, rather than a narrative response.

        1. Were the individuals who tragically died by suicide while 
        participating in this study minors?

        2. At which study sites did the two participants who died by 
        suicide receive treatment? On what date did the researchers 
        from these sites inform researchers at other participating 
        sites that a study participant had died by suicide?

        3. Please list the steps that were taken to halt and review the 
        study after the first and second deaths and the dates on which 
        these actions occurred.

                a. If a review took place, please provide the outcome 
                of that review.

        4. Were the other participants, as well as their parents, 
        notified that two participants died by suicide? If so, who 
        provided this notification?

        5. Were participants and their parents given the opportunity to 
        reconsider their consent and withdraw from this research in 
        light of the suicides?

        6. What steps were taken to provide ongoing monitoring of other 
        children participating in the study to ensure they were not at 
        risk for suicidal ideation?

        7. Have study participants been evaluated to assess sterility 
        or impaired fertility as a result of receiving cross-sex 
        hormones? If so, how many participants are now sterile or 
        suffering from impaired fertility?

        8. Will a follow-up occur to evaluate the long-term 
        physiological state of the subjects? If so, please provide an 
        expected date for this follow-up.

        9. The study notes that ``6 participants withdrew from the 
        study.'' Please provide the ages and Tanner stages at which 
        these participants withdrew and their reasons for withdrawing.

        10. Please provide all closed-meeting minutes from the NIH 
        regarding the approval of funding for this study.

        11. Please provide all closed-meeting minutes from the NIH, 
        researcher Johanna L. Olson, the Children's Hospital of Los 
        Angeles, and any relevant review boards regarding the approval 
        of children as young as 8 years old to receive cross-sex 
        hormones in the study titled ``The Impact of Early Medical 
        Treatment in Transgender Youth,'' redacting any information 
        that personally identifies study participants if applicable.

        12. Please provide all information that participants and their 
        parents received specifically regarding sterility or risks of 
        impaired fertility resulting from the use of cross-sex 
        hormones, redacting any information that personally identifies 
        study participants if applicable.

        13. Does the NIH still commit to funding Project Number R01 
        HD082554 through 2026? If so, please provide justification for 
        continuing this funding and detail what additional steps will 
        be taken to prevent such serious adverse events going forward.

        14. Please detail any ongoing or proposed NIH funding for 
        studies involving transgender or nonbinary identified minors.

    Thank you for your attention to this important matter.

            Sincerely,
                                              Josh Brecheen
                                                 Member of Congress
                                                   Ted Budd
                                                       U.S. Senator
                                                Marco Rubio
                                                       U.S. Senator
                                            Rand Paul, M.D.
                                                       U.S. Senator
                                             James Lankford
                                                       U.S. Senator
                                             Michael S. Lee
                                                       U.S. Senator
                                                Mary Miller
                                                 Member of Congress
                                                Randy Weber
                                                 Member of Congress
                                             Lauren Boebert
                                                 Member of Congress
                                                   Chip Roy
                                                 Member of Congress
                                                 Andy Biggs
                                                 Member of Congress
                                     Ronny L. Jackson, M.D.
                                                 Member of Congress
                                                  Eli Crane
                                                 Member of Congress
                                                Jeff Duncan
                                                 Member of Congress
                                              Michael Cloud
                                                 Member of Congress
                                 ______
                                 
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    [Whereupon, at 12:26 p.m., the hearing was adjourned.]

                                   [all]