Amanda Arellano felt a heavy weight pressing down on her chest. It was May of 2021, and the teenager struggled to breathe.
Maria Arellano rushed her 17-year-old daughter to the pulmonologist. Amanda has cerebral palsy, autism, epilepsy, asthma and a heart murmur. With COVID on the prowl, they couldn’t be too careful.
This wasn’t an asthma flare-up, the doctor told them. This was anxiety.
Sitting in a Jack in the Box near their home in the Los Angeles neighborhood of Boyle Heights last month, her eyes filling with tears, Maria searched for the words to describe watching her normally gregarious daughter struggle.
“It makes you feel very powerless,” she said.
Many California parents know this feeling well. Two years into the pandemic, many children are in pain. Rates of anxiety and depression have shot up so quickly that several national leaders — including the U.S. surgeon general — have issued urgent public health advisories. School-based therapists report long waiting lists and an increase in fighting and behavior issues. Emergency room doctors say they are overwhelmed by the number of children coming in after trying to harm themselves.
On top of all this, the state is facing a shortage of mental health providers.
Gov. Gavin Newsom’s administration has vowed to build a brand-new system to address these complicated challenges in the coming years. But pressure is mounting to help children like Amanda — now.
Dr. Mark Ghaly, a pediatrician who serves as the secretary of California's Health and Human Services Agency, told CalMatters he feels “concerned but hopeful” about the state’s ability to meet the growing need, though he’s also “very aware that even the most ... short-term interventions are not as immediate as I think we would like.”
Last year, Newsom’s administration allocated $4.4 billion in one-time funds to create a statewide system dubbed the Children and Youth Behavioral Health Initiative — a proposed sweeping transformation of the children’s mental health system that many observers describe as “unprecedented.” The bulk of the money has yet to be distributed, but efforts to develop a vision and work with stakeholders are underway.
Tony Thurmond, the state superintendent of public instruction, recently told CalMatters he has visited 45 schools since July, and said many of them told him they don’t have the resources to help students who are struggling with mental health issues.
“We know that this is job No. 1, to help our students address the trauma that they have experienced and are experiencing during the coronavirus pandemic,” he said. “That’s got to be our priority.”
Children’s advocates are enthusiastic about the state’s commitment to the issue, but also worry the help won’t come soon enough.
A crisis was brewing in California before the pandemic; COVID set it to a boil:
– Between 2019 and 2020, opioid-related overdoses among 15- to 19-year-olds nearly tripled, according to a CalMatters analysis of state data.
“I think what people are looking for is an emergency response,” said Lishaun Francis, director of behavioral health for the advocacy group Children Now. “That has never been the state of California’s plan.”
This month, Children Now was among a coalition of children’s advocates and health providers that sent a letter to Newsom, calling on him to formally declare the status of child and adolescent mental health in California a public health emergency. The challenges facing young people in the state, it said, are “dire and widespread.”
'It won't be this way forever'
For a moment, in March 2020, Amanda felt excited. Her school planned to close briefly; two weeks at home sounded like an unexpected vacation.
But school didn’t reopen that spring, or all the next school year. And many of the supports Amanda depended on — social therapy, music therapy, physical therapy — moved online or fell away completely.
Terrified of the virus, Amanda refused for months to venture out of the small blue house in Boyle Heights where she and her mother rent a room from another family.
Always a strong student, Amanda grew increasingly frustrated during virtual learning. Sometimes a shaky internet connection booted her out of Zoom class. Other times, teachers were hard to understand.
“I don’t know what I can do to calm myself down,” Amanda told her mother.
Maria would see tears in the long-lashed brown eyes of the daughter she’d always known to be creative, happy and resilient. She’d pull out photos they’d taken on pre-pandemic outings.
“It won’t be this way forever,” she’d tell Amanda. “One day this will end.”
Amanda tried meditation and exercise. She lost herself in video games, playing Roblox until her hands hurt.
As the months wore on, Maria saw the toll on her daughter’s self-esteem.
On Dec. 18, 2020, Amanda sent an email to a teacher, apologizing for missing certain assignments: “I am very embarrassed,” she began.
For months, she explained, “I have felt constant headaches and I have felt very dizzy; I have been extremely fatigued. Never, since I started school, have I left assignments without finishing them. I have always been a good student. But in this moment with the pandemic, my life has been impacted in many ways, especially with Distance Learning.”
Her teacher reassured her: “You are an amazing student that inspires everyone you meet.”
But the anxiety continued. In February 2021, Maria wrote to the school psychologist, asking for help.
'It's getting worse'
Young people’s suffering has been widespread, as revealed in a January report on the state of student wellness. Based on surveys of 1,200 California middle and high school students between April 2020 and March 2021, 63% of the students reported having had an emotional meltdown; 43% said they had a panic or anxiety attack; and 19% described suicidal thoughts, according to the report published by American Civil Liberties Union California Action, CSU Long Beach and the California Association of School Counselors.
“We know from the numbers it’s getting worse,” said Amir Whitaker, senior policy counsel for ACLU Southern California, who is the report’s lead author. “We’re not done yet.”
Whitaker oversees the Youth Liberty Squad, a group of high school students around the state who are advocating for better school-based mental health care. Many have experienced their own anxieties and traumas in the last two years. As life edges closer to normal, they find details of their lives changed in unsettling ways.
Joel Salas, a Los Angeles senior, spent a month isolated in his bedroom after the rest of his family contracted COVID-19. His mother fell extremely ill, and he ended up caring for her while studying and working five or six hours a day at his parents’ taco stand.
One of the biggest challenges for him now is the unrelenting uncertainty.
“You don’t know what’s happening next,” he said. “You don’t want to get your hopes up, because another wave might come.”
Another challenge is what’s left unsaid. Many of his classmates lost family members, he said. People rarely talk about it.
Amanda, who also is a leader in the Youth Liberty Squad, felt terrified when school resumed in person last August. What would happen if she were exposed to the virus? To protect herself physically, she distanced herself from her classmates.
Amanda’s mother, Maria, understands these fears. She also knows a teenager needs friends.
Workforce shortage means long waits for care
The trauma of the pandemic — the grief, fear, loneliness and boredom — is layered on top of concerns about food and housing insecurity, gun violence, climate change, political polarization, racism, transphobia, deportation and, now, the war in Ukraine.
Counselors who work in schools say more students are acting out. Some children struggle to get out of bed at all.
Josh Leonard, executive director of the East Bay Agency for Children, which provides mental health services for children, calls this “a natural, predictable response to the stress and anxiety at the moment.”
“Kids are struggling profoundly,” he said.
But big systems are not nimble enough to address the mounting emergency, he said. As waiting lists grow, workers at overwhelmed schools and mental health agencies like his are not always proactively reaching out to children and families, he said. Why bring children into the system when no one is available to serve them?
Alyssa Hurtado, a social worker with Leonard’s agency who works at a Newark elementary school, did her best to stay connected with families during the school closure. After more than a year of remote learning, many of her young clients now struggle with separation anxiety. Others have difficulties with motivation and concentration.
“Kind of like, ‘What’s the point?’” she said.
Hurtado herself is stretched thin. Five children are on a waitlist to get services at her school. In the meantime, she’s also been helping to cover a vacancy at another school.
Across the agency, Leonard says, 10 therapy positions remain unfilled out of a total of 50. Each of those positions would allow the organization to see 18 to 20 additional children. He and other nonprofit leaders say it’s difficult to compete with counties, school districts and big fish like Kaiser. Telehealth companies that sprang up during the pandemic have lured some clinicians away. Others are opting for the flexibility of working for themselves, avoiding onerous paperwork requirements by seeing patients who can pay out of pocket. Still others are moving to places with lower costs of living.
Those who remain often carry the extra load and face burnout.
“Every applicant has 20 different job opportunities right now,” said Stacey Katz, CEO of WestCoast Children’s Clinic in Alameda County, who also is trying to fill 15 to 20 openings.
“No one likes you to say you have a ‘waiting list,’” she said, describing pressure she and others say they receive from counties to avoid using that term. “I don’t know what you call it when there are 176 people waiting for services.”
The clinic’s public policy director, Jodie Langs, chimed in: “If we’re calling this a crisis in mental health, let’s respond to it like a crisis.”
Hope on the horizon?
Advocates recognize the tension of this moment. They commend the Newsom administration’s leadership and its willingness to invest the state’s budget surplus in solutions. But they also say the state is playing catch-up, having failed for years to address the spiraling need.
For many of these advocates — and for the families and children they serve — the state’s promises are only as good as the change they see on the ground.
Alex Briscoe, head of California Children’s Trust, an initiative to reform the state’s children’s mental health system, calls current state leaders “extraordinary” and their investment ‘“unprecedented.” But he also notes that California has “among the worst track records in the nation” when it comes to children’s mental health.
A 2018 report from The Commonwealth Fund put the state at 48th out of 50 in terms of the percentage of children age 3 to 17 who received needed mental health care. A 2020 progress report published by Children Now right before the first shutdown gave the state a D grade for children’s behavioral health, noting that mental illness was the leading reason kids here were being hospitalized. The 2022 report gave the state a D-plus.
“I don’t want to suggest nothing’s happening, but it’s unclear yet what it will signify,” Briscoe said.
Ghaly and others in the administration say they are working hard to develop a strategy. They aim to create an integrated system that focuses on prevention and equity and brings together public, commercial and private systems that often are siloed and highly fragmented — “something with a lot of entry points, a lot of front doors,” Ghaly said.
“The truth is we don’t really have a cohesive children’s behavioral health system,” he said. “I see a lot of opportunity to stitch something together.”
The administration is still primarily in the first phase of a three-phase plan it expects to roll out over five years. State leaders are gathering stakeholders, setting goals and figuring out big-picture issues. In the coming years, they plan to translate that into major initiatives — including a virtual mental health platform that would be available to all young people. They also envision a public awareness campaign to address stigma; a school-based treatment model that will be available regardless of insurance status; and the training of a bigger, more diverse workforce.
The state has so far rolled out CalHOPE, an online platform that offers mental health support. It also has formed a partnership with the Child Mind Institute to provide educational materials about mental health, and allocated new funding to support partnerships between schools and counties. And, as part of a statewide effort to transform Medi-Cal, the health insurance program for lower-income Californians, state officials recently announced that children and youth do not need a diagnosis to access specialty mental health services.
“Is it enough? Does it touch as many kids as we would like? No. But it is certainly trying to move the needle quickly,” Ghaly said.
Thurmond, the state schools superintendent, is supporting a legislative proposal to use loan forgiveness and deferrals to attract 10,000 new clinicians into schools and community-based organizations in the next few years.
He said his commitment derives from losing his own mother when he was 6 years old.
“I’m a believer that when there’s trauma, you must acknowledge it,” Thurmond said. “You must have an available workforce to address it.”
As these big initiatives roll out, though, what can be done now?
Some believe the answer lies, in part, with kids themselves. Students can be trained to act as peer counselors, and to be on alert for signs of suicide, many experts say. That can serve a double benefit — providing real-time support and helping build a pipeline of mental health providers from diverse communities.
“Students are not being tapped into enough,” said Whitaker of the ACLU.
In the past few years, Cal-HOSA, an organization focused on training students for careers in health, has piloted student mental health programs in 25 schools around the state. Students receive training to provide peer counseling support. The experience also allows them to consider careers in mental health.
'My life is so bright'
In the pandemic’s early months, Maria Arellano found herself in a situation familiar to many parents: She was her daughter Amanda's principal, teacher, nurse, tutor, playmate and advocate.
Maria knew how important it was for her daughter to use her own voice.
She suggested Amanda join some youth advocacy organizations, and also start making music videos, to “take out everything she was carrying within.”
In August 2020, Amanda posted one of these videos, “My Pandemic Song,” to her YouTube channel. Images of distraught medical workers and patients on ventilators scroll across the screen while she sings:
“You gotta calm yourself now, everything’s going to be alright (how?)
“The pandemic is on. Everyone’s anxious now.”
A year and a half later, much has changed in Amanda’s life. She is vaccinated against the virus and entering the final months of senior year: Prom. Senior trip. Graduation.
As mask mandates fall away, Amanda feels frightened. But, with the help of her mother, her therapist, and the strength she is discovering through her own advocacy, she is working to find peace within the new reality.
This past December, Amanda put up another video on her YouTube channel, with a new original song:
“I feel alive with all my might,” she sings. “My life is so bright. My life is so bright.”
Behavioral health coverage is supported by a grant from the California Health Care Foundation.
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