In 2020, the COVID-19 pandemic forced School-Based Health Centers (SBHCs) to quickly pivot to telehealth in order to continue delivering care among the chaos of school closures and ever changing COVID-19 guidelines and regulations. While some SBHCs were already utilizing telehealth, for others the transition was more abrupt. The NY School-Based Health Foundation (the Foundation), with the support of the Mother Cabrini Health Foundation, developed a telehealth technical assistance program to support SBHCs in making the transition. Emerging from the program were many creative uses of telehealth to meet children’s health care needs. Our first ever Telehealth Story Contest identifies some of the most innovative which we are sharing in the hope of inspiring others.
This is the story of how Children’s Aid transitioned their SBHCs to telehealth over the course of the pandemic, and the efforts of their school-based mental health team to address growing behavioral health needs of students. Special thanks to the Director of School-Based Mental Health, Tiffany Watson-Labbate, for her story submission.
As the United States approaches three years of the global COVID-19 pandemic, mental health issues and the demand for behavioral health services are at an all-time high among children and adults alike. A 2020 survey of 1,000 parents around the country found that 71% of parents said the pandemic had taken a toll on their child’s mental health (1).
This sentiment was echoed by many parents, particularly in regions of the country initially hit hardest by the pandemic. New York City’s lock-down in response to the COVID emergency, left many children without the social supports normally provided at school.
Continuing treatment for their over 4,000 students was of utmost importance to the school-based health team at Children’s Aid. Children’s Aid operates six SBHCs that provide comprehensive and continuous services to campuses in Washington Heights, the Bronx, and Staten Island. Four Children’s Aid SBHCs offer mental health services to middle and high schoolers. These clinics are located in high need schools and services are offered at no cost to students.
The pandemic presented low-income youth with multiple compounding challenges, including higher rates of infection and death within their families as well as the increased stress of economic instability. A report from the Poor People’s Campaign and the UN Sustainable Development Solutions Network (SDSN) reveals the disproportionate impact of COVID-19 on low-income communities in the U.S. and offers an initial analysis of the consequences of economic insecurity and systemic racism (2).
The 2022 report found that COVID-19 death rates in the lowest income group are double the death rates in the highest income group (2). It found that the Bronx experienced a death rate of 538 per 100,000 compared to Manhattan which experienced 328 deaths per 100,000. In the Bronx, the median income is $40,088 and the percentage of people living below the poverty line is 51%. To contrast, Manhattan’s median income is $86,553 and 28.9% of its population lives below the poverty line (2).
This comparison does not suggest that students in Manhattan inherently had an easier time coping with the pandemic, but rather it demonstrates health disparities faced by low-income students and their families, which are not unique to the COVID-19 crisis.
Consequently the need for ongoing health care, especially mental health care, was dire for students affected most by the pandemic and it was to this need that the school-based health team at Children’s Aid responded.
The Switch to Telehealth: How Children’s Aid Used Telehealth
According to Children's Aid’s Director of School-Based Mental Health, Tiffany Watson-Labbate, their team sought solutions to continue addressing the needs of their already established clients as well as the rising needs of new clients due to the pandemic.
At the start of the pandemic in March 2020, Children’s Aid began creating a plan to attain the needed telehealth technology and shift services to a remote basis. They shut down services for a week while they obtained and set up the equipment necessary to deliver virtual care.
Children’s Aid started by purchasing cell phones and devices for essential staff. While some providers worked on getting the IT set up, others were in touch with patients regarding the transition. Initially, medical staff held phone sessions with clients and later sent notes to their supervisors, who had access to their electronic medical system on secure devices.
Children’s Aid also sent students to their community clinics in Washington Heights and the Bronx while SBHCs were closed to in-person appointments. In Staten Island, dedicated staff met with clients in public to ensure students received their prescriptions.
A telehealth grant from the Foundation allowed Children’s Aid to buy more equipment and devices to outfit their SBHCs with computers that worked for virtual appointments and to increase their wifi connectivity.
After weeks of SBHCs being closed to in-person visits, the the Department of Health (DOH) and the Department of Education (DOE) collaborated to reopen in-person services in the summer of 2020.
Reopening their clinics in-person visits was of utmost importance to the school health team at Children’s Aid, according to Ms. Watson-Labbate, “A lot of our students– especially because a lot of school-based clinics are in some high need areas in the city, and the medical provider they have in the SBHC is their primary care provider (PCP). So to not have these sites open, now these students have no option to see their PCP and that’s another barrier that we were putting in place.”
Eventually, the DOH and the DOE allowed health centers to remain open even while schools were closed. Ms. Watson-Labbate describes that this made it easier to contain COVID-19 since students were not on campus and sick visits were not permitted due to schools’ screening tools.
The school health team at Children’s Aid used this time primarily to catch students up on their vaccines and start on follow-up appointments as the new school year approached. Students who needed to be seen in-person completed their health history over the phone prior to their appointment to minimize exposure time and later came into the clinic for their actual exam.
Children’s Aid continued primarily using telehealth when the 2020-21 school year began, due to DOE health and safety parameters, which included a minimum exam room size to allow for social distancing, windows, and an air filter.
With their telehealth system in place, Ms. Watson-Labbate described telehealth as a very useful tool when students are sick or during break periods going forward. In fact, Children’s Aid’s behavioral health services are still virtual, with providers working in-person in cases of mental health crises on campus.
The Growing Behavioral Health Needs of Students
Even before the onset of the COVID-19 pandemic, one in five children and adolescents struggled with a mental health or learning disorder, a cause of concern for pediatric mental health professionals (3). Then the pandemic hit, bringing with it an increase in youth reporting mental health challenges. In current surveys, 30–40% of young people say they feel anxious, depressed and/or stressed (3).
While there is not yet enough research on the COVID-19’s impact on child mental health, known risk factors for adults are economic instability, living in an area hit harder by the virus, and preexisting mental health problems (3).
Ms. Watson-Labbate reports that her students exhibited a similar increase in social anxiety and symptoms of depression and anxiety. While stuck at home and expected to keep up with school work, students were getting stir crazy without access to their social lives.
Alongside this social isolation, students often had to face the death and sickness of family members. Months later, Ms. Watson-Labbate notes that students had issues dealing with their grief because of the lack of mourning rituals during this initial period.
CDC data released in May 2022 showed “8,730 children in New York City have lost a parent or another co-residing caregiver to COVID-19,” according Dan Treglia, a contributor to COVID Collaborative which is a team of leading experts in health, education, and the economy,“This is a rate of 511 per 100,000 people. In other words, one of every 196 children has lost a co-residing caregiver to COVID-19. This is a significantly higher rate than we’ve seen for the United States overall, with wider disparities between Black and Hispanic children and white children than we see in the country as a whole” (4).
As students returned to in-person learning, Ms. Watson-Labbate noted a lot of aggression, likely as a result of these multiple compounding factors. “School violence has risen to levels that we haven’t seen quite frankly,” said Mo Canady, executive director of the National Association of School Resource Officers, “I don’t think it took a genius to see this coming” (5).
Teachers and school administrators across the country say they are seeing a rise in everything from minor misbehaviors to fighting in the hallways (5) although there is no national data on non-gun related instances of violence in schools.
For Children’s Aid’s SBHCs, the rates of suicidal ideation, suicide attempts, and sadly suicide completions have gone up. Ms. Watson-Labbate notes this increase has strained the already thin mental health staff.
Rising mental health crises are not just a problem faced by Children’s Aid. In a November 2020 finding, the CDC showed that, between April and October of 2020, the proportion of mental-health-related emergency room visits for children ages 5 to 11 had increased by 24% over the same period in 2019, while visits by 12- to 17-year-olds rose 31% (6).
Mental health crises opened Ms. Watson-Labbate’s eyes to the magnitude of students not currently receiving who would greatly benefit from mental health services. The SBHC in question serves 2400 students with just two full-time time mental health providers. This provider shortage is a major barrier to students receiving mental health support, with many factors contributing to its worsening over the past few years.
Challenges to Addressing Growing Mental Health Crisis
Increasing trauma experienced by young people, coupled with behavioral health staff leaving the field, places considerable strain on existing mental health staff. Ms. Watson-Labbate’s concern about burnout plaguing the field has caused her to check in on her staff and to encourage their self-care practices.
Ms. Watson Labbate sees two connected issues when it comes to staff shortages. The first is a general undervaluing of mental health staff who are often underpaid. First she notes that New York state offered ample money for licensed practical nurses (LPNs) from the onset of the pandemic, while mental health counselors were asked to donate their time.
Second, Mayor deBlasio’s announcement that the City would be hiring 500 social workers to be placed in schools for the 2021-22 school year, destabilized SBHCs such as Children’s Aid whose social workers left for higher paying city jobs (7).
Ms. Watson-Labbate is not the only person to feel the effects of the city's decision. A 2022 article published in the Gotham Gazette titled Alarming Workforce Shortage Facing Youth Mental Health Care Workers describes how these recruitment efforts by the city can negatively impact smaller organizations, “Agencies like Astor Services are working miracles to recruit and retain talented employees but are having a tough time competing with city agencies like the Department of Education and for-profit competitors (some even located outside NY), that in some cases can offer twice the salary and benefits. Remote employment, COVID-19 health concerns and other unprecedented back-to-work factors are further complicating matters of employee retention and satisfaction” (8).
Telehealth proved to be a useful tool in addressing staff shortages for Children’s Aid. Ms. Watson-Labbate recounts using telehealth to connect students remotely to therapists at different sites while their limited staff members were out sick, “We did this by signing the client on to a computer with a generic client account which allowed us to send a zoom invite and conduct the session via video conferencing.”
When it comes to solving these shortages across the board, expanded funding and resources are needed for vital mental health staff to continue meeting the needs of SBHC clients. By having a team of dedicated staff who feel valued and supported, great work can be done as seen by the SBHC team at Children’s Aid.
Children’s Aid SBHC Staff Goes Above & Beyond
On top of managing their caseload and conducting outreach to students and families, the school health team at Children’s Aid has been planning universal events for all students to join. Last winter, they held a virtual “Mentally Health for the Holidays” event to engage students who were stuck at home. Over 50 students participated in guided imagery, relaxation techniques, and breathing exercises. The school health team at Children’s Aid also provided attendees information on the health center in order to re-engage students in care.
To address growing mental health needs, Children’s Aid began hosting once a week drop-in for students, staff and families where they could learn relaxation exercises. The drop-in was especially helpful during the winter months when students were stuck inside, according to Ms. Watson-Labbate.
Now that school has returned to being completely in-person, Children’s Aid is continuing to provide targeted primary and behavioral health services as well as in-person events for students. Students have been asking for more in-person events, and the team has been going above and beyond to meet this need.
Recently, Children’s Aid hosted an in-person Suicide Awareness event for students. Activities included a Spin the Wheel game about suicide myths/facts, cards with warning signs and the suicide hotline number, information on teen depression and anxiety, and inspirational quotes. On top of that, staff encouraged students to seek care at their SBHC and students left with ample information on their schools’ health center. This particular event got a lot of interaction from students, who were grateful to be having an honest conversation on the topic.
The immense dedication of the school health team at Children’s Aid has overcome the many challenges presented by the pandemic. Looking to the future, Ms. Watson-Labbate is grateful for their telehealth capacity as it has become an important tool for their SBHCs, particularly for their mental health services. While students have now returned to campus full-time, she sees the equal value in providing both in-person and virtual care, and is excited to continue engaging with students through events that allow them to explore their mental health and wellness.
Check back here for future telehealth stories from contest winners!