Every child deserves the opportunity to grow up healthy in a safe, nurturing family and community. However, the COVID-19 pandemic and the national, statewide, and local responses to the crisis impacted the health and well-being of children and families in unique and disproportionate ways. The disruption of normal childhood activities and the trauma experienced by families during the pandemic fueled an already alarming rise of childhood behavioral health issues. In 2021, about 1 in 5 North Carolina teens seriously considered attempting suicide, and 1 in 10 had a suicide attempt.1 North Carolina’s child welfare system has approximately 12,000 children in foster care each year; like the persistently under-resourced child behavioral health system, the child welfare system came under increasing strain during the pandemic.2 Children and youth in foster care use inpatient and outpatient mental health services at a rate that is 15 to 20 times that of the general pediatric population.3
The COVID-19 pandemic also destabilized our early child care and education system. This system is critical in order for children to build strong brain architecture and skills that support their health and success in school and in life. Historic federal investments (i.e., the Coronavirus Aid, Relief, and Economic Security Act and the America Rescue Plan Act) and North Carolina’s Emergency School-Age Family Support Program were critical in supporting the early care and learning network and young families. Unfortunately, many child care centers are now having a hard time keeping their doors open. Similarly, more families faced challenges with having consistent access to healthy, safe, and affordable foods, also called nutrition insecurity.4 In North Carolina, approximately 1.2 million people, or approximately 10% of the population, are experiencing nutrition insecurity; 1 in 6 children in North Carolina faces hunger.5
North Carolina has long been committed to a whole-person approach to health, designing systems and innovations to finance health and not just health care.6 Medicaid expansion is among the most powerful tools available to promote and advocate for whole-child and whole-family health by bringing comprehensive health insurance coverage to more than 600,000 additional North Carolinians.7 With Medicaid expansion, thousands of adults, many of whom care for children with mental health issues and substance use disorders, will not have to forgo treatment because of the inability to pay for care. Thousands of families will no longer have to decide between putting food on the table, getting to the doctor, or having a prescription filled.
The COVID-19 pandemic further exposed the weaknesses and inequities in our child and family well-being systems, and it elevated the urgency of addressing the trauma experienced and implementing solutions to meet the needs of children and families. Authors in this issue have decades of expertise in pediatric medicine, advocacy, social work, research, health care administration, and legislation. Together, we outline the key practices and the necessary partnerships vital to North Carolina’s efforts to address the mental, physical, emotional, and social needs of children and families.
Integrated and Trauma-informed Solutions
North Carolina’s transformation to Medicaid managed care has been designed with a whole-person approach, including universal screening for social needs and the innovative Healthy Opportunities Pilots.7 In this issue, Cholera and coauthors describe a new pilot model for Medicaid-insured children and families called NC Integrated Care for Kids (NC InCK). NC InCK serves approximately 100,000 children in Central North Carolina and integrates care with schools, child welfare, juvenile justice, and the early childhood system.8 The authors discuss early learnings from this preventive model of care management that aims to better meet children’s needs.
Medicaid expansion in North Carolina will further increase the ability of systems to take a family-centered approach to health care. Mims and Smith highlight how expanding Medicaid coverage to an estimated 600,000 additional North Carolinians will improve the health and well-being of children.9 A key driver of the benefits for children is that strong and healthy adults raise strong and healthy children. Increased access to pre-conception and prenatal coverage for women will improve birth outcomes and help limit disparities, leading to a decrease in infant and maternal mortality.10 Medicaid coverage will reduce social stress in families and can reduce rates of adverse traumatic experiences in children.11
The need for more integrated and trauma-informed solutions is higher than ever because of the impacts of COVID-19. An estimated 3600 children in North Carolina lost a parent or caregiver to COVID-19.12 These devastating impacts are on top of the stress and trauma that pre-existed in many families before the pandemic. Here, Fishbein and coauthors describe a plan to prevent child trauma that was discussed at a recent statewide summit, “Leveraging North Carolina’s Assets to Prevent Child Trauma”.13 They describe a universal prevention approach to trauma-informed care in clinical settings and how engaged North Carolinians can focus on collective action to address intergenerational impacts of adversity to build resilience, particularly in marginalized communities.
Building resilience in the context of traumatic experiences promotes positive developmental outcomes for children and families, as described by Taylor and Giles.14 They describe leveraging the Positive Youth Development framework and emphasize meeting young people, who bring many unique strengths to the table, where they are.
Bipartisan Priorities for Child and Family Well-being
Bipartisan collaboration and advocacy on behalf of North Carolina’s children and families is critical to ensuring sustainable outcomes and promoting health and well-being. In an interview in this issue, Representatives Carla Cunningham and Dr. Timothy Reeder demonstrate the value of bipartisanship in addressing issues vital to health outcomes and ensuring a sustainable health care workforce for our state’s children, families, and aging populations.15 Evidence-based programming and accountability outcomes are necessary to ensure programs are effective and resources adapt to meet the changing needs of children and families. The lack of investment in behavioral and mental health resources and the escalation of the mental health crisis during the COVID-19 pandemic have further exposed the flaws in our health systems and managed care organizations. As the legislators discuss, solutions need not only focus on management of the current crisis, but must properly address the social, cultural, economic, and educational problems that all contribute to the mental and behavioral health of children throughout their lifespan.15
The Role of the Safety Net in Children’s Oral Health in North Carolina
Oral health is vital to the overall health of children. Dental caries is a common chronic disease with long-term consequences and a national prevalence of greater than 40% among children aged 2 to 19.16 In this issue, Harrell reflects on her 35-year experience in public health dentistry and the commitment of FirstHealth Dental Care Centers to improve the health of underserved populations.17 After school health nurses identified dental care as the most unmet need of children from families with lower household incomes, community stakeholders collaborated with FirstHealth and secured funding to open its first dental care centers in 1998. Harrell describes the successful expansion of these dental care centers, the impact on communities, and the vital partnerships with dental public health organizations.
Child Behavioral Health and Child Welfare
Over half of children with mental health issues in North Carolina do not receive treatment, and the state has been ranked lowest in the nation for children’s mental health access.18 North Carolina Department of Health and Human Services (NCDHHS) Secretary Kody Kinsley and Senator Jim Burgin make strong calls for doing more for the behavioral health of our children and investing more in our perpetually under-resourced systems.19 A recently released $1 billion roadmap for behavioral health and resilience in North Carolina outlines the significant financial investment that is urgently needed to tackle the growing mental health crisis for children and families.20 The plan outlines how to make behavioral health services more available when and where people need them; build strong systems to support people in crisis and people with complex needs; and enable better health access and outcomes with data and technology.
The right support at the right moment can help children overcome adversity, heal, and live productive lives—the kind of lives we all want for every child. Meeting children where they are means that schools should be a major point of access for prevention and treatment, as outlined in a recently published North Carolina Unified School Behavioral Health Action Plan.21 Close and coauthors describe the important role and positive impacts of school counselors, social workers, psychologists, and nurses, called Student Instructional Support Personnel (SISP), on children’s health and well-being.22 They synthesize the evidence on improved health (e.g., reduced substance use) and educational outcomes (e.g., reduced student absenteeism) of resourcing districts with improved ratios of these support personnel to students.
Behavioral Health Youth Crisis Impact
The increased prevalence of mental health disorders in children, adolescents, and young adults was raising alarms across the country prior to the COVID-19 pandemic. Pediatric patients with acute mental and behavioral health needs were presenting to primary care providers and emergency departments in numbers overtaking the available resources for evaluation and management. During this time, the leading cause of death for children aged 10 to 14 in North Carolina was suicide.23 Minoritized communities are experiencing a disparate and staggering increase in mental health problems and suicide-related behaviors.23
In this issue, the academic psychiatry department chairs from Duke University School of Medicine, UNC School of Medicine, Wake Forest University School of Medicine, and ECU Brody School of Medicine have collaborated with the chief psychiatrist at NCDHHS to author an impactful article outlining the pandemic’s disruption in the lives of young people and the catastrophic impact these increased needs have on a behavioral health system already struggling from lack of investment in workforce, programming, infrastructure, and strategic public health oversight.24 They describe how systems and organizations have answered the call to action and implemented programming to address the behavioral health crisis in North Carolina while highlighting the significant need for more investment in behavioral and mental health services to support communities where children, adolescents, young adults, and families can thrive and achieve their highest potential.24
Trauma-informed Child Welfare Practice Model
NCDHHS has implemented programming to address the lack of consistency in practice within Child Protective Services across counties. The foster care system is intended to be a temporary short-term solution until children can be reunified with their families or placed in another permanent home. Unfortunately, thousands of North Carolina children in foster care spend months, even years, in the foster care system, which relies on county Departments of Social Services and the court system to develop and implement permanency plans. In an interview, NCDHHS Senior Director for Child and Family Services Lisa Cauley outlines the response to low performance measures recognized prior to Rylan’s Law, the Social Services and Child Welfare Accountability Act passed by the General Assembly to create a better system of accountability.25 This third-party assessment of the child welfare system deeply analyzes what is working well and identifies major gaps and disparities. It is imperative to support the workforce of social workers and administrators to ensure they are equitably resourced, trained, and compensated. In addition, engaging counties to assess the utilization of programs helps NCDHHS identify disparities and barriers for families unable to access those services. The trauma-informed practice model utilizes evidence-based services that not only focus on identifying the trauma children experience, but also implementing supports and programming that builds the resiliency of children and families.26
Early Care and Education
North Carolina’s high-quality early childhood system produces better education, health, and economic outcomes for children and the state. However, Baker and coauthors describe how the COVID-19 pandemic has led to a child care staffing and mental-health crisis for staff and young children.27 Regarding the workforce, early childhood teachers can’t afford to stay in their jobs. They earn an average of $12 per hour, most often without health insurance, and struggle to make ends meet.28 More than 70% of child care slots are paid for by families, therefore many child care programs lost revenue during the pandemic when parents kept children out of child care.28 Now, inflation and competition for staff in other industries have driven wages up to levels that child care programs can’t meet. The social-emotional issues encountered by this strained workforce are rising in frequency and complexity. Baker and coauthors link the disruptions and stress of the pandemic with the behavioral health of infants and toddlers, as well as the mental health of members of the child care workforce.27
North Carolina is a national leader in early care and learning. The early learning system needs continued investment to strengthen all families and the state’s economy, particularly as child care stabilization funding from the pandemic runs out. A 2023 study by ReadyNation found that more than a quarter of parents surveyed (26%) quit their jobs because of child care problems.29 Additional investments in high-quality child care and early education will support children’s healthy development and learning, allow parents to work, and keep businesses running to promote a stronger economy.
Access to nutritious food is foundational for overall health and well-being. However, too many children in North Carolina, about 1 in 6, face hunger, and these rates are higher in Black and Hispanic households.30 Montez and coauthors describe the challenges, opportunities, and policy solutions to alleviate food and nutrition insecurity.31 They outline opportunities related to improving access to nutrition assistance programs (e.g., Food and Nutrition Services [FNS] and the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]) through data-sharing initiatives and new ways of paying for screening and interventions to address nutrition insecurity. Many of these ideas are aligned with the NCDHHS State Action Plan for Nutrition Security, which describes strategies to increase the reach of NCDHHS nutrition programs, build connections between health care and nutrition supports, and increase breastfeeding support and rates.32
Nutrition security came under new threat in 2022 during the national infant formula shortage.33 Wong and coauthors recount the state’s approach to addressing the infant formula shortage and how the tools and strategies developed can be leveraged in future public health crises.34 In addition to data-driven decision-making, proactive and equitable outreach to families and partners, and rapid work with federal regulators, they describe providing resources for transportation and working with businesses to support breastfeeding employees.
This issue of the NCMJ outlines the many factors impacting the health and well-being of children and families in North Carolina. The COVID-19 pandemic further amplified disparities in access to services and health outcomes. Programs addressing behavioral and mental health, education services, nutrition and food security, and health care coverage are vital to child well-being and ensuring every child and family can achieve their highest potential for health, educational, and economic outcomes.
Professionals working daily in medicine, health care administration, social work, advocacy, research, and policymaking clearly recognize the crisis we face, especially with regard to mental and behavioral health services, access to pediatric care (particularly inpatient hospital beds), and access to health care funding in the era of Medicaid expansion. Resources directed toward sustainable programming, while also focusing on prevention, are imperative to address these issues. In addition, burnout and the negative impact on well-being for those working in the agencies, health care settings, and programs that care for children and families have resulted in decreased retention of experienced professionals. Interdisciplinary collaboration across North Carolina is vital to not only address the crises impacting our children and families but also the impact on our workforce dedicated to serving them. This issue will highlight the key partnerships and resources needed to address factors affecting the well-being of children, young adults, and families in North Carolina. Working together to implement evidence-based programming and resources aligned to achieve positive outcomes, we can all play a vital role in making North Carolina a national leader in child health and well-being. It is the right thing to do, and a moral and ethical imperative in which we all have a part.
Disclosure of interests. The authors report no financial relationships to disclose or conflicts of interest to resolve.