For nearly a year, we’ve held town halls across North Carolina on behavioral health and disabilities. We’ve heard one message over and over from families, health care pro­viders, and community leaders: we need to do more for the behavioral health of our children.

We heard stories from parents like Melinda,[1] whose seventh grader began having suicidal thoughts. Melinda called every therapist she could find. They told her their caseloads were full or they didn’t accept her insurance. Parents like Melinda search for weeks or months to find treatment. With over half of our counties lacking any child and adolescent psychiatrists,1 it’s unsurprising that so many parents struggle to find care for their children.

While the system has been under-resourced forever, the need is growing rapidly. In 2021, 1 in 3 students said their mental health was not good most of the time.2 That year, 10% of North Carolina high school students attempted suicide and another 22% seriously considered it.2 Disturbingly, LGBTQ students faced even higher rates—21% attempted suicide, and nearly half seriously considered it.2 Over half of children with mental health issues in North Carolina don’t receive treatment, and we’ve been ranked last in mental health access for chil­dren.3

Our most vulnerable children—those in foster care, those with disabilities, and those with complex needs— are especially suffering. These are kids like Anne, whose developmental disabilities and complex behavioral health needs, in combination with family health issues, brought her into the custody of the county Department of Social Services (DSS). Anne’s needs continued to escalate, and her foster family could not manage the situation. Without other options, she ended up in the emergency depart­ment. Providers recommended residential treatment, but no facility was available to meet her complex needs. So, she “lived” in an emergency room for months, awaiting placement with limited access to family, school, and a clear path to recovery.

Anne is not alone. Nightly, over 60 kids in need of psychiatric care sleep in an emergency room and dozens more sleep in a DSS office. In the ER, the average stay is often weeks but sometimes months. After waiting too long for care, many families resort to out-of-state care. In 2022, 281 children ended up in residential treatment out­side North Carolina (unpublished data, NCDHHS). Some of these placements were as far as Arizona.

While more high-quality placements are needed, and facility-based providers need long-term increases in rates, we also need to invest in upstream community-based resources. With earlier needs assessments from trained clinicians, intensive in-home supports, and more assis­tance for foster parents, Anne may have never gotten to the point of crisis. Unfortunately, North Carolina ranks last in per-child funding across all states with decentralized child welfare programs.4

This is why we’re calling for a $1 billion investment to begin to rebuild North Carolina’s behavioral health sys­tem of care.5 The plan is a down payment on a system that has never been adequately funded. It includes invest­ments to raise behavioral health reimbursement rates and strengthen the behavioral health workforce—critical foun­dations that make the rest of our plan possible.

We’ve made sure services for children and families are at the center of the plan. For children like Anne, we’ve laid out a $100 million investment to ensure all children in foster care have safe and stable homes, especially those with complex behavioral health needs, so that every child receives the treatment and nurturing home they need to thrive.

In addition to the investment roadmap, we worked col­laboratively with DSS directors, community stakeholders, and families to design a specialty plan for children in foster care and their families.6 This plan creates a single state­wide system of care to strengthen services and support, encouraging safe, stable, caring families for all children. This plan changes how the Medicaid program works and requires legislation to go into effect. For the last several years we’ve worked to get this plan passed, and we hope this year—especially considering the rapidly escalating need—it will finally become law.

We’ve also worked hard to do everything we can out­side of legislation and new funding. In order to embed trauma-informed practices into child welfare work across the state, we developed a new trauma-informed child wel­fare model7 and rolled out new trainings for child wel­fare workers, foster parents, and kinship care providers. And in order to ensure we’re accurately identifying and meeting the needs of children in care, we’ve created a new trauma screening tool for child welfare workers.

To get upstream of these crises, we’re also work­ing to bring supports to children where they are—in school. The urgency for school-based supports has never been greater. In 2022, 68% of North Carolina teachers reported that their students’ mental health needs were greater than in a typical school year.8 Using COVID-19 funding, we’ve invested heavily in launching new school-based behavioral health supports. These investments ranged from building a school-based electronic health record to helping schools partner with community behav­ioral health resources. We want to continue building upon these initiatives, as outlined in the School Behavioral Health Action Plan.9

We’ve listened to families across the state and thought carefully about steps to improve the outlook for vulner­able children and families. We know the plan we’ve cre­ated will make a difference. This investment will ensure every child and adult in North Carolina can get the help they need, when and where they need it. We’ve heard from parents, providers, and youth who share our excitement about what this investment will do for their communities. There will, of course, be more to do. We’ll work hand in hand with communities to ensure our investments reach them. These are the first steps to a brighter future for all North Carolinians.

Disclosure of interests

Secretary Kinsley and the Department of Health and Human Services crafted the $1 billion Behavioral Health Investment Plan referenced in this article and currently before the North Carolina General Assembly. Key investments from the plan, which have been presented in the Senate’s budget, are in part due to leadership by Senator Burgin.

  1. All names in this article have been changed to protect the privacy of families and children.