CONTENT WARNING: This article references suicide. Please take caution when reading. If you need mental health support, please consult this page for resources.
By Jennifer Fernandez
The struggle with mental health issues for North Carolina’s children worsened during the COVID-19 pandemic, according to a new report.
And significant disparities exist among student groups, with LGBTQ+ students particularly affected.
The authors of the NC Child Health Report Card urged action on several measures to address mental health needs of children:
- Remove barriers to accessing mental health care.
- Enhance the availability of mental health care and crisis intervention in public schools, particularly in rural areas where specialty care is less available.
- Make it harder for children and youth to get access to lethal means of self-harm, including encouraging families to store firearms and prescription drugs safely.
“Even before the COVID-19 emergency and school closures, kids have been in crisis,” said Khristian Curry, project director with the N.C. Institute of Medicine, pointing to the overall increase in youth suicides in the past decade as one example during a May 4 webinar about the report card.
“That crisis is exacerbated by factors like lacking access to health care, food insecurity or family economic insecurity. So it’s deeply linked to many of the indicators that we have historically tracked in the Child Health Report Card.”
Reporting on child health
The report card, put together every two years by NC Child and the North Carolina Institute of Medicine, looks at 15 measures of child health. Those measures range from housing and economic security, to educational opportunities, to birth outcomes and mental health.
The 2023 report card showed that since the last time these statistics were compiled in 2021, the state improved in two areas, outcomes deteriorated in three others and remained the same on the rest.
For instance, the state’s grade on tobacco, alcohol and substance use improved from an F to a D.
The Preconception and Maternal Health and Support category, which tracks such data as how many women receive prenatal care or are insured, improved to a B grade. Despite that, birth outcomes are rated with an F, with 6.9 infants out of every 1,000 born in North Carolina dying in their first year. The rate of preterm birth remains above 10 percent.
“We’re celebrating improved coverage, but that does not always translate to availability of providers, of consistency of care, of all of these other aspects,” said Luna Homsi, a health policy analyst with NC Child, at the May 4 webinar. “There’s still a long way to go, and the disparities and birth outcomes are proof of that.”
Three areas dropped a grade level: teen births to C, education to D and school health to F.
Grades are subjective and assigned by a panel of health experts as a way to bring attention to how the state’s children are doing in “salient measures of health and well-being,” according to the report.
The North Carolina report card comes less than two months after the National Youth Risk Behavior Survey also raised alarms about the mental health of teens, particularly young girls and LGBQ+ youth. (The survey did not include questions for transgender youth.)
For every report card, NC Child picks a focus, a pressing issue that needs to be addressed.
In 2019, the nonprofit focused on youth suicide. Just four years later, the organizations turned their attention to the overall mental health of teens.
As teen suicides and mental health diagnoses increase, North Carolina’s schools remain woefully understaffed to address these issues with youth, the organization’s leadership said.
Though the school nurse-to-student ratio has improved slightly since 2018, it remains a far cry from the 750 students per nurse recommended by the Centers for Disease Control and Prevention. The ratio stood at 1,007 students for every nurse in the 2019-20 school year, according to the latest data available for the Child Health Report Card.
The American School Counselor Association recommends one school counselor for every 250 students. With 316 counselors per student, North Carolina fares better than the national average of 408, but still falls short.
“We are, right now, not providing the level of mental health support in our public schools that we need to be for our students,” NC Child Executive Director Erica Palmer Smith said in an interview. “We are not meeting national standards.”
Mental health diagnoses among children are on the rise. The number of children aged 3-17 receiving a diagnosis of depression or anxiety increased by 49 percent from 2016 to 2020, NC Child said.
In its report, NC Child noted that suicide became the leading cause of death for children ages 10-14 in 2019. The next year, “an unprecedented 67 children” aged 10-18 died by suicide in North Carolina.
In recent years, more of the state’s teens reported seriously considering attempting suicide. For high school students, the rate of suicidal ideation increased from 16.2 percent in 2017 to 22.3 percent in 2021, according to the Youth Risk Behavior Survey. One in 10 reported actually making an attempt at ending their lives.
The Youth Risk Behavior Study showed that LGBQ+ students in North Carolina schools were about three times as likely as their heterosexual peers to report seriously considering suicide, making a suicide plan or attempting suicide, the survey’s data show.
“There are some things we just, we can’t accept,” Palmer Smith said. “Our kids taking their own lives because we’re not making sure that they have the support that they need, that’s just not something that we can accept.”
From 2011 through 2020, 525 North Carolina children aged 17 and younger died from firearm injuries.
“The rise in firearm deaths, along with data showing how easily many high schoolers can access a loaded gun, is quite concerning,” Kella Hatcher, executive director of the NC Child Fatality Task Force, previously told NC Health News.
In 2021 alone, the number of child deaths due to firearms was 121.
The task force’s report showed that in 2021, children died by firearms in more than seven out of 10 percent of suicides and homicides of children. For older children — ages 15-17 — the number increased to 83 percent.
More than nine in 10 all the homicides of children over the age of 4 involved firearms.
Gun safety topped the task force’s recommended action items for state legislators released earlier this year.
The legislature acted on part of the recommendation — creating a program to promote the safe storage of firearms and facilitate the distribution of gun locks as part of a larger measure that loosened the ability to obtain a firearm. However, Senate Bill 41 did not include funding for the program. The Child Fatality Task Force had recommended a minimum two-year funding of $250,000.
Senate Bill 41, which became law in March after Republicans overrode Gov. Roy Cooper’s veto, also eliminated the pistol purchase permit requirement and loosened restrictions on some carry concealed permit holders.
So far, there’s no money allocated for safe storage of firearms in either the Senate or House versions of the budget. The two chambers are working on meshing their spending plans into a final state budget.
In an effort to address gun violence in the state, Cooper used his executive powers to create the North Carolina Office of Violence Prevention in March. The new office aims to help law enforcement and public health communities reduce violence through training efforts and organizational models that build upon successful community-based programs.
North Carolina’s struggle with gun deaths among children mirrors a national trend.
While overall child deaths had been declining in this country for decades, that trend began to reverse during the pandemic.
However, it wasn’t COVID-19 that was killing children during that time, according to Steven Woolf, director emeritus and senior adviser of the Center on Society and Health at Virginia Commonwealth University.
In a May 10 presentation, he blamed four main culprits driving that reversal: accidental drug overdoses, motor vehicle crashes, suicides and homicides.
Firearms accounted for about half of the increase in all-cause mortality for teens during 2020 and 2021, Woolf said during the National Institute for Health Care Management’s “The State of Our Children’s Health” webinar.
Mass shootings at schools or other locations, however, account for a small fraction of gun deaths among teens, Woolf said.
“Primarily, it’s coming from shootings that are occurring one at a time every day in communities across this country,” he said. “… Many of those involve our youth, and they’re adding up to such a massive number that it’s producing this shift in all-cause mortality.”
Using the data
Now that the data is out there, advocates will be using it in their discussions with legislators. County-level data will be released over the summer, timed so that the local data can be shared with lawmakers before they return in the fall, she said.
Homsi said the report card can also be used by nonprofits, agencies and parents.
The data and grades can serve as “an important jumping off point for essential work in our state,” she said.
Nonprofits can use the information to identify focus areas. For parents, it can be a tool when they’re talking about what they’re passionate about with friends and community members.
“If your community is debating whether or not to put in a new grocery store, you can use this data to show why kids need accessible healthy food to grow,” she said. “… And if your school doesn’t have a counselor, you can use this to show why funding mental health providers is so important.”
Previous efforts to effect change led to the state’s Children’s Health Insurance Program, said Kathy Colville, president and CEO of NCIOM, in an interview.
“We can make policy changes that make a difference in kids’ lives,” she said, noting that the push for child insurance is paying off because close to 95 percent of kids have that access.
“This is part of our responsibility as adults in North Carolina … to look at these [data] and understand them and take action,” she said.