Youth Mental Health in Crisis

In the years following the COVID-19 pandemic, youth behavioral health—both mental health and substance use—reached peak levels of crisis in the U.S. In 2022, approximately 1 in 5 adolescents reported experiencing symptoms of depression or anxiety, and suicide is the second leading cause of death for adolescents, despite rates decreasing from their peak in 2018. Deaths due to drug overdose among adolescents more than doubled from 2018 to 2022, driven in large part by increased prevalence of fentanyl, though rates have started to decline in the past two years.

While awareness of and attention to the behavioral health of young people has grown in recent years, many adolescents are still not receiving the support they need. A 2023 report found that 60 percent of youth with major depression are not receiving treatment, in part driven by a distrust and fear of the mental health system. This distrust may be exacerbated for Black and Brown youth, LGBTQ+ youth, and youth with disabilities, whose communities have been historically underserved and/or harmed by the medical community. To help break this distrust and improve behavioral health outcomes for young people, youth peer support services—delivered by youth, for youth— offer a positive, cost effective, high potential option for engagement and proactive treatment.

What are Youth Peer Support Services?

Youth peer support services center youth voices, connecting adolescents and young adults with other young adults who have faced similar challenges and are trained to use their experience to support others. A youth peer support specialist may work in an inpatient mental health hospital helping young people facing their first hospitalization or work a text help line, talking with young people about their own experiences, sharing a sense of hope for recovery, and helping that young person advocate for their own wellness. Like all peer supports, youth peer supports are grounded in respect and shared mutuality, community and belonging, and are an explicitly non-medical intervention. Youth peer supports are delivered in many settings, including mental health facilities, drop-in centers, schools, and juvenile justice settings.  In most cases, youth peer supports are transitional-aged youth (18-26) serving adolescents.

Adult peer support in the United States emerged during the 1960’s as a response to the dehumanizing treatment of individuals receiving medicalized mental health treatment, including institutionalized care. While not a clinical intervention, peer supports are an evidence-based treatment promoted by Substance Abuse and Mental Health Administration (SAMHSA), the Centers for Medicare and Medicaid Services, and the American Society of Addiction Medicine (ASAM). Research suggests that peer support services can result in increased community engagement, improved self-esteem, decreased substance misuse and psychotic symptoms, and improved physical health. Further, studies have found peer support services add significant value to the health care system by reducing the use of inpatient services and decreasing hospitalization rates. There are early research findings that peer supports for youth, specifically, increase engagement in treatment and help youth better manage their wellness in the community.

Youth peer support services are similar in many ways to adult peer support services, but there are some critical differences. For example:

• Youth peer support is meant to be delivered by youth for youth—recognizing that young people have their own ways of viewing the world and relationship with systems.
  • Research shows that adolescents can be hesitant to share personal issues with adult health care professionals.
• Youth receiving treatment and/or in the child welfare system lose autonomy and the ability to make fundamental decisions such as whether they can continue to live with their family.
• Peer support workers who are still young themselves are better positioned to use their recent experiences with services and systems to help the young people they support, compared with older peer support workers who may not have experience with youth-serving systems, or may have experience in the more distant past.
• Research has shown that young people have greater influence over one another compared to adults, and while attention has often been paid to negative “peer pressure” among teens, this influence can also be positive.

In short, youth peer supports can show young people a path forward, giving them a peer who whose story that can identify with.

Expanding Access to Youth Peer Support Services

In recent years, growing support for expanding youth peer support services has led to states expanding access across the country, largely driven by the youth behavioral health crisis. Currently, 18 states allow for Medicaid billing of youth peer support services, and many more organizations offer youth peer supports through alternative funding sources (e.g., SAMHSA grants, philanthropic funding, state funding, etc.). Additionally, the National Governor’s Association Youth Mental Health Playbook specifically recommends funding youth peer support programs.  Even internationally, organizations like Youth Aware of Mental Health (YAM) lead school-based youth peer engagement programs and have conducted sessions in 17 countries for nearly 200,000 teenagers.

CMS and SAMHSA currently provide broad guidance for the delivery of youth peer support services and the training and certification of youth peers. As a result, individual states manage their youth peer support programs a bit differently. Pennsylvania, for example allows Medicaid members ages 14 and up to receive youth peer supports, while Washington and Wyoming allow members as young as 13 to receive these services. Additionally, states vary in whether youth peer support specialists receive dedicated training focused on youth behavioral health or take “add-on” trainings once they’ve been certified as an adult peer support specialist.

Despite these variations across the country, some best practices have emerged for building a strong youth peer support system in a state. Most important across these best practices is ensuring youth voice is centered in the development and implementation of youth peer support programs. National leaders like Youth Move—which has 50 chapters across the country— recommend that youth peer support specialists be trained by other youth on topics focused on youth mental health and substance use (as opposed to behavioral health through the adult lens).

Further, youth peer support programs should be situated within the systems that youth interact with, and across the continuum of mental health and substance use disorder treatment services. This means not only ensuring youth peer supports are available in mental health centers, crisis response lines, and mental health drop-in centers, but also in schools and juvenile justice settings. CMS has provided guidance that states may cover youth peer supports in schools as a Medicaid-funded service, though no states have taken advantage of this benefit yet.

Finally, across peer support specialists, both adults and youth, lack of respect and understanding of the role remains a significant pain point. Many adult peer support specialists feel undervalued by their supervisors and co-workers when they work in clinical environments, and experience burnout related to the lack of supports they receive on the job. This unintended impact must be avoided as states expand youth peer support services, prioritizing paying peers a living wage, requiring appropriate supervision of youth peers (ideally being supervised by another, experienced youth peer support specialist), and that workplaces have resources to support the well-being of their peer workers and provide a career path for them to “level up” as a peer support specialist.  

Looking Ahead

Youth peer support services are largely publicly funded, through Medicaid benefits and a blend of state and federal sources. Potential cuts to Medicaid funding and cuts to the federal mental health workforce could have significant impacts on states’ opportunities to expand access to youth peer support services. Additionally, central to youth peer support services is ensuring youth receive culturally sensitive care. This requires an emphasis on diversity, equity, and inclusion. Current Administration’s policies regarding DEI initiatives and transgender health care not only harms LGBTQ+ youth and youth of color but could stifle youth peer support programs that are federally funded from delivering care that centers equity and inclusion for young people.

On a more hopeful note, youth peer support services have been supported by leadership across the political spectrum for the simple reason that they work. Now is the time to expand access to these effective services and bolster the youth peer support workforce through high-quality training, appropriate pay, and supportive working environments.