BUSPH researchers helps a mental health advocacy program for kids reach new heights during COVID-19 and beyond

Youth with unmet mental, behavioral, and emotional health needs disproportionally end up in the juvenile justice system either in the custody of the Department of Children and Families or incarcerated in a Department of Youth Services facility. Understanding what is at stake for these youth, the public interest law firm, Health Law Advocates (HLA), created the Mental Health Advocacy Program for Kids (MHAP for Kids). This program provides experienced staff attorneys at no cost to eligible families to break down barriers they face when seeking appropriate mental health services and ultimately prevent youth from becoming court-involved or more deeply court-involved.

Working with Boston University School of Public Health to facilitate the proper metrics

In 2014, just before launching their novel pilot program, HLA began working with the Boston University School of Public Health (BUSPH) to design and conduct an independent evaluation to ensure the model had the best possible outcomes for Massachusetts children and families struggling with accessing needed mental health services. HLA chose BUSPH faculty because of their strong reputation for professional evaluation and comprehensive study designs, as well as faculty expertise in working with vulnerable youths and their families.

When asked to share their experiences working with BUSPH, Marisol Garcia, the senior director for MHAP for Kids said, “The data collection and analysis done by the BUSPH team allowed us to demonstrate the effectiveness of our work and the return on investment to potential partners. We shared the data with the legislature, other stakeholders in government, and decision-makers in the healthcare industry who made significant financial investments in our model when they saw the evaluation.”

Leading the charge for stronger mental and behavioral health needs for kids

The BUSPH evaluation team led by Dr. Patricia Elliott, Clinical Associate Professor of Community Health Sciences, has been documenting the impact of MHAP for Kids since the program’s launch in March 2015. Health Law Advocates used data from the pilot evaluation to shift MHAP for Kids from its original court-based model into a community-based program. The evaluation and data that informed the adaptation allowed for:

1. 1. Greater access for youth who are not involved with the justice system and with more Black and Latinx youth who were underrepresented in the pilot. 
   2. Acquisition of an ongoing investment of public funds to expand the updated program’s reach to all counties across the Commonwealth by defining the program’s cost-savings thresholds and impacts on family outcomes 
   3. MHAP for Kids to understand how the pandemic was impacting their clients

Dr. Patricia Elliott, oversees the design of the evaluation and creation of data collection instruments, along with data collection, management, and analysis. The extensive experience of Dr. Elliott and her team, which includes MPH students who have worked on the project over the years, has helped HLA to understand how to use the evaluation findings in the program’s evolution and expansion to scale.

Ben’s Story from Tira Khan, Sugarhouse Media on Vimeo

The ongoing evaluation shows MHAP for Kids families experience high levels of stress, family conflict, and distress from youth mental health concerns before they start receiving services. Nearly all of the families report experiencing significant barriers to getting their child mental health care, and many resorted to seeking help from the police, the courts, or the foster care system. During the pilot program, the BUSPH evaluation team found that working with a staff attorney stabilized family functioning, reduced emergency crisis service use, and improved school engagement. However, COVID-19 has complicated this work as systems like special education, residential treatment facilities, and courts struggled to function early in the pandemic, and schools shut down, sending kids to learn at home. 

Navigating the challenges of COVID-19 to ensure the accessibility of mental and behavioral health services

Youth spend a significant amount of time in schools, which means schools can play an essential role in the delivery of mental health services. When working with schools, MHAP for Kids attorneys ensure youth are provided with a learning environment that accommodates their mental health concerns in accordance with the law. Special education and mental health services in schools are often hard-won, which made their disruption by the COVID-19 pandemic problematic for many families, like those in MHAP for Kids.

On March 15, 2020, Massachusetts Governor Charlie Baker issued two back-to-back orders suspending in-person instruction in all public, private elementary, and secondary schools in the Commonwealth to prevent the spread of COVID-19. School districts scrambled to develop and implement remote learning for students. For students with disabilities, including mental health disabilities, school closures meant an abrupt cessation of their in-person specialized instruction and related services, like school-based counseling. Families faced these and many other challenges as outlined in a white paper presented to the American Bar Association Commission on Homelessness and Poverty, co-authored by Dr. Elliott and MHAP for Kids senior director, Marisol Garcia.

HLA asked Dr. Elliott and her team to conduct another analysis of the impact of school closures during COVID-19. The public health crisis and resulting school closures have been stressful and potentially traumatic for all students, but especially for students who already faced challenges with existing mental health needs. Many families told their attorneys they noticed increased symptoms of depression and anxiety in their children, as well as significant difficulties engaging in the remote learning models. Clients referred to technology barriers, the demands of trying to make a living during the pandemic, and significant household stress as challenges to supporting their children’s remote learning. As program staff concluded, more resources were needed to expand the program to more families facing these challenges, but while their anecdotal stories were compelling, they may not be sufficient to persuade policymakers to increase their investment.

How research helps create positive and equitable change in real-time during the pandemic

To better understand the impact of COVID-19 disruptions, the BUSPH evaluation team worked with MHAP for Kids staff to design questions and was able to collect data by inviting families to fill out weekly logs during the school year since late spring 2020. During the pandemic, nearly all parents reported observing social, emotional, and or behavioral challenges in their youth. Parents also indicated that there were significant disruptions to the provision of special education services, as well. These findings, combined with other data, were presented back to HLA staff attorneys and compiled into periodic reports MHAP for Kids could share with stakeholders. Ongoing BUSPH evaluation efforts will help HLA learn not only the impact of MHAP for Kids but also how COVID-19 may have disrupted efforts or changed outcomes for these families.

Recently, the evaluation data were presented at a Massachusetts legislative briefing and used by program leadership in meetings with key legislators resulting in the program being written into the state’s budget for the fiscal year 2023 at an increased level of investment.

From pilot program to widespread initiative

First piloted as a court-based program in two juvenile courts in Massachusetts, MHAP for Kids, now provides no-cost legal services for youth in income-eligible households across the entire commonwealth, reaching over 1,300 since March of 2017. MHAP for Kids staff attorneys works on behalf of families to ensure that schools, state agencies, health insurers, as well as justice system personnel, work together to meet children’s mental health needs and keep youth out of the justice system.

The partnership with the BUSPH evaluation team has given MHAP for Kids the information they need to understand their program, pivot and adapt their model, share data with their stakeholders including funders, and bring their program to scale with public dollars while understanding the impact of unpredictable challenges like the COVID-19 pandemic. The connection with BUSPH extends beyond just faculty, as HLA has hosted several MPH students during their practicum and regularly participates in the BUSPH Maternal and Child Health Center of Excellence Practice Fellowship program, and has already supported four MPH year-long student fellows.

Read the full 2022 report here.

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Patricia Elliott, DrPH, is a Clinical Associate Professor of Community Health Sciences at Boston University School of Public Health. Her interests focus on using implementation science, systems science, and process evaluation methods to improve the health of vulnerable populations. She is particularly interested in adolescent and family access to health services, the intersection of mental health and juvenile justice, school health, and health policies at the local, state, and federal levels.