In spring of 2017, the elementary school staff of a small, Massachusetts town called an ambulance to take Ashley—a fourth-grader experiencing an acute mental health crisis—to the local hospital’s emergency room. On the way, Ashley struck an EMT in the face, and as a result, charges were pressed against Ashley for assault and battery. It didn’t matter that her offending behavior was the direct result of a serious illness and occurred while her family and school were actively seeking treatment for her mental health needs—the 9-year-old was summoned to the courthouse for a clerk magistrate hearing in juvenile court.
Ashley’s case is hardly unique. Many children end up in the juvenile justice system as a direct result of an untreated mental illness. This situation is one aspect of a societal trend known as the “school-to-prison pipeline” in which vulnerable children, including those with mental illness, are funneled out of the education system and into juvenile detention. It is also part of another ongoing challenge in our culture—the “criminalization of mental illness,” where behaviors associated with psychiatric conditions are punished rather than treated with medical care.
Health Law Advocates (HLA)—a non-profit, public interest law firm headquartered in Boston—is using legal advocacy to help children with mental illness overcome barriers to treatment and avoid the justice system. HLA began this work more than a decade ago and through its Mental Health Advocacy Program for Kids (MHAP for Kids) has now assisted more than 650 children who were either in, or close to entering, the justice system because they were not receiving the mental health services they needed.
The Beginnings of MHAP for Kids
In 2008, the executive director of HLA was approached by a juvenile court judge concerned that children in his court had a high rate of mental illness and often lacked appropriate mental health care services. His observations were backed up by data: The Center for Mental Health Services Research at the University of Massachusetts Medical School (UMass) reported that among court‐involved youth who end up in state detention, 60–70 percent need mental health care; but, only 4–11 percent of youth in Massachusetts courts are referred for mental health services according to a 2006 study by the Massachusetts Society for the Prevention of Cruelty to Children and Boston Children's Hospital. In response to the issue brought to light by the judge, HLA agreed to provide pro bono representation for children involved with the juvenile court, helping them obtain access to their needed services and often ending their court involvement.
Beginning in 2008, juvenile court judges in Worcester, Essex, Middlesex, and Suffolk counties appointed HLA attorneys to advocate for the best interest of more than 500 children in relation to their access to mental health services. These attorneys were named Mental Health Guardians Ad litem at first but were later appointed as Mental Health Advocates (MHA). When the program was started, the appointments’ duration was open ended and concluded when the judge terminated the appointment. Later, when the state adopted time limits for some juvenile court matters, the appointments were limited to six months with the option of renewing the appointment if further efforts were needed.
The work of the MHAs included, but was not limited to, the following:
- conducting an inquiry into a child’s situation to figure out the child’s needs and appropriate courses of advocacy;
- determining what is in the child’s best interest while respecting the child and parent(s)’ express wishes and communicating with the child’s legal counsel;
- reporting to the court in writing at each court appearance and advocating in court for the client’s position;
- making recommendations to the court, including recommendations for placement based upon opinions offered by reliable collaterals;
- working directly with community-based agencies, including schools, to ensure that the child received appropriate and needed services; and
- regularly engaging in advocacy activities such as: attending special education team meetings to advocate for eligibility for services or improved services; collaborating and advocating with the Department of Children and Families to ensure that placement decisions are informed by treatment providers; referring youth to recommended services not yet accessed; advocating for both eligibility and services from the Department of Mental Health; advocating against the use of juvenile detention while appropriate services are sought; and ensuring that health insurance carriers provide coverage for services.
Working with Stakeholders to Develop the Right Model to be Sustainable
In 2012, HLA established its goal of creating a sustainable statewide program to advocate for children who had become, or were in danger of becoming, court-involved due to unmet mental health needs. At that time, the program began a process for systematically consulting with juvenile justice and mental health system stakeholders to refine the program and provide its best chance for long-term success. Numerous entities including the Administrative Office for the Massachusetts Juvenile Court, the state’s Department of Mental Health, the state’s Probation Services, the Parent Professional Advocacy League, and others contributed many hours to the long-term planning process. During this period, HLA commissioned a scientific study on the impact of the program on children and their families.
Program Evaluation by Boston University School of Public Health
HLA contracted with a research team from the Boston University School of Public Health (BU) to conduct an in-depth, two-year program evaluation of the project. The project director facilitated BU’s work, which included both process and outcomes evaluation.
The process evaluation measured (1) the number of youth referred and enrolled in the program; (2) the number and type of referrals made by the MHAs to services; (3) the duration of MHA involvement in cases; and (4) the number, content, contact method, and duration of encounters MHAs had with youth and their families.
The outcomes evaluation measured (1) the children’s access to and engagement in mental health services using the Child and Adolescent Services Assessment and a review of relevant records, (2) the children’s involvement in the judicial and emergency mental health systems using court and medical records, and (3) youths’ functioning at school and at home using multiple instruments, such as the Center for Epidemiologic Studies Depression Scale.
The research team conducted a cost-benefit analysis to measure costs associated with MHA activities versus the benefits measured by youth outcome measures. The evaluation team also conducted extensive interviews of the MHAs and the project’s numerous stakeholders to receive general feedback about the advocacy program.
In the final report, data collected by BU indicated that MHAP for Kids serves young people and parents who have a “significantly elevated risk profile.” Of the children served:
- 83 percent are diagnosed with one or more mental illnesses with an average of 3.5 mental health related conditions per child;
- 89 percent experienced a barrier to mental health treatment;
- 63 percent accessed crisis or emergency mental health care services in the past year;
- 44 percent hospitalized for psychiatric care in the past year;
- 37 percent admitted to a residential mental health facility in the past year;
- 28 percent did not attend school at all or missed almost every day in the past three months; and
- 61 percent missed school more than one day per week in the past three months.
The study found that when MHAP for Kids intervenes in a child’s life, children experience:
- Improved school attendance—31 percent missing more than one day per week, reduced to 6 percent;
- Decreased use of emergency mental health services—70 percent with recent need, reduced to 24 percent;
- Lowered use of overnight hospital stays—44 percent with recent need, reduced to 14 percent; and
- Reduced use of emergency shelters—10 percent with recent need, reduced to 0 percent.
The study also found that families’ (children and parents/guardians) self-reported mental health, family conflict, and family difficulties had improved.
Transitioning to the Family Resource Centers
Because of HLA’s extensive consultation period with experts in the juvenile justice and mental health systems, the organization adjusted MHAP for Kids so that it aligned with the state’s juvenile justice policy reforms—in 2012, Massachusetts established a statewide network of Family Resource Centers (FRCs) to help divert youth from the juvenile justice system to health care and other services whenever possible. To work with these diversionary services, HLA moved its attorneys from private offices near juvenile courts to offices within the state’s two busiest FRCs in Lowell and Lynn, Massachusetts. HLA transitioned from a program serving only court-involved youth to a community-based program serving children with and without open court cases, the idea being that children should not have enter the justice system to receive help overcoming barriers to mental health care. But, HLA also continued to help children who couldn’t connect with MHAP for Kids until they became court-involved.
According to a study of the FRCs by UMass, 32 percent of youth they serve who are in, or at risk of involvement with, the juvenile court have a mental health disability. Working within the FRCs, the MHAP for Kids attorneys are readily available for these children who need help accessing treatment and steering clear of the court system. MHAP for Kids attorneys advocate for children's rights to mental health care within school systems, state agencies, health insurance plans, and the juvenile justice system. MHAP attorneys aggressively protect children's rights and use a collaborative problem-solving approach. They bring parties together to address children's needs using solutions that spread responsibility. For example, they forge cost-sharing agreements among schools, state agencies, and insurers to ensure youth receive needed services. They also work with juvenile court prosecutors to divert youth from delinquency charges to mental health services. And most importantly, MHAP for Kids attorneys collaborate with families to ensure their voices are heard.
Under the new community-based model, MHAP for Kids accepts clients referred from outside the staff of the FRCs in which they are embedded and provides direct representation for children as opposed to just working for children’s best interests on behalf of the court.
Since the MHAP for Kids attorneys are a limited resource, cases are prioritized when:
- a child is “stuck” in either the hospital or juvenile detention;
- a child is at risk of needing a higher level of care unless appropriate community-based programs are put in place;
- a child is at risk of being suspended and/or expelled from school; or
- a child is at risk of entering the juvenile justice system.
The staff attorneys are available only to assist children with known or suspected mental health challenges and can assist up to 30 children at a time.
Funding for the Program
The program has been primarily funded by private foundations. The largest supporter is the Peter and Elizabeth C. Tower Foundation, though other current foundation supporters include the Theodore Edson Parker Foundation, the Cabot Family Charitable Trust, the Mabel Louise Riley Foundation, the Ludcke Foundation, the Gardiner Howland Shaw Foundation, the John W. Alden Trust, the Fish Family Foundation, and the Bennett Family Foundation. Prior grants have been provided by the Klarman Family Foundation, the Blue Cross Blue Shield of Massachusetts Foundation, the C.F. Adams Trust, the Massachusetts Bar Foundation, and the Eastern Bank Foundation. MHAP for Kids joined with a MassHealth Accountable Care Organization, Community Care Cooperative, and a mental health center to receive a grant from the Health Policy Commission. Also, MHAP for Kids’ partnership with the Boston Public Health Commission was awarded a grant from the state’s Probation Service.
From the start, HLA’s vision has been to replicate and sustain their model for mental health advocacy for children. To further that goal, a key priority for the project has been to create stakeholder “buy-in” through numerous outreach efforts over the years. HLA ramped up these efforts to include intensive outreach to the state legislature—for example, the MHAP for Kids’ director has visited many members of the legislature whose constituents are represented by the program. HLA’s initial legislative goal was to secure funding for the period from February 15, 2017, through June 30, 2017, but it was not successful. However, by doing significant outreach to the legislature as well as working closely with the Children’s Mental Health Campaign, MHAP for Kids was given a $50,000 earmark in the budgets of both the 2018 and 2019 fiscal years.
MHAP for Kids is a lifeline that minimizes children’s exposure to the juvenile justice system and removes obstacles to the treatment and care they need to lead healthy and fulfilling lives. Its vision is to make MHAP for Kids available to every child in the state who can benefit from its services, and the organization hopes that other states will adopt its model for helping vulnerable children reach their potential.
As for Ashley, her treatment providers contacted MHAP for Kids immediately after she received the summons for court. The MHAP for Kids attorney prepared Ashley and her mother for her court appearance and appeared with them before the magistrate to ask that the charge be dismissed. Seeing that Ashley’s primary need was mental health treatment, the magistrate dismissed the charges. With the MHAP for Kids attorney’s advocacy, Ashley got her wish and transferred to a therapeutic day school where she is attending classes successfully and learning new coping skills.