This story is part of our series "Pandemic Generation" about how the mental health of children has been impacted by the pandemic. You can find the complete series here.
Mental health care for kids in Massachusetts is a confusing web of services. They can be hard to access — even in normal times.
There never seems to be enough inpatient psychiatric beds or outpatient therapists. A kid may not even be able to get a therapist if the family doesn't have certain insurance, and some providers don't any take insurance. There are mobile crisis teams, in-home psychologists, day programs, group homes, and residential schools.
The pandemic put immense strain on all of them.
Outpatient care went virtual in the pandemic, but teletherapy was tough for some kids.
Terry Alves-Hunter, of Falmouth, recently asked her 9-year-old son what it was like to have to see his therapist over a computer screen.
"The Zoom did not help me. The in-person helped me a lot, talking about my feelings and all of that," he said.
Alves-Hunter adopted her son from foster care when he was 3. He's diagnosed with post-traumatic stress disorder, an attachment disorder, ADHD, autism, anxiety and depression.
Alves-Hunter says things escalated with the the Zoom therapy, until her son gave up.
"He was bouncing back and forth on the chair, he couldn't focus, and he'd just start getting angrier and angrier, break things," she recalled.
According to mental health clinicians, virtual mental health care for kids is a mixed bag. Jillian Erlich is a clinical social worker with Riverside Community Care, which provides mental health care all over eastern and central Massachusetts. She supervises a team of child and adolescent mental health clinicians in Milford, and she counsels teens at Blackstone Valley Regional Vocational Technical High School in Upton.
"When kids were learning remotely in schools, I was still able to see them on a weekly basis by telehealth. And they were able to fit me in between their classes, and it worked well then," Erlich said. "There is a proportion of kids who it's difficult for. Usually you see those among the younger populations, the ones who are less verbal. The verbal kids generally have had very little trouble with telehealth and have even enjoyed it."
Erlich's clinic has "therapy boxes" that were donated, and clients can bring the boxes of items to their homes.
"And they have a box that matches the one that the clinician has at the center. [The therapist] can literally take out the same squishy toy, the fidget toy, the game of cards, the mindfulness tools, and use them at the same time as the kid," Erlich said. "It mimics the in-person therapy session, where you're both engaging with the same kind of tools, in a similar environment."
Erlich says privacy during telehealth therapy visits has been a big issue for many older kids.
"Because for a kid who's maybe having a hard time at home, maybe not getting along with their parents, they want to make sure their parents don't hear what they have to say," she explained. "The confidentiality of therapy is incredibly important, and that is one thing that telehealth can't always give us."
"I've had kids who go down into their basement when that happens," Erlich said. "Something I often suggest is, 'Is there a car you can sit in? Because, you know ... hopefully you still have WiFi access from your house. I have talked to kids for hours that way."
Erlich says Blackstone Valley Tech, the high school where she works, has allowed students to keep their school-issued laptops for the summer if they need them in order to access therapy virtually.
And then there's the question of how virtual mental health care is paid for. Insurance providers were required to cover it in the pandemic, and that coverage is now required indefinitely.
MassHealth says it plans to continue covering telehealth for both physical and behavioral health services, and it'll publish a long-term policy on that soon.
Terry Alves-Hunter says her son was without in-person mental health services from March to January. He missed meeting with his regular therapist, his behavioral therapist, and his mentor. Alves-Hunter says the impact on her son has been profound.
"He was closed off for so long that he's just starting to restart those relationships, so any progress that we made got erased," she said. "We didn't pick up where we left off — we picked up where we started at."
And here's something that really troubles Alves-Hunter. She says she had discontinued intensive in-home therapy for her son quite a while before the pandemic hit. She had decided he didn't need it anymore because he had made good progress. But now, because of the setbacks he's had in the pandemic, he needs those services again. And because of the pandemic and more kids needing help, he's on a long wait list.
Alves-Hunter, who works as an outreach and peer support specialist with several mental health-related organizations, wants people to understand there's a massive shortage of mental health care providers, especially for kids with really complex needs.
"Write your legislators, write everybody that we need to have psychologists and therapists that treat children with trauma," she said. "Invisible wounds, invisible disabilities matter just as much as somebody that breaks a leg."
Mobile Outreach And Inpatient Care
When it comes to inpatient psychiatric care for kids, pressure on the system is immense. The state says there's been a big spike in the pandemic in kids "boarding" in hospital EDs — emergency departments — or other medical units while they wait for psych beds to open.
Dr. Nalan Ward is a psychiatrist and Chief Medical Officer of Beth Israel Lahey Health Behavioral Services. The organization operates outpatient mental health care and mobile crisis teams for kids. Members of the teams go to families' homes 24/7 to assess kids in mental health crisis, and connect them with services.
Ward says the mobile crisis program made some new strides in the pandemic, because they went to see kids in more places.
"We were able to increase our community mobile crisis types of interventions for kids up to 50 to 60% in some regions," Ward said, "meaning that those kids are diverted from the ED, and we are able to see them in schools, in pediatric offices, in different places in the communities so that we prevent kids from going to the ED in the first place."
Erlich and Ward say the state needs better investment and reimbursement in outpatient and mobile crisis services, in order to keep more kids from reaching the point of psychiatric crises that land them in the emergency room and inpatient units.
But everyone seems to agree more beds are needed. The state says MassHealth has offered additional funding and increased reimbursement to providers who add inpatient beds for children and adolescents. More than 130 new beds for kids have been licensed for this year, according to the state Department of Mental Health. They will be added to the 357 beds that already exist, but 21% of those are currently off-line for COVID infection control and other reasons.
Gov. Charlie Baker's administration also recently released a plan known as the "Roadmap for Behavioral Health Reform." It calls for the creation of quick-access community-based behavioral health centers all over the state.
This project is funded in part by a grant from the NIHCM Foundation.