Dr. April Ping is a pediatrician in Livingston county. She's known by foster parents in her area as somebody who understands the complications the foster care system brings, and the health concerns it creates for kids.
The mental health care concerns for kids in the system can be extensive. Ping says she is the only pediatrician in her current practice, and the practice before this one, with extra training to meet these needs. “There are doctors in this county being forced to do it," she says. "They don’t have any extra training, or knowledge or interest."
By necessity and inclination, Ping has embraced her role in what is Michigan's very imperfect system of mental health care for vulnerable kids. The system relies heavily on pediatricians to plan and monitor the complicated diagnosis and treatment process child psychiatrists are better trained and more qualified to do. That is especially true when psychotropic medications are part of the treatment plan.
Powerful drugs for young bodies
Psychotropics are a huge class of drugs that alter mood or behavior that range from anti-psychotics to ADHD medication. These pills certainly help millions of people, but data going back decades show kids in the foster care system are somewhere between 3 to 5 times more likely to be put on psychotropic drugs than kids outside that system.
In Michigan, the over prescription of psychotropics was one of the original complaints in the lawsuit that still has court monitors keeping tabs on the state's child welfare system. Court monitors say, as of June last year, about 18% of kids in the system were on at least one psychotropic drug.
At least 150 of the kids on these drugs in the foster care system are under age 5.
These numbers come from a system that has been chastised for years by these same court monitors over the poor maintenance of kids' health care information.
Many of the children in foster care have experienced trauma. Some of them may have moods and behaviors that really do need to be treated, at least in part, with medication. Others certainly could be treated with less medically risky interventions. But national data show in many cases, these drugs are, in fact, the only mental health intervention given to these kids.
Ping says she does see kids younger than 5 years old come into her practice already on powerful psychotropic drugs. The effects of these medications on young brains are not well understood, so when a child under age 5 in foster care is put on these drugs, it is supposed to trigger a review. However, court monitors say that reviews occur in fewer than half those cases. A Department of Health and Human Services spokesperson said via email the department is working on this issue, and also growing the monitoring unit responsible for this kind of work though hiring more child psychiatrists.
What's different about foster care?
Ping shies away from the use of these kinds of medications on kids this young in her practice. She says she does prescribe these drugs on occasion, but is cautious because behavior that can look very troubling is not wholly inappropriate for a child who has endured the chaos and the trauma of abuse or neglect that landed them in the child welfare system in the first place. "A lot of behavior is over-tired, over-stimulated, fearful they’re never going to be fed again," she says.
“A lot of what they need is stability," she continues. "If I feel they’re in a foster care family who can provide that, I would rather avoid the medication and just try to provide the stability and the unconditional love and see if that kid can’t get better.”
A lot of kids in the system do not have that stability.
Child psychiatrists in short supply
In Michigan, if stability and unconditional love aren't enough and there is a more serious mental health concern looming for a child in the foster care system, it is likely to be very difficult to find a child psychiatrist to help, a problem not unique to the state.
"In the state of Michigan there are probably 8 or 10 counties where there's one," says Dr. Sheila Marcus. Marcus co-directs the Infant Mental Health Clinic at the University of Michigan. She is one of those child psychiatrists. Child psychiatrists are not the only professionals able or equipped to handle mental health concerns, but they are the professionals likely to have the most training and expertise.
At the clinic she helps run, Marcus is part of what an ideal mental health care system for kids, in foster care or otherwise, would look like. During a recent clinic appointment for 3 year old twins, there were as many as 6 health professionals crowded around a two way mirror at one time. They were taking notes and looking for indicators of trouble or strength as they watched the twins play and interact with their mother. Marcus is worried, in part, because at 3 years old, they have significant language delays. She's also worried domestic violence and instability the kids were exposed to is leading to some behaviors she is very concerned about.
Marcus' team makes a list of things the twins' mother does well, and a list of supports she may need as she continues to raise her children. This appointment is just one of three used to arrive at a treatment plan for the children. Clinic personnel take this extra time and care because it is very difficult to untangle if behaviors signal a legitimate mental health concern, a learned behavior from a chaotic environment, a developmental delay, or just typical 3 year old stuff.
This process is as expensive and time consuming as one might expect. It is only possible, Marcus says, because the clinic is part of a large teaching hospital. Clinic staff do make their training available to other doctors around the state to better prepare them to meet the mental health needs of the very young. The training helps allay Marcus's frustration that more patients are not able to get into the clinic because of limited space. "I’m embarrassed to say if you were to call our intake line now," she said a few weeks ago, "you probably wouldn’t get an appointment until September."
One indicator of how under-managed the mental health concerns of kids around the state are can be found in the places that pick up the pieces when comprehensive care is not to be found. One of those places is the emergency room. Marcus says in the pediatric emergency room at the University of Michigan about 3o% of all patients go there for help with psychotropic medications.
In Livingston county, about 25 miles away from that hospital, Dr. Ping says there are specialized mental health practitioners available to her patients, but rarely in person. "In our county all our patients through Community Mental Health, they see a T.V. doctor," says Ping. "I mean, it’s better than nothing, but it’s certainly not ideal.” The Community Mental Health system is responsible for the mental health care of low-income families and many others as well.