Majority of Louisiana babies born to addicted mothers are sent home — by law

Dr. Michael Ulich became a pediatrician for a simple reason: he wanted to help kids.

Ulich, who has practiced at Minden Pediatrics for the past 12 years, recently wrote The Times a frustrated email.

"I am a local pediatrician in Minden and have had patients that are born to mothers who test positive for meth, marijuana or other illicit substances," he wrote. "As a mandated reporter, I call the state hotline for CPS and the local CPS office, and they will not open a case on the legal guardian."

Dr. Arun Pramanik, a neonatologist at LSU Health Shreveport, voiced the same concern: Babies who do not test positive for drugs, even if their mothers do, rarely have cases opened immediately.

"If the mother tests positive, that is a red flag. But CPS here will not take action unless there is what they call an extenuating circumstance," he said. "It's a travesty, a tragedy, and a nationwide problem."

In Louisiana, Child Protective Services falls under the Department of Children and Family Services.

Rhenda Hodnett, the department's assistant secretary for child welfare, said Louisiana law does not require that case workers automatically open a child welfare case when a mother tests positive for drugs but the baby does not.

Louisiana law also does not require that babies born with drugs in their system be automatically removed from their parents, she said.

But Hodnett added that child protective services workers carefully assess the circumstances behind every call of suspected child abuse or neglect.

"DCFS takes these cases very seriously. These are some of the most vulnerable children," Hodnett said. "We must balance a parent's rights with our responsibility to protect children."

Negative babies, positive mothers

Ulich did not name patients directly, as doing so would violate federal law. But one case he described involved a mother who tested positive for meth and whose three other children already had already been taken from her.

The baby did not test positive for drugs. But concerned that he would be sending the baby home to experience "likely significant harm," Ulich called Webster Parish CPS and asked if it would open a case.

"I had them tell me the case 'does not meet the criteria,'" Ulich said.

Hodnett said babies who do not test positive for drugs, even when their mothers do, do not fit the criteria for being a "substance-exposed newborn."

For babies to be considered drug-affected newborns, they have to be no more than 30 days old, have withdrawal symptoms or positive toxicology screening results and have a mother who unlawfully used a controlled substance during pregnancy.

"The criteria for reports of prenatal neglect are clear, and if a report meets those criteria, we accept the case," she said.

Ulich said one problem with the state's current requirements is that babies exposed to meth often won't show what the state would classify as observable symptoms.

"A majority of babies with meth in their system don't have the same withdrawal as with narcotics," Ulich said. "They may be irritable, but not more irritable than the average baby."

Pramanik also said that babies born to drug-using mothers often will not test positive if the mother has not used drugs within the last 48 hours — unless given a "meconium" test, which he added is expensive.

"Once we say the baby's drug test is negative, they (CPS workers) are done. They will not open the case," Pramanik said. "They tell us, 'It's not a CPS case, the baby can go home,' and that's all we get from them."

Opening a case

Hodnett said doctors with concerns about babies who do not test positive for drugs can report those concerns as extenuating circumstances.

Ulich said that in at least one of the cases he reported as involving "extenuating circumstances," the case was not opened and the child died.

The case was from about nine years ago, Ulich said, and involved a mother living in a north Webster Parish town with her 3-month-old child. Nurses told Ulich the mother seemed "off" during an appointment: Her eyes were dilated, and she fell asleep while at the office with her baby still in her arms.

Ulich said he called Webster Parish CPS and asked that a social worker check on the child. The case was not opened, Ulich said, because it "did not meet the criteria."

Several weeks later the baby died in a hospital intensive care unit, the result of complications of shaken baby syndrome, Ulich said.

"I got a call from child protective services about 'Did I hear that this baby had died,' and I said, 'This is the same one I told you about three weeks ago,'" Ulich said. "If they had opened a case at that time, they probably could have saved this child's life."

Ulich, who followed the investigation into the child's death, learned the mother's boyfriend had shaken the baby when the baby's crying interrupted his playing video games. The investigation also revealed that the mother and her boyfriend had been selling drugs — including meth and crack cocaine — out of their home.

Hodnett said staff reviewed cases of substantiated child fatalities in the Shreveport Region — encompassing Bienville, Bossier, Caddo, Claiborne, DeSoto, Natchitoches, Sabine and Webster parishes — back through July 2011.

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The Department found one instance of a call about a potential substance-exposed newborn who was not accepted for investigation and later died.

In that case the mandated reporter stated that the mother had tested positive but was still waiting for test results to see if the baby had tested positive.

Hodnett said that the report did not contain additional information that would have indicated the child was at imminent risk of harm, and that "by law, the information reported did not meet the criteria for a case to be accepted for prenatal neglect."

DCFS never received word that the child had tested positive, and so a case was not opened, Hodnett said.

Hodnett added that the Department of Children and Family Services created a Centralized Intake Unit in 2011 to "dedicate staff to the intake function, thereby allowing a greater level of training and skill development" and to "ensure the laws and policies regarding reports of abuse and neglect are applied in a consistent way statewide."

Ulich said the new system has increased the trouble he's had connecting children with child welfare caseworkers even when he reports additional concerns.

Ulich said he now has to call an "800 number" to report suspected abuse and neglect. Staff at that number have a "checklist of criteria," Ulich said, adding that the list he's never seen doesn't leave much room for the extenuating circumstances he's been told to report.

"Unless I get loud and scream at the 800 number people and demand to speak to a supervisor, the case won't get opened," he said. "In the past 12 years, I'd estimate that I've had at least 12 to 15 patients experiencing severe abuse or neglect, and a case didn't get opened."

Substance-exposed newborns

Newborn babies who test positive for drugs are considered "substance-exposed."

Dr. Winston Koo, a former chief of neonatology at LSU Health Shreveport, told the Times in 2016 that most substance-exposed babies are sent home with their parents unless extenuating circumstances also are present.

Koo added that social worker checkups on a family will "in many cases" result in the baby then entering the child welfare system.

The Department of Child and Family Services has thus far reported 1,499 substance-exposed newborns in 2017 — nine more than in 2015, but almost 10 percent fewer than in 2016. A department spokeswoman said an additional 276 cases from 2017 remain open, meaning the year's tally may still grow.

About 70 percent of last year’s substance-exposed newborn cases that DCFS says it has validated either entered foster care (14 percent) or were transferred to family services (56 percent) within 60 days of the initial report, according to department data.

Hodnett described "family services" as an "in-home program that works with the family to prevent removal (of the child), while reducing any identified safety concerns and/or risk factors."

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Attending physicians, who are mandated reporters, have to report each case of a substance-exposed newborn to child protective services. Social workers can open cases on these children under the reporting category "pre-natal neglect."

CPS workers who open cases, based on state criteria, initiate an "assessment," which includes a safety and risk assessment and also a Plan of Safe Care, she said.

The Plan of Safe Care addresses the needs of the newborn and the family, which includes referring the parent for a substance abuse assessment and can also include a request for court-ordered services, a court-ordered safety plan, or custody of the newborn to state care, Hodnett said.

"If the child cannot remain safely in the home of their parent, DCFS would request custody of the newborn," Hodnett said. "However, it is our desire to maintain children in their home environment when safely able to do so."

A baby who tests positive for drugs will not be automatically removed from parents, Hodnett said.

"It's not a given that a parent who uses drugs cannot take care of their child," she said.

But Pramanik, the LSU Health Center neonatologist, said he's seen "horror stories" in his 35 years as a pediatrician.

One case involved a baby who was locked inside a closet while the parents were in the next room getting high. Another case involved an autopsy report that showed a substance-exposed newborn originally believed to have died from Sudden Infant Death Syndrome had actually suffered multiple fractures to the head.

Pramanik said his neonatology staff connect substance-exposed newborns to child protective services social workers. But he also acknowledged that Louisiana's child protective services staff have not always opened cases when his staff have voiced concerns.

"CPS has told me their hands are tied. I've been told it's because of state law, so that needs to change," Pramanik said. "The few rare examples I gave of where the baby passed away, that shouldn't have happened. It happened because these people are underfunded or the guidelines were too strict."

If a case is not opened, Pramanik said, he and other neonatology nurses flag their concerns in patient records so hospital staff can keep observe the children when the mothers come in for appointments.

But it's "a broken setup" that's part of a "broken system," he added.

"Unfortunately, our health care system is fragmented. We are relying on mothers to keep their appointments here," he said. "But the system is broken. There is no continuity of care.You hope and pray that you don't see a shaken child."

Pramanik said one of the best indicators of possible child abuse is when a mother avoids eye contact with her baby or otherwise does not interact with the baby during hospital visits.

"I've had babies where I'd call and say, 'Hey, the mother is not looking at the child,' which is a red flag, and then a few weeks later the baby is dead," Pramanik said.

Toward a better future

Substance-exposed newborns are among the most difficult for social workers to place, DCFS officials told The Times in 2016.

More: Homes needed more than ever for drug-exposed babies

Ulich said several hospitals in Arkansas have neonatology staff also licensed as foster care parents, so that substance-exposed newborns deemed in life-threatening danger can be placed immediately. Pramanik said several nurses he's worked with have fostered substance-exposed newborns.

Both doctors also said they were not advocating for automatic placement of newborns into foster care, but rather closer followup by the state.

"CPS should keep a closer eye on families. If the doctor feels like the baby is not doing well, they have to investigate that, and they should coordinate follow-ups with us," Pramanik said. "They should be our partners. It's the first few years that are the most formative. "

Pramanik said he'd also like more money placed into public health care and more public-private partnerships to increase resources for children and families.

DCFS Secretary Marketa Garner Walters said the department is "trying to do our very best for each child who comes to our attention."

But Walters noted the agency is working with a "constrained" number of staff — and significant budget cuts over the last few years.

The department's total budget for 2017-2018 is $786 million, of which slightly more than $174 million comes from the state's general fund, Walters said.

"The level of funding for DCFS in this year's budget does not even put us at what we are getting now," she said. "We are not getting any more humans. And we are still dealing with huge caseloads."

Walters said the national gold standard for caseloads of child protective services workers is a maximum of 10. But child protective services caseworkers in Shreveport carry average caseloads of 21 children each, DCFS data showed.

The department has taken significant steps to improve conditions for Louisiana's children, DCFS officials said.

Hodnett said the Department of Children and Family Services initiated legislation in 2017 to meet federal requirements of also addressing newborns affected by legal substances.

The department also recently initiated quarterly "stakeholder meetings," Hodnett said.

"The purpose of these meetings is to discuss the needs of substance-exposed newborns and their families, identify successes an barriers in meeting the needs of the newborns, and develop strategies to address any barriers identified," she said. "This would be an exceleent opportunity for any physician or other stakeholders to collaborate with DCFS in helping these families."

Walters said the agency also is working to see if it can pair social workers with substance abuse staff from the Department of Health at select birthing hospitals to ensure that mothers addicted to drugs receive needed help and counseling.

"We want to find out what happens to children. If we mess up, we will say so," Walters said. "We are trying to do our very best for every child that comes to our attention."

Resources for doctors

To report suspected prenatal neglect to the Child Protection Hotline: 1-855-4LA-KIDS (1-855-452-5437)

For more information about quarterly stakeholder meetings to discuss the needs of substance exposed newborns and their families: call Mona Michelli at (225) 342-6827 or email her at mona.michelli.dcfs@la.gov.

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