Abstract
Abstract
The Flint, Michigan, water crisis, in which lead leached into the city's drinking water, has wreaked havoc on the developmental and mental health of Flint residents, with children being particularly vulnerable to the effects of the crisis. Lead exposure is linked to neurodevelopmental challenges in children, even at very low levels of exposure. In addition, disasters—both natural and manmade—can result in serious negative mental health consequences, such as post-traumatic stress and fear, anxiety, and depression. Given the wide-ranging and long-term nature of these risks, the developmental and mental health of Flint children must be prioritized through response efforts and spending. Proven, evidence-based treatment and interventions should be implemented to give children their best chance at overcoming the effects and trauma of lead exposure. This article examines responsive measures already initiated by federal, state, and local governments to address the negative health consequences of the crisis on children and considers additional legal and policy interventions that may be employed to maximize the developmental and mental health of Flint children after the water crisis.
Introduction
I
The developmental and mental health effects of the crisis are likely to plague the Flint community for years into the future and, if unaddressed, may persist into adulthood for Flint children. Given the wide-ranging and long-term risks, the developmental and mental health of Flint children must be prioritized through response efforts and spending. This article examines responsive measures already initiated by federal, state, and local governments to address the negative health consequences of the crisis on children and considers additional legal and policy interventions that may be employed to maximize the developmental and mental health of Flint children after the water crisis.
Discussion
Developmental and mental health impacts of the Flint water crisis
Developmental impacts
Children are more sensitive than adults to neuropsychological effects of lead, because their central nervous systems are still developing and, therefore, more vulnerable to toxicants. 4 The significant neuropsychological impacts of childhood lead exposure are well documented, and experts have determined that there is no safe level of lead exposure for children. 5 Indeed, numerous studies have linked elevated blood lead levels with decreased IQ at levels well below 10 μg/dL, 6 which was the Centers for Disease Control & Prevention's (CDC) “level of concern” until only recently. 7 The CDC replaced the term “level of concern” with “reference value” and adopted a reference value of 5 μg/dL in 2012. 8
Specific cognitive functions affected by lead exposure include attention and executive functions, 9 visual-motor integration, 10 fine and gross motor skills, 11 verbal skills, 12 and learning. 13 Behavioral challenges are also associated with lead exposure, including “withdrawn, easily frustrated, hyperactive, and inattentive behavior in early childhood” and “aggressive, antisocial, and delinquent” behavior in adolescence. 14 Higher blood lead levels are also associated with increased risk of attention deficit hyperactivity disorder (ADHD). 15
Cognitive and behavioral effects of lead exposure persist over time and may yield adverse educational and social outcomes. 16 For example, early lead exposure is associated with reading disabilities 17 and poor academic performance in school, 18 as well as with decreased intellectual functioning in adulthood. 19 In turn, educational underachievement is associated with reduced wages, reduced participation in the workforce, and reduced lifetime earnings. 20 Studies have also linked early childhood lead exposure to delinquent behavior 21 and higher rates of adult arrests. 22 At least one study has observed that the association between lead exposure and criminal behavior may be largely explained by negative educational outcomes linked to lead exposure. 23
There is little research available to guide cognitive and behavioral interventions for children who have been exposed to lead. 24 Nevertheless, evidence suggests that an enriched environment (defined as including “complex inanimate objects and social stimulation” 25 ) may mitigate the cognitive and behavioral effects of lead exposure. 26 For example, a 2013 study found that an enriched home environment, demonstrated by maternal support of children's school work and extracurricular activities, was associated with less detrimental behavioral and cognitive effects of lead exposure. 27 Early childhood education programs, shown to have long-lasting positive impacts among children with and without disabilities and their families, have been identified as a promising strategy for ameliorating the effects of lead on child neurodevelopment. 28
Mental health impacts
It is well documented that childhood lead exposure results in cognitive function and behavioral deficits, but much less is known about the mental health effects of lead exposure on children or the consequences of childhood lead exposure in adulthood. Though little evidence exists regarding the mental health effects of lead exposure on children, there is some research on lead exposure in young adults and the general adult population
Elevated blood lead levels in young adults have been associated with adverse psychiatric outcomes, including an increased incidence of major depression and panic disorder. Researchers have found that individuals in the highest quintile for blood lead level (>2.1 μg/dL) had 2.3 times the odds of developing a major depressive disorder and 4.9 times the odds of developing a panic disorder versus those in the lowest quintile (<0.7 μg/dL); thus, exposure to lead at levels generally considered safe could result in adverse mental health outcomes for adults. 29 These researchers theorized that even low-level lead exposure disrupts brain processes associated with depression and panic disorders, triggering the development of such conditions in people predisposed to them, thus making the conditions more severe or reducing the response to treatment. 30 Research has also suggested a synergistic link between lead exposure during early life and a genetic risk factor for schizophrenia; thus, the risk of a genetically pre-disposed individual developing schizophrenia may increase with exposure to lead. 31
Beyond the direct neuropsychological effects of elevated blood lead levels, children affected by the Flint water crisis may experience mental health effects commonly seen in victims of disasters and other traumatic events. Children exposed to trauma, including natural and man-made disasters, exhibit symptoms consistent with individuals diagnosed with post-traumatic stress disorder (PTSD), attention deficit/hyper-activity disorder, depression, and conduct disorder/oppositional defiant disorder. 32
Legal & policy interventions
After the poisoning of Flint's water system was uncovered in the Fall of 2015, the county, city, state, and federal governments declared a state of emergency in the city and began to mobilize response efforts and funding. 33 Portions of this funding have been allocated to efforts that may directly or indirectly reduce long-term neurodevelopmental and mental health impacts on children.
Existing interventions
Initial government and community efforts focused on providing water filters and bottled water to Flint residents. 34 State and local discussions regarding replacement of lead pipes throughout the city are ongoing due to the high cost of such a project. Efforts to eliminate the source of lead exposure are critical first steps toward preventing further developmental and mental harm to exposed children.
Additional funding has been allocated to support increased blood lead testing of Flint children, continuous monitoring to increase the likelihood that exposed children will access needed services, and targeted nutrition supplementation to reduce absorption of lead. 35 Federal and state policy measures designed to mitigate long-term effects of lead exposure on Flint children include increased funding to support early childhood education programs and access to behavioral health services.
A significant legal intervention is the expansion of Medicaid for Flint residents effected by the water crisis. The Centers for Medicare & Medicaid Services (CMS) approved Michigan's five-year demonstration project under section 1115(a) of the Social Security Act on May 6, 2016, after an expedited review process enabled by President Obama's emergency declaration. 36 The project expands eligibility for Medicaid coverage in Flint beyond standard federal guidelines, covering all Flint children up to age 21 and pregnant women who have incomes up to 400% of the federal poverty level. 37 The project increases access to physical and behavioral health services (including mental health services) for Flint children and enables provision of targeted case management services to link children to social and educational services. 38
The U.S. Department of Health and Human Services (HHS) doubled Michigan's Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program grant, 39 provided additional funds to Flint's federally qualified health centers for activities responsive to lead poisoning, 40 and provided additional funds to Head Start grantees to expand and increase access to services. 41
The Michigan state government has also appropriated funding and expanded access to early childhood development and education programs in Flint. For example, the state allocated funds to support the provision of early intervention services similar to those described in the Early On state plan 42 to children under 4 years old as of September 1, 2016, and to ensure Flint children are assessed and evaluated at least twice annually to determine their need for services. 43 Additional funds have been allocated to enroll Flint children in Great Start Readiness programs 44 regardless of household income eligibility requirements. 45 Other appropriations support early literacy programs, summer preschool and early childhood programs, employment of school nurses and social workers, intensive behavioral health services, evidence-based home visiting programs, and child and adolescent health centers in Flint. 46
Potential legal and policy interventions
Interventions to address developmental issues
Expanded access to early childhood and special education services
The neurodevelopmental effects of lead exposure cannot be reversed through medical care or nutrition, so cognitive and behavioral deficits resulting from lead exposure could have lifelong impacts for affected children. 47 As one of the only evidence-based interventions thought to mitigate or reverse the effects of lead exposure, environmental enrichment is a tool that must be vigorously employed. Increased and sustained funding of early childhood education and development programs such as Michigan's Early On and Great Start programs is, therefore, essential to combatting neurodevelopmental damage among children exposed to lead. 48 Access to special education and other early intervention services should be expanded for older children experiencing developmental delays as well, particularly as very young children advance to elementary and high school.
Potential legal levers for expanding access to early childhood and special education services exist under the Individuals with Disabilities Education Act (IDEA) Parts B and C. 49 Part B of the Act governs special education services provided to children aged 3–21 to ensure individuals with disabilities receive a “free appropriate public education,” 50 and part C governs provision of services to infants and toddlers under age 3. 51 Early On is Michigan's Part C program. 52
One opportunity for expansion exists under IDEA Part C. Under Michigan's current Early On rules, children are eligible for services if they experience a developmental delay or have been diagnosed with an “established condition” defined by the state. 53 Lead exposure resulting in a blood lead level at or above the CDC reference value (5 μg/dL) constitutes a qualifying established condition in Michigan if it is diagnosed. 54 However, many children in Flint may have experienced elevated blood lead levels that were not timely diagnosed, so they may be at risk for developmental delays but ineligible for Early On services. Thus, the Michigan Department of Education should consider expanding Early On eligibility to include at-risk children as permitted under IDEA Part C. 55 Several states have implemented this option by establishing a list of risk factors, of which a certain number must be present to qualify for services in the absence of an established condition or existing developmental delay. 56 Michigan could similarly amend its Early On state plan to enable provision of services to children exposed to lead poisoned water and/or other risk factors. 57
Another opportunity, created through a 2004 amendment to the IDEA, allows local educational agencies to use up to 15% of funds provided under IDEA Part B for scientifically based coordinated early intervening services (CEIS). 58 CEIS may be provided to students in kindergarten through grade 12 (with particular emphasis on kindergarten through grade 3) who do not need special education services but “need additional academic and behavioral support to succeed in a general education environment.” 59 The rationale behind the program is that learning issues that are identified and addressed earlier will be more easily ameliorated or reduced. 60
Finally, eligibility for special education services could also be expanded to the limits permissible under federal law. Part B requires provision of services to children with specified disabilities, but it gives states discretion to expand eligibility to children aged 3–9 (or subsets of that age range) who do not have disabilities but who are experiencing developmental delays defined by the state in areas of physical, cognitive, communication, social or emotional, or adaptive development. 61 Michigan's regulations, however, define “early childhood developmental delay” to include children through age 7 “who manifest[] a delay in 1 or more areas of development equal to or greater than 1/2 of the expected development.” 62 To maximize provision of special education services before children fall behind in school, the definition of developmental delay in Michigan could be expanded to include children through age 9 and to address developmental delays sooner rather than waiting until a child has fallen far behind.
School discipline policy reforms
Given the importance of environmental enrichment to mitigate harmful effects of lead exposure—combined with the increased likelihood of behavioral challenges—existing state school discipline laws and local policies should be evaluated to determine whether they are designed in a manner that facilitates Flint students' success. Careful attention should be given to reforming exclusionary discipline practices such as expulsion and suspension, since these practices are often developmentally inappropriate for both young children and adolescents and may exacerbate normal developmental challenges. 63 Moreover, exclusionary policies are not supported by evidence and are, in fact, associated with adverse outcomes, including increased likelihood of academic failure, grade retention, dropping out of high school, and incarceration. 64 Nevertheless, exclusionary discipline occurs at high rates across the county, even in early childhood programs. 65 In addition, suspensions are frequently given for minor misbehaviors such as truancy that are unlikely to be improved through time away from school. 66
Despite the lack of evidence supporting exclusionary discipline, Michigan has among the most expansive zero tolerance laws 67 in the country, requiring mandatory expulsion for four types of offenses 68 rather than only for bringing or possessing a firearm at school as required by the federal Gun Free Schools Act of 1994. 69 To support continued education and enrichment rather than exclusion from school, state and local school discipline policies should be reviewed and revised to promote evidence-based discipline practices—such as bullying prevention, restorative justice, and positive behavior interventions 70 —for minor misbehaviors rather than expulsions, suspensions, or other exclusionary practices. In addition, state zero tolerance laws should be eliminated (except as specifically required by federal law) in favor of policies allowing greater flexibility for school staff to use graduated and alternative disciplinary strategies. 71 Implementation of some alternative discipline strategies, such as Positive Behavioral Interventions and Supports, may be supported by the federal IDEA Part B CEIS funds described earlier. 72
Developmentally appropriate juvenile justice
Behavioral issues are likely to escalate in later childhood if not appropriately addressed and may lead to interactions with the juvenile justice system. However, as noted by Dr. David Arredondo, an expert in child development and mental health, “developmentally inappropriate sanctions by a juvenile court” may lead to negative developmental consequences in children who are “still in the process of neurobiological, psychological, social, and moral development” and still forming their identities and struggling for autonomy. 73 For example, perceptions of unfairness or indifference may cause children to “lose respect for the social system that the court represents.” 74 Thus, an important opportunity to intervene in a manner that promotes a child's development lies with the juvenile justice system.
To avoid exacerbating normal developmental challenges as well as those associated with lead exposure, juvenile courts must be cognizant of the developmental stage of a particular offender and must craft an appropriate response that is fair, firm, and predictable, but not indifferent to the child's individual circumstances and identity. 75 Dr. Arredondo cautions that sanctions must be designed for the offender rather than the offense, such that the type, immediacy, duration, and frequency of sanction should be developmentally appropriate. In addition, the court process should be personal and respectful, and sanctions should be developmentally appropriate and evidence based. Most evidence-based sanctions occur in the community and home rather than through boot camps or incarceration. 76 Equipping Genesee County's juvenile prosecution division and juvenile court with education and training on child development and evidence-based disciplinary strategies provides an important avenue for protecting and promoting the well-being of lead-exposed children as they enter adolescence.
Interventions to promote mental health
Increased access to mental health treatment
The expansion of Medicaid for Flint residents affected by the water crisis is important for children's access to mental health services, especially since the Mental Health Parity and Addiction Equity Act (MHPAEA) guarantees financial parity for mental health services coverage for Medicaid beneficiaries participating in Managed Care Organizations, State alternative benefit plans, and the Children's Health Insurance Program. 77
Yet having coverage for mental health services is not enough to ensure the actual provision of services to Flint children. Genesee County has been designated as an HRSA Health Provider Shortage Area (HPSA) in Mental Health, 78 meaning that there are more than 30,000 people per psychiatrist. 79 This lack of mental healthcare providers means that many children will be unable to access mental health services, because they cannot obtain an appointment with a mental health provider.
There are several policy solutions that could be implemented to address this shortage. The National Health Service Corps Loan Repayment and Scholarship Programs is a federal program that is aimed at helping underserved communities recruit mental and behavioral health professionals. The Michigan State Loan Repayment Program is a similar state grant program that offers educational loan repayment programs for providers working in HPSAs. 80 The incentives under these programs could be increased for mental health professionals serving Genesee County.
The use of telemedicine could also increase access to mental healthcare providers for Flint residents. Under Medicaid, telepractice services can be authorized to teach parents to provide individualized interventions to their child and to engage in behavioral health clinical observation and direction. Qualified providers include board-certified behavior analysts, board-certified assistant behavior analysts, licensed psychologists, limited licensed psychologists, and qualified behavioral health professionals. 81 But to obtain services, patients must have a facilitator trained in telepractice technology physically present during the session. A telemedicine site that provides facilitators to patients should be established for Flint residents to allow them greater access to mental health services.
Trauma-informed care for affected youth
After a traumatic event, it is common for most people to have some kind of stress reaction, including a full range of mental and physical reactions. Some problems that manifest after a traumatic event include PTSD, depression, guilt or self-blame, suicidal thoughts, anger, aggressive behavior, and alcohol or drug use. 82 Recovery often occurs gradually, but some individuals may have a harder time recovering from trauma, especially those who think they have little control over what happens to them or lack the capacity to manage stress. 83 The City of Flint has been under the control of a state-appointed emergency manager for years, leaving many residents feeling disenfranchised and unable to make their voices heard or exert control over their community and lives. 84 This feeling of helplessness may put Flint residents at greater risk of the effects of trauma.
There is significant research on the effects of trauma on youth. The effects of trauma are additive and several traumatic experiences, such as being the victim of violence, abuse, or neglect, intersect to increase a person's risk for poor health outcomes. 85 Genesee County has almost twice the violent crime rate as the State of Michigan as a whole, 86 putting Flint children at greater risk of experiencing the compounding effects of multiple traumas. People who experienced trauma as children are also more likely to develop life-long psychiatric conditions, including personality disorders, conduct disorder, ADHD, depression, anxiety, substance abuse disorders, and PTSD. 87 They are also more likely to be perpetrators or victims of violence. It is, therefore, not surprising that youth in the juvenile justice system have experienced a disproportionately high number of traumatic events. 88 Childhood trauma is a specific risk factor for future involvement with the justice system. 89
Trauma can be treated and so it is crucial that a system be developed to address the traumatic experiences of the Flint water crisis before affected children enter the juvenile justice or criminal justice systems. Child-serving organizations, such as social services, public health, education, and medical providers, must routinely screen for and refer children for high-quality, evidence-based trauma-informed treatments and interventions.
It is crucial to screen all children entering the juvenile justice system for trauma and to provide affected youth with evidence-based trauma-informed treatment. For trauma-affected youth, it is also important to consider alternatives to incarceration, since incarcerated youth generally experience poorer health outcomes, including increased suicidal behavior, stress-related illness, and psychiatric problems, than youth who remain in the community. 90 In addition, children with trauma-induced PTSD who are diverted to mental health treatment, rather than juvenile detention centers, demonstrate higher recovery rates and lower recidivism. 91
Community resilience support
In addition to the effects of a disaster on individuals, the City of Flint has suffered a traumatic event that will continue to influence the community for years to come. In the community resilience context, a disaster is an event that impacts the entire community and has the potential to overwhelm local resources. The effects of a disaster are usually protracted and most residents are distressed by the event. 92 This almost perfectly describes the Flint water crisis.
If a community is resilient, the community will be able to respond to adversity in a healthy manner, coping and reestablishing stability after a disaster. If a community lacks resilience, a disaster can take a toll on residents' sense of safety and security, emotional well-being, and trust in community leaders to effectively help the community recover. 93
Some factors that enhance community resilience include access to support services, community networking, strong cultural identity, strong social support systems, norms against violence, identification as a community, and cohesive community leadership. 94 Flint's control by a state-appointed emergency manager for many years has had detrimental effects on many of these factors and has left the city unable to cope with the disaster in a healthy way. In addition, conflicts between the City of Flint and the State of Michigan have prevented the development of strong partnerships within and between government and nongovernmental organizations that is necessary for community resilience.
Research has shown that to improve recovery from disasters, all levels of a community, including individuals, organizations, businesses, government, and private entities, need to work together. 95 For the Flint community to recover, these entities within Flint and across Michigan must develop a community resilience strategy for Flint, with a particular focus on community wellness and access to high-quality physical, behavioral, and mental health, and social services to mitigate the ongoing mental health effects of the water crisis. A number of organizations, such as RAND 96 and the U.S. Department of Homeland Security, 97 provide guidance documents and training tools to assist communities in developing and implementing a community resilience strategy.
Litigation and medical-legal partnership
Several legal mechanisms for protecting children's developmental and mental health already exist but must be implemented and enforced with renewed rigor after the Flint water crisis. For example, eligible students with disabilities are entitled to a “free and appropriate public education,” including special education and related services, under the Individuals with Disabilities Education Act (IDEA). 98 The IDEA also provides procedural safeguards for children with disabilities in the context of disciplinary action. 99 Section 504 of the Rehabilitation Act 100 and Title II of the Americans with Disabilities Act 101 provide additional protection for children with disabilities by prohibiting public entities, including schools, from discriminating against individuals with disabilities. Because these well-established laws are not always adequately implemented at the state or local level, litigation may provide an important avenue for ensuring that Flint's children are able to access the full range of services and educational opportunities to which they are already entitled under law.
Litigation may take the form of high-impact class action lawsuits, such as a lawsuit filed recently by the American Civil Liberties Union and the Education Law Center on behalf of thousands of Flint children who have, or are at risk of developing, a disability due to exposure to lead in their drinking water. 102 Litigation or other advocacy may also be needed on a more individual basis as well. For example, a child facing a suspension or expulsion from school for a minor offense may need an advocate to challenge the chosen form of discipline. Poverty, mediated by parenting and stressful life events, is associated with inhibited neurodevelopment in children 103 ; thus, families may benefit from having an advocate to ensure they receive appropriate public benefits and to help overcome obstacles to employment, safe housing, and a stable home life. These issues may be addressed with the assistance of a civil legal aid attorney. A medical-legal partnership—a model that integrates free legal assistance into healthcare to address social determinants of health 104 —could provide an opportunity for families in Flint to access the additional supportive services they need to improve children's health and development after the Flint water crisis.
Conclusion
The physical, developmental, and mental health of Flint's children is in serious jeopardy due to the devastating and avoidable events of the Flint water crisis. Without further action, many Flint children will experience neurodevelopmental challenges and serious mental health consequences such as PTSD, anxiety, and depression. Research has shown that without proper treatment, these negative effects will last a lifetime and may extend to future generations. Local, state, and federal governments have already initiated some legal and policy measures to address negative health outcomes, but much more is needed to fully mitigate possible negative outcomes. Proven, evidence-based treatment and interventions should be implemented to give children their best chance at overcoming the effects and trauma of lead exposure. The developmental and mental health need of children must be of first priority, as all levels of government work to respond to the Flint water crisis.
Footnotes
Author Disclosure Statement
No competing financial interests exist.