DFCS Online Policies & Procedures

  DFCS Online Policies & Procedures

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Handbook 3: Assessment Guides
3-10 Assessment of Medical Neglect
Assessment Guides
3-10 Assessment of Medical Neglect
Reference Points
Overview
A Referral Allegiing Medical Neglect
Belief Systems Influence on the Medical Treatment of the Child
Psycho-Social and Economic Circumstances Affect the Child's Medical Treatment


Reference Points
Effective Date: 03/01/2006
Last Updated: 12/30/2005
 Legal Basis:
Popup Window Welfare Institutions Code (WIC) Section 300(b)
 Non CWS/CMS Forms:
MS Word Authorization for Use and Disclosure of Protected Health Information (SCZ 244)
 CWS/CMS Forms:
bullet Health Care Notebook
bullet Contact Notebook
bullet Case Plan


Overview  

Medical neglect can have a wide range of effects on a child from minor detriment to life threatening consequences.  Medical neglect can be caused by intentional acts and/or deliberate omissions.  Medical neglect may also occur as a result of the parent/caregivers's own limitations, problems and/or belief systems, which inhibit the parent/caregiver's ability to properly address and provide for the child's health needs.

Medical neglect is legally defined in Section 300(b) of the Welfare and Institutions Code as "the willful or negligent failure of the parent or guardian to provide the child with... medical treatment."  It may also involve a parent's condoning or permitting a harmful act by another person that affects the health of the child in circumstances in which it would be reasonable possible to prevent the harm and/or a parent forcing, allowing, coercing the child to commit harmful acts that result in detriment to the child's health.

Assessment involves a variety of factors including, but not limited, to a familiarity with normal developmental health requirements for children, knowledge of medical conditions and an evaluation of the parent/caregiver's ability to meet the child's health needs.  The social worker must work closely with the PHN to clarify and define the issues involved in medical  neglect. 

The social worker may receive a referral with specific allegations of medical neglect or the referral may involve other allegations, such as substance abuse, domestic violence or general neglect.  In all referrals, the social worker is in the position to observe the child, to determine the specific health care needs of each child, and to make a conclusion as to whether these needs are being met by the parent/caregiver. 

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A Referral Alleging Medical Neglect  

When a social worker receives a referral alleging medical neglect:

  • To verify that the child has or had an untreated health problem or condition or that a prescribed treatment plan was not implemented, contact the mandated reporter and/or the child's health care provider or person who made the referral, to obtain more detailed information regarding: 
    • the nature of the health problems or condition;
    • the seriousness of the current health problem/condition;
    • the prognosis for the child if th eocndeition is not treated;
    • the efforts of the health cae professional to work with the parent/caregiver to provide the recommended treatment and the results of these efforts. 
 
  • Based on the child's age, assess for:
    • the child's level of physical/psychological dependence on the parent/caregiver;
    • the child's ability to comprehend the nature of his/her condition;
    • the child's willingness/ability to comply with the prescribed treatment, diet and or specific behaviors, to counteract such conditions as diabetes, anorexia/bullimia. substance abuse, sexually transmitted deiseases (STDs);
    • the child's emotional reaction to his/her condition.
  • Interview the parent/caregiver to determine:
    • their perception of the health needs of thier child;
    • the degree to which they acknowledge that they ahve complied with the recommended treatment plan as perscribed by a medical provider;
    • the use of any non-prescription, herbal and/or homeopathic medications/treatments that the parent(s) is giving to the child;
    • the medical history of the child, including medical professionals’ names, addresses, and telephone numbers;
    • their efforts to change/correct an older child’s non-compliant behaviors and negative attitude towards the illness, including participation in counseling;
    • the existence of any underlying problems, e.g., substance abuse, mental illness, developmental delay, which may effect their ability to follow through on appropriate medical care.
  • Obtain the parent's signature on the scz 244
  • When a parent/caregiver is absent and therefore unable to consent for routine and/or emergency medical treatment:
    • Assess for all issues of neglect and abuse to determine the need for protective custody of the child. 
    • Note, See
     
    • Consult with the PHN to:
      • obtain additional medical information and verify information from medical professionals as well as from the parents;
      • explain and clarify medical conditions, appropriate treatments and possible side-effects;
      • consult with the involved medical professionals regarding the possible effects/complications on the child’s health when the parent uses non-traditional treatments/medications on the child;
      • explore the need for a joint home call to observe the child and parent/caregiver;
      • assist with the child’s developmental assessment;
      • provide resources that address the specific medical condition;
      • contribute to the development of the health portion of the case plan.
  • Document information and observations in the Contact and Health Care Notebooks.
    • NOTE:  PHNs will also document their information and observations in the Contact and Health Care Notebook.
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Belief Systems Influence on the Medical Treatment of the Child  

When a social worker responds to situations in which beleif systems infulence the medical treatment of the child:

  • In situations where religious beliefs prohibit medical treatment resulting in risk to the child, assess for the following:
    • What are the parent(s) beliefs and do these beliefs follow the tenents and practices of any recognized church or religious denomination?
    • Does the spiritual practitioner used in lieu of medical treatment, have a health services or medical background?
    • Did the parent/caregiver make an informed, appropriate medical decision based on consultation with a doctor who examined the child?
    • What is the nature and likelihood of success of the treatment proposed by the parent/caregiver?
    • What are the risks to the child posed by the alternative treatment?
    • NOTE: See Emergency Medical Consent
  • When the culture of the child/family prescribes alternative treatment methods, e.g., cupping, coining or healing through curanderos, herbalists, spiritualists or uses medical practitioners/clinics of the same culture which are unlicensed and dispense illegal, inappropriate and/or ineffective medication:
    • Clarify with the family as to the degree, if any, that licensed medical personnel is involved to meet the child’s health care needs.
    • Obtain a signed scz 244 from the parent/caregiver and verify that the medical practitioner is aware that alternative methods are or were being applied that appropriate medical treatment in now being received.
    • Educate the parent/caregiver regarding the need for health care by licensed medical professionals in conjunction with traditional cultural methods.
    • If necessary, refer the family to appropriate resources.
    • NOTE: When a parent/caregiver refuses to consult with and/or utilize the services of a licensed medical professional to meet the child’s health care needs, consult with the PHN (refer back to section:  Consult with PHN) and, if appropriate, See Emergency Medical Consent.
  • When a child is in the end stages of a life threatening illness, and the parent/caregiver refuses the continuation of painful treatments/medications in favor of quality of life issues, consult with and rely upon the expertise of the medical profession to determine the appropriateness of this decision.
    • NOTE: When severely handicapped, but viable infants and children are involved, the decision by a parent/caregiver to withhold nutrition, hydration, medication or other medically indicated treatments is regarded as medical neglect.

  • When disagreements occur between the parent/caregiver and medical professionals or between the custodial and non-custodial parents regarding diagnosis and treatment (the use of psychotropic drugs, the over-diagnosis of certain disorders such as Attention Deficit/Hyperactivity Disorder, application of experimental treatments for terminal conditions, severe diets, food restrictions, indiscriminate use of vitamins and herbs to treat mild to severe illnesses, refusal to obtain childhood immunizations):
    • Focus the assessment on the health, safety and best interests of the child.
    • Verify through a Family Law Court Order which parent has the legal right to consent to the child’s treatment.
    • Follow steps outlined in Section A. to ensure that disagreements in opinions are not misconstrued as medical neglect.
    • Verify that the child’s medical practitioner is aware of any alternatives (foods, herbs, vitamins) used by the parent/caregiver.
    • Consult with the PHN for assistance in obtaining and/or clarifying medical information.
    • Document all findings and observations in the Contact and Health Care Notebooks.
    • NOTE: PHNs will also document their information and observations in the Contact and Health Care Notebooks.
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Psycho-Social and Economic Circumstances Affect the Child's Medical Treatment  

When a social worker responds to situations in which psycho-social and economic circumstances affect the child's medical treatment:

  • Consider that the family's econoic status may contribute to medical neglect in the following ways:
    • insufficient or no medical/dental insurance,
    • a shortage of doctors/dentists/specialists serving poor communities, resulting in long waiting times for treatment, less preventative care, increased usage of unlicensed practitioners
    • inadequate means of transportation and lack of child care (for siblings) interfere with keeping scheduled appointments.
  • Identify support systems and refer the family to appropriate resources to resolve the issues of obtaining child care, transportation, medical and dental care.
  • Evaluate possible commnication issues between the parent/caregiver and medical provider such as:
    • illiteracy or developmental delays affecting the client’s ability to read, follow complex medical instructions or obtain prescriptions,
    • language barriers between non-English speaking families and medical personnel who only speak English,
    • language barriers between non-English speaking families and medical personnel who only speak English,
    • failure of a family to notify the medical provider that they have moved and/or chosen to continue critical care at another facility,
    • lack of information about the nature and severity of the medical condition.
  • When the child is identified as experiencing severe medical neglect/abuse and the diagnosis of Munchausen Syndrome by Proxy is suspected, consider referral to a scan team and/or physician with expertise in Munchausen Syndrome by Proxy. Always rely on the client’s medical practitioner for this diagnosis. The following should be done to prepare information to present to the Juvenile Court on behalf of the child:
    • Consult with the PHN to assist with a referral to a scan team and/or a physician with expertise in Munchausen Syndrome by Proxy.
    • Consult with the PHN to gather medical information regarding the child’s medical records from all facilities visited, missed appointments, hospital discharges against medical advise and patterns in the medical problems presented.
    • Review the medical records with the assistance of the PHN and look for such symptoms as vomiting, diarrhea, asthma/allergies, infection, seizures and failure to thrive.
    • Verify with hospital medical staff the nature of the parent/caregiver’s involvement in the child’s treatments (requests for tests, medications, surgery) and whether or not the parent/caregiver has had a psychiatric history and or evaluation [the most common diagnosis for most perpetrators is Factitious Disorder, Not Otherwise Specified (NOS)].
    • Maintain contact with the child’s health care provider for updates on the child’s condition and response from the parent.
    • Pending a court order, request that the medical staff be diligent regarding the parent having limited and closely monitored access to the child.
  • Document all findings and observations in the Contact and Health Care Notebooks.
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