This policy advises CSWs on how to assess for medical neglect in order to determine what, if any, services are needed to meet the family’s and child’s protection needs.

This policy guide was updated from the 07/21/09 version, as part of the Policy Redesign, in accordance with the DCFS Strategic Plan.

Medical Neglect of Children

The following actions and circumstances may constitute medical neglect:

• Intentional acts and/or deliberate omissions by a parent/caregiver
• Parent/Caregiver limitations, problems, or belief systems that inhibit their ability to properly address and provide for the child’s health needs
• A parent/caregiver’s decision to withhold nutrition, hydration, medication, or other medically indicated treatments when a severely handicapped, but viable infant or and child is involved

In all referrals, whether specifying medical neglect or not, the CSW 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. The CSW must work closely with the Public Health Nurse (PHN) to clarify and define the issues involved in medical neglect.

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, the CSW should consult with the PHN and requests emergency medical consent, if needed.

Receiving a Referral of Alleged Medical Neglect

ER/ERCP CSW Responsibilities

1. Contact the mandated reporter, the child’s health care provider, and/or the person who made the referral to obtain more detailed information regarding:
   1. The nature of the health problem(s) or condition(s)
   2. The seriousness of the current health problem or condition
   3. The prognosis for the child, if the condition is not treated
   4. The health care professional’s effort to work with the parent/caregiver to provide the recommended treatment and the results of these efforts.
2. Consult with the PHN to:
   1. Obtain and verify medical information from medical professionals and the parent(s)/caregiver(s) that clarifies and verifies:
      1. Existing medical conditions
      2. Appropriate treatments
      3. Possible treatment side-effects
      4. Any untreated health problem(s) or condition(s)
      5. Any un-administered prescribed treatment plans
   2. Discuss the effects and complications to the child’s health when the parent uses non-traditional treatments/medications on the child.
   3. Explore the need for a joint home call to observe the child and parent/caregiver.
   4. Assist with the child’s developmental assessment.
   5. Develop the health portion of the case plan.
3. Interact with the child and assess whether the child behaves in an age and developmentally appropriate manner. Based on the child’s age, specifically assess for the child’s:
   1. Level of physical/psychological dependence on the parent/caregiver
   2. Ability to comprehend the nature of their condition
   3. Willingness and ability to comply with the prescribed treatment plans
   4. Emotional reaction to their condition
4. Interview parents/caregivers to determine:
   1. Their perception of the health needs of the child
   2. Their acknowledged compliance with the medical provider’s recommended treatment plan
   3. The use of any non-prescription, herbal and/or homeopathic medications/treatments on the child
   4. The medical history of the child
   5. Their efforts to correct an older child’s non-compliant behaviors and negative attitude towards the illness, such as participation in counseling
   6. Any underlying problems with the parents/caregivers (e.g., substance abuse, mental illness, developmental delay) that may affect their ability to follow through on appropriate medical care.
5. Provide the parent/caregiver with resources that address the specific medical condition.
6. Complete the DCFS 179 for each health or mental health care provider and obtain the signature of parent(s), as appropriate.
7. 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.
   1. Pursue a request for medical consent and/or emergency medical consent.
8. Document all information and observations in the Contact Notebook and Health Notebook.

Responding to a Parent’s Belief System that Affects Medical Treatment

ER/ERCP CSW Responsibilities

1. Assess the nature of a non-medical treatment, when recommended based on the religious beliefs of a parent/caregiver. Also assess for:
   1. The parent’s beliefs follow the tenets and practices of a recognized church or religious denomination
   2. Likelihood for success
   3. Risks to the child
   4. The spiritual practitioner used in lieu of medical treatment. Ensure they have a medical background
   5. Medical decisions are based on consultation with a doctor who examined the child
2. Consult with the PHN for assistance in obtaining and/or clarifying necessary medical information.
3. In situations where the cultural beliefs of a parent/caregiver prescribe alternative treatment methods, the use of unlicensed medical practitioners/clinics of the same culture, or the dispensation illegal, inappropriate and/or ineffective medication:
   1. Clarify with the family the degree to which licensed medical personnel are involved.
   2. Obtain a signed DCFS 179-PHI from the parent/caregiver. Verify that:
      1. A medical practitioner is aware of alternative methods being applied
      2. Appropriate medical treatment is now being received
   3. Educate the parent/caregiver regarding the need for licensed health care and provide resources, as necessary.
   4. Mediate disagreements between the parent/caregiver and medical professionals, regarding the child’s diagnosis and treatment:
      1. Focus the assessment on the health, safety and best interests of the child.
      2. Verify through a Family Law Court Order which parent has the legal right to consent to the child’s treatment.
      3. Verify that the child’s medical practitioner is aware of any medical alternatives (foods, herbs, vitamins) used by the parent/caregiver
4. Assess for and respond to allegations of medical neglect to ensure that disagreements in opinions are not construed as medical neglect.
5. Document all findings and observations in the Contact Notebook and Health Care Notebook.

Evaluating How the Parent’s Circumstances Affect the Child’s Medical Treatment

ER/ERCP CSW Responsibilities

1. Consider how the family’s economic status may contribute to medical neglect, including:
   1. Insufficient or no medical/dental insurance
   2. A shortage of access to doctors/dentists/specialists
   3. Inadequate means of transportation
   4. Lack of child care
2. Identify a family’s support systems.
3. Refer the family to appropriate resources to resolve issues of obtaining child care, transportation, medical and dental care.
4. Evaluate possible communication barriers for the parent/caregiver that may affect interactions with a medical provider, including:
   1. Illiteracy or inability to speak English
   2. Developmental delays
   3. Language barriers
   4. Lack of information about the nature and severity of the medical condition
5. In preparation of Juvenile Court cases regarding suspected diagnoses of Munchausen Syndrome by Proxy:
   1. Always rely on, and maintain contact with, the child’s medical practitioner
   2. Consult with the PHN to:
      1. Assist with a referral to a Suspected Child Abuse and Neglect (SCAN) team and/or an experienced physician.
      2. Gather medical information regarding the child’s medical records, including all facilities visited, missed appointments, hospital discharges against medical advice, and medical patterns.
      3. Review medical records for such medical symptoms, including vomiting, diarrhea, asthma, infection, seizures, & failure to thrive.
   3. Verify with hospital medical staff:
      1. The parent/caregiver’s involvement in the child’s treatment
      2. Whether the parent/caregiver has a psychiatric history and/or has had a psychiatric evaluation.
      3. Pending a court order, request medical staff ensures the parent/caregiver have limited and closely monitored access to the child.
6. Document all findings and observations in the Contact Notebook and Health Care Notebook.

PHN Responsibilities

1. In cases and allegations of medical neglect, PHNs are responsible for:
   1. Defining issues involved in medical neglect
   2. Providing the CSW with medical information needed to verify medical neglect
   3. Offering clarification of medical conditions and appropriate treatments resulting from allegations of medical neglect
   4. Providing consultation to the CSW 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
   5. Assisting the CSW in obtaining medical information and in obtaining a referral to a SCAN team and/or a physician with expertise in cases regarding the suspected diagnosis of Munchausen Syndrome by Proxy
   6. Documenting all information and observations in the Contact Notebook and Health Notebook

PHN Approval

• To define issues involved in medical neglect
• To obtain medical information, needed to verify medical neglect
• To obtain referral and medical information regarding the suspected diagnosis of Munchausen Syndrome by Proxy

Forms

LA Kids

DCFS 179, (Spanish), Parental Consent and Authorization for Medical Care

DCFS 179-PHI (Spanish) (Armenian), Authorization for Disclosure of Child’s Protected Health Information

Referenced Policy Guides

0070-501.10, Communication Needs of Non-English Speaking Clients

0070-516.10, Assessing a Child's Development & Referring to a Regional Center

0070-524.10, Assessment of Failure to Thrive

0070-548.10, Investigation, Disposition and Closure of Emergency Response Referrals

0070-548.24, Structural Decision Making (SDM)

0070-548.25, Structured Decision Making (SDM) Safety Plans

0070-560.05, Joint Response Referral: Consulting with PHN

0600-500.20, Health and Medical Information

0600-501.10, Consent for Routine Medical Care

0600-501.15, Consent for Emergency Medical Care

0600.501.11, Cessation of Life-Sustaining Medical Treatment for Children