31: Medical Neglect

1. Definition of:
• Medical Neglect: The denial or deprivation, by those responsible for the care, custody, and control of the child, of medical or surgical treatment or intervention which is necessary to remedy or ameliorate a medical condition which is life threatening or causes injury. Medical Neglect includes not only serious, but mild and moderate medical neglect as well.
• Exception by Reason of Religious Belief: Failure to obtain specified medical treatment because of the legitimate practice of religious belief on the part of the child's parents, guardian, or others legally responsible for the child, will not be considered to be abuse or neglect. However, the juvenile court may order that medical services be provided to the child in such a situation if such services are necessary for the health of the child.
• Medical Malpratice and Negligence: Licensed medical practitioners who through negligence fail to provide adequate care and treatment to a child are not perpetrators of medical neglect. A person must have care, custody and control of a child to be considered a perpetrator of medical neglect.
2. Physical Indicators / Characteristics of Medical Neglect:

The indicators of child abuse and neglect vary. No child or caretaker will exhibit all of the physical or behavioral indicators listed, and some of the indicators are contradictory. The behavior of an abused or neglected child and other family members may be sporadic and unpredictable. Indicators should be used only as a general guide. The presence of multiple indicators or the pervasiveness of any one behavioral indicator warrants close scrutiny by the worker.

• Untreated serious physical or psychological illness or injury;
• Developmental delays (see Developmental milestones of children chart in appendix);
• Failure to thrive (see failure to thrive in appendix section).

Parental / Familial Characteristics

• Highly stressful family situations
• Single parent family
• Several children
• Recent marital problems
• Insufficient financial and other resources for medical care
• Isolation within the neighborhood
• Isolation from family members
• No community support systems
• Coldness, inability to empathize with child's needs
• Chemical dependency
• Loneliness
• Poor self-esteem
• Immaturity
• Dependent
• Lack of responsibility, poor or distorted judgement
• Depressed
• Parents' histories also reflect neglect
• Parents are indifferent, emotionally detached from each other and/or the children
• Disorganized, inconsistent family life
• Parents are unable to make decisions, passively accept events
• Parents are unwilling to accept referrals for tangible services
• Mental retardation
• Character disorder
• Emotional illness

Other Factors to Consider

• Failure of parent to follow through on a medical professional's advice/instructions
• Failure to seek treatment impairs the child physically or emotionally
• Parent is aware of the child's condition and risk of further harm to the child
• Parent fails to seek adequate treatment despite financial or other reasonable means to do so
3. Types of Evidence:

Evidence is collected by law enforcement personnel, Children’s Division (CD) and multi-disciplinary team members and used as both physical and credible verbal evidence to document the worker's investigative conclusion. Evidence for reports of medical neglect may include any one or all of the following:

• Child's Statement;
• Licensed Medical Practitioner Report;
• Perpetrator's Statement;
• Witness' Statement.

Chapter 210 requires the investigator to conduct a thorough investigation. To that end, investigators are allowed to contact anyone with information relevant to the CA/N report without the knowledge and/or consent of the subjects. This includes interviewing the child without the knowledge and/or consent of the parent. When the child is seen without parental consent, every effort should be made to involve the parents as quickly as possible.

Visible Signs

Visible signs are those observations made by the worker during the course of the investigation. Visible signs include, but are not limited to: the size, shape and location of an injury, behavioral indicators of family members, and physical condition of the family home.

4. Operational Definitions:

Preponderance of Evidence: A finding that physical abuse has occurred or is occurring, founded on the observation of visible signs, physical and/or credible verbal evidence provided to the investigator by the child, perpetrator or witnesses in accordance with the definition of physical abuse and which is supported to a degree of evidence that is of greater weight or more convincing than the evidence which is offered in opposition to it or evidence which as a whole shows the fact to be proved to be more probable than not.

Related Subject: Section 2, Chapter 4, Attachment L Preponderance of Evidence

Unsubstantiated-Preventive Services Indicated: A finding of Unsubstantiated-Preventive Services indicated is appropriate when insufficient visible signs, physical and/or credible verbal evidence exist, but where the investigator determines that indicators are present which if unresolved, could potentially contribute to child abuse/neglect.

Unsubstantiated: A finding of unsubstantiated is appropriate where insufficient physical or credible verbal evidence exists and where few or no indicators are identified and the worker has not identified a specific threat exists for the child.

Investigative Conclusion: This is determined after collecting and reviewing all evidence and/or indicators obtained during the course of the investigation. If there is a finding by a “preponderance of evidence” that child abuse and neglect exists the investigative conclusion will be "Preponderance of Evidence." If the evidence is inconclusive, but there are sufficient indicators to suggest a potential for abuse/neglect to a child, the investigative conclusion (determination) will be "Unsubstantiated-Preventive Services indicated." Lacking evidence and sufficient indicators, the investigative conclusion will be "unsubstantiated."

Priority Status: This is to be determined based on the degree of risk to the child and the immediacy of the treatment needs. In a large part, this is based on the investigator's judgment and knowledge of the family situation.

Investigative Recording: Shall be completed in a summarized narrative style on the CPS-1. It should be written in a clear, concise, easily understood manner and include but is not limited to the following components:

• A chronological listing of who, when, where each subject and/or collateral was contacted and the content of the interviews;
• A brief description of all credible verbal and/or physical evidence provided to the worker during the investigation;
• A statement justifying the investigators investigative conclusion i.e., Preponderance of Evidence, Unsubstantiated-Preventive Services indicated or unsubstantiated;
• A brief description of "reasonable efforts" used by the worker to prevent removal of the child; and/or
• Documentation for the reason services were not provided when a child is placed in emergency alternative care.
  

Chapter Memoranda History: (prior to 1/31/07)

CS03-51; CD04-79; CD05-35

Memoranda History: