This policy guide was updated from the 04/16 version to update medical examination requirements to reflect the Department's requirements in existence prior to April 20, 2016.

POLICY

State-Regulated Initial Medical Exams

State regulations require a medical exam for all children/youth placed in out-of-home care. The exam is routine, preventative, and the first of the periodic medical exams that must occur when a child is placed in out-of-home care under DCFS supervision.

Children/youth who are not at high risk must have his/her Initial Medical Exam within the first thirty (30) days of initial placement.

An Initial Medical Exam is to be conducted for high risk children/youth and for children birth to three (3) years of age within the first ten days (10) days of the child’s/youth’s initial placement, or sooner if required or recommended by a medical professional.

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Use of the Body Mass Index (BMI)

The Body Mass Index (BMI) is a statistical measurement of the weight of a person, scaled according to height. BMI (also called BMI-for-age) is age and sex specific for children and youth. The BMI must be calculated as part of the exam for children over two (2) years of age. BMI is not calculated for children under the age of two (2).

The long term goal of promoting healthy lifestyle practices is to have children/youth maintain a Body Mass Index (BMI) that is below the eighty-fifth (85th) percentile. This weight can be maintained by weight maintenance or a decrease in BMI velocity.

Monitoring the BMI and, when applicable, the child’s healthy lifestyle plan, is an ongoing collaborative effort by the CSW, the PHN, and the medical provider and/or specialist. CSWs and PHNs must work closely together to ensure that any identified healthy issue is addressed.

A physician should use the DCFS 561(a), Medical Examination Form, to capture and calculate BMI information when a child/youth is taken to either of the following:

A Medical HUB for an initial exam by a physician or

A physician’s office or Medical Hub for annual or bi-annual checks.

The following CDC weight categories are based on the BMI range:

Weight Category	BMI Criteria
Failure to thrive (FTT)	Equal to or less than the 3rd percentile
Underweight	Greater than 3rd but less than or equal to the 5th percentile
Healthy weight	Between the 6th and the 84th percentile
Overweight	Between the 85th and the 94th percentile
Obese	Between the 95th to 98th percentile
Obese (severely)	Greater than or equal to the 99th percentile

Although monthly monitoring of a child/youth’s weight and/or BMI is recommended, the monitoring frequency should be individualized to the family’s needs and the child/youth’s obesity risk factors.

A plan to develop more intensive healthy lifestyle interventions should be considered in the following situations:

An overweight child/youth has not responded to healthy lifestyle practices in the last three months.

An obese child/youth has a BMI above the ninety-fifth (95th) percentile.

The Special Projects tab on CWS/CMS is used to identify how many children with a BMI of 95% or greater are receiving services from DCFS.

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Healthy Lifestyle Plans (Juvenile Court Protocol)

A juvenile court protocol aims to help dependent children and youth maintain a lifestyle that is as healthy as possible.

A healthy lifestyle plan can assist children/youth in developing practices that encourage healthy eating behaviors and engagement in cardio-vascular activities. It may include working with the child/youth’s biological or adoptive parent, caregiver, legal guardian, or other adults involved in the child’s/youth’s life.

The following resources identify categories of healthy lifestyle practices, which can be used with a child/youth whether or not he/she has a Body Mass Index (BMI) score in a healthy percentile.

Guidelines for Promoting Healthy Lifestyle Practices.

The Resources for Social Workers and Nurses attachment provides a listing of programs to assist children/youth who struggle with healthy weight maintenance.

The Department's Bureau of Clinical Resources and Services website provides information on childhood obesity prevention. The website has community resource guides for free or reduced cost services for nutrition, physical activity, pregnancy/post-partum women, social and health services according to service planning areas (SPAs).

An examining physician, CSW, and PHN should develop a healthy lifestyle plan with the child/youth and caregiver for children/youth over the age of ten (10) whose BMI is not in the normal range (the 6th percentile to 84th percentile). The caregiver is to be involved in all discussions regarding the plan’s development and implementation.

If there is a court-appointed special advocate (CASA) on a child’s/youth’s case, he/she should work with the child/youth’s caregiver and social worker to gather information about the progress of the child/youth’s health, weight management, and healthy lifestyle practices.

Each attorney for a child/youth should speak to him/her about his/her health and, when applicable, his/her healthy lifestyle practices.

When a child/youth has not responded to healthy lifestyle practices within three (3) months, the court will order the CSW and the child’s/youth’s attorney to identify any impediments to the child/youth’s development of a healthy lifestyle plan.

If no plan exists, the court will order a health assessment and a healthy lifestyle (i.e. treatment) plan for the child/youth.

To obtain these, DCFS must refer the child/youth to either the nearest Medical HUB.

If a Medical HUB is not accessible or available, or if the child/youth is placed out-of-state or out-of-county, DCFS must refer him/her to a medical provider that has a relationship with the child and/or will provide the same quality of services as a Medical HUB.

The CSW and the PHN will develop prevention activities and address any impediments to a healthy lifestyle plan with the child/youth and caregiver.

The court will order a report from DCFS after four (4) weeks that details the results of the referral. The report will include whether the child/youth was evaluated by the Medical HUB, the results of the evaluation, and the healthy lifestyle plan that was developed with the child/youth and caregiver.

If the caregiver and/or the child/youth are reluctant to address the healthy lifestyle plan, the CSW and the child/youth’s attorney must determine who (e.g. the caregiver or therapist) will address this reluctance.

If the caregiver is uncooperative in addressing the healthy lifestyle plan, the court may order the CSW to arrange a case conference with external stakeholders, including the child’s attorney, doctors, or foster family agency (FFA) social worker f in an FFA. The case conference must address whether the caregiver is meeting the child/youth’s needs or requires additional assistance to maintain the placement.

The CSW, the PHN, and the medical provider should have information about the impact of any medications on the child/youth’s health and weight. This information should be used to:

Determine healthy patterns of food intake and activity/inactivity.

Help medical professionals, CSW, and PHNs develop and implement a healthy lifestyle plan.

Evaluate the suitability of a placement, including placement with relative(s), at a foster home, or at a group home.

For a child/youth for which no significant weight concerns have been documented by a medical provider, the CSW, PHN, and caregiver should work preventatively to encourage healthy lifestyle practices.

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Eating Disorders

Eating disorders are characterized by severe disturbances in eating behavior. Eating disorders are divided into three categories: Anorexia Nervosa, Bulimia Nervosa, and Binge Eating. A person with an eating disorder may use eating, purging, or restricting food to deal with his/her problems. Factors underlying an eating disorder may include the following:

Depression

Family communication problems

Feelings of loss of control

Feelings of worthlessness

Identity concerns

Inability to cope with emotions

Low self-esteem

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Court Reporting and the Health and Education Passport

Issues related to the child’s/youth’s health and/or weight should be discussed in court, in court report documentation, and in the HEP in a non-embarrassing and uncritical way. The following information should be clearly documented in the court report and/or Healthy and Education Passport:

The BMI score and whether or not it is in the normal range (the 6th to 84th percentile).

If a healthy lifestyle plan is in place, the child’s progress.

If the BMI is not in the normal range, whether the examining physician has, or is in the process of developing prevention activities that promote a healthy lifestyle plan or practice with the child and caregiver.

For instructions on documenting BMI related information, see Healthy and Education Passport (HEP).

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PROCEDURE

Responding to a Completed Initial Medical Exam

ISW or Case-Carrying CSW Responsibilities

Confirm that a BMI score for the child/youth was competed on the DCFS 561(a), Medical Examination Form.

If a BMI score is not documented, consult with the PHN to assist in determining the child/youth’s BMI score.

Consult with the PHN to determine if the child/youth’s BMI is in the normal range (the 6th percentile to 84th percentile). Based on the BMI score, adhere to the following steps:

Body Mass Index (BMI)	Next Steps
Below the 6th percentile	Consult with the PHN. Refer the child/youth to a Medical HUB, or to a medical provider who has a relationship with the child and/or that will provide the same quality of services as a Medical HUB.
Above the 85th percentile	Consult with the PHN to determine the next steps based upon juvenile court protocol.
Within normal range	Document all relevant information concerning the child/youth’s BMI score. Proceed as follows.

For predisposition cases, notify the DI of the child’s/youth’s BMI score.

If applicable, provide a copy of the healthy lifestyle plan that was developed by the medical provider to the caregiver and the PHN.

Document the discussion with the DI concerning the child’s/youth’s healthy lifestyle practices in the Contact Notebook.

PHN Responsibilities

Upon request of the CSW or upon review of the Well Child Exam that is documented on the DCFS 561(a) Medical Examination Form or PM 160 Confidential Screening/Billing Report, graph the following information about the child/youth on the appropriate gender and age specific CDC growth chart:

Height

Weight

Body Mass Index (BMI)

Blood pressure (B/P), when indicated

Document the following information about the child/youth in his/her Health and Education Passport (HEP):

Healthy lifestyle plan

Weight

Height

Blood pressure when indicated

Laboratory analysis and results

If it is determined that the child/youth meets the CDC criteria for obesity (BMI is above the 95th percentile), select the child/youth on the Special Projects Page of CWS/CMS.

Select the BMI-Obese option.

Enter the start data and the date of the most recent exam when the child/youth met criteria for obesity, if not the same.

Document all contacts in the Contact Notebook.

When applicable, enter the date that the child/youth’s BMI is in normal range (6th percentile to 84th percentile) on the Special Projects Page, and change the BMI option.

DI Responsibilities

Document all relevant information concerning the child’s/youth’s BMI score.

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Monitoring the Child/Youth’s BMI Score

Case-Carrying CSW Responsibilities

Determine if a BMI score for the child/youth was competed on the DCFS 561(a), Medical Examination Form.

Body Mass Index (BMI)	Next Steps
Below the 6th percentile	Consult with the PHN. Refer the child/youth to a Medical HUB or to a medical provider, which has a relationship with the child and/or will provide the same quality of services as a Medical HUB.
Above the 85th percentile	Consult with the PHN to determine the next steps based upon juvenile court protocol.
Within normal range	Proceed to the following procedural step for post-disposition cases.

For predisposition cases, notify the DI of the child’s/youth’s BMI.

For post-disposition cases, document all relevant information concerning the child’s/youth’s BMI score as set forth in Writing a Status Review Hearing Report for a WIC Section 364, 366.21(e) or (f), 366.22, or 366.25 Hearing, Writing the WIC 366.3 Status Review Hearing Report for Minor Dependents, or Writing the WIC 366.26 Hearing Report.

If not already submitted, provide a current copy of the healthy lifestyle plan that was developed by the medical provider to the caregiver and the PHN.

Document all discussions concerning the child’s/youth’s healthy lifestyle practices in the Contact Notebook.

During monthly face-to-face contacts with the child and caregiver:

Work with them to gather health-related information to include in court reports, such as information on the child’s food choices and eating habits and/or the physical activities the child engages in.

When additional information is needed, interview individuals who the child visits on a regular basis (e.g. parents, relative, etc.).

Document these discussions in the Contact Notebook and court report.

PHN Responsibilities

Follow all procedural steps under PHN Responsibilities for Responding to a Completed Initial Medical Health Exam.

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Monitoring a Child/Youth’s Weight Management Issue and Psychotropic Medication

Case-Carrying CSW Responsibilities

Document the child/youth’s progress with weight management.

Discuss the child/youth’s progress with the caregiver and, when appropriate, the child/youth.

On an ongoing basis, consult with the PHN regarding the suitability of the healthy lifestyle plan and the child/youth’s progress, given that the child is on psychotropic medication.

If his/her BMI score is below the 6th percentile or above the 85th percentile, consult with the child’s/youth’s treating physician regarding the following:

The child/youth’s progress with his/her healthy lifestyle plan and practices and with weight management

The child/youth’s compliance with follow-up appointments

The suitability of the healthy lifestyle plan

Document all contacts in the Contact Notebook.

Document all relevant information concerning the child/youth’s BMI score as set forth in Writing a Status Review Hearing Report for a WIC Section 364, 366.21(e) or (f), 366.22, or 366.25 Hearing, Writing the WIC 366.3 Status Review Hearing Report for Minor Dependents, or Writing the WIC 366.26 Hearing Report.

PHN Responsibilities

Every six (6) months review, assess, and graph on the appropriate gender and age specific growth chart the child/youth’s:

Height

Weight

Body Mass Index (BMI)

Blood pressure, when indicated

Provide the results of these assessments and graphs to the CSW.

Collaborate with the CSW on an ongoing basis, regarding the child/youth’s progress.

Document the healthy lifestyle plan in the child/youth’s Health and Education Passport.

Consult with the child/youth’s treating physician, as needed, regarding the suitability of the healthy lifestyle plan and the child/youth’s progress with weight management.

Update the CSW on the results of this consultation.

Update the healthy lifestyle plan on an ongoing basis.

When appropriate, discuss the child/youth’s progress with weight management with the caregiver and child/youth.

Document all contacts with the Contact Notebook.

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APPROVALS

None

HELPFUL LINKS

Attachments

Guidelines for Promoting Healthy Lifestyle Practices

Resources for Social Workers and Nurses

Forms

CWS/CMS

DCFS 561(a), Medical Examination Form

LA Kids

DCFS 561(a), Medical Examination Form

Referenced Policy Guides

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

0080-505.20, Health and Education Passport (HEP)

0300-503.15, Writing a Status Review Hearing Report for a WIC Section 364, 366.21(e) or (f), 366.22, or 366.25 Hearing

0300-503.16, Writing the WIC 366.3 Status Review Hearing Report for Minor Dependents

0300-503.20, Writing the 366.26 Hearing Report

0300-506.05, Communication with Attorneys, County Counsel, and Non-DCFS Staff

0600-500.00, Medical Hubs

Statutes

California Department of Social Services (CDSS) Manual of Policies and Procedures (MPP) Division 31-206.361 – Each child in placement shall receive a medical and dental examination, preferably prior to, but not later than, thirty (30) calendar days after placement.

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