Procedural Guide

Procedural Guide

0600-506.00

HEALTHY LIFESTYLE PLAN

Date Issued: 01/15/09
New Policy Release
Revision of Existing Procedural Guide 0600-506.00, Monitoring A Youth’s Body Mass Index (BMI), dated 07/23/08
Revision Made: NOTE: Current Revisions are Highlighted
This Procedural Guide has been updated to reflect recommendations made by our external stakeholder partners.
Cancels: None

DEPARTMENTAL VALUES

This policy supports the Department’s efforts to ensure child safety and well-being by establishing policy and procedures to monitor the health and weight issues of children/youth.

WHAT CASES ARE AFFECTED

This Procedural Guide is applicable to all new and existing cases.

OPERATIONAL IMPACT

The Presiding Judge of the Juvenile Court has established protocol to address the health and weight issues (i.e. overweight, obesity, failure to thrive, anorexia, bulimia and other eating disorders) of dependent children/youth under the supervision of the Department of Children and Family Services (DCFS). The purpose is to help our dependent children/youth be as healthy as possible and to maintain a healthy lifestyle that is conducive to good health.

Recently, the American Heart Association's Scientific Sessions 2008 indicated that the neck arteries of obese children and teens look more like those of 45-year-olds. According to Preventing Childhood Obesity: the need to create healthy places- A Cities and Community Health Report (Los Angeles County Department of Public Health, October 2007), obesity rates have tripled for children since the late seventies. The overall prevalence of childhood obesity for Los Angeles County is 23.3% with 1 in 5 students in 5th, 7th, and 9th considered obese. The report further found a higher prevalence of obesity in cities where families face economic burdens including poverty, lower educational attainment, lack of safe outdoor play areas, and more dependents. The Children's Council 2008 Score Card states that child obesity for children in middle school has gone up slightly.

In its Research Brief, First 5 LA indicated the results of the 2005 Los Angeles County WIC Survey that states that the number of children under 5 who are currently overweight is epidemic and increasing with studies showing that children ages 2-5 in California have a 1 in 5 chance of being overweight. In Los Angeles County, the overweight rates of 3- and 4 year-olds have increased by over 3% since 2003. Further, in 2003, 40% of children enrolled in California Head Start were overweight.

Pursuant to the protocol when a child/youth under the court’s jurisdiction is taken to a HUB for the child’s/youth’s initial exam or when the child is taken to a physician (selected by the caregiver) or a HUB for the subsequent annual or bi-annual check-ups, the physician is to calculate the child’s/youth’s Body Mass Index (BMI) for any child age two and older. The DCFS 561(a), Medical Examination Form, has been revised to capture that information.

Body Mass Index (BMI) is a statistical measure of the weight of a person scaled according to height. Body mass index is defined as the individual's body weight divided by the square of their height. BMI is age and sex specific for children and teens and is most often referred to as BMI-for-age. The following weight categories are based on the BMI range:

· Failure to Thrive(FTT): BMI less equal to or less than 3rd percentile

· Underweight: BMI greater than 3rd percentile and less than or equal to 5th percentile

· Healthy weight: BMI between 6th percentile to 84th percentile

· Overweight: BMI 85th percentile to 94th percentile

· Obese: BMI 95th percentile to 98th percentile

· Obese (severely): BMI greater than or equal to 99th percentile

Center of Disease Control and Prevention – Healthy Weight

http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/childrens_BMI/about_childrens_BMI.htm

Healthy Lifestyle Plan

A plan developed by a medical provider that assists the child/youth in developing life long practices that encourages healthy behaviors, healthy food choices and regular engagement in cardio-vascular activities.

NOTE: Addressing a child/youth's healthy lifestyle plan includes working with the child's caregiver, who may be the child's out of home caregiver, biological parent, legal guardian, or adoptive parent or other adults involved in the child’s/youth’s life (e.g., relatives, a mentor, etc.). Every evaluation and healthy lifestyle plan will take into consideration every medication - psychotropic or otherwise - that the child/youth is receiving.

For those children/youth whose BMI score is not in the normal range, the examining physician should develop a healthy lifestyle plan with the child/youth and caregiver to address this issue. If there is no healthy lifestyle plan in place for a child/youth with a BMI out of the normal range, the Court will order the social worker and the child’s/ youth’s counsel to determine whether there are any impediments related to the child/youth or the caregiver regarding the development of a healthy lifestyle plan. If none exists, the court will order DCFS to refer the child/youth to the nearest Hub or any medical provider within the community that has a pre established relationship with the child and/or will provide the same quality services as a Hub for a health assessment and the development of a treatment plan (i.e., health life style plan). For those children or youth who are placed out of state, out of county, or too far from the nearest Hub, DCFS shall refer the child/youth to another medical entity that will provide the same quality service as a HUB. The Court will order a report from DCFS in four weeks which details the results of the referrals including whether the child/youth was evaluated by the 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 cooperate in addressing this issue, there are a variety of options. If the child/youth is reluctant, the CSW and the youth’s attorney can work together to determine who can discuss this issue with the child/youth, such as the caregiver, or perhaps a therapist, if the child/youth has one. If the caregiver is uncooperative, the Court can order the social worker to arrange a case conference including consideration that key external stakeholders attend or, as an alternative, that information be obtained from key external stakeholders for inclusion in the discussion at the case conference.

When working with all children/youth and especially with children/youth who have weight issues, CSWs shall be very sensitive to the issues faced by these children/youth and shall work with these children/youth in a very accepting manner and provide them with encouragement and support to resolve their weight issues.

COURT REPORTS

CSWs must ensure that the BMI is calculated and that the court report reflects that this was done. Further, the court report should reflect whether the BMI was in the normal range or not. For those children whose BMI is not in the normal range, the report should state whether the examining physician has or is in the process of developing a healthy lifestyle plan with the child and caregiver to address this issue. If there is a healthy lifestyle plan, it should be explained in the report and future reports should indicate the child’s progress. See Procedural Guides 0300-503.10, Writing the Jurisdiction/Disposition Hearing Report, 300-503.15, Writing the Status Review Hearing; 0300-503.16, Writing the 366.3 Status Review Hearing Report; and, 0300-503.20, Writing the WIC 366.26 Hearing Report for instructions on documenting BMI related information into court reports. It is important for all to keep in mind that every time this issue is discussed in court, in court reports, in discussions with the child and/or caregiver, it should be done in a way that is not meant to criticize or embarrass anyone.

During the CSWs monthly face-to-face contacts with the child and caregiver the CSW should work with the caregiver and the child to gather health related information to include in court reports. For example, this may include information on food choices and eating habits, and physical activities that the child engages in. In addition, the CSW should interview individuals whom the child visits on a regular basis (e.g. parent, relative, etc.) when additional information is needed. Further, document these discussions not only in the Contact Notebook, but in the court report as well.

Child’s Attorney

As part of the obligation to remain in contact with clients, each attorney should speak to his/her child client regarding the child's health, and where applicable, the child's healthy living plan.

CASA

If there is a CASA on a case, the CASA should work with the child's caregiver and social worker to gather information regarding the progress of the child’s/youth's health/weight management plan.

In addition to the above information, everyone involved with the child should know what medication, if any, the child is taking which could have an impact on the child’s weight.

The reason to receive this information on a routine basis is to not only determine patterns of food intake and activity/inactivity which could contribute to weight issues, but also to have a significant record to provide to mediation and other professionals who are enlisted to work with the child and/or caregiver in the development of or implementation of a healthy lifestyle plan. Further, this documentation can also be helpful in evaluating the efficiency of placements, whether they be relatives, foster homes, or group homes.

The monitoring of BMI and when applicable, a child’s healthy lifestyle plan is an ongoing collaborative effort on behalf of the CSW and PHN. It is critical that CSWs and PHNs work closely to ensure that any identified health issue is addressed and that the child be as healthy as possible and that s(he) maintain a healthy lifestyle that is conducive to good health.

Procedures

A. WHEN: THE INITIAL MEDICAL EXAM HAS BEEN COMPLETED

State-regulations require a medical examination for all children/youth placed in out-of-home care. Initial medical examinations are to be conducted within the first 72 hours of initial placement following detention for high risk children/youth and children 0-3 years of age; all other children/youth are to have their Initial Medical Examination within the first 30 days of initial placement following detention.

The Initial Medical Exam is routine and preventive, and it is the first of the periodic medical exams that must occur when a child is first placed under DCFS supervision. As part of that exam the Medical Hubs will calculate a child’s BMI score. For those children/youth who are placed out of county and who are not taken to the HUB it may not be common practice for the examining doctor to calculate the youth’s BMI. As noted previously the DCFS 561(a), Medical Examination Form, has been revised to capture that information.

ISW or Case-Carrying CSW Responsibilities

Review the results of the initial medical exam as documented on the DCFS 561(a) to determine if a BMI score for the child/youth was completed.

a) If a BMI score is documented, proceed to Step 2.

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

Consult with the PHN to determine if the child’s/youth’s BMI score is within the normal range for that child.

a) If the BMI score is within the normal range, proceed to Step 3.

b) If the BMI score is not within the normal range (above or below).

i. Refer the child/youth to a HUB or any medical provider within the community that has a pre established relationship with the child that will provide the same quality services as a Hub for further evaluation and follow-up.

ii. Collaborate with the PHN to incorporate the medical recommendations into the child’s healthy lifestyle plan.

For Predisposition cases, notify the DI of the child’s/youth’s BMI score in order for the DI to document this information in the Jurisdictional/Disposition Report.

4. Provide a copy of the healthy life style plan developed by the medical provider to the caregiver and PHN.

NOTE: A useful resource for CSWs and PHNs in developing the child’s healthy lifestyle plan is:
Links addressing nutrition and activity:
http://www.mypyramid.gov/?gclid=CLGDmrr3spcCFQv7agodjkTJjw
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/childrens_BMI/about_childrens_BMI.htm

Public Health Nurse (PHN) Responsibilities

1. Upon request of the CSW or on review of a Well Child Exam [ as documented on the DCFS 561(a) or PM 160), graph the height, weight, Body Mass Index (BMI) and Blood Pressure (B/P, when indicated) in the appropriate gender and age specific CDC growth chart.

2. Document the Healthy Lifestyle Plan into the child’s or youth’s Health and Education Passport.

3. Document all contacts in the Contact Notebook.

DI Responsibilities

1. Document all relevant information concerning the child’s/youth’s BMI score as set forth in Procedural Guide 0300-503.10, Writing the Jurisdiction/Disposition Hearing Report.

B. WHEN: MONITORING THE CHILD’S/YOUTH’S BMI SCORE ON AN ONGOING BASIS

Case-Carrying CSW Responsibilities

1. Prior to the next scheduled status review hearing review the most current DCFS 561(a) to determine if a BMI score for the child/youth was completed.

a) If a BMI score is documented, proceed to Step 2.

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

2. Consult with the PHN to determine if the child’s/youth’s BMI score is within the normal range for that child.

a) If the BMI score is within the normal range, proceed to Step 3.

b) If the BMI score is not within the normal range (above or below)

ii. Collaborate with the PHN to incorporate the medical recommendations into the child’s healthy lifestyle plan.

3. Document all relevant information concerning the child’s/youth’s BMI score as set forth in procedural Guides 300-503.15, Writing the Status Review Hearing; 0300-503.16, Writing the 366.3 Status Review Hearing Report; and, 0300-503.20, Writing the WIC 366.26 Hearing Report.

4. Provide a copy of the healthy life style plan developed by the medical provider to the caregiver and PHN.

Public Health Nurse (PHN) Responsibilities

1. Upon request of the CSW or on review of a Well Child Exam [ as documented on the DCFS 561(a) or PM 160], graph the height, weight, Body Mass Index (BMI) and Blood Pressure (B/P, when indicated) in the appropriate CDC growth chart.