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Case Study 4

Leo is an eight-year-old son of divorced parents, Steve and Elizabeth. Steve and Elizabeth share custody of Leo. Leo's parents live in the same town of about 800 people in central Nebraska. You are the school nurse at the local public elementary school.

One day you receive a call from Nancy Carter, N.P., Leo's primary care provider. Nancy has been Leo's primary care provider all of his young life. Nancy calls to discuss Steve's concern that Leo has been unusually irritable and has had problems focusing on his homework. On a recent well child visit to her office, Nancy states Leo's weight decreased from the 50 percentile, where he has been most of his life, to the 25 percentile. Nancy states Leo was easily distractible and she noted a strange odor of cat urine in the room. You share with Nancy that you've noticed an increase in absenteeism and tardiness for Leo and that Leo's teacher has recently reported lower grades, although Leo has not exhibited learning difficulties in the past. You also report that Leo's clothes are frequently dirty and remember one time in the past few months, when although it was very cold outside, Leo came to school in a short-sleeved shirt, shorts and no coat. There is also a note in his health file from Leo's teacher that describes "a huge appetite during lunchtime and frequent complaining in the morning of hunger". Nancy requests a visit regarding these concerns between Leo's teacher, his parents, Nancy and yourself. You agree to arrange such a meeting.

That afternoon, you try to call Leo's parents. His mother does not have a telephone. Leo's father tells you that he is concerned about "the company his ex-wife keeps", stating "they are up all hours of the night over there". Steve states that a large change in his ex-wife's personality occurred in the last few months, including dramatic weight loss, extreme irritability and paranoia. Steve states that he has "heard around town" that his wife is a "methamphetamine head" and is also "making the stuff". Steve states he hasn't yet reported his concerns to authorities but wonders if Leo is "being drugged". As you check with Leo's teacher, she echoes Steve's concerns, stating she has heard such rumors, and states Elizabeth hasn't attended the last several months of parent conferences and school functions. In fact, she remembers, Leo missed the annual holiday music concert this year.

As a health professional, what might be your next steps?

The first priority would be to call the local police authority or child abuse/neglect reporting authority to report possible child neglect. Document conversations you've had with Leo's father, Leo's primary care provider and Leo's teacher and share this information with the identified reporting agency. You are obligated to report suspected child neglect under Nebraska statute.

It is now a few days later, you are still unable to reach Leo's mother. Again, she doesn't have a telephone, or emergency contact and a letter to her has been unanswered. You decide to drive by Elizabeth's home one day after school. You knock on the door, and while waiting for someone to answer, you hear a loud barking noise from inside the home, dark drapes over the windows and a strong smell of cat urine. The day before the scheduled school meeting, the principal calls you into his office. He states that Steve called this morning to report that Elizabeth was arrested last night shoplifting Ephedrine from the local pharmacy. Apparently the local police are investigating a possible methamphetamine lab in Elizabeth's home and have requested information about Leo from the school. From the information you have collected thus far, what information might have indicated that Leo was being exposed to methamphetamine manufacturing chemicals?

~Leo's irritability and distractibility, which is unusual for him.
~Smell of cat urine is an ammonia smell. Anhydrous ammonia is frequently used in Nebraska to make methamphetamine. Remember however, this is just a possibility; the family might also own several cats.
~Large dogs protecting the home are commonly used to alert the methamphetamine maker to police.
~Use of drapes over the windows also protects the methamphetamine maker from curious people or the police.
~Leo's mother's behavior (irritability and paranoia) and weight loss may be because she is using methamphetamine. Remember these symptoms may also be because of other etiology as well (e.g. mental illness, thyroid dysfunction). So these symptoms are not conclusive.
* * Please Note: The purpose of a home visit should NOT be to complete a "mini-investigation" before reporting your suspicions to authorities, especially when there are more than enough sufficient facts to make a report.

In talking directly to the police officer assigned to this case, she requests "any help you can give me, because I've never worked with a methamphetamine case before". You attended a workshop on methamphetamine labs last spring and received a copy of a protocol for health care professionals. Upon reviewing the protocol again, what are the most critical pieces of information to pass on to the officer for the immediate concerns for Leo? What are the most critical pieces of information for you and Nancy to keep in mind relating to Leo's short-term and long-term health needs? (Hint: Use the Nebraska CHEM-L Protocol for this question.)

~Immediate concerns: Leo's safety. Was he was there during Elizabeth's arrest? Leo's father needs to be contacted immediately (because he has custody of Leo) and if Leo is wearing any clothes from Elizabeth's house they should be removed, bagged and given to the police. The police should give Steve a copy of the Foster Care Guidelines (See protocol forms-both sides) to reinforce health concerns, contamination considerations and mental health considerations in regards to Leo. The police should document/take video or pictures of Leo's belongings at Elizabeth's home are also important to gather as evidence Leo was in the home at sometime for legal evidence. The police should fill out the Exposure Record (See protocol forms) and give this information to Nancy, Leo's primary care provider.
~Short-term health needs: (See protocol under V. Initial Urgent Medical Assessment.) If Leo was not at the scene, encourage immediate assessment with his primary care provider, Nancy, utilizing the section V of the protocol: Initial Urgent Medical Assessment. Nancy should fill out the Medical History Record (see protocol forms-both sides) and keep this information with Leo's permanent medical record. Nancy may want to consult a toxicologist for more health effects information based on what chemicals were found at Elizabeth's home.
~Long-term health needs: (See protocol under section VII. Comprehensive Health Assessment and Follow-Up-discuss). Encourage continuity in follow up with Nancy. It is important to have a continuous source of care.

Who else might you want involved in Leo's care?

~Leo should also be interviewed by a person trained to interview and gather evidence from children as mentioned in the protocol (section IV. Interviewing Children).
~A mental health practitioner may also be helpful to involve to help Leo deal with possible trauma from mother's methamphetamine use and lifestyle centered around methamphetamine manufacturing. Studies have shown that methamphetamine is extremely psychologically addictive and that the user only considers how to get "more and more methamphetamine" rather than caring for his/her own needs or the needs of those dependent on the person (such as children and/or pets).

Steve calls you to talk more about methamphetamine use. What are the key points you'd like Steve to know about the exposure of his son to a methamphetamine lab?

~The primary concern is Leo's exposure to the chemicals involved in the making of methamphetamine, not the methamphetamine itself, although accidental ingestion of the methamphetamine is possible. Many times children found at the scene of a methamphetamine lab, are not using the drug, they have health problems due to the caustic chemicals used in making the methamphetamine. This said, a laundry list of health effects may include (see health effects section of the initial medical assessment guidelines form); (a) stimulant overdose (methamphetamine or ephedrine/pseudoephedrine); (b) burns form caustic compounds (strong acids or bases, lithium, sodium, or anhydrous ammonia); (c) pulmonary damage (anhydrous ammonia or other gases); (d) CNS depression; (e) cardiac sensitization (from volatile organic compounds); and (f) other toxicity from exposure to metals, solvents, and other compounds.
~Potential effects depend on the specific chemical to which a person is exposed, the route of exposure, the dose of exposure, the duration of exposure, and specific vulnerabilities of the individual (e.g. children).

Physical and sexual abuse may have more obvious physical signs than emotional abuse or neglect, although neglect of children is more common. What are the signs of neglect in Leo's case?

~Because Elizabeth may be doing methamphetamine, neglect is possible. Methamphetamine is a psychologically addictive drug and parents who use the drug frequently neglect their children. Leo's weight loss and hunger at school along with his inappropriate dress and unkempt appearance at school are signs of neglect. Leo's unusual tardiness and increase in absenteeism from school and school events may also be signs of neglect. Elizabeth's lack of involvement in Leo's school conferences may also be a sign of neglect.

Where would you go to obtain more information on methamphetamine lab exposure in children?

~The full text and needed reporting forms for the Nebraska CHEM-L (CHildren Exposed to Methamphetamine Laboratories) Protocol can be assessed on the world wide web at: or by calling the Lincoln-Lancaster County Health Department's Children's Environmental Health Program at (402) 441-8000.
~The Nebraska CHEM-L Protocol was developed by a Medical Working Group of the Child Endangerment Subcommittee of the Precursor Committee of the High Intensity Drug Traffic Area (HIDTA) planning effort for Nebraska and has been endorsed for use by the Nebraska chapters of the American Academy of Pediatrics, American Medical Association, and the Nurse Practitioners Association. Nebraska Governor Mike Johannes endorsed the protocol on February 19, 2004.

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