impede the juvenile's capability to learn or speak. This may range from regular eye glasses or speech therapy to surgery, and should be undertaken without cost to the family. See Standard 4.217. Those services may be combined with remedial tutoring to accelerate the juvenile's progress.

For those with emotional or behavioral problems, psychological counseling combined with a specialized learning program may be necessary to develop self-discipline for studying or to reinforce the confidence of juveniles in their own ability to learn and attain a level of achievement commensurate with their intellectual capabilities.

Paragraph (c) covers juveniles who have specific learning disabilities which are not related primarily to basic intelligence, or physical or emotional problems, but rather to perceptual handicaps which affect their ability to correctly and consistently process verbal or written information. See Murray, supra at 12. Perceptual problems may be exhibited in a number of symptoms often associated with language processing, distinguishing spatial relations and hyperkinesis. Dyslexia, or "word blindness," one of the best know types of learning disabilities, includes a variety of problems in visual processing of language. "In its extreme forms, it can produce total inability to absorb meaning from written symbols, even though the victim of it may be able to understand spoken information with normal or above normal intelligence." See Murray, supra at 13. Another type of learning disability encompasses auditory and speech defects in addition to visual ones. Symptons would include repeating a set of nonsense syllables in an attempt to say or read a sentence; or being unable to understand language spoken at a normal speed, thus losing track of spoken instructions after a few words. See Murray, supra at 12-13. Inability to correctly perceive spatial relationship (left-right, up-down, or speed-distance) may result in clumsiness and lack of physical coordination. Hyperkinesis would be characterized by symptoms of a short attention span, impulsiveness, irritability, social awkwardness, and clumsiness.

The causes of learning diabilities are thought to be organic. Although they are generally attributed to some brain and neurological damage or dysfunction, no medical techniques currently available can determine the location or nature of the damage. See Murray, supra at 14. While the learning disabilities field is relatively new, and the literature on the effectiveness of various treatments is sparse, the fact that an individual's learning disabilities extend to other areas of daily functioning, suggests the need for a comprehensive approach

to treatment involving more than just the special education staff. See generally P. Meyers and D. Hammill, Methods for Learning Disorders (1969); and W. Cruishank and D. Hallahan, Perceptual and Learning Disabilities in Children, Volumes I and II (1975). Such an approach would call for substantial training of and communication among all staff members who work with juveniles with learning disabilities. In determining a juvenile's levels of intellectual and academic functioning and the need for further educational diagnostic study, tests which are biased against juveniles of a particular ethnic or cultural background or which deprive them of needed services should not be used. See Morales v. Turman, 383 F. Supp. 53, at 88 et. seq. (E.D. Tex. 1974). The court in the Morales case concluded that the Lorge-Thorndike IQ test and the Gray-Votow-Rogers Achievement Test, were inappropriate for testing for dyslexia. See Learning Disabilities, supra at 52-53 for tests administered by GAO consultants to determine the incidence of learning disabilities in a sample of adolescents in detention centers.

The provisions of the standards for the educational services which should be made available to juveniles in training schools, and especially to those who are in need of special education, reflect the spirit of current legislation, Pub. L. 94142, codified at 20 U.S.C. 1401 et.seq., Education for All Handicapped Children Act. The act specifies that all children, regardless of their handicaps, should be provided with free appropriate public education and related services designed to meet their unique needs.

4.217 Health and Mental Health Services

Training schools should provide programs designed to protect and promote the physical and mental well-being of juveniles placed therein, to discover those in need of short-term and long-term medical and dental treatment, and to contribute to their rehabilitation by appropriate diagnosis and treatment. Training schools should undertake treatment of health problems, without cost to the juvenile or his/her family including medical care and correction of health defects of a cosmetic nature. Procedures should be established for assuring the continuation and completion of treatment begun in a facility whenever a juvenile remains subject to the disposition of the family court following release from the training school.

Health services available to juveniles placed in a training school should be of equal quality to those available in the community.

Sources:

American Academy of Pediatrics, "Health Standards for Juvenile Court Residential Facilities, 52 Pediatrics, 452-457 (1973); See generally E.M. Brecher and R. Della Penna, Health Care in Correctional Institutions (1975); and American Public Health Association Standards for Health Services in Correctional Institutions (1976).

Commentary

This standard strongly urges that training schools develop a comprehensive approach to the provision of medical, dental, and mental health care services. See American Academy of Pediatrics, supra at 452; Institute of Judicial Administration/ American Bar Association Joint Commission on Juvenile Justice Standards, Standards Relating to Corrections Administration, Standard 7.6(1) (tentative draft, 1977) [hereinafter cited as IJA/ABA, Corrections Administration]. Such an approach requires that each juvenile's short-term and long-term rehabilitation needs be given attention. The primary objectives of the health care program should be to actively protect and promote physical and mental well-being of juveniles by assuring that appropriate diagnostic, treatment, and preventive services are provided by competent, qualified physicians, dentists, psychologists, and/or psychiatrists, with the assistance of appropriate support personnel. See Standards 4.2121 and 4.2122.

Standards 4.2121 recommends that a physician, dentist,

psychiatrist (or psychologist) be available at all times, and that a registered nurse be on duty 24-hours-a-day in case of an emergency. See Morales v. Turman, 383 F.Supp. 53, 101 (E. D. Tex. 1974). In addition to having these personnel and services available, the facility should establish and implement policies and procedures which provide juveniles with information about and access to these services without delay or interference. See Morales, 383 F. Supp. at 105; and American Public Health Association, supra at vii. Medical furloughs should be granted for procedures or treatment which cannot be safely or effectively administered in the facility, see National Advisory Committee on Criminal Justice Standards and Goals, Corrections, 36 (1973), and bilingual personnel should be available in areas where languages other than English are frequently spoken. See generally Morales.

In 1976, a national study was conducted to determine how certain standards recommended by the 1973 National Advisory Committee were being implemented in a representative sample of residential and nonresidential juvenile correctional programs. Juvenile respondents in training school-type facilities reported having less accessibility to health services than those in community-based programs, especially group homes. Inspite of the availability of in-house medical programs in the institutions and virtually none in group homes, only 35 percent of the juveniles in training schools reported ready access to medical services, compared to 75 percent of group home respondents. See P. Isenstadt, "National Standards and Program Practices," in R. Vinter (ed.), Time Out: A National Study of Juvenile Correctional Programs, 162-165 (1976). The report further indicated that reliance on existing health services in the community may be preferable to small self-enclosed units, both in terms of the cost and quality of health care.

Training schools should be responsible for acquiring the necessary treatment for juveniles and should establish procedures to assure the quality of services as well as the continuation and completion of desired treatment following a juvenile's release. When possible, juvenile facilities should contract for medical services with community hospitals for emergency, inpatient, and outpatient care services. The Purchase of Medical Services Contract between the New York City Department of Correction and Montefiore Hospital which covers services to some 7,000 inmates on Rikers Island serves as a useful model. See Brecher and Della Penna, supra at Ch. 10 and Appendix C (1975). The agreement also provides for a wide range of specialty diagnostic and treatment services and equipment. Similar prepaid contractual

agreements may also be negotiated for dental and mental health care services. Whether provided through contracts or delivered by facility staff, the quality of health and mental health services provided to juveniles in training schools should be subject to the same professional and legal standards applicable to private patients.

This standard goes beyond the traditional interpretations of what constitutes adequate medical care. With a few exceptions, courts have held that the only criterion on which to determine whether a person has been deprived of adequate medical services is whether medical treatment is needed or essential, as opposed to desirable. See Vinter, supra at 159. The standard reflects the position that health care at juvenile facilities should be an integral part of the individual's overall rehabilitation program. Thus, in addition to caring for immediate health care needs, the correction of a juvenile's physical defects may be considered appropriate, if such remedies are, in fact, desired by the juvenile and would contribute substantially to the juvenile's rehabilitation. This may include providing for such things as eye glasses, hearing aids, physical therapy, and elective therapeutic or cosmetic surgery. See Standards 4.216 and 4.2163. It should be stressed, however, that "no surgery should be permitted-except in the case of grave emergency—without the informed consent of the juvenile and the (juvenile's) parents or guardian." See IJA/ABA, Corrections Administration, supra at Standard 7.6(1).

Adequate facilities and the equipment necessary to conduct the initial health examination should be available. See Standard 4.2171. An infirmary which meets the same requirements as university and college infirmaries should be available for juveniles who need close medical attention for a limited period of time. See American Public Health Association, supra at 18. If the medical or psychiatric needs of a juvenile are such that they cannot be adequately provided for through the facility of placement, the juvenile should be returned to the family court for alternate pacement. See Standard 3.189; and National Advisory Committee on Criminal Justice Standards and Goals, Report of the Task Force on Juvenile Justice and Delinquency Prevention, Standard 24.10 (1977). However, the high cost of medical services required should not in itself be a valid reason for seeking alternative placement.

Whenever a juvenile in the course of treatment is released, efforts should be made to assure the continuation of the treatment to its completion. This does not mean that training schools should be responsible for the costs of continued postrelease care, nor that juveniles should be kept in a training school merely to ensure that they complete necessary medical treatment prior to release. Rather, it is intended to encourage training schools to make every effort to assure that treatment is continued through other sources of public funding or through referral to community health care programs.

The cost of medical care should be the responsibility of the state agency. Given the funding limitations of juvenile facilities, it is essential to seek additional sources of funding in order to provide adequate medical care. Rarely are benefits for the health care of incarcerated juveniles paid for by public health programs and private insurance companies-either

because of failure to utilize these options or the existence of explicit exclusionary policies. See Brecher and Della Penna, supra at 61. According to Section 1905(a) (17) of the Social Security Act, and 45 C.F.R. 248.60, juveniles incarcerated in public facilities are not eligible for Medicaid benefits. Until September 1977, youths who were eligible for Medicaid benefits prior to incarceration and participating in a Medicaid program lost their benefits immediately upon placement in a public facility. Although the Health, Education and Welfare administrative regulations were recently reinterpreted to extend benefits for the first thirty days of confinement, this notification affects only those juveniles who have previously been deemed eligible for Medicaid benefits.

The National Advisory Committee on Standards recommends that all legislation and administrative regulations which excluded incarcerated juveniles from full medical coverages be changed to include all incarcerated juveniles, regulations and their previous eligibility status for public medical assistance.

In the meantime, training school should thoroughly xplore previously untested alternatives for funding or providing medical health care for juveniles in the facility. One alternative would be to have someone such as a hospital clerk either working in the facility or training other personnel and volunteers to check each juvenile's eligibility statutes for various programs and benefits. Another alternative would be to explore cooperative arrangements with nearby medical schools for certain services.

Another problem area in health care delivery in institutions involves lines of authority. This standard does not specify whether services should be under the direct supervision of the state agency which is responsible for the administration of the facilities; an agency whose primary responsibility is health care delivery, see American Public Health Association, supra at viii, or multi-disciplinary health councils at each facility on which both health care and administrative staff serve to plan for service delivery, see American Academy of Pediatrics, supra at 452. Whatever administrative system is adopted, its primary function should be to obtain optimum service for juveniles from available medical resources, to assure the professional integrity and quality of care delivered by its staff, and protect the confidential relationship between patient and health professionals. To assure adequate protection of patients' rights, an ombudsman or other person acting as a juvenile advocate should have direct access to the administrative body responsible for health care services. Such advocates should represent the juveniles' interests in resolving individual problems as well as in formulating new policies and reviewing their implementation. See Standards 4.82 and 4.2172.

In the administration of health care services, prevention of potential health problems should be a focus of the health assessment and development of an individual's health program. A preventive approach to health care should also be promoted by developing and implementing a comprehensive health education program for juveniles covering a wide variety of health-related issues, including dental and personal hygiene, sex education, contraceptive measures, communicable diseases, nutrition, and alcohol and drug abuse. See American Academy of Pediatrics, supra at 457. All treatment

staff should be prepared and willing to answer juveniles' questions regarding health and health-related problems. Maintaining a physical environment which is both clean and free of hazardous obstructions will help prevent the spread of sickness or injury.

Standards 4.2171-4.2174 discuss specific issues related to the provision of health services including the need for an initial health examination and assessment, the training school's responsibility toward the patient, provision of adequate diet, and the administration of mental health services. While these standards relating to health care are found in this section on training schools, many of the same principles apply to the provision of health care and services in other types of residential facilities for youth.

4.2171 Initial Health Examination and Assessment

Each juvenile, as part of the admittance procedures, should be examined for apparent injuries, and for fever or other signs of illness. The examining officer should also note the juvenile's level of consciousness and level of gross motor function. Written standing orders should define the conditions which require prompt medical or nursing attention.

All juveniles placed in a training school should undergo a health assessment at the first possible opportunity after admission. Exceptions should only be made for juveniles with a written record of a thorough health assessment which is sufficiently current so that no substantial change can be reasonably expected. Health assessment should include physical examination within twenty-four hours of admission, the taking of a medical history, the taking of a mental health history if necessary, screening for vision and hearing defects, immunization status, and a dental examination. Health conditions which might affect behavior, such as epilepsy or diabetes, should be reported to the appropriate assessment team in a manner compatible with medical ethics and the rights of the patient.

Sources:

American Academy of Pediatrics, "Health Standards for Juvenile Court Residential Facilities," 52 Pediatrics, 452-457 (1973); and E. Brecher and R. Della Penna, Health Care in Correctional Institutions, 8-11 (1975).

Commentary

This standard urges that a preliminary health examination be conducted at the time a juvenile is admitted to a training school. This examination should take place prior to allowing the individual to have contact with other juveniles in the facility. This initial screening should be conducted and recorded by the attending nurse or a medical paraprofessional trained to detect any critical medical problems which would affect the juvenile's admission to the facility or subsequent processing. For example, the newly arrived juvenile may be suffering from a condition which, if left unattended, could result in further harm to the juvenile, or the spread of an infectious disease to others in the facility. Such precautions should be taken for the juvenile's own protection, for that of others in the facility, and for the facility itself which assumes liability for the individual's care upon admission. This

preliminary screening procedure should be conducted in a place which offers privacy.

Written procedures should be developed which specify what course of action should be taken given certain symptoms. These orders should serve a dual purpose-to assure consistent handling of new admissions, and to provide a guide for all other members of the staff in the handling of certain medical emergencies. These instructions should be prominently displayed throughout the facility and provisions should be made to acquaint staff with them.

The full health assessment, to be conducted within twentyfour hours of admission, should consist of three major elements: medical history, a physical examination, and laboratory tests. For those with a current assessment on file, only an abbreviated version of the examination may be

necessary.

Information about a juvenile's current and past medical, dental and mental health should be included in the medical

history. The history may be taken by the nurse and augmented as necessary by the doctor, dentist, psychiatrist, or psychologist in the course of their subsequent examinations. To obtain a complete medical history it may be necessary to talk with the juvenile's parents or guardians as well as the juvenile and request information from the juvenile's regular source of medical or dental care if one exists. The juvenile's regular source of medical care should only be contacted if the juvenile has granted written consent and only when the medical history reveals a gap of important information such as immunization status, dangerous allergic reactions, family history of certain illness, etc., unless during the course of the examination, the physician determines that such contact is necessary. See generally American Academy of Pediatrics, supra at 452.

The information collected in the medical history should be accurately recorded in the juvenile's medical file. Medical records should be maintained in a locked file, separate from other legal or administrative records. Records and any other medical information compiled during the juvenile's stay should be treated as confidential information. Access to it should be governed by the principles set forth in Standard 1.533, and those set forth in: (a) American Medical Association, Principles of Medical Ethics, §9 (1971), which states that "a physician may not reveal the confidences entrusted to him in the course of medical attendence . . . unless... the physician is required to do so by law or it becomes necessary in order to protect the welfare of the