Table of Contents
Newborns and infants are the most vulnerable population Children’s Division serves due to the fact that they are entirely dependent on others to survive and thrive. In some instances, a physician or healthcare provider may be hesitant about releasing an infant from the hospital due to concerns of parental drug use or other potentially dangerous family and/or household factors. A Newborn Crisis Assessment is generated because of concerns that have been reported by a physician or healthcare provider when assessing the home and family functioning. A physician or healthcare provider may also make a non-drug related referral when concerned about releasing a newborn from the hospital. Non-drug involved assessments will be accepted until the child is one year of age.
- If the physician/health care provider is concerned about releasing the infant from the hospital, they may contact the Child Abuse/Neglect Hotline to report their concerns. The request for a “Newborn Crisis Assessment” may be received by the Child Abuse/Neglect Unit and may be made prior to, or at the time of, the infant’s release from the hospital.
- Staff will handle the Newborn Crisis Assessment as an emergency, requiring the worker to assure the child’s immediate safety (no later than three (3) hours from when the referral was screened in by CANHU), unless it has been determined by the worker and supervisor that the child is not going to be immediately released from the hospital. This determination must be based on confirmation by the hospital through a multi-disciplinary (MDT) contact that the child will not be immediately released. Depending on the situation, assuring safety may require immediate face to face contact or may consist of phone contact with the reporter or hospital to confirm the child is safe and to discuss the plan for discharge.
- If staff has determined that the child’s immediate safety is not a concern due the child not being immediately discharged from the hospital and a MDT contact was utilized within three (3) hours from when the referral was screened in, staff shall still make face to face contact with the child as soon as possible but no later than seventy two (72) hours.
- If the worker recommends the child should not be released to the mother, father or other familial caretaker a referral to the juvenile court should be made.
- Contact with the Reporter (a physician or health care provider) who made the report to gather information on:
- Prenatal Care
- Delivery complications;
- Signs and symptoms of substance misuse prenatally and at birth;
- Mother/infant toxicology (obtain written medical documentation of the signs or symptoms of exposure at birth or toxicology test results);
- Other medical records that could include test results, discharge plans, growth chart, and other medical records;
- Mother/infant behavior while hospitalized;
- Father/infant behavior while hospitalized;
- Other caretaker/infant behavior while hospitalized;
- Other concerns noted by the physician or health care provider which include:
- Safety of the infant;
- The child’s specific vulnerabilities;
- The parent/caretaker’s protective capacities.
2. In person contact and safety assurance of infant within three (3) hours from the time the NCA was screened in by CANHU. If a multidisciplinary contact is utilized to assure initial safety of the infant, face to face contact must be had with the infant by the Children’s Service Specialist as soon as possible but no later than seventy-two (72) hours from the time the NCA was screened in.
3. Completion of face to face visits with the mother, father, and/or other identified caretakers at the hospital, if the child is still hospitalized and in their home(s) if they are no longer hospitalized, to assess the needs and protective capacities of the parent(s)/caretaker(s). Staff should assess the plans and abilities each parent/caretaker has with regard to caring for the infant prior to release from the hospital if possible. If the immediate safety of the child is in question, staff should develop a Safety Plan to assure immediate safety of the child with their parent or caregiver.
Overall needs assessment of the parent(s)/caretaker(s) should address:
- Prenatal care;
- Pregnancy complications (i.e., premature labor);
- Post-partum care;
- Physical, emotional, intellectual functioning;
- Observation of attachment and bonding with the infant;
- Planning for birth/hospital discharge (i.e., infant’s baby supplies, crib, bottles, formula);
- Substance use including treatment if necessary and potential for continued usage
- Mental health needs;
- Parenting/family support;
- Child care;
- Safe sleep knowledge and awareness through the distribution of the CD-278 Safe Sleep Flyer;
- Plans for infant’s sleeping environment and potential barriers to practicing safe sleep (i.e. continued substance use, prescribed medications, breast feeding practices, household space, cultural beliefs etc)
- Criminal history;
- Prior CA/N history
4. Face to face contact with all children residing in the home of the infant by the Children’s Service Specialist within seventy-two (72) hours of the Newborn Crisis Assessment to assure safety. There may be situations, however, in which safety of the additional household child(ren) should be assured much sooner than seventy-two (72) hours, as determined by the assigned worker and supervisor.
5. A visit shall be completed upon hospital discharge (prior to discharge if possible) in the home(s)of the mother, father, and any other familial caretaker with whom the infant is reported to reside and/or spend a significant amount of time to assess the following:
- Assessment of needs of all children in the home;
- Safe sleep knowledge as discussed through the distribution of the CD-278 Safe Sleep Flyer;
- Documentation and discussion of the safe sleep environment and any potential barriers to practicing safe sleep (i.e. continued substance use, prescribed medications, breast feeding practices, household space, cultural beliefs, etc)
- Support systems in place which may include the safety network such as family, friends, or other agencies involved. Staff may use genogram and culturagram tools to gather information;
- Presence of supplies for infant’s arrival (i.e., crib, clothes, bottles);
- Physical condition of the home;
- Observation/names of individuals residing in the home;
- Domestic relations (i.e., father or parent substitute is supportive);
- Contact with other adults in the home to assess the following:
- Verification of readiness for infant’s arrival;
- Expression of concern/support regarding any alcohol/drug use;
- Other household member’s description of available support;
- Ability of other caregivers parenting skills and abilities.
6. Contact with medical providers (other than the Reporter) as collateral contacts who have had or will have an ongoing relationship with the parent(s)/caretaker(s) and the infant to assist in the family needs assessment. Examples of important medical provider contacts include the Obstetrician who worked with the mother prenatally and could speak to any factors or services that Children’s Division should be aware of in assessing the needs of the family and infant. Another important contact would be the pediatrician who has been assigned to work with the infant. Contact with the assigned Pediatrician to the infant should be made prior to conclusion of the assessment to ensure continuity of services and ongoing support for the infant and family.
7. Development of a Plan of Safe Care (if needed). If during contacts with medical providers and the family, an infant is identified as having been born affected by substance use, experiencing withdrawal symptoms, likely to be affected negatively in some form by parents’/caretakers’ continued use of substances, having been born with Fetal Alcohol Spectrum Disorder, or suffering from Neonatal Abstinence Syndrome, a Plan of Safe Care shall be developed with the family.
The Plan of Safe Care shall be developed with input from the medical provider(s) who knows or has been assigned to work with the family and infant, as well as the family, and any service providers/agencies providing services to the family/infant. A Plan of Safe Care should address the health, physical safety, and substance use treatment needs of the infant and affected family or caregivers. The plan should also address potential barriers to positive family functioning and future safety of the infant. Staff should observe and assess the needs of each member of the family.
The Plan of Safe Care shall be documented thoroughly on the NCAT.
The plan should be inclusive of and address the following:
- Parents’ or infants’ treatment needs;
- Other identified needs that are not determined to be immediate safety concerns;
- Involvement of systems outside of Children’s Division;
- A plan that addresses the potential for continued substance use and how to mitigate safety risks;
- A plan that is able to address any immediate safety concerns and continue beyond the Children’s Division assessment if a case is not opened for further services;
- Conversations with medical providers who have worked with the Mother prenatally (such as an obstetrician)
A Plan of Safe Care should include the family’s safety network, which could be, but not limited to, the following:
- Caregiver and family members in the household;
- Extended family and friend(s);
- Medical professional(s);
- Hospital social worker(s);
- Substance abuse provider(s);
- Mental health provider(s);
- First Steps;
- Intensive In-Home Services and/or Family Centered Services;
- Home visiting;
8. Other community outreach and collaborative partner(s) observation and assessment of the infant (if a mother and infant are in the hospital in another county, staff may request a courtesy assist from CD staff in that county to visit the hospital and provide information to the county of residence). Observation and assessment of the infant should include:
- Signs of prenatal exposure to substances and withdrawal, including:
- Facial characteristics of fetal alcohol syndrome;
- Signs of prenatal exposure to substances and withdrawal, including:
- Irregular and rapid changes in states of arousal;
- Low birth weight;
- Difficulties with feeding due to poor suck;
- Irregular sleep-wake cycles;
- Decreased or increased muscle tone;
- Seizures or tremors;
- Excessive crying or high-pitched crying;
- Medical complications, such as those requiring treatment in a Neonatal Intensive Care Unit (NICU)
- Bonding and attachment to parent(s)/caretaker(s)
- The need for early care and education programs;
- Having supplies and materials to support the infant’s basic needs;
- Safe sleep environment (at every visit); and
- Special health care needs (including the need of home health care if recommended by a physician)
9. Completion of the Newborn Crisis Assessment Tool (NCAT) in order to document the circumstances surrounding the newborn and the response by the Children’s Division to any identified needs and services. Information obtained from the family and medical providers regarding the infant and family will be included in the documentation contained in the NCAT, including the Plan of Safe Care if needed.
10. Staff should distribute and have a thorough discussion of the information included in the CD-278 Safe Sleep Flyer with the parent(s)/caretakers(s) to ensure they are aware of safe sleep recommendations and the reasons for ensuring a safe sleep environment. Staff should also thoroughly explore the intended sleep environment for the infant and address any potential barriers to practicing safe sleep (I.E. continued substance use, prescribed medications, breast feeding practices, household space, etc). These discussions should be well documented in FACES in the communication log.
11. Requirement for a conversation about Home Visiting (HV) Services, and completion of the CD-261 (Referral for Home Visiting Services), if the family accepts services.
12. Provision of the Description of the Newborn Crisis Assessment, CS-24b, at the time of initial face to face contact with the mother, father and/or other familial caretaker. Staff should take time to answer any questions they may have about the process before proceeding. Staff should document that they have given and explained the CS-24b.
The Following is Required to Conclude a Newborn Crisis Assessment:
- Completion of the Newborn Crisis Assessment Tool (NCAT) in FACES, including a Plan of Safe Care if necessary;
- The NCAT is located on E-Forms and after completion shall be uploaded into OnBase.
- In person contact(s) with the infant and parent(s)/caretaker(s);
- Safety of infant to be verified no later than three (3) hours from the time the assessment was screened in by CANHU. If MDT contact is used to verify initial safety of infant, Children’s Division staff still need to complete in person contact with the infant no later than seventy two (72) hours from the time the assessment was screened in.
- In person contact to be had with all children residing in the household no later than seventy two (72) hours from the time the assessment was screened in.
- Provision of the Description of the Newborn Crisis Assessment, CS-24b at time of initial contact with parent(s)/caretaker(s).
- Home visit to be completed prior to infant discharge if possible, or as soon as possible after discharge;
- Medical provider collateral contact(s):
- Contact with the assigned Pediatrician shall be made prior to conclusion of the assessment, to include confirmation and discussion of the infant’s follow up well visits after birth and any continued concerns/plans for the infant.
- For instances in which there is a concern for Mother’s prenatal drug usage, contact with the Mother’s assigned Obstetrician should be made to discuss the development of a Plan of Safe Care and any ongoing concerns.
- To ensure meaningful contact with a medical provider collateral contact, newborn assessments should not be concluded any earlier than twenty (20) days upon receipt of the report;
- Staff may not conclude the newborn crisis assessment with an active Immediate Safety Intervention Plan (CD-263) still in effect, unless a Family-Centered Services (FCS) case is opened or the child is removed from the home;
- Documentation of the conversations with medical providers regarding the need/potential need of a Plan of Safe Care for the family/infant;
- Documentation of the conversation around safe sleep practices, as a result of the distribution of the CD 278 Safe Sleep Flyer, as well as observation of the infant’s safe sleep environment. These conversations shall include potential barriers to practicing safe sleep (I.E. continued substance use, prescribed medications, breast feeding practices, household space, cultural beliefs, etc);
- Documentation of the conversation about DSS Home Visiting services, and submission of the CD-261 (Referral for Home Visiting Services) if the family accepts services;
- Completion of the 72 hr Supervisory Consult, as well as a conclusive supervisory consult prior to conclusion, to ensure all needs have been addressed;
- Any and all contacts, visits, and conversations should be documented in the Contact Communication section of FACES;
- On the Conclusion Screen, summarize the assessment of the newborn and family in the Actions Taken Summary Section. The Actions Taken Summary should include the conclusion template identified below.
- Completion of the Newborn Crisis Assessment Tool (NCAT) in FACES, including a Plan of Safe Care if necessary;
Staff shall utilize the following completed template in the conclusion summary in FACES:
“The ( ) County Children’s Division received a Newborn Crisis Assessment report on ( ).
Summary of reported concerns:
How was safety assured of the child(ren):
Parental Protective Capacities:
Mother/Infant Toxicology Results:
Was a Plan of Safe Care Completed? (Why or Why Not):
-Substance use services referred to/already involved with:
-Plan for how to continue to ensure safety of infant given parental substance use:
Was an Immediate Safety Intervention Plan needed? If so, please explain how the safety threat(s) were resolved:
Safe Sleep Discussion (resources provided, acknowledgement of safe sleep discussion, description of sleeping environment, and discussion/resolution of potential barriers (if any) to practicing safe sleep):
Strengths of the Family and Safety Network:
Additional Services Referred to (IIS, Home Visiting, First Steps, etc):
Prior history reviewed and concerns were expressed in the past that included: (Note any significant history as it pertains to this report)
The Risk Assessment level scored (#) due to:
NCA Tool Completed and Uploaded
A Family Centered Service Case will/will not be opened for this report (Why or Why Not): ”
On July 22, 2016, President Barack Obama signed into law the Comprehensive Addiction and Recovery Act (P.L. 114-198). This is the first major federal addiction legislation in 40 years and the most comprehensive effort undertaken to address the opioid epidemic, encompassing all six pillars necessary for such a coordinated response – prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal. The Comprehensive Addiction and Recovery Act (CARA) establishes a comprehensive, coordinated, balanced strategy through enhanced grant programs that would expand prevention and education efforts while also promoting treatment and recovery.
CARA amended sections of Child Abuse Prevention Treatment Act (CAPTA) to remove the term “illegal” as applied to substance abuse affecting the identified infant and to specifically require that Plans of Safe Care address the needs of both infants and their families/caretakers. It also added requirements relating to data collection and monitoring. When assessing a family for needs and services, a Plan of Safe Care, if needed, is made to assist the family. Additional information about plans of safe care are listed below.
When determining if an infant has been “affected” by substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder, Children’s Division staff shall assess if the child’s physical, mental, or general well-being is affected by the use of substances by the parent/caretaker and a Plan of Safe Care is needed.
Examples of When a Plan of Safe Care may be needed:
- Infant tests positive at birth for a substance but is not exhibiting withdrawal symptoms. After assessment by a physician and/or a Children’s Division staff, it is determined that this exposure and substance use may have an adverse effect on the infant’s physical, mental, or general well-being.
- Infant is displaying withdrawal symptoms due to exposure to substances as determined by a physician.
- Infant is exhibiting Fetal Alcohol Spectrum Disorder symptoms as determined by a physician.
- Infant tested positive for a substance at birth and did not exhibit withdrawal symptoms, but the parent/caretaker’s continued use may adversely affect the safety and well-being of the infant or other children in the home. This could include parent/caretaker’s inability to make coherent decisions in regards to feeding, safe sleeping, caring, or transporting the infant or other children in the home.
- The infant tested negative for substances at birth and did not exhibit withdrawal symptoms, but the parent/caretaker’s continued use may adversely affect the safety and well-being of the infant and/or other children in the home.
- Mother tested positive for a substance at some point during her pregnancy and/or at birth, and the infant’s initial test results are negative for all substances. Mother reports using marijuana occasionally for nausea throughout her pregnancy and states she only uses occasionally. A Plan of Safe Care would still be needed to address realistic plans for when Mother does decide or could decide to use marijuana ensuring she is not caring for or waking up for infant feedings while under the influence. The plan could also address supports, services and education associated with substance use by parents and how substance use can directly affect the health, safety, and care of infants/children.
Examples of when a Plan of Safe Care may not be needed:
- Infant tests negative for substances at birth and Mother tests negative for substances during pregnancy and at birth. No concerns for substance use.
- Infant tests for substances are pending, Mother tests negative for substances during pregnancy and at birth. No concerns for substance use.
- Infant tests negative for substances at birth. Mother tested positive for a substance once very early on in pregnancy but not since and not at birth. Mother reports using prior to pregnancy but not since knowing she was pregnant. An assessment with the Mother, and input from medical provider(s) who worked with Mother throughout her pregnancy, do not identify a concern for continued usage of substances.
A Plan of Safe Care Should Include:
- Documentation of substance use services that the Mother/Caregiver(s) have been referred to or who they are already involved with;
- Documentation (if available) of discussions/plans/referrals by the medical provider assigned to work with the Mother throughout her pregnancy, as they relate to substance use;
- Mother/Infant Toxicology Results;
- The Drug of Choice;
- Plans for addressing the known/possible continued use of substances by the caregiver(s), including and most importantly how these plans will promote the safety and well-being of the infant as well as other children in the home.
- The family support team as appropriate (both informal and formal);
- The assistance and collaboration of the medical provider(s) and service provider(s) assigned to work with or who have worked with the Mother/caregiver(s)
Despite research and statistics about the importance of safe sleep, the number of babies who die in adult beds and other unsafe sleep environments is on the rise. These fatalities are often preventable with proper understanding and education.
Some of the common concerns identified as unsafe sleeping environments consist of:
- Co-sleeping with a parent or sibling;
- Sleeping on soft surfaces;
- Utilizing soft items, blankets and bumper pads in cribs;
- Placing an infant on their stomach to sleep;
- Allowing an infant to sleep in a car seat, baby seat, or swing.
Through family engagement and social connections, Children’s Division staff can provide education and empower caregivers as well as community partners about safe sleep recommendations. Staff should develop a Circuit protocol that identifies vulnerable children in the home and should provide education, resources, and discuss safe sleep practices identified in the CD-278 Safe Sleep Flyer with all families and individuals caring for children, two years old or younger. Information should also be provided to families who are expecting a new baby in the home. Safe sleep education should include a conversation around the potential barriers to practicing safe sleep, including continued substance use, prescribed medications, breast feeding practices, household space, cultural beliefs, etc). Children’s Division staff should also document observations of infant’s safe sleep environment at every visit.
American Academy of Pediatrics (AAP) recommendations for creating a safe sleep environment include:
- Placing the baby on his or her back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
- Avoid use of soft bedding, including crib bumpers, blankets, pillows and soft toys. The crib should be bare.
- Sharing a bedroom with parents/caretakers, but not the same sleeping surface, preferably until the baby turns 1 but at least for the first six months. Room-sharing decreases the risk of SIDS by as much as 50 percent.
- Avoid baby’s exposure to smoke, alcohol and illicit drugs.
If during an assessment of the family staff identifies an infant in the home, staff should provide education, resources, and discuss safe sleep practices identified in the CD-278 Safe Sleep Flyer with all families and individuals caring for children, two years old or younger.
Information should also be provided to families who are expecting a new baby in the home. Staff shall then document that they have discussed and provided the CD-278 Safe Sleep Flyer to the infant’s caregiver(s) in case documentation.
Related Practice Alerts and Memos: