CHILD WELFARE MANUAL

Section 2, Chapter 4 (Non-Child Abuse/Neglect Referrals), Subsection 4 – Newborn Crisis Assessments

(Effective10/9/20)

Table of Contents

4.4 Newborn Crisis Assessments “NCA”

4.4.1 The Comprehensive Addiction and Recovery Act (CARA)

4.4.2 Steps to Completing a Newborn Crisis Assessment

4.4.3 Safe Sleeping Environments for Young Children

4.4 Newborn Crisis Assessments

Newborns and infants are the most vulnerable population that we serve due to their basic welfare being dependent on others. 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 household conditions. A Newborn Crisis Assessment is generated because of concerns that have been reported by the 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 referrals 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 referral as an emergency, requiring the worker to assure the child’s immediate safety, 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 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, staff shall make face to face contact with the child within 72 hours.
  • If the worker recommends the child should not be released with the mother, father or other familial caretaker a referral to the juvenile court should be made.  

4.4.1 The Comprehensive Addiction and Recovery Act (CARA)

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 include:

    • 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 will have a probable adverse effect on 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.
    • The infant’s safety could be jeopardized by the continued use of substances by parent/caretaker or other household member.
    • 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.
    • Infant did not test positive for a substance at birth nor did they exhibit withdrawal symptoms, but parent/caretaker’s continued substance 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, caring, or transporting the infant or other children in the home.

Examples of when a Plan of Safe may not be needed:

    • Mother tested positive for a substance during pregnancy but did not test positive at birth nor did the child test positive at birth and there have been no signs of adverse physical effects on the infant.
    • Mother informed her physician at some point during pregnancy that she used a substance prior to knowing she was pregnant, neither she nor the child tested positive for a substance at birth, and no adverse effects have been noted by a physician.

4.4.2 Steps to Completing a Newborn Crisis Assessment

1. Contact with the physician or health care provider who made the referral to gather information on:

      • Delivery complications;
      • Signs and symptoms of exposure 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 growth chart, discharge plans, 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. 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.  Staff should assess the plans and abilities each parent/caretaker has with regard to caring for the infant upon release.  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.

3. Staff should distribute and have a thorough discussion of the content 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. This contact should be well documented in FACES in the communication log.

4. 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.

5. The Newborn Crisis Assessment Tool (NCAT) is to be used to assess the circumstances surrounding the newborn and to document the response by the Children’s Division to any needs and services. 

6. If during the initial assessment of the family medical personnel or staff identifies an infant born being affected by substance abuse, withdrawal symptoms, or a Fetal Alcohol Spectrum Disorder, a Plan of Safe Care shall be developed with the family.  A Plan of Safe Care should address the health and substance use treatment needs of the infant and affected family or caregiver.  The plan should be developed with input from the parents or other caregivers as well as any collaborating professional partners and agencies involved in caring for the infant and family.  Staff should observe and assess the needs of each member of the family.  The SOS Mapping Tool (CD-218) may be utilized by the worker to assist developing the Plan of Safe Care with the family. The Plan of Safe Care shall be documented on the NCAT.

A Plan of Safe Care should be inclusive of the following:

      • Parents’ or infants’ treatment needs;
      • Other identified needs that are not determined to be immediate safety concerns;
      • Involvement of systems outside of child welfare;
      • A plan that is able to continue beyond the child welfare assessment if a case is not opened for further services.

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;
      • Family Centered Services;
      • Home visiting;
      • Other community outreach and collaborator(s)

7. In assessing the needs of the parent/caretaker, staff 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;
      • Mental health needs;
      • Parenting/family support;
      • Child care;
      • Safe sleep awareness through the distribution of the CD-278 Safe Sleep Flyer;
      • Criminal history.

8. Observation 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 of the infant should include:                

Signs of prenatal exposure to substances and withdrawal:

      • Facial characteristics of fetal alcohol syndrome;
      • Irritability;
      • Irregular and rapid changes in states of arousal;
      • Low birth weight;
      • Prematurity;
      • 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);
      • Special health care needs (include home health care if recommended by a Doctor);
      • Linkage to early care and education programs;
      • Safe sleep environment.

9. Contact with all children, if any, residing in the home of the infant must be seen face to face by the Children’s Service Worker 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.

10. 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, if any, in the home (i.e., education, medical, mental health, developmental, and prior juvenile office involvement);
      • Safe sleep practices as discussed through the distribution of the CD-278 Safe Sleep Flyer;
      • Support systems in place, which may include their 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);
      • 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 regarding mother’s alcohol/drug use;
        • Other household member’s description of available support;
        • Ability of other caregivers parenting skills and abilities.

The following steps are required to complete a Newborn Crisis Assessment:

    • The NCAT is to be completed on every Newborn Crisis Assessment received.
    • The NCAT is located on E-Forms and after completion shall be uploaded into OnBase.
    • Initial contact with the child and family, home visits, collateral contacts, phone correspondence, and any additional contacts shall be documented in the Contact Communication section in FACES.
    • The worker must document that the child(ren) was verified as “SAFE” in the contact.  
    • To reduce redundant work, summarize the assessment of the family in the contact but do not repeat what has already been entered into the NCAT.
    • On the Conclusion Screen, summarize your assessment of the newborn and family in the Actions Taken Summary Section. The Actions Taken Summary may mirror the assessment summary on the NCAT.

4.4.3 Safe Sleeping Environments for Young Children

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.

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.
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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:

9-15-2020 – CD20-40 – Newborn Crisis Assessment Tool and Instructions