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2.2.14 Identifying, assessing and responding to high-risk infants

Last Modified: 19-Dec-2018 Review Date: 31-Oct-2021

Purpose

To guide child protection workers in:

  • understanding the types of abuse and neglect specific to high risk infants and identifying what risk factors may be present for an unborn infant or high risk infant.
  • determining when an infant is at risk of significant harm or an unborn infant is at risk of significant harm after birth, undertaking an assessment of these risks and taking action to reduce risks.
  • procedures for child protection practice with high risk infants and their families including response to abuse and neglect and safety planning.

 

This entry is to be read in conjunction with:

  • Determining whether an infant is at risk of significant harm, (Related resource) which outlines risk factors that indicate an infant is at high risk and activities to be undertaken to assess these risk factors.
  • Chapter 2.2 Assessment and investigation processes.
Practice Requirements
  • All infants and unborn infants who are referred to child protection district offices in the Department of Communities must be assessed to determine whether they are at risk of significant harm.
  • Where a child protection worker has assessed that an unborn infant is at risk of significant harm after birth, the matter must be referred for pre-birth planning and to Best Beginnings Plus (BB Plus).
  • Where an infant is open for Initial Inquiries and there is information to suggest they may be at risk of significant harm, a Safety and Wellbeing Assessment must commence as a priority one, within 24 hours.    
  • All unborn infants assessed to be at risk of significant harm after birth and high risk infants must be actively case managed until such time the risk factors have been addressed and there is sufficient safety to close the case. These cases are not to be placed on a monitored list.
  • Child protection workers must work with parents and carers to create a safe sleeping environment for the infant, i.e. in a cot or bassinet which is not cluttered with soft toys, pillows or other items.
  • Prior to the infant's birth (where possible) or at the first home visit, parents and/or carers must be provided with verbal information about:
    • the effects of shaking on an infant (abusive head trauma). This discussion must be documented in case notes
    • the risks associated with co-sleeping practices via the related resource, BB Plus safe infant sleeping checklist. This discussion must be documented in case notes.
  • Where an infant is at risk of significant harm and all attempts to support the infant to safely remain with the parents have been exhausted, consultation must occur with the district director to consider intervention action.
  • Where an infant has suffered significant harm, the child protection worker, team leader, district director and other specialist staff must immediately consider whether intervention action is required for the infant and their siblings.

Procedures

  • Overview
  • Determining whether an infant is at risk of significant harm or an unborn infant is at risk of significant harm after birth
  • Types of abuse specific to infants
  • Assessing concerns regarding infants and unborn infants
  • Working with medical practitioners
  • Family and domestic violence
  • Home visits
  • Signs of Safety Child Protection Practice Framework and safety planning
  • Working with Aboriginal families and culturally and linguistically diverse families
  • Best Beginnings Plus
  • Child protection worker is unable to access the high risk infant
  • The high risk infant’s whereabouts are unknown
  • Case closure
  • Overview

    ​Infants and babies (0-2 years of age) are extremely vulnerable to the effects of child abuse and neglect due to being totally dependent on others to meet their care needs, having restricted language and mobility, physical fragility and being socially 'invisible' due to having little contact with support services.

    High risk infant refers to infants who are considered to be at risk of significant harm or death due to the presence of risk factors, such as:

    • parents lacking maturity
    • parents with a childhood experience of abuse
    • parents with criminal histories/drug and alcohol use/mental health concerns/disabilities/poor parenting skills
    • family and domestic violence (FDV)
    • history of abuse towards siblings of the infant
    • complications at birth (premature/low birth weight, drug withdrawal and additional needs)
    • co-sleeping,
    • homelessness/chaotic or unsafe home environment.

     

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    Determining whether an infant is at risk of significant harm or an unborn infant is at risk of significant harm after birth

    ​Child protection workers must identify the risk factors which contribute to an infant being at high risk of abuse and neglect. The child protection worker's role is to undertake assessments to determine whether these risk factors are present in the family and if so, what impact they might have on the safety of the infant or unborn child.

    Risk factors to be considered are grouped into the following three areas and are explored further in related resource, Determining whether an infant is at risk of significant harm:

    • parental risk factors
    • infant risk factors, and
    • environmental risk factors. 

    When assessing risk factors, child protection workers should also be familiar with the Child Development and Trauma Guide, which provides information on infant milestones and development and possible indicators of trauma.

     

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    Types of abuse specific to infants

    1.    Bruising or injury to a non-mobile infant (physical abuse)

    Bruising is not common in infants because they are non-mobile. As such, any bruising or symptom of injury located on a non-mobile infant must be further assessed by a paediatrician, preferably with child protection experience.

    2.    Abusive head trauma (AHT) (shaken baby) (physical abuse)

    Abusive head trauma (AHT) refers to an injury to the skull or the intracranial contents (e.g. brain) due to inflicted blunt impact (infant being hit in the head or having their head hit against something) and/or shaking (whiplash). This type of injury can result in the most severe consequences for an infant's future wellbeing and is the leading cause of death amongst infants who have been abused.

    Infants aged less than six months are most vulnerable to abusive head trauma from shaking because of the combination of a heavy head, weak neck muscles, soft and rapidly growing brain, thin skull wall and lack of control of the head and neck.

    The greatest risk period for infants is between six weeks and four months of age when continuous crying can be particularly stressful for parents. If a child protection worker suspects that an infant has suffered AHT, urgent medical attention must be sought for the infant via an ambulance.

    Severe symptoms of AHT:

    • a bulging and/or spongy forehead
    • rigidity
    • seizures
    • loss of consciousness, or
    • difficulty breathing or alterations in breathing or temperature.

    Non-specific signs and symptoms of AHT:

    • irritability
    • tiredness
    • loss of appetite
    • poor feeding
    • vomiting
    • poor sucking or swallowing
    • lack of smiling or vocalising
    • poor muscle tone, or
    • pinpointed, dilated or unequal pupil size.

    3.    Non organic failure to thrive (FTT) (neglect)

    FTT is "significantly prolonged cessation of appropriate weight gain compared with recognised norms for age and gender…" (Block & Krebs 2005, Failure to Thrive as a Manifestation of Child Neglect).

    Organic FTT occurs when there is an underlying medical cause for the condition. Non-Organic FTT is caused by environmental factors and/or the actions or inactions of the parent or caregiver. The child protection worker's role is to ascertain from medical professionals if the FTT has resulted from non-organic causes and if so, to facilitate services and supports to assist the infants parents to better care for them. Symptoms of FTT include:

    • lack of weight gain
    • dehydration
    • delays in reaching developmental milestones such as rolling over, crawling and talking
    • learning disabilities
    • lack of emotions such as smiling, laughing or making eye contact
    • delayed motor development
    • fatigue/sleepiness/disinterest, or
    • irritability.

    FTT is often diagnosed by child and/or community nurses in conjunction with other health practitioners, who will conduct a medical assessment to exclude underlying medical conditions.

    4.    Co-sleeping and the risk of accidental suffocation (neglect)

    Co-sleeping is the practice of a parent (or any other person) being asleep on the same sleep surface as an infant. The concern is that the parent or bedding items will accidentally suffocate the infant or that a mother may fall asleep while breastfeeding the infant, smothering the infant with the breast or body.

    Between July 2009 and December 2011 in Western Australia, there were 91 infant deaths. Of these, 54 infants died suddenly and unexpectedly in their sleep. Of these 54 infants, 29 were co-sleeping at the time of their death[1]

    Where family domestic violence (FDV) is occurring, the adult victim may co-sleep with their infant as a protective measure, to protect themselves and/or the infant from the perpetrator. Where FDV and co-sleeping are occurring, the child protection worker should interview the adult victim alone in order to establish whether co-sleeping is being used as a protective measure, and use the common risk assessment tool in order to determine the level of risk to the adult victim and the infant whilst they remain in contact with the perpetrator.  

    Common risk assessment tool

    There is evidence that co-sleeping is associated with a greater incidence of sudden unexpected deaths in infancy (SUDI). The risks associated with co-sleeping are increased when:

    Parental risk factors:

    • the parent or carer has consumed alcohol or used drugs
    • the parent or carer has taken medication which may alter consciousness or cause drowsiness
    • either the parent or the carer is a smoker
    • the mother smoked during pregnancy
    • the parents or carers are experiencing extreme tiredness to the point where they may find it difficult to respond to the infant, and
    • the mother breastfeeds in bed and is likely to fall asleep during the feeding process.

    Infant risk factors: 

    • the infant is less than six months of age
    • the infant was born pre-term or is small for gestational age, and
    • pre-natal exposure to smoking.

    Environment risk factors: 

    • smoking in the home
    • adults, children or pets sleeping with the infant on any soft surface (for example on a sofa, couch, waterbed, bean bag or sagging mattress)
    • adults, children or pets sharing a bed with the infant
    • excessive bedding on the bed (risk of smothering), and
    • the infant does not sleep in their own cot or bassinet, or the cot or bassinet is cluttered with soft toys, pillows or other items.

    Further information on safe sleeping is available through the e-learning packages Safe Infant Sleeping and Safe Sleeping E-Learning Package

    [1] Investigation into ways that State Government departments can prevent or reduce sleep-related infant deaths, Ombudsman Western Australia, 2012.

     

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    Assessing concerns regarding infants and unborn infants

    ​Where referrals are received from medical professionals and hospital social workers regarding safety concerns for unborn infants or infants, the referrer must be consulted and the concerns thoroughly assessed.

    Determining whether an infant is at risk of significant harm (related resources) is used to assist child protection workers to make a thorough and holistic assessment of the initial concerns regarding unborn infants and infants.

    Where concerns about an infant are assessed as requiring no further action, a rationale for this decision must be documented in an Assist interaction or Initial Inquiry assessment and approved by the team leader. Feedback should be provided to the referrer.

    As part of pre-birth planning and/or the safety and wellbeing assessment (SWA) of a newborn infant, child protection workers refer to, and work in accordance with the Bilateral schedule, Interagency collaborative processes when an unborn or newborn baby is identified as at risk of abuse and/or neglect, between: The Department for child protection and family support and WA health (related resources).

    When undertaking pre-birth planning and SWAs with an unborn infant or infant assessed to be at high risk, Determining whether an infant is at risk of significant harm (Related resource) is used to undertake a psychosocial assessment[1] of the parent's and family's circumstances. An assessment of any relevant psychosocial risk factors must consider:

    • parent's understanding of the infant's needs and how they must respond
    • parent's ability and willingness to provide appropriate nutrition and stimulation
    • parent's previous parenting role models
    • impact of stress on the parents and their capacity to meet the infant's needs
    • impact of family and domestic violence on family functioning and whether power, control and violence is preventing the infant from having their needs met, and
    • parent's strategies for attempting to deal with difficult feeding issues or other complications, which can result in an unsettled or distressed infant.

    Assessment should not solely rely on telephone contact or parents self-reporting their progress. Information must be gathered from multiple sources (parents during home visits, other professionals and the safety network.)

    When there is suspicion that an infant has been harmed, child protection workers must conduct a visual check for injuries and bruising by engaging and respectfully inviting the parents to undress the infant, including removal of the nappy. If the parents refuse, the child protection worker must move to a place of safety and consult the team leader immediately.

    Infants with bruising, injuries, burns and/or other symptoms of injury such as vomiting, seizures, rigid appearance, a lack of response to stimuli, alterations in breathing/temperature, poor feeding, irritability or lethargy must be medically assessed immediately, via ambulance if necessary.

    Any infant found to have any injury or symptoms of injury must be medically assessed on the same day by a paediatrician, preferably with child protection experience. If a decision is made not to take the infant for a medical assessment, this decision must be made in consultation with a team leader and the rationale clearly documented in case notes.

    Where parents do not consent to an infant with symptoms of injury being medically assessed, child protection workers move to a place of safety and consult with their team leader immediately. The child protection worker must consider whether the infant is at immediate and substantial risk. Section 37 of the Children and Community Services Act (the Act) may be considered, in order to place the infant into provisional protection and care without warrant and allow for a medical assessment to be carried out. Any decision to enact s.37 of the Act is made by the district director. 

    [1] Psychosocial assessment: A holistic assessment which builds a comprehensive and broad understanding of a family's life, including mental health, drug and alcohol use, domestic violence, housing and other risk factors. Information is gathered from the family and other stakeholders.

     

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    Working with medical practitioners

    Where an infant presents with bruises or symptoms of injury, the child protection worker must attend the medical service in person with the infant (and where possible, a parent or relative of the infant), or telephone the service and provide the paediatrician (or the hospital social worker), with details of the concerns.  

    In the metropolitan area, infants are referred to the Perth Children's Hospital (PCH) Child Protection Unit (CPU). The child protection worker should phone ahead and make an appointment, then accompany the infant there.

    During business hours, PCH CPU services can be requested directed through the CPU Acute Service (6456 0089).

    For after-hours, the duty social worker can be contacted through the PCH Switchboard on 6456 2222.

    In regional areas infants are referred to their local medical service, where the assessing medical practitioner should consult their on call paediatrician as per their service's procedures.

    The child protection worker must seek clarification from the paediatrician as to whether the injury has been deemed to be accidental or non-accidental (NAI – non accidental injury, also can be referred to as an inflicted injury).

    Where an infant has been assessed by a medical practitioner who is not a paediatrician, for example a nurse, general practitioner or junior medical officer, the child protection worker must ask the medical practitioner whether they have consulted with a paediatrician linked with their service or 'on call' in their region. If this has not occurred, the medical practitioner and/or child protection worker must consult with PCH CPU on the same day.

    PCH CPU is available to provide medical advice to child protection workers and/or other medical practitioners when required (6456 0089 – PCH switchboard).

    A medical assessment by a paediatrician (preferably with child protection experience) is expected to:

    • provide treatment for the infant's injury and recommendations for further medical treatment
    • exclude any underlying medical conditions leading to the bruising or injury
    • document the current injury (written and photographic)
    • conduct an in depth health assessment including blood tests, bone scans, x-rays (where necessary), and an ophthalmological assessment (where necessary – an eye exam to identify retinal haemorrhages indicating abusive head trauma or shaken baby) in order to identify other possible injuries or indicators of previous injuries.
    • provide a medical opinion on the child's injuries, including the degree to which the explanation/mechanism matches the injury and whether the bruising is due to accidental or non-accidental causes, by considering:
      • age and developmental stage – can the infant do what the parents are saying?
      • consideration of the location of bruises - face, back, abdomen, arms, genitalia/perineum, buttocks, head, neck, torso, hands and feet are uncommon in accidental injury
      • number of bruises
      • size, shape or pattern – fingertip bruising, tramline bruising, pinch marks, slap marks, implement bruising
         

    Where an infant has been hospitalised as a result of a non-accidental or suspicious injury, safety planning needs to be implemented, monitored and tested, so that any future contact between the infant and the parents and/or possible perpetrators will not pose any further risk to the infant (e.g. supervision of contact between parents and the infant). Planning must also consider the safety of siblings/other children in contact with the parents or possible perpetrators.

    Where the parents do not comply with a safety plan, or the risk to the infant and their siblings is so great that a safety plan may not prevent further harm, the child protection worker must consult with their team leader regarding whether intervention action is necessary to promote the infant's safety.

     

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    Family and domestic violence

    Infants do not have to be present during a family and domestic violence (FDV) incident to be harmed by family violence. When an adult victim is at high risk of serious harm, the same level of risk applies to the infant.

    Screening for FDV occurs in all open child protection cases via the use of the Common risk assessment tool.

    Child protection workers conduct separate discussions with the adult victim and the perpetrator, as the adult victim of FDV may, in the presence of the perpetrator, feel intimidated and minimise the risk to themselves and the infant. In some instances the adult victim may take the blame for violence which has occurred and be fearful to report their partner's abuse. 

    Where the adult victim, the infant and their siblings have been assessed to be at risk of significant harm by the perpetrator of FDV, the child protection worker must consult with their team leader, undertake safety planning and take action to manage the risk posed by the perpetrator and increase the victim, the infant and their sibling's safety.

    Communities' response should both support the adult victim of FDV and also engage with and support behaviour change of the perpetrator (Chapter 2.3 Responding to perpetrators of emotional abuse – family and domestic violence).

    A multi-agency case management (MACM) meeting convened by the child protection worker is required in order to share information with other agencies, develop a comprehensive risk assessment and plan strategies to mitigate risks and work towards child and adult safety and perpetrator accountability.

    Child protection workers can use powers granted under the Restraining Orders Act 1997 s.10E to apply for a Family Violence Restraining Order (FVRO) on behalf of the infant and their siblings against the perpetrator (Chapter 2.3 Responding to perpetrators of emotional abuse – family and domestic violence).

    Where all attempts to support the high risk infant and their siblings to safely remain with the adult victim have been exhausted, immediate consideration must be given to whether the high risk infant and their siblings are in need of protection.

     

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    Home visits

    Once an infant has been assessed as being at high risk, and a safety plan is developed with the parents, the infant must be seen by the child protection worker at a minimum of once per week.

    Child protection workers should consult with other staff (including the Aboriginal Practice Leader) when planning home visits and initial attempts to engage families who are Aboriginal or culturally and linguistically diverse (CaLD). Consideration is to be given to the specific cultural background of the family, factors (e.g. intergenerational trauma), which may hinder attempts to engage the family and what strategies can be taken to promote engagement with the family.

    Where parents prevent the child protection worker from seeing the infant, the child protection worker must persist and attempt to see the infant, regardless of whether the infant is sleeping. If the child protection worker is unable to see the infant, on the same day they must consult with their team leader regarding the next steps to be taken.

    The more elevated the risk, the more frequent the visits – where necessary, daily visits should be carried out. Additional visits can be undertaken by the child protection worker and/or other approved safety people such as BB Plus worker, the child health nurse and/or a home visiting service.
     

    Engaging the infant

    At each visit, the child protection worker and/or other safety people (e.g. BB Plus worker/child health nurse) need to engage the high risk infant by holding them, interacting with them and actively assessing their presentation and circumstances.

    During home visits child protection workers should respectfully ask the parents if they (the child protection worker) can hold the infant, then engage the infant in a playful way, speak to them softly, engage in eye contact (mutual gaze) and demonstrate enjoyment in engaging the infant.

    ​Mutual gaze (eye to eye contact) is critical for infants, to promote optimal brain development, support a rich sense of self in the infant and promote attachment between the infant and caregiver.

    Child protection workers should explain the benefits of eye contact to parents. Engaging the infant in this way assists the child protection worker to assess the infant's presentation whilst also providing appropriate role modelling to parents.
     

    Observe the high risk infant at each visit

    • Is their skin clean and healthy? Are their nails dirty? (dirty nails on a non-mobile infant indicate the infant may not be being kept clean) Do they have an odour? Do they suffer from nappy rash? If so, how is this being treated? Are they dressed in clean clothing which is appropriate for the weather? Do they appear dehydrated? (watch for sunken eyes and/or fontanel (soft spot on the head) and strong smelling urine).
    • Take a keen interest in the infant and their routines, their sleeping arrangements and their feeding, refer to Determining whether an infant is at risk of significant harm (related resources).
    • Observe the infant with their parents and take note of how the parents interact with the infant.
    • Do the parents play with, show affection and communicate with the infant? Does the infant seek comfort from the parents and do they reciprocate in providing comfort? Do the parents speak about the infant with love and admiration or harshness?

    Observe the environment

    Child protection workers should consider who is residing at the home, whether the environment is overcrowded, unhygienic and/or dangerous, chaotic, what the sleeping arrangements are for the other occupants and whether the infant has their own uncluttered bassinet or cot.
     

    Engaging the parents

    It is important for child protection workers to use a naïve enquirer approach while taking a particular interest in the parents, their backgrounds and family of origin, current functioning, feelings towards the infant and the changes the infant has brought into their lives. 

     

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    Signs of Safety Child Protection Practice Framework and safety planning

    Safety planning with high risk infants is most successful when the danger statements and safety goals capture the concerning behaviours of the parents and the impact of the behaviour on the high risk infant.


    Safety goals make clear what parents need to do and for how long, in order to maximise safety and visibility in the community for the infant.


    The Signs of Safety planning process must include regular meetings with the parents, professionals and the safety network, as well as rigorous safety planning which considers:

    • Increasing the infant's visibility in the community and decreasing parental stress via the use of child care services, parenting and respite services.
    • Increasing parenting skills and providing strategies to manage the infant crying (such as BB Plus, Ngala or child health nurse led services).
    • A schedule of home visiting to ensure that the infant is seen by a member of the safety network, daily if necessary, to monitor the infant's safety and to provide support to the parents.
    • Safe sleeping practices are monitored and tested by the safety network, daily if necessary.
    • Family and domestic violence, assessment of risk and support to the adult victim (see FDV above).
    • Parents and caregivers are assisted to manage their anger and improve impulse control via referral to services if necessary.
    • Parents and caregivers are referred to drug and alcohol and mental health services as necessary.

    Child protection workers review safety planning weekly with the parents, their network of support people and professionals undertaking both a monitoring and supportive role.

     

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    Working with Aboriginal families and culturally and linguistically diverse families

    Where the high risk infant and/or their family are Aboriginal, the Aboriginal Practice Leader must be consulted.

    When working with Aboriginal families, the child protection worker must engage other staff and consult resources to plan for how best to engage the family and to deliver culturally informed and responsive practice, giving particular consideration to intergenerational trauma and Aboriginal child rearing practices.

    Where the infant and/or their parents are from culturally and linguistically diverse (CALD) backgrounds, the parents may have additional needs due to having experienced trauma in their country of origin, long lengths of time in refugee camps and having few supports in Australia.

    The child protection worker must gather information relevant to the family's culture via online research, from the CALD sharepoint site, and/or consultation with a CALD officer or a cultural advisor from the community (providing confidentiality is upheld).   

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    Best Beginnings Plus

    When an unborn infant or an infant aged 12 months or younger is identified as being at risk of significant harm, the child protection worker must consult with the local Best Beginnings Plus (BB Plus)team leader and forward a referral. It is important the BB Plus worker(s) is included in Signs of Safety planning meetings and safety planning.

    BB Plus home visits may be included in a visiting schedule set out as part of a robust safety plan where the infant is seen and monitored regularly by a safety network. Visits undertaken by BB Plus are in addition to those carried out by the child protection worker.

    If parents do not engage with BB Plus, BB Plus will use alternative strategies and/or active efforts to engage the parents. If this is unsuccessful, the child protection worker must discuss this with the team leader and consider whether in the absence of BB Plus's involvement, there is sufficient safety for the infant. Specific consideration must be given as to whether further actions are required in order to increase the infant's safety.   

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    Child protection worker is unable to access the high risk infant

    ​Where child protection workers have been unable to locate a high risk infant due to the parents or caregivers of the infant concealing them, or the child protection worker being unable to enter a place where the infant is believed to be, an application must be made for a warrant (access), to enable the child protection worker to assess the high risk infant. See Chapter 3.3: Intervention action and s.34 of the Child and Community Services Act 2004.

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    The high risk infant’s whereabouts are unknown

    Where safety concerns remain for the infant and the infant's whereabouts are unknown due to the parents moving, being transient or avoiding contact with the child protection district office, all reasonable efforts must be taken to locate the infant. Child protection workers are expected to refer to Chapter 2.2: Case allocations, management, transfer, requests for co-working or services, shared case management and case closure and undertake strategies to locate the family, including:

    • A Form 900 - Request for information from Centrelink must be completed to request information from the Department of Human Services (Centrelink/Medicare/Child Support Agency) to determine the parent's contact details.
    • Child protection workers must contact other divisions of Communities such as Housing and Disabilities and other government departments such as Western Australian Police (WAPOL), Health, Education and Justice, as appropriate.
    • Child protection workers must make enquiries within the community and with senior Communities workers (for example Aboriginal Practice Leaders) to try to locate the parents.
    • The child protection worker must place a broadcast alert on Assist within 24 hours, outlining the concerns for the infant and the best course of action if the infant is located during business hours and after hours.  
    • Where there are specific actions that should be taken by the Crisis Care Unit if the infant is located after hours, this should be detailed in a possible contact (Form 190 - Crisis Care Referral) and submitted to the Crisis Care Unit.
    • The child protection worker must contact the Department of Health (hospitals) and WAPOL and request that they place alerts on their systems which state that if WAPOL/Health have contact with the infant or their parents/caregivers, they should contact the child protection worker or the Crisis Care Unit after hours.

    Where it is suspected that the infant may have been taken interstate, the child protection worker must alert other states and jurisdictions of the concerns via the interstate liaison officer. Include other family member's details on alerts as appropriate.

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    Case closure

    Case closure can only occur after the parents have demonstrated engagement with services, the safety plan has been enacted, tested and monitored and is being adhered to for a timeframe agreed to by the team leader. Referring parents to a service and then closing the case is not sufficient to create safety for a high risk infant.

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Related Resources

 ‭(Hidden)‬ Policies

 ‭(Hidden)‬ Standards