Disability and complex medical needs - advice

See procedure Intake: NDIS and children with a disability and/or complex medical needs and Case management: NDIS and children with a disability and/or complex medical needs for tasks that must be undertaken.

Children and young people with a disability and/or complex medical need and their families are a particularly vulnerable group within Child Protection and the broader service system.

With the SAFER children framework, the essential information category for child, includes evidence-based risk factors of:

• Intellectual disability or low cognitive function
• Physical disability or poor physical health
• Frequent or unusual attendance of child at emergency department or health services.

These evidence-based factors support practitioners to seek, sort, store and share information about children with disability and complex medical needs. The information and evidence inform practitioners analysis and judgements about the consequence and likelihood of harm.

Care of this vulnerable group of children and their parents is best achieved through a partnership approach between major stakeholders including disability and health services as well as child protection. Where a child protection practitioner identifies a child may have a disability or medical needs, the child should be linked with relevant professionals for formal assessment/diagnosis to support service access and care planning which addresses their needs in a holistic manner. 

If there are clear and identifiable child protection concerns present, it is expected that child protection practitioners will consult widely and effectively with other professionals as they investigate and plan for the child with complex medical needs and/ or disability needs, in the context of their family. Professional consultation and collaboration should occur within a continuum of services including disability services, community health centres, maternal and child health services, general practitioners, paediatricians, children’s hospitals, and other medical specialists. 

The primary documents that guide and inform child protection’s assessment and case planning for children with a disability and/or complex medical need includes:

• SAFER children framework
• Suspicious or unclear hospital admission or discharge - advice
• Health and wellbeing of child protection clients - advice
• NDIS procedure for intake and case management
• Healthcare that counts: A framework for improving care for vulnerable children in Victorian health services
• Practice guidelines for The Orange Door, Integrated Family Services, Child Protection and Out-of-Home Care.

Disability Practice Advice Teams
Disability Practice Advice teams (DPAs) operate according to a divisional model. The DPA teams consist of: Principal Disability Practice Advisors, Senior Disability Practice Advisors and Disability Practice Advisors. The DPA teams support child protection practitioners to better understand disability in the context of a child’s everyday experience, the impact on a family in relation to caring for a child with a disability, the service system offerings, and how this impacts risk assessment and safety for a child. The DPA teams work collaboratively with child protection and family services to enhance and uplift practice and ultimately, improve outcomes for children and young people with a disability.

What is the role of a Disability Practice Advisor? 

• Provide disability and National Disability Insurance Scheme (NDIS) advice to support child protection and related staffing teams to:
  • understand and navigate the NDIS system and the disability sector
  • support practice in relation to working with children with a disability; and
• maximise the disability supports and NDIS outcomes for children with a disability who encounter the child protection system.  
• Work collaboratively with child protection to determine whether the child requires additional supports to maintain and sustain parental care due to the child’s disability support needs and to ensure the family is linked in with mainstream supports that can supplement NDIS funded supports and avoid the need for statutory intervention.
• To provide capacity building support to the Child and Family Services System to increase confidence and knowledge of both disability related issues and of the NDIS. 

Tip Sheets are available on the Working with Children and Young People with a Disability SharePoint Site, accessible to departmental staff. 

Practitioners can access more information on the Child Protection Learning Hub.

The Disability Discrimination Act 1992 defines disability as:

• total or partial loss of the person’s bodily or mental functions
• total or partial loss of a part of the body
• the presence in the body of organisms causing disease or illness
• the malfunction, malformation or disfigurement of a part of the person’s body
• a disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction
• a disorder, illness or disease that affects a person’s thought processes, perception of reality, emotions or judgment, or that results in disturbed behaviour

A complex medical need is a health need which requires a high and persistent level of supervision and individualised health care support. A child might have complex medical needs from birth, or after an illness or injury. See Health and wellbeing of child protection clients - advice for further information.

When speaking with medical professionals and disability support services to understand and record information about a child’s disability and or/complex medical need, ask questions that will clarify:

• the nature and extent of the child’s disability or complex medical need on the child’s day to day functional capacity
• the formal diagnoses and prognosis
• all current medications
• the existing treatment plan
• observations of and engagement by the parent/s with the services, and their understanding of the child’s disability or medical needs
• update child essential information category, adding supporting information and evidence about information.

• Children with disabilities and complex medical needs are statistically more vulnerable to abuse and neglect than other children due to their physical dependencies and  barriers to communication.
• Children with disabilities and complex medical needs are statistically more likely than their peers to develop additional comorbidities like a mental health diagnosis (dual disability), communication difficulties, neurodevelopmental disorders, multiple health disorders, and cognitive/neurological difficulties, increasing their vulnerability to experiencing attachment disruption and trauma.
• Children with complex medical needs and/or disability face distinct challenges in having their voice (wishes and choices) heard and included in decision making processes often due to communication challenges. The challenges associated with caring for a child with a disability and/or complex medical need can lead to  stress and parental mental health issues which may result in increased risk of abuse or neglect.
• Presence of enormous stress may overwhelm a parent, especially if they lack supports and respite, which can lead to abuse and neglect.
• Other complicating parental factors including violence, mental health issues, substance abuse and intellectual disability may be present.
• For children in care, inadequate behaviour support planning for children with behaviours of concern associated with their disability can lead to the child placing themselves, and others around them, at risk of physical, sexual and emotional harm. Children with disability require careful consideration of their additional support needs when undertaking placement planning. Insufficiently supported home based care placements may be unable to meet a child’s disability needs.
• Where behaviours of concern are present, effective, evidence informed  and person centred behaviour support plans will form an integral part of the child’s daily safety, communication and development needs. Behaviour support plans should contain information on the function of the behaviour (ie the purpose of the behaviour and why it occurs).  Refer to the department’s Positive practice framework: A guide for behaviour support practitioners for further information about behaviour support planning for children with a disability.
• Where the child is a participant of the NDIS, these behaviour support plans should be funded as part of the child’s NDIS plan budget. Behaviour and other specialist plans, as well as their implementation  must be regularly reviewed by Child Protection alongside other professionals involved, and included, as appropriate, in the child’s case plan. Where the child is in care, the effectiveness of plan implementation and the adequacy of the NDIS plan should be reviewed at each care team meeting, and when the case plan is being reviewed.
• Collaborative case planning and information sharing with community medical and support services are vital to address and reduce safety concerns for the child, as well as coordinating the provision of all their health and medical needs.

• The SAFER children framework guides risk assessment and decision-making.
• Determining the capacity of the child or young person’s parents to care for the child and promote their safety is paramount and should be reflected within the analysis and judgements of the risk assessment.
• Children with a disability and/or complex medical need may require early intervention services with a link to a comprehensive medical system. This should be included and reflected as part of Child Protection case planning and the case plan actions tables.
• Communication and collaboration with community medical and support services are vital to promote the child with a disability or complex medical needs’ safety and wellbeing. Child Protection must collaborate, share information about protective concerns and provide a copy of the child’s case plan to the child’s NDIS funded supports, other disability services and/or medical professionals involved.
• Child Protection or the contracted case manager is always responsible for undertaking lead case management and working with the child and family/carer toward the permanency objective, and in progressing children’s court orders or conditions which may be in place, regardless of how many other medical and/or disability professionals are involved. Establishing and coordinating regular care team meetings is essential for this purpose.
• Protective concerns must be acted upon promptly and thoroughly by Child Protection to promote the child’s safety, including children who reside in care. In addition to completing child protection risk assessment, additional specialist risk assessments may be required to meet the safety, development and wellbeing needs of the child and those around them. The child protection practitioner or contracted case manager must oversee the implementation of any recommendations from these assessments and review their ongoing effectiveness at each care team meeting.
• Siblings of children with a disability and/or complex medical need are also vulnerable and must have their safety, development and wellbeing needs met. Risk assessments should consider each child’s own experience, risks, and vulnerabilities individually.
• If direct child protection involvement with a young person with a significant or complex disability or complex medical needs is ceasing at or after 16 years 9 months but before 18 years of age, it is critical that appropriate arrangements are in place well before changes to service provision, to provide continued support, including consideration of referring to the Office of the Public Advocate. This will increase safeguarding for vulnerable young people who are close to, or are 17, where thereafter Child Protection no longer has statutory authority to intervene. It is also important that functional capacity assessments of the child with complex disability and medical needs occurs early to provide time to plan for transitions across service settings and develop and implement appropriate intervention support plans. 

Refer to practice guidance within the SAFER children framework and practice prompts in CRIS to undertake the four dimensions of analysis. These dimensions, informed by the essential information categories, provide a framework for considering vulnerability of the child, severity of harm, likelihood of harm and safety.

Consider:

• What is the nature and extent of the child’s disability or condition and are all medical terms, reports, diagnoses, and the prognosis understood?
• What is the opportunity for harm?
• What does previous involvement and intervention tell us about the parents’ capacity, and the child’s experience of harm? How is this considered in the analysis about probability of harm currently?
• What amount of time does the child spend, if any, in facility based respite care? Research supports the view that overreliance on  facility based respite care can lead to a climate of increased vulnerability and feelings of powerlessness.
• What is the child’s ability and opportunity to communicate their needs and any abuse being experienced? Consult with the parent/carer or other professionals involved in the child’s life about the best way to communicate with a child who is non-verbal or has communication issues associated with their disability. Do communication barriers increase a child’s vulnerability?
• Is the child stigmatised, depersonalised or devalued by their parents if they have assumed an almost professional nursing role? This may be an indication of lack of parenting attachment and can be a risk factor which needs considering in the analysis and judgements of the risk assessment. . 

• What are the parent’s attitudes and beliefs about this child?
• Are there contributing factors that increase risk such as drug and alcohol misuse, mental health and family violence?
• What support or assistance are the parents requesting? Do they need further support or are they directly or indirectly looking for placement of the child?
• What interventions and assessments have occurred before, what has been effective at reducing risks?
• Is there are a pattern or history that indicates a parent has been unable to sustain positive change or maintain service engagement, even if willing and/or seeking support initially? What has been the cumulative effect of this on the child over time?
• Can the parents independently identify and seek out needed supports and services for their child and themselves? Can they self-manage their child’s NDIS plan or do they require NDIS funded Support Coordination?
• What are the views, opinions and assessments of other professionals involved regarding the protective concerns, and observations of the parents' capacity to keep the child safe, and their needs met.
• If parents are asking for placement – what is the timeframe and motivation? Are they saying they may harm the child, need a break, or are they considering permanent relinquishment?
• How does the parent describe the child and what is the observed level of attachment and bonding to the child? How does this compare to the other children in the home, including any with no disability or complex medical needs. A secure attachment is known to be an important safety factor.
• Was there a long separation, or multiple separations, of parents and child caused by hospitalisations, facility based respite, or otherwise? This circumstance may result in disrupted early bonding and attachment which is a risk factor for harm.
• How isolated is the family? Do they have formal and informal networks of support? Does the extent of care the child requires result in minimal or no outside social contact?
• Do the parents themselves have a disability or complex health need, and do they receive appropriate supports for themselves?
• What is the level of stress in the family? A parent may become overwhelmed in caring for a child with a disability, or child with a complex health needs, especially if there is minimal support and respite.
• How do the parents view the other children in the family? How much do they rely on them to care for each other or act independently in an age-inappropriate manner due to the parents’ involvement with the child with a disability or complex health need? Are the parents emotionally available to each other and to the other children in the family?
• Are there other risk factors when assessing risk for children with disability and/or complex medical needs?
• Consider:
  • the child’s daily needs and care requirements including any behaviour support requirements
  • the extent to which the parents understand the specific care needs of the child
  • the extent to which parental intellectual disability or cognitive impairment, family violence, substance misuse or mental illness impact on the parents ability to meet the child’s daily needs and care requirements. Assess if the child’s heightened care needs are likely to exacerbate the protective concerns further.
  • the attachment style between the child and parent, including when relevant, how long the child spends in hospital and/or respite care
  • parental ability to prioritise all of the child’s daily needs and care requirements
  • pattern and history in relation to previous reports or information about the care of other siblings.
• Parents may experience feelings of guilt, shame, depression, and victimisation that require professional counselling. Parents’ needs also have to be considered.
• Have any grief and loss issues experienced by parents with a child with a disability or limited life expectancy been assessed?
• Does the family have adequate financial and practical support?

Undertake an intake risk assessment, risk assessment or review risk assessment to determine the risk to the child.

Review and update the essential information categories and complete the risk assessment taking care to ensure that the four dimensions of analysis are completed with particular attention to how the child’s disability or complex medical need impacts their vulnerability, the severity of the harm, the likelihood of harm and whether any safety can be identified.

Consider:

• Are there indicators of physical abuse (unexplained bruising, burns, rough handling)? Research has found a disproportionate number of children with disabilities in recorded cases of physical abuse.
• How many carers does the child have? Exposure to a wide range of carers increases the potential and opportunity for abuse.
• What is the mother’s role in the family and what is her level of involvement and support?
• What is the father’s role in the family and what is his level of involvement and support?
• What are the strengths, protections and safety for the child and siblings?
• Who is reporting to Child Protection and what are the reported protective concerns? Is this a call for additional supports or are they requesting placement?
• To what extent are services (including medical services and schools) working with the child sharing information and coordinating supports?
• Can the child with a disability or complex health need communicate their experience verbally? Is there any other means to facilitate and support communication?
• The relationship and compounding effect between disability needs, experience of abuse and trauma on the child’s presentation, including their behaviour.
• Have parents been known to deny the need for medical care or miss appointments? Medical neglect issues can place a child with a serious disability at particular risk of harm or death.

• Where does the child spend their time – facility based respite, hospitals, community respite, voluntary placements including grandparents and other relatives? To support the primary carers the disabled child may be cared for in a number of settings. How does the child understand their multiple carers?
• What is the case plan and permanency objective for the child? Are they in need of ongoing alternate out-of-home care? Have they been referred to the permanent care team?
• Is there an endorsed risk assessment and updated essential information categories?
• Has the consequence and probability of cumulative harm been considered for this child within the risk assessment?
• Has a Family-Led Decision Making (FLDM) meeting or Aboriginal Family-Led Decision Making (AFLDM) meeting been considered for this family?

• Are the child’s basic care and hygiene needs, including food and clothing, met?
• Do the parents and carers participate in formal and informal social activities with the disabled child and their siblings or are they isolated due to the severity of the disability or the degree of required care?
• Does the family resist using available supports? Are they reluctant to engage with outside help?
• Are the developmental needs of the child with a disability or complex health need and their siblings being met?
• Are the parents aware of community activities available for the disabled child and their siblings? Do they attend and engage with the available supports?
• Is the child receiving sufficient disability and medical supports? Do siblings attend school, child-care or kindergarten as appropriate, and other educationally appropriate services?
• Have all culturally relevant services been identified including Aboriginal and multicultural and multi-faith agencies?
• Has cumulative harm been considered and reflected in the risk assessment?
• Has the direct effect of the family’s stress on parental and sibling health and wellbeing been assessed?
• Has it resulted in physical, emotional harm or neglect?
• From these inquiries, update the essential information categories to build a comprehensive picture of the child and their family. This information supports the risk assessment and decision making.

• the nature and severity of the medical condition, disability and additional comorbidities
• the capacity of the parents to protect the child with a disability or complex health need and their siblings and respond to their needs
• establishment of a care team with a specified lead professional or agency
• consideration of the needs of all members of the family, especially siblings
• supports and resources to address the immediate and longer-term safety, care and wellbeing needs and risks
• the cumulative impact of disability and demands of caring for the child with a disability or complex health need on each member of the family
• the cumulative impact of harm if there is a history of the child’s needs not consistently having been met and the impact on the child if it continues
• the ongoing and long-term nature of the problems including the need for paediatric palliative care services.

Considerations when planning for children and young people in out-of-home care

• ensure the child has a current endorsed risk assessment on CRIS to inform all decision making and case planning
• promote the child’s life story and undertake case planning including the child’s voice needs and aspirations
• children exhibiting behaviours of concern require specialist risk assessments by Behaviour Support Practitioners to create a home environment that will meet the safety and wellbeing needs of the child and those around them
• regularly review any specialist or behaviour support plans and work with the care team to include trauma-informed approaches to the child’s care as required
• commence early planning with the NDIA for young people leaving care

After hours disability crisis response for children who are NDIS participants

• Where a child is a NDIS participant and a disability-related crisis occurs outside of business hours (5pm-9am weekdays, weekends and public holidays), After Hours Child Service (AHS) can contact the NDIS After Hours Crisis Response Service. Further information is available from the AHS NDIS After Hours Crisis Response Service advice. 

The Victorian Senior Practitioner (VSP) is available to provide consultation relating to children and young people with a disability and complex needs who may pose a risk of harm to self or others and are at risk of or currently are subject to restrictive practice. The VSP has a role in authorising restrictive practices contained in behaviour support plans implemented by disability service providers in Victoria and providing practice advice pertaining to positive behaviour support and best evidence informed practice when supporting children and young people with a disability. The VSP can be contacted via victorianseniorpractitioner@dffh.vic.gov.au and/or OPP Consultation request form. 

A restrictive practice is ‘any practice or intervention that has the effect of restricting the rights or freedom of movement of a person with disability’ (NDIS Act 2013). Under the National Disability Insurance Scheme (Restrictive Practices and Behaviour Support) Rules 2018, there are five restrictive practices that are subject to regulation and oversight by the NDIS Commission. These are chemical restraint, mechanical restraint, physical restraint, environmental restraint and seclusion.

Restrictive practices can only be used “as a last resort in response to risk of harm to the person with disability or others, and after the provider has explored and applied evidenced-based, person-centred and proactive strategies”. (NDIS Restrictive Practices and Behaviour Support Rules 2018). Restrictive practices cannot be implemented by an unregistered provider and can only be implemented under the guidance of a formal Behaviour Support Plan which is developed and monitored by appropriately qualified and authorised professionals.

The role of the NDIS Commission is to safeguard participants by regulating NDIS providers delivering NDIS funded supports across all environments, including in the family home. The Commission acknowledges that children and young people with disability require special considerations and safeguarding in order to protect them from harm whilst actively promoting their development and upholding their legal and human rights. It has developed the Regulated Restrictive Practices with Children and Young People with Disability Practice Guide.

The practice guide provides specific guidance to NDIS providers and NDIS behaviour support practitioners on the use of restrictive practices on children with disability by:

• Promoting the human rights of children and young people with disability and their families
• Outlining the human rights implications on children and young people who are subject to restrictive practices and how to identify reasonable restraint and when the becomes abuse
• Assisting in the identification of the special considerations and safeguards relevant to the use of restrictive practices with children and young people, including the use of a positive behaviour support framework to work collaboratively with children, their families and carers
• Improving knowledge of the reporting on the use of restrictive practices amongst children and young people through information sharing mechanisms between Child Protection and NDIS Behaviour Support practitioners including when concerns of restraint come to Child Protection’s attention and
• Strengthening understanding legislation and policy requirements concerning prohibited practices outlined by both the NDIS (Restrictive Practices and Behaviour Support) Rules 2018 and the Victorian Authorisation Process for Regulated Restrictive Practices

This guide should be read in conjunction with the Regulated Restrictive Practices Guide.

Restrictive Practices in a developmental context

The developmental needs of all children necessitate that some actions which restrict their movement or decision making be applied. The NDIA highlights that practices which promote child safety are not generally considered restrictive practices provided they are, age appropriate and in line with community expectations for any child regardless of having or not having a disability. Thus for registered providers “determining what constitutes a regulated restrictive practice for children and young people with disability needs to be made on a case-by-case basis”. 

As a guiding principle, there is an expectation that as a child ages, the need for restrictive approaches to maintain their safety will decrease. 

The NDIA’s 2021 Regulated Restrictive Practices with Children and Young People with Disability Practice Guide (Pp 11-12) provides specific examples of the difference between restrictive practices and- developmentally appropriate child safety activities.

Use of Restrictive practices by parents

A parent may at times use practices which if employed by a provider would be considered a ‘restrictive practice’. Parenting practices and decisions are, however, outside the scope of the NDIS framework for restrictive practice even where a child has a disability and is funded under the scheme.

The potential for harm of using excessive restrictive practices remains the same for children and young people whether it is employed by a provider or a parent. These harms include inhibiting a child’s development, causing physical or psychological harm and damaging the relationships between child family.

Behaviour Support Planning is an evidence-based intervention which can be funded through the NDIS. Behaviour Support Plans can be developed which provide parents the strategies and skills to support a child or young person in a manner which is least restrictive and promotes positive development, skills acquisition and parent-child relationships.

When assessing whether a parental response to disability needs is appropriate, practitioners should apply the same considerations as they would for any other child with or without a disability, namely assessing for developmental impact and whether parental action is proportionate to the risk being managed and developmental needs of the individual.

The NDIA’s 2021 Regulated Restrictive Practices with Children and Young People with Disability Practice Guide provides a summary of the negative impact of restrictive practices on page 13 which may support decision making regarding the appropriateness of parental use of restrictive techniques.
 

• Intake: Children with a disability and/or complex medical needs and NDIS
• Case management: Children with a disability and/or complex medical needs and NDIS procedure
• SAFER children risk assessment framework
• Suspicious or unclear hospital admission or discharge
• Health and wellbeing of child protection clients - advice
• Practice guidelines for The Orange Door, Integrated Family Services, Child Protection and Out-of-Home Care
• Healthcare that counts framework
• Positive practice framework: A guide for behaviour support practitioners
• AHS NDIS After Hours Crisis Response Service advice
• Child Protection Learning Hub