CHILD NEGLECT: definitions, causes, consequences and interventions

1
CHILD NEGLECT definitions, causes,
consequences and interventions

• Annlis Söderholm
• PhD, paediatrician
• The Fifth Nordic Congress on Child Abuse and
  Neglect
• 18-21 May 2008, Reykjavik, Iceland

2
Ambroise Tardieu 1818-1879

• Professor in forensics in Paris studied and
  described the classical features of almost all
  forms child abuse and neglect
• sexual abuse
• physical abuse
• neglect deprivation
• children in factories and coal mines (England,
  Scotland)
• physical abuse of small children death rates
• After his death child maltreatment was forgotten
  and the opinion that
  allegations of maltreatment were mainly the
  conseguences of childrens inventiveness
  prevailed both inside and outside medicine for
  almost 100 years
• Part of his works was recently translated and
  published (2005) into English and so became
  available for professionals outside the
  French-speaking area.
• Child Abuse Neglect 200529311-334

3
Neglect

• is a social as well as a medical, legal and
  psychological
• problem
• occurs in all countries and social groups
• more children are neglected than abused
• the true prevalence is unknown
• especially detrimental for infants and toddlers
• easier to neglect the problem than to intervene -
  neglect of neglect
• the majority of maltreatment studies do not
  specifically address neglect
• the role of fathers/father figures in neglect is
  insufficiently studied

4
The basic needs of the child

• love, care and nurturance
• respect and acceptance
• being seen and heard
• adequate nutrition, clothing, hygien
• safety and protection
• stimulation
• education
• health care (physical, mental, dental)

5
Definitional ambiquities

• The issue of defining abuse and neglect is one
  of central
• importance and logically precedes a disscussion
  of
• incidence, etiology (sequele), and treatment. The
  
• vagueness and ambiquities that surround the
  definition of
• this particular problem touch every aspect of the
  
• field reporting system, treatment program,
  research, and
• policy planning"
• Harold P. Martin. 1977 Analysis of child abuse
  and neglect research, U.S, Childrens Bureau,
  Administration for children, youth and families,
  U.S. Department of Health, Education and Welfare
  1978

6
Neglect by caregiver

• the failure of the childs parent or
  caretaker, who has the material resources to do
  so, to provide minimally adequate care in the
  areas of health, nutrition, shelter, education,
  supervision, affection or attention and
  protection
• Wolock I, Horowitz B. Child maltreatment as a
  social problem The neglect of
• neglect. American Journal of Ortopsychiatry
  198454530-543

7
Definition of child neglect

• Neglect is a condition in which a childs basic
  needs are
• not met regardless of cause
• Dubowitz H, Black M, Starr RH, Zuravin S. A
  conceptual definition of child neglect. Criminal
  justice and behaviour 1993208-26

8
Subtypes of neglect

• Physical neglect
• Emotional neglect and abuse
• Neglect of health care (physical, mental, dental)
• Educational neglect
• -----------------------------
  --
• Structural, societal neglect
• a society is contributing to child neglect by
  neglecting the poor
• Professional neglect (neglect of child neglect)

9
Emotional neglect and abuse

• more or less present in all forms of maltreatment
  x)
• describes an attitude of the parent/caregiver
  towards the child
• no physical contact is presupposed
• difficult to diagnose because of absence of clear
  physical evidence
• occurs also in families that from outside look
  socially and economically well-functioning
• child protection authorities are often not
  involved
• x)Claussen AH, Crittenden PM. Physical and
  psychological maltreatment relations among types
  of maltreatment. Child Abuse Neglect
  1991155-18

10
Emotional neglect and abuse

• the issue for recognition is not whether there
  is
• unseen or secret abuse, but rather whether what
  is
• observed is described and named as ill-treatment
  
• Glaser D. Prior V. Predicting emotional abuse
  and neglect. In K.D. Browne, H. Hanks, P.
  Stratton, C. Hamilton (eds). The early prediction
  and prevention of child abuse A handbook.
  Chichester John Wiley Sons Ltd 2002

11
Emotional neglect and abuse

• Emotional unavailability, unresponsiveness, and
  neglect
• Negative attributions and misattributions to the
  child
• Developmentally inappropriate or inconsistent
  interactions with the child
• Failure to recognize or acknowledge the childs
  individuality and psychological boundary
• Failure to promote the childs social adaptation
• Glaser D. Emotional abuse and neglect
  (psychological maltreatment) a
• conceptual framework. Child Abuse Neglect
  200226697-714

12
Dental neglect

• The dentist can be the first professional to
  suspect or
• recognize neglect!
• Dental neglect is the wilful failure of
  parent or guardian
• to seek and follow through with treatment
  necessary to ensure a level of oral health
  essential for adequate function and freedom from
  pain and infection
• American Academy of Pediatric Dentistry.
  Definition of dental neglect. Pediatric
  Dentistry 200325(suppl)7

13
Professional and societal neglect

• Children who are neglected by their parents are
  also frequently further neglected by the services
  established to protect them from significant harm
• Minty B, Pattinson G. The nature of child
  neglect. British Journal of Social Work
• 199424733-747
• If the society defines parenting as a private,
  individual act, it may rightly be judged
  neglectful, in contrast to a society that
  recognizes parenthood as a social contract
• Garbarino J, Collins CC. Child neglect. The
  family with a hole in the middle. In
• H. Dubowitz (ed). Neglected children. Research,
  practice and policy.
• Thousand Oaks, CASage Publications 1999

14
Etiology

• The basis of the ecological model is that child
  neglect and
• abuse is multiply determined by forces at work in
  the
• individual, in the family, in the community and
  in the society
• and that these determinants are nested within one
  another
• individuals
• child
• parents
• family
• community
• societal, structural factors
• Bronfenbrenner U. The ecology of human
  development. Cambridge MA Harvard
• University Press 1979
• Belsky J. Child maltreatment An ecological
  integration. American Psychologist
• 198035320-335

15
Risk factors

• The strongest risks of child maltreatment are
  from socio-economic deprivation and from factors
  in the parents own background - parental
  background factors are largely, but not entirely,
  mediated through their impact on socio-economic
  factors
• Risk factors are risks and not indicators or even
  necessarily predictors
• Sidebotham P, Heron J, The ALSPAC Study Team.
  Child maltreatment in the
• Children of the nineties A cohort study of
  risk factors. Child Abuse Neglect
• 200630497-522
• Sidebotham P. Invited comments Red skies, risk
  factors and early indicators.
• Child Abuse Review 20031241-45

16
Risk factors promotive factors

• Potentiating factors (stressors)
• Compensatory (promotive, protective) factors
  (supports)
• the balance of risk factors and promotive
  factors determines whether child maltreatment
  will take place or not
• multipathology is usually associated with a
  plenitude of risk factors and a paucity of
  promotive ones
• Cicchetti D, Toth S. A developmental
  psychopathology perspective on child abuse and
• neglect. Journal of American Academy of Child and
  Adolescent Psychiatry 199534541-565
• Belsky J. Child maltreatment An ecological
  integration.
• American Psychologist 198035320-335
• Sameroff AJ. Developmental systems of
  psychopathology.
• Development and Psychopathology 200012297-312

17

• Dynamic ecological models may be essential for
• understanding the sources of health and disorder
  that are
• the central concern of developmental
  psychopathology.
• In these wiews if we find simplicity, it is an
  artifact
• Sameroff AJ. Developmental systems of
  psychopathology. Development and Psychopathology
  200012297-312

18
Child (risk factors)

• age
• prematurity
• disease or disability
• but child characteristics alone do not account
  for
• neglect or other forms of maltreatment!

19
Parental background (risk factors)

• adverse childhood experiences
• psychiatric history
• low educational achievment
• young parental age
• substance abuse
• intellectual disability x)
• x) Lutzker JR. Behavioral treatment of child
  neglect. Behavioral Modification
• 199014301-315

20
Family community(risk factors in the childs
environments)

• low level of social support - insularity
• social exclusion of families at risk
• intimate partner violence (IPV)
• long-term economic hardship
• structure of the family
• single parent
• presence of a step-father in the family
• large households
• symptoms in the child due to neglect can be
  misinterpreted both in the family and in the
  childs different environments outside the home

21
Social exclusion

• is defined as
• the inability of our society to keep all
  groups and individuals within reach of what we
  expect as a society and the tendency to push
  vulnerable and difficult individuals into the
  least popular places
• Power A. Social exclusion. Royal Society of Arts
  Journal 2000247-51
• Editors choice. Social exclusion old problem,
  new name. BMJ 2001323174

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The drivers of social exclusion

• Low income
• Unemployment
• Poor educational attainment
• Poor health
• Poor housing
• Problematic neighbourhoods and networks
• Crimes
• Bradshaw J, et al. The Drivers of Social
  Exclusion Review of the Literature
• or the Social Exclusion Unit in Breaking the
  Cycles, Series, London Office of
• the Deputy Prime Minister, 2004

23
Structural, societal factors

• laws and legislation
• culture, religion, norms, beliefs and attitudes
• health, social and education politics
• economic politics in society (obs. poverty!)
• when we as a society ignore the poor, we
  contribute to child neglect
• Garbarino J. Collins CC. Child neglect. The
  family with a hole in the middle. In H. Dubowitz
  (ed ). Neglected children. Research practice and
  policy. Thousand Oaks, CA Sage Publications 1999
  

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• Poverty is denial of all human rights
• Mohammad Yunus
• Nobel Peace Price Winner 2006

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Consequencies (1)

• Depend on
• the subtype(s)
• age of onset
• severity
• duration
• co-occurrence of other forms of maltreatment
• risk factors
• (single multiple)
• the resilience of the child

• Depend also on
• the different professionals willingness and
  ability to suspect or regognize neglect in a
  child and on their unwillingness to contribute to
  neglect of neglect
• the competence in the multiprofessional handling
  of neglect

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Consequencies (2)

• Infants and toddlers
• fewer positive social interactions
• non organic failure to thrive
• cognitive and language problems
• Later on
• cognitive and academic deficits
• poor social skills - social withdrawal
• limited peer interactions
• low self-esteem
• behavioral problems e.g. aggression
• Hildyard KL, Wolfe D. Child neglectdevelopmental
  issues and outcomes.
• Child Abuse Neglect 200226679-695
• Kotch et al. Importance of early neglect for
  childhood aggression.
• PEDIATRICS 2008121725-731

27
Consequencies (3)

• The consequencies of emotional neglect
  (psychological
• unavailable parenting) have been found to be
  greater
• and more enduring than physical neglect and the
• other types of maltreatment
• Gaudin JM jr. Child neglect. Short-term and
  long-term outcomes. In In
• H. Dubowitz (ed). Neglected children. Research,
  practice and policy.
• Sage Publications 1999
• Farrell Erickson M, Egeland B. Child neglect. In
  JEB Myers, L Berliner,
• J Briere, CT Hendrix , C Jenny, TA Reid (eds).
  The APSAC Handbook
• on Child Maltreatment. Thousand Oakes, CA Sage
  Publications 2002

28
Consequencies (4)

• death from neglect can occur as a result of
  inadequacies in physical protection, supervision,
  nutrition, or health care
• it can be more difficult to investigate and
  prosecute than physical and sexual abuse
• this difficulty in determining the ultimate cause
  of death can result in a lack of protection for
  the siblings and other children in the household
• Bonner BL, Crow SM, Logue MB. Fatal child
  neglect. In H. Dubowitz (ed).
• Neglected children. Research, practice and
  policy. Thousand Oakes, CA Sage
• Publications 1999

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Intervention and prevention

• prevention x)
• universal prevention (aimed at the whole
  population)
• selective prevention (interventions aimed at
  families at risk)
• indicative prevention (aim to stop further
  maltreatment)
• screening by asking
• shared responsibility (family - professionals)
• continuity of health care
• x)
• MacLeod J, Nelson G. Programs for the promotion
  of family wellness and the
• prevention of child maltreatment a meta-analytic
  review. Child Abuse Neglect
• 2000241127-1149
• Rae Grant NI. Preventive interventions for
  children and adolescents Where are
• we now and how far have we come. Canadian Journal
  of Community Mental
• Health 19941317-36

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The treatment of the child and her/his parents

• If you want a genuine
• dialogue avoid attitudes as
• aggression
• blame
• contempt
• infantilizing
• lamentation
• moralilizing
• threat
• uninterest
• voyerism (unprofessional curiosity)

• A motivating treatment
• freedom from prejudice
• presence
• genuine interest
• empathy
• understanding
• matter-of-factness
• to treat child and parents as human beings

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What does a neglected child need

• Early intervention
• A medical home with professionals, who are
  trained in child maltreatment issues and
  interprofessional and intersectorial working, and
  who are genuinely motivated to treat neglected
  children, and to offer them continuity of health
  care as well as long-term treatment, support and
  follow-up (primary health care paediatrics,
  child neurology, child psychiatry)
• Child protection support and follow up
• Experiences of the world as a safe and reliable
  place

32
Research challenges

• Clear, detailed definition(s) of neglect
  subtype(s)
• Exploration of age-specific risk factors and
  developmental effects of neglect
• Research to confirm the effectiveness and
  generalizability of different forms of prevention
  and intervention treatment programmes for
  neglected children and their families
• The role of fathers/father figures in neglectful
  families
• Detailed longitudinal studies of risk populations
  with clear comparison groups from the normal
  population, as well as large-scale
  epidemiological studies

33
References (1)

• Allin H, Wathen CN, MacMillan H. Treatment of
  child neglect A systematic review. The Journal
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• American Academy of Pediatrics. Block RW, Krebs
  N, and the Committee on Child Abuse and Neglect,
  and the Committee on Nutrition. Failure to thrive
  as a manifestation of child neglect. PEDIATRICS
  20051161234-1237
• Belsky J. Child maltreatment An ecological
  integration. American Psychologist
  198035320-335
• Bronfenbrenner U. The ecology of human
  development. Cambridge MA Harvard University
  Press 1979
• Cicchetti D, Toth S. A developmental
  psychopathology perspective on child abuse and
  neglect. Journal of American Academy of Child and
  Adolescent Psychiatry 199534541-565
• Connell-Carrick K. A Critical review of the
  empirical literature Identifying correlates of
  child neglect. Child and Adolescent Social Work
  Journal 200320389-425
• Christensen E.The prevalence and nature of abuse
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34
References (2)

• Daniel B, Taylor J. Gender and child neglect
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• DeBellis MD. The psychobiology of neglect. Child
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• Dubowitz H (ed). Neglected children. Research,
  practice and policy. Thousand Oakes, CA Sage
  publications 1999
• Dubowitz H, Black MM. Child neglect. In R.Reece,
  ML Stephen (eds). Child Abuse. Lippincott,
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• Dubowitz H, Papas MA, Black MM, Starr RH. Child
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• Dubowitz H, Pitts SC, Black MM. Measuremenst of
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35
References (3)

• English DJ, Thompson J, Graham C, Briggs EC.
  Toward a definition of neglect in young children.
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• Farrell Erickson M, Egeland B. Child neglect. In
  JEB Myers, L Berliner, J Briere, CT Hendrix , C
  Jenny, TA Reid (eds). The APSAC Handbook on
  Child Maltreatment. Thousand Oakes, CA Sage
  Publications 2002
• Garbarino J, Collins CC. Child neglect. The
  family with a hole in the middle. In H. Dubowitz
  (ed). Neglected children. Research, practice and
  policy. Thousand Oaks, CASage Publications 1999
• Gaudin JM jr. Child neglect. Short-term and
  long-term outcomes. In H. Dubowitz (ed).
  Neglected children. Research, practice and
  policy. Thousand Oakes, CASage Publications 1999
• Glaser D. Emotional abuse and neglect
  (psychological maltreatment) aconceptual
  framework. Child Abuse Neglect 200226697-714
• Glaser D. Prior V. Predicting emotional abuse and
  neglect. In K.D. Browne, H. Hanks, P. Stratton,
  C. Hamilton (eds). The early prediction and
  prevention of child abuse A handbook.
  Chichester John Wiley Sons Ltd 2002

36
References (4)

• Hildyard KL, Wolfe D. Child neglect
  developmental issues and outcomes. Child Abuse
  Neglect 200226679-695
• Hines DA, Kaufman Kantor G, Holt MK. Similarities
  in siblings experiences of neglectful parenting
  behaviour. Child Abuse Neglect 200630619-677
• Kellogg N, the Committee on Child Abuse and
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  and neglect. PEDIATRICS 20051161565-1568
• Killen K. Barndomen varar i generationer. Om
  förebyggande arbete med utsatta familjer.
  Wahlström Widstrand 2000
• Kotch et al. Importance of early neglect for
  childhood aggression.
• PEDIATRICS 2008121725-731
• Labbé J. Ambroise Tardieu The man and his work
  on child maltreatment a century before Kempe.
  Child Abuse Neglect 200529311-324
• Lacharité C, Ethier L, Couture G. The influence
  of partners on parental stress of neglectful
  mothers. Child Abuse Review 1996518-33
• McKinsey Crittenden P. Child neglect. Causes and
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References (5)

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• Sidebotham P, Heron J, The ALSPAC Study Team.
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• Sidebotham P. An ecological approach to child
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  research and practice. Child Abuse Review
  20011097-112

38
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