Identifying and Assessing Neglect

1
Identifying and Assessing Neglect

• Patrick Ayre
• Department of Applied Social Studies
• University of Bedfordshire
• Park Square, Luton
• email pga_at_patrickayre.co.uk
• Presentation can be downloaded from
• http//patrickayre.co.uk/Presentationd.htm

2

• NEGLECT

• Parents who neglect their children basically just
  dont know any better because of their own poor
  upbringings. If we send them to a family centre
  for Parental Skills training, all will be well.

3

• NEGLECT

• Parents who neglect their children basically just
  dont know any better because of their own poor
  upbringings. If we send them to a family centre
  for Parental Skills training, all will be well.
• IF ONLY!!....

4

• NEGLECT

• So neglected children who come into care may be a
  bit thin, a bit dirty, badly in need of seeing a
  doctor or dentist, maybe a bit wild.
• But we can place them with foster carers for a
  bit of looking after, a bit of TLC, a bit of
  structure and everything will be fine. The
  children will absolutely love it and will
  immediately start to thrive. Simple really!

5

• NEGLECT

• So neglected children who come into care may be a
  bit thin, a bit dirty, badly in need of seeing a
  doctor or dentist, maybe a bit wild.
• But we can place them with foster carers for a
  bit of looking after, a bit of TLC, a bit of
  structure and everything will be fine. The
  children will absolutely love it and will
  immediately start to thrive. Simple really!
• IF ONLY!!....

6
Brain development

• By the age of 3, a babys brain has reached
  almost 90 percent of its adult size.
• The growth in each region of the brain largely
  depends on receiving stimulation.
• This stimulation provides the foundation for
  learning.

7
Experience Affects the Structure of the Brain

• Brain development is activity-dependent
• Every experience excites some neural circuits and
  leaves others alone
• Neural circuits used over and over strengthen,
  those that are not used are dropped resulting in
  pruning

8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
Poor integration of hemispheres and
underdevelopment of the orbitofrontal cortex

• Difficulty regulating emotion,
• Lack of cause-effect thinking,
• Inability to recognize emotions in others,
• Inability to articulate own emotions,
• Incoherent sense of self and autobiographical
  history
• Lack of conscience.

12
Other physiological issues

• Serotonin emotional stability and feeling good
• Malnutrition cognitive and motor delays,
  anxiety, depression, social problems, and
  attention problems
• Myelination
• Sensitive periods (infancy attachment)

13
Emotional development

• Sensitive period for emotional development up to
  18 months
• Shaped primarily by the way in which the prime
  carer interacts with the child
• Emotional deficits harder to overcome once the
  sensitive window has passed.
• How often do we intervene assertively at this
  point?

14
Building a child

• Building a child is like building a house, each
  new level built on the one below. If the lower
  levels are unsound, no amount of tinkering with
  the upper floors will make it stable.

15
Capturing chronic abuse

• Single events often only significant in context
• Can often only understand present by setting in
  context of past
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

16
The pattern of neglect atypical
17
The pattern of neglect
18
The pattern of neglect
19
The pattern of neglect
20
The pattern of neglect
21
Cumulativeness
22
Failure of cumulativeness
23
Whats the problem?

• Chronic abuse and the principle of cumulativeness
• Files very long and badly structured
• Patterns missed and chronic abuse overlooked
• The problem of proportionality
• Acclimatisation (case, agency and geographical)

24
Why do parents neglect?

• We need to understand the interaction between
• 3 Ns Nurture, Nature, Now
• Circumstantial factors and fundamental factors

25
Why do parents neglect?

• Circumstantial
• Poverty
• Particular relationships
• Lack of skill/knowledge
• Temporary illness
• Lack of support
• Environmental factors

• Fundamental
• Lack of parenting capacity
• Deep seated attitudinal/behavioural/
  psychological problems
• Long term health issues
• Entrenched problematical drug /alcohol use

26
The effects of neglect

• Howe identifies 4 types of neglect
• Emotional neglect
• Disorganised neglect
• Depressed or passive neglect
• Severe deprivation
• Each is associated with different effects and
  implications for intervention

27
Emotional neglect

• Sins of commission and omission
• Closure and flight avoid contact, ignore
  advice, miss appointments, deride professionals,
  children unavailable
• However, may seek help with a child who needs to
  be cured
• Intervention often delayed

28
Emotional neglect parents

• Cant cope with childrens demands
  avoid/disengage from child in need dismissive or
  punitive response
• Six types of response
• Spurning, rejecting, belittling
• Terrorising
• Isolating from positive experiences
• Exploiting/corrupting
• Denying emotional responsiveness
• Failing medical needs

29
Emotional neglect children

• Frightened, unhappy, anxious, low self-esteem
• Precocious, streetwise
• Withdrawn, isolated, aggressive fear intimacy
  and dependence
• Behaviour increasingly anti-social and
  oppositional
• Brain development affected difficulties in
  processing and regulating emotional arousal

30
Disorganised neglect

• Classic problem families
• Thick case files
• Can annoy and frustrate but endear and amuse
• Chaos and disruption
• Reasoning minimised, affect is dominant
• Feelings drive behaviour and social interaction

31
Disorganised neglect carers

• Feelings of being undervalued or emotionally
  deprived in childhood so need to be centre of
  attention/affection
• Demanding and dependant with respect to
  professionals
• Crisis is a necessary not a contingent state

32
Disorganised neglect carers

• Cope with babies (babies need them) but then
• Parental responses to children unpredictable
  driven by how the parent is feeling, not the
  needs of the child
• Lack of attunement and synchronicity

33
Disorganised neglect children

• Anxious and demanding
• Infants fractious, fretful, clinging, hard to
  soothe
• Young children attention seeking exaggerated
  affect poor confidence and concentration
  jealous show off go to far
• Teens immature, impulsive need to be noticed
  leads to trouble at school and in community
• Neglectful parents feel angry and helpless
  reject the child to grandparents, care or gangs

34
Depressed neglect

• Classic neglect
• Material and emotional poverty
• Homes and children dirty and smelly
• Urine soaked matresses, dog faeces, filthy
  plates, rags at the windows
• A sense of hopelessness and despair (can be
  reflected in workers)

35
Depressed neglect carers

• Often severely abused/neglected own parents
  depressed or sexually or physically abusive
• May have learning difficulties
• Passive helplessness response to demands of
  family life
• Have given up both thinking and feeling

36
Depressed neglect carers

• Listless and unresponsive to childrens needs and
  demands, limited interaction
• Lack of pleasure or anger in dealings with
  children and professionals
• No smacks, no shouting, no deliberate harm but no
  hugs, no warmth, no emotional involvement
• No structure poor supervision, care and food

37
Depressed neglect children

• Lack interaction with parents required for mental
  and emotional development
• Infant Incurious and unresponsive moan and
  whimper but dont cry or laugh
• At school isolated, aimless, lacking in
  concentration, drive, confidence and self-esteem
  but do not show anti-social behaviour

38
Severe deprivation

• Eastern European orphanages, parents with serious
  issues of depression, learning disabilities, drug
  addiction, care system at its worst
• Children left in cot or serial caregiving
• Combination of severe neglect and absence of
  selective attachment child is essentially alone

39
Severe deprivation children

• Infants lack pre-attachment behaviours of
  smiling, crying, eye contact
• Children impulsivity, hyperactivity, attention
  deficits, cognitive impairment and developmental
  delay, aggressive and coercive behaviour, eating
  problems, poor relationships
• Inhibited withdrawn passive, rarely smile,
  autistic-type behaviour and self-soothing
• Disinhibited attention-seeking, clingy,
  over-friendly relationships shallow, lack
  reciprocity

40
The assessment of neglect

• An approach based on the Graded Care Profile by
  Dr OP Shrivastava
• GCP provides
• Framework for making assessment
• Baseline measurement
• An element of objectivity
• Judgement about care
• Reliable standardised evidence
• http//www.lutonlscb.org/index.php?optioncom_cont
  entviewarticleid183Itemid52

41
GCP users

• Health visitors
• School nurses
• Social workers
• Family centre workers
• Education welfare workers

42
GCP uses

• Pre-referral assessments
• Snapshot assessments
• Contribution to CAF assessments
• Contribution to Core Assessment (parenting
  capacity)
• Self-assessment (parents and carers)
• Young persons assessment of parenting
• Tool for setting goals and assessing progress
• Tool to facilitate discussion

43
Domains of Care
Stimulation Approval Disapproval Acceptance
Sensitivity Responsivity Reciprocity Overtures
Self actualisation
Esteem
Love and belongingness
Present absent
Safety
Physical needs
Nutrition. Housing, Clothing, Hygiene Health
Maslow, A. 1954
44
What to observe
Nutrition Housing Clothing Hygiene Health
Quality, Quantity, Preparation, Organisation,
A. PHYSICAL B. SAFETY C. LOVE D. ESTEEM
45
Grades of Care
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Level of care All childs needs met Essential needs fully met Some essential needs met Most essential needs unmet Essential needs entirely unmet/hostile
Commitment to care Child first Child priority Child/carer at par Child second Child not considered
Quality of care Best Adequate Equivocal Poor Worst
46
Example AREA C LOVE
Sub-areas 1 2 3 4 5
1. Carer
A Sensitivity Anticipates or picks up very subtle signals- verbal or nonverbal expression or mood. Comprehends clear signals distinct verbal or clear nonverbal expression. Not sensitive enough stimuli and signals have to be intense to make an impact e.g. cry. Quite insensitive needs repeated or prolonged intense signals. Insensitive to even sustained intense signals or aversive.
B Response Synchronisation Timing Responses well synchronised with signals or even before in anticipation Responses mostly synchronised except when occupied by essential chores. Not synchronised for own recreational engagement synchronised if fully unoccupied or child in distress. Even when child in distress responses delayed. No responses unless a clear mishap for fear of incrimination.
C Reciprocation (quality) Responses complementary to the signal. Both emotionally and materially, can get over stressed by distress signals from child. Warm. Material responses (treats etc.) lacking, but emotional responses warm and reassuring. Emotional reciprocation warm if in good mood (not burdened by strictly personal problem), otherwise flat. Emotional reciprocation brisk, flat and functional, annoyance if child in moderate distress but attentive if in severe distress. Aversive/punitive even if child in distress, acts after a serious mishap mainly to avoid incrimination, any warmth/remorse deceptive.
47
Sub-Area Scores Scores Scores Scores Scores Area Score Comments
(A) Physical 1. NUTRITION 1 2 3 4 5
(A) Physical 2. HOUSING 1 2 3 4 5
(A) Physical 3. CLOTHING 1 2 3 4 5
(A) Physical 4. HYGIENE 1 2 3 4 5
(A) Physical 5. HEALTH 1 2 3 4 5
(B) Safety 1. IN CARERS PRESENCE 1 2 3 4 5
(B) Safety 2. IN CARERS ABSENCE 1 2 3 4 5
(C) Love 1. CARER 1 2 3 4 5
(C) Love 2. MUTUAL ENGAGEMENT 1 2 3 4 5
(D) Esteem 1. STIMULATION 1 2 3 4 5
(D) Esteem 2. APPROVAL 1 2 3 4 5
(D) Esteem 3. DISAPPROVAL 1 2 3 4 5
(D) Esteem 4. ACCEPTANCE 1 2 3 4 5
48
Targeting Items of Care
Targeted Areas Current Score Target Score Timescale Reviewed Score
1
2
3
4
5
49
Making an assessment

• Guidance provided (follow up scores of 4 or 5)
• Evaluates strengths as well as weaknesses
• Allows progress to be assessed
• A relatively objective measure
• Allows help to be targeted where needed

50
Making an assessment

• Common language, common reference
• Objective measure child focussed
• Effective tool to promote partnership assessments
  and planning with parents
• User friendly
• Comprehensively covers all areas of care
• Child and carer specific

51
  Scale for Assessing Neglectful Parenting
(Northamptonshire)

• 179 individual questions under the following
  headings
• Food and Eating Habits
• Health and Hygiene
• Warmth/Clothing
• Safety and Supervision
• Emotional Needs
• Cognitive Development
• Educational Needs
• http//northamptonshirescb.proceduresonline.com/ch
  apters/p_lscbn_neg.html

52
  Example questions (Health and Hygiene)
21 The home lacks showering or bathing facilities
which work, and are available for maintaining
personal hygiene   22 The bath and basin are
dirty, or inaccessible 23 The family lacks a
toilet which works   24The toilet is regularly
left dirty or stained 25 Toddlers potties are
left unemptied containing urine and faeces   26
The kitchen is dirty (eg cooker ingrained with
old food, grime on walls, floor, kitchen
utensils, sink)
53
  Making an assessment

• Each statement scored 1, 2 or 3 according to how
  true it is.
• Blank spaces for Summary, Conclusions and Action
  Plan
• Lengthy and comprehensive list of relevant
  factors
• No guidance on making overall judgments
• Statements all identify weaknesses
• Allocation of questions to headings a little
  eccentric at times

54
The chain of reasoning

• Facts
• ?
• Analysis/summary
• ?
• Conclusions/recommendations/action

55
The chain of recording

• What happened/what you saw
• ?
• What this means
• ?
• What you did/what should be done (and why, if
  this is not clear from the above)

56
The chain of recording

• But how do you know which facts?
• Must be informed by a basic risk assessment
  (would not always be spelled out on paper)

57
Risk assessment

• The dangers involved (that is the feared
  outcomes)
• The hazards and strengths of the situation (that
  is the factors making it more or less likely that
  the dangers will realised)
• The probability of a dangerous outcome in this
  case (bearing in mind the strengths and hazards)
  
• The further information required to enable this
  to be judged accurately and
• The methods by which the likelihood of the feared
  outcomes could be diminished or removed.

58
Bias and Balance

• Include information favourable to the other
  side as well as that favourable to yours
• It is your job to make judgements but
• avoid empty evaluative words like inappropriate,
  worrying, inadequate
• Give evidence for descriptive words like cold,
  dirty and untidy
• Beware the danger of facts

59
Bias and Balance

• Born in 1942, he was sentenced to 5 years
  imprisonment at the age of 25. After 5
  unsuccessful fights, he gave up his attempt to
  make a career in boxing in 1981 and has since had
  no other regular employment

60
Lies, damned lies and killer bread

• Research on bread indicates that
• More than 98 percent of convicted felons are
  bread users.
• Half of all children who grow up in
  bread-consuming households score below average on
  standardized tests.
• More than 90 percent of violent crimes are
  committed within 24 hours of eating bread.
• Primitive tribal societies that have no bread
  exhibit a low incidence of cancer, Alzheimer's,
  Parkinson's disease, and osteoporosis.
• In the 18th century, when much more bread was
  eaten, the average life expectancy was less than
  50 years infant mortality rates were
  unacceptably high many women died in childbirth
  and diseases such as typhoid, yellow fever, and
  influenza were common.

61
Incomplete or out of date
62
(No Transcript)
63
Can you trust a snapshot?
64
Assessment Pitfalls

• Parents behaviour, whether co-operative or
  uncooperative, often misinterpreted
• Information from family friends and neighbours
  undervalued
• Coping with aggressive or frightening families
• Failure to give sufficient weight to relevant
  case history Start again syndrome
• Not enough attention is paid to what children
  say, how they look and how they behave
  maintenance of a wholly child-centred approach

65
A child centred approach

• The purpose of assessment is to understand what
  it is like to be that child (and what it will be
  like in the future if nothing changes)

66
Information handling pitfalls

• Picking out the important from a mass of data
• Facts recorded faithfully but not always
  critically appraised
• Too trusting/insufficiently critical
• Decoyed by another problem
• False certainty undue faith in a known fact
• Discarding information which does not fit the
  model we have formed
• Department of Health (1991) Child abuse A study
  of inquiry reports, 1980-1989, HMSO, London

67
Assessment pitfalls

• Rule of optimism
• Natural love
• Cultural relativism
• Too much
• not enough

68
Information handling pitfalls

• Keeping your head down
• Hesitancy to challenge other professionals or the
  conventional wisdom
• Tendency to move from facts to actions without
  showing your working

69
But what is analysis?

• You have gathered lots of information but now
  what?
• All you need to do is ask yourself my favourite
  question
• So what?
• You have collected all this data, but what does
  this mean, for the service user, for the family
  and for my setting?

70
Conclusions and recommendations

• Summarise the main issues and the conclusions to
  be drawn from them. (The facts do not necessarily
  speak for themselves it is your job to speak for
  them.)
• Define objectives as well as actions
• Draw conclusions from the facts and
  recommendations from the conclusions
• Explain how you arrived at your conclusions (Have
  you demonstrated the factual/theoretical basis
  for each?)
• Consider and discuss alternative possibilities

71
Conclusions and recommendations

• In drawing conclusions be aware of the extent and
  limitations of your own expertise.
• Conclusions may be supported by research (Dont
  go outside expertise be careful with new or
  controversial theories be aware of counter
  arguments)
• Your recommendation should usually be specific
  (not either/or)
• Remember conclusions may be attacked in only two
  ways
• founded on incorrect information
• based on incorrect principles of social work

72
Conclusions and recommendations

• Problems
• Unsupported assertions or judgements
• Inability or unwillingness to analyse and draw
  conclusions
• Failure to answer the key question So what?

73
Reaching a decision

• Often a decision is made first and the thinking
  done later (Thiele, 2006)
• As humans, we resort to simplifications, short
  cuts and quick fixes!
• We reframe, interpret selectively and
  reinterpret.
• We deny, discount and minimise
• We exaggerate information especially if vivid,
  unusual, recent or emotionally laden and
• We avoid, forget and lose information

74
Good Assessments

• Are clear about the purpose, legal status and
  potential outcomes
• Are based on a clear theoretical framework
• Are clear about context and value base
• Are collaborative and promote accessibility for
  service users
• Are based on multiple sources of information
• Value the expertise and understanding service
  users bring to their situation
• Are clear about missing information

75
Good Assessments

• Identify themes and patterns about needs, risks,
  protective factors and strengths
• Generate and test different ways of understanding
  the situation
• Give meaning to themes, using knowledge based on
  experience/research
• Lead to an evidence-based conclusion
• Use supervision to assist reflection, hypotheses
  and objectivity
• Are able to record and explain outcomes
• Are reviewed, updated amended in light of new
  information

76
Spotting the bad onesOrganisational Clues

• Mythology exists about the family this family
  is/always/behaves like
• Negative stereotypes about other agencies exist
  so their information is discounted
• Sudden changes about view of risk not explained
• Sudden changes of plan not rationally explained

77
Worker clues

• Gut feelings says something is wrong
• Worker does not ask difficult questions
• Analysis does not account for facts/history
• Proposed plan does not address issues raised in
  assessment
• Practitioner is working much harder than the
  parents to explain significant concerns
• The childs story is missing

78
Inter-Agency Clues

• Agencies have conflicting views of the
  family/risk
• Agencies have strong views but offer
  ambiguous/limited evidence
• Some agencies unwilling to share information
• Pressure to agree suppresses permission to
  question / inter-agency acclimatisation

79
Family Clues

• Parental intentions not supported by actions
• Parental optimism involves denial of difficulties
• Children's accounts conflict with parents
• Parents talk about their child is
  contradictory/lacks coherence
• Co-operation is only on the parents terms

80
A final thought

• We are guilty of many errors and many faults
  but the worst of our crimes is abandoning our
  children, neglecting the fountain of life. Many
  of the things we need can wait. The child cannot.
  Right now is the time his bones are being formed,
  his blood is being made, and his senses are being
  developed. To him we cannot answer 'Tomorrow.'
  His name is 'Today.'
• Gabriela Mistral (Chilean poet, 1889-1957)