Understanding and assessing neglect

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Understanding and assessing neglect

• Patrick Ayre
• Department of Applied Social Studies
• University of Bedfordshire
• Park Square, Luton
• email pga_at_patrickayre.co.uk
• web http//patrickayre.co.uk

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• NEGLECT

• Neglect is the persistent failure to meet a
  childs basic physical and/or psychological
  needs, likely to result in the serious impairment
  of the childs health or development. Neglect may
  occur during pregnancy as a result of maternal
  substance abuse. Once a child is born, neglect
  may involve a parent or carer failing to
• provide adequate food, clothing and shelter
• protect from physical and emotional harm or
  danger
• ensure adequate supervision
• ensure access to medical care or treatment.
• It may also include neglect of, or
  unresponsiveness to, a childs basic emotional
  needs.

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• NEGLECT

• Neglect is the persistent failure to meet a
  childs basic physical and/or psychological
  needs, likely to result in the serious impairment
  of the childs health or development. Neglect may
  occur during pregnancy as a result of maternal
  substance abuse. Once a child is born, neglect
  may involve a parent or carer failing to
• provide adequate food, clothing and shelter
• protect from physical and emotional harm or
  danger
• ensure adequate supervision
• ensure access to medical care or treatment.
• It may also include neglect of, or
  unresponsiveness to, a childs basic emotional
  needs.

4

• NEGLECT

• Neglect is the persistent failure to meet a
  childs basic physical and/or psychological
  needs, likely to result in the serious impairment
  of the childs health or development. Neglect may
  occur during pregnancy as a result of maternal
  substance abuse. Once a child is born, neglect
  may involve a parent or carer failing to
• provide adequate food, clothing and shelter
• protect from physical and emotional harm or
  danger
• ensure adequate supervision
• ensure access to medical care or treatment.
• It may also include neglect of, or
  unresponsiveness to, a childs basic emotional
  needs.

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NEGLECT

• Behavioural
• Constant hunger
• Constant tiredness
• Frequent lateness or non-attendance at school
• Destructive tendencies

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NEGLECT

• Low self-esteem
• Neurotic behaviour
• No social relationships
• Running away
• Compulsive stealing or scavenging

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NEGLECT

• Physical
• Poor personal hygiene
• Poor state of clothing
• Emaciation, pot belly, short stature
• Poor skin and hair tone
• Untreated medical problems

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SIGNIFICANT HARM

• Harm is defined by Children Act 1989
• ill-treatment (including sexual abuse and, by
  implication, physical abuse)
• impairment of health (physical or mental) or
  development (physical, intellectual, emotional,
  social or behavioural)

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THE CHILD'S BASIC NEEDS

• basic physical care
• affection
• security
• stimulation of innate potential
• guidance and control
• responsibility
• independence

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Why do parents neglect?

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

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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

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A scale for assessing motivation

• Shows concern and has realistic confidence.
• Shows concern, but lacks confidence.
• Seems concerned, but impulsive or careless
• Indifferent or apathetic about problems
• Rejection of parental role.

13
Shows concern and has realistic confidence.

• Parent is concerned about childrens welfare
  wants to meet their physical, social, and
  emotional needs to the extent he/she understands
  them.
• Parent is determined to act in best interests of
  children
• Has realistic confidence that he/she can overcome
  problems and is willing to ask for help when
  needed
• Is prepared to make sacrifices for children.

14
Shows concern, but lacks confidence

• Parent is concerned about childrens welfare and
  wants to meet their needs, but lacks confidence
  that problems can be overcome
• May be unwilling for some reason to ask for help
  when needed. Feels unsure of own abilities or is
  embarrassed
• But uses good judgement whenever he/she takes
  some action to solve problems.

15
Seems concerned, but impulsive or careless

• Parent seems concerned about childrens welfare
  and claims he/she wants to meet their needs, but
  has problems with carelessness, mistakes and
  accidents. Professed concern is often not
  translated into effective action.
• May be disorganised, not take enough time, or
  pays insufficient attention may misread
  signals from children may exercise poor
  judgement.
• Does not seem to intentionally violate proper
  parental role shows remorse.

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Indifferent or apathetic about problems

• Parent is not concerned enough about childrens
  needs to resist temptations, eg competing
  demands on time and money. This leads to one or
  more of the childrens needs not being met.
• Parent does not have the right priorities when
  it comes to child care may take a cavalier or
  indifferent attitude. There may be a lack of
  interest in the children and in their welfare and
  development.
• Parent does not actively reject the parental role.

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Rejection of parental role

• Parent actively rejects parental role, taking a
  hostile attitude toward child care
  responsibilities.
• Believes that child care is an imposition, and
  may ask to be relieved of that responsibility.
  May take the attitude that it isnt his or her
  job.
• May seek to give up the responsibility for
  children
• (Magura et al,1987)

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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

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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

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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

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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

22
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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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Capturing chronic abuse

• Judging the quality of care is an essential
  component of any assessment but how well do we do
  it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

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Capturing chronic abuse

• Judging the quality of care is an essential
  component of any assessment but how well do we do
  it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

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Our image of assessment
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The reality of assessment?
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Capturing chronic abuse

• Judging the quality of care is an essential
  component of any assessment but how well do we do
  it?
• Judgements subjective and prone to bias
• Intangible Difficult to capture and compare
• High threshold for recognition
• Neglect is a pattern not an event

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The pattern of neglect
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The pattern of neglect
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The pattern of neglect
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The pattern of neglect
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The pattern of neglect
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Cumulativeness
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Failure of cumulativeness
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Information handling

• Picking out the important from a mass of data
• Interpretation
• Distinguishing fact/opinion too
  trusting/insufficiently critical
• Mistrusted source
• Decoyed by another problem
• False certainty undue faith in a known fact
• Discarding information which does not fit
• First impressions/assumptions
• Department of Health (1991) Child abuse A study
  of inquiry reports, 1980-1989, HMSO, London

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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

46
Assessment Pitfalls

• Parents behaviour, whether co-operative or
  uncooperative, is often misinterpreted
• Not enough weight to information from family
  friends and neighbours
• Not enough attention is paid to what children
  say, how they look and how they behave
• Attention is focused on the most visible or
  pressing problems and other warning signs are not
  appreciated
• When faced with an aggressive or frightening
  family, professionals are reluctant to discuss
  fears for their own safety and ask for help
• In Cleaver, H, Wattam, C and Cawson, P Assessing
  Risk in Child Protection, NSPCC, 1998

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Serious Case Reviews

• Great disquiet over assessment practice
• Failure to give sufficient weight to relevant
  case history
• Facts recorded faithfully but not always
  critically appraised
• Guidance and thresholds
• Protection plans omit objectives and outcomes

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Assessment Practice

• Use of trained staff
• Assessment of male carers
• Maintenance of a wholly child-centred approach
• Too much mouth and ears, not enough eyes
• Formal assessment of risk

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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.

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Bias and Balance

• Include strengths and weaknesses
• 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

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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

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Seeing the whole picture
Kouao always dressed immaculately. Her clothing
and jewellery seemed expensive and her hair was
very well done. She did not in any way look
destitute, contrary to what she always claimed.
In contrast, Victoria was poorly dressed. I
cannot recall exactly what she wore but there
were times when she did not seem to be dressed
appropriately. She always appeared to look as if
she was in hand-me-down clothes. I thought she
looked shabbily dressed
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Seeing the whole picture
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The danger of snapshots
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Drawing conclusions and making 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.)
• 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?)

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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)

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Wirral assessment tool for neglect

• 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

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When do you make a GCP assessment?

• Concerns about parenting
• Child exhibiting problems
• Children in need of protection
• Children in need
• Devising a programme of intervention
• Any other parenting concerns

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GCP users

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

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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

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Why choose GCP?

• Child focused
• User friendly
• Common language
• Promotes partnership

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Why choose GCP?

• Evaluates strengths as well as weaknesses
• Allows progress to be assessed
• A relatively objective measure
• Allows help to be targeted where needed

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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
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What to observe
Nutrition Housing Clothing Hygiene Health
Quality, Quantity, Preparation, Organisation,
A. PHYSICAL B. SAFETY C. LOVE D. ESTEEM
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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
Wirral rating No concern No concern Recommend prevention support Child protection Child protection and legal strategy meeting
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Scoring

• Rating 5 25
• Use on every child in the family
• Use with different carers
• Complete with the parent/carer
• Use information, observation, records

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Scoring

• Score as actually fits the manual
• DO NOT JUSTIFY BY REASONS
• If there is a score of 20 or 25, this overrides
  any other scores
• Scores between 5 and 15, record the one which
  crops up most
• If there is an even split, the highest score is
  entered

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Scoring

• Complete individual scores in the manual
• Transpose to the record sheet
• Agree action, targets and timescales

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A
AREAS
PHYSICAL CARE
Sub-areas
1
?
Items
a
b
c
d
5
15
10
15
2
?
c
a
b
10
20
10
3
?
c
a
b
15
5
10
4
15
5
?
d
a
b
c
15
15
10
10
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Scoring

• Score as actually fits the manual
• DO NOT JUSTIFY BY REASONS
• If there is a score of 20 or 25, this overrides
  any other scores
• Scores between 5 and 15, record the one which
  crops up most
• If there is an even split, the highest score is
  entered

72
A
AREAS
PHYSICAL CARE
Sub-areas
1
?
Items
a
b
c
d
5
15
10
15
2
?
c
a
b
10
20
10
3
?
c
a
b
15
5
10
4
15
5
?
d
a
b
c
15
15
10
10
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A
AREAS
PHYSICAL CARE
Reference Sheet
Sub-areas
1
15
Items
a
b
c
d
5
15
10
15
2
20
c
a
b
10
20
10
3
15
c
a
b
15
5
10
4
15
5
15
d
a
b
c
15
15
10
10
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Record sheet
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Targeting Items of Care
Targeted Areas Current Score Target Score Timescale Reviewed Score
1
2
3
4
5
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Unique Advantages

• 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

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What helps in working with neglect

• Proactive assessment
• Addressing causes not symptoms
• An ecological framework
• Multidisciplinary assessment
• Understanding histories and patterns

79
What helps in working with neglect

• Matching interventions to identified needs
• Clear objectives and timescales
• Work with parents
• Work with children in a resilience framework

80
Substance use and neglect

• Experimental drug users
• Recreational drug users
• People who use legal substances
• People who are dependent on illegal drugs or
  alcohol
• But we focus on the stage when the use of drugs
  or alcohol is having a harmful effect on a
  persons life

81
Some statistics

• Between 50 and 90 of families on social
  workers child care caseloads have parent(s) with
  drug, alcohol or mental health problems
• Glasgow 1998/9 40 of Child Protection Orders
  cited drug abuse
• Dundee Child protection conferences involving
  parents with problems over drug or alcohol use
  rose from 37 in 1998/9 to 70 in 2000

82
Effects vary, but

• Substance misuse may become central preoccupation
• Reduce or alter appetite
• Reactions to pain and discomfort dulled
• Self-neglect
• Social relationships narrow
• Trouble with money, housing and the law
• Poor physical and mental health
• Interpersonal conflict and poor family
  relationships

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Effects on children

• Parental substance misuse alone is neither a
  necessary nor sufficient cause of problems in
  children (Mountenay, 1998)
• International literature on the children of drug
  users does not support an assumption that child
  abuse and neglect automatically follow when a
  parent uses drugs (Hogan,1998)
• But, families need comprehensive assessment and
  active support to promote resilience and repair
  damage

84
Effects on children

• Alcohol and/or substance misuse greatly increase
  the likelihood of family problems (Sher 1991
  Zeitlin, 1994)
• Substance use can become the central focus of the
  adults lives, feelings and social behaviour.
• CAMH services report substantial risk of poor
  childhood mental health (Mountenay, 1999)
• Poor long-term outcomes for children (Rutter and
  Rutter, 1992)

85
Effects on children

• I hated weekends when mum had all her friends
  round drinking all night.
• Sarah daughter of problem drinker
• She was just always dead moody, she was always
  in her bed all the time and she would never go
  out and buy food and she would never have money
  to go out and get it.
• (Barnard 2002)
• the children of problem drinkers forgotten
  children, a hidden tragedy, and or unseen
  casualties (Wilson 1982)

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Specific effects (mainly US Studies)

• High risk of maltreatment, emotional or physical
  neglect or abuse, family conflict and
  inappropriate parental behaviour Famularo,
  Kindscherff and Fenton, 1992 Wasserman and
  Levanthal, 1993, Barlow, 1996).
• Exposed to drug-related activity and associated
  crime (Hogan, 1998)
• Inconsistent and lukewarm care, ineffective
  supervision and overly punitive discipline
  (Kandel, 1990 Boyd, 1993).

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Specific effects (mainly US Studies)

• More likely to
• display behavioural problems (Wilens et al,
  1995),
• experience social isolation and estrangement from
  family and peers, and stigma (Kumpfer and De
  Marsh, 1986),
• misuse substances themselves when older (Hoffman
  and Su, 1998 McKeganey 1998)
• In the longer term isolation, difficulties with
  change and learning to have fun (Barlow, 1996)

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Pre-birth, infancy and pre-school

• Risk of physical harm pre-birth
• Neglect and injury through drugged state of
  parent, access to drugs
• Inappropriate emotional care through unhappiness,
  tension, irritability, preoccupation
• Cognitive and emotional development affected by
  lack of stimulation and inconsistent/unpredictable
  behaviour, unstable environment

89
Pre-birth, infancy and pre-school

• Poor contact with other children
• Materially deprived environment
• Self-esteem and positive sense of identity
  affected by physical and emotional neglect
• Experience violence
• Where parents behaviour is particularly
  unpredictable and frightening, symptoms of PTSD

90
Pre-birth, infancy and pre-school

• Baby Adele was carried along the harbour wall by
  her father who was under the influence of
  alcohol. Neighbours thought this carried the risk
  of dropping her in the water.
• (Scottish Executive 2002)
• My parents started giving me alcohol when I was
  1 (year old) to put me to sleep. I got taken into
  hospital to have my stomach pumped.
• Helen, aged 12

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Primary school

• Symptoms of extreme anxiety and fear of hostility
• Boys more quickly exhibit behavioural problems
  (but girls equally affected)
• Self-blame and poor self-esteem
• Academic attainment and social development
  affected by neglect and poor attendance, poor
  concentration
• Shame and embarrassment lead to isolation
• Young carers

92
Primary school

• I used to feel angry when my Mum was on drugs
  cause I used to think how could this have
  happened to me? I was just sad all the time and
  then I would get angry. And we would have
  arguments all the time.
• Anne, aged 11
• I used to get really embarrassed at school when
  mum turned up drunk to collect me. I knew that I
  would have to make the tea when I got in.
• Billy, aged 9

93
Secondary school

• Puberty without parental support
• Increased risk of conduct disorders, bullying and
  sexual aggression
• Beyond parental control and increased risk of
  injury by parents
• Socialised into substance misuse

94
Secondary school

• I knew they loved me but they just didnt care
  that I was there and I needed stuff as well
• Elaine, aged 14
• At school, if your pals know your mas on drugs
  you get called a junkie
• (Aberlour 2002)

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Protective factors

• Sufficient income
• A consistent caring adult
• Regular monitoring and respite
• Refuge from violence
• Regular school/nursery attendance
• Sympathetic and vigilant teachers
• Organised out of school activities

96
The significant harm threshold

• The threshold is probably passed when
• Parental drug and alcohol use is adversely
  impacting on the childs health and development
• There is no one parental figure able to provide a
  stable secure environment for the child
• There is no evidence that parental behaviour will
  change within a timeframe congruent with the
  needs of the child
• (Luton LSCB Safeguarding Inter-Agency
  Procedures, 2006)

97
When enough is enough

• When a parent consistently places procurement and
  use of alcohol or drugs over their childs
  welfare and fails to meet a childs physical or
  emotional needs, the outlook for the childs
  health and development is poor. Problem alcohol
  or drug using parents themselves acknowledge this
  and it is the duty of professionals to act in the
  childs best interests when parents cannot.
• (Getting our priorities right, 2003)

98
Referral triggers

• Use of the family resources to finance the
  parents dependency, characterised by inadequate
  food, heat and clothing for the children
• Children exposed to unsuitable caregivers or
  visitors, e.g. customers or dealers
• The effects of alcohol leading to an
  inappropriate display of sexual and/or aggressive
  behaviour
• Chaotic drug and alcohol use leading to emotional
  unavailability, irrational behaviour and reduced
  parental vigilance

99
Referral triggers

• Disturbed moods as a result of withdrawal
  symptoms or dependency
• Unsafe storage of drugs and/or alcohol or
  injecting equipment
• Drugs and/or alcohol having an adverse impact on
  the growth and development of the unborn child
• (LSCB Safeguarding Inter-Agency Procedures,
  2006

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Assessment

• Generic
• CAF
• GCP (assessment of parenting)
• Specialist substance misuse and/or child
  protection assessment

101
Assessment principles

• Focus on the child
• Consider outcomes for the child, not the intent
  of the parent
• Focus more on the childs lived experience than
  on specific incidents
• Adults management of their own lives is a good
  indicator of their ability to look after a child
• Take full account of historical information
• Information from a variety of sources is better
  than information from one

102
Working together

• Complex network of intervention
• Support parents and parenting
• Stabilise/reduce substance misuse
• Reduce risk and harmful effects on children
• These objectives may not always be compatible,
  especially with regard to timescales

103
Substance misuse workers vs child care workers

• Mutual incomprehension and misunderstanding
• Working on the same case but not working jointly
• False expectations and assumptions
• Abdicating responsibility (both ways)
• Need for interpreters

104
Working with parents

• It is good practice to work in partnership with
  parents
• Professionals should be open and honest with
  parents about the problems and risks they
  perceive
• Working with parents as partners does not mean
  their wishes determine decisions, but that their
  views are sought and taken into account.

105
Working with parents

• It is important to recognise that
• Parents will often hide the extent of their
  problem for fear of the consequences
• They may find it very hard to change, despite the
  consequences
• This means testing and checking their accounts