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.

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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.

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• 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.

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• 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!!....

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• 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!

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• 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!!....

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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.

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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

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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.

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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)

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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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Forms 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
• (Howe, D (2005) Child Abuse and Neglect,
  Basingstoke Palgrave Macmillan)

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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
• Associated with avoidant/defended patterns of
  attachment

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Emotional neglect parents

• Cant cope with childrens demands
  avoid/disengage from child in need dismissive or
  punitive response
• Children provided for materially but there is a
  failure to connect emotionally
• More rules everyone has a role and knows what to
  do.
• Parents may feel awkward tense when alone with
  their children.

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Emotional neglect children

• When attachment behaviour rejected
• Learns that caregivers physical and emotional
  availability is reduced when emotional demands
  are made
• Caregiver most available when child is showing
  positive affect, being self-sufficient,
  undemanding and compliant
• Reverse roles, false brightness to care for/
  reassure parent.

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Emotional neglect children

• Frightened, unhappy, anxious, low self-esteem
• Withdrawn, isolated, fear intimacy and dependence
• Precocious, streetwise, self-reliant

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Emotional neglect children

• May show compliance to dominant caregivers but
  anger and aggression in situations where they
  feel more dominant.
• May learn that power and aggression are how
  relationships work and you get your needs met
• Behaviour increasingly anti-social and
  oppositional
• Brain development affected difficulties in
  processing and regulating emotional arousal

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Emotional neglect case management

• Help parents to learn to use others for support.
• Teach parents to engage emotionally with their
  children.
• Must be highly structured as neither parent or
  child know how to interact normally
  spontaneously.
• Fear of affect need clear rules roles

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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
• Worker may feel agenda co-opted by familys
  immediate needs

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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
• May be regarded as overwhelmed but amenable to
  services
• Crisis is a necessary not a contingent state
• Associated with ambivalent/coercive patterns of
  attachment

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Disorganised neglect carers

• Cope with babies (babies need them) but then
• Parental responses to children
• unpredictable and insensitive (though not
  necessarily hostile or rejecting).
• 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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Disorganised neglect case management

• Logic would argue for warding off crises for a
  while so that families can be taught to organise
  their lives, but
• Family may want to have needs met, but cannot
  delay gratification or trust logic and planning
• Without intense demands associated with crises,
  have no way of being important to others
• Will CREATE new crises.

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Disorganised neglect case management

• Feelings must be addressed
• Need a structured, predictable environment with
  no surprises where
• There are rewards for clear, direct, and
  undistorted communication of feelings and
  accurate cognitive information about future
  outcomes
• Family can learn the value of compromise
• Teach parents how to use cognitive information to
  regulate feelings (without denying them)

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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 seem unmotivated, mild learning disability
• Learned helplessness in response to demands of
  family life
• Stubborn negativism passive-aggressive
• 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

• Younger the child, more debilitating the effects
• 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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Depressed neglect case management

• Involves much more than teaching appropriate
  parenting
• All family members must learn that their
  behaviour has predictable and meaningful
  consequences
• Teach that it helps to share feelings with
  empathetic others.

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Depressed neglect case management

• Our standard approaches dont work
• Threats / punitive approaches particularly
  ineffective
• Parents dont believe they can change so dont
  even try.
• Even most reasonable pressure results in
  shutting down / blocking out all info.
• Parent education may be ineffective because
  judgment impaired and gains not transferable.

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Depressed neglect case management

• These families need
• Long term involvement
• Supportive approach
• Responsiveness to familys signals and needs
• BUT these need to be balanced with a recognition
  of the childrens needs. (How long is too long?
  How much is too much?)

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Depressed neglect infants and children

• Must experience responsive and stimulating
  environments that also provide human comfort for
  a few hours each day.
• The longer the child is exposed to helplessness,
  the more intense and longer the intervention
  needed to remedy the situation.

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Depressed neglect parents

• Must learn appropriate ways to show their
  feelings
• Practice smiling, laughing, soothing
• May be mechanical at first
• Genuine feelings will emerge with repetition
• As parents learn to show their feelings, the
  childs responsiveness will increase virtuous
  spiral

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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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Severe deprivation case management

• Highly unlikely to be in the childs best
  interests to remain in the environment which
  caused the harm
• It is probable that the child and new carers will
  require substantial therapeutic and emotional
  support
• Significant challenges often persist despite a
  move to a caring and predictable environment.

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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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Cumulativeness
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Failure of cumulativeness
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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

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Assessment Pitfalls

• Parents behaviour, whether co-operative or
  uncooperative, is often misinterpreted
• Not enough weight to information from family
  friends and neighbours
• Attention is focused on the most visible or
  pressing problems 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
• Not enough attention is paid to what children
  say, how they look and how they behave
  maintenance of a wholly child-centred approach
• In Cleaver, H, Wattam, C and Cawson, P Assessing
  Risk in Child Protection, NSPCC, 1998

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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)

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Information handling

• Picking out the important from a mass of data
• Interpretation
• Too trusting/insufficiently critical Facts
  recorded faithfully but not always critically
  appraised
• Mistrusted source
• 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

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Information handling
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Serious Case Reviews

• Failure to give sufficient weight to relevant
  case history Start again syndrome
• Failure to recognised increased vulnerability of
  neglected children
• Use of trained staff
• Assessment of male carers
• Maintenance of a wholly child-centred approach
• Too much mouth and ears, not enough eyes

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So what?

• We have spent some time considering how to
  recognise and respond to neglect.
• What does this mean for us? What are the
  implications for services in South Wales? What,
  if anything, will be different?

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Working with resistance

• In many cases parents were hostile to helping
  agencies and workers were often frightened to
  visit family homes. These circumstances could
  have a paralysing effect on practitioners,
  hampering their ability to reflect, make
  judgments, act clearly, and to follow through
  with referrals, assessments or plans. Apparent or
  disguised cooperation from parents often
  prevented or delayed understanding of the
  severity of harm to the child and cases drifted.
  Where parents made it difficult for professionals
  to see children or engineered the focus away from
  allegations of harm, children went unseen and
  unheard.
• Families tended to be ambivalent or hostile
  towards helping agencies, and staff were often
  fearful of violent and hostile men. Although
  parents tended to avoid agencies, agencies also
  avoided or rebuffed parents by offering a
  succession of workers, closing the case, losing
  files or key information, by re-assessing ,
  referring on, or through initiating and then
  dropping court proceedings.
• Brandon, M, and others (2008) Analysing child
  deaths and serious injury through abuse and
  neglect what can we learn? London Department
  for Children, Schools and Families

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Engagement

• Engagement is the basic task of a child and
  families worker but can never be taken for
  granted and must always be worked for

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Context

• Involuntary work may be characterised by
• Guardedness or reluctance to share information
• Avoidance and a desire to leave the relationship
• Strong negative feelings such as anxiety, anger,
  suspicion, guilt or despair.

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Context

• We need to accept that
• The best we may be able to achieve is honesty
  rather than positive feelings and a high degree
  of mutuality
• Conflict and disagreement are not something to be
  avoided, but are realities that must be explored
  and understood.

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How might resistance show itself?

• By only being prepared to consider 'safe' or low
  priority areas for discussion.
• By not turning up for appointments
• By being overly co-operative with professionals.
• By being verbally/and or physically aggressive.
• By minimising the issues.
• (Egan, 1994)

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Potential parental responses

• Genuine commitment
• Compliance / approval seeking
• Tokenism
• Dissent / avoidance
• (Horwath and Morrison, 2000)

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Identifying resistance 4 categories

• Hostile resistance anger threats, intimidation,
  shouting
• Passive aggressive surface compliance covers
  partly concealed antagonism and anger
• Passive hopeless Tearfulness and despair about
  change
• Challenging Cure me if you can!

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Strategies for enhancing engagement

• Before you start, check your mindset (your own
  biases and assumptions)
• Have realistic expectations
• It is reasonable that involuntary clients resent
  being forced to participate
• Because they are forced to participate,
  hostility, silence and non-compliance are common
  responses that do not reflect my skills as a
  worker
• Due to the barriers created by the practice
  situation, clients may have little opportunity to
  discover if they like me
• Lack of client co-operation is due to the
  practice situation, not to my specific actions
  and activities
• (Ivanoff et al, 1994 )

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During initial contacts

• Adopt a non-defensive stance
• Be clear, honest and direct and acknowledge the
  involuntary nature of the relationship
• Clarify roles and expectations, including what is
  required of the client
• Explain consequences of non-compliance and the
  advantages of compliance
• (Ivanoff et al, 1994 )

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Try to

• Invite participation
• Understand how the client sees the problem as
  well as how we see it
• Understand what the client wants, as well as what
  we want
• (Ivanoff et al, 1994 )

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What might we be doing to make it worse?

• Becoming impatient and hostile
• Doing nothing, hoping the resistance will go away
• Lowering expectations
• Blaming the family member
• Allowing the family member to control the
  assessment inappropriately
• Failing to acknowledge our fear

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What might we be doing to make it worse?

• Becoming unrealistic
• Believing that family members must like and trust
  us before assessment can proceed.
• Ignoring the enforcing role of some aspects of
  child protection work and hence refusing to place
  any demands on family members.
• (Egan, 1994)

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Avoid

• Expressions of over-concern
• Moralising
• Criticising the client
• Making false promises
• Displaying impatience

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Avoid

• Ridiculing the client
• Blaming the client for his/her failures
• Being dogmatic
• Rejecting the clients right to express different
  values and preferences
• (Ivanoff et al, 1994 )

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Productive approaches

• Give practical, emotional support - especially by
  being available, predictable and consistent
• See some resistance and reluctance as normal
• Explore our own resistance to change and by
  examining the quality of our own interventions
  and communication style
• (Egan, 1994)

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Productive approaches

• Helping family members to identify incentives for
  moving beyond resistance
• Tapping the potential of other people who are
  respected as partners by the family member
• Understanding that reluctance and resistance may
  be avoidance or a signal that we are not doing
  our job very well
• (Egan, 1994)

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Confrontation

• In child welfare services, the Childrens Service
  Worker must be a skilled confronter.
  Confrontation is, basically, facing the client
  with the facts in the situation and with the
  probable consequences of behaviours
• (Texas Department of Human Resources)

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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.

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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.

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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.

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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)