1. Childhood neglect: Why it matters and how to identify it earlier
Great to have chance to speak
As I work with looked after and adopted children this is very important issue
Preparing adoptive parents has been much more about discussing the impact of neglect and looking into a crystal ball.
Over the years we have realised that good health is not enough
Some of the behaviours that parents have to cope with are really challenging and I hope this will explain why
The doctor’s view
Dr Sarah Steel and Dr Sarah Maxwell

2. Objectives What is neglect? The impact on the developing brain
Attachment
How do children present?
Long term consequences
evidence from systematic reviews

3. Physical Neglect Emotional Neglect Failure to provide:
Less likely to come to the attention of child protection authorities
Associated with more serious long term consequences
Good evidence that neglect has an even more negative effect on brain development than abuse
the persistent failure to meet a child’s basic physical and/or psychological needs
failure to protect a child from physical and emotional harm or danger
disregard or unresponsiveness to a child’s basic emotional needs
Emotional neglect
Failure to provide:
Food
Clothing
Shelter
Medical care
Educational provision
Failure to provide:
Comfort
Protection
Love
Discipline
Encouragement

4. Recognition of risk factors
Social and environmental risk factors
Poverty, social isolation, poor housing
Care giver risk factors
Mental ill-health, domestic violence, parental conflict, substance misuse, parental history of abuse
Persistent harmful caregiver-child interaction
Symptoms and signs in the child's functioning
Recognising risk factors important these are the families we need to watch closely and whose children we need to monitor closely
Male brain more vulnerable as matures more slowly?
Emotionally unavailable
Primary carer preoccupied with own health, unavailable to child
Little emotional or psychological interaction between carer and child
Fails to respond to child or interact with child
Negativity towards child
Developmentally inappropriate interaction

5. What is the impact of neglect on child development?
Altered neurobiology
Attachment disorders
Low self esteem
Less social interaction
Aggression
Low IQ
Attempted suicide

6. Structural brain differences
due to reduced sensory input
Early neglect chacterised by decreased sensory input eg poverty of words touch social interactions similar effect on growth of human brain Reduced cerebral cortical volume
Human cortex makes synaptic connections as it grows in size develops complexity modifies as a function of the quality and quantity of sensory experience
Sensory motor and cognitive deprivation leads to under development of the cortex in rats, noon human primates and humans Perry 2002
Neurons make fewer connections
The cortex can inhibit reposnses from the lower primitive brain brain stem, problems interpreting emotions

7. Brain development Learning starts in the fetus
Brain size more than doubles in first year of life
40,000 new synapses formed every second in the infant’s brain
Influenced by social forces and so is ‘experience- dependent’
Male brain more vulnerable as matures more slowly
a child's rapidly developing brain organizes to reflect the child's environment.
This is because neurons, neural systems, and the brain change in a "use-dependent" way.
Early life experiences, therefore, determine how genetic potential is expressed, or not. As the brain organizes, the lower more regulatory systems develop first.
In utero and during the first four years of life
The human brain mediates our movements, our senses, our thinking, feeling and behaving. The amazing, complex neural systems in our brain, which determine who we become, are shaped early.
Physical connections between neurons — synaptic connections — increase and strengthen through repetition, or wither through disuse.
During the first years of life, the higher parts of the brain become organized and more functionally capable. Brain growth and development is profoundly "front loaded" such that by age four, a child's brain is 90% adult size! This time of great opportunity is a biological gift. In a nurturing environment, a child can grow to achieve the full potential pre-ordained by underlying genetics. We promote this by fostering conditions of optimal development.

8. Anatomy of brain
Brain stem primitive brain :Starts in utero rapid development both in utero and post natally. born with developed brain stem
Little connections in cortex
Ie trauma in utero experience anxiety of mother brain stem will be affected
Brian stem crucial to emotional regulation brain development will be affected exposure to drugs, alcohol, depression , domestic violence, chaos the
Hippocampus role in episodic memory (times places events)
Limbic system Hippocampus
Sensitive to stress hormones
Amygdala: emotional memory, fight and flight response fire alarm system crucial role in fear , control aggressive, oral and sexual behaviours
Cortex thinking brain conscious thinking, planning, communication , voluntary motor action
Inhibits lower more reactive brain
Reacts in socially acceptable way rapid development postnatally as this is relatively undifferentiated at birth most undifferentiated organ in the body genes and early experience shape the way the neurones connect to one another and thus give rise to mental processes.
Experiences in early life have a tremndous impact on developing mind
Siegal 1999 dais the ‘lack of experience can lead to cell death’
Cerebellum: Important role in motor function. Controlling coordination, role in attention language social behavioural and emotional disruptions greatest increase in size postnatal

9. Parent-infant interaction.

10. Still face experiment
Still face

11. Attachment Attachment = interactive regulation of emotion
Infants seek closeness and comfort from an attachment figure, especially in danger through display of distress signal (crying/ clinging)
Learn to develop strategies for internal regulation of distress
Right brain to right brain
Especially at night

12. The arousal-relaxation cycle
Need
Displeasure
Satisfaction of Need
Quiescence
Trust
Security
Attachment
Fahlberg (1988)

13. ventral tegmentum, is a group of neurons close to the midline on the floor of the midbrain
origin of the dopaminergic cell bodies
mesocorticolimbic dopamine system and is widely implicated in the natural reward circuitry of the brain.
. The VTA contains neurons that project to numerous areas of the brain, from the prefrontal cortex (PFC) to the caudal brainstem and several regions in between.
each brain adapts uniquely to the unique set of stimuli and experiences of each child's world.

14. The positive interaction cycle
Child responds positively
Parent initiates positive interactions with the child
Self worth
Self esteem
Fahlberg (1988)

15. Positive interaction cycle
serve and return
Responsiveness

16. Attachment First year of life – right brain development
Visual, acoustic communication
Emotional and social processing
Response to danger
Second year of life – left brain develops
Father important- stimulation, regulation of aggression
Cognitive development, speech
Down regulates negative emotional states AND up regulates positive emotions
Strong evidence that primary caregiver both soothes and calms so down-regulates negative emotions but also stimulates through play positive emotional states. So when evaluating relationship need to look at both ability to calm but also play.
Early attachments directly influence the final wiring of the brain for future social and emotional coping strategies of the child
It will affect the abilty to regulate emotions including positive emotions like joy , interest as well as negative emotions such as fear and aggression
Solomon and siegal 2003

17. Gender implications
Typically mothers are calming and fathers more arousing and energetic
Suggests contact with parents may be important at different times
1st year Mum and 2nd year Dad?
Mother essential for fear regulation in 1st year and father for aggression regulation later
Implications for contact decisions?
Night time contact?
2 halves do not make a whole – giving infant half of each parent will not ness make for a secure attachment
Women tend to be better at reading emotional or non verbal states
Orbitofrontal cortex bigger in women
Disorganised-disorientated mother with history of abuse will not be able to regulate – early repeated care with primary caregiver that dysregulates increases predisposition to psychopathology

18. Things to consider
Who can fill the role of predictable, consistent & emotionally available primary caregiver
Who will be intuitively sensitive to child’s emotional needs
Who can act as regulator of child’s emotional states
At what points of time are these needed

19. Stress!

20. Hypothalamic-pituitary-adrenal axis
Core stress response system
Stress leads to (CRH) hormone release from hypothalamus
Stimulates ACTH secretion acts on adrenal gland to produce cortisol
Maltreatment may lead to atypical responsiveness of HPA axis to stress that predisposes to psychiatric vulnerability later in life
Corticotrophin relasing hormone stimulates adreno-corticotrophic hormone
Cortisol crosses the placenta so the emotional state of the mother in pregnancy has already begun to influence the baby.
Not just the intensity of the stress but also the duration

21. Highlight the direction of travel brainstem interconnected high functions
Exposure to abuse and neglect chaos and violence will have major impact on the developing brain
The earlier the impact the more severe the difficulties a child will experience
The longer the child lives in adverse circumstances the more severe the impact
Depends on stage of development i.e. stressing system in 1st year while it is organising will have a much more negative impact than in the 3rd or 4th year
1st set of neuron connections made 1st years of life form basis of perceptions for rest of our life
Brain starts to make millions of connections from birth as experiences touch, small, sounds taste

22. Habitual ways of responding and emotional control sensitive periods early
Language longer impact thus longer the neglect greater the problems

23. Presentation of child

24. Core–info: Cardiff child protection systematic reviews
180 articles reviewed 41 answered question
Mixture of case control and cohort studies
Age from 0-6 years
Further school age and teenager review as well
Cardiff group have looked at relevant studies
Case control study match child with behaviour with no behaviour
Gives you an odds ratio of risk of exposure to adverse event
Case + behaviour and exposure neglect
Cohort study look at group of children neglected and see what present with

25. Features in the child Preschool
0-20 months
(7 studies,349 cases,237 controls)
20-30 months
(3 studies, 125 cases, 113 contols)
3-4 years
(4 studies, 86 cases, 125 controls)
Description
Avoidant and disorganised insecure attachment
During play demonstrated greater negativity
Greater negative affect during play
Developmental delay and Language delay
less positive social interaction
Developmental delay, in particular language delay
Passive and withdrawn behaviour
Greater memory deficits
Less ability to discriminate emotions
Assessment of attachment status, evaluated by Strange Situation , comparing neglected with abused and / or control children
Neglected children showed avoidant attachment
Neglected children also showed more insecure-disorganised attachment
Evaluation of neglected toddlers during play demonstrated greater negativity than seen in controls
Neglected children demonstrated less positive social interaction in comparison to abused children or controls.
Neglected children were also the most passive, and spent more time alone than the other two groups.
With increasing test difficulty, neglected children showed greater memory deficits than physically abused children or controls
Again there was no difference between controls and neglected children on play complexity, however play was strongly influenced by cognitive function performance.
Developmental delay, in particular language delay, was apparent in the neglected children in comparison to physically abused children or controls
Receptive language (auditory comprehension quotient) and expressive language development (verbal ability quotient) were particularly delayed
The neglected children showed the lowest scores on auditory and verbal scores
In observing play, both free and with parents, the neglected toddlers had a greater negative affect than physically abused children or controls
There was no demonstrable difference in discriminating emotions between emotionally abused, physically abused or neglected children.  An allowance was made for intelligence quotient (IQ).  However, all of these groups showed less ability to discriminate emotions than those with normal IQ 3

26. Emotional behavioural development
Attachment pattern
12 months ambivalent-insecure
18 months avoidant, however some are classified as ‘secure’
If anxiously attached by two years of age
angry, frustrated and non-compliant
negative affect
Poor coping skills
The attachment pattern demonstrated by neglected children changed from ambivalent-insecure in those aged 12 months to avoidant in those aged 18 months, however some are classified as ‘secure’
Children who were anxiously attached at 1-18 months became angry, frustrated and non-compliant with more negative affect than controls by two years of age
The neglected children were worse at coping than both abused children and controls
Crittenden et al showed how neglected children aged 12 months onwards displayed aggressive and resistant behaviour towards their carers, particularly up to 2.25 years of age 1
Children neglected after an early period of normal care do not show same level of aggressive behaviour

27. Infant
Feeding difficulties, crying, poor sleep patterns, delayed development
Irritable, non cuddly, apathetic, non-demanding baby
‘difficult baby’, ‘does not belong to me’, ‘does not love me’, ‘spoiled’, ‘greedy’, ‘attention seeking’, ‘lazy’
We need to be better at identifying these behaviours and understanding why child presents with this behaviour can be subtle at this stage but important to pick up early

28. Toddler Head banging, rocking, bad temper ‘Violent’, clingy
Overactive-apathetic, noisy to quiet
Immobile and silent
Developmental delay
Language delay
Poor social skills
Case JS recent child presented with severe bruising to forehead from head banging, dysregulated, hyperactive at 18 months underweight , grubby
Mother no understanding of his needs

29. Features in the child Infant school age
4-5 years
(6 studies,110 cases, 128 controls)
5-6 years
(5 studies, 155 cases, 155 controls)
Description
Language delay becomes more evident
Insecure avoidant attachment
Problems discriminating emotional expressions (particularly between angry, sad and fearful expressions) , poor emotional regulation
Poor peer relationships, rate self as angry oppositional
Poor peer relations, less social interactions , more aggressive, conduct problems
Low self esteem
Helpless outlook, view ‘others’ nit as source of help
Less moral more inclined to break rules and cheat
Neglected children showed the least number of social interactions in comparison to controls and abused children
Neglected children also showed cognitive deficits and disruptive behaviour
Neglected children showed an increase in conduct problems in comparison to abused children and controls (as rated by mothers) 8
Teachers rated neglected children’s behaviour as worse than the controls and abused children 8
less likely to expect parents to relieve their distress
more difficulty discriminating emotional expressions (particularly between angry, sad and fearful expressions)
low self-esteem and the lowest scores on positive self-representation
Overall, neglected children were more insecurely attached than controls
The emotionally abused children were anxiously attached at 18 months and, by 24 months, showed more anger and frustration than controls
By 42 months, the neglected children showed more apathy / withdrawal and hyperactivity / distractibility

30. Minnesota study: developmental sequelae
More self-destructive, inattentive and overactive behaviour.
Anxious, withdrawn, unpopular, aggressive and obsessive- compulsive
Lacking humour,
Little sensitivity and empathy
Poorer at following directions and expressing themselves. 
By 64 months they showed more self-destructive, inattentive and overactive behaviour.
They were rated by teachers to be anxious, withdrawn, unpopular, aggressive and obsessive-compulsive in comparison to abused children and controls.
Teachers rated the children as lacking humour, showing little sensitivity and empathy, as well as being poorer at following directions and expressing themselves in comparison to control groups. 

31. Physical examination Underweight and or stunted growth
Sad, withdrawn, over affectionate, angry, apathetic
Restless, frozen and non moving, destructive, over active, distant, over friendly
Developmental signs: failure to achieve milestones, failure to thrive, academic failure, under achievement

32. School age

33. Behaviour Soiling and wetting Present as aggressive and hostile
More impulsive
Poor concentration
May be particularly quiet or withdrawn
The impact on behaviour is often greatest when neglect starts early in a child’s life, or if the child is both neglected and emotionally abused
They may present as aggressive and hostile, for example, the child may be prone to angry outbursts or lashing out towards others
They may be more impulsive than other children, and may show features seen in Attention Deficit Hyperactivity Disorder (ADHD), for example, poor concentration or impulsive behaviour
Neglected children specifically, may be particularly quiet or withdrawn

34. Relationships with other children:
Difficulty with friendships
Problems socialising,
Few friends
Perceived as more likely to be aggressive or disruptive
The children may have difficulty with friendships and have more problems socialising, than other children do. They may describe another child as their ‘best friend’ but the other child does not reciprocate this
The child may have few friends, and be perceived by other children as more likely to be aggressive or disruptive

35. Emotional or self-perception issues:
Little self-confidence
Low self esteem
Experience symptoms of depression
Difficulty interpreting emotions, such as anger or sadness
Mood swings
Show levels of affection towards others, which are inappropriate for the situation
. The majority of literature addresses children aged 7-11 years.
They may have little self-confidence, and the more severe neglect they experience, the lower their self esteem
They are more likely than their classmates to experience symptoms of depression
They have difficulty interpreting emotions, such as anger or sadness
They may also experience more mood swings than would be expected for their age, or show levels of affection towards others, which are inappropriate for the situation

36. Emotional or self-perception issues
Worthless to others
What happens is beyond their control
Anxiety and helplessness
Fewer effective coping skills
Angry, or restrict their emotional displays
Consider suicide
. Many of these children give up on tasks before they have even started, because they simply do not see the point in trying
When they become upset they are less likely to distract themselves through play, or talk it over with someone else
Neglected children may see themselves as being worthless to others
They often believe that what happens is beyond their control, which leads to anxiety and helplessness to do anything to improve their situation
They have fewer effective coping skills than other children. They may become angry, or restrict their emotional displays
Some children may think about, plan or attempt suicide

37. School performance Poor performance in school Poor attendance
Difficulty carrying out complex task
Lower IQ than their classmates
May be better at problem solving, planning and abstract thinking
, particularly when they are required to understand and follow instructions that involve visual and motor integration; this was tested by asking the children to trace geometric shapes of increasing difficulty against the clock.
They often have more difficulty than their classmates carrying out complex tasks
They are likely to have a lower IQ than their classmates, although results of literacy or numeracy assessments varied across studies
Despite poor performance in some areas, neglected children may be better at problem solving, planning and abstract thinking than other children

38. Relationships with parents
Family members lonely
Little exchange of information
Lack of emotional warmth
Parents are more negative
Make demands of their children
Children come to expect less support from their mothers
One study of neglected children showed that:
Living in the family can be lonely for both parent and child because there is little exchange of information, and there may be a lack of emotional warmth between them
Some parents are more negative in comparison to non-neglecting parents
The parents may make more demands of their children, and are unlikely to respond to requests from their children for support. Neglected children come to expect less support from their mothers, in comparison to non-neglected children

39. Implications Early recognition vital Recovery potential
1st year Significant
2nd year Some recovery
3rd year Less recovery
4th year No change (need school support and public funding)
Long term consequences significant for health education and social care
Bruse perry

40. Challenges
Once children are showing the signs of neglect we have missed the oppourtunity to prevent significant harm thus need to act quickly
Waiting until the harm has happened means life long consequences for these children
Need to identify those families at risk and improve assessments of parents ability to nurture their child
Work intensively for limited period but child’s time frame is SHORT
To maximize child's potential need to remove early

41. Summary Early neglect causes long term irreparable brain ‘damage’
Features in child are on a continuum
Neglect more damaging than a single episode of physical harm but physical harm still triggers a response when neglect does not
Health need to work intensively with families at risk
Children's services need to become involved early
The legal system need to understand the urgency in managing neglect

42. References
‘Family Law and the Neuroscience of attachment, Part 1, Allan Schore & Jennifer Mcintosh, Family Court Review, Vol 49 No 3, 2011
Child protection companion 2013: Royal college of paediatrics and child health
Welsh systematic reviews