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Dr Sarah Steel and Dr Sarah Maxwell. Objectives What is neglect? The impact on the developing brain Attachment How do children present? Long term consequences.

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Presentation on theme: "Dr Sarah Steel and Dr Sarah Maxwell. Objectives What is neglect? The impact on the developing brain Attachment How do children present? Long term consequences."— Presentation transcript:

1 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: 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

5 What is the impact of neglect on child development?

6 Structural brain differences

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

8 Anatomy of brain

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


14 Child responds positively Parent initiates positive interactions with the child Self worth Self esteem The positive interaction cycle 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

17 Gender implications Typically mothers are calming and fathers more arousing and energetic Suggests contact with parents may be important at different times 1 st year Mum and 2 nd year Dad? Mother essential for fear regulation in 1 st year and father for aggression regulation later Implications for contact decisions? Night time contact?

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



23 Presentation of child

24 Core–info: Cardiff child protection systematic reviews Systematic review 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

25 Features in the child Preschool 0-20 months (7 studies,349 cases,237 controls) months (3 studies, 125 cases, 113 contols) 3-4 years (4 studies, 86 cases, 125 controls) DescriptionAvoidant 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

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

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’

28 Toddler Head banging, rocking, bad temper ‘Violent’, clingy Overactive-apathetic, noisy to quiet Immobile and silent Developmental delay Language delay Poor social skills

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) DescriptionLanguage 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

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.

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

34 Relationships with other children: Difficulty with friendships Problems socialising, Few friends Perceived 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

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

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

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

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

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

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