1. Placing the Graded Care Profile in a wider strategy for the assessment of neglect Patrick Ayre Department of Applied Social Studies University of Bedfordshire Park Square, Luton email: pga@patrickayre.co.uk web: http://patrickayre.co.uk

2. A wider strategy The Graded Care Profile is an excellent tool to help us to identify when neglect is present. But then what? Spotting neglect has to be a good start, but our aim must be to try to change things and we cannot hope to do this unless we understand why the carers are neglecting their children in the first place. A one-size-fits-all approach just does not work for neglect, and I would suggest to you that, at present, most of us waste about 85% of all the resources devoted to neglect because we simply do not understand this.

3. 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

4. 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)

5. 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

6. Emotional neglect: parents Can’t cope with children’s 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.

7. Emotional neglect: children When attachment behaviour rejected: Learns that caregiver’s 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.

8. Emotional neglect: children Frightened, unhappy, anxious, low self- esteem Withdrawn, isolated, fear intimacy and dependence Precocious, ‘streetwise’, self-reliant

9. 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

10. 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

11. 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 family’s immediate needs

12. 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

13. 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’

14. 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

15. 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.

16. 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)

17. 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)

18. 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

19. Depressed neglect: carers Listless and unresponsive to children’s 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

20. 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 don’t cry or laugh At school: isolated, aimless, lacking in concentration, drive, confidence and self-esteem but do not show anti-social behaviour

21. Depressed neglect: case management These families need: Long term involvement Supportive approach Responsiveness to family’s signals and needs BUT these need to be balanced with a recognition of the children’s needs. (How long is too long? How much is too much?)

22. Depressed neglect: case management Our standard approaches don’t work Threats / punitive approaches particularly ineffective: –Parents don’t believe they can change so don’t 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.

23. 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.

24. 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.

25. 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 child’s responsiveness will increase; virtuous spiral

26. 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

27. 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

28. Severe deprivation: case management Highly unlikely to be in the child’s 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.

29. Checkpoint: case management Do ww have the knowledge and resources to recognise and work with: Emotional Neglect Disorganised neglect Depressed neglect Severe deprivation What do I need to do about it?

30. Putting it all together: The chain of reasoning in assessment Facts  Analysis/summary  Conclusions/recommendations/action

31. The chain of recording What happened/what you saw  What this means  What you did/what should be done (and why, if this is not clear from the above)

32. The chain of recording But how do you know which facts? Must be informed by a basic risk assessment (would not always be spelled out on paper)

33. 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.

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

35. 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

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

37. Incomplete or out of date

39. Can you trust a snapshot?

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

41. 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)

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

43. Assessment pitfalls Rule of optimism Natural love Cultural relativism Too much not enough Adult services and children’s services (hand-in-hand or hand-to-hand?)

44. Children’s services and adult services Working on the same case but not working jointly Mutual incomprehension and misunderstanding False expectations and assumptions Abdicating responsibility Need for ‘interpreters’

45. Information handling pitfalls Keeping your head down Hesitancy to challenge other professionals or the conventional wisdom Tendency to move from facts to actions without ‘showing your working’

46. Challenge your dodgy thinking I am only a… and he is a…, so I had better keep my opinion to myself. I am obviously in a minority, so I had better keep my opinion to myself. We need to maintain harmonious relations, so I had better keep my opinion to myself.

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

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

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

50. Conclusions and recommendations Problems: Unsupported assertions or judgements Inability or unwillingness to analyse and draw conclusions Failure to answer the key question: ‘So what?’

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

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

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

54. Spotting the bad ones: Organisational Clues Mythology exists about the family – ‘this family is/always/behaves like Negative stereotypes about other agencies exist so their information is discounted Sudden changes about view of risk not explained Sudden changes of plan not rationally explained

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

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

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

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