Understanding and assessing neglect

Understanding and assessing neglect
Patrick Ayre Department of Applied Social Studies University of Bedfordshire Park Square, Luton web:

Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s 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 child’s basic emotional needs.

Parents who neglect their children basically just don’t 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.

Parents who neglect their children basically just don’t 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!!....

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!

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!!.... The damage is not on the surface, it often runs quite deep and we need to understand how it got there in order to put it right. Painful though it is, we need to understand what it does to you to be neglected.

Brain development By the age of 3, a baby’s 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.

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”

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.

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)

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

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

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

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)

The child's basic needs basic physical care affection security stimulation of innate potential guidance and control responsibility independence

Why do parents neglect? We need to understand the interaction between: 3 Ns: Nurture, Nature, Now Circumstantial factors and fundamental factors

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

Forms of neglect Understanding and assessing 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)

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

Emotional neglect: parents
Understanding and assessing neglect 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.

Emotional neglect: children
Understanding and assessing neglect 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.

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

Understanding and assessing neglect 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

Emotional neglect: case management
Understanding and assessing neglect 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

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

Disorganised neglect: carers
Understanding and assessing neglect 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

Disorganised neglect: carers
Understanding and assessing neglect 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’

Disorganised neglect: children
Understanding and assessing neglect 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

Disorganised neglect: case management
Understanding and assessing neglect 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.

Disorganised neglect: case management
Understanding and assessing neglect 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)

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)

Depressed neglect: carers
Understanding and assessing neglect 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 It is a personality trait marked by a pervasive pattern of negative attitudes and passive, usually disavowed resistance in interpersonal or occupational situations. It can manifest itself as learned helplessness, procrastination, stubbornness, resentment, sullenness, or deliberate/repeated failure to accomplish requested tasks for which one is (often explicitly) responsible. It is a defense mechanism, and usually only partly conscious.

Depressed neglect: carers
Understanding and assessing neglect 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

Depressed neglect: children
Understanding and assessing neglect 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

Depressed neglect: case management
Understanding and assessing neglect 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.

Understanding and assessing neglect 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.

Understanding and assessing neglect 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?)

Depressed neglect: infants and children
Understanding and assessing neglect 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.

Depressed neglect: parents
Understanding and assessing neglect 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

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

Severe deprivation: children
Understanding and assessing neglect 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

Severe deprivation: case management
Understanding and assessing neglect 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.

Capturing chronic abuse
Understanding and assessing neglect 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

Our image of assessment
Understanding and assessing neglect Our image of assessment

The reality of assessment?
Understanding and assessing neglect The reality of assessment?

Capturing chronic abuse
Understanding and assessing neglect 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

The pattern of neglect

Cumulativeness Child protection system is triggered when threshold of likely significant harm has been crossed. Physical and sexual abuse, where a serious precipitating incident comes to light which clearly crosses the threshold at once. Many chronic cases may be characterised by a lengthy pattern of actions or incidents, none of which is in itself sufficient to trigger intervention. They have to get added together like this

Failure of cumulativeness
Understanding and assessing neglect Failure of cumulativeness

What’s 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 Three principle reasons for this failure of cumulativeness. The first is that the incidents giving rise to concern may lie scattered through the relevant files, recorded and responded to separately with no one making cumulative connections between them. They may lie unshared on the files of a variety of different interested agencies or unremarked within the files of a single agency. Picked up and put down Many 'duty worker' and 'team responsibility' systems may be prone to this failing. The notion of proportionality: uncomfortable about invoking the full might of the system over a 'minor' incident, even where this incident is just one of a very worrying series. Acclimatised to unacceptably low standards, typified by remarks such as 'What can you expect from this family?' or 'That's the way they are; they've always been the same'. Conditions likely to cause significant harm come to be regarded as the norm and all future incidents come to be judged against this depressed standard with the result that incidents have to be increasingly bad to be identified as causing concern at all and the cumulative effect on the child is overlooked.

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

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)

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, , HMSO, London

Information handling

Serious Case Reviews Understanding and assessing neglect 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

So what? Understanding and assessing neglect 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 Hampshire? What, if anything, will be different?

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

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”

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.

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.

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)

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

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!

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 )

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 )

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 )

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

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)

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

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

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)

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)

Confrontation In child welfare services, the Children’s 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)

A scale for assessing motivation
Understanding and assessing neglect 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.

Shows concern and has realistic confidence.
Understanding and assessing neglect Shows concern and has realistic confidence. Parent is concerned about children’s 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.

Shows concern, but lacks confidence
Understanding and assessing neglect Shows concern, but lacks confidence Parent is concerned about children’s 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.

Seems concerned, but impulsive or careless
Understanding and assessing neglect Seems concerned, but impulsive or careless Parent seems concerned about children’s 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.

Indifferent or apathetic about problems
Understanding and assessing neglect Indifferent or apathetic about problems Parent is not concerned enough about children’s needs to resist ‘temptations’, eg competing demands on time and money. This leads to one or more of the children’s 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.

Rejection of parental role
Understanding and assessing neglect 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 isn’t his or her ‘job’. May seek to give up the responsibility for children (Magura et al,1987)

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