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

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

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

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

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

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

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.

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

Parent-infant interaction .

Still face experiment Still face

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

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

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.

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

Positive interaction cycle serve and return Responsiveness

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

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

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

Stress!

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

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

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

Presentation of child

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

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

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

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

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

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

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. 

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

School age

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

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

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

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

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

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

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

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

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

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 http://www.core-info.cardiff.ac.uk