1. Neglect, Resilience and Resistance Patrick Ayre Department of Applied Social Studies University of Bedfordshire Park Square, Luton email: pga@patrickayre.co.uk web: http://patrickayre.co.uk

2. NEGLECT 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.

3. NEGLECT 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.

4. NEGLECT 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.

5. NEGLECT 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.

6. NEGLECT 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.

7. NEGLECT 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!!....

8. NEGLECT 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!

9. NEGLECT 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!!....

10. Brain development At birth our brains are only 25% developed By age 3, a child’s brain has reached almost 90% of its adult size and has accomplished 80% of its total development. The growth in each region of the brain largely depends on receiving stimulation. This stimulation provides the foundation for learning.

11. 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”

15. 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.

16. 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)

17. Emotional development Sensitive period for emotional development: up to 18 months Shaped primarily by the way in which the prime carer interacts with the child Emotional deficits harder to overcome once the sensitive window has passed. How often do we intervene assertively at this point?

18. Building a child Building a child is like building a house, each new level built on the one below. If the lower levels are unsound, no amount of tinkering with the upper floors will make it stable.

19. Checkpoint 1: timing intervention If we wait until we can see the evidence of neglect in a child’s behaviour, it may be too late to put it right completely.

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

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

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

23. 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)

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

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

26. 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

27. 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)

28. 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

29. 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.

30. 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.

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

32. 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

33. 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

34. 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

35. 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’

36. 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

37. 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)

38. 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

39. 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

40. 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

41. 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?)

42. 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.

43. 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

44. 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

45. 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

46. Checkpoint 2: case management How should we manage cases of: Emotional Neglect Disorganised neglect Depressed neglect Severe deprivation

47. 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

48. 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.

49. 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)

50. 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.

51. 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.

52. 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.

53. 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

54. 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

55. 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

56. The pattern of neglect: atypical

57. The pattern of neglect

61. Cumulativeness

62. Failure of cumulativeness

63. 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 (case, agency and geographical)

64. 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

65. 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)

66. 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

67. 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?)

68. 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’

69. 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’

70. 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.

71. The chain of reasoning Facts  Analysis/summary  Conclusions/recommendations/action

72. 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)

73. 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)

74. 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.

75. 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?

76. Checkpoint 3: So what? We have spent some time considering how to recognise and respond to neglect. What does this mean for us? What are the implications for local services? What, if anything, will be different?

77. Why do some sink and some swim? Why do some children thrive in situations of grave adversity, whilst others are severely damaged? What can we to promote the first outcome and avoid the second? Part of the answer lies in the concept of RESILIENCE ‘Normal development under difficult conditions’ (Fonagy et al 1994)

78. Seven characteristics Personal anchors Cognitive competence Success Active coping Positive temperament Social climate open and supportive, in home and out Additional support http://content.iriss.org.uk/fosteringresilience/

79. Individual level Benard, 1996

80. Environmental level Benard, 1996

81. Blending demand and support DemandingUndemanding ResponsiveAuthoritativeIndulgent UnresponsiveAuthoritarianNeglectful

82. Neglectful parenting DemandingUndemanding Responsive  Unresponsive  Neglectful

83. Authoritarian parenting DemandingUndemanding Responsive  UnresponsiveAuthoritarian

84. Indulgent parenting DemandingUndemanding Responsive  Indulgent Unresponsive

85. Good parenting DemandingUndemanding ResponsiveOptimal Unresponsive

86. Three building blocks A secure base Good self esteem Self-efficacy or a sense of mastery and control Daniel, B. and Wassell, S. (2002) Assessing and Promoting Resilience in Vulnerable Children, London, Jessica Kingsley Publishers.

88. Secure base Individual: Does the child appear to feel secure? Family: Do the child’s carers provide a secure base? Community: What wider resources contribute to child’s attachment networks?

89. Education Individual: Does the child show curiosity and interest in learning, school or college? Family: Do carers facilitate learning? Community: What wider support is there for learning?

90. Friendships Individual: What characteristics does the child have that help to facilitate making and keeping friends? Family: Do carers support the development of friendships? Community: What are the child’s friendships currently like?

91. Talents and interests Individual: What talents or interests? Family: Do carers encourage? Community: What resources are there for nurturing talents and interests?

92. Positive values Individual: Level of moral reasoning; understanding of own feelings and empathy with others? Family: What level of helpful behaviour does the child show? Community: What level of pro-social behaviour does the child show?

93. Social competencies Individual: Do the child’s personal characteristics contribute to social competence? Family: Do carers encourage social competence? Community: What opportunities are there for developing social competence?

94. Resilience matrix in assessment

95. Checkpoint 4: Resilience Three things I will do to improve the way I and colleagues work with resilience at the child, family or community level.

96. 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 paralyzing 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

97. 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

98. 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.

99. 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.

100. 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)

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

102. 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!

103. 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 )

104. 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 )

105. 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 )

106. 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

107. 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)

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

109. 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)

110. 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)

111. 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)

112. Checkpoint 5: Resistance I am good at working with resistance because… I could be better at working with resistance because…

113. 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)

114. Bonus material

115. A scale for assessing motivation 1. Shows concern and has realistic confidence. 2. Shows concern, but lacks confidence. 3. Seems concerned, but impulsive or careless 4. Indifferent or apathetic about problems 5. Rejection of parental role.

116. 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.

117. 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.

118. 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.

119. 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.

120. 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)