Child neglect: what we know and to where we might go

Abstract

Neglect is the most common form of child maltreatment, responsible for the death of thousands of children every year. Research has provided evidence on risk factors increasing the likelihood of the occurrence of neglect, on its effects on child development, and on promising prevention and intervention strategies. However, the definition of neglect is constantly under development due to its dynamic and multi-factorial nature; many cases of child neglect still remain undiagnosed and thousand others unreported; effective prevention and intervention strategies need to be tested with different populations and in other contexts; and research on the mechanisms of resilience from neglect are understudied. All these limitations in our understanding of the phenomenon of child neglect make research, clinical practice and policy-making a requiring task. In this context, future directions for research are discussed.

Introduction

It may sound ironic, but child neglect is systematically neglected by scientists, policy makers and the general public, worldwide.[Browne and Lynch 1998, Glaser 2002]. At the same time, other types of child maltreatment, such as sexual abuse, present a systematic increase in the attention they attract, as is clear by the increasing number of published research on this issue.[Behl et al. 2003] Yet, the majority of published research on child neglect has been carried out in the United Kingdom and the USA, while little is known about child neglect in other countries and continents.

Definitions, characteristics and types of child neglect

Child neglect definitions are constantly under development,[Zuravin 2001] often contemplate its severity and course, are influenced by factors related to the victim, the perpetrator, and their environments, and are associated with the observer’s identity. The process of defining child neglect also reflects the fact that neglect is largely about omissions, not acts. Also, it is not directly observable, but inferred from observations of the child’s general condition, his/her environment, and his/her interaction with primary caregivers, among others. Furthermore, it is noteworthy that definitions of child neglect often differ among distinct communities, depending on locally accepted norms of social behavior.[Roditti 2005]

A commonly accepted definition describes neglect as the failure of the adult caregiver to satisfy the child’s basic needs, which are necessary for healthy physical, mental and emotional development.[Straus and Kantor 2005] A child’s basic needs are considered to be the provision of appropriate and sufficient food, clothing, shelter, and medical care, appropriate surveillance and protection against all dangers. However, professionals should bear in mind that neglectful parents are often unaware of their child’s unmet needs, or the degree to which this may be dangerous for their child’s health.[Perry et al. 2002]

Child neglect is usually distinguished into physical, emotional, medical and educational neglect. However, relevant literature has also reported on more specific types of neglect, such as prenatal and community neglect.[Polonko 2006] Among all types of child neglect, physical neglect has been more widely recognised and studied. Emotional neglect has also attracted some attention, and it was well described by the American Humane Association[2011] as a passive or passive/aggressive deprivation of attention concerning a child’s emotional needs and emotional welfare. In research, emotional neglect is often defined as the caregiver’s lack of emotional availability and insensitivity in relation to emotional and communicative signals offered by the child.

Although the research community has agreed on some working definitions for child neglect, many questions concerning its nature remain unanswered. What is appropriate and what is inappropriate in the conditions of sheltering and food provision? When the caretaker is unable to satisfy a child’s basic needs due to socioeconomic difficulties, should we still consider the diagnosis of neglect? Or should the diagnosis of neglect be decided only in the case of a caregiver voluntarily depriving the child from what is considered basic for his/her healthy development? Should the diagnosis of neglect be given only in the case of children already suffering the consequences of neglect, or may children at risk of neglect also receive the diagnosis? Is it viable to decide on one, universally accepted, definition of neglect, considering the reality of such a culturally variable globe? More research is certainly needed in order to provide answers to such fundamental questions.

Epidemiology of child neglect

Child neglect is the most common form of child maltreatment.[American Human Association 2011, US Department of Health and Human Services 2010]. In the United States, the number of children suffering neglect is greater than the number of children suffering physical and/or sexual abuse.[Child Welfare Information Gateway 2001]. For example, in 2007, 59% of the estimated 794.000 victims of maltreatment were neglect cases [US Department of Health and Human Services 2010]. Adding to the already large number of neglect cases, are estimates that less than 1/3 of child neglect cases are reported to Child Protective Services (CPS),[Sedlak and Broadhurst 1996] and 50 to 60% of child fatalities resulting from neglect are not recorded. [Crume et al. 2002]

The duration of child neglect may be short and temporary, or chronic; and its severity may differ significantly from case to case, sometimes resulting in death. The US Department of Health and Human Services,[2003] for example, has reported that child neglect is responsible for 35.6% of child fatalities, resulting after maltreatment, when the respective number for child abuse was 26.3%. Similarly, in Finland, the majority of infanticides are due to neglect.[Putkonen et al. 2007]

Child neglect often co-occurs with other types of child maltreatment,[Dong et al. 2004, Rodgers et al. 2004] while its co-occurrence with household dysfunction is also common.[Dong et al. 2003] The identification of co-occurring forms of maltreatment is particularly important considering that the effect of each form of maltreatment functions cumulatively on child’s development – that is, the more the child is subjected to different forms of maltreatment, the more the adverse effects on his/her development are.

Concerning the relation between child neglect, child’s sex and age group, findings are yet inconclusive. For example, Kaplan et al.,[1999] have reported that the frequency of child physical and emotional neglect is the same for girls and boys, although its distribution seems to differ for different age groups. Particularly, the greatest number of cases of neglect referred to children from six to eight years old. On the other hand, a study by Margolin[1990] carried out in the US showed that the most common profile of victims of child neglect resulting in death was: being a boy, under the age of three, and living in a house with more than two or three siblings. Yet, in the United Kingdom, it has been reported that boys are less likely to receive appropriate surveillance than girls, while girls are more likely to be subjected to emotional neglect than boys.[Cawson et al. 2000]

The alarming number of child neglect cases requires immediate attention from the scientific community, policy-makers and civil society. Coordinated action against child neglect must include new evidence-based policies and further research on the peculiarities of this multi-factorial phenomenon, which is responsible for the death of thousands of children every year. In addition, assigned research in regions for which there is lack of knowledge on the epidemiology and further characteristics of child neglect is necessary.

Diagnosis of child neglect

The diagnosis of child neglect is not an easy task. This is because neglect is a multi-factorial phenomenon and its understanding requires the consideration of a number of child, family and environmental factors; for instance, the child’s characteristics (e.g. temperament, developmental milestones), medical history, developmental stage and course of development; also, the parents’ life and medical history, family structure and household function; and, finally, the environment’s characteristics (e.g. violent neighbourhood, lack of basic goods such as sanitation, limited number of rooms for a large family). The involvement of so many factors in the diagnosis of child neglect makes the cooperation between professionals from different scientific backgrounds paramount; sharing of expertise and findings, as well as joint decisions on intervention strategy are also essential.

As already stated, neglect more often than not refers to omissions, and not to acts. Thus, its diagnosis is principally based on clinical observations of a child’s general condition and parent-child interaction, on reports from third persons, or on a child’s medical record review of frequent accidental injuries. Most substantiated cases of neglect are diagnosed by general hospital doctors and professionals working in child protection services. These professionals often base their diagnosis of neglect on the International Classification of Diseases and Related Health problems (ICD) system, developed by the World Health Organization.[1992] However, ICD is a statistical classification and professionals are required to follow a set of strict rules before applying any code. In the case of maltreatment, there must be unambiguous clinical evidence of maltreatment for the relevant code to be applied. If maltreatment is not substantiated by available clinical evidence and/or further investigation is needed to conclude whether there is maltreatment or not, the coder cannot apply a definitive maltreatment code. Instead codes indicating possible maltreatment or problems resulting from previous suspected maltreatment may be applied; even so, many maltreatment cases are missed due to the ICD’s inflexible codification rules. The lack of sensitivity of the ICD system has motivated attempts to identify cases of maltreatment by using other complementary sources of data; yet, many maltreatment cases remain unidentified urging further research on non-fatal child maltreatment surveillance schemes.

In this context, and in order to provide more validity and reliability to the diagnostic process of child neglect and maltreatment in general, some standardised assessment measures have been developed. Most of them assess adequacy of parenting and establish the minimal parenting standards, which, if not met, constitute evidence of neglect. Some examples of such standardised measures are the Neglect Scale,[Kaufman et al. 1994, McGee et al. 1995] the Child Well-Being Scales,[Magura and Moses 1987] the Family Functioning Style Scale,[Deal et al. 1988] and the Home Observation for Measure of the Environment.[Caldwell and Bradley 2001, Totsika and Sylva 2004] There has also been an interesting study which investigated the perceptions of British Health Visitors concerning which factors usually help them to decide whether a particular family has child neglect issues.[Lewin and Herron 2007] The first ten characteristics pointed out were: a) violence against the child, b) exclusion of the child from family activities, c) inappropriate or insufficient child surveillance, d) domestic violence, e) family atmosphere characterised by critical attitude, rejection and lack of sensitivity and warmness, f) unsafe environment, g) lack or very low availability of food, h) parents had experienced maltreatment during their childhood, and i) insufficient medical care due to parental negligence. Studies registering health professionals’ perceptions, clinical practices and experiences are extremely important, as they may well inform future research on child neglect diagnostic tools and strategies.

Risk and protective factors

Studies have associated a number of risk factors with child neglect. Risk factors may be grouped in four domains: a) caregiver factors, b) child factors, c) family factors, and d) environmental factors. Some examples of risk factors associated with child neglect are parental immaturity, marital conflict, alcoholism and substance abuse, unemployment, financial difficulties, limited social support, parental mental disorder, and single-parent family.[Kolko et al. 1993, Ney et al. 1992, Paavilainen et al. 2001] Special interest has been shown in the indirect effects of financial insecurity on caregivers, such as anxiety, social exclusion, adolescent pregnancy, residency in dangerous neighbourhoods, etc. These adverse effects on caregivers, in turn, have been associated with an increased likelihood for child neglect.[Coulton et al. 1995]

Although risk research has already provided important information on the net of factors associated with child neglect, many issues remain to be disentangled. For example, there is a lack of studies on how child, caregiver and community factors interact with each other and influence the likelihood of child neglect and/or the effectiveness of prevention and intervention programs. Furthermore, the constantly increasing number of people concentrating in urban centers, the consolidation of new forms of family structure and the increased mobility of the workforce, which promotes cultural mingling, are factors that have not been studied in relation to child neglect and child maltreatment, in general; more research is needed towards this direction.

An important part of risk research is the identification of protective factors, which are related to resilience. When protective factors, such as a good relationship with at least one of the parents or another adult available to offer security and emotional warmth to the child, an earlier satisfying family atmosphere and experience, the characteristics of the child (e.g. temperament) and the general level of the child’s life structure, are present, there is a good chance for the child to overcome the adverse effects of neglect and to proceed to healthy development. For example, a retrospective study which investigated resilience in 676 substantiated cases of child abuse and neglect when the children were adults, showed that 22% of participants who had been maltreated as children met the criteria for resilience; more females were resilient than males.[McGloin and Widom 2001] Research on the mechanisms of resilience would inform prevention and intervention strategies for child maltreatment and, in particular, neglect.

Finally, it should also be underlined that there is a vast field for further research on the interaction between risk and protective factors, and their interaction with child, caregiver and environmental characteristics. Longitudinal studies are needed towards this direction.

Effects of neglect on child’s development

A developing child needs the support of its environment to unfold its full developmental potential and to successfully manage the many challenges of the developmental process. One’s family may be the context in which s/he will learn to trust others, to develop the perception that s/he is worthy of love, to feel secure in order to encounter all new experiences as well as to overcome difficulties. The family also constitutes the context in which basic needs for survival will be fulfilled, preventing in this way illness, organic deficiencies and disabilities. Thus, child neglect, which is more often than not an intra-family phenomenon, threatens to adversely affect this very paramount process for child’s development, namely, the formation of trusting, early relationships which are usually formed in one’s (either nuclear or extended) family.

Chronic neglect occurring early in life may adversely affect neuro-developmental processes;[Perry 2002] while in some cases it may lead to the syndrome of non-organic failure-to-thrive, or result in the child's death. Yet, even in the case of less severe neglect in infancy, its effects on later development may be long-lasting and difficult to revert. Neglect during infancy is associated with insecure attachment, but only when the mother is the perpetrator;[Erickson et al. 1989] experience of neglect makes it more difficult for children to trust others, which in its turn negatively affects the development of social skills and consequently, increases the likelihood of difficulties in interpersonal relationships throughout life.[Peretti et al. 1998, Veltman and Browne 2001] It is well evidenced that problems in forming satisfying interpersonal relationships may lead to low self-esteem, depression and anxiety.

Child neglect has also been found to have adverse effects on cognitive development as well. A recent study compared children, three to 10 years old, who had a history of familial neglect with children who had received institutional rearing and others without a history of neglect.[Spratt EG et al. 2012] Both, children with a history of neglect and those who had received institutional care, showed lower cognitive and language scores and more behavioural problems than children with no history of neglect. In addition, children with a history of familial neglect were more likely to show internalising and externalising behavioural problems than the other two groups of children. Moreover, child victims of neglect have evidenced poorer academic performance than matched maltreatment victims,[Kurtz et al. 1993] and more suspensions, grade repetitions and disciplinary referrals.[Kendall-Tackett and Eckenrode 1996] Both abuse and neglect have also been associated independently with impaired cognition and academic functioning in 14-year-old adolescents.[Mills et al. 2011]

Children victims of neglect are often found to present psychopathological behaviours and/or mental disorders. Egeland and Erickson[1999] reported that two-year-old victims of neglect exhibit more anger, aggression, frustration, non-compliance, and express less enthusiasm and contentment as compared to non-neglected children. In childhood, aggressive and antisocial behaviour is sometimes expressed as behaviour disturbance and oppositional defiant disorder.[Fergusson et al. 1996, Flisher et al. 1997]. Actually, children victims of neglect from five to 10 years old have been found to present high rates of attention deficit hyperactivity disorder, oppositional defiant disorder and posttraumatic stress disorder.[Famularo et al. 1992]

Thus, it has been very well substantiated that child neglect may have severe, long-lasting effects on a child’s development. However, neglect’s influence on a child’s development is not always an easy equation to solve. It seems that factors such as neglect’s severity and frequency, the child’s characteristics (e.g. developmental stage, temperament) and the environment’s characteristics (e.g. family’s socioeconomic conditions, neighbourhood’s characteristics) play an important role in whether a child will be adversely affected by neglect, whether s/he will only temporarily present adverse outcomes, or whether s/he will even be resilient. The mediating role of the aforementioned factors on the relationship between child neglect and child development remain yet to be evidenced. Well validated causal models concerning the effects of child neglect on development are also lacking. More longitudinal studies, including large and homogeneous samples, may be able to give answers to such questions.

Prevention and intervention

By reviewing literature on prevention and intervention programs, one may conclude that there are relatively more treatment outcome studies with families at-risk for future maltreatment, than families already referred for child abuse and neglect. In each case, however, of either prevention or intervention, the program to be applied must be tailored to the type of neglect and to the results of the assessment carried out with the child and his/her family. DePanfilis[2006] stated that professionals intending to intervene in a family due to children’s unmet needs should: a) have an ecological-developmental framework, b) understand the importance of outreach and community, c) carry out a comprehensive family assessment, d) establish a helping alliance and partnership with the family, e) utilise an empowerment-based practice, f) emphasise family strengths, g) develop cultural competence, and h) ensure developmental appropriateness. After having met the aforementioned requirements, the next step may be to decide on the intervention program. Dubowitz and Poole[2012] suggest that, although the circumstances vary from case to case, the decision on the intervention must follow certain core principles: a) to address the contributors to the problem, b) to forge a helping alliance with the family, c) to establish clear achievable goals and strategies for reaching them with the family, d) to carefully monitor the situation and adjust the plan if necessary, e) to address the specific needs of neglected children and those of other children in the home, and f) to ensure that interventions are coordinated with good collaboration among the professionals involved.

Intervention and prevention programs for child neglect may be child-centred, parent-centred or family-centred; sometimes, a selective use of all three categories may be appropriate. For families who are at risk for child neglect, the use of formal and informal community services, social support networks or law enforcement (in the case of severe risk) may be effective, as well as the involvement of schools, faith-institutions or other local communities.

In this context, a considerable number of prevention programs for child neglect has been developed and tested, some of which have been proven promising. Particularly, home visitation programs, especially those carried out by trained professionals who accompany the family prenatally and after birth, seem to be effective. [Olds 2007] Positive outcomes were also achieved with parenting programs, such as the Triple P intervention,[Prinz et al. 2009] or programs such as Family Connections,[DePanfilis and Dubowitz 2005] which were designed to enhance protective factors and reduce risk factors in families at-risk for child neglect. Other prevention programs have focused on strengthening the relationship between primary health professionals and family, such as Safe Environment for Every Kid (SEEK).[Dubowitz et al. 2009] Finally, Parent-Child Interaction Therapy (PCIT)[Eyberg and Matarazzo 1980] has also been tested as a means to reduce child behavioral problems and other parent and child factors associated to maltreatment, with promising results.[Chaffin et al. 2004, Eyberg et al. 2001, Hood and Eyberg 2003]

Apart from prevention, several intervention programs targeting families which have already neglected children have been developed. The principal aim of such intervention programs is to either decrease the likelihood of recidivism or reduce the adverse outcomes of neglect on child development. A number of such interventions are based on the cognitive-behavioural approach and use behaviour modification techniques in individual therapy sessions with caregivers who have neglected their children. Other individual interventions include mental health inpatient and outpatient counselling, crisis intervention, stress management or play therapy. The already mentioned PCIT[Eyberg and Matarazzo 1980] has also been applied to families with a history of abuse, neglect and child behavioural problems with promising results. Finally, structured programs for child neglect intervention including a mixture of selected techniques originating from various theoretical backgrounds have been developed, such as the STEEP (Steps Towards Effective, Enjoyable Parenting) project[Egeland and Erickson 1993, Erickson et al. 2009] and the SafeCare program.[Gershater-Molko et al. 2002]

Future research – conclusions

Child maltreatment, and child neglect in particular, is a major public health issue. Millions of children are subjected to maltreatment every year, and thousands die because of it.

Indicatively, in 2008, US Children Protection Services estimated that 772,000 children were victims of maltreatment, of which 71% were victims of neglect.[Centers for Disease Control and Prevention 2010] With such high incidence, child maltreatment constitutes not only a health problem, but also a serious financial issue for modern societies. Wang and Holton[2007] reported that child maltreatment costs the USA more than 100 billion dollars a year; much of this is for neglect. Thus, one may conclude that its prevention may prove to be great value for money.

However, due to child neglect’s multi-factorial nature, the influence of culture on its definition, as well as the novel forms of child neglect that modern life entails, a coordinated action from all sectors of society is necessary in order to fight it effectively. The scientific community, policy-makers and broader society must cooperate to limit the increasing number of child neglect cases. Prevention and intervention models involving not only health professionals and child protection services, but also local communities must be developed and methodically tested with different populations and in various contexts. Then, good practices arising from clinical research should inform national action plans against child maltreatment.

Meanwhile, assigned research in regions for which there is lack of knowledge on the epidemiology and other characteristics of child neglect is crucial. An example of such regionally-focused research on child maltreatment is the BECAN program (Balkan Epidemiological Study on Child Abuse and Neglect), which by the end of 2012 will provide for the first time systematically gathered information on the situation of child maltreatment in the Balkan countries.[Νikolaidis et al. 2010]

Risk research on child neglect is another direction that future studies should consider. More longitudinal studies examining the interactions between risk and protective factors on one hand, and child, family and community characteristics on the other, are needed. In addition, the mediating role of all aforementioned factors in the relationship between neglect and child development remain yet to be evidenced. Of special importance in this context is research on the mechanisms of resilience in child neglect victims. The making of a resilience framework for child neglect could inform clinical practice and policy-making concerning prevention of child neglect.

Last, but not least, comes a reminder concerning a large population almost forgotten: the suspected millions of children with developmental disabilities, mental health and/or behavioural problems who are victims of maltreatment. Maltreatment against these populations may take place in the home, foster care institutions, foster families, detention centers for minors, refugee camps and schools, among others. We usually address the most apparent condition characterising these children (e.g. being a refugee, being a prisoner, being an autistic child, having learning difficulties, etc.) and we forget other important parameters of their well-being and healthy development; sometimes their most obvious condition may even be the symptom of our neglectful care of them.

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