Understanding and assessing neglect
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Understanding and assessing neglect. Patrick Ayre Department of Applied Social Studies University of Bedfordshire Park Square, Luton email: [email protected] web: http://patrickayre.co.uk. NEGLECT.

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Understanding and assessing neglect

Understanding and assessing neglect

Patrick Ayre

Department of Applied Social Studies

University of Bedfordshire

Park Square, Luton

email: [email protected]

web: http://patrickayre.co.uk


Understanding and assessing neglect

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.


Understanding and assessing neglect

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.


Understanding and assessing neglect

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.


Understanding and assessing neglect

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.


Understanding and assessing neglect

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.


Understanding and assessing neglect

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!!....


Understanding and assessing neglect

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!


Understanding and assessing neglect

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!!....


Brain development

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

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

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

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)


Neglect

Neglect

Behavioural

  • Constant hunger

  • Constant tiredness

  • Frequent lateness or non-attendance at school

  • Destructive tendencies


Neglect1

Neglect

  • Low self-esteem

  • Neurotic behaviour

  • No social relationships

  • Running away

  • Compulsive stealing or scavenging


Neglect2

Neglect

Physical

  • Poor personal hygiene

  • Poor state of clothing

  • Emaciation, pot belly, short stature

  • Poor skin and hair tone

  • Untreated medical problems


Significant harm

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

The child's basic needs

  • basic physical care

  • affection

  • security

  • stimulation of innate potential

  • guidance and control

  • responsibility

  • independence


Why do parents neglect

Why do parents neglect?

We need to understand the interaction between:

  • 3 Ns: Nurture, Nature, Now

  • Circumstantial factors and fundamental factors


Why do parents neglect1

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

Why do parents neglect?


Forms of neglect

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)


Emotional neglect

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

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

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.


Emotional neglect children1

Emotional neglect: children

  • Frightened, unhappy, anxious, low self-esteem

  • Withdrawn, isolated, fear intimacy and dependence

  • Precocious, ‘streetwise’, self-reliant


Emotional neglect children2

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

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

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

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 carers1

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

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 too 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

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 management1

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

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

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


Depressed neglect carers1

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

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

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.


Depressed neglect case management1

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.


Depressed neglect case management2

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

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

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

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

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

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

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


Capturing chronic abuse1

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

Our image of assessment


The reality of assessment

The reality of assessment?


Capturing chronic abuse2

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

The pattern of neglect


The pattern of neglect1

The pattern of neglect


The pattern of neglect2

The pattern of neglect


The pattern of neglect3

The pattern of neglect


Cumulativeness

Cumulativeness


Failure of cumulativeness

Failure of cumulativeness


What s the problem

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


Assessment pitfalls

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

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

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, 1980-1989, HMSO, London


Information handling1

Information handling


Serious case reviews

Serious Case Reviews

  • 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

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 services in Hampshire? What, if anything, will be different?


Working with resistance

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

“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

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.


Context1

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

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

Potential parental responses

  • Genuine commitment

  • Compliance / approval seeking

  • Tokenism

  • Dissent / avoidance

    (Horwath and Morrison, 2000)


Identifying resistance 4 categories

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

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

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

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

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 worse1

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

Avoid

  • Expressions of over-concern

  • Moralising

  • Criticising the client

  • Making false promises

  • Displaying impatience


Avoid1

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

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 approaches1

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

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

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

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

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

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

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

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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