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11.11 Practice Guidance - Neglect and Graded Care Profile

AMENDMENT

In February 2015, three new Appendices were added (see below).


Contents

  1. Aims of this Practice Guidance
  2. Introduction
  3. Defining Child Neglect
  4. Types of Neglect
  5. The Assessment Framework
  6. Child Neglect and Significant Harm
  7. Reasons for Neglectful Parenting
  8. Recognition
  9. Risk Factors for Child Neglect
  10. Summary of Risk and Protective Factors in Child Neglect
  11. Effects of Neglect on Children from Birth to 54 Months
  12. Effects of Neglect on Children from Infancy through Adolescence
  13. Child Neglect - Current Problems and Operational Issues
  14. A Framework for Assessing Child Neglect (Horwath, 2005)
  15. Graded Care Profile (GCP)
  16. Measuring

    Appendix 1: Graded Care Profile Tool

    Appendix 2: Graded Care Profile Instructions

    Appendix 3: Graded Care Profile Leaflet for Families


1. Aims of this Practice Guidance

This practice guidance is for use by all those who work with children and families in all agencies and settings. It draws on national and local research into child neglect and its aim is to help practitioners form judgments about their intervention.

It includes some tools that practitioners may find helpful in their work with children and families. It is not, however, exhaustive and practitioners may well choose to add other tools or resources to it that have been found to be useful in practice.

This practice guidance aims to unravel some of the difficulties experienced when working in this area and to suggest ways to avoid or resolve them. No guidance can, however, provide answers to all circumstances or difficulties, the aim of this guidance is to support the use of professional judgment at all stages of our interventions with families.


2. Introduction

Every child has the right to develop healthily, and to do this their basic needs must be met. The Children Act (1989) does not specify needs or rights, it does however, assert the general principle of the paramouncy of the child's welfare.

Children's needs for, and rights to, healthy development can be identified within 'The United Nations Convention of The Rights of the Child' (1989). There is an international consensus on the basic needs of children. The Convention specifically identifies the right to:

  • Life and the best possible chance to develop fully;
  • An adequate standard of living primarily provided by parents, but with half from the State;
  • Day to day care;
  • Health and health care;
  • A safe, healthy, unpolluted environment with safe nutritious food and unpolluted water;
  • Disabled children should be helped to be as independent as possible, and to take a full and active part in everyday life;
  • To have their views ascertained and to be listened to;
  • To have a standard of living adequate for their physical, mental, emotional, spiritual, moral and social development;
  • To have access to education to achieve their full potential.

Neglect of children is one of the most difficult areas within the child care and protection field to identify, communicate effectively to professionals, assess and intervene in. Whilst it is emerging as the most prevalent type of harm children experience this has not always been the case and this is concerning since Neglect results in more profound cognitive, social and psychological deficits than many other forms of abuse. 

There are a number of important factors which have contributed to the delayed recognition and management of Neglect and they include:

  • The advent of thresholds for the provision of a social work service has emerged as a means of managing the gap between identified need and available resources. Many thresholds are governed by incidents that have induced a crisis and which require immediate responses. This does not accommodate cases of Neglect which are often an accumulation of a number of concerns over a period of time with different professionals holding small pieces of a jigsaw;
  • One of the first issues confronting social workers in these cases can be the amount of information available and deciding what is most relevant to inform the decision on whether the child is being neglected.  The problem for agencies coming to an agreement about Neglect is that perceived negatives in one aspect of a child's life may be thought to be balanced out by positives in another.  For example, if a child's physical appearance, hygiene, and health care are a cause of concern but school attendance and performance is good, agencies may see the positive effect of school as balancing out some of the negatives of other concerns.  Similarly, if there are concerns about physical Neglect and school attendance but the family are very willing to work with social services, then the positive acceptance of intervention may be thought to balance out the negative of Neglect.  Furthermore, these balancing acts are more likely to favour positive aspects over those that are negative in the context of a highly pressurised system;
  • The confusion about when and what information to collect and share between professionals acts as an obstacle to putting the jigsaw together prospectively, reinforcing an incident-based response. Even where information is shared, there is a process difficulty in trying to assemble an expression of concern based on anything but incidents;
  • In order to establish Neglect, evidence has to be gathered in a systematic way over a period of time, rather than at a specific point in time.  Indeed, there has to be a change in mid set away from an event specific incident to recognition that Neglect is a long-term developmental issue rather than an event-specific crisis;
  • In cases of child Neglect it is often quite difficult to know where to attribute blame, i.e. with the parent, the environment, or a mixture of both? There is a  tendency to blur the distinctions between poverty and child Neglect despite the research confirming that Neglect is more an issue of poor parenting rather than poverty.  Child Neglect is more to do with deficits in parenting behaviour that operate independently of economics rather than flawed parenting judgements that result from economic hardship.  Although the eradication of poverty is to be desired, it ought not to be seen as a necessary pre-requisite for effectively targeting and reducing the incidence of child Neglect;
  • On occasions workers focus upon the rights of the parents to the detriment of the rights of the child, with the parent being given numerous opportunities to improve the family situation.  This emphasis upon family preservation within the United Kingdom is a fundamental tenet of the Children Act (1989).  The problem is that the two legal requirements of family preservation and working in partnership with parents can create tensions and pose difficulties for those who work with families who neglect children.  Some neglectful parents do not have the capacity to work constructively and systematically with social workers and others who try to help them.  Some are unwilling and refuse to have any involvement with social workers:  they do not open a door, are not home in spite of arranged visits to take a child to see the GP, to a hospital appointment, to group work, or to attend a Family Centre etc.  They quite often refuse to have anybody advising them or directly trying to help them with parenting skills. 


3. Defining Child Neglect

Generally, child Neglect means the failure of a parent or a caretaker responsible for the child's care to provide minimally adequate food, clothing, shelter, supervision, and/or medical care for the child. Defining "minimally adequate" levels of care, and reaching consensus on these definitions, however, are not easy processes.

Defining Neglect is complicated by the necessity of considering the following:

  • What are the indispensable, minimally adequate types of care that children require?
  • What actions or failures to act on the part of the parents or other caretaker constitute neglectful behaviour?
  • Must the parent's or caretaker's action or inaction be intentional, wilful or not?
  • What are the effects of the actions or inactions on the child's health, safety, and development?
  • Is the family's situation a result of poverty, or a result of parental Neglect?

Child Neglect is rarely an intentional act of cruelty, however there are occasions when Neglect is perpetrated consciously as an abusive act by a parent. More often Neglect is defined as an omission of care by the child's carers, when for many different reasons parents are unable to consistently meet the needs of their child or children.

In contrast to other forms of abuse, where specific and critical incidents can highlight Significant Harm, the less tangible indicators of Neglect combined with its diversity in presentation, often make Neglect cases more difficult to identify as those requiring a child protection response.

Furthermore, differences in opinion about what constitutes "persistent failure", "serious impairment of health or development" and "adequate" make this definition, as with others, more open to interpretation, resulting in confusion and lack of consensus amongst child-care professionals about what neglect actually involves.

A simple and helpful way to view Neglect is to consider the needs of children and whether or not their parents or carers are consistently meeting such needs.  If not, then Neglect may very well be an issue.

Neglect is often more than a child being persistently hungry or dirty and practitioners must focus upon the range of needs that children have when considering this question.

Although any definition of Neglect will always be open to a degree of judgment, there are a number of key factors that, as a rule, are consistent.

  • Neglect is a passive form of abuse.  The importance of contextual information rather than incidental factors is crucial to the identification of Neglect;
  • Its presentation as a "chronic condition" requires the collation and analysis of sometimes small and seemingly insignificant events that only when viewed together provide evidence that Neglect is an issue of concern;
  • The intent to harm the child by the parent or carer is not always present;
  • Neglectful families often face multiple problems;
  • Child Neglect can cause serious harm and death.


4. Types of Neglect

One of the main reasons why Neglect can be quite difficult to define is that the term 'Neglect' itself operates as an umbrella for numerous forms of child maltreatment.  In an attempt to overcome this problem several potential components of the definition are described below.

Physical neglect

  • Refusal of Health Care - Failure to provide or allow needed care in accordance with recommendations of a competent health care professional for a physical injury, illness, medical condition or impairment;
  • Delay in Health Care - Failure to seek timely and appropriate medical care for a serious health problem, which any reasonable layperson would have recognised as needing professional medical attention;
  • Abandonment - Desertion of a child without arranging care and supervision.  This category includes cases in which children were not claimed within two days, and when children were left by parents/substitutes who gave no (or false) information about their whereabouts;
  • Expulsion - Other blatant refusals of custody, such as permanent or indefinite expulsion of a child from the home without adequate arrangement for care by others, or refusal to accept custody of a returned runaway;
  • Other Custody Issues - Custody-related forms of inattention to the child's needs other than those covered by abandonment or expulsion.  For example: repeated shuttling of a child from one household to another due to apparent unwillingness to maintain custody, or chronically and repeatedly leaving a child with others for days/weeks at a time;
  • Other Physical Neglect - Conspicuous inattention to avoidable hazards in the home; inadequate nutrition, clothing, or hygiene; and other forms of reckless disregard for the child's safety and welfare, such as driving with the child while intoxicated, leaving a young child unattended in a motor vehicle, and so forth.

Supervision

  • Inadequate Supervision - Child left unsupervised or inadequately supervised for extended periods of time or allowed to remain away from home overnight without the parent/substitute knowing (or attempting to determine) the child's whereabouts.

Emotional neglect

  • Inadequate Nurturance/Affection - Marked inattention to the child's needs for affection, emotional support, attention or competence;
  • Chronic/Extreme Abuse or Domestic Violence - Chronic or extreme spouse abuse or other domestic violence in the child's presence;
  • Permitted Other Maladaptive Behaviour - Encouragement or permitting of other maladaptive behaviour (e.g. severe assaultiveness, chronic delinquency) in circumstances in which the parent/guardian had reason to be aware of the existence and seriousness of the problem but did not attempt to intervene;
  • Refusal of Psychological Care - Refusal to allow needed and available treatment for a child's emotional or behavioural impairment or problem in accord with competent professional recommendation;
  • Delay in Psychological Care - Failure to seek or provide needed treatment for a child's emotional or behavioural impairment problem, which any reasonable layperson would have recognised as needing professional psychological attention (e.g. severe depression, suicide attempt);
  • Other Emotional Neglect - Other inattention to the child's developmental/emotional needs not classifiable under any of the above forms of emotional Neglect (e.g. markedly overprotective restrictions which foster immaturity or emotional over-dependence, chronically applying expectations clearly inappropriate in relation to the child's age or level of development).

Educational neglect

  • Permitted Chronic Truancy - Habitual truancy averaging at least five days a month was classifiable under this form of maltreatment if the parent/guardian had been informed of the problem and had not attempted to intervene;
  • Failure to Enrol/Other Truancy - Failure to enrol a child of mandatory school age, causing the school-aged child to remain at home for non-legitimate reasons (e.g. to work, to care for siblings) an average of at least 3 days a month;
  • Inattention to Special Educational Need - Refusal to allow or failure to obtain recommended remedial educational services, or neglect in obtaining or following through with treatment for a child's diagnosed learning disorder or other special educational need without reasonable effort.

Medical neglect

Charges of medical Neglect tend to focus upon the parents' neglectful behaviour that may be serious or life threatening for the child, rather than parental fear of not being able to pay for medical services or a lack of understanding the importance of specified medical treatment. 

Preventable accidents

Preventable accidents are a major cause of morbidity in neglecting families and the significance of repeated accidents should be recognised in the Accident and Emergency department. 

Types of neglect and impact on attachment

Crittenden (1999) developed the following framework for considering the impact of four different types of neglect (disorganised neglect, emotional  neglect and depressed neglect) on attachments:

Click here to view the Types of neglect.

Current state of play

Operational definitions of neglect differ in three ways:

  • Between the professionals that use them (e.g. social workers, caseworkers, protective service investigators, police officers and juvenile court judges);
  • Between these professionals and the lay community;
  • Between different cultural groups.

This lack of consistency in definition and approach contributes to a context of confusion when attempting to target and tackle neglect.

Definition of neglect in safeguarding children (DfES, 2006)

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 and clothing, shelter including exclusion from home or abandonment, failing to protect a child from physical and emotional harm or danger, failure to ensure adequate supervision including the use of inadequate care-takers, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.


5. The Assessment Framework

Assessing the developmental needs of children is a complex process, which requires all relevant aspects of a child's life experience to be addressed. The process of assessment is a positive opportunity to respond to the needs of children and families. It is likely to be most helpful to the child and family if it brings together the knowledge and experience of a multi-agency group.

A link can be made between impairment of the child's health and development and neglect of aspects of their care provided by their parents or carers. Neglect may involve all aspects of a child's development. As such, the Assessment Framework for Children in Need and Their Families should form the background for consideration of the problem of Neglect. This framework provides a foundation for all professionals and agencies who work with children and families and it can be supported through the introduction of more specific tools that examine in more detail the impact on the child across more than physical domains and also examine the origins of the parental problems that contribute to their neglectful behaviour.

The Framework for the Assessment of Children in Need and their Families identifies several dimensions of a "Child's Developmental Needs", "Parenting Capacity" and "Family and Environmental Factors" that are all intrinsically linked to the overall wellbeing and needs of children. Reference should always be made to these areas when considering the possibility of child neglect. If concerns are identified that a child's need are being unmet, neglect can be considered as a hypothesis and tested in terms of Significant Harm and whether or not there exists a deficit in parenting capacity to cause the shortfall. It is important to remember that the recognition of unmet needs may not in itself indicate neglectful parenting, rather it may point towards the need for intervention.

A wide view of the child's circumstances and an effective assessment identifying why such needs remain unmet will always be required.


6. Child Neglect and Significant Harm

The key issue in understanding Neglect is that healthy child development is a holistic concept within which aspects of physical, emotional, intellectual and social needs interact. Neglect of any one of these may cause Significant Harm, especially to young children. Thus, assessment involves an understanding of each aspect of development but also an appraisal of the extent of the deficit in the different aspects.

Serious Neglect, leading to Significant Harm, creates the need for a Section 47 Enquiry. However, Neglect even when less serious will require a 'Child in Need' assessment under Section 17 Children Act 1989. Such earlier intervention may have preventative value.

More than any other form of abuse, Neglect is often dependent on establishing the importance and collation of seemingly small, undramatic pieces of factual information. When collated these may present a picture that may identify a child suffering from Significant Harm. Neglect which constitutes 'Significant Harm' is that which is:

  • Persistent;
  • Cumulative;
  • Chronic or Acute;
  • Resistant to Intervention.

Professionals should remember that discovering a child "home alone" does not in itself indicate a risk of continuing Significant Harm and each situation requires thorough exploration.  As a rule, ensure that you consider the following together with the main areas highlighted within the Significant Harm section.

  • The child's/supervisor's age and level of maturity;
  • The length of time the parent/carer was absent and their explanation;
  • Who has/had access to the house when home alone/inappropriately supervised;
  • The family's ethnicity/culture and child rearing patterns (i.e. is leaving a child on their own usual practice in the family' s country of origin?);
  • Whether this has happened before?

Neglect often occurs in families living in poverty. However the children at greatest risk are those whose parent's own emotional impoverishment is so great that they do not know how to parent or understand their children's needs. In spite of considerable intervention from professionals, voluntary and charitable organisations, these parents may be unable to provide for even the most basic needs of their children.

The persistent nature of Neglect is corrosive and cumulative, therefore there is the danger of irreversible damage. Children who are neglected will not inevitably become neglectful parents to their own children, but research and practice identify the inter-familial nature of much Neglect. Appropriate intervention can therefore contribute to the prevention of the cycle of inter-generational neglect.

The behaviour of seriously neglectful parents is frequently characterised by care which lacks consistency and continuity. There may be brief intervals when care is marginally improved. This may raise the hopes of those providing services, but improvements are usually short lived creating a sense of hopelessness for those supporting the family. Other characteristics include:

  • A lack of concern about physical household standards which falls well below ordinary families, quite often associated in part with animals in the household;
  • A failure to keep routine health appointments for the children (and themselves?);
  • Failure to stimulate and/or interact creatively or humorously with the children;
  • Difficulty in exercising appropriate discipline and control over children;
  • Lack of judgment about whom to trust with care of children;
  • Difficulty in putting children's needs first;
  • Parental low self esteem;
  • Poor or destructive relationships with extended family or local community.

The quality of parenting can be described as being on a continuum of care;

quality of parenting


7. Reasons for Neglectful Parenting

The majority of parents care well for their children, often in difficult circumstances, with the support of their friends and family if needed. Many children in our community are at risk of having their health or development neglected for a number of reasons such as homelessness, unemployment, poverty or a particular difficulty within the family.

Some will need a little extra support as a result of difficulties, usually provided by universal services, to ensure that their children's developmental milestones are met and that they are cared for adequately.

A small number of children, however, will need more co-ordinated and comprehensive support services, as a result of the complexity or seriousness of their family circumstances, to ensure that they are cared for adequately throughout their childhood.

Local and national research identified a number of factors that feature in relation to the parents of children at risk of being neglected including:

  • Violent relationships;
  • Experiences of significant loss or bereavement;
  • Substance misuse;
  • Parental learning disability;
  • Mental ill-health;
  • Episodes in local authority care as children.

In addition research clearly identifies the particular risks faced by the 0-4 age group as well as the social isolation faced by older children who are neglected.

Neglect can have a significant impact on a child's emotional and physical development, the effects of which can last into adulthood. It impacts on all aspects of a child's health and development including their learning, self-esteem, ability to form attachments and social skills.

The following factors may impact on parenting capacity and should always be considered by agency professionals when they have concerns about Neglect and throughout the Social Work Assessment of Needs and Strengths.

Domestic violence

Children may be harmed by violence, even when they are not directly assaulted.  Growing up in violent and threatening environments can significantly impair the health and development of children as well as exposing them to an ongoing risk of indirect physical harm. Chronic, unresolved disputes between adults, whether these involve violence or not, may indicate that some of the child's needs are being persistently unmet and hence Neglect may be an issue. Professionals need to remain alert to the indicators of neglect whenever domestic violence is raised as an issue.  Carefully explore and assess the circumstances and if violence is re-currant, think of the likely consequences for the child in terms of their development and well-being.

  • Neglect may occur when the mother and children are deprived of food, money and material goods;
  • The cumulative impact of the above on the mother;
  • The expectation of agencies/professionals that mothers are always able to care for and protect their children;
  • Expectations of mothers to deal with crisis in the adult relationships;
  • In such situations, adults involved may be preoccupied with their relationship.

Adult Mental Health Issues

The experience of a mental health difficulty by a parent or carer should not in itself lead any practitioner to assume an impaired ability to provide appropriate parenting. However, it is acknowledged that mental health difficulties can significantly impact upon parenting capacity depending on the type of mental illness and individual circumstances.  As such, they should be considered as a possible contributory factor to Neglect when identified.

  • Severe depression or psychotic illness impacting upon the ability to interact with or stimulate a young child and/or provide consistency in parenting;
  • Delusional beliefs about a child, or being shared with that child, to the extent that the child's development and/or health is compromised;
  • Extreme anxiety states in an adult leading them to limit or curtail their child's developmentally appropriate activities.

Specialist advice as to the impact of mental health difficulties on parenting capacity must always be sought from an appropriate mental health practitioner.

  • Differing impact of chronic or acute illness on the parents capacity to care;
  • Effects of 'diagnostic combinations' - e.g. mental health difficulties, alcohol/drug misuse, learning difficulties etc;
  • Impact of medication upon their capacity to care;
  • Difficulties which professionals may have in working together, different areas of expertise, different roles, different focus.

Alcohol or Substance Misuse

Certain parental behaviours will be associated with elevating the risk of child Neglect. Substance misuse is one of them.  Children can be seriously neglected if substance use is chaotic, with the needs of the parents' addiction overriding their ability or willingness to meet the basic needs of their children. Whenever substance misuse is identified as a concern, a thorough assessment of the impact upon parenting and potential implications for the child must be completed.

  • Parental denial, minimisation, secrecy, manipulation etc;
  • Adverse effect of dependency on alcohol and/or drugs, and the availability of financial resources to meet the children's needs;
  • Safety and supervision issues;
  • Professional disagreement/uncertainty re: level of risk;
  • Possible conflict between professionals in terms of belief systems and values;
  • Possible conflict between workers re confidentiality.

Parents with Learning Disabilities or Learning Difficulties

  • Different professional groups may use differing definitions in relation to the severity of the difficulty/disability;
  • Learning disabilities or difficulties may be present in those with an above average IQ but associated with specific conditions such as Autism or Aspergers' Syndrome.

Mental health and behavioural problems can mask or accentuate the degree of disability.

When parents have some degree of disability, the child's health and temperament may further influence the parents' capacity or ability to parent. An additional factor would be whether the pregnancy resulting in this child's birth was planned. It seems that a substantial number of parents who seriously neglect their children and are referred to Social Services are thought to have a degree of learning disability. However, it is not always clear whether this in itself causes the problem or whether the parents themselves have been deprived of positive parenting experiences in their own childhood. It is also important to identify precisely the areas of difficulty in parenting which may be attributable to intellectual defects.


8. Recognition

A pre-requisite in recognising Neglect in general terms, is a knowledge and understanding of children's development, of their families, their life events and experiences. This does not initially imply 'expert knowledge', although in some instances urgent expert assessment may be needed. Research messages suggest professionals often take a narrow view of family functioning, and fail to assimilate research findings of behaviours, both professional and parental, which are harmful to children.

Children's needs which are not being met by their parents, may in the first instance, be identified by those agencies providing universal services i.e. health and education. It may be the failure of parents to use or access healthcare or education that raises concerns. Features of Neglect may be apparent to many professionals and others who have contact with the family. It is essential that there is inter-agency and inter-professional collaboration to bring together facets of concern regarding the care of the children. Failure to accurately record, assimilate, and communicate information about the child's welfare is a recurrent feature of Case Reviews in which Neglect is a factor.

One or more indicators of Neglect may be present, which may be sustained or episodic, and may reflect what is happening in the family at a particular point in time. The impact of Neglect on individual children needs to be considered in the context of the child's age and development. However the outcome may be the same, i.e. it may cause Significant Harm to the child's health and development.

Barriers to Recognition of Seriousness of Neglect

Professionals may fail to identify Neglect as serious because of:

  • A failure to observe and listen to children;
  • A belief that Neglect can be addressed solely by relieving poverty;
  • A failure to recognise children as part of a wider community, whose responses to the neglected child may be to socially exclude them;
  • Taking a collective view of children in the same family, when an individual assessment is required;
  • A belief that parenting is innate and natural and therefore parental behaviours must be right;
  • A fear of imposing professional and class values on others;
  • Making assumptions about race and culture that could under or over state the risks;
  • Viewing Neglect as inevitable as the parents are unable to change their lifestyle/behaviour;
  • Developing pervasive belief systems that as long as the children seem happy, other omissions of care are of less importance;
  • A lack of knowledge of results and long term consequences of Neglect;
  • An adherence to a belief in the adults rights to 'self determination' which may deny or be in conflict with the rights and/or best interests of the child;
  • Over identification with vulnerable parents, leading to denial of children's needs;
  • A belief that nothing better can be offered to children.

Studies have shown that once the 'rule of optimism' develops, it is then difficult for workers to change their views about the family. This may be in spite of compelling evidence of Neglect and Significant Harm.

Indicators of neglect using the domains and dimensions of the Assessment Framework

Click here to view the Indicators of Neglect.

These lists provide useful triggers in terms of children's needs and characteristics that may indicate they are being neglected. However, they need to be taken along side other considerations such as the age of the child, whether they have a disability or how long they have been a feature of the child's life.


9. Risk Factors for Child Neglect

Socio-demographic factors:

  • Less than 21 years old at first pregnancy;
  • Low educational level (less than 11 years);
  • Single parenting for more than six months;
  • Low family income;
  • Low employment status.

Relational factors:

  • Mother without social support from immediate family;
  • Separation of mother and child (for more than one week) during first months of life (hospitalisation, placement);
  • Marital violence reported by mother;
  • Violence in family of origin of mother;
  • Neglect in family of origin of mother;
  • Child in family placed in foster home;
  • Mother placed in foster home or centre during her childhood;
  • Mother indifferent, intolerant or very anxious towards her child;
  • Previous referral to social services agencies;
  • Significant stress during pregnancy and perinatal period (e.g. separation, death, loss of employment).

Medical factors:

  • Health problems during pregnancy;
  • Pre-term baby (less than 37 weeks);
  • Low birth weight baby (less than 2.5k);
  • Illness or handicap of members of family;
  • Serious neonatal illness;
  • Mental problems, maternal depression;
  • Alcohol or drug abuse by mother or father.

Age-Specific Risk Indicators of Child Neglect

Key Features in infants (0-2)

Physical Development Behaviour
  • Failure to thrive, weight, height and head circumference small;
  • Recurrent and persistent minor infections;
  • Frequent attendance at G.P, casualty departments.  Hospital admissions with recurrent accidents/illness;
  • Late presentation with physical symptoms (impetigo, nappy rash).
  • Late attainment of general development milestones.
  • Attachment disorders, anxious, avoidance, difficult to console;
  • Lack of social responsiveness.

If babies are not fed appropriately for their age they may present as failing to thrive.  If they are habitually cold and wet they make take longer to recover from recurrent infections. If they develop nappy rash it may be a sign that they are not being changed regularly.

Key Features in Pre-school Children (2-5)

Physical Development Behaviour
  • Failure to thrive, weight and height affected;
  • Unkempt and dirty/poor hygiene.
  • Language delay, attention span limited;
  • Socio-emotional immaturity.
  • Overactive, aggressive and impulsive;
  • Indiscriminate friendliness;
  • Seeks physical contact from strangers.

Persistent neglect through the pre-school period often results in poor growth (height and weight).  Poor language development and emotional immaturity are also common to the neglected child.

The attention span of neglected children is often limited and may be associated with hyper-activity.  Peer relations can be difficult to make and sustain as neglected children may not have the ability to develop the social skills necessary for co-operative play.  Some children may elicit intimate contact from complete strangers and crave physical contact ("touch hunger")

Key Features in School Children (5-16)

Physical Development Behaviour
  • Short stature, variable weight gain;
  • Poor hygiene, poor general health;
  • Unkempt appearance;
  • Underweight or obese;
  • Delayed puberty.
  • Mild to moderate learning difficulties;
  • Low self esteem;
  • Poor coping skills;
  • Socio emotional immaturity;
  • Poor attention.
  • Disordered or few relationships;
  • Self stimulating or self injurious behaviour or both;
  • Soiling, wetting;
  • Conduct disorders, aggressive, destructive withdrawn;
  • Poor erratic/attendance at school;
  • Runaways, delinquent behaviour.

In the child who has reached school age the effects and main indictors of long term neglect are usually found in poor social and emotional development, behavioural problems and learning difficulties.

In many cases there is no direct evidence of an effect on growth.  Schools may be unable to compensate for the long-term lack of cognitive stimulation at home because neglected children have huge difficulties attending to learning tasks.  This may be exacerbated by poor attendance.

Neglect should be considered as a possible cause in children who are disruptive and difficult to mange.


10. Summary of Risk and Protective Factors in Child Neglect

  Child Neglect
Risk factors
  • Poverty and material deprivation;
  • Racial discrimination;
  • Undereducation;
  • Single mothers/absent fathers;
  • Dangerous neighbourhoods;
  • Inadequate child care resources;
  • Unemployment;
  • Age of child (younger), duration of neglect (longer);
  • Substance abuse/addiction;
  • Physical and mental illness;
  • Affective and personality disorders;
  • Low self-concept and self-esteem;
  • Poor social, coping, problem-solving, child-rearing, and other life skills;
  • Prematurity and low birth weight;
  • Faulty attachments;
  • Other types of maltreatment including domestic violence;
  • Divorce/family disruption;
  • Social isolation and loneliness;
  • High stress levels;
  • Multiplicity of problems.
Protective factors
  • Social support, including caring adults in the child's life, especially mothers and fathers;
  • Well-paid, enriching maternal employment;
  • Child's intelligence and self-esteem (both higher), temperament (more outgoing), age (older), coping strategies, competent behaviour, perceived internal locus of control;
  • Adequately parented and resilient parents who are good role models;
  • Family cohesion/marital harmony;
  • Siblings;
  • Cultural practices;
  • Material adequacy;
  • Adequate health care resources;
  • Relatively few sources of stress;
  • Safe and supportive neighbourhoods.


11. Effects of Neglect on Children from Birth to 54 Months

Click here to view the Effects of Neglect on Children from Birth to 54 Months.


12. Effects of Neglect on Children from Infancy through Adolescence

Click here to view the Effects of Neglect on Children from Infancy through Adolescence.

Resilience requires consideration

Many children exposed to sustained neglectful parenting may show no evidence of harm in any of the identified areas. This may be a product of their resilience. The resilience -vulnerability matrix offers a visual portrayal of how to understand why some children in a family are harmed and others are not and this is important when having to consider the likelihood of harm materializing at some future point

Click here to view the Resilience/ Vulnerability Matrix.


13. Child Neglect - Current Problems and Operational Issues

Before embarking upon any intervention, professionals should familiarise themselves with a number of key practice issues that must always be considered when addressing concerns of abuse or neglect.  Recognising the influence and importance of these concepts will focus the assessment and guide professionals towards an appropriate response.

13.1 Focus on the Child

Professionals working with children will spend a large amount of their time interacting with adults in order to affect a positive change in parenting capacity.  This is necessary and reflects good practice when intervening with families. However, contact with parents or carers must not be at the expense of losing focus on why the professional is actually there - the child. Neglecting parents are often emotionally and materially deprived and they may attempt to use professionals to meet their own needs.  In such circumstances it can be easy to lose focus on the child.  Supervision, consultation and maintaining multi-agency networks are all essential to maintaining a child focused perspective.

13.2 Sharing information - Working Together

Given the nature of Neglect as "multi-factorial" and the usual absence of a precipitating critical incident, it will be unlikely, except in cases of chronic Neglect, that the neglected child will be immediately recognised by a single agency working in isolation from other professionals.

Different organisations will hold different information that when brought together will enable professionals to consider concerns of Neglect more fully in terms of Significant Harm.  It is imperative that all agencies and professionals ensure a solid commitment to the process of information sharing, recognising that this will be paramount to the effectiveness of protecting children and assessing and providing for need.

13.3 The Rule of Optimism

For a variety of reasons, professionals can often think the best of families with whom they work.  This can lead to a lack of objectivity and focus on the child, minimising concerns, failing to see patterns of abuse and generally not believing or wanting to believe that risk factors are high.

During both the initial stages of investigation and the longer term work with cases of Neglect, it is imperative that professionals maintain their focus on the child and the areas of risk that are being assessed.  The full extent of Neglect will only be identified after a thorough assessment of the family.  If during this process, optimism replaces objectivity, the risk to the child will be heightened as the protective professional network "relaxes".

One factor that possibly prevents professionals recognising and intervening in cases of Neglect has been the assumption that children will not die.  This CAN and unfortunately DOES happen.  Professionals must be alert to the possibility of such grave consequences, particularly where babies or toddlers are concerned.

13.4 Ethnicity and Culture

It is important that professionals are sensitive to different family patterns and lifestyles and to child rearing patterns that vary across different ethnic and cultural groups.

The assessment of Neglect should always maintain focus on the needs of the individual child, with the family's strengths and weaknesses being understood in the context of their wider social environment.  Consideration should always be given to the way religious beliefs and cultural traditions influence values, attitudes and behaviour and how they structure and organise family and community life.

These factors will neither explain or justify acts which place a child at risk of Significant Harm through Neglect, but are vital to the determination of whether Significant Harm is an issue or not.  Professionals should guard against myths and stereotypes when assessing Black or minority ethnic families.

13.5 The Impact of Values and Difference

Neglect, more than other forms of abuse, is open to significant degrees of interpretation.  This interpretation will undoubtedly vary amongst professionals who will differ in opinion about whether certain circumstances are neglectful or not. For example a family's home conditions may be assessed as neglectful by one practitioner and "good enough" by another. Differences in opinion are to be expected and do not necessarily impinge on the assessment of neglect, rather they can and should encourage further exploration to justify Significant Harm or not.

Professionals must always bear in mind that values, ideologies and theories have the potential to influence observable facts.  Staff must ensure that such issues do not confuse or cloud the necessary objective view of the situation in terms of Significant Harm. Professionals must be explicit when describing concerns of Neglect.  Separating fact from opinion and backing up opinion with evidence from research and/or professional knowledge and experience is vital.

13.6 Low Warmth/High Criticism

Messages from Research (DoH, 1995) highlights the concept of "low warmth/high criticism" environments as those which are most damaging to children.

Within cases of Neglect this concept can be particularly useful to practitioners when considering both the child's needs and the parental/carer response to these.  Professionals will need to distinguish between those families who are needy and those who are neglectful. Low warmth/high criticism as a concept can assist workers in evaluating the child's circumstances through a focus upon whether the child is cared for within a loving and nurturing environment or one in which they are undervalued and seen as "a burden" to the carers.  The latter will, of course, raise the level of concern and contribute to the assessment of risk. Professionals need to guard against making assumptions and assessing certain parenting styles as being indicative of low warmth environments.  Parental - child interactions can differ across cultures, with parents taking different roles and responsibilities with their children. The fact that a parent is not observed as being tactile or particularly involved in the practical upbringing of their child does not in itself suggest the child's environment is abusive.

13.7 Drift of Cases

The drift of cases can be caused by a variety of different reasons.  The threat of such drift is that there will be insufficient professional contact with the child and family to ensure that the child's welfare is being safeguarded and promoted. The ongoing exposure of the child to significantly harmful circumstances and the absence of professional support and monitoring substantially increases the level of risk to the child concerned. Frequent supervision together with ongoing inter-agency consultation must be maintained to ensure the children do not "slip through the net" and that levels of risk are regularly reviewed. Neglect cases are often long term and it is important to maintain focus on the child and their needs throughout intervention.


14. A Framework for Assessing Child Neglect (Horwath, 2005)

This framework can be used alongside the Department of Health Framework (2000) as the prompts link into the three domains that are central to the English and Welsh framework: child's developmental needs, parenting capacity and family and environmental factors.

Click here to view A Framework for Assessing Child Neglect.


15. Graded Care Profile (GCP)

This tool gives an objective measure of the care of a child by a carer.  The tool provides a qualitative grading for actual care delivered to a child taking account of commitment and effort shown by the carer. Personal attributes of the carer, social environment or attributes of the child are not accounted for unless actual care is observed to be affected by them. Thus, if a child is provided with good food, good clothes and a safe house the GCP will score better even if the carer happened to be poor.  The grades are on a five point (extending from best to worst) continuum.  Grade one is the best and five the worst. This grading is based on how carer(s) respond to the child's needs. This is applied in four areas of need - physical, safety, love and esteem.  Each area is made up of different sub-areas and some sub-areas are further broken down into different elements of care. The score for each area is made up of scores obtained from each of these elements. Methods are described below in detail.  It can be scored by the carer/s themselves if need be or practicable.

How is it Organised

It has two main components which are described below.

The tool has been updated and can be accessed at Appendix 1: Graded Care Profile Tool

The Record Sheet (Appendix 1)

It is printed on an A4 sheet with 'areas' and 'sub-areas' in a column vertically on the left hand side and scores (1-5) in a row of boxes horizontally against each sub-area. Underneath the boxes are numerical scores for each column. 5 being no concerns to 25 indicating legal advice is recommended.

The Reference System

A capital letter denotes an 'area'.  Numerals denote a 'sub-area' and a small letter denotes an 'element'.  For example, A/1a = area of 'physical' care sub-area 'nutrition' for this area/element 'quality' for this sub-area; meaning quality of nutrition for physical care.

Detailed Guidance for Completing the Tool with Families is included at Appendix 2: Graded Care Profile Instructions.

How to Use the Record sheet

Fill in the clients name and the date of assessment at the top of the Record Sheet.

The Main Carer:  the person to whom these observations relate (one or both parents as the case may be, substitute carer or each parent separately if need be);

  • One or both parents;
  • Substitute carer;
  • Each parent separately.

Make note of it in the appropriate place at the top right corner of the GCP Record Sheet.

A useful leaflet for families is included at Appendix 3: Graded Care Profile Leaflet for Families.

Methods

For prescriptive scoring it is necessary to visit the home to make observations. Lists of prompts are available with the GCP and should be referred to during the visit. It can also be used retrospectively where there is already enough information on the elements or sub-areas to enable scoring.

Situations

  1. So far as practicable, use the steady state of an environment and discount any temporary insignificant upsets e.g. no sleep the night before;
  2. Discount the effect of extraneous factors on the environment (e.g. house refurbished by welfare agency) unless carers have made a positive contribution - keeping it clean, making additions in the interest of the child such as a safe garden, outdoor or indoor play equipment, or safety features etc;
  3. Allowances should be made for background factors which can affect interaction temporarily without necessarily upsetting steady state e.g. bereavement, recent loss of job, illness in parents.  It may be necessary to revisit and score at another time;
  4. If carer is trying to mislead deliberately by giving a wrong impression or inaccurate information - score as e.g. 'misleading explanation' - grade five otherwise score as if it is not true.

Obtaining information on different items or sub-areas

A) PHYSICAL

Nutritional (a) quality (b) quantity (c) preparation and  (d) organisation

Take a comprehensive history about the meals provided including nutritional contents (milk, fruits etc.), preparation, set meal times, routine and organisation. Also note the carers knowledge about nutrition, and the carers reaction to suggestions made regarding nutrition (whether keen and accepting or dismissive).

Without being intrusive observe for evidence of provision, kitchen appliances and utensils, dining furniture and its use.  It is important not to lead, but to observe the responses carefully for honesty. Observation at a meal time in the natural setting (without special preparation) is particularly useful.  Score on amount offered, and the carers intention to feed younger children, rather than the actual amount consumed. Be aware some children may have eating/feeding problems.

Housing (a) maintenance (b) décor (c) facilities

Observe. If deficient, ask to see if effort has been made to remedy.  Ask yourself if the carer is capable of doing them him/herself.  Discount if the repair or decoration is done by welfare agencies or landlord.

Clothing (a) insulation (b) fitting (c) look

Observe. See if effort has been made towards restoration, cleaning and ironing. Refer to the age band.

Hygiene

Child's appearance (hair, skin, behind ears and face, nails, rashes due to long term neglect of cleanliness, teeth). Ask about practice.  Refer to age band.

Health Opinion (a) sought (b) follow-up (c) surveillance (d) disability

Sought information from other professionals or some knowledgeable adults on matters of health, check about immunisation and surveillance uptake, reason for non-attendance if any, see if reasons can be appreciated particularly if appointment does not offer a clear benefit. Corroborate with relevant professionals.  Distinguish genuine difference of opinion between carer and professional from non-genuine misleading reasons. Beware of being over sympathetic with carer if the child has a disability of chronic illness.  Remain objective.

B) SAFETY

In Presence (a) awareness (b) practice (c) traffic (d) safety features

This Sub-Area covers how safely the environment is organised.  It includes safety features and the carer's behaviour regarding safety in every day activity (e.g. lit cigarettes left lying in the vicinity of child).  The awareness may be inferred from the presence and appropriate use of safety fixtures and equipment in and around the house or in the car (child safety seat etc.), by observing handling of young babies and supervision of toddlers. Also, observe how the carer instinctively reacts to the child being exposed to danger. If observation is not possible, then ask about the awareness.  Observe or ask about the child being allowed to cross the road, play outdoors etc. If possible, verify from other sources.  Refer to the age band where indicated.

In Absence

This covers child care arrangement when the carer is away.  Take account of reasons, periods of absence, and age of the minder.  This could be a matter for investigation in some cases. Check from other sources.

C) LOVE

Carer (a) sensitivity (b) response synchronisation (c) reciprocation

This mainly relates to the carer.  Sensitivity denotes the carer showing awareness of any signal from the child. The carer may become aware, yet respond a little later in certain circumstances. Response synchronisation denotes the timing of carer's response in the form of appropriate action in relation to the signal from the child. Reciprocation represents the emotional quality of the response.

Mutual Engagement (a) overtures (b) quality

Observe mutual interaction during feeding, playing, and other activities.  Observe what happens when the carer and the child talk, touch, seek out for comfort, seek out for play, babies reaching out to touch while feeding or stop feeding to look and smile at the carer. Skip this part if child is known to have behavioural problems as it may become unreliable.

Spontaneous interaction is the best opportunity to observe these items.  Observe if carer spontaneously talks and verbalises with the child or responds when the child makes overtures. Note if both the carer and the child, either or neither, derive pleasure from the activity. Note if it is leisure engagement or functional (e.g. feeding etc).

D) ESTEEM

Stimulation

Observe or enquire how the child is encouraged to learn.  Examples with infants (0-2 years) include: stimulating verbal interaction, interactive play, nursery rhymes or joint story reading, learning social rules, providing developmentally stimulating equipment. If lacking, try to note if it was due to carer being occupied by other essential chores. The four elements (i, ii, iii and iv) in age bands 2-5 years and 5 years are complimentary.  A score in one of the elements could suffice.  If more elements are scored, use which ever column describes the case best.  In the event of a tie, choose the higher score.

Approval

Find out how and how much the child's achievement is rewarded or neglected.  It can be assessed by asking how the child is doing or simply by praising the child and noting the carer's response (agrees with delight or neglects).

Disapproval

If the opportunity presents, observe how the child is reprimanded for undesirable behaviour, otherwise enquire tactfully (does the child throw tantrums?  How do you deal if it happens when you are tired yourself?)  Beware of discrepancy between what is said and what is done. Any observation is better in such situations e.g. child being ridiculed or shouted at. Try and prove if carer is consistent.

Acceptance

Observe or probe how carer generally feels after she has reprimanded the child, or when the child has been reprimanded by others (e.g. teacher), when child is underachieving, or feeling sad for various reasons.  See if the child is rejected or accepted in such circumstances as shown by warm and supportive behaviour.

Scoring

Make sure your information is factual as far as possible.  Go through the constructs in the order - (Sub-Areas and Elements). Find the construct which matches best, read one grade on either side to make sure, then shade over the construct (use pencil which can be erased and Record Sheet can be reused).  The number at the bottom of the column will be the score for that element or sub-area.  Where more than one element represents a sub-area, use the method described below to obtain the score for the sub-area.

Obtaining a score for a sub-area from score in its elements

Read the score for the shaded areas for different elements of a particular sub-area: if there is a clear mode but none of the shaded areas are beyond (3) score the mode for that particular sub-area. To score on the Neglect Summary Analysis Sheet shade the appropriate score box against the sub-area.

Example:
  1 2 3 4 5
Nutrition   x      
Quality   x      
Quantity   x      
Preparation-Orgnisation     x    

The score for this sub area would be two.

Obtaining a score for an 'area' from a score in its constituent sub-areas is the same.

If there is even a single score above point 3, score that point regardless of mode.

This method helps identify the problem even if it is one sub-area or element.  I's primary aim is to safeguard child's welfare while being objective.  If a mathematical computation, like calculating the mean, is done to obtain a common score, it will not be possible to refer to an element or sub-area which gave a poor score.  Being able to target such elements or areas is an advantage with this scale.  This is why it has been left as a categorical scale.

Transferring the score onto the Neglect Summary Analysis Sheet (Appendix 1).

Having worked out the score for the sub-areas and elements, transfer the scores onto the Neglect Summary Analysis sheet, shading in the corresponding boxes.

Targeting (Appendix 1).

If the care is of a poor grade in an element or sub-area, it can be identified for targeting by noting it in the table on the Target Sheet. Interventions can then be planned with the family to aim for a better score after a period of intervention. Aiming for one grade better will place less demand on the carer than aiming for the ideal in one leap.


16. Measuring

It is envisaged that Wirral's Assessment Tool for Neglect should be used to bench mark change, progress and deterioration at specified intervals.

The assessment tool and record sheet appear as Appendix 1 - Graded Care Profile Tool.

Analysis and planning

General Guidelines for Intervention

  • Most neglectful parents want to be good parents, but lack the personal, financial, and/or supportive resources;
  • Professional helpers must assume that parents want to improve the quality of care for their children;
  • Interventions must be developed with that assumption;
  • All parents have strengths that can be mobilized;
  • The hidden strengths of the neglectful parent must be identified during the assessment process, reinforced, and interventions planned to build upon those strengths;
  • Assumptions and generalizations about neglectful families lead to inappropriate intervention decisions;
  • Neglectful parents often require nurturing themselves to enable them to nurture their children adequately;
  • They may have negative perceptions of themselves as parents and little confidence in their abilities to improve their parenting;
  • Treatment goals must include building feelings of hope, self-esteem, and self-sufficiency;
  • Intervention with neglectful parents requires that the helper "parent the parent" and "begin where the parent is.";
  • It is essential to set clearly stated, limited, achievable goals that are shared with and agreed upon by the parents and children;
  • Goals should emerge from the problems identified by the parents and the professional helper and from the causes or obstacles to remedying the problems;
  • Goals should be clearly expressed in a written service/treatment plan, which is developed with the family.

Indictors of poor prognosis for change

The following list should be used as a guide when considering those parents or carers who are least likely to improve when multi-agency intervention occurs to address Neglect.

  • Highly anti-social, aggressive or violent behaviour;
  • Severely inadequate in parenting capacity;
  • Major interpersonal difficulties;
  • Persistent denial or lack of acceptance of responsibility for what they have done;
  • Poor motivation to be involved with professionals or treatment;
  • Persistent and chaotic substance misuse;
  • Learning difficulties with accompanying mental health difficulties;
  • Significant and profound mental illness;
  • Poor capacity to empathise with child - blame child for professional involvement;
  • Experience of serious childhood abuse (although it is important to note that certain factors appear to mediate against generational repetition).

Setting Goals and Outcome Indicators

  • We are poor at setting specific goals: usually goals are global and vague e.g. need to "improve relationships" or "improve parenting";
  • This can lead to possibilities of misinterpretation by family and other professionals: different views of what the goals would look like. "Happy" and "adequate" mean different things to different people;
  • Goals cannot be properly monitored;
  • Goals should be as precise as possible.

Good practice protects

  • Prioritise information sharing/Working Together

    Neglect is characterised by many minor incidents occurring over a period of time - without talking to other agencies - you won't get a full picture of the child's circumstances.  Phone other professionals regularly / maintain contact in between multi-agency meetings. Any significant events/information- share this with colleagues in different disciplines. Work harder to communicate and share information across agencies involved with the child;
  • Risk assessments must maintain a multi-agency focus to include ALL children.

    Read previous files and summarise content (all agencies).  Use the following tools to aid the assessment:
    • Use of chronology/incident list to build a picture of the child's history - place chronology at front of agency file for ease of reference. Chronology should be referred to or brought to any convened strategy discussion;
    • Use of Eco Map to identify protective network/areas of strength;
    • Use of Genogram to identify support network and/or patterns of concern or risk evident within the family.
  • Overcome the rule of optimism.
    Any strengths (as well as weaknesses) in the family must be evidenced not based on assumption;
  • Thresholds vary with time.
    Ensure that you are clear about the threshold for intervention and that a firm understanding exists about Neglect with regards to Significant Harm;
  • Ensure focus on the child:
    • Adopt a developmental perspective to assessments;
    • Record the child's wishes/feelings/behaviour - talk to and listen to what the child is saying;
    • Note the impact of intervention on the child? (Evidence of improvement/ deterioration?).
  • Clear multi-agency plans
    Develop and evaluate plans through regular inter-agency meetings (Core Groups);
  • Time-scales for change/actions/outcomes must be explicit in any developed plan;
  • Supervision of staff is essential in managing cases of Neglect.
    Avoid drift and ensure that the team manager countersigns any decisions regarding intervention on file.


Appendices

Appendix 1: Graded Care Profile Tool

Appendix 2: Graded Care Profile Instructions

Appendix 3: Graded Care Profile Leaflet for Families

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