Introduction to

Child Neglect
Clinical Psychologist Aslı Akiş
 What is child neglect?

• "Child neglect" means harm or threatened harm to a child's

health or welfare by a parent, legal guardian, or any other
person responsible for the child's health or welfare that occurs
through either of the following:
• (i) Negligent treatment, including the failure to provide
adequate food, clothing, shelter, or medical care.
• (ii) Placing a child at an unreasonable risk to the child's health
or welfare by failure of the parent, legal guardian, or other
person responsible for the child's health or welfare to intervene
to eliminate that risk when that person is able to do so and has,
or should have, knowledge of the risk.
 Neglect

• “A condition in which a childʼs basic needs are not

met, regardless of cause” (Dubowitz).
• Acts of omissions by those responsible for the childʼs
health or well-being. Neglect occurs when the actions
or non-actions of a caregiver place a child at
• risk of harm
Clear and identifiable harm or injury is the legal
context for definition
 Neglect

Subtypes of neglect
• Medical

• Supervisional

• Physical

• Educational
 Neglect

‘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 (including exclusion from home or
abandonment);

- protect a child from physical and emotional harm or danger;

- ensure adequate supervision (including the use of inadequate caregivers); or

ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional
needs’
 Types of neglect: Child
protection law
• Physical Neglect - Negligent treatment, including but not limited to
failure to provide or attempt to provide, the child with food, clothing, or
shelter necessary to sustain the life or health of the child, excluding those
situations solely attributable to poverty.
• Failure to Protect - knowingly allowing another person to abuse and/or
neglect the child without taking appropriate measures to stop the abuse
and/or neglect or to prevent if from recurring when the person is able to
do so and has, or should have had, knowledge of the abuse and/or neglect.
• Improper Supervision - placing the child in, or failing to remove the child
from, a situation that a reasonable person would realize requires judgment
or actions beyond the child’s level of maturity, physical condition, or
mental abilities and results in harm or threatened harm to the child.
 Types of neglect: Child
protection law
• Abandonment - The person responsible for the child’s health and
welfare leaves a child with an agency, person, or other entity
(e.g., DHHS, hospital, mental health facility, etc.) without:
•• Obtaining an agreement with that person/entity to assume
responsibility for the child.
•• Cooperating with the department to provide for the care and
custody of the child.
• Medical Neglect - Failure to seek, obtain, or follow through with
medical care for the child, with the failure resulting in or
presenting risk of death, disfigurement or bodily harm or with the
failure resulting in an observable and material impairment to the
growth, development, or functioning of the child.
 Risk factors for neglect
1) Child
• – Low birth weight
• – Prematurity
• – Chronic disabilities

2) Parent
• – Substance abuse
• – Mental health
• – Cognitive delay
• – Overly focused on career and/or activities away from home
• – Lack of knowledge of normal growth and development
What difference do you see between the 2year and Adult pictures?
 Blooming and Pruning
• Between conception and age three, a child’s brain undergoes an impressive amount of
change. At birth, it already has about all of the neurons it will ever have. It doubles in
size in the first year, and by age three it has reached between 80 and 90 percent of its
adult volume. Even more importantly, synapses are formed at a faster rate during these
years than at any other time. In fact, the brain creates many more of them than it needs:
at age two or three, the brain has up to twice as many synapses as it will have in
adulthood. These surplus connections are gradually eliminated throughout childhood
and adolescence, a process sometimes referred to as blooming and pruning.

• e.g. a child that experiences little empathy will lose the ability to empathise with others
and to respond to such care in healthy ways when it is shown to them in later life

• Damage in the early years can be largely repaired, but therapeutic input needs to be
consistent and begun as soon as possible
 Perinatal (pregnancy and early infancy)
• Maternal physical health has significant impact on the developing fetus e.g. diabetes
• Environmental factors e.g. cigarette smoke, alcohol & domestic abuse
• Emotional stress can also have physical effects e.g. “double dose” of cortisol pre-birth
• Cortisol the “stress hormone” crosses the placenta to enter the baby’s bloodstream, and
triggers the baby’s own production too. Cortisol has physical effects and can result in a
baby born to a couple in a volatile or abusive relationship being very unsettled and
crying excessively i.e. the sort of behaviour they are least able to cope with.
• Studies on monkeys have demonstrated their need for emotional support and physical
comfort/affection. 2nd generation study monkeys who were not parented by their
mother were unable to parent as adults
• Some children severely deprived of love and stimulation in Romanian orphanages
during the 1980s appeared to be disabled (global developmental delay) when adopted
by families in other countries e.g. USA. Most of them eventually became “normal”
children and adults, but it took many years of excellent care and sometimes therapeutic
input.
 Baby to Pre-school

• Baby/Toddler: under-stimulation, nappy rash, infections,

withdrawn or lethargic, failure to thrive, self-stimulating behaviour
e.g. rocking.

• Pre-School: short stature, dirty or unkempt, delay in learning new

skills, lacking social skills (aggressive or withdrawn),
indiscriminate friendliness, shame or self-doubt, lack of
confidence, expectation of failure.

Frequent minor illnesses, especially D&V OR never attends health

services; D&V = diarrhoea and vomiting i.e. gastroenteritis
 The Primary School Years
• Dental decay, dirty/unkempt/smelly, poor problem solving, poor reading
and writing, encopresis, enuresis, guilt/self-blame, poor eating patterns,
poor lunch boxes. (Encopresis – soiling/messing/ “pooing pants”,
Enuresis – wetting/ “accidents”. (Bedwetting is correctly called nocturnal
enuresis and is rarely an issue before 6 or 7) Either may be due to a range
of physical/medical causes, poor or lack of toilet training or emotional
factors. Unpleasant toilet facilities may be a factor
• A child who seems to always be unwell OR Health appointments not kept

• A child who is over-friendly and eager to please OR withdrawn and

unresponsive OR angry and disruptive
• A child who will not talk about home OR fantasises and tells improbable
stories
 When does a head louse infestation suggest neglect?

• Not always – any child can acquire an infestation and some well-cared for children do so
frequently
• SEVERE infestation suggests that parents/carers have not addressed the infestation early enough
or consistently. Regular or frequent sightings of head lice e.g. falling onto book or desk from a
child’s head are strongly suggestive of neglect, but it should be checked first that parents/carers
have current and accurate information of evidence-based methods of control i.e. Prescribable
insecticidal products and wet-combing
• Nits are white or pale and are empty egg-cases usually stuck to the hair shaft close to the scalp.
They are completely harmless but may be unsightly if there are lots left after a heavy infestation.
They should not be confused with live lice or viable eggs which are dark – brown or black
• Irritation and scratching can become very uncomfortable, distract a child in class and disturb
sleep. Children (and their families) may be ostracised by peers. Severe untreated infestations
can lead to anaemia because the lice feed on blood in the scalp capillaries. Some parents
mistakenly keep infested children off school, depriving them of their education – as long as
treatment is underway they should NOT be kept off school.
• Scratching occurs when children have had head lice for a while as a fresh infestation will inject
an anaesthetic like toxin so you don’t feel them at first, it is only when the body becomes
immune to that toxin does the scratching stop.
 Effect on development

 Cumulative neuro-developmental consequences

 Children may survive but not thrive

 Poor cognitive development

 Poor behaviour disrupting education

 Smashed attachments leading to…

 Poor relationships – family and friends - isolation

 Injuries through lack of supervision

 Poor sense of identity and poor resilience

 Pre-Teens, Teens
Adolescents – Risk taking behaviour.
o Trauma related behaviour
o Feel out of control and out of parent’s control
o Running away; street wise; self reliant vs immature; needy
o Compulsive stealing
o Oppositional anti-social behaviour; in trouble with teachers and police
o Friendships disrupted
o Disruptive behaviour/poor concentration in school; low academic achievement
o Depression/low self esteem; Felt inferiority; felt helplessness; Shame; Loneliness
o Impairment in interpersonal relationships, impulse control, regulation of
aggression
 Young Adults
Young Adults – social isolation, homelessness, poor diet, poor
mental health, early/unplanned parenthood.
• It is normal and to some extent healthy for adolescents to
take some risks, but young people who are (emotionally)
neglected are more likely to take the sort of risks that result
in harm to their health or to their long-term life prospects
• What types of behaviour might you see?:
Substance misuse
Unhealthy relationships/sex
Anti-social/Criminal behaviour
For “Street-wise” read “Vulnerable”
 The reasons for harmful
behavior
1. low self-esteem

2. 2. lack of parental/adult guidance

• Poor role models in their parents and other adults can lead to
difficulties in establishing and maintaining healthy
friendships, couple relationships and relationships with older
adults who could supplement the guidance and support from
their own parents.
• Similarly if they become parents very young they are unlikely
to have acquired the skills they need to keep well physically
or mentally and to run a home and parent children
 Disability and neglect
• Disabled children are 3.8 times more likely to be
neglected
• Research shows that disabled children are more likely
to be maltreated than others
• Parenting capacity may be diminished by denial,
“chronic sadness” or sheer exhaustion
• Children with disabilities need exceptionally skilled
and committed parents in order to achieve their
potential.
Physical and
Sexual Abuse

Neglect and
Emotional
Abuse
Difficulties in deciding how
to respond to neglect arise
because there may not be the
understanding or clarity
about the range and types of
neglect. (Jones 2016)
Typologies of Neglect

• Type 1 Passive

• Type 2 Chaotic

• Type 3 Active
 Type 1 - Passive
Parents:-

- Often single parent mothers, are ground down and exhausted by previous and current circumstances

- Overwhelmed by chronic poverty, damp, poorly furnished, poorly maintained housing

- Poor physical and mental health

- Debt – unpaid bills, unopened letters, threats from debt collectors, rent arrears

- No extended family support

- Previous experience of domestic abuse

- Involvement from multiple agencies – demanding of parents time

- Isolated

- Anxious and depressed

- Finds it difficult to get up in the morning so seeing children often late for school

- May be using alcohol and/or anti depressants

- Lethargic with no routine and no energy

 Type 1 - Passive

• Children

- Lacking in boundaries

- School attendance issues

- Caring for parent – worried about parent and sometimes

angry about this responsibility
 Type 2 - Chaotic
Parents:-
- May have had poor parenting experiences themselves

- Have little understanding of the needs of their children and how to parent well

- Parents focussed on their own needs

- Little tolerance and no routine

- Not lacking in energy and may be very active but with the focus on themselves
and not their children
- Not necessarily intentionally uncaring, and may fight hard for their children in
disputes with schools, neighbours and social care

Children:-
- May be unsupervised as parents craves excitement and friendship with others
Neglect can become “normalised”.

Both Type 1 and Type 2 neglect are examples of the slow

process
 Type 3 - Active

• Deliberate and intentional

• This is not about poverty or lack of competence this is

about power and control!
• Socially powerful people also need to be challenged.
 Type 3 - Active

• Unlike 1 and 2 it is not about an exhausted parent or a parent

lacking competence – its about anger and control
• Its where a parent or parents turn on and scapegoat a
child/children and it might involve only one child amongst
several children in the family – this child becomes the focus and
target of parental anger.
• The child might be seen by the parent to be linked with memories
of traumatic or hated events or relationships
• The adult may be excited by feeling powerful and controlling

• Might also be associated with domestic abuse

 Type 3 - Active

• THE REAL DANGER IN TYPE 3 IS THAT THERE

MIGHT BE A RAPID AND UNSEEN ESCALATION
TO SEVERE ABUSE
• STEP PARENT OR NEW PARTNER ABUSE OF A
CHILD AS PROVOKED BY JEALOUSY OF A
PARTNER’S PREVIOS RELATIONSHIP
 Risk factors for neglect
3) Family
• – Problems in parent - child relationship
• – Poor parenting skills
• – Social isolation
• – Domestic violence
• – High stress (unemployment, poverty)

4) Community and Societal

• – Few resources and poverty
• – Poor access to health care
• – High drug availability and use
• – Under funded child welfare system
• – Inadequate educational system
 What to focus?

1) Failure to provide necessary care

 Focus on caregiver
Ø Punitive

2) Failure to receive necessary care

Ø Child’s basic needs not met

Ø Multiple people, entities, circumstances may be

responsible
 Reporting

• When a report is made, the clinician should disclose this to the

caregiver.
• Rather than blaming the caregiver, the clinician should explain his
or her desire to support the caregiver to best care for his or her
child and alleviate some of the stress or barriers the caregiver is
experiencing.
• Emphasizing a caregiver’s strengths and being empathetic can help
a clinician build rapport with the caregiver.
• The clinician will likely continue caring of the child and should
maintain a positive, collaborative relationship with the mother, to
the degree possible.
 Effects of neglect:

• The physical and psychological effects of neglect are serious.

• Chronic neglect is particularly detrimental to a child’s development and
often requires intense, ongoing involvement with community-based
caseworkers.
• Neglect, particularly chronic neglect, can result in
• – aggression and conduct problems
• – negative self-esteem
• – anxiety
• – cognitive and language delays
• – poor growth
• – social-emotional impairment
• – posttraumatic stress disorder
 Medical neglect

• The diagnosis of medical neglect requires that the following

criteria be met (FIRST 3 ARE THE MOST RELEVANT):
• A child is harmed or at risk of harm because of lack of
health care.
• The recommended care would benefit the child.

• The benefit of care significantly outweighs the risk.

• The family has access to care but has not used it.

• The caregiver understands the clinician’s recommendations.

Protective factors for neglect

• Nurturing relationship between caregiver and child

• Social connections

• Caregiver’s understanding of child development

• Child’s emotional and social competence are protective

 In cases of medical neglect, the
medical provider needs to:
• Describe the illness

• Discuss the noncompliance issues

• Describe why compliance is important

• Describe harm that has occurred from parental action/inaction

• Describe future risk/harm if noncompliance continues

• Describe the cause (if known), or what ISN’T the cause

• Describe what has been done to try to help the family

• Discuss results of all interventions provided

 How do we help?

• Screen for risk factors of neglect

• Search for the underlying cause
• Communicate with medical provider(s) and team caring
for these children

• Help parent obtain additional resources

– Educate parent
– Provide community referrals

– Connect with other parents

Difficulty in diagnosing neglect

• Explain a complicated process

• Lack physical findings of harm in some cases

• Communicate urgency about a chronic process

 Important

• Recognizing neglect requires a multidisciplinary team

• Different forms of maltreatment coexist together

• Medically fragile children are at a higher risk of

• maltreatment

• Prevention and ensuring adequate education, services

and support is essential