Neglect Contents Introduction Categories of Neglect




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Staffordshire & Stoke-on-Trent

Safeguarding Children Board
Section 4P
Multi Agency Good Practice Guidance for
Recognising and Responding to Cases of Child Neglect

2


Neglect

Contents

  1. Introduction

  2. Categories of Neglect

  3. Effects on the Child

  4. Neglect of Adolescents

  5. Identifying Neglect

  6. Indicators of Neglect and the Assessment Framework

  7. Additional Risk Factors

  8. Child Neglect and Significant Harm

  9. Assessment of Neglect

  10. Graded Care Profile

  11. Practice Issues

  12. The Assessment

  13. Resistance and Risk

  14. Some General principles for Intervention

  15. Appendix One – Stoke-on-Trent Guide to Levels of Need




  1. Introduction

Neglect is the ‘most serious type of child maltreatment and the least understood, it is the direct cause of at least one in six deaths and serious injuries in serious case reviews and is a salient feature in many more (Brandon 2009).


It is the most common reason for a child to become subject to a child protection plan in the UK as over 40% of child protection registrations in the UK related to children considered to be at risk of neglect.
The perception of child neglect has changed significantly over time and is now recognised as one of the most dangerous forms of abuse because of its harmful and sometimes fatal effects. However, neglect is a complex phenomenon which is difficult to define and can be based on personal perceptions. These include the concept of ‘good enough care’ and what a child’s needs might be.
Most families where neglect is a feature will have complex needs and interventions will frequently involve different agencies with a variety of professional backgrounds and perspectives. This can lead to vital pieces of information being lost or not being effectively communicated across agencies and an effective interagency approach to cases of neglect is essential.
This guidance has been produced because it is recognised that neglect is a complex and multi faceted issue. In order to work together agencies need to have a shared understanding of neglect and the best way to effect change. It is intended to assist good inter-agency work, so that all can play an effective role in improving outcomes for children. It also reflects practice requirements referred to in ‘Working Together to Safeguard Children 2013 and the SCB interagency procedures.
Neglect is difficult to define because it is difficult to objectively describe the absence of something like love or attention. Neglect often co-exists with other forms of abuse and adversity and although it generally refers to the absence of parental care and the chronic failure to meet children’s basic needs, defining what those needs are is not straightforward.
Experiences of neglect are effectively located on a continuum with the mild and episodic at one end and severe and chronic physical neglect and emotional abuse at the other.

Research into neglect is revealing less obvious forms of neglect, such as depriving children of adequate stimulation, protective discipline or reliable health care. Equally, there is an increasing recognition that emotional neglect can occur even when physical needs are met whereas physical neglect always has some emotional impact on the child (Minty 2005). This understanding challenges traditional assumptions that a child can be “dirty but happy”.



2. Categories of Neglect
A helpful way to view neglect is to consider the needs of children and whether or not their parents or carers are consistently meeting them. If not, then neglect may very well be an issue.
Categories of neglect have been identified (by Howarth 2007) as including:
Medical minimising or denying children’s illnesses and/or health needs. Failing to seek appropriate medical attention or administer medication and treatments
Nutritional Inadequate calories for normal growth, sometimes linked to the concept of ‘failure to thrive’ recognising that there are other reasons why a child may not develop physically as well as psychologically. More recently childhood obesity resulting from an unhealthy diet and lack of exercise is increasingly being viewed as neglectful given its serious long term consequences
Emotional being unresponsive to a child’s basic emotional needs, including failing to interact or provide affection, failing to develop a child’s self-esteem and sense of identity. Differs from emotional abuse in that it is an act of omission
Educational Failing to provide a stimulating environment, show an interest in the child’s education, support their learning, or respond to any additional needs or failure to comply with statutory requirements around school attendance
Physical Not providing appropriate clothing, food, cleanliness and living conditions. There is a need however to avoid confusion with deprivation and in making judgements based on cultural norms and standards of appropriate physical care
Supervision and Guidance failure to provide an adequate level of guidance and supervision to ensure a child is safe and protected from harm including: leaving a child to cope alone, abandoning them or leaving with inappropriate carers and failing to provide appropriate boundaries about behaviours such as under age sex or alcohol use. This affects children of all ages

3. Effects on the Child
Neglect is known to be damaging in the long and short term. It can seriously impair children’s emotional, physical, cognitive and behavioural development

The impact of neglect for a particular child, as with other forms of abuse, will be influenced by a number of factors that either aggravate the extent of the harm, or protect against it.


Relevant factors include the individual child’s means of coping and adapting and the family support and protective networks available to them or the way in which professionals respond and the success of any intervention initiated to safeguard and promote the welfare of the child.
Generally however, the sustained physical or emotional neglect of children is likely to have profound, long lasting effects on all aspects of a child’s health, development and well being.

4. Neglect of Adolescents
Neglect in adolescence is more difficult to assess. It is important to note that significant harm must be due to the care given, or the care not given, or the child being beyond parental control.
When considering cases of neglect in adolescence some of the factors which may be used to define neglect may exist despite the best efforts of caring parents and are due to the child choosing to behave in certain ways. As a child becomes older influences in the community can be as significant as the home on the child’s development. It is therefore important to take an ecological or holistic perspective when assessing neglect in adolescents i.e. account must be taken of all the influences on the child’s life.
The fact is that some children put themselves at risk. Such cases will not usually be dealt with within the child protection system. Young people in these circumstances are more likely to be children in need and would benefit from advice support and assistance from agencies who are equipped to deal with a particular problem, e.g. Drug and Alcohol Team, Sexual Health Advisory Clinic.
The significant word here is choice. If a young person is choosing to behave in a certain way they must have the capacity to make a choice. That is they must understand the action in which they are engaged and the consequences of that action. (The effects of any learning disability must be assessed).
In practice it has been noted that Neglect in Adolescents results in rapid deterioration because of young person’s increased capacity to demonstrate their suffering/distress with extreme behaviour.


Specific considerations when defining adolescent neglect



Research Themes



Issues for workers

Definitions of neglect need to vary according to age

The core assessment records provide age sensitive measures which are relevant to assessing neglect for teenagers

Neglect is usually seen as an act of omission

For adolescents some acts of omission may be seen as neglect or contribute to young people being neglected e.g. abandoned by parents or being forced to leave home

Neglect from different viewpoints

There may be differences between viewpoints for example between the views of social workers, other professionals and young people themselves. Awareness of these different viewpoints is a starting point for establishing a working consensus

Young people may under-estimate neglect

This may be related to young people’s acceptance of their parents’ behaviour, young people’s sense of privacy or their loyalty to their families

Neglect is often seen as a persistent state

It is necessary to look for a pattern of neglect over time and recognise the impact of both acute and chronic neglect

There is difficulty in making a connection between emotional abuse & neglect

These are associated, especially when neglect is seen as an omission of care. What matters is not the label but the consequences for the young person’s health and development

Neglectful behaviour & experience of neglect

Defining neglect should include both maltreating behaviour as well as how the young person experiences neglect i.e. the consequences for them

There may be overlaps between neglect & other forms of maltreatment

It may be better to consider maltreatment as a whole rather than look at different aspects of it

Neglect is often seen as culturally static

The concept of neglect will vary according to contextually acceptable standards of care. However caution is required in placing too much emphasis on cultural factors – attention should be paid to healthy child development and well-being


5. Identifying Neglect
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.




Points to Consider: it is essential that there is multi-agency professional collaboration to bring together facets of concern regarding the care of children. Failure to accurately record, assimilate, and communicate information about the child’s welfare is a recurrent feature of Serious 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.


Neglect differs from other forms of abuse in that there is rarely a single incident or crisis which draws attention to the family. It is repeated, persistent neglectful behaviour which causes incremental damage over a period of time. However, this should not deter staff from discussing initial concerns with managers and designated child protection personnel within their organisation.
There is no single criterion for determining the presence of neglect and there is no substitute for professional judgement. In any situation where there are a series of minor incidents, or mounting concern about a child, agencies should consider the possibility that the child is neglected. This hypothesis can then be tested to determine whether the child is in need of services and/or protection. In all cases of professional concern, the impact upon the child, of care given, must be the critical focus.
It is only in the most extreme cases that neglect will be recognised by a single agency. Testing a hypothesis of neglect will generally require sharing information between agencies involved with the family. Information held by one professional may take on meaning when laid alongside information held by others.
Identifying neglect by focussing on the actions and inactions of the parents raises difficulties. Neglect can be more easily understood from a child-centred perspective by asking:–



  • What are the child’s needs?




  • What is the child’s experience of care given? (What does it feel like to stand in their shoes)?




  • Do the parents understand the child’s needs?




  • Are the parents able and willing to meet the child’s needs



6. Indicators of Neglect and the Assessment Framework
The Assessment Framework identifies several dimensions of:


  • Child’s Developmental Needs;

  • Parenting Capacity;

  • Family and Environmental Factors;

These dimensions are all intrinsically linked to the overall wellbeing and needs of children.


Assessments for some children – including young carers, children with special educational needs (who may require statements of SEN or Education Health and Care Plans subject to the passage of the Children and Families Bill), unborn children where there are concerns, asylum seeking children, children in hospital, disabled children, children with specific communication needs, children considered at risk of gang activity, children who are in the youth justice system – will require particular care. Where a child has other assessments it is important that these are coordinated so that the child does not become lost between the different agencies involved and their different procedures. (Working Together to Safeguard Children 2013: Chapter 1)
Reference should be made to these areas when considering the possibility of child neglect and should always be considered alongside Stoke-on-Trent’s ‘Guide to the Levels of Need’ document: www.safeguardingchildren.stoke.gov.uk or Staffordshire’s Threshold Framework document ‘Accessing the Right Help at the Right Time’ at: http://www.staffsscb.org.uk/professionals/thresholds/

If concerns are identified that a child’s needs 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.


The Stoke-on-Trent Guide to the Levels of Need document (Appendix 1) or Staffordshire’s Threshold Framework document ‘Accessing the Right Help at the Right Time’ should also be referred to and has been developed in order to assist professionals in making judgements about:



  • What is good enough parenting?




  • When poor parenting becomes neglect




  • Knowing when the level of neglect is likely to constitute significant harm


7. Additional Risk Factors


Research Note:
Certain family and environmental factors may be seen as pre-disposing risk factors for child neglect. This should not be taken to assume a linear cause/effect model


  • Children with a learning or physical disability

  • Parent(s) with a psychiatric disorder, including depression

  • Children who live in conditions of severe social disadvantage

  • Children living in larger families with siblings close in age

  • Parent(s) with a learning disability

  • Children who live with / experience domestic abuse

  • Parents with substance misuse issues (including alcohol)

  • Children who are subject to stressful parental relations

  • Early parenthood

  • Pre-occupied/exhausted parents

  • Families headed by a lone mother, or who have a transient male

  • Parental history or physical and/or sexual abuse in childhood

  • Needy parents, pre-occupied with their own needs, physically and psychologically unavailable for their children.

NB: the existence of multiple, pre-disposing risk factors significantly increases the possibility of a child suffering significant harm as a result of neglect.





8. 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 child protection enquiry (Children Act 1989 Section 47). However, neglect even when less serious will require a ‘child in need’ assessment (Section 17). Such earlier intervention may have preventative value.
More than any other form of abuse, neglect is often dependent on establishing the significance of seemingly small, less than dramatic, pieces of factual information. Which, when considered together may present a picture that identifies a child suffering significant harm.
Neglect which constitutes significant harm is that which is:


  • Persistent

  • Cumulative

  • Chronic or Acute

  • Resistant to Intervention


9. Assessment of Neglect
Effective intervention to prevent or remedy child neglect is dependent on accurate and continuing assessment. Assessment is an ongoing process that begins with the first contact and continues throughout the life of a case.
Children about whom there are concerns about neglect may be assessed in two different ways:


Where a child has ‘additional support needs’ the Common Assessment Framework (CAF)1 will be used by a variety of professionals in different settings to assess the child’s development; how well their parents or carers are supporting their development; and how the wider environment impacts upon them. The thresholds for intervention are clearly laid out in Stoke-on-Trent’s Guidance to Levels of Need document (which can be found at www.safeguardingchildren.stoke.gov.uk or Staffordshire’s Threshold Framework document ‘Accessing the Right Help at the Right Time’ http://www.staffsscb.org.uk/Professionals/Procedures/Section-One


Should the child be deemed to have more ‘complex needs’ then a detailed assessment should be carried out.


There are various tools which are available to assist workers in assessing the seriousness of the neglect. However, these are not formal check lists or rating scales and cannot be used as a substitute for judgements based on overall observation. They are useful as a guide, an aide memoir, and a focus for concentration on the detail of a child’s development and family circumstances.


These guidelines refer to the assessment of and interventions for neglect with regard to a child’s primary carers. If concern is aroused as a result of neglectful care provided by secondary carers, such as childminders the following action should be taken.


  • Inform the child’s parents, so that they can take appropriate action to protect their child; and



  • Inform the registration authority for the secondary carer (e.g. Ofsted or Local Authority), who can consider the possible implications for the children.



10. Graded Care Profile
Agencies have increasingly been turning to the Graded Care Profile, a tool which describes care-giving behaviour in the following four areas, divided in to subsections:


  • Physical care: nutrition; housing; clothing; hygiene; health.




  • Safety; in carer’s presence; in carer’s absence




  • Love: from carer; mutual engagement; and




  • Esteem: stimulation; approval; disapproval; acceptance

This can be used to complement and inform the findings of assessment and as a tool to monitor change and progress. The Graded Care Profile is based on Maslow’s hierarchy of needs and allows practitioners to explore the four areas, or “domains” of care – physical care, safety, love and esteem – and to judge the parenting which they observe against simple predetermined criteria.


The results of the assessment are entered on to a summary sheet which pinpoints those areas of deficit which require further attention.
The forms and the accompanying guidance can be found at:

http://www.careanddevelopment.org.uk/Charts.html. The Graded Care Profile can and should be supported by other available assessment tools and checklists as appropriate.


  1. Practice Issues


Start Again Syndrome
Brandon et al (2008), in their review of Serious Cases warn of the ‘start again syndrome’, where practitioners, overwhelmed by the complexity of the family, put aside knowledge of the past and focus on the present, supporting parents to make a fresh start. Any new or re-assessment of a family must take into account the family’s history in order to make sense of the present.
This will be important for neglect cases where parents and carers can make small improvements. The test should be whether any improvements in adult behaviour are sufficient and sustained. (Working Together to Safeguard Children 2013: Chapter 1)

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”.

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 any child and their circumstances.

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.



Low Warmth/High Criticism
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 which 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.

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 increase 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.



  1. The Assessment

Assessment should be a dynamic process which analyses and responds to the changing nature and level of need and/or risk faced by the child. A good assessment will monitor and record the impact of any services delivered to the child and family and review the help being delivered. Whilst services may be delivered to a parent or carer, the assessment should be focussed on the needs of the child and on the impact any services are having on the child.


Practitioners should be rigorous in assessing and monitoring children at risk of neglect to ensure they are adequately safeguarded over time. They should act decisively to protect the child by initiating care proceedings where existing interventions are insufficient. (Working Together to Safeguard Children 2013 Chapter 1)

13 Resistance and Risk: measurement considerations
A crucial task for the professional is to assess the parent’s real commitment to engaging and implementing change.
Resistance can take a variety of forms, and there are a number of different categorisations to draw from:



  • Hostile resistance – shown through overt anger, threats, physical intimidation and shouting




  • Passive-aggressive resistance – conveyed under a guise of niceness or obsequiousness, with overt compliance on top of covert antagonism, anger and the suppression of explosive behaviours




  • Passive-hopeless resistance – a more overt presentation demonstrated by tearfulness, immobility, and an attitude of despair towards any help that is offered




  • Challenging resistance – which is manipulative behaviour along the lines of ‘cure me if you can’

Many children exposed to chronic neglectful parenting may show no evidence of harm in any of the identified areas. This may be a product of their resilience.


There are many factors associated with resilience, but research suggests that there are three fundamental building blocks:


  • A secure base whereby the child feels a sense of belonging and security.




  • Good self-esteem, that is an internal sense of worth and competence.




  • A sense of self efficacy that is, a sense of mastery and control, along with an accurate understanding of personal strengths and limitations.

One method that practitioners have found helpful to assist them in the identification of resilience and vulnerability, as well as adversity and protective factors is to use the Stoke-on-Trent LSCB Risk and Resilience tool which is designed to explore the strengths and pressures the child is experiencing in relation to the both resilience and risk.


This tool has been designed to add to the existing practitioner ‘tool box’ and has not formally replaced any other assessment document. For further information and to access this tool please go to: www.safeguardingchildren.stoke.gov.uk



Research Note:
Hill et al (2007) suggests strategies for building resilience across the life-cycle. Key to this is school and community resources.




14. Some General Principles 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 and interventions must be developed with that assumption.

All parents have strengths that can be mobilised and 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 generalisations 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. ­­­­­­­­­­­

To access Staffordshire Thresholds for Intervention Guidance please use the link below:

http://www.staffsscb.org.uk/professionals/thresholds/
To access Stoke-on-Trent’s Guidance to Levels of Need document please use the link below: www.safeguardingchildren.stoke.gov.uk


1 In Staffordshire this is known as the Staffordshire CAF and in Stoke-on-Trent this is known as the Early Help Assessment

Version 4

Revised - June 2014

Review Date – June 2015




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