Neglect; a theoretical approach to the

clinical assessment of the “invisible child”

Jo Tully

VFPMS seminar

March 2019

Nursing Orientation 2016

Substantiated abuse types Australia

2015/16

Victorian statistics 2015/16Abuse type Australian totals Victoria

Emotional abuse 20,339 9,133

Neglect 11,403 583

Physical abuse 2,975 8,361

Sexual abuse 1,463 5,559

Victoria has the largest proportion of emotional abuse substantiations and

the smallest proportion of neglect substantiations (4.1%)

Neglect substantiated (as 2nd form) in 25% of physical abuse cases

Indigenous children 7x more likely to have neglect/abuse substantiated than

non-indigenous children

LoveWarmth Shelter &

clothing

Food

Emotional enrichment,

moral/spiritual

guidance/stability

Medical treatment

Protection/safety

Education

Appropriate stimulation

Play &

social

connection

Optimal Health

& Wellbeing

A child needs…...

Neglect – WHO definition

“The failure to provide for the development of the child in all

spheres: health, education, emotional development, nutrition,

shelter and safe living conditions, in the context of resources

reasonably available to the family or caretakers, and

causes or has a high probability of causing harm to the

child’s health or physical, mental, spiritual, moral or social

development. This includes the failure to properly supervise and

protect children from harm as much as is feasible.”

Consequences for child rather than on parental behaviour…..

Intention to harm child not required

WHO Report of the consultations on Child Abuse Prevention. Geneva, Switzerland. March 1999

And to make it simpler…..

“Any serious act or omission by a person having care of a child that, within the bounds of cultural definition, constitutes a failure to provide conditions that are essential for the healthy physical and emotional development of a child”

The sub-optimal professional

response to neglect• Definitional difficulties – actual harm/likely

harm…?

• Threshold uncertainties

• Repetitive, sub-threshold events

• Sub-optimal parenting or neglect?

• No clear critical event to trigger PS’s response

• Chronicity results in greater harm

• Often multiple reports involving many children

• Lack of evidence about management

• Lack of evaluation of intervention strategies

Concepts surrounding neglect

Child

Society

Family/caregiver

Community

Secure

attachment to

consistent

caregiver

Maternal physical

& mental health

Income

Parenting style

Parental health

Parental education

Crime

Overcrowding

Green spaces

Policing

Education

Family supports

Economics

Population income

Employment

Immigration

Cultural attitudes

Racism

Conflict

Ecological model of child neglect–

the requirements

Child

Society

Family/caregiver

Community

Age, prematurity

Behaviour

Disability/delay

Planned/unplanned

Chronic illness

Mental health esp depression

Stress

Abuse history

Substance abuse

Domestic violence

Young age, single parent

Isolation, transience

Low education

Chronic poverty

High unemployment

Low education

Limited green

spaces

High crime/drug

rates

Cultural attitudes

Low income

High unemployment

Poor access to health

Underfunded child

welfare system

Remember resilience-promoting and

protective factors

Ecological model of child

neglect – the risk factors

Tier 3 – child’s

functioning of

concern

Tier 2 – harmful

child-caregiver

interaction

Tier 1 – caregiver

risk factors

Tier 0 – social and

environmental risk factors

Ways of thinking about neglect –

‘Tiers of Concern’

Glaser, D Child abuse and neglect 2011

The 3 Axis of neglect

• Types - classification

• Thresholds – degrees/severity – continuum

of harm, chronicity, urgency of intervention,

type of intervention

• Outcome – likelihood of harm, harm already

present, defining the harm, the “arrow of

time”

Danya Glaser 2011

Category Example

Physical Inadequate/inappropriate; • Food• Clothing• Warmth/shelter• Hygiene/personal care

Environmental Unsuitable/unhygienic, dirty, cluttered, hoardingRestricted access to suitable play/learning environments

Developmental/educational

Failure to provide tools/opportunities for learningFailure to enrol/attend school, erratic attendance

Medical/dental Failure to provide proscribed medical/dental needsFailure to heed signs of illness or follow instructions

Supervisory/abandonment

Failure to supervise, suffers harm. Carer whereabouts unknown.

Emotional Failure to provide reliable responsive care

Types/categories of neglect

Continuum of child/caregiver interaction

Satisfactory (“good enough”) Undesirable Harmful

Thresholds

“the ill-treatment of the child and/or impairment of the

child’s development which is attributable to the care

given to the child or likely to be given to the

child…not being what it would be reasonable to

expect”

Outcomes

No current or future harm likely –Undesirable behaviours/interactions…

Child FIRST referral, supports in place, monitor

•No current harm, future harm likely

•Important group but no legal remit

•Current harm but no future harm – single

adverse act…might be catastrophic

•Current and future harm

•Clearly state harms and relate to caregiver-child

interactions

Cumulative harm

Cumulative harm is experienced by a

child as a result of a series or pattern of

harmful events and experiences that may

be historical, or ongoing, with the strong

possibility of the risk factors being

multiple, inter-related and co-existing over

critical developmental periods

Cumulative Harm: A conceptual overview Vic Gov DHHS

Developmental stage Cognitive, developmental and psychosocial outcomes

Infancy and preschool Anxious attachmentAnger, frustration, decreased problem-solving skills Developmental delay

Primary school Aggression to or withdrawal from peersOften dislikedAttention difficulties – ADHD, ODD, ASDHigh rate repeating years, absences, lower grades

Adolescence Juvenile delinquency Absconding from homeArrests for violent crimeSexual exploitationDrug abusePersonality disorders/mental ill-healthDecreased high school completion

Adulthood Lower IQ’sEmployment - <7% in professional employmentCrime

Cumulative harm – putting it all together –

the neglect assessment

The assessment pathway

• Observations and information gathering

• Organise considering tiers of concern

• Explicitly state

• Type/s of neglect

• Risk factors, harmful interactions

• Indicators of harm or potential harm

• Estimate severity

• Interventions to change trajectory of child’s life

• Write a report with impact

The arrow of time

• Chronic and insidious

• Follow-up paramount

• Demonstrate improvement/deterioration

in domains of impairment and in parent-

child interactions

• Be explicit

N.E.G.L.E.C.T.I.N.G – an acronym

• Nurture

• Emotional needs

• Growth and nutrition

• Learning and development

• Environment at home

• Clothing

• Teeth

• Immunisations, infections, infestations

• Normal social activity

• General health

VFPMS website

under Guidelines

Conclusions• Thorough assessment

• Identify types of neglect

• Statements regarding severity/thresholds

• Identify harms or likely harms

• Make clear recommendations

• Follow up

• BE EXPLICIT

• Don’t be afraid

• Our aim is to change the trajectory of this child’s life

References & resources

• Understanding the effects of maltreatment on brain development; Child Welfare Information Gateway April 2015

• The effects of child maltreatment on the developing brain; Glaser D; Medico-legal journal 2014 Vol 82 (3) 97-111

• The neuroendocrinological sequelae of stress during brain development: the impact of child abuse and neglect; Panzer ; African Journal of psychiatry Feb 2008

• Reversing the real brain drain Early years study April 1999

• The pervasive and persistent neurobiological and clinical aftermath of child abuse and neglect; Nemeroff et al; J Clin Psychiatry 2013

• Epigenetic programming by maternal behaviour; Weaver et al; Nat Neuroscience 2004

• Early-life experiences, epigenetics and the developing brain; Kundakovic et al; Neuropsychopharmacology 2015

• Epigenetic mechanisms for the early environmental regulation of hippocampal glucocorticoid receptor gene expression in rodents and humans; Zhang et al; Neuropsychopharmacology 2013

• www.developingchild.harvard.edu

• www.childtrauma.org

• www.nctsn.org