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Identifying and Assessing Neglect
Patrick Ayre
Department of Applied Social Studies
University of Bedfordshire
Park Square, Luton
email: [email protected]
Presentation can be downloaded from:
http://patrickayre.co.uk/Presentationd.htm
NEGLECT
Parents who neglect their children basically just don’t know any better because of their own poor upbringings. If we send them to a family centre for Parental Skills training, all will be well.
NEGLECT
Parents who neglect their children basically just don’t know any better because of their own poor upbringings. If we send them to a family centre for Parental Skills training, all will be well.
IF ONLY!!....
NEGLECT
So neglected children who come into care may be a bit thin, a bit dirty, badly in need of seeing a doctor or dentist, maybe a bit wild.
But we can place them with foster carers for a bit of looking after, a bit of TLC, a bit of structure and everything will be fine. The children will absolutely love it and will immediately start to thrive. Simple really!
NEGLECT
So neglected children who come into care may be a bit thin, a bit dirty, badly in need of seeing a doctor or dentist, maybe a bit wild.
But we can place them with foster carers for a bit of looking after, a bit of TLC, a bit of structure and everything will be fine. The children will absolutely love it and will immediately start to thrive. Simple really!
IF ONLY!!....
Brain development
By the age of 3, a baby’s brain has reached almost 90 percent of its adult size.
The growth in each region of the brain largely depends on receiving stimulation.
This stimulation provides the foundation for learning.
Experience Affects the Structure of the Brain
Brain development is “activity-dependent”
Every experience excites some neural circuits and leaves others alone
Neural circuits used over and over strengthen, those that are not used are dropped resulting in “pruning”
Poor integration of hemispheres and underdevelopment of the orbitofrontal cortex
Difficulty regulating emotion, Lack of cause-effect thinking, Inability to recognize emotions in others, Inability to articulate own emotions, Incoherent sense of self and
autobiographical history Lack of conscience.
Other physiological issues
Serotonin: emotional stability and feeling good
Malnutrition: cognitive and motor delays, anxiety, depression, social problems, and attention problems
Myelination Sensitive periods (infancy &
attachment)
Emotional development
Sensitive period for emotional development: up to 18 months
Shaped primarily by the way in which the prime carer interacts with the child
Emotional deficits harder to overcome once the sensitive window has passed.
How often do we intervene assertively at this point?
Building a child
Building a child is like building a house, each new level built on the one below. If the lower levels are unsound, no amount of tinkering with the upper floors will make it stable.
Capturing chronic abuse
Single events often only significant in context;
Can often only understand present by setting in context of past
Intangible: Difficult to capture and compare
High threshold for recognition
Neglect is a pattern not an event
The pattern of neglect: atypical
The pattern of neglect
Intervention Intervention
The pattern of neglect
'G ood enough' level
Intervention Intervention
The pattern of neglect
Intervention Intervention
'G ood enough' level
Intervention ceases
The pattern of neglect
Cumulativeness
T h r es h o ld f o rin te r v en tio n
SEXUAL
ABUSE
PHYSICAL
ABUSE N
EGLECT
NEGLECT
NEGLECT
Failure of cumulativeness
T h r es h o ld f o rin te r v en tio n
SEXUAL
ABUSE
PHYSICAL
ABUSE
NEGLECT
NEGLECT
NEGLECT
NEGLECT
What’s the problem?
Chronic abuse and the principle of cumulativenessFiles very long and badly structured
Patterns missed and ‘chronic abuse’ overlooked
The problem of proportionality
Acclimatisation (case, agency and geographical)
Why do parents neglect?
We need to understand the interaction between:
3 Ns: Nurture, Nature, Now
Circumstantial factors and fundamental factors
Why do parents neglect?
Circumstantial Poverty Particular relationships Lack of
skill/knowledge Temporary illness Lack of support Environmental factors
Fundamental Lack of parenting
capacity Deep seated
attitudinal/behavioural/ psychological problems
Long term health issues Entrenched
problematical drug /alcohol use
The effects of neglect
Howe identifies 4 types of neglect
Emotional neglect
Disorganised neglect
Depressed or passive neglect
Severe deprivation
Each is associated with different effects and implications for intervention
Emotional neglect
Sins of commission and omission
‘Closure’ and ‘flight’: avoid contact, ignore advice, miss appointments, deride professionals, children unavailable
However, may seek help with a child who needs to be ‘cured’
Intervention often delayed
Emotional neglect: parents Can’t cope with children’s demands:
avoid/disengage from child in need; dismissive or punitive response
Six types of response:
– Spurning, rejecting, belittling
– Terrorising
– Isolating from positive experiences
– Exploiting/corrupting
– Denying emotional responsiveness
– Failing medical needs
Emotional neglect: children Frightened, unhappy, anxious, low self-esteem
Precocious, ‘streetwise’
Withdrawn, isolated, aggressive: fear intimacy and dependence
Behaviour increasingly anti-social and oppositional
Brain development affected: difficulties in processing and regulating emotional arousal
Disorganised neglect Classic ‘problem families’
Thick case files
Can annoy and frustrate but endear and amuse
Chaos and disruption
Reasoning minimised, affect is dominant
Feelings drive behaviour and social interaction
Disorganised neglect: carers
Feelings of being undervalued or emotionally deprived in childhood so need to be centre of attention/affection
Demanding and dependant with respect to professionals
Crisis is a necessary not a contingent state
Disorganised neglect: carers
Cope with babies (babies need them) but then…
Parental responses to children unpredictable; driven by how the parent is feeling, not the needs of the child
Lack of ‘attunement’ and ‘synchronicity’
Disorganised neglect: children Anxious and demanding
Infants: fractious, fretful, clinging, hard to soothe
Young children: attention seeking; exaggerated affect; poor confidence and concentration; jealous; show off; go to far
Teens: immature, impulsive; need to be noticed leads to trouble at school and in community
Neglectful parents feel angry and helpless: reject the child; to grandparents, care or gangs
Depressed neglect
Classic neglect
Material and emotional poverty
Homes and children dirty and smelly
Urine soaked matresses, dog faeces, filthy plates, rags at the windows
A sense of hopelessness and despair (can be reflected in workers)
Depressed neglect: carers
Often severely abused/neglected: own parents depressed or sexually or physically abusive
May have learning difficulties
Passive helplessness response to demands of family life
Have given up both thinking and feeling
Depressed neglect: carers Listless and unresponsive to children’s
needs and demands, limited interaction
Lack of pleasure or anger in dealings with children and professionals
No smacks, no shouting, no deliberate harm but no hugs, no warmth, no emotional involvement
No structure; poor supervision, care and food
Depressed neglect: children
Lack interaction with parents required for mental and emotional development
Infant: Incurious and unresponsive; moan and whimper but don’t cry or laugh
At school: isolated, aimless, lacking in concentration, drive, confidence and self-esteem but do not show anti-social behaviour
Severe deprivation
Eastern European orphanages, parents with serious issues of depression, learning disabilities, drug addiction, care system at its worst
Children left in cot or ‘serial caregiving’
Combination of severe neglect and absence of selective attachment: child is essentially alone
Severe deprivation: children Infants: lack pre-attachment behaviours of
smiling, crying, eye contact
Children: impulsivity, hyperactivity, attention deficits, cognitive impairment and developmental delay, aggressive and coercive behaviour, eating problems, poor relationships
Inhibited: withdrawn passive, rarely smile, autistic-type behaviour and self-soothing
Disinhibited: attention-seeking, clingy, over-friendly; relationships shallow, lack reciprocity
The assessment of neglect An approach based on the Graded Care
Profile by Dr OP Shrivastava
GCP provides: Framework for making assessment Baseline measurement An element of objectivity Judgement about care Reliable standardised evidencehttp://www.lutonlscb.org/index.php?option=com_content&view=article&id=183&Itemid=52
GCP users
Health visitors
School nurses
Social workers
Family centre workers
Education welfare workers
GCP uses Pre-referral assessments Snapshot assessments Contribution to CAF assessments Contribution to Core Assessment (parenting
capacity) Self-assessment (parents and carers) Young person’s assessment of parenting Tool for setting goals and assessing progress Tool to facilitate discussion
Domains of Care
Physical needs
Safety
Love and belongingness
Esteem
Self actualisation
Sensitivity
Responsivity
Reciprocity
Overtures
Stimulation
Approval
Disapproval
Acceptance
Present & absent
Nutrition. Housing, Clothing, Hygiene & Health
Maslow, A. 1954
What to observe
A. PHYSICAL
B. SAFETY
C. LOVE
D. ESTEEM
Nutrition
Housing
Clothing
Hygiene
Health
Quality,
Quantity,
Preparation,
Organisation,
Grades of Care
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Level of care All child’s needs met
Essential needs fully met
Some essential needs met
Most essential needs unmet
Essential needs entirely unmet/hostile
Commitment to care
Child first Child priority Child/carer at par
Child second Child not considered
Quality of care
Best Adequate Equivocal Poor Worst
Sub-areas 1 2 3 4 5
1. Carer
A Sensitivity
Anticipates or picks up very subtle signals- verbal or nonverbal expression or mood.
Comprehends clear signals – distinct verbal or clear nonverbal expression.
Not sensitive enough – stimuli and signals have to be intense to make an impact e.g. cry.
Quite insensitive – needs repeated or prolonged intense signals.
Insensitive to even sustained intense signals or aversive.
B Response
Synchronisation
Timing
Responses well synchronised with signals or even before in anticipation
Responses mostly synchronised except when occupied by essential chores.
Not synchronised for own recreational engagement; synchronised if fully unoccupied or child in distress.
Even when child in distress responses delayed.
No responses unless a clear mishap for fear of incrimination.
C Reciprocation
(quality)
Responses complementary to the signal. Both emotionally and materially, can get over stressed by distress signals from child. Warm.
Material responses (treats etc.) lacking, but emotional responses warm and reassuring.
Emotional reciprocation warm if in good mood (not burdened by strictly personal problem), otherwise flat.
Emotional reciprocation brisk, flat and functional, annoyance if child in moderate distress but attentive if in severe distress.
Aversive/punitive even if child in distress, acts after a serious mishap mainly to avoid incrimination, any warmth/remorse deceptive.
Example: AREA C: LOVE
Sub-Area Scores Area Score
Comments
(A) Physical
1. NUTRITION 1 2 3 4 5
2. HOUSING 1 2 3 4 5
3. CLOTHING 1 2 3 4 5
4. HYGIENE 1 2 3 4 5
5. HEALTH 1 2 3 4 5
(B)Safety
1. IN CARER’S PRESENCE 1 2 3 4 5
2. IN CARER’S ABSENCE 1 2 3 4 5
(C) Love
1. CARER 1 2 3 4 5
2. MUTUAL ENGAGEMENT 1 2 3 4 5
(D) Esteem
1. STIMULATION 1 2 3 4 5
2. APPROVAL 1 2 3 4 5
3. DISAPPROVAL 1 2 3 4 5
4. ACCEPTANCE 1 2 3 4 5
Targeting Items of Care
Targeted Areas
Current Score
Target Score
Timescale Reviewed Score
1
2
3
4
5
Making an assessment Guidance provided (follow up scores of
4 or 5)
Evaluates strengths as well as weaknesses
Allows progress to be assessed
A relatively objective measure
Allows help to be targeted where needed
Making an assessment Common language, common reference Objective measure – child focussed Effective tool to promote partnership
assessments and planning with parents User friendly Comprehensively covers all areas of
care Child and carer specific
Scale for Assessing Neglectful Parenting (Northamptonshire)179 individual questions under the following headings:Food and Eating HabitsHealth and HygieneWarmth/ClothingSafety and SupervisionEmotional NeedsCognitive DevelopmentEducational Needshttp://northamptonshirescb.proceduresonline.com/chapters/p_lscbn_neg.html
Example questions (Health and Hygiene)
21 The home lacks showering or bathing facilities which work, and are available for maintaining personal hygiene
22 The bath and basin are dirty, or inaccessible
23 The family lacks a toilet which works 24The toilet is regularly left dirty or stained
25 Toddler’s potties are left unemptied containing urine and faeces
26 The kitchen is dirty (eg cooker ingrained with old
food, grime on walls, floor, kitchen utensils, sink)
Making an assessment Each statement scored 1, 2 or 3
according to how true it is. Blank spaces for Summary,
Conclusions and Action Plan Lengthy and comprehensive list of
relevant factors No guidance on making overall
judgments Statements all identify weaknesses Allocation of questions to headings a
little eccentric at times
The chain of reasoning
Facts
Analysis/summary
Conclusions/recommendations/action
The chain of recording
What happened/what you saw
What this means
What you did/what should be done (and why, if this is not clear from the above)
The chain of recording
But how do you know which facts?
Must be informed by a basic risk assessment (would not always be spelled out on paper)
Risk assessment The dangers involved (that is the feared outcomes);
The hazards and strengths of the situation (that is the factors making it more or less likely that the dangers will realised);
The probability of a dangerous outcome in this case (bearing in mind the strengths and hazards);
The further information required to enable this to be judged accurately; and
The methods by which the likelihood of the feared outcomes could be diminished or removed.
Bias and Balance
Include information favourable to ‘the other side’ as well as that favourable to yours
It is your job to make judgements but: – avoid empty evaluative words like
inappropriate, worrying, inadequate – Give evidence for descriptive words like
cold, dirty and untidy Beware the danger of facts
Bias and Balance
Born in 1942, he was sentenced to 5 years imprisonment at the age of 25. After 5 unsuccessful fights, he gave up his attempt to make a career in boxing in 1981 and has since had no other regular employment
Lies, damned lies and killer breadResearch on bread indicates that More than 98 percent of convicted felons are bread users. Half of all children who grow up in bread-consuming
households score below average on standardized tests. More than 90 percent of violent crimes are committed within
24 hours of eating bread. Primitive tribal societies that have no bread exhibit a low
incidence of cancer, Alzheimer's, Parkinson's disease, and osteoporosis.
In the 18th century, when much more bread was eaten, the average life expectancy was less than 50 years; infant mortality rates were unacceptably high; many women died in childbirth; and diseases such as typhoid, yellow fever, and influenza were common.
Incomplete or out of date
Can you trust a snapshot?
Assessment Pitfalls
Parents’ behaviour, whether co-operative or uncooperative, often misinterpreted
Information from family friends and neighbours undervalued
Coping with aggressive or frightening families
Failure to give sufficient weight to relevant case history; ‘Start again syndrome’
Not enough attention is paid to what children say, how they look and how they behave; maintenance of a wholly child-centred approach
A child centred approach
The purpose of assessment is to understand what it is like to be that child (and what it will be like in the future if nothing changes)
Information handling pitfalls Picking out the important from a mass of
data Facts recorded faithfully but not always
critically appraised Too trusting/insufficiently critical; Decoyed by another problem False certainty; undue faith in a ‘known
fact’ Discarding information which does not fit
the model we have formed
Department of Health (1991) Child abuse: A study of inquiry reports, 1980-1989, HMSO, London
Assessment pitfalls
Rule of optimism
Natural love
Cultural relativism
Too much
not enough
Information handling pitfalls
Keeping your head down
Hesitancy to challenge other professionals or the conventional wisdom
Tendency to move from facts to actions without ‘showing your working’
But what is analysis?
You have gathered lots of information but now what?
All you need to do is ask yourself my favourite question:
“So what?”
You have collected all this data, but what does this mean, for the service user, for the family and for my setting?
Conclusions and recommendations Summarise the main issues and the conclusions
to be drawn from them. (The facts do not necessarily speak for themselves; it is your job to speak for them.)
Define objectives as well as actions Draw conclusions from the facts and
recommendations from the conclusions Explain how you arrived at your conclusions
(Have you demonstrated the factual/theoretical basis for each?)
Consider and discuss alternative possibilities
Conclusions and recommendations In drawing conclusions be aware of the
extent and limitations of your own expertise. Conclusions may be supported by research
(Don’t go outside expertise; be careful with new or controversial theories; be aware of counter arguments)
Your recommendation should usually be specific (not either/or)
Remember: conclusions may be attacked in only two ways– founded on incorrect information– based on incorrect principles of social work
Conclusions and recommendations
Problems:
Unsupported assertions or judgements
Inability or unwillingness to analyse and draw conclusions
Failure to answer the key question: ‘So what?’
Reaching a decision ‘Often a decision is made first and the thinking
done later’ (Thiele, 2006) As humans, we resort to simplifications, short
cuts and quick fixes! We reframe, interpret selectively and reinterpret. We deny, discount and minimise We exaggerate information especially if vivid,
unusual, recent or emotionally laden and We avoid, forget and lose information
Good Assessments Are clear about the purpose, legal status and
potential outcomes Are based on a clear theoretical framework Are clear about context and value base Are collaborative and promote accessibility for
service users Are based on multiple sources of information Value the expertise and understanding service
users bring to their situation Are clear about missing information
Good Assessments
Identify themes and patterns about needs, risks, protective factors and strengths
Generate and test different ways of understanding the situation
Give meaning to themes, using knowledge based on experience/research
Lead to an evidence-based conclusion Use supervision to assist reflection, hypotheses and
objectivity Are able to record and explain outcomes Are reviewed, updated & amended in light of new
information
Spotting the bad ones:Organisational Clues Mythology exists about the family – ‘this
family is/always/behaves like Negative stereotypes about other agencies
exist so their information is discounted Sudden changes about view of risk not
explained Sudden changes of plan not rationally
explained
Worker clues Gut feelings says something is wrong
Worker does not ask difficult questions
Analysis does not account for facts/history
Proposed plan does not address issues raised in assessment
Practitioner is working much harder than the parents to explain significant concerns
The child’s story is missing
Inter-Agency Clues
Agencies have conflicting views of the family/risk
Agencies have strong views but offer ambiguous/limited evidence
Some agencies unwilling to share information
Pressure to agree suppresses permission to question / inter-agency acclimatisation
Family Clues
Parental intentions not supported by actions
Parental optimism involves denial of difficulties
Children's accounts conflict with parents’
Parents’ ‘talk’ about their child is contradictory/lacks coherence
Co-operation is only on the parents’ terms
A final thought
“We are guilty of many errors and many faults but the worst of our crimes is abandoning our children, neglecting the fountain of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him we cannot answer 'Tomorrow.' His name is 'Today.'”
Gabriela Mistral (Chilean poet, 1889-1957)
