Transcript Child abuse on the front page: Learning lessons from the

Understanding and assessing neglect
Patrick Ayre
Department of Applied Social Studies
University of Bedfordshire
Park Square, Luton
email: [email protected]
web: http://patrickayre.co.uk
NEGLECT
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, clothing and shelter
 protect from physical and emotional harm or danger
 ensure adequate supervision
 ensure access to medical care or treatment.
It may also include neglect of, or unresponsiveness to, a
child’s basic emotional needs.
NEGLECT
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, clothing and shelter
 protect from physical and emotional harm or danger
 ensure adequate supervision
 ensure access to medical care or treatment.
It may also include neglect of, or unresponsiveness to, a
child’s basic emotional needs.
NEGLECT
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, clothing and shelter
 protect from physical and emotional harm or danger
 ensure adequate supervision
 ensure access to medical care or treatment.
It may also include neglect of, or unresponsiveness to, a
child’s basic emotional needs.
NEGLECT
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, clothing and shelter
 protect from physical and emotional harm or danger
 ensure adequate supervision
 ensure access to medical care or treatment.
It may also include neglect of, or unresponsiveness to, a
child’s basic emotional needs.
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)
Neglect
Behavioural

Constant hunger

Constant tiredness

Frequent lateness or non-attendance at
school

Destructive tendencies
Neglect

Low self-esteem

Neurotic behaviour

No social relationships

Running away

Compulsive stealing or scavenging
Neglect
Physical

Poor personal hygiene

Poor state of clothing

Emaciation, pot belly, short stature

Poor skin and hair tone

Untreated medical problems
Significant harm
Harm is defined by Children Act 1989:

ill-treatment (including sexual abuse and, by
implication, physical abuse)

impairment of health (physical or mental) or
development (physical, intellectual, emotional,
social or behavioural)
The child's basic needs

basic physical care

affection

security

stimulation of innate potential

guidance and control

responsibility

independence
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
Forms 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
(Howe, D (2005) Child Abuse and Neglect, Basingstoke: Palgrave Macmillan)
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

Associated with avoidant/defended patterns of
attachment
Emotional neglect: parents

Can’t cope with children’s demands:
avoid/disengage from child in need; dismissive or
punitive response

Children provided for materially but there is a
failure to connect emotionally

More rules; everyone has a role and knows what to
do.

Parents may feel awkward & tense when alone
with their children.
Emotional neglect: children
When attachment behaviour rejected:
 Learns that caregiver’s physical and emotional
availability is reduced when emotional demands
are made;
 Caregiver most available when child is showing
positive affect, being self-sufficient,
undemanding and compliant;
 Reverse roles, “false brightness” to care for/
reassure parent.
Emotional neglect: children

Frightened, unhappy, anxious, low selfesteem

Withdrawn, isolated, fear intimacy and
dependence

Precocious, ‘streetwise’, self-reliant
Emotional neglect: children

May show compliance to dominant caregivers but
anger and aggression in situations where they feel
more dominant.

May learn that power and aggression are how
relationships work and you get your needs met
 Behaviour increasingly anti-social and oppositional

Brain development affected: difficulties in
processing and regulating emotional arousal
Emotional neglect: case management

Help parents to learn to use others for support.

Teach parents to engage emotionally with their
children.

Must be highly structured as neither parent or
child know how to interact normally &
spontaneously.

Fear of affect – need clear rules & roles
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

Worker may feel agenda co-opted by family’s
immediate needs
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
 May be regarded as overwhelmed but amenable to
services
 Crisis is a necessary not a contingent state

Associated with ambivalent/coercive patterns of
attachment
Disorganised neglect: carers

Cope with babies (babies need them) but
then…

Parental responses to children
– unpredictable and insensitive (though not
necessarily hostile or rejecting).
– 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 too 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
Disorganised neglect: case management

Logic would argue for warding off crises for a while
so that families can be taught to organise their lives,
but…

Family may want to have needs met, but cannot
delay gratification or trust logic and planning;

Without intense demands associated with crises,
have no way of being important to others;

Will CREATE new crises.
Disorganised neglect: case management

Feelings must be addressed

Need a structured, predictable environment with no
surprises where:
– There are rewards for clear, direct, and undistorted
communication of feelings and accurate cognitive
information about future outcomes
– Family can learn the value of compromise

Teach parents how to use cognitive information to
regulate feelings (without denying them)
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 seem unmotivated, mild learning disability

Learned helplessness in response to demands of
family life;
Stubborn negativism; passive-aggressive
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

Younger the child, more debilitating the effects

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
Depressed neglect: case management

Involves much more than teaching appropriate
parenting

All family members must learn that their
behaviour has predictable and meaningful
consequences

Teach that it helps to share feelings with
empathetic others.
Depressed neglect: case management
Our standard approaches don’t work
 Threats / punitive approaches particularly
ineffective:

– Parents don’t believe they can change so don’t
even try.
– Even most reasonable pressure results in
“shutting down” / blocking out all info.

Parent education – may be ineffective
because judgment impaired and gains not
transferable.
Depressed neglect: case management
These families need:
 Long term involvement
 Supportive approach
 Responsiveness to family’s signals and needs
 BUT these need to be balanced with a
recognition of the children’s needs. (How long
is too long? How much is too much?)
Depressed neglect: infants and children

Must experience responsive and stimulating
environments that also provide human comfort
for a few hours each day.

The longer the child is exposed to
helplessness, the more intense and longer the
intervention needed to remedy the situation.
Depressed neglect: parents

Must learn appropriate ways to show their
feelings
– Practice smiling, laughing, soothing
– May be mechanical at first
– Genuine feelings will emerge with repetition

As parents learn to show their feelings, the
child’s responsiveness will increase; virtuous
spiral
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, autistictype behaviour and self-soothing

Disinhibited: attention-seeking, clingy, over-friendly;
relationships shallow, lack reciprocity
Severe deprivation: case management

Highly unlikely to be in the child’s best interests to
remain in the environment which caused the harm;

It is probable that the child and new carers will
require substantial therapeutic and emotional
support;

Significant challenges often persist despite a move
to a caring and predictable environment.
Capturing chronic abuse

Judging the quality of care is an essential
component of any assessment but how well do
we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event
Capturing chronic abuse

Judging the quality of care is an essential
component of any assessment but how well do
we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event
Our image of assessment
Assessment
The reality of assessment?
Assessment
Capturing chronic abuse

Judging the quality of care is an essential
component of any assessment but how well do
we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event
The pattern of neglect
Intervention
Intervention
The pattern of neglect
'Good enough' level
Intervention
Intervention
The pattern of neglect
Intervention ceases
'Good enough' level
Intervention
Intervention
The pattern of neglect
Cumulativeness
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Threshold for
intervention
Failure of cumulativeness
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Threshold for
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What’s the problem?

Chronic abuse and the principle of
cumulativeness
 Files very long and badly structured
 Patterns missed and ‘chronic abuse’ overlooked
 The problem of proportionality
 Acclimatisation
Assessment Pitfalls





Parents’ behaviour, whether co-operative or
uncooperative, is often misinterpreted
Not enough weight to information from family friends
and neighbours
Attention is focused on the most visible or pressing
problems; other warning signs are not appreciated
When faced with an aggressive or frightening family,
professionals are reluctant to discuss fears for their
own safety and ask for help
Not enough attention is paid to what children say,
how they look and how they behave; maintenance
of a wholly child-centred approach
In Cleaver, H, Wattam, C and Cawson, P Assessing Risk in Child Protection,
NSPCC, 1998
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

Picking out the important from a mass of data

Interpretation

Too trusting/insufficiently critical; Facts recorded
faithfully but not always critically appraised

Mistrusted source

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
Information handling
Serious Case Reviews

Failure to give sufficient weight to relevant case
history; ‘Start again syndrome’

Failure to recognised increased vulnerability of
neglected children

Use of trained staff

Assessment of male carers

Maintenance of a wholly child-centred approach

Too much mouth and ears, not enough eyes
So what?
We have spent some time considering how to
recognise and respond to neglect.
What does this mean for us? What are the
implications for services in Hampshire? What,
if anything, will be different?
Working with resistance
“In many cases parents were hostile to helping agencies and workers
were often frightened to visit family homes. These circumstances could
have a paralysing effect on practitioners, hampering their ability to reflect,
make judgments, act clearly, and to follow through with referrals,
assessments or plans. Apparent or disguised cooperation from parents
often prevented or delayed understanding of the severity of harm to the
child and cases drifted. Where parents made it difficult for professionals
to see children or engineered the focus away from allegations of harm,
children went unseen and unheard”.
“Families tended to be ambivalent or hostile towards helping agencies,
and staff were often fearful of violent and hostile men. Although parents
tended to avoid agencies, agencies also avoided or rebuffed parents by
offering a succession of workers, closing the case, losing files or key
information, by re-assessing , referring on, or through initiating and then
dropping court proceedings”.
Brandon, M, and others (2008) Analysing child deaths and serious injury through abuse and neglect: what can we learn?
London: Department for Children, Schools and Families
Engagement
“Engagement is the basic task of a child and
families worker but can never be taken for
granted and must always be worked for”
Context
‘Involuntary’ work may be characterised by

Guardedness or reluctance to share
information

Avoidance and a desire to leave the
relationship

Strong negative feelings such as anxiety,
anger, suspicion, guilt or despair.
Context
We need to accept that:

The best we may be able to achieve is
honesty rather than positive feelings and a
high degree of mutuality

Conflict and disagreement are not
something to be avoided, but are realities
that must be explored and understood.
How might resistance show itself?





By only being prepared to consider 'safe'
or low priority areas for discussion.
By not turning up for appointments
By being overly co-operative with
professionals.
By being verbally/and or physically
aggressive.
By minimising the issues.
(Egan, 1994)
Potential parental responses

Genuine commitment

Compliance / approval seeking

Tokenism

Dissent / avoidance
(Horwath and Morrison, 2000)
Identifying resistance: 4 categories




Hostile resistance: anger threats,
intimidation, shouting
Passive aggressive: surface compliance
covers partly concealed antagonism and
anger
Passive hopeless: Tearfulness and
despair about change
Challenging: Cure me if you can!
Strategies for enhancing engagement


Before you start, check your mindset (your own
biases and assumptions)
Have realistic expectations:
–
–
–
–
It is reasonable that involuntary clients resent being
forced to participate
Because they are forced to participate, hostility,
silence and non-compliance are common responses
that do not reflect my skills as a worker
Due to the barriers created by the practice situation,
clients may have little opportunity to discover if they
like me
Lack of client co-operation is due to the practice
situation, not to my specific actions and activities
(Ivanoff et al, 1994 )
During initial contacts




Adopt a non-defensive stance
Be clear, honest and direct and
acknowledge the involuntary nature of the
relationship
Clarify roles and expectations, including
what is required of the client
Explain consequences of non-compliance
and the advantages of compliance
(Ivanoff et al, 1994 )
Try to

Invite participation

Understand how the client sees the
problem as well as how we see it

Understand what the client wants, as well
as what we want
(Ivanoff et al, 1994 )
What might we be doing to make it worse?






Becoming impatient and hostile
Doing nothing, hoping the resistance will
go away
Lowering expectations
Blaming the family member
Allowing the family member to control the
assessment inappropriately
Failing to acknowledge our fear
What might we be doing to make it worse?



Becoming unrealistic
Believing that family members must like
and trust us before assessment can
proceed.
Ignoring the enforcing role of some
aspects of child protection work and
hence refusing to place any demands on
family members.
(Egan, 1994)
Avoid

Expressions of over-concern

Moralising

Criticising the client

Making false promises

Displaying impatience
Avoid

Ridiculing the client

Blaming the client for his/her failures

Being dogmatic

Rejecting the client’s right to express
different values and preferences
(Ivanoff et al, 1994 )
Productive approaches



Give practical, emotional support especially by being available, predictable
and consistent
See some resistance and reluctance as
normal
Explore our own resistance to change and
by examining the quality of our own
interventions and communication style
(Egan, 1994)
Productive approaches



Helping family members to identify
incentives for moving beyond resistance
Tapping the potential of other people who
are respected as partners by the family
member
Understanding that reluctance and
resistance may be avoidance or a signal
that we are not doing our job very well
(Egan, 1994)
Confrontation
In child welfare services, the Children’s
Service Worker must be a skilled confronter.
Confrontation is, basically, facing the client
with the facts in the situation and with the
probable consequences of behaviours
(Texas Department of Human Resources)
A scale for assessing motivation
1.
2.
3.
4.
5.
Shows concern and has realistic
confidence.
Shows concern, but lacks confidence.
Seems concerned, but impulsive or
careless
Indifferent or apathetic about problems
Rejection of parental role.
Shows concern and has realistic confidence.

Parent is concerned about children’s welfare;
wants to meet their physical, social, and
emotional needs to the extent he/she
understands them.

Parent is determined to act in best interests
of children

Has realistic confidence that he/she can
overcome problems and is willing to ask for
help when needed

Is prepared to make sacrifices for children.
Shows concern, but lacks confidence



Parent is concerned about children’s
welfare and wants to meet their needs,
but lacks confidence that problems can be
overcome
May be unwilling for some reason to ask
for help when needed. Feels unsure of
own abilities or is embarrassed
But uses good judgement whenever
he/she takes some action to solve
problems.
Seems concerned, but impulsive or careless



Parent seems concerned about children’s
welfare and claims he/she wants to meet their
needs, but has problems with carelessness,
mistakes and accidents. Professed concern is
often not translated into effective action.
May be disorganised, not take enough time, or
pays insufficient attention; may misread ‘signals’
from children; may exercise poor judgement.
Does not seem to intentionally violate proper
parental role; shows remorse.
Indifferent or apathetic about problems



Parent is not concerned enough about
children’s needs to resist ‘temptations’, eg
competing demands on time and money. This
leads to one or more of the children’s needs not
being met.
Parent does not have the right ‘priorities’ when it
comes to child care; may take a ‘cavalier’ or
indifferent attitude. There may be a lack of
interest in the children and in their welfare and
development.
Parent does not actively reject the parental role.
Rejection of parental role



Parent actively rejects parental role,
taking a hostile attitude toward child care
responsibilities.
Believes that child care is an ‘imposition’,
and may ask to be relieved of that
responsibility. May take the attitude that it
isn’t his or her ‘job’.
May seek to give up the responsibility for
children
(Magura et al,1987)