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 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
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)
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
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
'Good enough' level Intervention Intervention
The pattern of neglect
Intervention ceases 'Good enough' level Intervention Intervention
The pattern of neglect
Cumulativeness
A B U S E S E X U A L A B U S E P H Y S I C A L N E G L E C T N E G L E C T N E G L E C T
Threshold for intervention
Failure of cumulativeness
A B U S E S E X U A L A B U S E P H Y S I C A L N E G L E C T N E G L E C T N E G L E C T N E G L E C T
Threshold for intervention
Information handling
Picking out the important from a mass of data Interpretation Distinguishing fact/opinion; too trusting/insufficiently critical Mistrusted source Decoyed by another problem False certainty; undue faith in a ‘known fact’ Discarding information which does not fit First impressions/assumptions Department of Health (1991)
Child abuse: A study of inquiry reports, 1980-1989
, HMSO,
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 Not enough attention is paid to what children say, how they look and how they behave Attention is focused on the most visible or pressing problems and 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 In Cleaver, H, Wattam, C and Cawson, P
Assessing Risk in Child Protection
, NSPCC, 1998
Serious Case Reviews
Great disquiet over assessment practice Failure to give sufficient weight to relevant case history Facts recorded faithfully but not always critically appraised Guidance and thresholds Protection plans omit objectives and outcomes
Assessment Practice
Use of trained staff Assessment of male carers Maintenance of a wholly child-centred approach Too much mouth and ears, not enough eyes Formal assessment of risk
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 strengths and weaknesses 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
Seeing the whole picture
“Kouao always dressed immaculately. Her clothing and jewellery seemed expensive and her hair was very well done. She did not in any way look destitute, contrary to what she always claimed. In contrast, Victoria was poorly dressed. I cannot recall exactly what she wore but there were times when she did not seem to be dressed appropriately. She always appeared to look as if she was in hand-me-down clothes. I thought she looked shabbily dressed”
Seeing the whole picture
The danger of snapshots
Drawing conclusions and making 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.) 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?)
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)
Wirral assessment tool for neglect
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 evidence
When do you make a GCP assessment?
Concerns about parenting Child exhibiting problems Children in need of protection Children in need Devising a programme of intervention Any other parenting concerns
GCP users
Health visitors School nurses Social workers Family centre 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
Why choose GCP?
Child focused User friendly Common language Promotes partnership
Why choose GCP?
Evaluates strengths as well as weaknesses Allows progress to be assessed A relatively objective measure Allows help to be targeted where needed
Domains of Care
Sensitivity Responsivity Reciprocity Overtures Self actualisation Esteem Love and belongingness Safety Physical needs Maslow, A. 1954 Stimulation Approval Disapproval Acceptance Present & absent Nutrition. Housing, Clothing, Hygiene & Health
What to observe
A. PHYSICAL B. SAFETY Nutrition Housing Clothing Hygiene Health C. LOVE D. ESTEEM Quality, Quantity, Preparation, Organisation,
Grades of Care
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Level of care Commitment to care
All child’s needs met Child first Essential needs fully met Some essential needs met Child priority Child/carer at par Most essential needs unmet Essential needs entirely unmet/hostile Child second Child not considered Worst
Quality of care Wirral rating
Best No concern Adequate No concern Equivocal Poor Recommend prevention support Child protection Child protection and legal strategy meeting
Scoring
Rating 5 25 Use on every child in the family Use with different carers Complete with the parent/carer Use information, observation, records
Scoring
Score as actually fits the manual – DO NOT JUSTIFY BY REASONS If there is a score of 20 or 25, this overrides any other scores Scores between 5 and 15, record the one which crops up most If there is an even split, the highest score is entered
Scoring
Complete individual scores in the manual Transpose to the record sheet Agree action, targets and timescales
AREAS Sub-areas Items A PHYSICAL CARE 1 2 3 4 ?
a 15 ?
a 20 ?
a 5 15 b 10 b 10 b 10 c 15 c 10 c 15 d 5 5 ?
a 15 b 15 c 10 d 10
Scoring
Score as actually fits the manual – DO NOT JUSTIFY BY REASONS If there is a score of 20 or 25, this overrides any other scores Scores between 5 and 15, record the one which crops up most If there is an even split, the highest score is entered
AREAS Sub-areas Items A PHYSICAL CARE 1 2 3 4 ?
a 15 ?
a 20 ?
a 5 15 b 10 b 10 b 10 c 15 c 10 c 15 d 5 5 ?
a 15 b 15 c 10 d 10
AREAS Sub-areas Items A PHYSICAL CARE Reference Sheet 1 2 15 a 15 20 3 a 20 15 4 a 5 15 b 10 b 10 b 10 c 15 c 10 c 15 d 5 5 15 a 15 b 15 c 10 d 10
Record sheet
1 2 3 4 5
Targeting Items of Care
Targeted Areas Current Score Target Score Timescale Reviewed Score
Unique Advantages
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
What helps in working with neglect
Proactive assessment Addressing causes not symptoms An ecological framework Multidisciplinary assessment Understanding histories and patterns
What helps in working with neglect
Matching interventions to identified needs Clear objectives and timescales Work with parents Work with children in a resilience
Substance use and neglect
Experimental drug users Recreational drug users People who use legal substances People who are dependent on illegal drugs or alcohol But we focus on ‘the stage when the use of drugs or alcohol is having a harmful effect on a person’s life’
Some statistics
Between 50% and 90% of families on social workers’ child care caseloads have parent(s) with drug, alcohol or mental health problems Glasgow 1998/9: 40% of Child Protection Orders cited drug abuse Dundee: Child protection conferences involving parents with problems over drug or alcohol use rose from 37% in 1998/9 to 70% in 2000
Effects vary, but:
Substance misuse may become central preoccupation Reduce or alter appetite Reactions to pain and discomfort dulled Self-neglect Social relationships narrow Trouble with money, housing and the law Poor physical and mental health Interpersonal conflict and poor family relationships
Effects on children
‘Parental substance misuse alone is neither a necessary nor sufficient cause of problems in children’
(Mountenay, 1998)
“International literature on the children of drug users does not support an assumption that child abuse and neglect automatically follow when a parent uses drugs”
(Hogan,1998) But, families need comprehensive assessment and active support to promote resilience and repair damage
Effects on children
Alcohol and/or substance misuse greatly increase the likelihood of family problems (Sher 1991; Zeitlin, 1994) Substance use can become the central focus of the adults’ lives, feelings and social behaviour.
CAMH services report substantial risk of poor childhood mental health (Mountenay, 1999) Poor long-term outcomes for children (Rutter and Rutter, 1992)
Effects on children
“I hated weekends when mum had all her friends round drinking all night.”
Sarah – daughter of problem drinker
“She was just always dead moody, she was always in her bed all the time and she would never go out and buy food and she would never have money to go out and get it.”
(Barnard 2002) the children of problem drinkers: ‘forgotten children’, a ‘hidden tragedy’, and or ‘unseen casualties’ (Wilson 1982)
Specific effects (mainly US Studies)
High risk of maltreatment, emotional or physical neglect or abuse, family conflict and inappropriate parental behaviour Famularo, Kindscherff and Fenton, 1992; Wasserman and Levanthal, 1993, Barlow, 1996).
Exposed to drug-related activity and associated crime (Hogan, 1998) Inconsistent and lukewarm care, ineffective supervision and overly punitive discipline (Kandel, 1990; Boyd, 1993).
Specific effects (mainly US Studies)
More likely to: display behavioural problems (Wilens et al, 1995), experience social isolation and estrangement from family and peers, and stigma (Kumpfer and De Marsh, 1986), misuse substances themselves when older (Hoffman and Su, 1998; McKeganey 1998) In the longer term: isolation, difficulties with change and learning to have fun (Barlow, 1996)
Pre-birth, infancy and pre-school
Risk of physical harm pre-birth Neglect and injury through drugged state of parent, access to drugs Inappropriate emotional care through unhappiness, tension, irritability, preoccupation Cognitive and emotional development affected by lack of stimulation and inconsistent/unpredictable behaviour, unstable environment
Pre-birth, infancy and pre-school
Poor contact with other children Materially deprived environment Self-esteem and positive sense of identity affected by physical and emotional neglect Experience violence Where parents’ behaviour is particularly unpredictable and frightening, symptoms of PTSD
Pre-birth, infancy and pre-school
“Baby Adele was carried along the harbour wall by her father who was under the influence of alcohol. Neighbours thought this carried the risk of dropping her in the water.”
(Scottish Executive 2002)
“My parents started giving me alcohol when I was 1 (year old) to put me to sleep. I got taken into hospital to have my stomach pumped.”
Helen, aged 12
Primary school
Symptoms of extreme anxiety and fear of hostility Boys more quickly exhibit behavioural problems (but girls equally affected) Self-blame and poor self-esteem Academic attainment and social development affected by neglect and poor attendance, poor concentration Shame and embarrassment lead to isolation Young carers
Primary school
“
I used to feel angry when my Mum was on drugs ‘cause I used to think how could this have happened to me? I was just sad all the time and then I would get angry. And we would have arguments all the time.”
Anne, aged 11
“I used to get really embarrassed at school when mum turned up drunk to collect me. I knew that I would have to make the tea when I got in.”
Billy, aged 9
Secondary school
Puberty without parental support Increased risk of conduct disorders, bullying and sexual aggression Beyond parental control and increased risk of injury by parents Socialised into substance misuse
Secondary school
“I knew they loved me but they just didn’t care that I was there and I needed stuff as well”
Elaine, aged 14
“At school, if your pals know your ma’s on drugs you get called a junkie”
(Aberlour 2002)
Protective factors
Sufficient income A consistent caring adult Regular monitoring and respite Refuge from violence Regular school/nursery attendance Sympathetic and vigilant teachers Organised out of school activities
The significant harm threshold
The threshold is probably passed when: Parental drug and alcohol use is adversely impacting on the child’s health and development There is no one parental figure able to provide a stable secure environment for the child There is no evidence that parental behaviour will change within a timeframe congruent with the needs of the child (Luton LSCB Safeguarding Inter-Agency Procedures, 2006)
When enough is enough
When a parent consistently places procurement and use of alcohol or drugs over their child’s welfare and fails to meet a child’s physical or emotional needs, the outlook for the child’s health and development is poor. Problem alcohol or drug using parents themselves acknowledge this and it is the duty of professionals to act in the child’s best interests when parents cannot.
(Getting our priorities right, 2003)
Referral triggers
Use of the family resources to finance the parent’s dependency, characterised by inadequate food, heat and clothing for the children Children exposed to unsuitable caregivers or visitors, e.g. customers or dealers The effects of alcohol leading to an inappropriate display of sexual and/or aggressive behaviour Chaotic drug and alcohol use leading to emotional unavailability, irrational behaviour and reduced parental vigilance
Referral triggers
Disturbed moods as a result of withdrawal symptoms or dependency Unsafe storage of drugs and/or alcohol or injecting equipment Drugs and/or alcohol having an adverse impact on the growth and development of the unborn child (LSCB Safeguarding Inter-Agency Procedures, 2006
Assessment
Generic CAF GCP (assessment of parenting) Specialist substance misuse and/or child protection assessment
Assessment principles
Focus on the child Consider outcomes for the child, not the intent of the parent Focus more on the child’s lived experience than on specific incidents Adults’ management of their own lives is a good indicator of their ability to look after a child Take full account of historical information Information from a variety of sources is better than information from one
Working together
Complex network of intervention: Support parents and parenting Stabilise/reduce substance misuse Reduce risk and harmful effects on children These objectives may not always be compatible, especially with regard to timescales
Substance misuse workers vs child care workers
Mutual incomprehension and misunderstanding Working on the same case but not working jointly False expectations and assumptions Abdicating responsibility (both ways) Need for ‘interpreters’
Working with parents
It is good practice to work in partnership with parents Professionals should be open and honest with parents about the problems and risks they perceive Working with parents as partners does not mean their wishes determine decisions, but that their views are sought and taken into account.
Working with parents
It is important to recognise that: Parents will often hide the extent of their problem for fear of the consequences They may find it very hard to change, despite the consequences This means testing and checking their accounts