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Research report into child neglect NSW Australia

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Child neglect
Executive summary
This literature review of neglect has been undertaken to assist in refining definitions, examining risk factors, investigating developmental consequences, guiding management of cases, informing policy and identifying service strategies.
Definitions
There is a lack of consistency in how ‘neglect’ is defined.
Several definitions of neglect have been proposed. Most commonly they emphasise that a child’s basic developmental needs have not been met by acts of omission by those responsible for that child. In contrast, abuse is associated with acts of commission resulting in harm to the child.
Usually neglect is categorised into physical, emotional, supervisory, medical and educational neglect with several sub-categories for each type.
Greater specificity of definition is hampered by debates about what constitutes basic developmental needs and the level of care considered adequate to meet these needs.
Definitions are further qualified by debates about actual harm, potential harm, impaired development, social conditions, cultural beliefs, levels of chronicity and severity and the intent of caregivers.
Prevalence
Neglect is the most common form, and also the fastest growing category, of maltreatment in Canada, United States and the United Kingdom. In Australia overall rates of neglect appear lower. However, definitional differences make international and interstate comparisons in Australia, difficult.
Correlates of neglect
Neglectful parenting is most strongly associated with poverty. It often occurs where there are large numbers of children being cared for by a young single mother with little social support. Substance abuse, mental health issues and domestic violence often add to already limited parenting capacity and serve to exacerbate the situation.
It may be misleading to generalise the findings of research carried out in the United States to the Australian context. Given the strong association between neglect and poverty, the very different family welfare policies in the two countries may contribute to the perception of neglect, and how it is treated, in these countries.
Young children (infants and toddlers) and those with a disability are those most likely to be neglected, suggesting high levels of dependency are associated with neglect. Unlike other forms of child maltreatment, neglect seems to be unrelated to temperament and gender. In the United States it has also been shown to be unrelated to ethnicity once other socio-demographic variables have been taken into account.
Effects of neglect
While each neglectful incident may seem trivial, the long-term consequences of chronic neglect may be more damaging than isolated incidents of physical abuse.
Children who have been neglected are prone to internalising problems such as low self-esteem, depression, social withdrawal, apathy, passivity and helplessness. They are often delayed in their cognitive and language development and have poor communication skills. They have difficulty with interpersonal relationships.
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Child neglect
In the longer-term neglected children lack the ability to participate fully in society as adults.
An estimated half of the maltreatment fatalities are attributable to childhood neglect. Childhood maltreatment fatalities are most often the result of a single life-threatening incident. This makes their prediction, and therefore prevention, extremely difficult.
Service provision
Service providers need to be able to recognise early indicators of neglect. While there are a number of scales which purport to measure caregiving quality, they rarely have the predictive validity needed to be useful to practitioners.
Guidelines to assist social workers dealing with neglectful families stress the importance of treating the families with respect, targeting their strengths, being culturally sensitive, setting clear achievable goals that require only small incremental change, and brokerage to cover basic necessities and purchase services. The threat of legal action should be used only as a last resort.
Effective interventions are those that support the parent and provide the child with the cognitive stimulation and the emotional warmth that they lack at home. For this reason high quality child care, home visiting programs and co-located multi-component services, which target both parent and child, may be effective.
Given the association with poverty, interventions need to be concrete and meet the families’ identified priorities. The greater the severity and chronicity of neglect the more directly the intervention needs to target the child.
Family preservation programs have only had limited success with neglectful families. Where neglect is severe and chronic children may be better served by permanent placement with another family.
Barriers to service provision
Neglectful families are extremely hard to recruit and engage. Service providers may not report neglect because:
Given their history and current disadvantage, it is not surprising that Indigenous families in Australia have higher levels of neglect than non-Indigenous families. Offers of intervention are regarded warily by this group following decades of a policy of child removal. These families need to be treated with greater sensitivity by service providers due to cultural and historical factors.
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• • • •
each incident seems too trivial on its own
they are reluctant to pathologise families already disadvantaged by poverty
they tend to prioritise more violent maltreatment when resources are scarce
they see the problem in terms of the parents’ substance abuse or mental health and organise treatment for the adult to which children’s services are not linked.
Child neglect
Implications
Questions that need further analysis are:
•    What characteristics/behaviours of families lead to a classification of neglect?
•    Do current assessments accurately identify neglect cases?
•    What happens to children who suffer from being chronically but less severely neglected?
•    What services are provided and which are most effective? Is some type of family support more beneficial in the first instance?
A nested study could examine the effectiveness of different types of interventions.
More accurate information and a more in-depth understanding could be gained by prospectively tracking the progress of a group of children classified as neglected at notification.
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1. Introduction
1.1    Overview
The focus of this literature review is specifically on child neglect. The first section examines issues associated with defining neglect and examining its prevalence. It then summarises the research in relation to risk factors, effects on child development, assessment issues and effective service sector response. Neglect issues relevant to Indigenous communities are addressed in a separate section. The evidence base relies heavily on overseas research, for the most part carried out in the United States. The welfare and legislative context in Australia differs markedly from that of the United States especially in relation to issues surrounding neglect. It is proposed further research be undertaken to understand neglectful families within the Australian context.
1.2    A focus on neglect
The review is primarily based on a library search of the search engines EBSCO, Gale, OVID, CSA, Informit and Ingenta for access to peer reviewed scientific journal articles. This included the following databases: SocINDEX with fulltext, Psychology and Behavioural Science Collection, PsycARTICLES, PsycINFO, MEDLINE, PsycBOOKS, PsycEXTRA, Academic Search Premier, Sociological Collection, Sociological Abstracts, Social Services Abstracts, and Expanded Academic ASAP. Government reports from the National Centre for Child Abuse and Neglect in Washington, the Australian Institute of Family Studies and the Canadian Incidence Study of Child Abuse and Neglect were accessed through APAIS as well as a more general Google search using ‘neglect’ in combination with ‘child’; ‘neglect’ in combination with ‘child abuse’; and, ‘neglect’ in combination with ‘child maltreatment’ as key words.
During the course of this literature search it became apparent that ‘child abuse and neglect’ have become fused into a single entity, as if describing one phenomenon. In fact most research focuses on abuse. As a result it has become commonplace in child protection research to refer to the ‘neglect of neglect’. A search of PsycINFO published in the five years to December 2004 revealed 3888 entries for child abuse (often also incorporating neglect) but only 57 that concentrated specifically on neglect. This conceptual merging of abuse and neglect has made the assessment of the differential impact of each one difficult to disentangle. The articles which do focus on neglect are often theoretical with an emphasis on refining definitional issues rather than providing the hard data to inform practice and policy. However without a clear definition to underpin the research, conclusions necessarily remain qualified.
1.3    Definitional debates and issues
The attempt to be all encompassing within a single, succinct definition of neglect has often resulted in broad definitions that are vague, and therefore limited in their usefulness. An alternative approach has to been to compile detailed lists of possible neglectful behaviours. Although clearer, these lists have the disadvantage of not taking context into account, being unwieldy and prescriptive.
Child physical, sexual or emotional abuse is traditionally defined in terms of harm to the child. In contrast, neglect is defined by what is not happening to the child rather than what is happening.
Several definitions have been proposed, each with a slight difference in emphasis (eg Gaudin, 1993; United States Department of Health and Human Services [USDHHS], 2001; Polansky, Chalmers, Williams & Buttenwieser, 1981; Straus & Kantor, 2005). The common broad elements usually include that a child’s basic developmental needs have not been met (or development has been impaired) as a result of acts of omission on the part of those responsible for a child. The definitions, whichever slant they take, tend to be phrased in the negative. Often added to such definitions are qualifiers relating to factors such as social conditions, cultural beliefs, the importance of chronicity, the level of potential or actual harm to the child, or the intent of the caregivers.
Whether a broad or narrow definition of neglect is adopted depends upon whether it is to be used for legal, research, policy or service provision purposes.
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Child neglect
A narrow legal definition of neglect is needed to protect the rights of the family. Narrower definitions include that the child has been harmed or has been placed in a situation that is potentially harmful. They are also more likely to hold a specific person responsible. For researchers the definition is also often very narrow to ensure a valid sample. In this case, samples are often sought through the child protection agencies and are made up of substantiated neglect cases.
A broad definition is needed when the intention is to provide appropriate services. The focus is then on ‘at-risk’ families, who may have trouble meeting all a child’s needs without support. This broadening of the definition is in line with a shift towards early intervention and prevention in the service response. However, by broadening the definition, a greater number of children will be captured within its rubric and classified as neglected. The breadth of the definition needs to be taken into account when assessing trends in neglect as changes in definition will be reflected in the numbers categorised.
Whichever approach is adopted, there is still a lack of consensus about what constitutes neglect. The same questions have predominated in the literature on neglect over the past decade (see Gaudin, 1993; Straus & Kantor, 2005).
These include: •    What constitutes meeting the developmental needs of children? •    How socially and culturally dependent is the concept of neglect? •    To what extent is neglect defined by harm to the child? •    To what extent is neglectful behaviour wilful or intended? •    Does failure to meet needs have to be persistent?
1.3.1
What constitutes meeting developmental needs?
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The broadest definition of neglect, proposed by Dubowitz (2004) is an unelaborated ‘the basic needs of the child are not met’. The rationale for such a broad definition was to avoid the notion of ‘blaming’ someone for not meeting these needs (Dubowitz, 2004). However, if some of the purpose of a definition is for clarification and ease of categorisation, the fundamental questions regarding what constitutes the minimal standard of care required to meet basic needs, and who might be responsible for meeting them, remains unanswered.
Early definitions of neglect focused on physical neglect, such as inadequate living environment, personal hygiene or nutrition perhaps because this type of neglect is most readily apparent (James, 2000a). Definitions have since expanded to include multiple categories such as supervisory neglect, abandonment or desertion, and educational or medical neglect. Psychological and emotional neglect have been added, which are less easy to recognise and quantify, for instance how can the amount of nurturing required to secure a child’s emotional wellbeing be measured? It is even more difficult to define and measure how much ‘lack of nurture’ is emotionally damaging.
Cut-off points above or below which any type of neglect is considered to have occurred are not sharply defined (May-Chahal & Cawson, 2005).1 It is difficult to define the point on the continuum of duty of care at which behaviour becomes neglectful. There is substantial agreement by observers in the more obvious cases where there is a failure to protect from harm, for example toddlers left unsupervised, five or six year olds being left home alone, children who are not fed regularly, are chronically dirty, or absent from school (Gaudin, 1993). For the more borderline cases, whether parents are failing to meet basic needs or failing to promote wellbeing, several authors suggest the context needs to be considered (Dubowitz, 2004; Gaudin, 1993; Polansky et al., 1981).
1    Cawson, Wattam, Brooker and Kelly (2000) give some guidelines as to what constitutes eg supervisory neglect, but these may only serve to highlight the difficulties in finding agreement. For instance, there may not be agreement with their proposal that serious neglect is considered to have occurred when a nine- year old is at home unsupervised or intermediate neglect has occurred when a child age 10 or 11 years is at home without an adult.
Child neglect
1.3.2    Are developmental needs socially and culturally defined?
Although there is agreement across social and ethnic backgrounds on what constitutes serious neglect, whether a child’s basic developmental needs have or have not been met is, to some extent, socially and culturally constructed. In Australia, there is both a relatively large, and an increasing gap between the rich and the poor (Harding, 2005; United Nations Development Program, 2004) and great cultural diversity (ABS, 2004, Cat. no. 3412). Ambiguity generated by this heightens the risk of an inaccurate assessment of neglect. This may occur by imposing an Anglo, middle-class notion of ‘children’s needs’ on a social and cultural minority and attributing ‘neglect’ where it is not warranted. However, it also increases the chance of overlooking neglect as social workers hesitate to ‘blame’ minority group families or those living in poverty (Tanner & Turney, 2003; Tomison, 1995).
Cultural differences are likely to relate to the age at which a child can adequately care for themselves after school (self-care) or safely look after a younger sibling. In Laos or Cambodia, an infant could be expected to be left in the day-long care of a seven or eight year old sibling; both children would be considered neglected in Australia (Korbin & Spilsbury, 1999, cited in Straus & Kantor, 2005).
1.3.3    Does a child have to be harmed for neglect to have occurred?
This is part of the broader question about whether to define neglect on the basis of adult behaviour or the outcome for the child.
Within a narrow definition, the behaviour of caregivers has to result in specific physical harm or identifiable symptoms of emotional harm in order for their behaviour to be considered neglectful. Polansky et al. (1981), for example, argue that actual harm has to have occurred, or that development must be impaired.
In contrast, Straus and Kantor (2005) argue that the focus should be on the actions of the caregivers, not the consequences of their behaviour, nor their intent or culpability. Unlike children who have been abused, only 25 per cent of children reported to a child protection agency for neglect suffered immediate physical harm (Zuravin, 1988). As an example, if a four-year-old and a five-year-old child are left alone for 24 hours and manage to look after themselves and no harm befalls them, the behaviour of the parent is still neglectful. The same children may be left alone for 10 minutes and may be injured in that time. Both acts may be neglectful but, if defined on the basis of harm the latter would be considered more extreme, if defined on the basis of parental action, the former would be considered more neglectful.
If only those children who are harmed are considered neglected, the prevalence of neglect will be vastly underestimated. Policies and services that could support children and their families before harm occurs are less likely to be put into place. It also makes it difficult to examine the harmful effects of neglectful caregiver behaviour as the neglectful behaviour and the resulting harm are considered to be the same concept, or in research terms, measured by the same variable (Straus & Kantor, 2005).
1.3.4    Is harm intended?
If neglect were defined in terms of harm to the child, there is no longer the need for the subjective interpretation of parental intention (Connell-Carrick, 2003). However, the same behaviour and the same harm done to children may be judged differently depending on how the intentions of the parents are perceived.
Some parents are unable to meet their child’s basic needs despite good intentions (for example, through poverty). Others may lack the knowledge to provide a nutritious diet, or lack the understanding of child development and so allow a child to play unsupervised in a dangerous situation.
Social workers are less likely to report mothers who are seen not to have the capacity to provide adequate care, than those who are considered capable of providing adequate care but fail to do so (Coohey, 2003). Minty and Pattinson (1994) incorporate this into their definition of neglect by qualifying that the child’s basic needs are not met, ‘in spite of the parents having the economic resources to meet these at a basic level’.
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Child neglect
By not classifying as neglected those children whose parents are well-intended but fail to meet their needs, their numbers will be underestimated, with a consequent failure of policy makers and service providers to take remedial measures. It can be argued that asking the reasons for caregivers being unable to meet the children’s needs is a separate question. To understand how some impoverished parents manage to meet their children’s basic needs when others do not, all children whose needs are not met need to be identified, regardless of cause (Straus & Kantor, 2005). The extent to which parents are culpable may define the type of intervention provided but it should not preclude the classification of a child as neglected.
1.3.5    Does the failure to meet basic needs have to be persistent?
Some definitions suggest differentiating chronic or persistent neglect from episodic, reactive or transitory neglect. This differentiation recognises that some parents may struggle to deliver appropriate care at times of crisis and that there is an implicit cultural tolerance of rarely occurring neglectful behaviour for parents, all of whom may be occasionally inattentive (Tanner & Turney, 2003; Straus & Kantor, 2005).2 Chronic neglect, on the other hand, is characterised by an ingrained sense of hopelessness in the parents and an unremitting low level of care for the children (Tanner & Turney, 2003).
While the severity (presumed harmfulness or illegality) as well as the chronicity (frequency and duration) of the neglectful behaviour are important considerations (Barnett, Miller-Perrin & Perrin, 1997; Straus & Kantor, 2005) it can also be argued that even a single incident can constitute neglect. Leaving a pre-schooler unsupervised for several hours is neglectful behaviour whether it is a single incident or has occurred several times (Zuravin, 1999).
1.4    Towards a working definition
A working definition of neglect needs to be broad enough to encompass systemic change by recognising the impact of policy decisions on child outcomes, but it also needs to allow field workers to identify children who are neglected. It needs to be able to include children who have not been harmed but whose development will be impaired without supportive interventions.
It is argued that a child-focussed definition of neglect should be considered. A child is neglected if, within cultural expectations, his or her developmental needs are not met by those responsible regardless of intent, culpability, or social or ethnic background.3 Levels of intent and culpability, chronicity and severity, as well as social and ethnic background should be taken into account when considering the legal implications and appropriate service provision.
The definition adopted here is most closely aligned with that proposed by Straus and Kantor (2005, p. 20) which states:
Neglectful behaviour is behaviour by a caregiver that constitutes a failure to act in ways that are presumed by the culture of a society to be necessary to meet the developmental needs of a child and which are the responsibility of a caregiver to provide.
A broad definition may need to be complemented by more detailed descriptions differentiating subcategories of neglect. Although this often entails long lists of acts of omission or commission, it is likely to be of more use to practitioners.
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3
The definition of the Department of Health in the United Kingdom emphasises chronicity. Neglect is seen as ‘a 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. It may involve a parent or carer failing to provide adequate food, shelter or clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.’ (Department of Health – Working Together definition, 1999, p. 6, cited in Tanner & Turney, 2003).
A child in a refugee camp who does not access schooling suffers educational neglect regardless of whether it is because there is no schooling available or because the parents permit the child not to attend. The responsibility to remedy the situation differs.
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Child neglect
In an attempt to overcome the problem of non-uniform definitions, the US Department of Health and Human Services (USDHHS, Sedlack & Broadhurst, 1996) proposed a standard definition of neglect. They differentiated five major types of neglect with 17 subcategories. These definitions have since been added to and adapted by others, such as Gaudin (1993) and Sullivan (2000) and apply to all those caring for children. These categories proposed are detailed in Appendix A and include:

• •

Physical neglect
Supervisory neglect Emotional neglect4
Educational neglect
with subcategories of general neglect (eg failure to provide adequate food, clothing and shelter), medical neglect, abandonment and expulsion.
related to inadequate supervision dependent on the age of the child involved.
with subcategories of inadequate nurturance or affection, chronic or extreme spousal abuse, permitted drug or alcohol use, permitted maladaptive behaviour, refusal of psychological care, delay in psychological care, or other emotional neglect.
with subcategories of permitted or chronic truancy, failure to enrol or inattention to special educational need.
4    Emotional neglect may also overlap to some extent with emotional abuse, however the latter is usually considered to be more active (Tanner & Turney, 2003). Abuse comprises the sustained assault on the identity and personality of the child, through threatening, yelling and verbal degradation, terrorising, exploiting, corrupting and refusing to be emotionally responsive whereas emotional neglect is related more to the psychological unavailability of the parent and the absence of consistent interaction. Emotional neglect often emanates from parental unawareness and ignorance, depressive moods, chaotic lifestyles, poverty, lack of support and inappropriate child-rearing models (Sullivan, 2000).    5
Child neglect
Summary
A precise definition of neglect is often hampered by the consideration of abuse and neglect as the same phenomenon. Abuse refers to acts of commission whereas neglect refers to acts of omission.
Much of the literature is centred around debates about the following questions: •    What constitutes meeting developmental needs of children? •    How socially and culturally dependent is the concept of neglect? •    To what extent is neglect defined by harm to the child?
•    To what extent is neglectful behaviour wilful or intended?
•    Does failure to meet needs have to be persistent?
Some of the answers to these questions depend on the purpose of the definition. Narrower definitions are needed for legal and research purposes than are required for service provision purposes.
Straus and Kantor (2005, p. 20) state:
‘Neglectful behaviour is behaviour by a caregiver that constitutes a failure to act in ways that are presumed by the culture of a society to be necessary to meet the developmental needs of a child and which are the responsibility of a caregiver to provide’.
A useful definition may be one that provides a broad understanding of the concept of neglect in combination with detailed descriptions of subcategories of neglectful behaviour including physical, supervisory, emotional and educational neglect.
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Child neglect
2.    Prevalence of neglect
2.1    International and national trends
In Canada, the United States and the United Kingdom, neglect is the most common form of maltreatment. In the United States, 61 per cent of all child maltreatment victims suffer from neglect (USDHHS, 2005). There is a substantiation rate of 7.5 per 1000 for neglect compared with 2.3 per 1000 for physical abuse (USDHHS, 2005). Neglect is also the primary reason for a report in 42 per cent and 40 per cent of all maltreatment cases in the United Kingdom and Canada respectively (Department for Education and Skills, 2004; Trocmé, MacLaurin, Fallon, Dacuik, Billingsley, Tourigny et al., 2001).
Neglect is also the fastest growing form of maltreatment. In the United Kingdom the proportion classified as neglected within the maltreated population, more than tripled between 1991 to 2001 (Evans, 2002; City & Hackney Area Child Protection Committee, 2002), although the rates have plateaued since then (Department for Education and Skills, 2004). In the United States there was an increase in both emotional neglect (333 per cent) and physical neglect (102 per cent) between the Second and Third National Incidence Study of Child Abuse and Neglect (NIS-2 to NIS-3, 1986-1993; Hildyard & Wolfe, 2002). In Canada the rate doubled between 1993 and 1998. Compared with physically abused children, neglected children are also 44 per cent more likely to suffer a recurrence (Fluke, Yuan & Edwards, 1999; USDHHS, 2001).
These figures paint a somewhat distorted picture as neglect is difficult to isolate from other forms of maltreatment. Co-occurrence of types of maltreatment is not uncommon. Nevertheless, in Canada, 31 per cent of all reports involved neglect as a single category. Neglect was the most common type of single category report of maltreatment, compared with single category physical abuse of 22 per cent, single category sexual abuse of 8 per cent and emotional abuse of 15 per cent (Trocmé & Wolfe, 2001). Co-occurring with neglect were another 4 per cent of cases involving physical abuse, 2 per cent involving sexual abuse, 8 per cent involving emotional abuse and 2 per cent involving neglect with physical abuse and emotional abuse (Trocmé et al., 2001). In Australia, Tomison (1995) found 15 per cent of cases labelled as neglect also involved some physical abuse.
Of those children who are neglected in the United States, the most common category was physical neglect which accounts for 43 per cent of all neglect (Sullivan, 2000 – she includes supervisory neglect in this category). Physical neglect may have received more attention than other forms of neglect because people are more likely to report a child who is malnourished, unclothed or unsupervised than one who is emotionally deprived. Amongst those living in poverty in the United States, 60 per 1000 suffer physical neglect whereas only 20 per 1000 suffer emotional neglect (Sullivan, 2000).
Coohey (2003) suggests that supervisory neglect represents the largest single type of child maltreatment (30 per cent) more than physical abuse (19 per cent) or sexual abuse (10 per cent). In Canada it accounts for almost half the cases of neglect (Trocmé et al., 2001). Despite this, few studies have been published that focus on supervision problems (Bloom, 2000).
In Australia, there are comparatively lower rates of neglect. In 2002-20035, 31 per cent of substantiations of child maltreatment were classified as neglect (Australian Institute of Health and Welfare (AIHW) 2004); an increase from 23 per cent of cases from 1992-1993 (AIHW figures, cited in Tomison, 1995). Figures range from 19 per cent in NSW to 42 per cent in South Australia (AIHW, 2004). Differences in rates between states are likely to be a function of differences in definition, differences in capacity to follow up and the categorisation adopted to inform service response. In Western Australia neglected children are likely to attract a Concern Report and in Tasmania many neglectful families would be passed directly to support services and thus not be included in the maltreatment statistics (AIHW, 2002).
Neglect is still the most common category of substantiation in Australia. By comparison, 27 per cent of substantiations were of physical abuse, 25 per cent of emotional abuse and 13 per cent of sexual abuse, although again definitional differences resulted in large variation between states (extrapolated from AIHW, 2004).
5    2003-2004 data are not available for NSW. This paper relies on the more complete data set available across Australia in 2002-2003.    7
Child neglect
2.2    Neglect rates and a comparison of welfare systems
Australia’s low rate of neglect compared with the United States may be in part explained by the greater welfare support available in Australia. Welfare to Work programs in the United States have a capped lifetime limit of five years that a family can receive public assistance. If a parent has a criminal record or a drug problem, public assistance can be denied outright (Berry, Charleson & Dawson, 2003). After welfare benefits cease, families can ask for assistance from the child welfare system but it does not have any programs to meet the financial needs of families. The most common response to the needs of neglectful families is to place their children in foster care (Duerr-Berrick & Duerr, 1997). There are now increasing numbers of children in foster care in the United States after a decline during the 1980s. Many of these children are victims of neglect rather than abuse (Berry et al., 2003).
Relatively recent changes in legislation in the United States in 1997 (Adoption and Safekeeping) states that courts must pursue termination of parental rights once the child has been in foster care for 15 of the last 22 months of care (Berry et al., 2003). Of children in the welfare system in the United States 41 per cent of children have been in out-of-home placement for at least 18 months (Berry et al., 2003).
In contrast in Australia, there is broader eligibility for welfare benefits which, unless welfare conditions are breached, are likely to continue as a function of the age of children involved. With these benefits, careful budgeting and perhaps some assistance from charitable and/or other organisations, most families are likely to be in a financial position to provide for children’s basic needs. Nevertheless some children are likely to suffer neglect. Parents with intellectual disabilities, substance abuse problems or mental health problems are amongst those, not only most likely to be neglectful, but also to incur breaches of welfare conditions and to lack the resources to cope on a limited budget. While the situation might be quite precarious for some families, there is not the depth and breadth of poverty (including unemployment and homelessness) as exists in the United States.
There is a lower level of all child maltreatment in Australia than the United States as well, with a substantiation rate of around 5.7 per 1000 in Australia compared with 12.4 per 1000 in the United States (AIHW, 2004; USDHHS, 2005), although figures tend to be a bit ‘rubbery’ because of the definitional issues. The narrower the definition the fewer the number of children likely to be classified as maltreated, whereas the broader the definition the more children are likely to be captured. This makes accurate comparisons difficult.
Summary
Neglect is the most common form of maltreatment and also the fastest growing category in Canada, United States and the United Kingdom. Between 40 and 60 per cent of all reports of maltreatment are for neglect with about two thirds of these being for neglect only.
The rate of neglect is lower in Australia, particularly in NSW, although it is still the most common form of maltreatment. The welfare and legislative context in Australia differs markedly from that of the United States especially in relation to issues surrounding neglect, making comparisons of prevalence difficult. Even within Australia, differences in definition and classification for the purposes of service response, means rates of neglect in the States and Territories cannot be easily compared.
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3.    A socio-ecological model of neglect
3.1    The socio-ecological model
Efforts to reduce the incidence of neglect aim at prevention through an understanding of its causes. Traditionally, neglectful parenting was seen as a function of the parental characteristics (Éthier, Lacharité & Couture, 2000, p. 20; Evans, 2002; Crittenden, 1996; Belsky, 1993). Consequently, Swift (1995, p. 75) argued that ‘scrutiny of personal characteristics of mothers continued as a primary focus for social workers concerned with the care of children’.
As an understanding of the influence of social context on developmental outcomes has increased over the past twenty years, researchers have examined correlates of neglect within the broader framework of the socio-ecological model (Bronfenbrenner & Ceci, 1994). This expanded the focus of explanation of developmental outcomes from the parents to include the influences of the broader social context and characteristics of the child (see Figure 1).
The child, with a given genetic predisposition, is seen as being at the centre of a series of concentric circles. The family is still conceptualised as the most powerful influence on a child. However, other proximal influences such as the child’s extended family, peer group, school and the local neighbourhood are also included. Furthermore, distal influences such as the media, governmental family policies, current cultural beliefs and values are seen as contributing to shaping a child’s developmental health. In between the proximal and distal influences are such influences as the parents’ workplaces, parents’ informal and formal supports and the interaction between them.
Although, Bronfenbrenner and Ceci (1994) had originally conceptualised this model as a way of understanding individual children’s developmental outcomes, Keating and Hertzman (1999) expanded this concept and argued that the broader societal influences could influence the developmental health of the society in which people lived. There is now some evidence to support the notion that variations in developmental wellbeing across countries may be related to the macro-economic policies of these countries (Phipps, 1999).
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Figure 1: Bronfenbrenner’s Socio-ecological Model
Media
Chronosystem
GP
Early Childhood Centres
Societal Attitudes Formal Services
Extended Family
Neighbours    Friends
Immediate Family
The Child
Temperament Ability Health Gender
Work Friends    Informal Support Network
Community Government Policy
Time
(Sociohistorical conditions and time since events)
Health
Education
Culture
Patterning of environmental events and transitions over the life course: sociohistorical conditions
Source: Bronfenbrenner & Ceci (1994) adapted by K. Furst
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3.2.1    A pathway approach
The developmental pathway or trajectory a particular child follows is hypothesised to be a function of multiple proximal and distal factors (Rubin, LeMare & Lollis, 1990; Belsky, 1993). Proximal influences that support or erode parental efforts (for example, the level of pre-natal care received, parenting style, family situation and parental mental health) can be considered, as well as distal influences (such as, work/family policies, availability of child care and societal attitudes). Some of these factors will increase the child’s risk, some will protect and some will add to the child’s resilience.
The socio-ecological theoretical model considers societal, family and child characteristics. In societies that offer only marginal support to parents, where jobs are often insecure or casual, or where attitudes towards single parents are negative, the groundwork is laid for some groups, such as disadvantaged single mothers, to feel alienated and insecure. If, in addition, they have little social support from family and friends, are poor and live in a dangerous neighbourhood, this heightens their insecurity. Limited intelligence and education may further compound their problems. If their own childhood has been characterised by abuse and neglect, and their current relationships are characterised by conflict, violence and substance abuse, the additional demands of a new baby (exhausting enough for those with many psychological and material resources) may be quite overwhelming. If the baby is grizzly, difficult or demanding, this may increase the chance of either abuse, or just keeping out of earshot and ignoring the child’s needs. Where the child is placid and quiet, the child may also be easily ignored. A child whose bids for attention are generally ignored and whose few interactions are without affect or joy soon learns to give up trying and becomes quiet and apathetic. The lack of physical care and hygiene may result in the child becoming dirty and smelly, increasing the chances that this pattern is repeated in the world outside the family as the child attends preschool or school. Teachers may find them slow and unappealing and their peers may subject them to taunts and bullying behaviour.
In this model (see Figure 2), it can be seen how each risk factor acts in a cumulative way to increase the chances of a negative outcome for the child but that many of the risk factors are likely to be inter- related (such as single parenthood and poverty). The existence of one risk factor then increases the chance of another risk factor occurring, often compounding the negative effects.
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Child neglect
Figure 2:
12
Socio-ecological model – Interrelationship between risk factors and neglect
An example of a developmental pathway of a neglected child
Unfavourable socio-political situation
Lack of parental skills and role models
Parental stress/ neglectful parenting practices
Lack of parental skills and role models
Poor peer
relations, rejection by peers
Teacher overlooks quiet, slow, dirty child
Whinging unresponsive neonate
Apathetic,
uncertain, unresponsive, dirty, smelly preschooler
Preschool
Easily picked on, slow to retaliate, miserable, poor academic performance socially neglected
Primary school
Depressed, withdrawn, under-acheiving, drops out of
school early
High school
Disadvantaged socio-demographic background
Socio- political/ demographic
Unstable parent characteristics substance abuse, DV
Parental/ family characteristics
Infant characteristics
Irritated
parent, ignores baby
Parent- child interactions
Source: Watson, J. & Furst, K. (2005)
Child neglect
3.2    Testing the theoretical model
There are two main ways of examining relationships between the child, family and socio-demographic variables and developmental outcomes. First, a longitudinal design can be adopted which follows the developmental trajectories of a cohort of children and their families over a period of time. This allows causal relationships to be established between variables, so that the mechanisms by which risk is transmitted can be isolated.
Where longitudinal studies have been carried out, the sub-samples of neglected children within them have, until recently, been small (eg Egeland, Sroufe & Erickson, 1983, n = 24; Hoffman-Plotkin & Twentyman, 1984, n = 14 abused and 14 neglected). This is partly because neglect of children, although common amongst maltreated children, is a relatively rare occurrence within the general population. In addition, few studies have differentiated neglect from physical abuse making it difficult to discern the unique effects of neglect (or specific types of neglect) on children’s functioning. Indeed, as children rarely experience only one type of neglect, it is likely that there is a cumulative effect of these different types.
Second and more commonly, a cross-sectional design is adopted. These studies examine the correlations between variables at one point in time. This research is less costly and time consuming but only highlights associations. A danger here is that some factors will correlate with neglect and become implicated in the model only by their association with a risk mechanism. As an example of this Rutter (2000) argues that social disadvantage is associated with an increased risk in poor developmental outcomes but he states there is clear evidence that ‘this is largely because these broad social features predispose to poor parenting. The proximal risk mechanism lies in the poor parenting rather than the poverty or social disadvantage as such’ (Rutter, 2000, p. 653).
Cross sectional studies often examine children who are defined as neglected through substantiated reports. They then examine the correlates of neglect. Those correlates that are in the child’s background (for example, poverty, single parent family, lack of social support) are categorised as risk factors for neglectful parenting, while correlates with child development (poor peer relationships, low academic achievement) are categorised as ‘developmental outcomes’. The risk factors are presumed to predispose to neglectful parenting which then mediates adverse developmental outcomes.
Summary
Traditionally, individual psychopathology was seen as the explanation for neglect by parents. Explanations of neglect have expanded to include the broader social context adopting the socio- ecological approach proposed by Bronfenbrenner and Ceci (1994).
Most research investigating neglect has relied on cross-sectional methodology which limits conclusions to associations between variables. Longitudinal studies are needed if causes and effects are to be understood.
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4.    Risk factors associated with caregiver neglect
Most of what is known about neglect comes from cross-sectional studies. A recent review of correlates of neglect was conducted by Connell-Carrick (2003). Studies published between 1990 and 2002 were included. After an initial cull, the review was finally narrowed to concentrate on correlates of physical and supervisory neglect or to those studies where neglect was used as an aggregate criterion variable. Educational and medical neglect were excluded. There were 68 articles that examined correlates of neglect and abuse and 24 met the criteria of inclusion in her review. Most were atheoretical but a socio-ecological model was implied in the breadth of factors selected as possible correlates. The samples were not probability samples but most samples were large. Connell-Carrick’s (2003) review provides the framework for this section. Some early findings from Scannapieco and Connell-Carrick’s (2005) analysis of case-file records have also been included.
4.1    Socio-demographic factors associated with neglect 4.1.1    Poverty
In all the studies reviewed by Connell-Carrick (2003) socio-economic status emerged as the major correlate of neglect. These were families who lived in poverty, were poorly educated and had low status jobs or were unemployed.
It has been reported that 100 per cent of neglectful families and 84 per cent of abusive families live below the poverty line in the United States (Palacio-Quintin & Éthier, 1993, cited in Sullivan, 2000). In the United Kingdom, a Department of Health commissioned study showed that 98 per cent of families whose children were at risk of suffering emotional maltreatment or neglect were characterised by the extreme poverty of their material situation (Evans, 2002).
If relying on a harm or endangerment standard, the risk of physical neglect for those living in poverty was increased 44 times if the family income was below the poverty line of $15,000 compared with those whose family income was over the median wage of $30,000 (Bloom, 2000; USDHHS, NIS-3, 2001). This means that there are 27.2 children per 1000 suffering neglect amongst those living in poverty compared with 0.6 per 1000 for those in families earning at least the median wage.
The rate is lower if looking at substantiations of neglect. For substantiations the comparable rates by income are six times as high for poor families in the United States (Lee & George, 1999). Of neglecting parents in Canada, 85 per cent had incomes below the Canadian low cut off limit and 11 per cent were economically vulnerable (Sullivan, 2000).
Not surprisingly, poverty emerged as a stronger indicator of neglect than of physical abuse (Barnett et al., 1997; Knutson, DeGarmo, Koeppl & Reid, 2005). Poverty is implicated almost by virtue of defining physical neglect as the inability to provide adequate shelter, nourishment, clothing and hygienic conditions. In the United States the neglect rate is highest amongst the ‘poorest of the poor’. This suggests that families who no longer have access to welfare payments are over-represented in neglect cases. These families are also less likely to be able to afford good substitute care when the need arises and may then be considered neglectful for failing to protect their child, or for providing inadequate supervision. Dubowitz et al. (1993, p. 22, cited in Evans, 2002) write ‘it can be argued that in a society with immense resources, poverty per se constitutes child neglect’.
Cawson et al. (2000, p. 39) however suggest that poverty ‘is not necessarily a cause of neglect, despite the correlation between the two’. She suggests that the link between poverty and neglectful parenting is because poverty is ‘a contributory factor to feelings of helplessness and social distance or exclusion ... and susceptibility to physical and mental illness’.
Nevertheless as Sullivan (2000) points out, despite the apparently strong link between poverty and neglect, most poor families do not neglect their children. Caution needs to be applied by social workers that they do not suggest there is neglect where there is only poverty, nor should they ignore neglect by attributing this behaviour to poverty (Sullivan, 2000).
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Child neglect
In considering the effect of socio-economic status it also needs to be borne in mind that wealthier families may have the resources to hide physical and supervisory neglect while being psychologically or emotionally neglectful. Poor and minority families, whose children are more likely to suffer physical neglect, are also more likely to come to the attention of the authorities.
Indeed it can been argued that in middle class areas where both parents often work longer hours, children may not be immune to the effects of parents becoming less psychologically available or providing them with what may be seen as inadequate supervision. As well, many children may be subjected to an unhealthy fast food diet and have unrestricted and unsupervised access to television, computer games and the internet. It has been speculated that unmanaged childhood obesity is a type of neglect (Bloom, 2000).
4.1.2    Number of people in the home
Mothers who neglected their children had more children than non-neglecting mothers (Brayden & Altemeier, Tucker, Dietrich & Vietze, 1992). The number of children aged under six years and the number of live births are some of the best predictors of neglect (Zuravin & DiBlasio, 1996).
If there were more than four people in the home the rate of overall neglect more than doubled and physical neglect was triple the rate of single child family (Connell-Carrick, 2003).
The number of children in the family was also a risk factor for a child dying of neglect. For children who died from neglect there was an average of 4.9 persons in the home. This suggests that the task of looking after a number of small children with little support creates difficulties for families already under stress.
4.1.3    Single parenthood and marital status
Non-married status and single parenthood were significantly associated with neglect. Sedlack and Broadhurst (1996, NIS-3) found single parent status increased all types of neglect by 87 per cent. Most of these single parents had a partner and the social support that accompanies it, but they had usually been with this partner for a lesser number of years than those who were married (Sedlack & Broadhurst, 1996).
4.2    Parental factors 4.2.1    Gender of parent
As mothering and parenting are often used interchangeably, even if the family is intact, it is the mother who will be seen as neglectful if the child is not adequately cared for or supervised. In line with this finding, 85 per cent of child fatalities due to neglect are seen as the mother’s fault. Mothers who are victims of domestic violence are often held responsible for a ‘failure to protect’ their children from exposure to domestic violence or from direct physical abuse from the perpetrator (Davidson, 1995; Davis & Gettinger, 1995; Hartley, 2004; Magen, 1999; Kantor & Little, 2003). Palacio-Quintin and Éthier (1993) cited in Sullivan (2000, p. 38) argue that:
It is unacceptable for mothers to be held solely responsible for neglect and the only parent implicated in CPS [Child Protection Service] investigations. Fathers have a direct influence on their children as well as indirect, in supporting the mother, emotionally and financially, in nurturing the child... Neglectful parenting has to be seen in the context of the whole family, including the father.
Fathers in neglecting families were less involved, showed less family leadership, had less clear negotiation skills, and were less willing to assume responsibility for feelings in neglectful families (Connell-Carrick, 2003).
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Child neglect
Dubowitz, Black, Kerr, Starr and Harrington (2000) found that the presence of a father figure decreased the likelihood of neglect. Presence of a father figure or father involvement resulted in less neglect when the duration of the relationship with the mother was longer, when involvement in household tasks and childcare was less, and when they had a greater sense of parental self-efficacy. The difference between the perception of mothers’ and fathers’ responsibilities is highlighted by the fact that a parent not being involved in looking after children might reduce the chance of neglect.
Straus and Kantor (2005) overcome this gender bias by referring to the agreed parenting roles of each person if there is more than one caregiver. If one caregiver has the responsibility to provide food, they are held responsible if there is no food. Nevertheless the assumption of maternal responsibility is apparent in the focus of research.
4.2.2    Maternal age
Poverty interacts with maternal age to increase the chances of child neglect. In poor areas children born to mothers 17 years of age or younger were 17 times more likely to have a substantiation of neglect than children born to mothers who were 22 years of age or more (Drake & Pandey, 1996). Even without the influence of poverty, young maternal age was consistently found to be a factor for child neglect (Lee & George, 1999).
4.2.3    Maternal mental health
When causes of neglect were first investigated in the 1980s, researchers tended to look for pathology in the mother without taking broader circumstances into consideration. In this vein, Polansky et al. (1981) suggested that neglecting mothers suffer from ‘apathy-futility syndrome’. He suggested that this was characterised by feeling that nothing was worth doing, emotional numbness and loneliness; they shared a reluctance to talk about feelings and had poor problem solving skills. Compared with control mothers they were more bored, depressed, restless, lonely, less pleased with and less interested in life than control-group mothers (Zuravin, 1988).
These findings are in line with more recent studies that have found high levels of depression amongst neglecting mothers. The Canadian National Incidence Study of Child Abuse and Neglect (Trocmé et al, 2001) found that 27 per cent of mothers were depressed. Four out of the five studies reviewed by Connell-Carrick (2003) found that mothers were likely to be depressed (see also Culp, Culp, Soulis & Letts, 1989; Coohey, 2003 and Scannapieco & Connell-Carrick, 2005 for similar findings). Depression may be more strongly associated with particular types of neglect. Coohey (2003) found that in 57 per cent of cases of supervisory neglect, the mother suffered clinical levels of depression compared with 35 per cent of mothers whose supervision was adequate.
The difference between neglectful and non-neglectful mothers from similar poor and uneducated backgrounds was their lack of impulse control, low self-esteem and self-confidence, external locus of control and difficulty expressing themselves. This was accompanied by a flatness of affect and lack of empathy (Brown, Cohen, Johnson & Salzinger, 1998; Chaffin, Kelleher & Hollenberg, 1996).
4.2.4    Limited intellectual functioning
Neglectful parenting practices may be related to low intellectual capacity. An estimated 72 per cent of neglectful mothers suffered intellectual impairment compared with only 5 per cent of physically abusive mothers (Connell-Carrick, 2003). They tended to answer in single words, found it hard to consider new ways of doing things, and were often rigid in their approach, had difficulty understanding their children’s behaviour or the complexities of parent-child relationships (Erickson & Egeland, 1996).
Sullivan (2000) suggests that parents of neglected children have unrealistic expectations of their children partly fuelled by lack of knowledge of child development. They lack empathy with their children and have little understanding of the complexity of human relationships. They have trouble
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Child neglect
engaging positively with their children and tend to put their own needs first. They are rigid and limited in their conceptualisation of human behaviour, tending to think in ‘all-or-nothing terms rather than the shades of grey that more realistically capture human behaviour’ (Sullivan, 2000, p. 39; Salmelainen, 1996).
4.2.5    Own poor parenting patterns
Neglecting adolescent mothers were not only three times more likely than non-neglecting mothers to have been sexually abused as children but also nearly four times as likely to have been in foster care as a child (Éthier, Couture & Lacharité, 2004). They were twice as likely to have run away, more than twice as likely to have appeared in juvenile court, and three times more likely to have had an abortion or miscarriage before the birth of their first child (Connell-Carrick, 2003).
4.2.6    Substance abuse
Substance abuse in parents is a commonly mentioned risk factor for neglect with drugs and alcohol implicated in 41 per cent of supervisory (Coohey, 1998) and close to half of cases of general neglect (Trocmé et al., 2001; Coohey, 1998; City & Hackney Area Child Protection Committee, 2002; Dunn et al., 2002; Coohey, 2003; Sullivan, 2000). This may be more of a problem in the United States and Canada where cocaine is a major problem, as an estimated 50 per cent of users neglect their children (Cash & Wilke, 2003). The availability of cocaine is low in most jurisdictions in Australia, although it is easier to obtain in Sydney (Milner & McGregor, 2004).
In the Quebec Incidence Study of Reported Child Abuse, Neglect and Abandonment and Serious Behavioural Problems (QIS, 2002), it was found that parental drug or alcohol use was the second most important factor (after the young age of neglected children) in differentiating neglected children from other children reported to the welfare authorities (Mayer, Lavergne & Baraldi, 2004). In a case-control design of 203 neglectful mothers, substance abuse emerged as the strongest predictor of neglect status among low socio-economic status (SES) women, ahead of depression, lack of social support and negative life events. Substance abuse was also the strongest predictor of parental disposition and adequacy of the home environment (Ondersma, 2002). It is not just the impaired care when under the influence of drugs or alcohol, but the time using it, the time involved in looking for it and the money spent on it which contributes to neglect in multiple ways (Cash & Wilke, 2003).
Substance abuse is also predictive of later maltreatment. Rates of substantiated maltreatment (mostly neglect) were two to three times higher in infants who had been exposed prenatally to illicit drugs (Jaudes, Ekwo & Van Voohis, 1995). In a large sample of over 7,000 children, substance abuse at the first wave of data collection tripled the rate of neglect evident at the second wave of data collection (Chaffin et al., 1996).
In neglecting families substance abuse often co-occurred with other risk factors (Mayer et al., 2004):
• • •
substance abuse and domestic violence in 41.7 per cent of families substance abuse and criminal activity in 32.2 per cent of families substance abuse and mental health problems in 31.3 per cent of families.
Domestic violence
4.2.7
There are higher substantiations of neglect where mothers have been subjected to domestic violence (Smith, Sullivan & Cohen, 1995; Zuravin & DePanfilis, 1997). In the Canadian Incidence Study nearly one quarter (23 per cent) of mothers of neglected children experienced spousal violence (Trocmé et al., 2001).
Domestic violence adds to the risk of neglect over and above the risk of other maltreatment (Beeman, Hagemeister & Edleson, 2001). The more severe the domestic violence, the more likely the child is to suffer from supervisory neglect (Hartley, 2002).
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Child neglect
4.2.8    Lack of social support
Neglecting mothers have smaller social support networks and less contact with them. They have less emotional support and less access to practical support, such as babysitting, help with household chores, provision of advice or help in making a decision (Gaudin, Polansky, Kilpatrick & Shilton, 1993; Coohey, 1996). They see their neighbourhood as less friendly and less helpful than do their neighbours (Gaudin, 1993). They are more socially isolated and feel more lonely even if relatives live nearby (Bloom, 2000). This feeling of loneliness may relate to other mental health issues such as depression.
Residential mobility was associated with less maternal supervision, poorer attachment and increased parental rejection (Sampson & Laub, 1993). This may also have implications for corporate and military families where increasing globalisation has seen families move around the world every few years to follow a corporate career.
Similar parental characteristics predict both physical abuse and neglect of children (Kelleher, Chaffin, Hollenberg & Fischer, 1994; Sedlak & Broadhurst, 1996), although physically abusive parents were more likely to be even younger (Brown et al., 1998) and more hostile and aggressive than neglecting parents (Caspi & Elder, 1988).
4.3    Family interaction
To understand within-family factors and parental styles, researchers tend to rely on qualitative studies or the expertise of experienced clinicians. These ‘paint a picture’ of the families, albeit a patchy one, but lack the strength of research evidence.
Dubowitz (2004) has researched and published widely on the subject of neglect. Some of his ideas are not research-based and stem from his clinical practice. Along with Crittenden (1999) he suggests three types of neglectful families. He argues that physically neglectful families are more chaotic, less organised and less expressive of positive affect than non-neglectful families. They tend to do what is easiest at that moment resulting in an inconsistent and haphazard approach to parenting. The second family typology consists of highly organised families where there are clear roles and rules, so that physical needs are met but parents fail to connect emotionally with their children. The third type of family are depressed, parents are withdrawn and disinterested, modelling passivity and helplessness that is passed on to their children.
Creating these typologies may be useful in helping practitioners select effective interventions and encouraging them to look further than physical health and hygiene. However, there is little research evidence to support the typologies as separate entities and the risk is run of oversimplifying the complexity of families. For instance, disorganised families may well be depressed and emotionally cold as well as physically neglectful.
4.4    Child characteristics 4.4.1    Age
The increased helplessness and vulnerability of infants and toddlers heightens the risk of their needs not being met. They are more likely to be neglected than to suffer other forms of maltreatment (Connell-Carrick, 2003). Although neglect affects children of all ages, children aged three years or younger are the most vulnerable and suffer the most devastating consequences. Ninety per cent of deaths due to neglect occur in children four or under (Scannapieco & Connell-Carrick, 2002).
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Child neglect
4.4.2    Temperament
Unlike children who are abused, where a difficult temperament seems to attract physical abuse, there is no association between infant temperament and the chance of being neglected (Connell-Carrick, 2003).
4.4.3    Ethnicity
There have been some associations in the United States between ethnicity and neglect but these disappeared after other variables had been taken into account (Connell-Carrick, 2003; Scannapieco & Connell-Carrick, 2005). In Australia, Indigenous children are more often victims of neglect than non-Indigenous children (AIHW, 2004). This is not surprising considering the poverty in these communities and the interrupted parenting suffered by many of the current generation of parents. Minority groups are also more likely to come to the attention of the authorities due to their over-representation in the child welfare system through poverty (Connell-Carrick, 2003).
4.4.4    Gender
Whereas more boys are physically abused, and more girls sexually abused there was no conclusive evidence to support an effect of gender on the likelihood of being neglected, although it seems boys may be more likely to die from neglect than girls (Connell-Carrick, 2003).
4.4.5    Disability
Children who suffer a disability, especially boys, are more likely to be neglected. For children who already have a developmental disability, 10 to 25 per cent are likely to experience abuse and neglect (Trocmé et al., 1998). As many as 11.5 per cent of children with developmental delay suffer neglect compared with only 1.5 per cent of other children (Verdugo, Bermejo & Fuertes, 1995, cited in Brown & Schormans, 2004).
Summary
The typical neglecting family is likely to be a young, single mother who has experienced poor parenting herself, lives in an overcrowded chaotic household with several children and is dependent on public assistance for support. She is likely to have inadequate social support, abuse substances, be depressed and, if partnered, suffer domestic violence. She is so overwhelmed by life and perhaps drugs or alcohol that she fails to adequately care for, be psychologically available to, or supervise her children. The victims are likely to be those who are most vulnerable, that is, children under four and/or children who have a disability. The consequences of neglect can sometimes be fatal (Scannapieco & Connell-Carrick, 2002). The risk factors for neglect are more likely to be characteristics of the parents than specific child characteristics.
Implication: Services should select families based on characteristics of the parents that are associated with neglect. Services should provide the most intensive support for these parents when the child is under 12 months, especially if he or she has a disability.
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Child neglect
5.    Developmental outcomes of neglected children
Although lack of parental care and nurturing, the hallmarks of neglect, are considered to pose one of the greatest threats to children’s well being and development (Rutter & Sroufe, 2000; Sameroff, 2000), research directly investigating the consequences of child neglect is sparse (Herrenkohl, 1990; Knutson, DeGarmo & Reid, 2004). Again it has been overshadowed by research investigating the effects of abuse (Wolock & Horowitz, 1994).
A complication to understanding the effects of neglect has been the tendency to treat all neglect as the same, such that supervisory neglect is equated with emotional neglect. For instance, using Crittenden’s (1999) family typology, lack of supervision in a large, chaotic, but otherwise warm and affectionate family may produce remarkably independent and resilient children if they manage to avoid physical injury. The effects are likely to be quite different for an emotionally neglected child in a strictly supervised environment.
In general, neglected children tend to suffer more from internalising symptoms than their peers or victims of other forms of maltreatment. They appear passive, withdrawn, apathetic and uninvolved with their social or physical environment, revert to helplessness under stress and show significant developmental delays. It is thought that the child internalises the message about their own worthlessness and assumes they will not succeed at making friends, learning at school or being noticed. They give up trying, perpetuating their neglected status outside the home environment (Egeland et al., 1983; Erickson & Egeland, 1995; Egeland, Yates, Appleyard & van Dulmen, 2002).
Hildyard and Wolfe (2002) have recently reviewed the literature on the effects of neglect including the observations of 267 high risk children in the longitudinal Minnesota Mother-Child Project. In this group there were 44 maltreated children, 24 of whom were neglected. The following section summarises their review. The effects are reported separately by age group however, the same underlying pattern is evident. The research is still patchy as there are only a few studies, sample sizes are small and there are only a few outcome measures, but they all contribute to a consistent overall picture.
The small numbers of neglected children in each study is, to some extent, compensated for by the longitudinal methodology adopted in some of the studies.
5.1    Infants and pre-schoolers 5.1.1    Socio-emotional development and peer relations
The neglected infants in the Minnesota Mother-Child Project tended to be more anxiously attached than control children at 12 to18 months. They were overly dependent, clingy and prone to crying (Erikson et al., 1996).
As preschoolers these children had lower ratings on agency (self-confidence and assertiveness) than control children (Egeland, Sroufe & Erikson, 1983). This is supported by more recent similar findings showing them to be more dependent and having lower self-esteem as well as a large number of pathological behaviours such as tics, excessive tantrums, stealing, soiling accidents, frequent physical complaints and self-punishing behaviours (MacFie, Cicchetti & Toth, 2001).
Hoffman-Plotkin and Twentyman (1984) compared a group of physically neglected pre-school children with a group of physically abused children and a control group (all groups consisted of 14 children; abuse was defined by a substantiated report to the Child Protection Service). Physically neglected pre-schoolers had the least positive and the most negative affect; they had fewer peer interactions and were more socially isolated. They were less aggressive than children who suffered from other types of abuse, but more aggressive, uncooperative and non-compliant than control children.
Other researchers report similar results with neglected pre-schoolers displaying apathy, passivity, and a lack of flexibility, persistence and enthusiasm when compared with non-abused preschoolers (Becker, 1995, cited in Sullivan, 2000). They seemed to have some difficulty with emotional self-regulation,
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Child neglect
were confused by displays of emotion by others and were less able to discriminate emotions than non- abused or maltreated children (Pollack, Cicchetti, Hornung & Reed, 2000). They had negative representations of themselves and others, seeing themselves as unworthy of love and others as unavailable (Toth, Cicchetti, MacFie, Maughan & Vanmeenen, 2000; Waldinger, Toth & Gerber, 2001).
5.1.2    Cognitive
Emotionally neglected infants showed the most dramatic decline in development quotient on the Bayley Infant Development Scale between the ages of nine and 24 months (dropped from over one standard deviation above the mean to nearly one below the mean (Hoffman-Plotkin & Twentyman, 1984). This, in part, may reflect the measurement of development shifting from predominantly motor skills towards more verbal and problem solving skills. It is likely that speed of development of verbal and problem solving skills is more dependent on environmental stimulation than gross motor skills, so the lack of environmental stimulation becomes more apparent at this age.
By preschool age, physically neglected pre-schoolers continued to show poor auditory comprehension and problems with expressive and receptive language development (Gowan, 1993, cited in Dubowitz et al., 2002) and suffered significant cognitive delays compared with non-neglected or abused children (Culp et al., 1991; Hoffman-Plotkin & Twentyman, 1984)
By kindergarten, physically neglected children’s performance on standardised intelligence tests was the lowest of all maltreated groups including emotionally maltreated children. If children already had a difficulty such as prematurity, the effects of neglect on their readiness to start school were compounded (Strathearn, O’Callaghan & Wood, 2001).
5.2    School-aged children 5.2.1    Socio-emotional and peer relationships
Neglected school-aged children continued with negative representations of themself and others, had negative interpersonal expectations and difficulties solving problems in relationships (Shields, Ryan & Cicchetti, 2001).
They remained avoidant of, and unpopular with, peers (Kaufman & Cicchetti, 1989; Eriksen & Egeland, 1996) and had fewer reciprocated playmates (Bolger, Patterson & Kupersmidt, 1998). Again they were more likely to be aggressive, disruptive and un-cooperative than non-maltreated children but less so than physically abused children (Erikson & Egeland, 1996; Manly, Kim, Rogosch & Cichetti, 2001). They lacked social skills and were isolated (high internalisation scores) rather than displaying the aggression that characterised abused children (Manly et al., 2001).
Where children had suffered severe neglect, particularly in the pre-school years, their wellbeing was still impaired at school-age. Early neglect therefore, seems to be an important predictor of later outcomes (Toth, Manly & Cicchetti, 1992; Hildyard & Wolfe, 2002).
5.2.2    Cognitive development
The cognitive problems children have in preschool years continue unabated into middle and late childhood. Physically neglected children had difficulty coping with demands of school, performed poorly on tests of achievement, and by second grade they were likely to need special education services (Egeland, 1991). They were rated by their teachers as inattentive, uninvolved, having difficulty comprehending day-to-day work and lacking in the persistence, initiative and confidence to work on their own. They were seen as being dependent on the teacher, somewhat helpless, passive, withdrawn and angry (Erickson & Egeland, 1996). Early emotional neglect was associated with lower scores on verbal ability in grades one, two, three and six (Erikson & Egeland, 1996).
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Child neglect
Physically neglected children suffered more severe cognitive developmental consequences than children who were physically abused, sexually abused or who had parents who were psychologically unavailable (Gaudin, 1993).
Neglect, regardless of whether by itself or in conjunction with other sorts of maltreatment was associated with low academic achievement levels. Unlike physically abused children they performed poorly across all areas of the curriculum (Wodarski, Kurtz, Gaudin & Howring, 1990).
5.3    Adolescents
There is little research on the longer term consequences of neglect (Hildyard & Wolfe, 2002). Much of it relies on one longitudinal study (Coleman & Widom, 2004) which followed up a large sample of adolescents into adulthood (n = 664 abused or neglected and n = 515 matched controls). The tables included in the reporting of this study suggest that neglect has more adverse effects on adult relationships than abuse but the differentiation between abuse and neglect is not examined any more closely. In addition, follow up data from a subgroup of children from a larger 1975 cohort, have provided valuable information, but the sample size of the neglected children was very small (n = 15) (Cohen, Brown & Smailes, 2001; Hildyard & Wolfe, 2002).
5.3.1    Socio-emotional and peer relationships
Childhood emotional, physical and supervisory neglect were associated with an increased risk of personality disorders and elevated symptoms of anxiety and depression in adolescence. This association held even after the childhood physical and sexual abuse were controlled for statistically (Johnson, Cohen, Brown, Smailes & Bernstein, 1999). Children who had been emotionally neglected were more likely to manifest suicidal and self-mutilative behaviour than physically neglected children (Lipschutz et al., 1999).
In a study of 587 runaway and homeless adolescents, just under half had been physically abused but about half were classified as ‘throwaways’ (Greene, Ringwalt & Kelly, 1995), suggesting many neglected adolescents end up living on the streets. Sexual abuse and neglect were associated with prostitution (suggesting low self-worth), an association not found with physical abuse. There was no association with teenage parenthood (Widom & Kuhns, 1996).
5.3.2    Cognitive
Given the findings for younger children it is not surprising that adolescents who were neglected as children have lower scores on intelligence and reading ability (Perez & Widom, 1994).
5.3.3    Juvenile crime
Neglect, like physical abuse, is associated with arrests for violent crimes as a juvenile and an adult (20 per cent for neglect and 21 per cent for physical abuse; Maxfield & Widom, 1996).
In an early meta-analysis of longitudinal studies looking at the relationship of family factors to juvenile delinquency, Loeber and Stouthamer-Loeber (1986) found that the most powerful predictors of delinquency were neglectful parenting, more specifically, the level of parental supervision, parental rejection, child’s rejection of parent and the parent-child involvement.
Australian research shows the clearest links for adolescents are to be found between neglect and juvenile crime (Weatherburn, Lind & Ku, 1997). In this research, juvenile crime was predicted by poverty, single parent families and crowded dwellings. These factors accounted for 56 per cent of the variation in juvenile participation in crime across postcodes. They are also factors strongly associated with neglect. Indeed the rate of child neglect, on its own, was found to explain 57 per cent of the variation in juvenile participation in crime across postcodes. These findings suggest that it is mainly
22
Child neglect
through their association with increased rates of neglect, that poverty, single parent families and crowded dwellings are associated with the level of juvenile participation in crime (Weatherburn et al., 1997; Weatherburn, 2001).
To give an idea of the strength of the detrimental effect of neglect, Weatherburn et al. (1997) calculated that, with all other factors remaining the same, an increase of 1000 neglected children would result in an additional 256 juveniles involved in crime. The contribution of poverty in this equation is clear but less strong; with other factors remaining the same, an increase of 1000 poor children would result in an additional 141 juveniles involved in crime.
The increase in juvenile court appearances resulting from such increases in neglect would be 466 for each additional 1000 neglected children, or 257 for each additional 1000 poor families (Weatherburn et al., 1997).
5.4    Adult outcomes
Little is known about the effects on adults of neglect in childhood. There are a few scattered findings that do not as yet give a clear picture.
People with a history of neglect are at risk for delinquency and adult criminal behaviour, and violent criminal behaviour (Maxfield & Widom, 1996; Rivera & Widom, 1996; Widom, 2001). There was also a relationship between abuse and neglect and adulthood depression, antisocial personality disorder and alcohol problems. Nevertheless, some of the problems common amongst adolescents who had been neglected (suicidal and self-mutilation) seemed to go into remission in adulthood, whereas those with physical abuse backgrounds showed increasing anti-social behaviour (Cohen et al., 2001).
Both maltreatment and neglect have been associated with dissociation in adulthood (Ogawa, Sroufe, Weinfield, Carlson & Egeland, 1997). This is reinforced by data which suggests that parents of neglected children had also been neglected implying inter-generational transmission of parenting styles. As well, adults who have been neglected in childhood are less likely to be able to maintain a long-term intimate relationship (Colman & Widom, 2004). This seemed to be a stronger finding for adults who had been neglected as children than those who had been abused (Widom, Raphael & DuMont, 2004).
As stated by Hildyard and Wolfe (2002, p. 690) ‘more research examining the long-term consequences of neglect is clearly needed’.
5.5    Deaths due to neglect
The most tragic result of neglect is when a child dies. Nearly half of the fatalities (44.3 per cent) attributed to child maltreatment in the United States resulted from neglect (Sullivan, 2000, p. 51). In NSW neglect has been recorded as one of the primary reasons for child deaths. Again it is important to record the type of neglect as it includes incidents such as overlaying a child while co-sleeping.
A distinction is made between two types of neglect fatalities. One is critical incident or accident neglect deaths usually due to ‘supervisory neglect’. The other is related to chronicity (‘chronic neglect’ deaths). Supervisory neglect deaths, according to the NSW Child Death Review Team Report (2003, p. 2) ‘result from inadequate supervision at critical moments – the parent or caregiver is absent or unavailable and the child is killed by a suddenly arising danger’. Furthermore, Margolin (1990) found that fatal neglect was most often an accident associated with a single life-threatening incident (supervisory neglect) rather than chronic forms of neglect such as malnutrition, starvation and dehydration. Supervisory neglect fatalities in NSW are mostly in the form of drowning, house fires or transport accidents involving alcohol or excessive speed (NSW Child Death Review Team, 2005). In the United States, gun accident fatalities and choking are also included as being commonly associated with supervisory neglect fatalities (Margolin, 1990). Because of this ‘critical incident’ factor it is difficult to predict (and therefore prevent) supervisory neglect deaths. Fatalities due to chronic neglect are less common but have a greater chance of being prevented due to increased predictability.
23
Child neglect
One clear association between neglect and child deaths is age. Only 10 per cent of deaths due to neglect occur in children over four. Most victims of neglect who die are under the age of two and 41 per cent of them are under the age of one (Scannapieco & Connell-Carrick, 2002). Similarly Delambre and Wood (1997) found that in 79 per cent of deaths due to neglect, the child was aged under three with 45 per cent of them below 12 months of age (cited in Scannapieco & Connell-Carrick, 2002).
Studies have found other associations with fatal child neglect but the difficulty in prediction is that the associations found are often contradictory. Although amongst child maltreatment fatalities, a high proportion are neglect-related, at a population level, neglect fatalities are a rare event and therefore apparent patterns are sometimes spurious.6 Margolin (1990) and Alfaro (1983; n = 9) agreed that children who died were mostly under three years of age, were more likely to be boys than girls with between 60 per cent and 70 per cent having no previous involvement by child protection services. However, Margolin (1990) found that the families usually consisted of single mothers with more than three children, while Alfaro (1983) found that they were most likely from two parent homes and the youngest or the only child in the family (cited in Gaudin, 1993).
Conflicting data, and the large number of families who could be described as possessing these characteristics but who have no problems at all, make it extremely difficult to predict fatal neglect with any accuracy.
5.6    Pathway approaches – specifying type of neglect and developmental outcome
The recent move to fund larger scale longitudinal studies apparent in the United States, Canada, the United Kingdom and Australia, may provide more answers over the coming years. One five-year study of neglect, funded by the Consortium of Longitudinal Studies in Child Abuse and Neglect in the United States (LONGSCAN), first received funding in 1991. This study followed the progress of 136 children from three to five years old (Dubowitz, 1999). Children were recruited from primary clinics because of either failure to thrive (he estimates the n was about 40) or risk of HIV (n = 35). There was also a control group (n = 60). Of the subtypes of neglect, only psychological neglect was significantly associated with increased internalising (withdrawn symptomatology) and externalising behaviour problems (acting out symptomatology) at age three. A Cumulative Neglect Index designed to assess the effects of multiple types of neglect (physical, psychological and environmental) was associated only with internalising (Dubowitz, Papas, Black & Starr, 2002).
More recently, Knutson et al. (2005) examined 310 first grade and 361 fifth grade children in a disadvantaged area, following them up after a five year period. In an attempt to examine the mechanism of transmission (or the determining process) they examined specific types of neglectful parenting behaviour and the effects in terms of specific outcomes. They looked at social disadvantage, ‘denial of care’ neglect, supervisory neglect and punitive discipline in relation to aggressive and anti- social behavioural outcomes. The sample was a universal sample with neglectful parenting and punitive discipline measured by a parent-completed questionnaire, so the children were not necessarily all neglected or experiencing punitive discipline. They found that neglectful parenting contributed to antisocial and delinquent behaviour over and above the effect of disadvantage and punitive discipline, but the effect also depended on the age of the child. They argue that part of the mechanism of transmission may be related to the low level of interaction, especially positive interaction, neglecting
6
There were about 1,300,000 children under the age of 18 in NSW (AIHW, 2005) and 216,000 reports of maltreatment in 2004/2005. In 2004, according to the NSW Child Death Review Team Report (2005) there were 545 deaths of children and young people of which 117 were due to external conditions. Nearly half of the deaths were caused through motor vehicle accidents, and nearly half of these again were in the 15-17 year old age group and were often involved in risk taking behaviours. Eight children died as a result of fatal assault. Where neglect can be seen to be implicated, deaths could include those by drowning (n = 16) or house fires (n = 8). There were 43 deaths due to Sudden Infant Death Syndrome, a small proportion of whose parents may have contributed through inappropriate parenting practices (such as parental cigarette smoking, using pillows or doonas). From the larger population generally, or even the smaller maltreated population of children, it is difficult to isolate factors that would predict the small number of children who might be at risk of death through neglect as they share common risk factors with thousands of children.
24
Child neglect
parents have with their children (‘denial of care’ neglect). This hampers the development of the children’s social competence and positive peer relationships leading to rejection by their peers. These socially rejected children may then develop affiliations with delinquent and anti-social peers who encourage and model anti-social behaviour. The effect is further exacerbated when parents fail to adequately supervise their children and attempt to curb the behaviour by harsh and punitive methods.
Summary
Researchers have found neglected children have learning and academic problems, tended to be inattentive and uninvolved in learning, often had language delays, had difficulty maintaining positive self-esteem and were often socially isolated. They tend to ‘internalising’ problems such as depression, withdrawn behaviour and were passive and apathetic in their approach to life, expecting to fail in what they did and often giving up trying to succeed. They often had trouble understanding complex messages as their communication skills were poor. Their experience of neglectful relationships in the family led them to expect neglect in their relationships outside the family. These expectations are likely to be met as they have no experience in conducting healthy and sustaining relationships. They tended to be impulsive, lacked persistence and had trouble delaying gratification.
In the long term, persistent underachievement in school and educational neglect deprives these children of the ability to support themselves in the future and to participate fully in society.
The most devastating consequence of neglect is when a child dies. Nearly half the fatalities attributed to child maltreatment resulted from neglect. Fatal neglect was most often an accident associated with a single life-threatening incident (supervisory neglect) rather than chronic forms of neglect such as malnutrition. The association of fatalities with a single critical incident makes the prediction and therefore prevention of fatalities extremely difficult, although younger children are more at risk of fatal neglect.
Longitudinal studies are needed in order to be able to make more conclusive statements about specific types of neglect and particular outcomes. The severity and chronicity of the neglect needs to be considered.
25
Child neglect
6.    Key issues for service providers
There has been a recent trend to suggest that the type of abuse is a less important consideration than chronicity or severity of maltreatment (Bromfield & Higgins, 2005). This argument may carry some validity with regard to effects of abuse. It is clear that a range of adverse developmental outcomes are predicted by fewer common risk factors and/or adverse childhood experiences (Rutter, 2000). For instance, sexual abuse and emotional abuse may result in similar child symptomatology and the degree of distress may depend largely on the chronicity and severity of abuse. In terms of predictive validity of behaviour problems and adaptive functioning, longitudinal data from the LONGSCAN study suggest that maltreatment severity definitions that preserve ratings within types of maltreatment may be a more fruitful approach (Litrownik et al., 2005).
However service providers need more specific information in order to provide appropriate and effective intervention. The treatment for a maltreated child who has been emotionally neglected might involve using strategies to strengthen the attachment between the ‘perpetrator of the abuse’ and the ‘victim’ such as encouraging joint activities and outings (Crittenden, 1999). This is less likely to be an effective intervention if the child has been sexually abused.
First, service providers need to be able to recognise neglect from the behaviour and appearance of the child and family (clinical judgement). This may be backed up by a more formal risk assessment. A clinical judgement can then be made as to which intervention is likely to be most effective for the specific type of neglect and family.
6.1    Recognising neglect
It is important for service providers to recognise the symptoms of neglect. To assist with this, possible symptoms have been listed. Some lists tend to concentrate more on physical neglect (including medical and dental neglect) while others focus on emotional neglect. Supervisory neglect straddles both physical and emotional neglect. Both often co-occur and physical neglect can have emotional effects and emotional neglect can have physical effects. Lists of both are included; however the overlap in both cause and symptomatology should be borne in mind.
6.2    Physical neglect 6.2.1    Infants and young children
Generally the younger the child the greater the vulnerability and the more serious the potential risk in terms of their immediate health or the longer term emotional or physical consequences. Babies and toddlers often initially present with failure to thrive.
6.2.1.1    Failure to thrive
Failure to thrive usually describes babies and young children who fail to gain weight adequately. It is diagnosed if an infant’s weight is 20 per cent below the ideal weight for their height and there is poor weight gain over time. Most of the time this will be due to illness or metabolic disorders and is termed ‘organic failure to thrive’. About 30 per cent will probably have an organic cause, while 50 per cent of cases have non-organic reasons and are likely to be due to extreme neglect and dysfunctional mothering. The remainder are usually errors in feeding and formula preparation (Sullivan, 2000).
The City and Hackney Area Child Protection Committee (2002) and the US National Clearing House on Child Abuse and Neglect (USDHHS, 2003) have both published signs and symptoms of child neglect for practitioners which are reproduced below.
26
Child neglect
Physical indicators
Inadequate warmth/shelter resulting in: • hypothermia
•    cold injury • pneumonia •    red, swollen, cold hands and feet •    recurring chest infections.
Inadequate food/rest/inappropriate diet resulting in: •    abnormally large appetite (at school or nursery) •    diarrhoea (poor or inadequate diet) •    general physical immobility or lethargy •    impaired brain growth (small brain circumference) • malnutrition •    lack of response to stimuli or contact •    poor skin condition •    sores or extreme nappy rash • rickets •    stunted growth/protruding abdomen •    vitamin deficiencies.
Inadequate hygiene/physical care resulting in: •    alopecia – bald patches
• scabies •    clothing inadequate or inappropriate for the time of the year– dirty • dirty/smelly •    dry, thin hair •    nappy rash •    repeated gastroenteritis •    skin infections.
Emotional, social and intellectual and behavioural indicators
(These indicators are not exclusive to neglect) •    low self-esteem
• anxiety •    distressed in parent presence •    ‘frozen watchfulness’ • rocking •    child moves away from parent under stress •    little or no distress when separated from their primary carer (although this may depend on
how used they are to being left with trusted others) •    clearly avoids contact with carer •    inappropriate emotional responses •    unpredictable and unprovoked attacks by the child on the parent/carer •    eating disorders including stealing and hoarding food •    language delay.
27
Child neglect
6.2.2    School-aged children
The National Clearing House for Child Abuse and Neglect (USDHHS, 2003) and the Washington State Department Social and Health Services (2005) include the following signs of neglect.
The child: •    is frequently absent from school •    begs or steals food or money •    lacks needed medical or dental care, immunisations or glasses •    is consistently dirty and has severe body odour •    lack sufficient clothing for the weather •    states that there is no-one at home to provide care •    comes to school or other activities early, stays late and does not want to go home •    has not received any help for physical or mental problems brought to the parent’s attention •    is ostracised at school •    has low self-esteem •    has cognitive and socio-emotional delays •    has sudden changes in school performance •    is always watchful as if waiting for something bad to happen •    has learning problems or difficulty concentrating not attributable to specific physical or
other psychological causes •    is overly compliant, passive or withdrawn.
The parent: •    shows little concern for the child, appears indifferent to the child •    denies the existence of, or blames the child for, the child’s problems at school or at home •    asks teachers or other teachers to use harsh physical punishment if the child misbehaves •    sees the child as entirely bad, worthless or burdensome •    demands a level of physical or academic performance that the child cannot achieve •    looks primarily to the child for care, attention and satisfaction of emotional needs •    seems apathetic or depressed •    behaves irrationally or in bizarre manner •    abuses alcohol or drugs •    leaves the child in an unsafe place.
Parent and child:
• • • • •
rarely touch or look at each other consider their relationship entirely negative state that they don’t like each other child moves away form parent under stress unpredictable and unprovoked attacks by the child on the parent/carer.
Assessment of neglect
6.3
Some measures of neglect are investigative. They aim to determine whether or not neglect has occurred, its nature, severity and chronicity. These measures are used for investigative purposes such as are involved in legal and research issues. The questions aim to find out, for instance, if the child is in fact neglected, and if so, in what way, how severe or chronic the neglect is, whether the type or chronicity of neglect affect developmental outcomes and if so how is this apparent, or whether it is safe for the child to remain with the family.
Other assessments aim to determine whether or not a child has a heightened risk of being neglected in the future. This type of assessment is useful for those offering preventative services. These assessments tend to look at broader correlates of neglectful parenting which are treated as risk factors. Often these are treated in a cumulative way such that families with more than a threshold number of risk factors
28    are offered services.
Child neglect
6.3.1    Investigative assessment
Neglect as a concept is quite heterogeneous which makes it more difficult to measure. A child may suffer emotional neglect but not educational neglect (that is, they may receive little by way of emotional nurturing but still attend school every day). From the legal point of view the type of neglect, its severity and its chronicity may be deciding factors in whether a child is removed from the family or not. For service providers, the type of neglect needs to be clear so that interventions can be tailored to suit the family. Also, it is important to distinguish between types of neglect from the research point of view as one type might have different or similar causes and consequences than another (Strauss & Kantor, 2005).
Investigative assessment has an additional problem in that parents may respond in a socially desirable way rather than admitting to neglectful behaviours. This is particularly the case where there is the threat of legal action. It is also difficult to research neglect when relying on self-report if parents do not feel safe in disclosing their behaviour. Strauss and Kantor (2005) argue that using terms such as abuse, neglect, violence, injury or harm should be avoided. They suggest prefacing a question with a phrase such as ‘Many parents find it difficult to provide nutritious meals for their children’ and then ask ‘How many times has this happened to your family in the past referent time frame?’ rather than asking for a ‘yes’ or ‘no’ answer which has greater social desirability demand characteristics.
Straus and Kantor (2005) also argue that harm and neglectful behaviour need to be assessed separately because the harmful effects of neglectful behaviour cannot be examined if both the parents’ behaviour and the consequences for the child are called ‘neglect’. This can be overcome by using an ‘endangerment standard’. For instance, educational neglect is considered to have occurred if a child averages five days a month away from school without good reason and without the parents attempting to intervene. Where this has occurred, the effects in terms of the child’s developmental progress can be examined as a function of the type and chronicity of the educational neglect (that is, levels of compromised achievement as a function of duration and frequency of school absence). If the developmental delays are considered to be neglect, as well as the school absences, the nature of the relationship between the two cannot be examined as they are both considered to be the same thing, namely, neglect.
Similarly, neglectful behaviour and the causes or correlates of neglectful behaviour should be measured separately. For instance, if parents live in poverty and are unable to provide, their child is still neglected, regardless of the cause. The intervention adopted to overcome the neglect will be different but the child is suffering neglect regardless of cause.
Investigative assessment also needs to take account of the transitory or chronic nature of the neglect, the age of the child and the frequency of occurrence of neglectful behaviours within a specified time frame.
It is generally agreed that self-report by children or retrospective adults’ reports are unreliable (Stowman & Donohue, 2005; Strauss & Kantor, 2005).
The LONGSCAN study of 702 children reports agreement between the Child Protection Service (CPS) reports and the Maltreatment Classification System (MMCS) questionnaire. With regard to neglect, the CPS and the MMCS subtypes of neglect were moderately correlated. Their associations with child outcomes were also similar (Dubowitz et al., 2005). It is argued that the MMCS obtains useful, descriptive information on the nature of neglect more quickly but as reliably as the considerable effort that is otherwise involved in coding neglect subtypes from CPS narratives (Dubowitz et al., 2005).
29
Child neglect
6.3.2    Risk assessment
Structured risk assessment instruments are primarily focussed on whether a child will be maltreated in the future, either by identifying unreported families before they neglect their children or assessing the likelihood of recurrence of neglect in already reported families (Stowman & Donohue, 2005). They have been introduced in the hope of increasing the accuracy of prediction across a number of people in a shorter time frame. Where parents have not been reported, structured risk assessments are usually based on general correlates of neglectful parenting. The more traditional risk assessment instruments have placed reliance on the mothers’ own childhood history to see if she has suffered abuse or been fostered as a child. They investigate her level of useful social support and her current and past mental health and substance abuse record. Parents selected through this assessment process are likely to be parents who are parenting under difficult circumstances, but most will not be neglectful.
These assessments often take the child’s age, the number and ages of other children in the family, and the family’s previous contact with child protection into account, as these factors are associated with heightened vulnerability. In addition, motivation of the caregiver to change, or conversely, levels of hostility towards the service provider are being recognised as important predictors of actual change.
Structured risk assessment of neglect has unfortunately not been as successful as had been hoped (for a review see Gershater-Molko, Lutzker & Sherman, 2003). Most instruments may differentiate, with some degree of accuracy, families who are involved with child protection services from those who are not, but they do not predict later neglect amongst a population not yet involved with the child protection services (see Appendix B).
Gaudin (1993, p. 33) suggests that child protection workers use risk assessment instruments as a guide to understand, recognise and supplement clinical judgement but argues that they should not be applied as rigid criteria for decision making.
30
Child neglect
7.    Interventions
The organisation of systems of interventions to meet service needs have followed a variety of approaches. In line with the shift away from understanding neglect in terms of family or individual pathology, there has also been a shift towards a broader socio-ecological approach to intervention.
7.1    Levels of intervention – a socio-ecological approach
Interventions can take place at the systems level, the community level or the family level. Change to the system may include changes in policy or the system of service provision (for example, providing direct financial assistance to families with young children in need, or providing subsidised childcare for impoverished families). At the community level, interventions may focus on improving social capital through increasing formal and informal support (such as ensuring neighbourhoods have access to a range of supports, such as high quality childcare, community health centres, pre-schools or neighbourhood centres). At the family level direct support may be provided on a universal or targeted basis either to the parents or to the child.
7.1.1    Systems level 7.1.1.1    Poverty reduction
It is clear that a significant number of children are being neglected, especially in countries like the United States, because many families are desperately poor. Australia has lower rates of neglect partly because the welfare net ensures that parents who have the ability to comply with imposed conditions will receive some benefits to care for their children.
Swift (cited in Sullivan, 2000) suggests that the most effective intervention would be at this level. She argues that if chronic neglect is a matter of poverty (frequently the poverty of disadvantaged women) then it should be dealt with as a resource issue rather than a personal, individual problem. If situational neglect occurs (for example, a family is evicted and cannot find somewhere else to live for a period of time) she suggests that proving these parents unfit to care for their children in court wastes time and serves to damage parent-child relationships. It would be better to support these families with temporary voluntary care orders. She proposes that neglect should only be dealt with by the legal system where neglect occurs and the offer of help is refused. This involves a shift in attitude from one of policing to one of support (Callahan, 1993, cited in Sullivan, 2000) which is evident in varying degrees in several countries, including Australia.
In the same vein, MacDonald and Winkley (1999, p. 5) argue there are socio-economic interventions (such as tax transfers of wealth) that would:
be more likely to impact positively on the lives of the thousands of children who come within the remit of the child protection system, than the sum total of the effort currently expended by health and social care professionals in this field.
The National Longitudinal Study of Canadian Youth (NLSCY, Willms, 2002) suggests that some negative developmental outcomes could be improved by an increase in income, but only to a degree. Once parents’ ability to meet their children’s basic needs is not hampered by poverty, extra income may no longer make any difference.
At the same time, those providing services are constrained by what is possible. Reducing the depth and breadth of poverty may well reduce the incidence of parents being unable to provide adequate shelter, food and clothing for their children, especially in countries without a strong welfare net. Most service providers are however operating on a community or family level of intervention and can do little to alleviate anything but short term personal economic crises.
31
Child neglect
7.1.2    Community level
Levels of social capital within a community are reflected by levels of formal and informal support. There is evidence that children have improved developmental outcomes on starting school if there are a range of community services such as libraries, parent education classes, child care, pre-schools, parks and toy libraries within easy walking distance (Janus & Offord, 2000).
Where these services (for example, high quality child care, preschool) are co-located and have strong links to those providing services such as health care (for example, baby immunisations) and parent education and support, developmental outcomes are improved (Reynolds, Ou & Suh-Ruu, 2004).
The universal community services model used by Scandinavian countries has been promoted as being very effective (Durrant & Olson, 1997; Durrant, 2000; Tomison & Wise, 1999). It ensures that all families have easy access to antenatal/postnatal parent education, home visiting for the first two years, assistance in baby-proofing houses, voluntary but effective building and appliance codes to help prevent accidents, as well as preventative and supportive health care and universal subsidised child care. In this model some of the long-term needs of children are taken care of via the education system as each school has a doctor or a nurse who monitors the well-being of the children at that school (Durrant, 2000; Tomison & Wise, 1999, p. 13).
According to Tomison and Wise (1999) the Scandinavian family support model is demonstrated to be highly effective, since the rate of child abuse notifications in Scandinavian countries is eight times lower than in the United States and four times lower than in Australia.7
If there is not a universal preventative system in place, services rely on responding to demand. It is clear that priority needs to be given to children who are in immediate danger. As a result, neglected children whose development is compromised on a daily basis, but whose safety is not in immediate danger, may be further neglected by the system. In most States in Australia, a report of neglect is initially likely to be classified as being a matter of concern, but unless the child’s safety is compromised, the priority for follow up is low.
7.1.3    Family level interventions
Although changes in policy and accessibility and delivery of services may make population level changes by assisting families seeking services, many neglecting families will also need more direct support to address personal, psychological and interpersonal factors. Social workers and case managers are faced with the more immediate task of providing an effective intervention for families where children are already being neglected.
Despite increase in the incidence of neglect, effective family level interventions have been difficult to demonstrate. Neglect cases are less likely to succeed, when compared with child abuse, because underlying severe neglect is indifference to the child and lack of empathy. The lack of interest in the children makes neglecting families particularly difficult to recruit and engage into programs (Daro, 2000).
7.1.3.1    Severity and chronicity
The strategies used are likely to be defined not only by the severity of the neglect but also by its chronicity (also known as ‘new’ vs. ‘old’ neglect) (Nelson, Saunders & Landsman, 1993; Gaudin, 1993). With increasing severity and chronicity, it could be argued that in order to intervene effectively, the focus of the intervention should move away from the parent and towards more direct intervention with the child, up to the point of removal from the family.
If the neglect is not very severe and is in response to an immediate crisis, such as a death in the family, the support needed may be as little as providing some emotional support for the parent and practical support to ensure that meals are provided and the house cleaned until the crisis is resolved (Hilyard & Wolfe, 2002; James, 2000b).
32    7    Despite some reaction to the lauding of the Scandinavian system, this still appears to be the case (Durrant, 2004).
Child neglect
As the chronicity increases more ongoing support is needed (Hilyard & Wolfe, 2002; Sullivan, 2000). For less severe cases the support may only need to be directed towards the mother, giving her emotional support and helping her with parenting skills (Tomison, 1995).
As the neglect becomes more severe (especially where the mother is hostile and reluctant to change) the focus of the intervention needs to be directed more towards the child. Primarily the safety of the child or children need to be ensured (for example, baby-proofing the home, providing fencing for a garden or establishing curfews). This should also include promoting the wellbeing of the child. Depending on the child’s age this might consist of providing childcare that has a breakfast program and hot lunch, as well as stimulating activities in a caring environment. For older children this might include providing an after school care program with a nutritious breakfast and substantial afternoon meal. In this program, additional supportive interventions such as a social skills program (for example, learning for life) or paying the registration for a team sport, ballet or music lessons and ensuring that transport is organised so children are able to attend (Offord, 2000). This encourages social and team interaction and can be used to promote self-esteem. Some families may need respite care for their children in order to cope (for example, Big Brother or Sister programs, or programs which provide an aunt, uncle or grandmother figure in the neighbourhood). Aldgate and Bradley’s (1999) study in the United Kingdom suggested that parents were very positive about their children receiving voluntary respite care in the neighbourhood. The children were less enthusiastic but accepting of it.
7.1.3.2    Interventions based on family typology
Based on clinical practice (Crittenden, 1999; Dubowitz, 1999) or discussions with practitioners (Tomison & Poole, 2000) some authors have attempted to delineate different family typology in order to specify which treatments might be most effective.
Where families are chaotic but affectionate and children mostly suffer physical and supervisory neglect, mothers are often receptive to receiving help (Crittenden, 1999), and are likely to be regarded quite warmly by social workers (Tomison & Poole, 2000). They are seen as cooperative and motivated to change if somewhat limited in their responses and responsibility towards their children. Crittenden (1999) suggests that a ‘befriending’ model may assist these families.
For Crittenden’s (1999) second type of neglecting family type (those who provide adequately for children’s physical needs, have clear rules and roles, but are emotionally neglectful), Crittenden (cited in City and Hackney Area Child Protection Committee, 2002) suggests organising joint activities rather than ‘befriending’. She argues that these parents are often professionals and may be easily alienated by the stigmatisation of social worker involvement or use of out-of-home care.
Crittenden’s (1999) third type of family is the ‘typical’ neglecting family where the mother is disengaged, withdrawn and apathetic either through depression, limited cognitive capacity, substance or alcohol abuse or other mental health issues. Children in these families may benefit from a stimulating and responsive environment such as is provided by high quality child care. It is suggested that these parents are likely to require long-term support. Where sufficient stimulation, nutrition, care and emotional warmth cannot be provided by day care to counteract the negative effects of their home life, children may need to be permanently placed in out-of-home care.
7.2    Barriers to effective intervention
Even if social workers are aware that a child is being neglected and have an idea about what supports might be effective, neglecting families are very difficult to recruit and engage in programs of intervention (Daro, 2000). There is little research identifying what family characteristics might indicate greater amenability to intervention attempts. This information is, for the most part, gleaned from practitioner knowledge.
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7.2.1    Family factors – hard to engage
According to the City and Hackney guidelines for practice (City & Hackney Area Child Protection Committee, 2002), the parents of neglected children who are least likely to change are characterised by:
•    antisocial and hostilely aggressive attitude •    severely inadequate parent capacity •    major interpersonal difficulties •    persistent denial or acceptance of responsibility for what they have done •    poor motivation to be involved with professional support
•    substance abuse •    learning difficulties •    significant or profound mental illness •    poor capacity to empathise with the child or blaming the child for professional involvement.
Littell and Tajima (2000) found substance-abusing parents have significantly lower levels of collaboration with caseworkers. This problem was reduced when the caseworker received training in how to engage difficult families (Tomison & Poole, 2000). Use of active engagement techniques was considered to improve treatment adherence, for example, having a formal signed contract, goal setting, constructive relationships with caseworkers and strengths-based techniques.
7.2.2    Service provider factors
Service providers are also slower to report neglect than other forms of abuse, so many eligible families may miss being offered services. This is not the result of any one factor but several factors which conspire to reduce the likelihood of reporting or intervening in neglecting families.
7.2.2.1    Neglect known to be difficult
Minty and Pattinson (1994) contend that social workers have intrinsically negative perceptions about the probability of effecting lasting change with neglectful families. Intervention produced lasting change in only 40 per cent of neglecting families, which compared unfavourably with success rates of sexual and physical abuse (Daro, 1988, cited in Salmelainen, 1996). Neglect remains the most resistant to current prevention and treatment initiatives.
7.2.2.2 Poverty
Neglect may be seen as less important because of its link to poverty. Social workers see its prevalence as reflecting the low priority accorded to alleviating poverty within society and are reluctant to pathologise families already disadvantaged by being poor (Wolock & Horwitz, 1984).
7.2.2.3    System overload
In Britain, in the past, Birchall (1989) noted that the bulk of neglect cases were not being registered on the child abuse register. It was suggested that this lack of registration may have been due to the professional inability to adequately define the cases, or an awareness that the CPS system cannot cope with the volume of neglect cases. Also, the link between poverty and neglect is well-known and this is a burden that being placed on the child abuse register does not ease. If the system becomes overloaded, the threshold for intervention moves upwards (Little, 1995).
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7.2.2.4    Case labelling and minimisation of child neglect
Minimising neglectful concerns occurs for a number of reasons including ‘the rule of optimism’ (coined by Dinwall, Eekelaar & Murray, 1983; Tomison, 1995). This means that workers tended to look for the most positive interpretation of parents’ behaviour (‘doing their best’, ‘trying to discipline’) and to be overly positive about the child’s wellbeing or safety. This can happen in a number of ways:
•    Each incident is too trivial to report as ‘maltreatment’. Neglect is chronic and less incident- based than abuse. It manifests over time, with each incident too trivial to provide a concerning enough ‘trigger event’ and so the risk often remains unrecognised (Tanner & Turney, 2003). The cumulative effect is damaging but the caseworker needs to be able to testify in court. Is it neglect if a toddler does not have a jumper on a cold day, missed out on lunch or was standing on the footpath unsupervised in a dirty nappy? Even where neglect is serious enough to be clearly detrimental it is possible that caseworkers have to wait for a ‘trigger event’ before they have strong enough evidence to present a case in court for a child to be removed.
•    ‘Cultural relativism’ is an agency-level justification for allowing some deviant behaviour to be justified by labelling it as a cultural practice. In this way, otherwise unacceptable levels of neglect are just written off as an act required by the culture (in relation to abuse the most extreme form may be genital mutilation; in relation to neglect it may be young children left caring for infants and babies). Deviant ‘cultural’ acts become excusable, with members of one culture having no right to criticise other cultures. When cultural relativism applies the act is not abusive or neglectful, but seen as appropriate (Dinwall, Eekelaar & Murray, 1983; Tomison, 1995).
•    ‘Natural love’ is the general assumption that parents love their children (James, 2000b). Workers interpret all evidence of child neglect under the assumption of natural love, so finding incontrovertible proof of child maltreatment becomes difficult.
•    The tendency to minimise is further strengthened by the pressure on workers to avoid incorrect classification due to the grave consequences to the family (Department of Health, 1995). Workers operate in a culture which looks for overwhelming evidence of abuse before action is taken. This becomes critical in cases of suspected neglect which are more difficult to describe.
•    Workers become focussed on the rights of parents to the detriment of the rights of the child. They sympathise with the efforts of the parents and fail to see the gradual damage being done to the child (City and Hackney Area Child Protection Committee, 2002).
•    Sometimes workers misclassify cases in order to give family eligibility to a particular sort of treatment. For instance, if there is both ‘risk of sexual abuse’ and ‘neglect’, the sexual abuse may be put forward as the primary concern so that the court can become involved. If there is both physical abuse and neglect, in some states in Australia they may minimise the abuse and label it neglect because neglect cases are generally dealt with by the provision of family support whereas physical or sexual abuse are likely to require more stringent child protection measures (Tomison, 1995) This may keep the child neglect cases out of the child protection system and reliant on a more voluntary system of services where it is easier to fall through the gaps.
•    ‘Case drift’ is the label given to the phenomenon of children being left without services despite ongoing negative effects such as when social workers become inured to the child’s state (City and Hackney Area Child Protection Committee, 2002). Social workers get to know a family and adapt to them and the state of the child. Behaviour or circumstances that shock them if they encountered this for the first time becomes ‘normal’ for this family and they let the case drift and do not notice how bad the situation has become. Where social workers have some sympathy with the parents, they may over-identify with them resulting in a reluctance to further ‘punish’ parents who are already in a difficult situation (Katz, 2005).    35
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It seems the ‘rule of optimism’ was only discounted when parents refused to cooperate with the caseworkers and rejected help, or alternatively when so many workers became involved with the case that the pressure for protective action became greater.
7.3    Effective strategies to engage and help families 7.3.1    Meet immediate needs
The importance of meeting the immediate needs of families in the treatment process by providing concrete services needs to be emphasised. Neglecting families often face many barriers to engagement, including inadequate housing, poverty, unemployment, lack of childcare and lack of transport. Many practitioners still focus on parenting and therapeutic needs of families rather than concrete needs and social inequities (Macdonald, 2001). Families with children must have sufficient funds to be able to provide for their basic needs before other strategies can be tried out.
Meeting the family’s identified priorities helps to overcome family’s hopelessness, resistance and distrust of professional helpers. Research shows that families of all types who receive simple and effective services at the beginning of their treatment are more likely to build and maintain a relationship with their caseworker (Lewis, 1991, cited in Berry et al., 2003). In some cases this may be as simple as repairing a washing machine or providing disposable nappies.
7.3.2    Need to be long-term
Chronic neglect in children is likely to require long-term intervention. Tomison and Poole (2000) contend that even if families received an initial follow up after a neglect report, there is a lack of appropriate, intensive long-term services that can support a neglecting family. The lack of availability of these services is a common theme in the United States, Britain and Australia (Hallett & Birchall, 1992; Nelson et al., 1993; Tomison, 1994).
In Tomison’s (1995) child abuse tracking study, the only support services that could be offered were short-term. Client support was then terminated and they had to cope on their own. It is reported that these families then invariably ended up returning to child protection services voluntarily in order to try and receive more support. This cycle continued until the caregivers could no longer adequately care for their child and the family became dysfunctional enough for child protection workers to apply for a supervision or guardianship order. Where families did learn to manage by themselves this was often achieved by the parent becoming part of an informal community or neighbourhood network which could provide ongoing non-professional support (Tomison & Poole, 2000). Officially these families were seen as successfully treated as they had been referred on and had been allocated and received services. These ‘quick fixes’ were, however, the only options available to workers and generally provided little more than respite for staff hence the chronic, cyclical nature of the cases. Often the child’s situation had to deteriorate to the point where it became serious enough for the family to be considered for long-term services.
7.3.3    Need health promotion as well as prevention
Tomison and Poole (2000) stress the importance of the difference between prevention and health promotion. They argue that child abuse prevention traditionally reflects a negative, problem-focussed approach where the objective is to prevent social ill as opposed to promoting positive, life-enhancing strategies such as good interpersonal relationships, positive parenting and pro-child policies.
In a promotion approach, ‘positive’ language and focus is adopted (that is, ‘mental health promotion’ as opposed to ‘prevention of mental disorder’). It is argued that to effect change the target population is required to accept and act on the messages being conveyed. The target population is more likely to accept and act on positive messages as opposed to negative ones. Services for parents are best offered
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within a promotional framework and title. For instance, it is better to offer a ‘healthy lifestyle’ program, than clearly stigmatise vulnerable families by referring to an ‘early intervention’ program. Some services (Northern Rivers region in Australia) offer a Toy Making Craft program so parents with similar aged children meet in an informal and non-threatening atmosphere where they can informally discuss issues related to parenting.
Developmental prevention strategies combine aspects of both these approaches and concurrently aim to prevent the development of child maltreatment by reducing the incidence of specific risk factors whilst simultaneously working to promote protective factors that may reduce the risk of child maltreatment.
7.4    Effective programs of intervention
There has been little or no research aimed at specifically identifying effective programs for neglected children. However, the strong association between disadvantage and neglect suggests that programs that have positive effects for disadvantaged children may also have positive effects for neglected children.
7.4.1    High quality childcare
Given the lack of stimulation and nurturing in neglectful families, the most effective way of improving outcomes for these children may be to target them directly in the form of high quality childcare and education. Providing physical care, nourishing food, stimulating programs and emotional nurturing directly to disadvantaged children has a more positive impact on child outcomes than if the intervention is aimed at parents (Marshall & Watt, 1999). These effects can last into adulthood (Schweinhart, 2005). It also provides parents with respite from the day-to-day responsibility and care of young children, making it easier for them to cope in the evenings and mornings. The care also needs to be affordable and accessible. Provision of free transport and free or heavily subsidised costs are likely to improve attendance rates. While disadvantaged children have been shown to derive greater benefits from high quality care than other children, very severely distressed children may require more one-to- one therapeutic intervention.
7.4.2    Home visiting programs
According to Tomison (1995) home visitation services can act as an early detection mechanism prior to cases entering the statutory system, and also to alleviate concerns once the case has become ‘known’ to the system.
Nevertheless there is, as yet, little evidence that home visiting reduces the rate of child abuse and neglect (Elkan, 2000; MacMillan et al., 2005). The results of Eckenrode, Zielinski, Smith, Marcynyszyn, Henderson, Kitzman, Cole, Powers and Olds (2001) study suggested there may an association between home visiting and the number of substantiated reports generated by a small group of twelve persistently maltreating mothers (that is, a group who abused and/or neglected their children both in childhood and adolescence). The number of substantiated reports, when considered over a 15 year period, is lower amongst these persistently maltreating mothers if they were home visited in the first two years of life. There were no differences, as a function of home visiting, in the numbers of substantiated reports amongst the mothers who abused their children either only during early childhood or only during adolescence. Sweet and Applebaum’s (2004) meta-analysis suggests that paraprofessional home visitors may be more effective in this regard than nurses.
Many of the studies showed that home visiting actually increased the rate of reported child abuse and neglect (Elkan, 2000; MacMillan, 2005) although it is likely that these results are confounded by a ‘surveillance effect’. Nevertheless most authors currently agree that there is little evidence that home visiting is effective in preventing child abuse and neglect. It is likely that some home visiting programs are effective but effects are masked by pooling evidence from any program which is delivered in the home, regardless of service provider characteristics and program quality, intensity or duration.
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7.4.3    Co-located multi-component programs
Parents and children from disadvantaged areas in Chicago attending programs which are co-located in Child-Parent Centres have made positive gains (Reynolds et al., 2004). Greatest gains are made where both parents and children attend and programs are extended to cover the toddler period as well as into school age. Parents are required to assist in the structured child care program so that they become familiar with the activities and adult-child interactions modelled by centre staff. Besides specific programs to enhance cognitive and social development, children are offered a healthy diet and an age-appropriate physical development program.
7.4.4    Family preservation programs
Many models, including family preservation programs, report greater success with physical abuse than with neglect. However, intensive family preservation, in comparison to regular child welfare services, has a limited effect in reducing out-of-home care placements for families with either neglected children or highly oppositional adolescents (Berry, 1994; Wells & Tracy, 1996; cited in Berry et al., 2003).
7.4.5    Implications for social workers
The following list has been derived from the literature after examining current interventions that are designed specifically for the treatment of families who neglect (Berry et al., 2003). It suggests techniques for social workers to help them engage and treat families successfully. The difficulty of the social worker’s job becomes apparent in the listing:
•    Focus on the family rather than just the parents or the child. The child’s best interests must remain paramount. Family-centred child welfare aims to decrease the family’s total amount of chronic stress in the long-term as well as the short-term (Reding & Wijnberg, 2001).
• Mental health services. Maternal depression is a prime contributor to child neglect. Referring the mother for medication or counselling rather than focusing on her parenting efforts may be more beneficial. This is viewed by mothers as supportive and helpful and aids engagement and adherence to a program. The family may be used to support the person with a mental illness to help re-establish connections. Establishing a stronger more supportive social network for the mother, or reconnecting her with supportive family and friends may assist.
•    Substance abuse treatment. Substance abuse is treatable and yet 46 per cent of parents with substance abuse problems who are also involved in the child welfare system were neither offered nor provided with any substance abuse services in the United States (Berry et al., 2003). Services should meet the needs of the caregivers as well as children.
•    Let the families set the priorities for assistance first. If the families define the priorities for assistance rather than the caseworker, it helps remove barriers to seeking and participating in treatment. The priorities that families set may be transport, household repair and maintenance, respite and child care, acquiring furniture and white goods, amongst other things.
•    Early intervention. Children whose parents take an active role in an early intervention program show improved developmental outcomes compared with those who do not take part (Lernieux, 2001). There was a marked improvement in disadvantaged and maltreated children if they attend child care, with significant social and motor improvements reported (Early Head Start, Child-Parent Centres etc).
•    Community supports and social networks. Programs were more effective when workers established warm and empathetic relationships with clients.
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8.    Indigenous communities
Aboriginal and Torres Strait Islander children are over-represented in the child protection system in Australia. In 2003-2004, Indigenous children were, on average, the subject of a child protection substantiation at 5.3 times the rate of non-Indigenous children. This represented an increase from 2001-2002, when the rate of substantiation of abuse and neglect was on average 4.3 times higher than for non-Indigenous children. The rate within the Indigenous community was 20.4 per 1000 in 2002- 2003 and increased to 24.7 per 1000 in 2003-2004. This suggests that there is either an escalating problem or a decrease in reluctance to report, or both.
In 2003-2004 the Indigenous rate was 6.2 times the rate for other children on care and protection orders, and for children in out-of-home care, 6.5 times the rate (AIHW, 2005).
Stanley, Tomison and Pocock (2003) suggest that official figures are likely to be underestimates. Much of the child abuse in Indigenous communities may remain unreported due to fears of racist responses from the system, the high number of Indigenous deaths in custody, police response and pay-back from relatives and reprisal from the perpetrator due to closely linked communities. As Indigenous children are more likely to remain in their communities, with proportionally more children being placed at home or with relatives (50.2 per cent) compared with non-Indigenous families (Ah Kee & Tilbury, 1999), this may add to the reluctance to report.
The rate of substantiation was proportionately fewer in Indigenous communities for sexual abuse (7 per cent compared with 16 per cent) yet proportionately higher for neglect (39 per cent compared with 31 per cent) than in the non-Indigenous population (AIHW, 2004).
Unfortunately there are no child abuse and neglect data available for NSW for 2003-2004 due to the modification of the Department of Community Services’ data system. For 2002-2003, while showing relatively high rates of substantiations for Indigenous children, data are also unable to be compared for the same reason (AIHW, 2005). This section of the paper therefore relies on Australia-wide data.
8.1    Causes
Libesman (2004) argues that the impact of colonisation on Indigenous peoples around the world has been similar. Libesman (2004, p. 2) outlines these historical problems as including:
inter-generational traumas from the effects of child removal; social dislocation; community dislocation and consequent or related mental health problems; marginalisation from social services for health, housing, education and policing and child and family welfare services and general loss of power and community cohesion stemming from colonial experiences.
A range of current factors make Indigenous Australian families more susceptible to becoming involved in child protection and juvenile justice systems. These include high levels of poverty, unemployment, single parenthood, homelessness, ill health, poor education, substance abuse, incarceration of adults, violence as well as the experiences of dispossession and marginalisation. These are also all factors associated with neglectful parenting.
Where entire communities are made up of families with predominantly the same history and current situational factors, and there are few counterbalancing factors present, the developmental risks for children born into these communities are compounded. In addition, these communities are often isolated and have few support services. Many existing support services are regarded with justifiable suspicion given the history of welfare agency intervention. Other services (such as child care) are under-utilised by Indigenous people who may prefer the family to care for their children and do not regard centre-based care as desirable.
This is reinforced by the Human Rights and Equal Opportunity Commission National Inquiry Report (1997, p. 181) which sought to understand the current ramifications of past policy and societal attitudes. This report argues that ‘early loss of a mother or prolonged separation from her before age 11 is conducive to subsequent depression, choice of an inappropriate partner and difficulties in parenting the next generation. Anti-social activity, violence, depression and suicide have also been suggested as likely results of the severe disruption of affectional bonds’.    39
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Pocock (2003, cited in Stanley et al., 2003, p. 9) points out that the high level of disadvantage within Indigenous communities means that ‘the boundary between the socio-economic disadvantage experienced by many Indigenous people and personal culpability for child neglect is neither understood or defined’. For example, poor single females are often responsible for rearing a large number of children (possibly due to family violence) in often derelict houses with inadequate safety which allows intruders to enter and children to wander (Robertson, 2000, cited in Stanley et al., 2003).
8.2    Service response
Libesman’s (2004) report on child abuse and neglect in a number of Indigenous communities argues that conventional ‘individualistic’ responses to children’s wellbeing do not significantly improve conditions for Indigenous communities and families.
Australian research by Cuneen and Libesman (2002, cited in Tomison, 2004) agrees, arguing that the traditional model utilised in child protection services response ‘individualises’ and ‘pathologises’ particular families. They suggest that families would be better served by adopting a more holistic and community-based response system that seeks to address the underlying causes of health and social problems.
Indeed, Libesman (2004) points out that many Indigenous organisations have called for models that focus on Indigenous collaboration, community development, community participation and community control.
A number of authors point out that services are being redesigned and programs becoming more community-centred through forging alliances with local communities to improve the physical and social environments of those communities (Cohen, Ooma & Hutchins, 1995; Argyle & Brown, 1998, cited in Stanley et al., 2003).
Tomison (2004, p. 62) argues that even though this model highlights a new path for effective services for Aboriginal communities, it does not seem to ‘address issues of how to place a child within their community if it is beset by family violence, substance abuse and other social problems. Furthermore, Tomison (2004) argues that the model does not provide solutions that address the reluctance of both Indigenous and non-Indigenous statutory authorities to intervene with Aboriginal families which may leave children exposed to serious harm. It is further criticised for failure to address the issue of effective prevention and/or community development to minimise the removal of children and violence in the first place.
However, the approach proposed by this model is one that is embraced by Indigenous groups and agencies (and to some extent government departments) in Australia. According to Tomison (2004), however, Australia is yet to trial such a statutory child protection service controlled and run by the Indigenous community.
As with non-Indigenous service response models, Tomison (2004) argues that effective interagency collaboration and coordination are key aspects of service provision for the Indigenous community. Tomison (2004) argues that statutory intervention, without the development of family support and prevention services, is unlikely to produce positive outcomes for children, families and communities.
Blagg (2000) puts forward the following key tenets as imperative in planning services for Aboriginal communities with respect to child protection:
• participation • ownership/self-determination •    infrastructure (training and education) •    support services needed to support child protection function.
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As part of a Department of Community Services’ report, Watson’s (2002) review of effective services for Indigenous communities suggests that parenting interventions likely to be most effective with Indigenous communities are those which:
•    are designed and implemented in collaboration with the Indigenous community in which they will be used (Podnieks, 2000). Given the diverse nature of the Aboriginal people, and the variation in degree to which links have been maintained to their culture, programs need to be designed in collaboration with the specific community at which they are aimed (Ralph, 1997). Franks (2001) points out that self-determination is a crucial element of service delivery and in ensuring the wellbeing of a community
•    employ Indigenous people to run services aimed at their communities. This is a significant positive strategy in attracting Indigenous people to use services to benefit them (Podnieks, 2000; Ralph, 1997)
•    include ‘old’ elements of traditional approaches and ‘new’ elements from western learning (Podnieks, 2000)
•    are comparatively highly resourced. The most disadvantaged groups often require home visiting to ensure service delivery. The use of financial or other incentives, and help with transportation assists with retention rates (Hamner & Turner, 2001)
•    target the entire community. Targeted universal sampling is necessary to avoid stigma and the risk of increasing any existing sense of failure. Also, the entire community may prefer to be involved in the development and implementation of a new program (Podnieks, 2000)
• build on strengths. Programs work better when they are positive and preventative in approach rather than remedial (Mitchell, 2000) and when they are based on principles of empowerment (Blagg, 2000)
•    recruit through communities rather than schools. This method of recruitment has higher establishment rates with disadvantaged groups (Hamner & Turner, 2001). Given the strengths of intra-community connections, this is most likely to be of value for Indigenous groups
•    provide a ‘joined-up’ or ‘seamless’ delivery of services. Services in Australia tend to be fragmented with multiple agencies involved in a variety of aspects of child and family health and wellbeing. As a result, there are long waiting times for different services, and families have to attend multiple sites and see many people to obtain the help they need
•    are linked to initiatives on health, alcohol abuse and similar problems in a holistic manner (Blagg, 2000)
•    place greater emphasis on the need to work with men (Blagg, 2000)
•    involve key local community members. The Bibbulung Gnarneep (Solid Kid) project in Western Australia and the Parenting Australia (Jesuits/Anglicare/Centacare) programs which run in Alice Springs with the Tangentyere Council indicate that this is crucial to the success of the project. As well, feeling that the community has some control over the program and similarity between the social status of those delivering the program and those receiving it makes attendance less threatening (Mitchell, 2000)
•    have a home visiting component. Feedback from pre-and post-natal home visiting programs run by NSW Health as part of the Families First initiative suggest that this is a more effective way of reaching Indigenous families than group meetings. Anecdotal evidence suggests that these programs are running successfully in Moree and Tamworth although funding imposes some restrictions with regard to intensity and duration. A methodologically more stringent evaluation of a pilot program being undertaken in the South West Sydney area is showing excellent participation and retention rates (Nosser, 2002, personal communication).    41
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Summary
The realisation that there is ‘no quick fix’ in relation to child abuse and neglect applies even more strongly to Indigenous families.
Serial inter-generational disadvantage has resulted in high levels of risk for young Indigenous children in Australia. It is the current high levels of neglect that contribute to their over- representation in the child protection system. While some of this may be explained by their specific history of child removal and loss of societal and cultural identity, the high levels of poverty, unemployment, substance abuse, domestic violence and mental illness which are common in Indigenous communities are also major predictors of neglect.
Services need to take cultural sensitivities as well as the historical dispossession of land and family, and the resultant wariness of government, into account when intervening in Indigenous communities.
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9.    Conclusions and research implications
9.1    Limitations of research findings
Knowledge in the area of neglect is limited by several factors, the most significant of which have been identified as being:
•    imprecise definitions. Definitions are broad and too vague to be useful or detail behaviours which may be regarded as neglectful resulting in long, unwieldy lists of possible neglectful behaviours. Researchers often use a sample of children who are on a child protection register as representing a maltreated group. This is often based on clinical judgement of a situation and reveals little about what constitutes neglect, its chronicity, severity or frequency
•    bias in the welfare system. This bias contributes to the disproportionate number of low income and minority families being reported, screened and substantiated (for example, if only poor areas are screened, then more families in this area will appear in the data)
•    severity of cases. Studies based on substantiations only get the most severe forms. What happens with less severe cases – how does this affect development?
•    lack of comparability of findings. Neglect is a heterogeneous concept incorporating a wide range of concepts (abandonment, lack of food, lack of attention to health care needs). Different types of neglect cannot be compared although they are all called neglect
•    there is little research on consequences of neglect especially the long-term sequelae. Are the effects different if the neglect is psychological, physical or environmental?
•    the data is mostly correlational. Samples with longitudinal data have been small. Few studies have disentangled neglect from physical abuse making it difficult to discern unique effects
•    few studies have controlled for confounding variables such as maternal education, maternal depression and poverty impeding the ability to discern the effects specifically attributable to neglect.
Consequently our current knowledge of outcomes needs to be interpreted cautiously.
9.2    Research implications
Before more effective assistance can be offered it is important to have a more in-depth understanding
of what • • • • • • •
• •
happens to neglect cases. The issues to be further examined are:
What is classified as neglect when a report is received by the Helpline?
How many of these are re-referrals?
How often have they been re-referred and over what period?
How many of these cases are followed up?
To what extent do the secondary risk of harm assessments validate the original categorisation?
What services are the families most likely to be offered?
Have families been offered other services by other agencies in the past or is statutory child protection the first to offer assistance?
To what extent do families engage in the services offered? (Is there a difference between take-up rates of different types of services?)
Which of these services is most effective in terms of developmental and parental outcomes?
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The information is best answered prospectively by tracking a sample of children reported to the Helpline and following their progress through the system. As there would need to be strong caseworker support for such a project, the research is probably best done in collaboration with the caseworkers. The danger otherwise, is that caseworkers feel threatened by the intrusion and close examination of their work. This can lead to lack of co-operation and altering practice.
A sample of current files can be examined as a pilot project. This would also enable a better understanding of the nature and design of a prospective study. Baseline data on current practice would be captured and provide a description of the characteristics of these cases and the likely progress through the service system.
9.3    General conclusions
From the existing research it can be concluded that neglect is still a neglected area, and that this extends beyond research knowledge and investigation. It is strongly linked to poverty, and is more likely in families where the mother is a young, single parent with little social support and where there are also mental health and/or substance abuse issues.
Despite being the most common form of child maltreatment, the lack of precise definition, the range of behaviours it covers and the low probability of neglectful parents seeking help, predisposes these children to be further neglected by service providers. It is likely that neglect has reached chronic levels by the time the family is referred by the community or other helping professionals to statutory child protection services. Even then, Tanner and Turney (2003) suggest that the apparent trivial nature of each incident contrasts sharply with the competing priority of children whose safety is in immediate danger, with the result that the neglect is even more severe and chronic before the threshold of intervention by statutory child protection agencies is reached.
Although neglected children are often not in danger of immediate harm, the long-term sequelae of persistent neglect may be as damaging, and in some cases more damaging than isolated but more serious incidents of physical abuse.
Most research has been carried out in the United States or the United Kingdom making generalisations of conclusions to other jurisdictions difficult. Even within Australia, different jurisdictions have different definitions of neglect so data is not always comparable.
Furthermore, neglect commonly elicits internalising symptomatology, characterised by withdrawn passivity. Again this is behaviour that does not draw immediate attention from other adults who come in contact with these children, especially in educational settings such as school and preschool where undemanding children are easily overlooked. Dirty, smelly, gummy-eyed children with running noses, who are quiet, inattentive and slow to grasp concepts may well attract less sympathy (and more often disgust) from their peers and often adults than a clear physical injury such as bruising.
These children are then overlooked by their parent/s, their peers, other adults and service providers further compounding the difficulties they face.
Given the high prevalence and negative developmental outcomes for these children a more concerted effort needs to be made to understand and provide assistance for them. Where parents just lack sufficient knowledge about child development and are easily overwhelmed, providing emotional and practical support may be sufficient. However, where neglect arises through indifference and offers of help are greeted with hostility, interventions directly targeting the child may be more effective.
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Child neglect
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Appendices
Appendix A: Categories of neglect Physical neglect
General
Medical neglect
Abandonment
Expulsion
Supervisory neglect
Inadequate supervision
Inadequate nutrition, clothing or hygiene, conspicuous inattention to avoidable hazards in the home or other forms of reckless disregard for of the child’s safety and welfare, such as driving with the child while intoxicated, or leaving a young child unattended in a motor vehicle etc
Refusal of health care: Failure to provide or allow competent health care professional for a physical injury, illness, medical condition or impairment Delay in health care: Delay in seeking timely and appropriate medical care for a serious health problem which any reasonable layman would have recognised as needing professional medical attention
Desertion of child without arranging for reasonable care and supervision. This includes leaving children and not claiming them within two days, and when parents or caregivers leave children and give no (or false) information about their whereabouts
A refusal of custody such as permanent or indefinitely expulsion of a child from the home without adequate arrangement for care by others, or refusal to accept custody of a returned runaway. Custody related issues such as repeated shuttling of a child from one household to another due to an apparent unwillingness to maintain custody, or chronically and repeatedly leaving a child with others for days or weeks at a time.
A child is left unsupervised or inadequately supervised for extended periods of time (eg a toddler being out of sight for over an hour) or allowed to remain away from home overnight without the parent or caregiver knowing or attempting to determine the child’s whereabouts (eg for a 13-16 year old).
54
Child neglect
Emotional neglect
Inadequate nurturance
or affection
Chronic/extreme abuse
Permitted drug or alcohol use
Permitted maladaptive behaviour
Refusal of psychological care
Delay in psychological care
Other emotional neglect
Educational neglect
Permitted chronic truancy
Failure to enrol
Inattention to special educational need
Marked inattention to the child’s needs for affection, emotional
support, attention of competence
Chronic or extreme spouse abuse or other domestic violence in the child’s presence
Encouraging or permitting drug or alcohol use by the child; parent or caregiver not attempting to intervene having been informed of the problem
Encouraging or permitting behaviour such as chronic delinquency or severe assaultiveness or not attempting to intervene having been informed of the behaviour
Refusal to allow needed and available treatment for a child’s emotional or behavioural problem in accord with professional recommendation
Failure to seek or provide needed treatment for a child’s emotional or behavioural problems which any reasonable layman would have recognised as needing professional psychological attention
Inattention to the child’s developmental or emotional needs not already classified (eg markedly overprotective restrictions which foster immaturity or emotional dependence, chronically applying expectations clearly inappropriate in relation to the child’s age or level of development).
Habitual or chronic truancy averaging at least five days month if the parent had been informed of the problem and had not attempted to intervene
Failure to enrol or register a child of mandatory school age causing the school aged child to remain at home for non-legitimate reasons (eg to work, to care for siblings etc) an average of at least three days a month
Refusal to allow or failure to obtain remedial educational services or following through the treatment of a child’s diagnosed learning disorder or other special educational need without reasonable cause.
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Appendix B: Risk assessment
While some of these structured assessments are predictive of abuse there is no evidence that the matrix model (eg Washington State Risk Assessment Matrix (Palmer, 1988) or the Child Endangerment Risk Assessment Protocol (an empirical predictor model from the Illinois Department of Children and Family Services, 1996) predict neglect (Straus & Kantor, 2005).
The behaviourally-anchored scales had stronger associations with neglect. The Child Well-Being Scales (Magura & Moses, 1986) have been shown to discriminate between neglecting (79 per cent accuracy) and non-neglecting (81 per cent accuracy) families. The strongest discriminating factors have been household adequacy (Gaudin, 1993) and to a lesser extent health care, diet, clothing, hygiene sanitation, child supervision and utilities (Casady & Lee, 2002) suggesting that the association may be through poverty. Again, this instrument is not designed to predict neglect in families without a history of child protection involvement. Based on the same model the Ontario Child Neglect Index specifies type and severity of neglect
Comprehensive ecologically structured scales are based on the ecological approach which views child neglect as an association between the child, the community and societal factors. The Child and Risk Field System (CARF) is probably the best known of these however Stowman and Donohue (2005) report that there is only low inter-rater reliability, poor internal consistency, system and service effects appear marginal and there is no validation data.
Another approach, which may be more useful for neglect are the environmentally focussed assessment measures. These include the Home Accident Prevention Inventory and the Home Safety and Beautification Tour (Donohue, Van Hasselt, Miller & Hersen, 1997) which look at potential hazards in the home8 (HAPI – Tertinger, Greene & Lutzer, 1984) and the Checklist for Living Environments to Assess Neglect (CLEAN – Watson-Perczel, Lutsker, Greene & McGimpsey, 1988) which looks at home cleanliness. They are thought to relate to neglect as homes of neglected children are often messy and unsanitary but their psychometric properties including predictive validity are unclear (Stowman & Donohue, 2005).
The Childhood Level of Living Scale (Polansky, Chalmers, Buttenwieser & Williams, 1981) was designed specifically to capture neglect in children between the ages of four and seven years. It is intended to be used by the caseworker of the family who knows them, as a tool to give more structure and reduce the professional bias that may accompany decision making relying on clinical experience only.
8    It should be noted here that by introducing ‘baby-proofing’ guidelines for buildings and households and visiting homes of new mothers in Sweden, the child injury rate was reduced by 75 per cent in a forty-year period (Durrrant, 2000)..

MAY 2005
RESEARCH REPORT
Child neglect
Literature review
Child neglect
Literature review
Child neglect
Author
Dr Johanna Watson
Acknowledgments
Many thanks to Upekha Nadarajah whose 2004 paper on neglect helped shape this document, and for the background information and editorial comments provided by Trevor Spratt, Ilan Katz, Gül Izmir, Peter Walsh and John Williams.
Produced by
Centre for Parenting & Research
NSW Department of Community Services 4 – 6 Cavill Avenue Ashfield NSW 2131 Phone (02) 9716 2222
May 2005 ISBN 0 7310 4384 7
Literature search cut off date: November 2004. Selected articles included in the revision up to May 2005.
www.community.nsw.gov.au
Child neglect