Child neglect

Definition and clinical features

Neglect refers to the underprovision of the child's basic needs, both physical and psychological. Most incidents comprise omissions of care by parents and others in the parental role. However, institutional neglect also occurs, mainly in the form of collective caretaking failure—for example, residential children's homes in the United Kingdom, orphanages and nurseries in Eastern Europe, and neglect of care by educational establishments and outdoor pursuit centres.

Definition problems include whether neglect should include the apparent impact on the child and/or the degree to which it was intended. (3,36) There are cultural variations in what might be perceived as neglect. The practice of putting young children into separate bedrooms, while considered normal practice in much of Western Europe, would be considered frankly neglectful in some Eastern cultures. Notwithstanding these definition problems, various forms of neglect are delineated.

The most common form is physical neglect. This principally involves the lack of provision of the child's basic physical requirements such as adequate food, shelter, and clothing. It also includes failure to protect the child from physical harm or danger. This is the most common form of neglect, and the most common form of child maltreatment to be reported to child protection agencies in the United States and Western Europe. Even within cultures, there is wide variation in the standards of provision for children, much of this related to poverty and social disadvantage.

Emotional neglect has been defined as inattention to the child's emotional needs, requirements for nurturing, or emotional well being. It represents a failure to give both love and affection, as well as attentiveness to the child's emotional cues. Some authors have preferred the term 'psychological unavailability' to describe those parents who ignore their infants' cues and signals, despite their cries and pleas for warmth and comfort. (36)

Medical care neglect refers to the failure to provide the necessary medical treatment (including immunizations, prescribed medications, surgery, and other interventions) for serious diseases or injuries. It is at its most contentious when the religious views of parents collide with the community's collective view of reasonable parental behaviour. However, less high-profile situations occur (for instance, lack of antibiotics for serious infections or insulin for diabetes, has led to morbidity and death). In the courts there have been interesting differences between countries on the interpretation of these relative rights and responsibilities. For example in the United States, where Jehovah's Witnesses have refused blood transfusions for their children, the courts have taken a more 'rights based' stance than in the United Kingdom, where the courts have supported medical appraisals concerning the most appropriate treatment for the children.

Mental health neglect refers to parents' refusal to comply with recommended therapeutic procedures in situations where children have serious, treatable psychiatric disorder. Although less well recognized, it can be an issue in anorexia nervosa, pervasive refusal syndrome, or chronic fatigue syndrome.

Educational neglect is normally linked with regulations and laws concerning the responsibility of parents to ensure that their children attend school. It is not uncommon, however, for cases involving physical and psychological neglect to also include educational neglect.

Diagnosis and presentation

Although most reported cases involve younger children, neglect occurs at all ages. Many cases are followed for years before being finally identified by professionals. Non-organic failure to thrive can precipitate earlier recognition. Otherwise neighbours, relatives, or school teachers report the child's plight to protection agencies, by which time the effects are severe and neglectful caretaking entrenched. Recognition may also come about through the child's presentation with developmental delay, language problems, school non-attendance, inadequate medical or dental care, or with significant psychological difficulties.

Epidemiology

The incidence of neglect in the United States has been estimated at 13.1 per 1000 children per year, of which half is physical neglect. (12) The equivalent figure in the United Kingdom is 1.2 per 1000 children.(13> Neglect constitutes 44 per cent of child protection caseloads in the United Kingdom, (13> and similar proportions in the United States.

Aetiological and background factors Characteristics of neglectful parents

Neglectful parents are likely to be poor, have pervasive inadequacies, and to display what has been described as the apathy-futility syndrome. Parents show immature personality characteristics, with low self-esteem, impulsivity, and an inability to plan or demonstrate choice in such important areas as adult partners, having children, or employment. Neglectful parents frequently hold inaccurate or unrealistic expectations about their children's development or behaviour. Neglect may derive from parental psychiatric illness such as schizophrenia, depression, or drug or alcohol abuse.

Characteristics of neglected children

Neglected infants have abnormal anxious attachments with their caretakers. Later in childhood they are more aggressive than comparison children, though less so than physically abused children. Neglected toddlers show non-compliance and become easily frustrated, later developing low self-esteem and self-assertiveness and showing less flexibility or self-control. Both in preschool and school they lack persistence and enthusiasm, and become socially isolated.

Family aspects

Child neglect is normally embedded within broader family insularity, lack of cognitive stimulation, affection or emotional nurturing between its members, and significant household disorganization. Neglectful parents are likely to be unresponsive to both their infants and older children, showing a paucity of prosocial positive behaviours, less interactions and stimulation, and more negative behaviours than controls. Even though there is a strong link with poverty, families containing a neglected child stand out among their equally impoverished neighbours.

Course and prognosis

The seeds for the neglected child's long-term difficulties with social interaction, relationships, and educational progress can be observed in infancy. Neglected children tend towards passiveness and helplessness under stress. They show significant developmental delays, especially language problems, attention-seeking behaviour, and superficial displays of affection, as well as conduct problems, persistent defiance, and hostile behaviour. Studies of children who as infants were subjected to psychologically unavailable caretaking reveal persisting difficulties with anger, non-compliance, low frustration tolerance, little enthusiasm or persistence for tasks, poor impulse control, relative rigidity, and lack of creativity. Similar negative developmental outcomes have been reported to occur following non-organic failure to thrive in infancy. Recent research has emphasized the summative effect of non-organic failure to thrive combined with physical neglect, leading to long-term cognitive delay and poor educational attainment. Children who as infants experienced psychologically unavailable parenting do even worse than physically abused children, showing a greater number of emotional problems, inattention, social withdrawal, and unpopularity with other children. (36)

Psychological maltreatment Definition and clinical features

The term psychological maltreatment (in preference to emotional abuse) encompasses acts of omission and commission, which are considered potentially psychologically damaging, by conveying to children that they are worthless, flawed, unloved, unwanted, endangered, or of value only in meeting another's needs. k.7 It is important to distinguish these psychological acts from any consequences that might accrue. In all, six forms of psychological maltreatment have been described, though most cases involve mixtures of the following: spurning (hostile rejection or degradation), terrorizing, isolating, exploiting or corrupting, denying emotional responsiveness (ignoring), and mental health, medical, and educational neglect. The overlap with neglect is evident from this list. Psychological maltreatment can be direct or indirect, for example being terrorized by witnessing domestic violence directed towards a loved parent, or observing parental involvement in antisocial activities such as drug abuse. Psychological maltreatment occurs in institutional settings as well as in families.

Spurning includes both verbal and non-verbal acts that reject and degrade the child through demeaning, belittling, degrading, ridiculing, shaming, or consistently singling out for criticism or humiliation. Terrorizing involves behaviour that threatens the child directly or indirectly through threatening the child's attachment figures. Isolating means the consistent denial of the child's opportunities to meet and interact, for example through confining or unreasonably limiting the child's freedoms. Exploiting and corrupting incorporates those acts which encourage the child to develop inappropriate or antisocial behaviours, for example criminal activities or sexually illegal activities such as involvement in pornographic productions or prostitution. Denying emotional responsiveness (insufficient affection, care, or expression of emotion in interaction with the child—psychologically unavailable caretaking), and neglect of medical and educational needs have already been described. Psychological maltreatment can occur alone, but usually coexists with other varieties of maltreatment.

Diagnosis and recognition

Recognition usually follows detection of other kinds of child maltreatment, or when domestic violence or parental substance abuse is uncovered. It also occurs when children are referred to child developmental or mental health clinics, or through reported observations of neighbours or professionals (e.g. teachers, police). Diagnosis requires detailed history with examples, direct observations of parent-child interactions, and interviews with the older child.

Epidemiology

Psychological maltreatment constitutes 3.0 per 1000 per year in the United States (12> nd 0.5 per 1000 in the United Kingdom.^3) It accounted for 17 per cent of the caseloads of child protection agencies in the United Kingdom in 1999. (1.3>

Aetiological and background factors

Characteristics of abused children

Reports of emotional abuse in children become more frequent throughout childhood into adolescence. Reported cases are more likely to be linked with lower socio-economic status. There is no particular link with racial or ethnic groups. Psychological maltreatment is frequently integral to other forms of maltreatment and so distinguishing different aetiological factors and consequences is difficult.

Characteristics of abusers

Although not systematically studied, this probably varies according to the mixture of subtypes present, and whether any other kind of abuse or neglect coexist. Course and prognosis

Psychological maltreatment in infancy has a very poor outlook (see discussion of neglect). Much less is known about the outcome of different mixtures of psychological maltreatment identified during childhood and adolescence. There are indications that the degree and extent of psychological maltreatment is a better predictor of case outcome than the extent of any coexisting physical or sexual abuse, thus underlining its importance to the developing person's mental health.

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