Neglect and Noncompliance

Although this form of child abuse is perhaps the most common, it is also the most difficult to identify and manage. Although neglect may manifest as a more dramatic physical failure to thrive (psychosocial growth retardation), the ophthalmologist is more often confronted with parents and other caregivers who fail to attend scheduled appointments or adhere to prescribed treatment regimens such as occlusion therapy for amblyopia. Apparent noncompli-ance may result from confounding factors that significantly impair a parent's ability to comply: poverty leading to an inability to afford care, access to care (transportation, insurance coverage), lack of child care for siblings, inability to leave work, misunderstanding of the instructions or the seriousness of the eye disease, and others. When concerned about possible abusive neglect and noncompliance, the ophthalmologist should first explore such factors, perhaps with the help of a social worker or other support personnel. Absent such factors, the ophthalmologist can enter into written contracts with patients, documented in the chart and signed by the patient and a witness, that indicate the physician's expectations and the consequences (e.g., reporting to child protective services) should the behavior continue. This will empower the report once it is made, as otherwise, the agency receiving the report may blame misunderstanding and miscommunication rather than neglectful behavior.

• The ophthalmologist must ensure that explanatory factors (e.g., poverty) for non-compliance are identified and addressed

• Written contracts with parents/guardians can be helpful in managing non compliance

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