TOULMIN ESSAY ON CHILD NEGLECT

Healio.com /Pediatrics | 73 C M E 1. Learn how to manage the com - plexities of defining neglect in children. 2. Examine the multiple contributors to neglect. 3. Understand principles for effec - tively intervening in a child neglect situation.

Howard Dubowitz, MD, MS, is Professor of Pediatrics, University of Maryland School of Medicine; Director, Center for Families, University of Maryland, Baltimore; and Chief, Division of Child Protection, Depart - ment of Pediatrics, University of Maryland Hospital.

Address correspondence to: Howard Dubowitz, MD, MS, University of Maryland School of Medicine, 520 W. Lombard Street, Baltimore, MD 21201; fax: 410-706-3017; email: [email protected].

Disclosure: Dr. Dubowitz has no relevant financial relationships to disclose.

doi: 10.3928/00904481-20130326-11 EDUCATIONAL OBJECTIVES CM E C hild neglect is by far the most common form of child maltreat - ment. Approximately two-thirds of reports to child protective services in - volve neglect. 1 Per a community survey in 2006, the frequency of neglect is 30.6 per 1,000 children, with lower rates of 6.5, 2.4, and 4.1 for physical, sexual, and emotional abuse, respectively. 2 Neglect is not as benign as the term suggests. Neglect can have substan - tial and long-term effects on children’s physical and mental health and cognitive development. Examples include fatali - ties, 1 impaired brain development, 3 and adult problems such as liver 4 and isch - emic heart disease. 5 Neglect also has been associated with inferior academic performance, 6 emotional, and behavioral problems, 7 as well as depression and sui - cidality decades later. 8 Neglect poses challenges to pediatri - cians. There is often uncertainty regard - ing what constitutes neglect and how best to address it. This article covers defini - tional considerations and principles for assessing and addressing neglect, preven - tion, and advocacy.

DEFINITION OF CHILD NEGLECT Defining child neglect is not an aca - demic exercise. It guides our thinking and practice concerning identifying and ap - proaching this prevalent problem. State laws focus on omissions in care by parents or caregivers that result in actual or poten - tial harm. 9 Parents are held responsible, or culpable, for failing to provide necessary care. The challenge is in knowing whether Neglect in Children Howard Dubowitz, MD, MS © Shutterstock PEDIATRIC ANNALS 42:4 | APRIL 2013 74 | Healio.com /Pediatrics C M E it is reasonable and constructive to blame a parent for a lapse in care, such as not get - ting a prescription filled. Understandably, many professionals feel uncomfortable in - voking “neglect.” Parental Responsibility and Blame Parents are primarily responsible for meeting their children’s needs. However, there are usually multiple and interacting contributors to parenting and to neglect.

For example, a single, depressed mother who has lost her job and health insurance may not have filled a prescription for her daughter’s medications. Other situations are even further beyond parental control, such as schools that fail to meet children’s educational needs. Child protection ser - vices (CPS), however, typically become involved only when a parental inaction is deemed the major contributor to the child’s need(s) not being met.

Inadequately Met Needs An alternative to the customary focus on parental omissions is to define neglect as occurring when a child’s basic needs are not adequately met. 10 Advantages to this approach include: 1) fitting well with a broad medical goal, which is help - ing ensure children’s safety, health, and development; 2) being less blaming and more constructive, a key issue as profes - sionals strive to work with families; and 3) drawing attention to other contributors to neglect, aside from parents, thus encour - aging a broader response to underlying problems. Clearly, not all circumstances within this child-centered view of neglect warrant CPS involvement; alternative in - terventions may be more appropriate.

ADEQUATE CARE The extent to which a child’s needs are met exists on a continuum from optimal to grossly inadequate, often without natural cut points. Crude categories of “neglect” or “no neglect” are too simplistic. It is dif - ficult to determine at what point inadequate emotional support, for example, is harmful. And, with relatively few extreme situa - tions, the proverbial gray zone is large. How might the adequacy of care be as - sessed? Examples of adequate health care include: reasonable care for minor prob - lems (eg, parent comforting a child after a fall); professional care sought for more severe problems (eg, child cutting her - self); adequate treatment (eg, adherence to treatment regimen); and professional care meets accepted standards. The last example illustrates again how deficits in care are not always due to parents. With the extent to which needs are met being on a continuum, many circumstances may need to be addressed, even if they do not meet the threshold for “neglect.” ACTUAL VS. POTENTIAL HARM States’ legal definitions of neglect generally include both actual and poten - tial harm; however, many CPS agencies restrict their practice to circumstances involving actual harm. Nevertheless, po - tential harm is important; the impact of neglect may be apparent only years later. It is difficult to predict the likelihood and nature of future harm. Epidemiological data sometimes help, such as the increased risk of a serious head injury from a fall off a bicycle when not wearing a helmet. 11 In addition to the likelihood of harm, we should consider the nature of the potential harm. A high likelihood of minor harm (eg, bruising from a short fall) might be accept - able. In contrast, a low likelihood of severe harm (eg, suicide) is unacceptable.

HETEROGENEOUS NATURE OF NEGLECT The different types of neglect chil - dren experience vary considerably. The following are types most commonly en - countered by psychiatrists.

Nonadherence with Health Care Recommendations This form of neglect occurs when recommendations for health care are not implemented, resulting in actual or po - tential harm. The term “nonadherence” is preferred; it lessens the blaming connota - tion of “noncompliance.” 12 It is important to ascertain the extent to which care was not received, and whether that led to the child’s problem. We should acknowledge that some recommended care may not be important; such lapses should not be la - Figure 1. Contributors to child neglect.

PEDIATRIC ANNALS 42:4 | APRIL 2013 Healio.com /Pediatrics | 75 C M E beled neglectful. For example, occasional missed appointments are unlikely to re - sult in harm and should not be considered neglect. Encouragement to keep appoint - ments, however, is reasonable.

Delay or Failure to Provide Health Care Neglect occurs when necessary health care is not sought in a timely manner, or not at all. CPS typically considers neglect when a parent does not seek care for a significant problem that an “average lay - person” can reasonably be expected to act upon, such as severe anorexia.

Cultural and Religious Issues Another circumstance involves differ - ent cultural practices, such as the South - east Asian folkloric remedy of “cao gio”.

Used for a variety of symptoms, cao gio involves vigorous rubbing with a hard ob - ject that causes bruising and welts. Con - cerns of neglect arise when complications ensue, especially when effective medical treatment is available (eg, for depres - sion). The appropriateness of interven - ing is guided by the level of certainty that the approach used was harmful or inef - fective, and that a distinctly preferable treatment exists. The same principles ap - ply when children do not receive medi - cal care for religious reasons. Thirty-four states and the District of Columbia have religious exemptions in their civil codes on child abuse or neglect, exempting par - ents who do not obtain medical care for sick children based on their religion. The American Academy of Pediatrics strong - ly opposes these exemptions, advocating that “the opportunity to grow and develop safe from physical harm with the protec - tion of our society is a fundamental right of every child.” 13 Overall, the recognition of what con - stitutes neglect is not very culture-bound.

Several US studies found adults from dif - ferent racial/ethnic and socioeconomic groups generally agree on what consti - tutes child neglect. 14 More broadly, the United Nations Convention on the Rights of the Child attests to a remarkable inter - national consensus regarding what chil - dren need to ensure their health, develop - ment, and safety. 15 Failure-to-Thrive and Overweight The etiology of failure-to-thrive (FTT) is often multifactorial; the old dichotomy of “organic or nonorganic” is no longer recommended as most growth problems involve both nutritional and psychosocial factors. In terms of nutritional needs not being adequately met, most children with FTT can be said to experience neglect.

However, CPS focuses on problems where omissions in parental care are pri - marily responsible. Pediatric overweight has dramati - cally increased in prevalence; over 17% of children have a BMI > 95th percentile.

The morbidity associated with obesity is clear. Like FTT, the etiology of obesity is multifactorial, and neglect is a concern when the problem is not addressed de - spite available interventions.

Drug-Exposed Children Aside from the potential direct harm of the drug, the compromised caregiving abilities of substance-abusing parents are a major concern. Not surprisingly, paren - tal substance abuse has been associated with neglect.

Inadequate Protection from Environmental Hazards A basic need of children is to be pro - tected from environmental hazards — inside and outside the home. Injuries, exposure to guns and intimate partner violence, and extreme risk-taking behav - ior may represent inadequate protection and supervision, threatening children’s health, development, and safety. In gen - eral, neglect is a concern when there is a pattern of inadequate protection and su - pervision. A single incident (eg, witness - ing parents physically fighting) should probably not be construed as neglect. New and Other Forms of Neglect As knowledge evolves concerning chil - dren’s health and development, new forms of neglect become apparent. For example, we have learned of the impact of second- hand smoke on children, especially those with pulmonary disease. Attitudes have shifted toward parents who leave guns ac - cessible to children. Twenty-seven states SIDEBAR 1. General Principles for Assessment of Possible Neglect • Verbal children should be separately interviewed, at an appropriate develop - mental level. Possible questions include:

“What happens when you feel sick? Who helps you if you have a problem? Who do you go to if you’re feeling sad?” • Do the circumstances indicate that the child’s need(s) is/are not being met adequately? Is there evidence of actual harm? Is there evidence of potential harm and on what basis?

• What is the nature of the neglect?

• Is there a pattern of neglect? Are there other forms of neglect, or abuse? Has there been prior CPS involvement?

• What is the risk of imminent harm, and of what severity?

• What is contributing to the neglect? Con - sider categories listed under “Etiology.” • What strengths/resources are there?

– Child (eg, child wants to go to school, requiring better health) – Parent (eg, parent wants child to be happy) – Family (eg, other family members willing to help) – Community (eg, programs for par - ents, families) • What interventions have been tried, with what results? What has the psychiatrist done to address the problem?

• What is the possibility of other children in the home also being neglected (a com - mon occurrence)?

• What is the prognosis? Is the family motivated to improve the circumstances and accept help, or resistant? Are suitable resources, formal and informal, available?

PEDIATRIC ANNALS 42:4 | APRIL 2013 76 | Healio.com /Pediatrics C M E have laws holding parents criminally li - able. As the benefits of mental health treatments become increasingly clear, be - ing denied such care may be construed as emotional neglect.

OTHER ASPECTS OF NEGLECT THAT INFLUENCE RESPONSE Intentionality regarding neglect is a common concern, although it prob - ably does not apply to most neglectful situations. Most parents do not intend to neglect their children. Rather, prob - lems impede their ability to adequately care for them. In practice, as we strive to strengthen families, viewing their shortcomings as intentional may be counterproductive, especially if it fos - ters a negative stance toward parents.

As a practical matter, it’s very difficult to assess intentionality. Even in extreme cases, such as children who are deliber - ately starved or kept in a basement, es - tablishing specific “intentionality” is not necessary in order to ensure the child’s safety, such as by removal from the ne - glectful environment. Context influences our response to neglect. A constructive approach requires understanding the underlying contribu - tors to best tailor an approach that meets the needs of the child(ren) and family. ETIOLOGY OF CHILD NEGLECT Neglect is best understood as a symp - tom, with many possible contributors spanning the individual (parent and child), familial, community, and societal levels.

Professional actions and inactions may also contribute to neglect. This framework guides a comprehensive assessment of what may underpin neglect, which then guides the intervention. The following ex - amples illustrate each category (see Figure 1 on page 74).

Parents Mothers’ mental health problems, es - pecially depression and substance abuse, have been linked to neglect. 16 Limited involvement of fathers in their children’s lives can also be seen as neglect. 17 Child Child characteristics such as low birth weight, prematurity, or disabilities may challenge parents and contribute to ne - glect. 18 The behavior of older children may be difficult, despite a parent’s appro - priate efforts.

Family Intimate partner violence and child maltreatment frequently co-occur. Chil - dren need to feel safe and secure at home, not afraid or threatened.

Community The community context and its resourc - es influence parent–child relationships and possible neglect. Parents’ negative percep - tions of the quality of neighborhood life have been related to maltreatment. 19 Professionals Professionals may also contribute to neglect. Poor communication with parents may result in them not understanding the treatment plan. 23 Psychiatrists may not comply with recommended approaches and may fail to identify children’s medi - cal or psychosocial needs, contributing to neglect. SIDEBAR 2. General Principles for Addressing Child Neglect • Convey concerns to family, kindly but forthrightly. Avoid blaming.

• Be empathic and state interest in helping, or suggest another psychiatrist.

• Help address contributing factors, prioritizing those most important and amenable to being rem - edied (eg, recommend treatment for a mother’s depression). Parents may need their problems addressed to enable them to adequately care for their children. Parenting programs can help.

• Begin with least intrusive approach, usually not child protective services.

• Establish specific objectives (eg, a child’s hyperactivity will be adequately controlled), with measurable outcomes using standardized rating scales. Similarly, advice should be specific and limited to a few reasonable steps.

• Engage the family in developing the plan, solicit their input and agreement.

• Build on strengths, providing a valuable hook to engage parents and children.

• Encourage positive family functioning, such as how a father can be more involved.

• Be innovative and consider available resources, such as using pots and pans for play. Encour - age reading to promote both literacy and intimacy. 24 • Encourage informal supports from family and friends.

• Consider support available through a family’s religious affiliation.

• Consider need for concrete services (eg, Medical Assistance, Temporary Assistance to Needy Families, Supplemental Nutrition Assistance Program).

• Consider children’s specific needs, given what is known about the possible outcomes of neglect.

• Be knowledgeable about community resources, and facilitate appropriate referrals.

• Consider the need to involve child protective services, particularly when moderate or serious harm is involved, and, when less intrusive interventions have failed.

• Present the report as necessary to clarify the situation, so that the child and family will get the appropriate help. Most states have recently developed alternative response systems — especially for neglect. This approach focuses on supporting families to do better, rather than on investigating what was done wrong. It attempts to be conciliatory and constructive, rather than punitive. Most importantly, it prioritizes the heart of the problem: addressing the needs of children and families.

• A written, signed contract helps document the agreed-upon plan — one copy for the parent and one for the medical chart.

• Provide support, follow-up, review of progress, and adjust the plan if needed.

PEDIATRIC ANNALS 42:4 | APRIL 2013 Healio.com /Pediatrics | 77 C M E Society Many broad societal factors compro - mise parents’ abilities to care adequately for their children. In addition, these soci - etal or institutional problems can be direct - ly neglectful of children. In one study, only 70% of children with learning disabilities received special education services; fewer than 20% of children received needed mental health care. 20 Neglected dental care is widespread. 21 And if health insurance is a basic need, 7.3 million (9.8%) children experienced this neglect in 2012. 22 Such circumstances can be considered soci - etal neglect. In addition, poverty appears strongly associated with neglect, 2 as well as impeding children’s health and devel - opment. This too, in an affluent society, constitutes societal neglect.

ASSESSMENT OF POSSIBLE NEGLECT The heterogeneity of neglect does not allow one specific approach for assess - ing the array of possible circumstances.

Instead, a list of general principles and questions are offered in Sidebar 1, and principles for approaching the problem are offered in Sidebar 2. It is important to recognize that neglect often requires long-term intervention with ongoing support and monitoring.

Regarding different cultural and religious practices, humility is essential. Avoid an ethnocentric approach (ie, believing “my way is the right way”). Alternatively, al - though it is important to respect different cultural practices, we should not accept those that clearly harm children. We can work with parents and religious and cul - tural leaders to seek a satisfactory com - promise; however, sometimes agreement cannot be reached and the child is harmed or at risk. Criteria for legal involvement include: 1) the treatment refused by the parents has substantial benefits over the alternative; 2) not receiving the recom - mended treatment will cause serious harm; 3) with treatment, the child is like - ly to enjoy a “high quality” of life; and 4) in the case of teenagers, they should consent to treatment. 25 CONCLUSION Pediatricians can help families and ne - glected children beyond simply treating the child. For example, if CPS has intervened, providers can remain involved after a CPS report in helping the family obtain servic - es. Conferring with specialists is generally helpful, especially so in such circumstanc - es. Efforts to develop a program and to improve policies and institutional practices concerning children and families are other forms of useful advocacy. At the broader level of state and national government, pediatricians can advocate for policies and resources to help meet the needs of chil - dren and families. Thus, there are different ways that pediatricians can be effective ad - vocates on behalf of neglected children.

REFERENCES 1. U.S. Department of Health and Human Servic - es, Administration on Children Youth and Fami - lies. Child maltreatment 2010, U.S. Washington, DC: Government Printing Office; 2011. 2. Sedlak AJ, Mettenburg J, Basena M, et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress. Washington, DC: U.S. Department of Health and Human Services, Administration for Chil - dren and Families; 2010. 3. Teicher MH, Dumont NL, Ito Y, et al. Childhood neglect is associated with reduced corpus callo - sum area. Biol Psychiatry. 2004;56(2):80-85. 4. Dong M, Dube SR, Felitti VJ, Giles WH, Anda RF. Adverse childhood experiences and self-reported liver disease: new insights into a causal pathway. Arch Intern Med. 2003;163(16):1949- 1956. 5. Dong M, Giles WH, Felitti VJ, et al. Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circula - tion . 2004; 110(13):1761-1766. 6. Eckenrode J, Kendall-Tackett KA. The effects of neglect on academic achievement and disci - plinary problems: a developmental perspective. Child Abuse Negl. 1996;20(3):161-169. 7. Dubowitz H, Papas MA, Black MM, Starr RH. Child neglect: outcomes in high-risk urban pre - schoolers. Pediatrics. 2002;109(6):1100-1107. 8. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempt - ed suicide throughout the life span: findings from the adverse childhood experiences study. JAMA . 2001;286(24):3089-3096. 9. DePanfilis D. How do I determine if a child is neglected? In: Dubowitz H, DePanfilis D, eds. Handbook for Child Protection Practice. Thou - sand Oaks, CA: Sage, 2007. 10. Dubowitz H, Black M, Starr R, Zuravin S. A conceptual definition of child neglect. Criminal Justice Behav. 1993;20(1):8-26. 11. Wesson D, Spence L, Hu X, Parkin P. Trends in bicycling-related head injuries in children after implementation of a community-based bike hel - met campaign. J Pediatr Surg. 2000;35(5):688- 689. 12. Liptak GS. Enhancing patient compliance in pe - diatrics. Pediatr Rev . 1996;17(4):128-134. 13. American Academy of Pediatrics Committee on Bioethics.Religious objections to medical care. Pediatrics . 1997;99(2):279-281. 14. Dubowitz H, Klockner A, Starr, R., Black MM. Community and professional defi - nitions of neglect. Child Maltreatment . 1998;3(3):235-243. 15. UN Convention on the Rights of the Child. Available at: www.unicef.org/crc. Accessed Feb. 20, 2013. 16. Ondersma SJ. Predictors of neglect within low socioeconomic status families: the importance of substance abuse. Am J Orthopsychiatry . 2002;72(3):383-391. 17. Dubowitz H, Black MM, Kerr M, Starr RH, Harrington D. Fathers and child neglect. Arch Pediatr Adolesc Med . 2000;154(2):135-141. 18. Jaudes PK, Mackey-Bilaver L. Do chronic con - ditions increase young children’s risk of being maltreated? Child Abuse Negl . 2008;32(7):671- 681. 19. Garbarino J, Sherman D. High-risk neigh - borhoods and high-risk families: the human ecology of child maltreatment. Child Dev . 1980;51(1):188-198. 20. Burns BJ, Costello EJ, Angold A, et al. Chil - dren’s mental health service use across service sectors. Health Aff (Millwood). 1995;14(3):147- 159. 21. Chung LH, Shain SG, Stephen SM, Weintraub JA. Oral health status of San Francisco public school kindergarteners 2000-2005. J Public Health Dent . 2006;66(4):235-241. 21. Uninsured children. Available at: www.chil - drensdefense.org/policy-priorities/childrens-health/uninsured-children. Accessed Feb. 20, 2013. 22. Farrell MH, Kuruvilla P. Assessment of paren - tal understanding by pediatric residents during counseling after newborn genetic screening. Arch Pediatr Adolesc Med . 2008;162(3):199- 204. 23. Lam BC, Lee J, Lau YL. Hand hygiene prac - tices in a neonatal intensive care unit: a multi - modal intervention and impact on nosocomial infection. Pediatrics . 2004;114(5):e565-571. 24. Duursma E, Augustyn M, Zuckerman B. Read - ing aloud to children: the evidence. Arch Dis Child . 2008;93(7):554-557. 25. Bross DC. Medical care neglect. Child Abuse Negl . 1982;6(4):375-381.

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