Child neglect: Evaluation and management

Forty years ago, Dr Henry Kempe’s landmark paper, “The Battered Child,” raised public awareness of overt physical abuse. Widespread recognition of neglect, however, lagged far behind. Child neglect is the most common form of child maltreatment. In the recent Canadian Incidence Study of Reported Child Abuse and Neglect, neglect was the most common reason for initiating a child protection investigation. Allegations of neglect accounted for 40% of reported cases.[1]

Neglect in itself has been neglected by professionals in the past. Perhaps this is because in some cases professionals do not perceive neglect to be a serious issue. In other cases, the problems of neglect can seem insurmountable and other forms of maltreatment can seem more acute and compelling. Sometimes neglect is readily apparent (as in the unkempt appearance of a child who comes to school without a bath or adequate clothing) and sometimes it is nearly invisible until it is too late.[2]

In addition, neglect often involves chronic situations, not as easily identified as specific incidents of abuse. It can, however, be a single lapse in care (e.g., leaving an infant alone in a bathtub). Some types of neglect typically leave no physical marks, but can have a devastating impact on a child’s development. The morbidity and mortality associated with neglect are substantial. Problems can include injuries, poisonings, inadequately treated illnesses, serious dental problems, and malnutrition.

Researchers estimate that neglect accounts for 50% of the annual fatalities attributed to child maltreatment.[3] Because of the prevalence and severity of neglect, physicians must be aware of how to identify this form of child maltreatment and how to intervene appropriately.

Types of neglect

Child neglect occurs when a child’s basic needs are not met. Basic needs include adequate food, clothing, health care, supervision, education, nurturance, and shelter.[4] Neglect is defined as an act of omission and may or may not be intentional. Adequacy of care exists on a continuum from excellent to very poor. Different degrees of inadequacy of care require different responses. The cultural context in which children’s needs are not met (e.g., different ways of showing affection and caring) must also be considered.[3]

Physical neglect

Physical neglect is the most widely recognized and most commonly identified form of neglect. It occurs when a child suffers or is at substantial risk of suffering harm by the caregiver’s failure to provide necessities. Abandonment is a form of severe physical neglect.

Every child deserves proper food, clothing, and shelter. When parents fail to provide one or more of these necessities, neglect can often be readily documented. Poor growth from suboptimal nutrition or physical illness associated with inadequate or unhygienic living conditions are clues to this form of physical neglect.

Lack of supervision by a parent or supervision by an inappropriate substitute can have irreversible or fatal consequences for a child. Clues to this form of physical neglect may include repeated accidents or toxic ingestions. In cases of substantiated neglect, “failure to supervise” was the most common reason for concern (Figure).[1]

Physical harm can also come to a child whose parents are living a dangerous or criminal lifestyle.

Unmanaged morbid obesity may represent a form of neglect. In these cases, it could be argued the child’s basic needs for proper nutrition and physical activity are not being met. There may also be untreated mental health problems in these situations.

Emotional neglect

This occurs when the child does not receive the necessary nurturing and affection for his or her optimal emotional growth. This is more difficult to document because of the absence of physical evidence and the fact that it goes on in the privacy of the home. Severe emotional neglect may lead to nonorganic failure-to-thrive. Some indicators of emotional neglect include parents being obviously uninterested in an infant, and leaving a child in a crib or a baby seat for long periods. Failure to provide the necessary mental health care is also a form of emotional neglect.

Educational neglect

This occurs when a child is not involved in any educational program or is chronically truant from school. Children who have significant delays and are denied remedial services may also be considered victims of educational neglect. It should be noted that home schooling is legal in British Columbia, but there are still legislated requirements a parent must meet to ensure the child is receiving a proper education.

Medical neglect

This occurs when a child’s basic health care needs are not met, resulting in harm or potential harm.[5] It occurs in the following situations:

• When a parent fails to seek care for illness or injury in a timely manner.
• When a parent fails to comply with medical recommendations (e.g., failing to administer prescribed medications in the appropriate manner, or administering medications in a manner that impairs the child’s recovery). 
• When a parent fails to provide or consent to treatment for a treatable condition that may be life threatening.

Parents have the right to seek alternative health care for their children. However, if proven recommended medical treatments are not provided and the child’s health is suffering, this is considered medical neglect.

Possible forms of neglect

With new knowledge, we are becoming aware of other possible forms of neglect.[3] Consider the following situations a child might face:

• A child with severe asthma is constantly exposed to secondhand smoke.
• A child is regularly transported in a car without proper restraints.
• A child lives in a home with unsecured firearms.
• A child is allowed unlimited, unsupervised Internet access.

Are these examples of neglect? While these situations have not yet been designated as neglect, they may become the focus of more attention in the future.

Risk factors for neglect

A clear understanding of the complex factors contributing to neglect is key to effective intervention. Seldom is there a single cause of neglect. Usually there are multiple codependent factors.

While numerous studies have linked poverty to an increased risk of neglect and poverty may be the biggest risk factor for neglect,[3] most poor families do not neglect their children.

Young children may be at higher risk of neglect, but studies have not proven this conclusively.

Children who were premature or who have chronic disabilities may be at greater risk.[6]

Male and female children are usually neglected equally.

Untreated maternal depression may be an important factor in some cases. Other risk factors pertaining to parents include substance abuse, developmental delay, and lack of education. In the Canadian Incidence Study, almost half the caregivers in substantiated neglect cases suffered from substance abuse (47%), more than one-quarter had mental health problems (27%), and nearly one-quarter experienced spousal violence (23%). Other risk factors seen in neglectful families include social isolation, unemployment, and illness.

Effects of neglect

Child neglect often does at least as much damage to its young victims as physical abuse.[2] First of all are the physical effects—dental problems and the consequences of injury, toxic ingestion, and malnutrition. A recent 14-year longitudinal study of child neglect showed that neglect may also affect brain growth and development.[7] In the Canadian Incidence Study, more than 50% of children who had been neglected showed some functional problems. There were significant behavior problems described in 26% of children and developmental delays in 11%.

Emotional neglect, especially during the first 2 years of life, has a particularly striking and long-lasting impact on a child’s relationship with his or her peers and on his or her ability to function within the school system. The effects of neglect are above and beyond the negative impact of poverty and its correlation with the child’s development. Aggressive behavior and difficulties relating to peers may persist long after correction of the home situation is made.[8]

Educational neglect will deprive a child of the ability to support himself or herself in the future and to participate fully in society.

Neglected children may have impaired problem-solving ability, delayed language development, and lower academic achievement when compared with controls. Children who have been neglected also show an increase in criminal and delinquent behavior in later life.[8]

Finally, neglect can be fatal:

• A child who does not receive necessary medical attention can die. 
• A child not fed can starve to death. 
• A child left unattended near water can drown. 
• A child with unsupervised access to firearms can be shot.

Fatal child neglect most often affects young children, usually those under 3 years of age. At least 70% of cases of fatal child neglect involve males. Often there are many children in the affected family. One study found there was an average of 3.3 children in the home where there had been a fatal case of neglect.[9] Also, in approximately 40% of fatal cases, there had been prior child protection services involvement.

Assessment of neglect

Early recognition of child neglect is critical. The first step is to determine if there is harm or potential harm from the parent’s action, and if the harm is due to a basic need not being met. A checklist (Table 1) can help health professionals begin to evaluate possible neglectful situations.

A physician assessing a case needs to observe the child (What is his or her affect? What is the child’s developmental level?) and the parent-child interaction (What is the rapport between them? Is there appropriate bonding?).

The physician should then determine if there is a pattern to the neglect by reviewing the full medical record for previous health problems, injuries, and accidents. After this, the frequency, chronicity, and severity of the neglect needs to be determined and key contributing factors (e.g., poverty, drug abuse, mental health problems) need to be identified.[8]

Medical assessment is only one aspect of the overall assessment. Input from community members is usually needed to assess the environment and provisions in the home as well.

Management

The family physician is often the first to recognize the problem. He or she may note a decline in growth rate, repeated accidents, missed appointments, or poor compliance with medical recommendations. If the child has a medical problem, this obviously needs to be dealt with and the child may need to be hospitalized. In some cases, the extent of the neglect will only be apparent after the child has been observed in hospital, where the eating patterns, growth, and overall behavior can be seen.

Management of a case of child neglect depends on the pattern of neglect and its severity, but some general recommendations can be followed in all cases (Table 2). The families in neglect cases need long-term intervention and support. A “quick-fix” is usually not effective. Supports are often similar to those needed when a child has a chronic illness. In spite of difficult circumstances, many children and their families have significant strengths. The physician should try to determine what these strengths are and work with them.[3]

The Child, Family and Community Service Act, (Section 13 [1]) states that a child needs protection in many circumstances, including the following:

• If the child has been, or is likely to be, physically harmed because of neglect by the child’s parent.
• If the child is deprived of necessary health care.
• If the child’s development is likely to be seriously impaired by a treatable condition and the child’s parent refuses to provide or consent to treatment.
• If the child has been abandoned and adequate provision has not been made for the child’s care.

The physician should always report situations of concern to the local Ministry of Children and Family Development (MCFD) office. In some cases, neglect can be so severe that immediate action will be required by child protection services. Usually, however, this is not the case.

Addressing risk factors

First of all, the physician should attempt to address the risk factors such as maternal depression, substance abuse, and domestic violence. The physician needs to review what has been tried already (what interventions have been attempted and with what results).

The physician needs to build on the family’s strengths and begin with the least intrusive approach. Home visiting programs and family support centres appear to be effective in managing neglect. If at all possible, there should be one primary physician who can proceed slowly and have specific objectives (e.g., the purchase of a car seat). The physician should make suggestions practical and straightforward, communicate clearly, and give simple written instructions.

Working with other professionals

When management of a case of neglect by the family physician alone is unsuccessful, a multidisciplinary approach is essential. Other professionals can contribute to the management of the situation:

• A pediatrician can determine if there is a significant underlying medical problem.
• The community health nurse can visit the home regularly and address concrete problems with the parents. 
• Mental health professionals can assess the parent’s mental status and provide treatment. They can also assess the child’s mental health and developmental level. 
• Teachers and school counselors can contribute valuable input regarding the older child’s school performance and behavior. 
• A social worker from the Ministry of Children and Family Development can assess the home environment as well as provide specialized parent education programs and family support resources. The social worker may also help coordinate the multidisciplinary team.

It is important for all of the professionals to meet together in a complex case to discuss the best approach. If the less intrusive strategies have failed, or if the neglect is severe, the Ministry of Children and Family Development will need to consider taking more serious action, including placement of the child in another environment.

Conclusion

Neglect is a serious pediatric problem. Assessment and intervention are complex and may involve many different professionals. If children are identified early and effective interventions are put in place, the children can usually remain in the home. If the case is severe or supports fail, removal of the child from the home may be necessary. Ultimately, the goal of sustained, multidisciplinary management is a thriving child in a thriving family.

Acknowledgments

Special thanks to Ms Adrienne Glen, MSW, and Mrs Val Redpath of BC’s Children’s Hospital for their assistance in the preparation of this article.

Competing interests
None declared.

Table 1. Neglect checklist.

 Table 2. Recommendations for practitioners managing a case of child neglect.

Jean Hlady, MD, FRCPC

Dr Hlady is director of the Child Protection Service Unit at BC’s Children’s Hospital, a clinical professor in the UBC Department of Pediatrics, and was a member of the Child Multi-disciplinary Team, British Columbia’s Children’s Commission, 1996–2002.