3.1 Children who are Neglected
Also see the local Neglect toolkits that are available:
- What is neglect?
- Effects of neglect
- Recognising neglect
- Dealing with concerns about neglect
- Good practice
- Pitfalls to be avoided in making decisions about neglect
- Missed Appointments/ Was Not Brought - Children and Family Engagement
- Safeguarding Supervision
What is neglect?
‘the 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. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:
- provide adequate food, clothing and shelter (including exclusion from home or abandonment)
- protect a child from physical and emotional harm or danger
- ensure adequate supervision (including the use of inadequate care-givers)
- ensure access to appropriate medical care or treatment.’
Categories of neglect
- Medical - minimising or denying children’s illnesses and/or health needs. Failing to seek appropriate medical attention or administer medication and treatments.
- Nutritional - inadequate calories for normal growth, sometimes linked to the concept of ‘failure to thrive’ recognising that there are other reasons why a child may not develop physically as well as psychologically. More recently childhood obesity resulting from an unhealthy diet and lack of exercise is increasingly being viewed as neglectful given its serious long term consequences.
- Emotional - being unresponsive to a child’s basic emotional needs, including failing to interact or provide affection, failing to develop a child’s self-esteem and sense of identity. This differs from emotional abuse in that it is an act of omission.
- Educational -failing to provide a stimulating environment, show an interest in the child’s education, support their learning, or respond to any additional needs or failure to comply with statutory requirements around school attendance.
- Physical - not providing appropriate clothing, food, cleanliness and living conditions. There is a need however to avoid confusion with deprivation and in making judgements based on cultural norms and standards of appropriate physical care.
- Supervision and guidance - failure to provide an adequate level of guidance and supervision to ensure a child is safe and protected from harm including: leaving a child to cope alone, abandoning them or leaving with inappropriate carers and failing to provide appropriate boundaries about behaviours such as under age sex or alcohol use. This affects children of all ages. (Horwath 2007)
Effects of neglect
Neglect is known to be damaging in the long and short term. It can seriously impair children’s emotional, physical, cognitive and behavioural development.
The impact of neglect during the first two years of a child's life can have profound and lasting effects on the development of the brain, leading to later problems with self-esteem, emotional regulation and relationships.
Neglect during the first five years of a child's life is likely to damage all aspects of the child's development. A neglected child is likely to have difficulties with:
- Basic trust;
- Ability to control their behaviour;
- Social interaction;
- Educational attainment; and
Neglect in childhood is also likely to lead to problems with aspects of adult life such as:
- Independent living in the community;
- Accepting adult responsibilities;
- Anti-social behaviour such as criminality, substance misuse;
- Increased vulnerability to being in abusive relationships (including the risk of sexual exploitation and being trafficked);
- Life chances and opportunities such as employment and education;
- Parenting - children who experience neglect lack a role model for good parenting, and so are vulnerable to becoming neglectful or abusive parents; and
- Self-care - for example nutrition, general health, risk-taking behaviour.
A particularly damaging combination for children is growing up in an environment of low warmth and high criticism - that is, parents/carers who switch unpredictably between helpless (neglectful) and hostile (abusive) care.
Neglect can affect children of all ages.
In addition, where parents/carers have specific beliefs, which may involve how the child receives health care and treatment or general nutrition, the outcome can be that the child's health and well-being can be dangerously compromised.
It is important to remember that neglect can be fatal to the child.
"The majority of neglect related deaths of very young children involve accidental deaths and sudden unexpected deaths in infancy where there are pre-existing concerns about poor quality parenting and poor supervision and dangerous, sometimes unsanitary, living circumstances which compromise the children's safety …. these issues include the risks of accidents such as fires and the dangers of co-sleeping with a baby where parents have substance and/or alcohol misuse problems." (Brandon et al, 2013).
The recognition and prompt response to indicators of neglect is crucial if the neglected child is to be protected. The longer a child is exposed to neglect, the more difficult it will be to reverse the adverse effects of neglect. Signs and symptoms of abuse and neglect must always be viewed in context and conclusions must not be made without a thorough assessment of the child's individual circumstances.
Neglect differs from other forms of abuse in that there is rarely a single incident or crisis that draws attention to the family. It is repeated, persistent neglectful behaviour that causes incremental damage over a period of time.
It is important to avoid 'Start Again' syndrome. Neglect should not only be measured by the most recent set of events but should be judged by the cumulative impact on the child of any previous incidents.
There is no set pattern of signs that indicate neglect other than that the child's basic needs are not adequately met. In this context:
- The child's basic needs are for food, shelter, clothing, warmth, safety, stimulation, protection, nurture, medical care, including immunisations, education, identity and play;
- Adequately means sufficient to avoid harm or the likelihood of Significant Harm;
- Failure to meet the child's needs does not necessarily mean that the parents/carers are intentionally neglectful, but it does point to the need for intervention;
- It is essential to monitor the outcome of intervention - are the child's needs being adequately met after the intervention and is there a sustainable improvement?
The essential factors in demonstrating that a child is being seriously neglected are:
- The child is suffering, or is likely to suffer, Significant Harm;
- The harm, or risk of harm, arises because of the failure of parents or carers to meet the child's needs;
- Over time, the harm or risk of harm has become worse, or has not improved to the point at which the child is consistently receiving a "good enough" standard of care;
- Persistent, severe neglect indicates a breakdown or a failure in the relationship between parent and child.
Where there are concerns about standards of care, there are toolkits that can be used for assessment, planning, intervention and review, for example The practitioner’s guide to recognising the severity of neglect (Southampton). This gives an objective measure of the care of the child across all areas of need, showing both strengths and weaknesses. Improvement and/or deterioration can be tracked across the period of intervention. It allows professionals to target work as it highlights areas in which the child's needs are, and are not, being met. It may also help parents/carers who may have experienced neglect themselves to understand why such behaviours are harmful.
Dealing with concerns about neglect
In supporting a family in which neglect is an issue, the greatest of care must be taken to resist the pressure to focus on the needs of the parents/carers: intervention should concentrate on ensuring that the child's needs are being met. This may require action to ensure that the parents/carers have access to specialist (and if necessary independent) advice and assistance, including assistance in communicating with professionals.
Neglect may arise from lack of knowledge, competing priorities, stress or deprivation. It may also be linked to parents/carers who retain cultural behaviours which are inappropriate in the context in which the family is living.
When a child's needs are unmet because the parents/carers lack knowledge or skill the first choice for intervention should generally be the provision of Early Help services such as information, training and support services. If there is no progress and the assessment by professionals is that progress is unlikely without more proactive intervention a referral to Children's Services in line with the Referrals Procedure should be considered.
Neglect often occurs in a context in which parents/carers are dealing with a range of other problems such as substance misuse, mental ill-health, learning disability, domestic violence, and lack of suitable accommodation.
On many occasions the birth of an additional child may add to the pressure on the family. The parents/carers may provide an acceptable standard of care until a new pressure or an unexpected crisis arises: then they lose sight of their child's needs. In this situation the first choice for intervention should be the provision of support in dealing with the competing pressures. This may require referral to appropriate adult services or family support services.
- Practical resources are often beneficial but their impact on meeting the child's needs must be kept under review;
- Relieving financial poverty does not necessarily relieve emotional poverty;
- Neglectful families are more likely to be isolated and to have weak informal networks. Providing volunteer support, and facilitating better relationship with family and in the community, can be effective in raising standards of care;
- Dealing with neglect can be overwhelming for professionals: support and regular supervision are crucial;
- It is important to carry out regular reviews of the rate at which the required change is being achieved in terms of the child's improved health and development.
Pitfalls to be avoided in making decisions about neglect
Neglect is characterised by a cumulative pattern rather than discrete incidents or crises, and so drift is always a potential problem. Drift may result in a loss of focus on the needs of the child, and a change in professional expectations of what an acceptable level of care might be.
Accurate, detailed and contemporaneous recording by all professionals, and sharing of this information, are crucial to the protection of the child. In any service, professionals should work from a single set of records for each child. All entries in case notes should:
- Be factual and evidence based;
- Rigorously separate fact and opinion;
- Be dated and timed;
- Give names and agencies in full; and
- State agreed responses and outcomes.
Records should include a detailed Chronology of what has been tried, and to what effect.
Cultural Factors and Neglect
There is a risk of confusion about the difference between style of care and standard of care. Styles of appropriate care vary widely, influenced by gender, class, culture, religion, age etc. It may be difficult to see why the care offered by a particular family does not lie within this range. The common factor in all styles of appropriate care is that they address the needs of the child. Neglectful care may have some factors in common with various styles of appropriate care, but it fails to address the child's needs and falls below an acceptable standard.
Missed Appointments/ Was Not Brought - Children and Family Engagement
Non-attendance at or repeated cancellations of appointments and lack of access to the child on visits are indicators that should increase concern about the child's welfare. All NHS providers should have policies for the management of children not brought to health care appointments. See the following documents for more information:
- Child and Family Engagement Guidance: Principles and guidance for secondary and tertiary health care when a child is not brought or misses an appointment
- Child and Family Engagement Guidance: Principles and guidance for primary health care when a child is not brought or misses an appointment
- What happens when a child is not brought to their appointment? Information for children, parents and carers
All agencies should be aware of the need for supervision and challenge of staff who are monitoring cases of chronic neglect:
- Professionals often want to think the best of the families with whom they work, and interpret events accordingly;
- Familiarity with the family's lifestyle may cause professionals to minimise concerns and accept that the observed standards are normal for this family;
- Changing the worker also carries risks as it takes time to see the pattern of events that identifies care as neglectful.
Supervision must provide an independent review, keeping the focus on the child's needs and the adequacy of parenting over time.
If the child appears resilient, professionals should not accept this at face value, but should check for evidence of unmet needs and impaired health and development.
See Principles and Standards for Safeguarding Supervision for more information.