Neglect

Neglect is defined in Working Together to Safeguard Children as "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 the child from physical and emotional harm or danger;
• Ensure adequate supervision (including the use of inadequate care-givers); or
• Ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.

Neglect is relationship based and about the ability for the caregiver to connect love with care for their child.

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 may have difficulties with:

• Basic trust;
• Self-esteem;
• Ability to control their behaviour;
• Social interaction;
• Educational attainment; and
• Problem-solving.

Neglect in childhood can also lead to problems during adulthood including:

• Living independently 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, criminal 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, including adolescents and older children.

Where parents/carers have specific beliefs, which may influence their views on 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).

Neglect differs from other forms of abuse in that there is rarely a single incident or crisis that draws attention to the family. Rather 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, 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 points 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 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.

Physical Care:

1.  To be clean;
2. To be warm;
3. To have clean, well-fitting clothing;
4. To live in clean comfortable accommodation;
5. To have nutritious food;
6. To have regular dental checks;
7. To have medical care when needed.

Development (to learn):

1. To attend nursery/school regularly;
2. To have access to books and toys;
3. To have opportunity for play and to develop social skills;
4. To have support with reading, writing and learning at home;
5. To be supported to experience success and achievement;
6. To have targeted help when the child has additional needs.

To be loved and wanted:

1. To feel safe and securely attached to one or more person;
2. To have a stable home environment;
3. To feel valued and have a sense of belonging;
4. To understand who they are and where they come from;
5. Support to develop friendships;
6. To have praise and encouragement to build esteem;
7. Support to help the child regulate their behaviour and emotions through positive role models.

To be safe:

1. To be protected from unsafe adults;
2. To be protected from exposure to danger at home and in the community;
3. To have clear and consistent boundaries;
4. To be properly supervised;
5. To be helped to understand potential dangers in the community;
6. To be protected from exposure to harm from social media; phone, computer etc.

Physical Care:

1. The child or young person frequently looks unkempt and has poor personal hygiene;
2. The child or young person is unnecessarily exposed to the cold due to a lack of warm clothing and bedding;
3. The child or young person regularly has unclean, ill-fitting clothing that is not suited to the weather conditions;
4. The child or young person is given food that lacks nutrition or is being under or over fed;
5. Regular dental checks are missed causing signs of decay;
6. Medical appointments or follow up on treatment are missed when needed;
7. The child or young person has frequent accidental injuries.

Development (to learn):

1. Attendance at nursery/school is irregular and children are often late;
2. The parent/care giver does not promote the child’s access to books and toys;
3. The parent/care giver restricts opportunities for play and to develop social skills when their own needs come first;
4. The parent/care giver limits support with reading, writing and learning at home as their own needs come first;
5. There may be lots of changes in care and an environment that creates behavioural problems in the child;
6. The child or young person experiences feelings of worthlessness which creates sadness and anger;
7. The child or young person lacks stable and secure friendships;
8. The child or young person feels frequently criticised, experiences limited physical comfort and low emotional warmth;
9. The parent/carer frequently shouts or loses control with the child or young person

Being unsafe:

1. Boundaries are inconsistent or absent;
2. Children are regularly left unsupervised at home, i.e. in the bath, or in the community, even for short periods;
3. There is a failure to recognise or take action when a child or young person is exposed to an unsafe adult (risk of sexual and physical harm);
4. There is a failure to recognise or take action to ensure children are supervised by trusted and known adults;
5. There is a failure to help the child or young person understand danger and risksto them from an unsafe home environment, or in the community from strangers, road safety, exposure to drugs and alcohol, fire and water hazards;
6. There is a failure to recognise and take action when a child or young person is exposed to social media without adequate parental controls.

The consequences of neglect:

Babies under 1 year are statistically more at risk of dying from neglect.

0-5 years:

• Failure to thrive; stunting, poor height and weight gain;
• Developmental delay, not meeting milestones e.g. not sitting, crawling;
• Pale skin, poor hair and skin condition;
• Understimulation, head banging, rocking;
• Language delay;
• Emotional, social and behavioural difficulties e.g. frequent tantrums, persistent attention seeking or demanding, impulsivity or watchful and withdrawn; 
• Frequent attendances at A&E; 
• Persistent minor infections.

5-11 years:

• Poor concentration and achievement at school;
• Speech and language delay;
• Aggressive/withdrawn;
• Emotional, social and behavioural difficulties as above;
• Frequent attendances/admission to A&E;
• Isolated or struggles to make and keep friendships;
• Problems with taking turns and negotiation;
• Poor physical co-ordination/dexterity;
• Is bullied or bullies others.

11-18 years:

• Failure to learn;
• Poor motivation;
• Socially isolated/poor peer relationships;
• Increasingly high risk anti-social behaviour;
• Potential for self-harm/substance use;
• Feelings of low self-worth and alienation;
• Poor self-esteem and confidence.

Long Term Effects: Young people who experience the cumulative effects of neglect are most at risk and can result in:

• Taking it out on yourself;
• Taking it out on others;
• Substance use;
• Eating and sleeping disorders;
• Mental health difficulties/self-harm;
• Criminality and violence;
• Anti-social behaviours;
• Problems with intimacy and separation;
• Suicide.

In North East Lincolnshire we have developed a local toolkit and guidance to support consistent identification and response to indicators of neglect. It is recommended to use the screening tools to support identification and reflection tools to organise thinking. Please read: North East Lincolnshire Neglect Toolkit.

Consider Jane Wiffin’s questions in response to neglect:

1. The importance of Persistence and Change;
2. Types of Neglectful Care giving:
   • Physical Care;
   • Health;
   • Safety and supervision;
   • Love and care;
   • Stimulation and education.
3. What is the Harm; Impact – from child’s point of view and from the evidence before us  – what can we predict using the evidence base for the future:
   1. Why the failure? What causes neglect? What drives it?
   2. Understanding omission or commission;
   3. What other kinds of abuse is neglect enabling? 

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.

It is important that children and young people receive the right service at the right time. For this to happen, all professionals who have contact with children, young people and families should identify these issues at the earliest opportunity and assess what intervention is required.

 Assessment should be a dynamic process that identifies, analyses, and responds to the changing nature and level of need and/or risk faced by a child.

 A good assessment will enable practitioners to intervene at the right time with the right level of support and to monitor and record the impact of any services delivered to the child and family.  The assessment framework can support a professionals holistic assessment of the child’s strengths and needs. See Assessment Triangle.

Where there are concerns about standards of care the Graded Care Profile 2 provides a tool for assessment, planning, intervention and review. 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.

Continuous assessment is crucial in ensuring that the help and support being delivered is having the intended impact.

When a child's needs are unmet 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 Report a concern about a child process should be considered.

Neglect often occurs in a context of 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.

Using assessments early in intervention as needs arise will support positive outcomes for children, meaning onward referral may not be required.  

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.

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. The common factor in all styles of appropriate care is that they address the needs of the child. Neglectful care may have a host of common factors with various styles of appropriate care, but it fails to address the child's needs and falls below an acceptable standard.

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 agencies should be aware of the need for supervision 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.

When reviewing progress in cases of neglect it is important to look for evidence of sustained improvement in the child's health and development. Where there is a pattern of short-lived improvements, the overall situation remains unsatisfactory - if adequate standards of care cannot be sustained, the child remains at risk of significant harm.

Professionals must resist the temptation to "start again" at key points such as the birth of a new child or a change of worker. It is important to see current events in the light of the full history of safeguarding and child protection issues, including previous responses to support. The family histories of neglectful families are often complex and confusing, and professionals may be tempted to set them aside and concentrate on the present. This can result in an over-optimistic approach to a family with deeply entrenched problems.

As noted above, neglectful adults are often enmeshed in a complex network of problems. The clamour of the parents'/carers' needs tends to draw professional attention away from the unmet needs of the children. When addressing the needs of neglectful parents/carers, it is necessary to ask repeatedly:

• Do they understand what action is needed and within what timescales?
• Are they able and willing to meet the child's needs?
• Are they doing so?
• Are they able to access appropriate support services?
• Is anything changing for the child? Is the change enough to bring the standard of care up to an acceptable level?

If adult services are supporting the parents/carers, it is important to stress the need for them to notify children's practitioners if the parents/carers fail to engage with the services offered.

If there is a vulnerable adult living in the same household as a child whose needs are neglected, then their needs may also be neglected or unmet. Practitioners should report any concerns about the welfare of vulnerable adults to adult social care.

SAFERNEL- Prevention and Early Help

SaferNEL | Neglect - SaferNEL

For further information and support services contact:

Families First Information Service

Email: fis@nelincs.gov.uk
Telephone: 01472 326292 (option 1)

Simply connect information service 

Health Visiting and School Nursing Service: 01472 323660

NSPCC Grimsby Service Centre: 01472 803500

If you are worried about a child, contact:

• North East Lincolnshire Children’s Front Door on 01472 326292
  (option 2, option 2) (Monday to Thursday 8.30am to 5pm and Friday 8.30am – 4.30pm); or
• NSPCC HELPLINE on 0808 800 5000.

Missed Opportunities; Indicators of Neglect – What is Ignored, Why, and What Can be Done? November 2014

NSPCC

NSPCC. Neglect: learning from case reviews.

Learning for the future: final analysis of serious case reviews, 2017 to 2019 (publishing.service.gov.uk)