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Child neglect identification: the health visitor's role.

INTRODUCTION

HM Government (2015:93) describes child neglect as the persistent failure to meet physical and psychological needs, including:

* Inadequate nutrition, clothing and shelter

* Inadequate protection from harm or danger

* Impassiveness to a child's emotional needs

* Poor or no access to health care.

Although this definition encompasses the spectrum of neglectful behaviours, criticism may arise at the use of the word 'persistent, since neglect can also involve one-off incidents (NICE, 2009). For example, parental supervision may usually be very good but may falter for short periods during a family crisis. Such incidents can have a damaging impact and should not be disregarded.

Impairment of the developing infantile brain occurs when caregivers are not responsive to a child's physical and emotional needs (NICE, 2012). Not only does this lead to poor outcomes during childhood, it may lead to low educational attainment, mental health issues and a higher prevalence of risk-taking behaviours (drug/alcohol usage, risky sexual practices, self-harm and suicide) during adolescence/adulthood (NICE, 2009). However, neglect is not easily identified and often concealed--leading to chronic maltreatment over many years (Dubowitz, 2013). Therefore, the aim of this paper is to ascertain strategies for more effectively identifying neglect.

LIMITATIONS

This paper centres upon child neglect. The intention is not to isolate neglect from other forms of abuse, nor undermine the severity and impact of physical, emotional and sexual abuse; merely to act as a focus so that sufficient depth is given. Additionally, while prevention and early response is of paramount importance surrounding neglect, this is not the paper's focus.

METHODOLOGY

The methodology was a library based literature review, undertaken during February-April 2014, as part of an MSc study programme at the University of Bolton.

A brief literature search of the online database CINAHL was conducted initially, as recommended by Aveyard (2010). This developed understanding of basic theories and concepts. Following this, a broader search of several online databases was conducted, focusing on the key terms and synonyms of the paper's title. Table 1 details the findings.

Online and hand searches of relevant professional journals were also conducted including the Journal of Advanced Nursing, British Journal of Social Work, Community Practitioner, Child Abuse Review and Child and Family Social Work, as well as professional and organisational websites--such as NSPCC, UNICEF, DH, DfE and Action for Children. Finally, relevant books were searched online and by hand using the university library catalogue. The search ended when articles and authors reoccurred.

For all search methods, the inclusion criteria permitted only full-text articles, written in the English language, and published within the last 10 years. This enabled papers to be comprehensively analysed, and ensured the review was based upon the most up-to-date literature available.

The search identified 44 potentially relevant papers for review. This was further refined by reading each paper's title and abstract thoroughly, and'scan reading' the entire paper, as recommended by Aveyard (2010). Papers were omitted if deemed irrelevant to the research question: 'What evidence-based strategies can be used within health visiting practice to more effectively identify child neglect?' The remaining papers were comprehensively read and, again, omitted if considered unrelated to the research question. The final selection of articles included those that were the most up-to-date and pertinent to the research question. The process located 26 relevant literature pieces of qualitative and quantitative research, SCR evidence, policy documentation and theoretical literature written by academic experts.

A grid reference system was produced to highlight similarities and differences between papers' findings (Burns and Grove, 2011). This enabled themes to be generated, upon which this review is structured.

RISK FACTORS

In an attempt to predict and identify neglect, literature highlights risk factors that practitioners can be alert to (Daniel et al, 2011; Brandon et al, 2014). The aim is to identify concerns earlier and provide targeted and intensive support to 'higher risk' children (Munro, 2011). Risk factors are identified at various ecological levels: child, family and societal.

'Child-related' risk factors that render children more vulnerable to neglect are:

* Younger age--especially those less than one year.

* Low birth weight and prematurity--imposes heightened emotional stressors upon parents.

* Child disability--by imposing additional pressures (financial, practical and emotional), and in terms of disabled children not always fulfilling parental expectations.

(Rose and Barnes, 2008; Brandon et al, 2013).

Health visitors can be alert to families where these characteristics exist, and consider the heightened potential for neglect.

Extensive research has also been conducted into 'parent-related' factors, in particular the presence of domestic abuse --perpetuated through undermining the carer's parenting capacity, and when physical assaults leave them unable to nurture and protect children (Davies and Ward, 2012). In a UK study, Dixon et al (2007) found that domestic abuse and child neglect coincided in 40 per cent of cases. Interestingly, the adult victim was more likely to neglect the child, while physical child abuse was perpetrated by the abusive partner (Dixon et al, 2007). Therefore, children can suffer neglect and physical abuse simultaneously when domestic abuse exists.

Literature indicates that poor parental emotional well-being renders children vulnerable to neglect (Kohl et al, 2011; Long et al, 2012; NICE, 2012). This occurs in a variety of ways: parental preoccupation with their own needs, insensitivity to children's emotional and physical needs, and unrealistic expectations (Daniel et al, 2011; Kohl et al, 2011).

Furthermore, findings from a large-scale study (Marquis et al, 2008) and a longitudinal study (Forrester and Harwin, 2008) found significant correlations between neglectful parenting and substance misuse (illicit substances and hazardous alcohol consumption), with these children more likely to be removed into foster care placements. The impact is felt in several ways: antenatal use of illicit substances or alcohol impairs foetal growth, reduces parental cognitive ability, causes financial constraints, and children's safety is compromised if drugs or needles are improperly discarded (Davies and Ward, 2012). Moreover, the partner of a drug or alcohol abuser may emotionally neglect the child through a preoccupation with the substance misuser (Horwath, 2007).

These risk factors are significant for health visitors who have identification and supportive roles to play in domestic abuse, mental health and substance misuse (DH, 2009; Cowley et al, 2013). Therefore, health visitors have a key role to play and are ideally placed to identify children at increased risk.

At societal level, literature identifies poverty as a risk factor, including: unemployment, low income, poor community resources and social support, inadequate or overcrowded housing and health inequalities (Daniel et al, 2011; Brandon et al, 2014). The link between poverty and child neglect is complex. It is suggested that financial constraints act as 'stressors' leading to harsh, inconsistent or passive parenting, reduced happiness and morale; and a sense of hopelessness (NSPCC, 2008). Furthermore, poverty is associated with substance misuse and poor mental health (NSPCC, 2008), creating an intricate network of factors. Indeed, the phrase 'toxic trio' is used to describe the co-existence of domestic abuse, substance misuse and mental ill-health, which Brandon et al (2012) found to co-exist in 86 per cent of serious neglect cases.

But caution must be exercised, as the presence of risk factors does not demonstrate causality and absence of risk factors does not exclude neglect. Indeed, Browne and Hamilton-Giachritsis (2007) warn that practitioners who hold stereotypical viewpoints of the circumstances in which neglect occurs, may fail to recognise vulnerable situations where there are no apparent risk factors. Powell (2007) advises that practitioners should acknowledge the correlations between circumstances and neglect, but appreciate that children may remain vulnerable where there are no apparent risk factors. Therefore, it is recommended that risk factors be used as pointers to the increased potential for neglect (Powell, 2007). Similarly, Brandon et al (2014) differentiate between risk factors for possible neglect, and signs of actual neglect, as discussed next.

SIGNS AND INDICATORS

Table 2 displays the numerous signs that neglect might be occurring, with some discussed below in more detail.

Research indicates that neglectful environments (inadequate play space and materials, limited opportunities for play, and impassiveness to a child's play needs) impair children's fine and gross motor skills, communication and cognitive development (NSPCC, 2008; Long et al, 2012). Therefore, in some cases developmental delay may signal neglect. As developmental assessment is a significant role of health visitors, they are in a key position to recognise concerns and consider neglect as a possible cause (DH, 2009). However, practitioners must consider other causes, and be mindful that children are unique in their developmental trajectories.

NICE (2009) identifies that faltering growth may be a signal of neglect. However, there is a dearth of up-to-date research to support this. Although a UK study (Wright et al, 2000) highlighted that neglected children are five times more likely to experience faltering weight, the study is more than a decade old, which may affect the finding's transferability to contemporary practice. Evidently there is a need for further research surrounding faltering weight as a sign of neglect.

Birth to five years is considered the most critical growth period and thus a very vulnerable stage (Daniel et al, 2011). Health visitors are recognised as especially skilled in the assessment of weight and growth in this population (Hall and Elliman, 2008). Hall and Elliman (2008) recommend the use of centile charts on all children to identify faltering growth. However, in the Serious Case Review [SCR] of Peter Connelly, his weight deteriorated from the 75th centile to the 9th and was noted by the health visitor but not acted upon promptly (Haringey LCSB, 2010). This indicates the absolute necessity of timely and appropriate professional intervention, when concerns arise. Indeed, HM Government (2015) recognises that delaying action when abuse/neglect is suspected significantly impinges children's welfare. This highlights that it is not enough to just observe for signs of neglect.

Family behaviours may also signal neglect, for example failed attendance at appointments, delays in seeking medical attention (NICE, 2009; Brandon et al, 2013). Indeed, one third of children subject to a neglect SCR, has a history of poor health appointment attendance (Brandon et al, 2013). Furthermore, a large-scale UK-based study of paediatric burns attendees found that among cases attributed to neglect, medical aid was sought 24 hours or more after the incident (Chester el al, 2006). However, this study involved children aged up to 16 years. Since it includes children of extremely different supervisory requirements, the results must be viewed with caution.

Dubowitz (2013) advises that although occasional missed appointments are unlikely to cause harm, it could be argued that failure to attend for a single appointment may have devastating effects, for example following a serious accident. Indeed, Powell and Appleton (2012) have stressed the importance of following up children who are 'not brought' to their appointments. In practice, the significance of a missed appointment needs to be established through further 'searching for health needs', focused on the presence or absence of other signs or risk factors. Health visitors, particularly, can be alert to children's health appointment attendances since they receive correspondence from allied health professionals and are in a position to accumulate a fuller picture of the frequency and nature of missed appointments and A&E attendances. This also highlights the necessity of multi-agency information-sharing.

Cowley et al (2013) recognise that health visitors have comprehensive and specialist knowledge of neglect signs and risk factors; meaning that neglect can be identified more promptly. Furthermore, a health visitor's unique position within the community --having universal contact with children and their families, often within the home--means that they can generate knowledge of family circumstances over time, observe for deteriorations in home conditions, and observe parenting within a more 'natural' environment (Laming, 2009; Cowley et al, 2013).

BARRIERS TO IDENTIFICATION

The negative consequences of neglect upon child development, and the subsequent behaviours that practitioners can be alert to, have already been discussed. However, literature also describes those children who flourish despite adverse circumstances and show minimal (if any) signs of their circumstances--a concept known as resilience (Brandon et al, 2014). Generally, resilience is regarded positively; denoting adaptability and resistance to adversity (Daniel et al, 2012; Brandon et al, 2014). However, another perspective is that this 'false resilience' masks poor parenting, with children minimising their distress (Brandon et al, 2014) and ultimately leads to professional oversight of neglect. Indeed, Rose and Barnes' analysis of SCR's (2008) found that children presenting as bright, intelligent and alert remained susceptible--if not more so--to harm.

Parental non-engagement and/or hostility also presents a barrier (Munro, 2011; Brandon et al, 2013). Neglectful parents are more likely to disengage with professionals, leaving children invisible and vulnerable (Powell, 2007). Indeed, Brandon el al's (2013) analysis of SCR's indicates that health visitors often had a number of 'no access' visits. Additionally, practitioners may deliberately avoid contact with, or fail to challenge families, who are aggressive out of fear of reprisal. Indeed, Baby Peter's mother was noted to be extremely volatile which prevented professionals from challenging her (Haringey LSCB, 2010).

Compounding this is the notion of 'disguised compliance', whereby neglectful families mislead services into believing they are co-operative and engaging (Brandon et al, 2014). In practice, disguised compliance might be seen through short-term improvements in home conditions or sporadic attendances at school/nursery/appointments. Disguised compliance can be extremely damaging to a child's welfare since it delays identification of neglect and disguises the reality of the child's life (NSPCC, 2014).

The very nature of neglect also inhibits identification. The 'threshold of significant harm' (HM Government, 2015) is the legal definition of abuse or neglect and the point at which state intervention is compulsory. However, Brandon et al (2013) recognise that individual instances of neglect (surrounding the same child) rarely reach this threshold. As a result, practitioners may fail to share minor incidents with one another, so that the cumulative impact is unknown (Davies and Ward, 2012).

Brandon et al (2013) also describe the practice of 'start again syndrome, whereby practitioners feel so overwhelmed by complex cases that they cast aside historical information as a professional coping mechanism. However, this practice loses information surrounding patterns of past behaviours that prove vital in cases of enduring neglect. Laming (2009) discusses professionals having unfounded empathy for parents undergoing difficult circumstances, meaning that they lose focus on the child. Munro (2011), cites Dingwall et al (1983), and describes the 'rule of optimism' whereby professionals perceive parents as caring and nurturing of their children, and take at face value parents' explanations and views of home circumstances. This can be seen in the case of Daniel Pelka whose mother was often seen as the victim within the home.

USE OF ASSESSMENT TOOLS/ FRAMEWORKS

To counteract these barriers, literature recommends 'significant event' front summary sheets, for all families, to generate a cumulative chronology (Munro, 2011). Joint professional visiting might help reduce the 'threat' of parental hostility, while reflective practice, professional supervision and multi-agency training are recommended to gain clearer perspectives on family circumstances when working with complex families (Munro, 2011; Davies and Ward, 2012; Brandon et al, 2013 and 2014).

Assessment tools and frameworks are also helpful in identifying neglect. The Graded Care Profile (GCP) provides a specific tool for assessing neglect (Srivastava et al, 2005). Based upon Maslow's Hierarchy of Needs, it assesses parental care on a continuum from one (all areas of the child's needs met) to five (needs grossly unmet/not considered). As a result, the tool is considered more objective and acknowledges the grey area between 'acceptable'and 'unacceptable' care or parenting--often present in cases of neglect (Horwath, 2007). The GCP therefore supports referrals to social care through the implementation of an approved 'upper limit' for intervention, thus minimising the issue of thresholds previously discussed (Horwath, 2007). Interestingly, health visitors use this tool more than any other professional (Srivastava et al, 2005). Additionally, the Assessment Framework (DH, 2000) offers practitioners an 'open ended' method of assessing children's health/ development, parenting capacity, and family/environmental factors. It is considered pertinent to neglect identification as it identifies factors at various levels that enhance and detract from care (Daniel et al, 2011). Also, the sub-component 'Family History and Functioning' allows for consideration of current and previous circumstances--potentially avoiding 'start again syndrome'. Using these frameworks, professionals can accumulate information about children's needs, plan their interventions, be alert for the need for 'Early Help' (formerly a Common Assessment Framework) if family circumstances present challenges for the child, and make onward referrals to other agencies/services as required.

CONCLUSION

Childhood neglect can have a considerable detrimental impact upon physical, emotional and social health, with impact often persisting into adulthood. But neglect is not easily identifiable--leading to chronic maltreatment over many years. This paper seeks to review the evidence regarding effective measures for identifying neglect.

The paper identifies multiple risk factors for neglect. However, it acknowledges that risk factors do not diagnose neglect. Likewise, absence of risk factors does not eliminate neglect. Instead, they act as pointers to an increased potential, which professionals can be alert to. Signs and indicators were also examined. Evidence indicates that these may demonstrate more substantial verification of neglect. However, the paper also highlighted a number of barriers that may occlude professional's judgement. To overcome these, evidence highlights the importance of multi-agency training and information-sharing, professional supervision and reflection, joint visiting and the use of chronologies and assessment tools/ frameworks.

This paper examined the health visitor's role, and highlights the significance of this profession in terms of their universal contact with families within the home, and their specialist knowledge of the family, and risk factors and signs of neglect. This paper may go some way to remind health visitors of their crucial importance in protecting children from neglect.

In conclusion, early identification, and subsequent timely intervention and support are essential for the short- and long-term welfare of children in cases of neglect, with SCR evidence highlighting the devastating consequences of delayed action.

Key points

* Child neglect is detrimental to the physical and emotional health of children--often persisting into adulthood

* The identification of risk factors and signs can enable professionals to identify potential and actual neglect

* Multiple barriers exist making identification difficult

* Health visitors are recognised as being well placed and skilled at identifying child neglect.

RACHEL AKEHURST RM, RHV, BSc (Hons), MSc. Health Visitor, Bridgewater Community Healthcare, Ashton, Leigh and Wigan Division

References

Aveyard, H. (2010). Doing a Literature Review in Health and Social Care: A Practical Guide. Berkshire. Open University Press.

Brandon, M., Bailey, S., Belderson, P. et al (2013.) Neglect and serious case reviews. London. NSPCC.

Brandon, M., Glaser, D., Maguire, S. et al (2014). Missed opportunities: indicators of neglect--what is ignored, why, and what can be done? London. DfE.

Brandon, M., Sidebotham, P., Bailey, S. et al (2012). New learning from serious case reviews: a two year report for 2009-2011. London. DfE.

Browne, K. and Hamilton-Giachritsis, C. (2007). Child abuse: defining, understanding and intervening. In: Wilson, K. and James, A. (Eds). The Child Protection Handbook. Philadelphia. Bailliere Tindall.

Burns, N. and Grove, S. (2011). Understanding Nursing Research --Building An Evidence-Based Practice. Philadelphia. Elsevier Saunders.

Chester, D., Jose, R. and Aldlyami, E. (2006) Non-accidental burns in children--are we neglecting neglect? Burns. 32(2): 222-8.

Cowley, S., Whittaker, K., Grigulis, A. et al (2013). Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. London. King's College London.

Daniel, B., Taylor, J., Scott, J. et al (2011). Recognizing and helping the neglected child. Evidence-based practice for assessment and intervention. London. Jessica Kingsley Publishers.

Davies, C. and Ward, H. (2012). Safeguarding Children Across Services: Messages from Research on Identifying and Responding to Child Maltreatment. Philadelphia. Jessica Kingsley Publishers.

DH (2000) Framework for the Assessment of Children in Need and their Families. London. TSO.

Dingwall, R., Eekelaarl, J. and Murray, J. (1983). The Protection of Children: state intervention and family life. Oxford. Blackwell.

Dixon, L., Hamilton-Giachritsis, C., Browne, K. et al (2007) The co-occurrence of child and intimate partner maltreatment in the family: characteristics of the violent perpetrators. Journal of Family Violence. 22(8):pp.675-689.

Dubowitz, H. (2013). Neglect in Children. Pediatric Annals. 42(4): 73-77.

Forrester, D. and Harwin, J. (2008). Parental Substance Misuse and Child Welfare: Outcomes for Children Two Years after Referral. British Journal of Social Work. 38(8): 1518-35.

Hall, D. and Elliman, D. (2008). Health for all children. Oxford. Oxford University Press.

Haringey LCSB (2010) Serious Case Review: Child A, March 2009. London. DfE.

HM Government (2015). Working together to safeguard children --A guide to inter-agency working to safeguard and promote the welfare of children. London. HM Government.

Horwath, J. (2007). Child Neglect--Identification and Assessment. Hampshire. Palgrave Macmillan.

Kohl, P., Kagotho, N., and Dixon, D. (2011). Parenting practices among depressed mothers in the child welfare system. Social Work Research. 35(4):pp.215-25.

Laming, L. (2009). The Protection of Children in England--A Progress Report. London. TSO.

Long, T., Murphy, M., Fallon, D. et al (2012). Four-Year Longitudinal Evaluation of the Action for Children UK Neglect Project. Outcomes for the Children, Families, Action for Children and the UK. Salford. Action for Children.

Marquis, R., Leschied, A., Chiodo, D. et al (2008). The relationship of child neglect and physical maltreatment to placement outcomes and behavioral adjustment in children in foster care: a Canadian perspective. Child Welfare. 87(5): 5-25.

Munro, E. (2011). The Munro Review of Child Protection Final Report: A Child-Centred System. London. DfE.

NICE (2009). When to suspect child maltreatment. London. NICE.

NICE (2012). Social and emotional wellbeing--early years. London. NICE.

NSPCC (2008) .Poverty and child maltreatment. See: http//www. nspcc.org.uk/Inform/research/briefings/povertypdf_wdf56896.pdf [Accessed: 1st March 2014].

NSPCC (2014). Disguised compliance: learning from case reviews. London. NSPCC.

Powell, C. (2007). Safeguarding Children and Young People--A Guide for Nurses and Midwives. New York. Open University Press.

Powell, C. and Appleton J. (2012). Children and young people's missed health care appointments: Reconceptualising 'Did Not Attend' to 'Was Not Brought'--a review of the evidence for practice. Journal of Research in Nursing. 17(2): 181-192.

Rose, W. and Barnes, J. (2008). Improving safeguarding practice: study of serious case reviews 2001-2003. Nottingham. DCSF.

Srivastava, O., Stewart, J., Fountain, R. et al (2005). Common Operational Approach Using the 'Graded Care Profile' in Cases of Neglect. In: Taylor, J. and Daniel, B. (Eds). Child Neglect--Practice Issues for Health and Social Care. London. Jessica Kingsley Publishers.

Wright, C., Loughridge, J. and Moore, G. (2000). Failure to thrive in a population context: two contrasting studies of feeding and nutritional status. Proceedings of the Nutrition Society. 59(1):pp.37-45.

Table 1: Literature searches using online databases

Online Database        Search Term        "Hits"   Potential
                       Combinations                 Papers

CINAHL             (Child neglect) AND     144        22
                       (identify OR
                    identification OR
                   assess OR recognise)

                    Child neglect AND       36         6
                      health visitor

Proquest Central    Child neglect AND      156        13
                    identification AND
                      health visitor

Science Direct      Child neglect AND      456        32
                    identification AND
                      health visitor

PubMed Central      Child neglect AND      345        24
                    identification AND
                      health visitor

Table 2: Signs of neglect in pre-school children

Child Physical      * Dental decay/pain.

                    * Swellings/burns/lacerations/fractures.

                    * Faltering weight.

                    * Developmental delay.

                    * Poor hygiene, chronic nappy rash,
                    severe and persistent infestations (such
                    as scabies, head lice).

                    * Non- or delayed immunisations (with no
                    evidence of parental informed choice).

Child Emotional     * Withdrawn, unresponsive or passive
                    infant (aged 0-18 months), developing
                    more aggression and extreme attention-
                    seeking behaviours towards two years.

                    * Poor play/imaginative skills.

                    * Begging for, and stealing or hoarding
                    food.

                    * Self-comfort--rocking, head banging,
                    "masturbation".

Parent Behaviours   * Limited parent/child interaction;
                    criticism, aggression, indifference;
                    little affection/love.

                    * Repeated failed attendance for child's
                    appointments and non-or poor engagement
                    with services.

Environmental       * Overcrowding, unsanitary, hazardous
                    housing.

                    * Poor food provision.

                    * Limited (if any) age-appropriate toys.

(NICE, 2009; Brandon et al, 2014)
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Title Annotation:PROFESSIONAL AND RESEARCH
Author:Akehurst, Rachel
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Nov 1, 2015
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