Child neglect, the most commonly reported form of maltreatment, can significantly impact a child’s long-term development. Pediatricians must understand how to recognize and respond to neglect. This article reviews the definition, epidemiology, risk factors, and consequences of neglect. It provides a step-wise approach to the assessment of neglect, highlighting the situations in which a report to child protective services is necessary. Additionally, promising strategies for child neglect prevention are described.
Definition of Neglect
The definition of neglect varies among the different disciplines involved in the care and protection of children. The Child Abuse Prevention and Treatment Act (CAPTA) is the primary federal legislation defining child abuse and neglect. Reauthorized in 2010, CAPTA provides a minimum definition for child maltreatment:
“Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.”1
State laws vary slightly, but in general, they define neglect as a caregiver’s failure to meet a child’s basic needs, leading to harm or risk of harm. These needs include adequate nutrition, clothing, shelter, supervision, medical care, and education. However, states differ in whether actual or intentional harm is required for child neglect. Some statutes identify additional circumstances that constitute neglect (eg, parental substance abuse, abandonment). Over half of the states provide exceptions for religiously motivated parental behavior.2
Child welfare laws define situations that require child protective services (CPS) intervention. They focus on situations in which caregiver action or inaction is the primary cause of harm to the child. Yet there are times when broader (non-caregiver) factors threaten a child’s well-being. Pediatricians must consider these factors when evaluating cases of neglect, most of which will not warrant CPS involvement.
A broader view of neglect requires only that a child has unmet basic needs, but does not ascribe culpability to any particular individual or entity. This view appropriately shifts the pediatrician’s focus to the child’s needs and enables thoughtfully targeted interventions.
Contributors to Neglect
Multiple, interrelated risk factors contribute to child neglect (see Sidebar 1). Some of these factors, such as prematurity or chronic illness, may increase a child’s needs. Other factors, including parental mental illness or intellectual disability, may limit the caregiver’s capacity to meet these needs. Families of neglected children often possess several co-occurring risk factors. In general, the risk of neglect increases as these factors accumulate.
Contributors to Child Neglect
- “Difficult” temperament.
- Behavioral problems.
- Complex medical conditions (eg, low birth weight, prematurity, chronic illness, disabilities).
- Mental illness (eg, depression).
- Substance abuse.
- Intellectual or cognitive disabilities.
- Limited education or literacy.
- Physical illness or disabilities.
- Inadequate caregiver capacity.
Health care provider:
- Dysfunctional caregiver-child relationship.
- Interpersonal violence.
- Family stress.
- Poor caregiver role modeling.
- Social isolation or inadequate support (within family or community).
- Poor caregiver health literacy assessment.
- Inadequate communication.
- Lack of cultural competency.
- Limited local resources (eg, lack of accessible transportation, affordable child care, healthful foods, and recreational activities).
- Unsafe housing conditions.
- Community violence.
- Conflicting belief systems and practices (eg, religious, cultural).
- Lack of health insurance.
- Language barriers.
- Gaps in federal and state policies to empower caregivers and promote child health.
Poverty and Neglect
Abundant evidence indicates that poverty is associated with neglect.3–5 Poverty may increase caregiver stress or limit access to basic childcare resources. For example, based on data from the National Youth and Longitudinal Survey, families in the lowest income quartile were the least likely to have taken their child to a dentist in the last 12 months. They also provided the least cognitive stimulation and emotional support.3 Low-income caregivers more frequently reported being unable to provide sufficient food and obtain appropriate pediatric medical care.4
Twelve states and the District of Columbia have exemptions in their child neglect laws for caregivers who are unable to financially provide for their children.2 Those who adopt the broader definition of neglect argue that a child whose basic needs are not being met, regardless of family poverty, is still a neglected child that requires attention. While CPS involvement is often unnecessary, a primary care intervention that reduces the burden of poverty should be considered (see Sidebar 2).
Primary Care Interventions for Child Neglect
Caregiver or family-focused:
- Behavioral or mental health treatment.
- Optimizing medical care.
- Educational support.
Health care provider-focused:
- Mental health or substance abuse treatment.
- Health education.
- Parenting education, skills training, and stress management.
- Life skills instruction (eg, budgeting, employment).
- Income support programs (eg, cash assistance, transportation vouchers, childcare and nutritional subsidies, fuel assistance, health insurance, disability benefits).
- Family therapy.
- Enhancing social supports.
- Safe housing advocacy.
- Cultural competency training.
- Interpreter-facilitated communication.
Whether or not to label a child as neglected may be a semantic argument, but pediatricians should remember two things. First, while poverty is an important risk factor for child neglect, poverty does not lead inevitably to neglect. Many poor families adapt to raise their children successfully. Support from health care providers and communities can facilitate their efforts. Secondly, neglect of a poor child is not always the result of poverty. Often, other contributing factors are present. A systematic approach to identify these factors and intervene appropriately may be used to guide the evaluation of a child with suspected neglect, regardless of income status.
Epidemiology of Neglect
Determining the burden of child neglect is challenging because neglect lacks a standard definition. The number of neglect cases can be counted in three ways: collating the neglect reports made to CPS agencies, collecting case-level information from community sentinels, and directly sampling the general population. Comparisons of these estimates reveal that neglect is both under-recognized and under-reported.
The National Child Abuse and Neglect Data System (NCANDS) provides national and state maltreatment data from CPS agencies. In 2010, there were approximately 3.3 million CPS referrals alleging maltreatment of 5.9 million children. Of the 436,321 substantiated cases, more than 78.3% were victims of neglect, representing by far the most common type of child maltreatment. More than one-third (32.6%) of the child fatalities from maltreatment were attributed exclusively to neglect.6 Since the NCANDS data is limited to CPS-reported cases, it under-represents the total burden of child neglect.
Epidemiological data from other sources, including the National Incidence Study of Child Abuse and Neglect (NIS), demonstrate that the majority of child neglect cases are not referred to CPS. NIS collects data from both CPS agencies and community sentinels.
The most recent study (NIS-4, 2005–2006) reported that the incidence of neglect that resulted in serious harm was 771,700 children (10.5 per 1,000 children). Educational and physical neglect were the most common, followed by emotional neglect. Using a broader definition to include children in danger of being harmed, the incidence rose to more than 2 million children (30.6 per 1,000 children).5
Population-based studies, which estimate neglect prevalence through direct population sampling, provide an alternative perspective. In a telephone survey of 1,435 households in the Carolinas, 5.7 per 1,000 mothers reported being unable to provide enough food for their child at least three times in the preceding month. Eighty-four per 1,000 mothers reported being unable to obtain necessary medical care for their child in the last year. Two per 1,000 mothers admitted to leaving their child (younger than age 6) home alone for more than an hour in the last month.4 In a sample of 2,869 young adults (aged 18 to 24 years), 6% reported serious lapses in physical care during childhood.7 These national and population-based studies underscore the pervasiveness of neglect.
Impact of Neglect
Neglect may profoundly affect a child’s development. Neglected preschoolers can have impaired auditory comprehension and verbal ability,8 while neglected school-age children and adolescents can have lower grades, more suspensions, more disciplinary referrals, and more grade repetitions.9 Children referred to CPS for suspected neglect had lower cognitive scores, perceptual reasoning, and reading ability in prospective birth cohorts followed for up to 14 years.10,11
During observations of children (aged 3 to 4 years) born to first-time, low-income mothers, neglected children were less flexible and creative, and more apathetic and withdrawn than non-maltreated controls. They showed less affection toward their mothers and demonstrated more adjustment problems.12 Dubowitz et al reported similar internalizing and externalizing behavior problems in psychologically neglected children.13 Early neglect has been associated with childhood aggression,14 and adult post-traumatic stress disorder and criminal behavior.15
Furthermore, Widom et al reported poor long-term physical health outcomes in a cohort of neglected children,16 consistent with studies demonstrating a relationship between self-reported adverse childhood experiences and adult chronic disease.17
Approach to Neglect
Neglected children can present to the pediatrician in a variety of ways (see Sidebar 3).18 Figure 1 illustrates a systematic approach that pediatricians may use to identify and address important risk factors, and recognize those situations that require CPS involvement.
Types of Neglect Encountered by Pediatricians
- Nonadherence with health care recommendations.
- Delay or failure to seek health care.
- Inadequate nutrition, failure to thrive, or unmanaged morbid obesity.
- Inadequate protection from environmental hazards (eg, smoke, guns, interpersonal violence, car accidents).
- Inadequate supervision, with or without injury.
- Unaddressed emotional and behavioral problems.
- Unmet educational needs.
- Newborn or childhood drug exposure/ingestions.
- Abandonment or homelessness.
- Inadequate hygiene or clothing.
Figure 1. Evaluation of child neglect. Adapted from the Boston Medical Center Child Protection Team.39
The first step is to characterize the neglect: the extent, severity, frequency, chronicity, and health consequences should be evaluated. Is there actual or potential harm? Is there an immediate health risk? These factors inform the urgency and nature of the pediatrician’s response.
Next, the pediatrician should identify contributors to the neglect (Table 1), focusing on factors that limit a caregiver’s understanding or capacity. Active listening (ie, listening with full attention) to caregivers is essential, as they may share beliefs that shed light on how they care for their children.
Finally, the pediatrician should collaborate with the family to design an intervention (see Sidebar 3). In a minority of cases, the intervention will include a CPS report. Allen et al originally proposed three criteria that justify a CPS report in the context of childhood obesity; however, these criteria provide a good framework for understanding when CPS involvement is warranted in any case of neglect: 1) when serious or imminent harm threatens a child’s health and safety; 2) when alternative interventions are unavailable or have been unsuccessful; and 3) when there is a reasonable likelihood that CPS intervention will be effective.
When these three conditions have been met, a report to CPS should be filed.19 Urgent reporting is required whenever a child has been severely harmed or there are active safety concerns. Where available, pediatricians may consult child abuse specialists for guidance. Regardless of CPS involvement, pediatricians should arrange close follow-up with families to re-evaluate the prescribed intervention.
Prevention of Neglect
There is a paucity of evidence-based, neglect-specific prevention programs.20,21 However, the following maltreatment prevention programs have emerged as promising strategies for child neglect.21,22 These programs vary with respect to their target population, goals, services, and delivery.
Positive Parenting Program
Positive Parenting Program (Triple P) is a community-based system of parenting and family support that aims to prevent childhood social, emotional, and behavioral problems by strengthening caregiver capacity. Interventions can include: 1) multimedia delivery of positive parenting information; 2) brief caregiver guidance in medical clinics and schools; and 3) intensive in-home parental skills training.22,23
Triple P dissemination, as compared to services-as-usual, improved population-level child maltreatment outcomes in a southeastern state.24 Further clinical trials are needed to replicate these findings in other communities and to evaluate Triple P’s effect on child neglect.
Safe Environment for Every Kid
Safe Environment for Every Kid (SEEK) is a promising model of enhanced pediatric primary care in which physicians receive special training and social work support to address child maltreatment risk factors. SEEK was found to reduce CPS maltreatment reports, medical neglect, and severe physical abuse in a pediatric resident clinic serving predominantly low-income, black families.25 A subsequent study in private practice clinics serving a wealthier, predominantly white population showed no significant benefit on CPS reports.26 Additional studies are needed to define the optimal target population.
Nurse Family Partnership
Nurse Family Partnership (NFP) is a home visiting program for first-time, expectant mothers. Registered nurses provide pre- and postnatal visits through the child’s second birthday. Nurses promote health-related behaviors, parenting competency, education, employment, and supportive relationships.22,28–31 In randomized controlled trials, NFP-visited families had significantly fewer health care encounters for child injuries and ingestions,27,28 and fewer indicated maltreatment cases.27
The reduction in child maltreatment persisted after 15 years, although lacked statistical significance.29 Benefits of NFP are greatest for unmarried, low-income mothers,27–30 and attenuated by interpersonal violence.31 With ongoing NFP expansion (in 41 states to-date),32 maintaining program fidelity becomes a challenge.33
Other Community Programs
Strengthening Families is a child maltreatment prevention strategy adopted by 30 states to-date that mobilizes families, communities, and local and national organizations to build protective factors within families ( www.cssp.org/reform/strengthening-families). Other community-level interventions have been piloted, including Project SafeCare,22,34 Childhaven,22,35–37 and Family Connections.38 While these and other promising interventions are not widely available at this time, pediatricians may be effective advocates for the implementation and dissemination of such programs.
Neglect is a public health problem with potentially serious consequences for children. The pediatrician plays an important role in identifying and intervening on behalf of neglected children. By using a systematic approach, pediatricians can work with families to mitigate risk factors for neglect and promote child health. In certain circumstances, a report to CPS may be necessary to ensure a child’s safety. Promising maltreatment prevention programs are available to reduce the burden and alleviate the impact of child neglect.
- About CAPTA: A legislative history. Child Welfare Information Gateway, US Department of Health and Human Services, Children’s Bureau. Washington, DC: 2011: 1–3. Available at: www.childwelfare.gov/pubs/factsheets/about.pdf. Accessed Nov. 6, 2012.
- Definitions of child abuse and neglect. Child Welfare Information Gateway, US Department of Health and Human Services, Children’s Bureau. Washington, DC: 2011: 1–92. Available at: www.childwelfare.gov/systemwide/laws_policies/statutes/define.pdf. Accessed Nov. 6, 2012.
- Berger LM. Income, family structure, and child maltreatment risk. Child Youth Serv Rev. 2004; 26:725–748. doi:10.1016/j.childyouth.2004.02.017 [CrossRef]
- Theodore A, Chang JJ, Runyan D. Measuring the risk of physical neglect in a population-based sample. Child Maltreat. 2007;12:96–105. doi:10.1177/1077559506296904 [CrossRef]
- Sedlak AJ, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS–4): report to Congress. U.S. Department of Health and Human Services, Administration for Children and Families. Washington, DC: 2010. Available at: www.acf.hhs.gov/programs/opre/abuse_neglect/natl_incid/reports/natl_incid/nis4_report_congress_full_pdf_jan2010.pdf. Accessed Nov. 6, 2012.
- Child Maltreatment 2010. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Washington, DC: 2011. Available at: www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf. Accessed Nov. 6, 2012.
- May-Chahal C, Cawson P. Measuring child maltreatment in the United Kingdom: a study of the prevalence of child abuse and neglect. Child Abuse Negl. 2005;29:969–984. doi:10.1016/j.chiabu.2004.05.009 [CrossRef]
- Allen RE, Oliver JM. The effects of child maltreatment on language development. Child Abuse Negl. 1982;6:299–305. doi:10.1016/0145-2134(82)90033-3 [CrossRef]
- Kendall-Tackett KA. The effects of neglect on academic achievement and disciplinary problems: a developmental perspective. Child Abuse Negl. 1996;20:161–169. doi:10.1016/S0145-2134(95)00139-5 [CrossRef]
- Strathearn L, Gray P, O’Callaghan M, et al. Childhood neglect and cognitive development in extremely low birth weight infants: a prospective study. Pediatrics. 2001;108:142–151. doi:10.1542/peds.108.1.142 [CrossRef]
- Mills R, Alati R, O’Callaghan M, et al. Child abuse and neglect and cognitive function at 14 years of age: findings from a birth cohort. Pediatrics. 2011;127:4–10. doi:10.1542/peds.2009-3479 [CrossRef]
- Egeland B, Sroufe A, Erickson M. The developmental consequence of different patterns of maltreatment. Child Abuse Negl. 1983;7:459–469. doi:10.1016/0145-2134(83)90053-4 [CrossRef]
- Dubowitz H, Papas MA, Black MM, et al. Child neglect: outcomes in high-risk urban preschoolers. Pediatrics. 2002;109:1100–1107. doi:10.1542/peds.109.6.1100 [CrossRef]
- Kotch JB, Lewis T, Hussey JM, et al. Importance of early neglect for childhood aggression. Pediatrics. 2008;121:725–731. doi:10.1542/peds.2006-3622 [CrossRef]
- Nikulina V, Widom CS, Czaja S. The role of childhood neglect and childhood poverty in predicting mental health, academic achievement and crime in adulthood. Am J Community Psychol. 2011;48:309–321. doi:10.1007/s10464-010-9385-y [CrossRef]
- Widom CS, Czaja SJ, Bentley T, et al. A prospective investigation of physical health outcomes in abused and neglected children: new findings from a 30-year follow-up. Am J Public Health. 2012;102:1135–1144. doi:10.2105/AJPH.2011.300636 [CrossRef]
- Felitti VJ, Anda R, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14:245–258. doi:10.1016/S0749-3797(98)00017-8 [CrossRef]
- Dubowitz H, Giardino A, Gustavson E. Child neglect: guidance for pediatricians. Pediatr Rev. 2000;21:111–116. doi:10.1542/pir.21-4-111 [CrossRef]
- Allen DB, Fost N. Obesity and neglect: it’s about the child. J Pediatr. 2012;60:898–899.
- Allin H, Wathen CN, MacMillan H. Treatment of child neglect: a systematic review. Can J Psychiatry. 2005;50:497–504.
- MacMillan HL, Wathen CN, Barlow J, et al. Interventions to prevent child maltreatment and associated impairment. Lancet. 2009;373:250–266. doi:10.1016/S0140-6736(08)61708-0 [CrossRef]
- California Evidence Based Clearinghouse for Child Welfare. Available at: www.cebc4cw.org/search/topic-areas. Accessed Nov. 6, 2012.
- The Triple P System: Levels of intervention. Available at: www.triplep-america.com/pages/triplep_system/levels_intervention.html. Nov. 6, 2012.
- Prinz RJ, Sanders MR, Shapiro CJ, et al. Population-based prevention of child maltreatment: The U.S. Triple P system population trial. Prev Sci. 2009;10:1–12. doi:10.1007/s11121-009-0123-3 [CrossRef]
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- Dubowitz H, Lane WG, Semiatin JN, Magder LS. The SEEK model of pediatric primary care: can child maltreatment be prevented in a low-risk population?Acad Pediatr. 2012;12:259–268. doi:10.1016/j.acap.2012.03.005 [CrossRef]
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