Neglect is a serious form of harm and is a factor in 60 per cent of serious case reviews.
Both families and professionals can become overwhelmed and demoralised by issues of neglect. Children may experience repeated attempts by professionals to try to improve the situation.
Published case reviews highlight that professionals face a big challenge in identifying and taking timely action on neglect.
The learning from these reviews highlights that professionals from all agencies must be able to:
- Recognise physical and emotional neglect.
- Understand the impact of cumulative and long-term effects of neglect.
- Take timely action to safeguard children.
Reasons case reviews were commissioned
This briefing is based on case reviews published in 2014 and 2015, where neglect was a key factor.
It pulls together and highlights the learning contained in the published reports.
In these case reviews, children died or suffered serious harm in the following ways:
- Chronic neglect over a long period sometimes co-existing with physical, emotional and sexual abuse.
- Death or serious harm from physical or sexual abuse where neglect was a feature or preceded the abuse.
- Sudden Unexpected Death in Infancy related to neglect risk factors such as malnutrition, poor social circumstances or parental substance misuse.
- Accidents - sometimes with an element of forewarning - when long-term neglect in a family resulted in an unsafe environment.
- Attempted suicide of a young person as a result of the effect on mental health of long-term neglect.
Risk factors
Risk factors highlighted in these case reviews impact on parents' ability to provide safe and appropriate care and to meet their children's needs. These include:
- Living with domestic abuse, drug and alcohol misuse, and parents with mental health problems.
- Young parents.
- Postnatal depression - maternal depression was also linked to social isolation.
- Patterns of improvement in parental care, followed by deterioration.
- Financial problems including housing problems, homelessness, poverty and unemployment.
- Lack of resources. High caseloads and understaffing may result in absence of supervision and support for social workers. High staff turnover makes it difficult to establish meaningful relationships with families.
Learning for improved practice
Vulnerable groups
Newborn babies, premature babies and babies with ongoing health needs are particularly vulnerable to neglect, and neonatal professionals have a key role in identifying it.
Teenagers' needs can be missed, especially where there are younger siblings. Professionals should understand the impact of long-term neglect on a teenager's emotional wellbeing and consider the risk of self-harm or suicide.
Neglecting a child's health needs, such as tooth decay, may indicate neglect. Dental services should consider initiating further enquiries or making a safeguarding referral.
Monitor missed appointments
Professionals in all agencies should understand the significance of missed medical appointments for children. In one case, the only indication of a sudden change in parenting capability was an emerging pattern of non-attendance at appointments.
A system should be in place that allows:
- Missed appointments to be monitored.
- Professionals to know what action to take when there are concerns.
Pay attention to accidents and injuries
Frequent accidents may be an indicator of poor-quality parenting through lack of supervision or living in an unsafe home.
Repeated visits to hospital emergency departments should raise concern among professionals.
In addition, lack of supervision may include inappropriate supervision such as unacceptably young babysitters or unsuitable adults.
Parental capability to change
It is important that professionals have the confidence and knowledge to assess parents' ability and capacity to change their situation. Considerations include:
- Be clear with parents about what needs to change and by when. Parents should be respectfully challenged when they fail to follow formal agreements.
- When there is no long-term positive change, the lead professional should co-ordinate support and services. Doing this will help agencies work effectively together.
- Warm relationships between parents and children should not override concerns about neglect.
- Maintain focus on the best interests of the child rather than the immediate needs of a parent who may be dominant or very needy.
- Improvements to poor home conditions should be regularly reviewed, especially if the family is unlikely to sustain them.
- Be aware of the possibility of disguised compliance.
Long-term effects of neglect
Professionals need to understand the long-term impact that experiencing neglect can have on a child. Factors to consider include:
- Always take the full history of the family into account and patterns of previous episodes of neglect. Include background information of the parents' own childhood to better assess parenting capability.
- Record all circumstances that may affect the level of care the child receives - for example, substance misuse. Establish any patterns of care, such as the child being left with neighbours.
- As well as ensuring a healthy physical environment, make sure the child is helped to build healthy relationships.
- Alongside proactive case management and decision-making, identify and record all incidents of neglect to build a picture of what is going on in the child's life.
- Emotional neglect is particularly difficult to evidence. Individual observations of emotional neglect should be systematically collated.
- Family doctors and other general practice staff should be more actively curious when engaging with a family where there are concerns about neglect.
Identifying concerns and planning interventions
- Where there is risk of neglect, families should be supported within a model of early intervention.
- Compile a multi-agency chronology of key events.
- Invite health professionals such as the health visitor or school nurse to meetings.
- Thresholds for intervention should be clearly understood across agencies so that professionals can challenge each other with confidence.
- Ensure terminology is free from jargon and clearly understood by the family and all professionals involved.
- Roles and responsibilities must be clearly understood.
- When undertaking multi-agency assessments, all agencies must be aware of which agency is leading and what action is being taken.
- Where families refuse to engage with early assessments, this should not prevent professionals from sharing information or making referrals about child protection concerns.
- Where neglect coexists with physical or sexual abuse, a criminal prosecution for abuse should not be viewed as the only means of child protection. Where criminal cases do not result in a prosecution, child protection proceedings may still be necessary to keep the children safe from harm.
Undertake robust and comprehensive assessments
- Use a risk assessment toolkit and approach such as the Graded Care Profile, which seeks to prevent case drift by focusing on specific areas of need.
- Ensure the assessment is timely.
Focus on improving outcomes
Feelings of hopelessness in families experiencing neglect for a long time may also be felt by professionals. Where there is no change for the better, professionals may sometimes struggle to know how to proceed. The reviews show that sometimes cases were transferred to a colleague, or even closed.
- A review should always take place before a case is closed or transferred.
- Interventions must be linked to specific improvement outcomes. Professionals should undertake regular reviews to check improvements are being made. Where they not being sustained, professionals must decide whether legal proceedings are necessary to protect the child.
Avoiding case drift
Hope for change for families must be balanced with the absolute need to avoid case drift.
Effective and reflective supervision should enable practitioners to assess children's development and behaviours in families with high levels of need.
- If a case becomes "stuck", there should be a process where practitioners can escalate the situation to senior managers. This may help to provide a fresh, objective approach to address the problems.
- There should be an opportunity to stop and review the whole case. Supervision should assist practitioners with the discipline of reflective thinking.
- The main focus should always be whether the child's needs are being met and how that can be achieved to prevent significant harm.
FURTHER READING
Neglect And Serious Case Reviews: A Report From the University of East Anglia. Brandon, M. et al (2013).
New Learning from Serious Case Reviews: a Two-Year Report for 2009-2011. Brandon, M. et al (2012), Department for Education.
Child Neglect: Planning and Intervention. Horwath, J. (2013), Palgrave Macmillan.
Safe Care - Home-based intervention that helps parents improve their awareness of the physical and emotional needs of children aged 0-5 years.
The North Carolina Family Assessment Scale - A tool to determine how a family is functioning and inform professional decision making on neglect.
The Graded Care Profile - Provides a structure for assessing the type and level of neglect so it can be addressed in a timely and appropriate way.
