EYFS Best Practice: All about ... Child neglect

The NSPCC and other welfare organisations believe child neglect to be the most under-reported and underestimated of all types of maltreatment. This is mainly because it is such a complex and difficult thing to define, making it hard for professionals to know when to make a referral. What we do know for certain is that neglect is a serious concern for society as a whole.

Neglect impacts on children's lives in both the long and short term and in extreme cases it can be fatal. Neglect not only causes great distress to children while it is happening, it also leads to a wide range of physical and mental health problems, insecure and disordered attachments, poor educational attainment, an increased risk of substance misuse and difficulties with adult relationships and parenting skills in later life. Breaking this cycle of neglect is important not just for the individuals involved, but for the whole of society.

WHAT DO WE MEAN BY NEGLECT?

On its website, Action for Children describes child neglect as 'an ongoing failure to provide the right care and attention to a child's needs, including food and a safe environment, or to a child's emotional needs, including warmth, security and love. A lack of these is likely to result in serious damage to the child's health or development.' Thinking about neglect in terms of what is 'lacking' can be a helpful starting point in trying to make sense of how it differs from other forms of child abuse or maltreatment. Neglect is about persistently failing to provide for the basic needs of a child, rather than harm actively directed towards them, although it is still a very complex issue.

Dr Patricia Moran has produced a report for Action for Children on the research evidence on neglect and how that can inform practice that attempts to address it.

In her report, Neglect: research evidence to inform practice, Dr Moran describes different definitions and how the one common aspect is an 'emphasis on neglect as an act of omission'. She draws on the work of Jan Horwath (2007), who identified different types of neglect.

Definitions of neglect

Medical neglect - carers minimising or denying children's illness or health needs, and failing to seek appropriate medical attention or administer medication and treatments.

Nutritional neglect - this typically involves a child being provided with inadequate calories for normal growth. This form of neglect is sometimes associated with 'failure to thrive', in which a child fails to develop physically, as well as psychologically. However, failure to thrive can occur for other reasons, independent of neglect.

More recently, childhood obesity resulting from an unhealthy diet and lack of exercise has been considered as a form of neglect, given its serious long-term consequences.

Emotional neglect - a carer being unresponsive to a child's basic emotional needs, including failing to interact or provide affection, and failing to develop a child's self-esteem and sense of identity. Some authors distinguish it from emotional abuse by the intention of the parent.

Educational neglect - a carer failing to provide a stimulating environment, show an interest in the child's education at school, support their learning, or respond to any special needs, as well as failing to complying with state requirements regarding school attendance.

Physical neglect - not providing appropriate clothing, food, cleanliness and living conditions. It can be difficult to assess, due to the need to distinguish neglect from deprivation, and because of individual judgements about what constitute standards of appropriate physical care.

Lack of supervision or guidance - failure to provide an adequate level of guidance and supervision to ensure a child is physically safe and protected from harm. It may involve leaving a child to cope alone, abandoning them or leaving them with inappropriate carers, or failing to provide boundaries about behaviours such as under-age sex or alcohol use. It can affect children of all ages.

Intention

Generally, definitions emphasise the fact that the neglect is ongoing and persistent. However, it is also possible for it to be 'episodic' or come and go, depending on family circumstances.

Opinions also differ with regard to the emphasis placed on the intention - or lack of it - behind the neglect. Some authors think it is important to distinguish between deliberate neglectful practice and the neglect that happens as a result of parental ignorance and what researchers describe as 'competing carer priorities' (Golden et al, 2003). These include situations where a parent's mental or physical health may prevent them from being able to prioritise when to put their child's needs before their own.

Other schools of thought believe that the reasons behind the neglect should never be allowed to over-shadow its impact on the child and our responses to it.

RECOGNISING NEGLECT

Action for Children provides a list of possible indicators of neglect, but is careful to point out that these may also be the symptoms of poverty and deprivation, which is not the same as child neglect. This is an important point and one that many organisations strive to address properly.

It is possible to grow up in poverty and with limited resources and yet be adequately nurtured and cared for by parents who are able to prioritise their children's needs. However, that doesn't make poverty acceptable, nor does it address the extra challenges of parenting in difficult circumstances. In the same way, a child can be living in relative comfort and yet still not be receiving the care, protection and nurture required for physical and emotional well-being. So, although it is the physical factors of food, clothing and looking clean and 'cared for' that might first spring to mind, we need to be very aware of the complexities of neglect and all its implications.

Indicators

In Neglect: research evidence to inform practice, Action for Children suggests the following as possible indicators of child neglect:

• - frequently going hungry
• - frequently having to go to school in dirty clothes
• - not being taken to the doctor when they're ill
• - regularly having to look after themselves at home alone under the age of 16
• - being abandoned or deserted
• - living in dangerous conditions - ie around drugs, alcohol or violence
• - finding it difficult to adapt to school
• - children who are often angry, aggressive or self-harming
• - children who find it difficult to socialise with other children

THE IMPACT OF NEGLECT ON YOUNG CHILDREN

We cannot and must not ignore the serious wide-ranging impact neglect has on children - and on the adults they will eventually become. Research evidence suggests that neglect impacts on all areas of a child's development - their physical, social, emotional, cognitive and behavioural developmental needs are all affected by neglect in their early years.

Increasingly, research is providing evidence that early neglect can have an even more powerful impact than abuse, or neglect that occurs later on in life. The US research project by Kotch et al (2008), Importance of Early Neglect for Childhood Aggression, concludes that 'child neglect in the first two years of life may be a more important precursor of childhood aggression than later neglect or physical abuse at any age.'

We can begin to make sense of these findings now that advances in neuroscience allow us to see what happens to young brains that experience neglect and how they differ from the developing brains of children who receive 'good enough' parenting.

In his article, 'The Psychobiology of Neglect' (2005), Michael D De Bellis considers how research into the effects of neglect is increasingly being informed by MRI scans of the brains of children and adults who have experienced neglect.

His conclusions draw similarities between their brains and those of adults diagnosed with post-traumatic stress disorder (PTSD) - for example, traumatised soldiers returning from war. Other writers, such as Bruce Perry, Allan Schore and Bessel Van der Kolk, also talk of the traumatising effects of early neglect (see 'Other research' box, page 18).

ATTACHMENT AND BRAIN DEVELOPMENT

Human babies need attachment to others for their survival and are very active in ensuring we give them the attention they need. Their instinctive attachment-seeking behaviours are there to attract the care-giving behaviours of others. But babies don't just want physical needs met. They are instinctively triggering the responses and sensory stimulation from others that will help build their brains.

A parent or carer who is tuned into a baby will be sensitive to them and able to provide what they need. It is this recognition by carers of the baby's states that helps a baby to know who they are and to develop a strong sense of 'self' and a positive identity. These positive experiences are also developing 'neural pathways' in their brains that allow the child to develop 'executive functioning skills'. These are vitally important as a child develops independence and approaches adulthood. Put simply, these skills support a child's ability to learn from others, to regulate their impulses and emotions and to function well in society. Early neglect gets in the way of this.

A child who has no assurance that their basic needs will be met lives with constantly high levels of stress. Their brains are flooded with cortisol (a stress hormone) and they rarely benefit from 'feel-good' hormones, which soothe and relax them.

As they grow, these children are likely to have lower stress 'thresholds' and to have difficulty coping in stressful situations. They are likely to react either with depression or, as suggested by the research mentioned above, by behaving aggressively. Again, in simple terms, the brain of a neglected child is likely to be underdeveloped and traumatised.

Camila Batmanghelidjh, founder of Kids Company, 'a charity that works to support neglected and traumatised children', describes neglect as a 'continuous lack of love' that 'deprives the child of a personal soothing repertoire' ('Colourful character', The Independent, 3 January 2009).

A child with secure attachments knows that their caregivers are responsive, sensitive, affectionate and reliable. They will help soothe and make them feel better when they are distressed. When a child's caregivers do not (or are unable to) respond predictably with sensitivity and affection, putting their own needs before those of the baby, the child has no-one to help make them feel better. Their attachments become 'insecure' or 'disordered' and inevitably they feel entirely alone and fearful.

Everything a child then does is an instinctive attempt to cope with this neglectful care-giving. They do this either by containing their distress (in withdrawn, passive or self-harming behaviours and extreme self-reliance) or by protesting loudly through aggressive and anti-social, attention-seeking behaviours.

The profound impact that neglect can have on the developing brain may also be seen in other negative effects that occur throughout childhood and into adulthood. Dr Moran draws on a wide range of literature to compile a list that includes:

• - inadequate growth and failure to thrive
• - consistent hunger and fatigue
• - apathy
• - skin afflictions
• - extreme mood swings
• - social isolation and poor social skills
• - low educational attainment
• - craving physical contact and attention, linked to vulnerability to sexual abuse and also to teenage pregnancy
• - substance abuse
• - suicidal tendency
• - relationship difficulties and domestic violence
• - depression and other mental health issues.

An inability to empathise with others, together with poor impulse control, may also lead to criminal activity and imprisonment. Increasingly, research into the early childhood experiences of prison populations is suggesting a high incidence of early neglect and poor attachments (Levinson and Fonagy, 2004).

Understanding that neglect traumatises and interferes with brain development helps explain the kinds of behaviours that a neglected child might display - and also why the behaviours may continue even if the child is removed from the neglectful environment. This is the experience of many foster carers and adoptive parents who find that long-term, skilful 'therapeutic re-parenting' is essential for children who have experienced neglect.

CAUSES OF NEGLECT

There is no sure single cause of neglect. Instead, it is likely to result from a complex mix of contributing factors. Action for Children, however, has identified a long list of family characteristics and circumstances that are often associated with neglect. By themselves, none of these are tied to or lead to neglect. They can be seen as risk factors that raise the chances of neglect occurring, particularly where several occur together, but can't be used to predict it. The factors are:

• - lone motherhood
• - young mothers
• - isolated mothers
• - larger families, more pregnancies and unplanned pregnancies
• - premature or very low birth-weight baby
• - low-income families
• - unemployed carers
• - carers with low educational attainment
• - relationships featuring domestic violence or high levels of conflict
• - substance-misusing parents or carers
• - parental mental health problems, including maternal depression
• - personal history of childhood maltreatment
• - insecure attachment patterns in own childhood
• - maternal low self-esteem
• - families that are less cohesive and poorly organised, with little positive interactions between parents and/or carers and their children
• - parents/carers lacking sensitivity or responsiveness towards their own children

Once again, attachments and relationships are highly significant in understanding the causes of neglect. A parent's own early experiences, the security of their attachments and their sense of self - these will all play a big part in their ability to relate to their baby and put them first. Research has found that neglectful mothers are more likely to have experienced neglectful, non-nurturing childhoods themselves (Stevenson 1998).

Similarly, insecure attachment is linked with adolescent (and later) substance abuse (tobacco, drugs, and alcohol), which can severely limit a parent's ability to be emotionally available to their child, as well as straining their finances and damaging their health. The strong links between a parent's own early experiences, their adult mental health and their future children's well-being make a very strong case for early intervention as the most effective way of breaking the cycle of neglect.

PROTECTIVE FACTORS

Many of the factors above contribute to a lack of resilience on the part of the parent to be able to deal with the stress of parenting, or the challenges of their circumstances. There are, however, some protective factors that can contribute to resilience against neglect - for the parent or the child. The presence of secondary attachment figures can make a big difference for a child when the primary attachment figure is unable to respond to their needs.

A shift in appreciation of the role of fathers has led to more interventions to increase their involvement, particularly where a mother's vulnerability or depression, for example, prevent her responding well to her children.

In the past, the presence of a strong network of an extended family, many of whom would have had childcare experience, was probably the single most protective factor against neglect. Changes in society and the increase in young parents living away from family members, means that is less likely to happen nowadays, but good networks of family or friends and supportive relationships can make a big difference.

INTERVENTIONS

It is important to remember that, severe though the impact and repercussions of neglect are, we can make a difference. However, at this stage there is still little evidence about what works best in reducing or, ideally, preventing neglect. This would seem to be a result of the blurring of boundaries between abuse and neglect and the fact that neglect itself has for too long been neglected and not prioritised for study. It is certainly not going to be something that can be 'fixed' quickly - either for individuals or society - a fact often lost on Government ministers looking for dramatic short-term results.

Dame Clare Tickell, Action for Children's chief executive, has said, 'It's not the amount of money government spends, but how it spends it. Skewing investment towards picking up the pieces has a devastating effect on the most vulnerable children. Governments need to invest to change people's lives, particularly the most vulnerable. There has been a long-term understanding and belief in the benefits of early intervention and prevention - but with too little action to back it up.'

Dr Moran outlines promising aspects of intervention that show signs of being the most effective. These include: home-visiting programmes that are begun during pregnancy; basing social workers in schools; parent training; social network support and therapeutic approaches with parents and children. However, given the complexity of all the many different social factors that can contribute to neglect, she warns that we mustn't forget the importance of wider social policy in alleviating the problems faced by many families. This is supported by the findings of a study produced by the Joseph Rowntree Foundation, Diversity, Complexity and Change in Parenting, by Waylen and Stewart-Brown (2008).

This study suggested that the mental and physical health of the mother had the biggest impact on how well a child was parented. Because they saw evidence that improving the mental and physical health of the mother improved the quality of parenting much more than any other kind of intervention (for example, financial or social support), the authors concluded that: 'Greater benefit may be seen if parenting policy were to emphasise the promotion of parents' mental and physical health alongside measures to improve parenting and reduce childhood poverty.'

This might well mean that a combination of interventions and 'packages of care' might be needed to respond to the needs of individual families. The NSPCC has highlighted this in its research briefing, Child Neglect, by Silvie Bovarnick (October 2007): 'The needs of neglectful families are varied and complex. This calls for a joined-up, inter-agency approach.' This makes obvious good sense, but the NSPCC also points out that: 'Practitioners' understandings of neglect, however, are often shaped by different professional backgrounds and can vary within and across different services. This can contribute to vital pieces of information in neglect cases not being picked up, information being lost or not effectively communicated across different agencies.'

Improving the quality of relationship and communication between health, education and social services is fundamental if we are to really make a difference to the lives of vulnerable children.

Given that neglectful parents are likely to be dealing with many difficulties, conventional approaches (to intervention or prevention) may not 'hit the spot' for a person who is displaying attachment-challenged behaviour and is wary or mistrustful of 'help' and intervention.

A focus on attachment as a guiding principle would seem to be a useful way of structuring approaches that:

• - engage early with families - through home visiting and outreach programmes providing pre-natal and ongoing support
• - recognise the significance of a parent's own early experiences in creating, or avoiding, neglect
• - acknowledge the role of fathers and other family members as essential supportive secondary attachments
• - build parenting programmes that emphasise the crucial importance of secure attachments and unconditional love, rather than behaviour modification and consequences
• - provide therapeutic interventions that build and nurture strong attachments and relationships within families
• - maximise the role of children's centres, childminders, childcare settings and schools, by recognising the value of supportive relationships (for parent and child) and initiatives such as, for example, nurture groups.

Children's centres, in particular, are at the forefront of providing targeted support for vulnerable families in the first five years of a child's life and we have to hope that all the good work achieved so far is not wasted by short-sighted reductions in their future funding.

THE CASE FOR INVESTMENT

Action for Children has produced a rationale for future investment in preventative measures. This challenges, among other things, Government focus on short-term spend rather than long-term investment in children's well-being and what Action for Children describes as 'a narrow definition of societal progress, couched in economic terms, which fails to account for the multi-dimensional nature of child well-being or the value of "good childhoods".'

High-quality, early years practice in the EYFS has always promoted an holistic approach to children's well-being. An effective setting recognises the many factors that contribute to the well-being of a child and their family, as well as the way it impacts on learning and development.

Feeling nurtured and cared for, with opportunities to play and learn at their own pace, in an inclusive environment alongside caring adults, can make all the difference to a child whose home circumstances are less than ideal.

Skilled, observant practitioners who build strong, supportive relationships with children and families, are well-placed not just to spot neglect when it happens, but also to be part of the solution.

If you have concerns about neglect or the well-being of a child, there is detailed guidance on how to respond in the free DfES publication, 'What to do if you suspect a child is being abused', available at: http://publications.education.gov.uk/ eOrderingDownload/6840-DfES-IFChildAbuse.pdf

OTHER RESEARCH AND ARTICLES

Bonding and attachment in maltreated children: consequences of emotional neglect in childhood, by Bruce D Perry, www.childtrauma.org/images/stories/Articles/attcar4_03_v2_r.pdf

The effects of early relational trauma on right brain development, affect regulation, and infant mental health, by Allan N Schore, www.allanschore.com/pdf/SchoreIMHJTrauma01.pdf

Developmental trauma disorder: towards a rational diagnosis for children with complex trauma histories, by Bessel A van der Kolk, www.traumacenter.org/ products/pdf_files/preprint_dev_trauma_disorder.pdf

Importance of early neglect for childhood aggression, by Jonathan B Kotch et al, Pediatrics Vol 121 No 4 April 2008, pp725-731, (doi:10.1542/peds.2006-3622): http://pediatrics.aappublications.org/cgi/content/full/121/4/725

The psychobiology of neglect, by Michael D De Bellis (Duke University 2005), http://cmx.sagepub.com/content/10/2/150.abstract

Adult attachment security and college student substance use, by Kassel Wardle et al (2007), www.acsu.buffalo.edu/(approx)robertsj/kassel.pdf

Offending and attachment: the relationship between interpersonal awareness and offending in a prison population with psychiatric disorder, by Levinson and Fonagy (2004), Canadian Journal of Psychoanalysis, 12:225-251, www.pep-web.org/document.php?id=cjp.012.0225a

Nursery World's series on attachment by Anne O'Connor was published on 10 October 7 November, 5 December 2007 and 10 January and 14 Feburary 2008.

REFERENCES

• - NSPCC www.nspcc.org.uk
• - NSPCC and Barnardo's NI - Briefing Paper on Neglect (November 2009), www.nspcc.org.uk/Inform/policyandpublic affairs/NorthernIreland/briefings/neglect_wdf69986.pdf
• - Child neglect: NSPCC: Child protection research briefing, by Silvie Bovarnick (October 2007), http://tinyurl.com/38ghd39
• - Action for Children, www.actionforchildren.org.uk
• - Neglect: Research evidence to inform practice, by Dr Patricia Moran, www.actionforchildren.org.uk/uploads/media/37/9739.pdf
• - Gough, D (2005), Horwath, J (2007), Stevenson, O (1998) and Golden et al (2003) are all cited in Dr Moran's report.
• - Backing the Future: Why investing in children is good for us all, www.actionforchildren.org.uk/uploads/media/36/7857.pdf
• - Child Neglect: Experiences from the frontline, www.actionforchildren.org.uk/uploads/media/37/9732.pdf
• - Rowntree Foundation, www.jrf.org.uk
• - Diversity, complexity and change in parenting, by Waylen, A and Stewart-Brown, S (2008), http://tinyurl.com/399wf8p
• - Kids Company, www.kidsco.org.uk.