Abstract
Neglect is often a neglected form of child maltreatment even though it is the most common and deadliest form of child maltreatment. Pediatric nurse practitioners (PNPs) will most likely encounter neglected children in their practice. It is crucial that PNPs recognize child neglect in a timely manner and intervene appropriately. This continuing education article will help PNPs understand and respond to child neglect. Neglect will be defined and risk factors will be discussed. Children who are neglected can experience serious and lifelong consequences. The medical assessment and plan of care for children with concerns of suspected neglect will be discussed.
Key words
Neglect is the most common and deadliest form of child maltreatment. According to the U.S. Department of Health and Human Services, more than 2 million American children were victims of maltreatment in 2010. More than 75% (78.3%) of those children experienced neglect compared with physical abuse (17.6%) and sexual abuse (9.2%;
Child Welfare Information Gateway, 2012
). The consequences of child neglect are not benign when compared with other forms of abuse. More than 30% of child maltreatment deaths were attributed to neglect in isolation, with 22.9% attributed to physical abuse and 40.8% attributed to multiple forms of maltreatment (Child Welfare Information Gateway, 2012
). Neglect is often a neglected form of child maltreatment despite the significant numbers of children affected by the problem and its potential for serious consequences. Child physical abuse and sexual abuse continue to receive the greatest amount of professional attention and research. Child neglect has not been the focus of many empirical studies (Stoltenborgh et al., 2012
). Neglect is a serious problem affecting many American children, and it is imperative that pediatric nurse practitioners (PNPs) identify neglect in their patient populations and intervene appropriately. This continuing education article will define neglect and discuss risk factors, consequences, and implications for practice.Definition
Defining neglect is not an easy task. The World Health Organization (
World Health Organization, 1999
) defines child neglect as the failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter, and safe living conditions. This failure must be gauged in the context of resources reasonably available to the family or caretakers and whether it causes or has a high probability of causing harm to the child's health or physical, mental, spiritual, moral, or social development. The WHO definition also includes the failure to provide proper supervision and protect children from harm whenever possible (World Health Organization, 1999
). Appleton, 2012
emphasizes that neglect can rarely be identified from a specific incident; rather, it most often relies on health care providers, teachers, day care workers, and other professionals working with children to make a decision about the inadequacy of ongoing care of the child within the context of the child's family. For example, it is difficult to identify a child who misses school for 1 day without an illness or family crisis as being neglected, but if unexcused absence becomes a repeated pattern, then concerns of child educational neglect are warranted. Chronic failure to meet a child's needs and provide loving care is often significant and can result in cumulative negative effects that become increasingly detrimental to the child over time (Daniel et al., 2011
, Dubowitz et al., 2000
).Neglect involves acts of caregiver omissions, whereas abuse involves acts of commission. Legal definitions of child neglect vary from state to state. However, certain concepts are essential to consider when defining neglect. The concept of harm, both actual and potential, is necessary. If harm is not likely to occur in the situation, then neglect is most likely not occurring. Harm is not limited to only physical harm; neglect can also result in psychological harm. It is important to note that neglect can result in both immediate and long-term harm. Typically, neglect involves omissions that are repeated over time, and it is the pattern of omissions that makes the behavior neglectful (if a child misses one single feeding, true harm is difficult to determine; however, repeated missing feedings can result in failure to thrive or even more serious health concerns, including death). At times, acts of neglect are so heinous that child neglect can be identified from a single incident (e.g., when a 2-year-old is left home alone and the child wanders into a pond).
Caring for children is not an easy task, and the adequacy of care exists on a continuum from excellent to very poor (
Dubowitz et al., 2000
). The continuum requires the provider to assess the adequacy of care and patient safety related to any identified inadequacies of care and to intervene in ways appropriate to where the care that is provided lies on the continuum. When assessing the adequacy of care, one must be cognizant of the influence of culture both on the care given to the child and the practitioner's own perception of the care that is provided. PNPs need to have a practical and thorough understanding of child neglect, be aware of their own cultural biases, and be able to recognize when neglect is occurring and intervene appropriately. In some neglect situations the threat of harm to the child is severe and a referral to Child Protective Services (CPS) is warranted. However, other neglect situations require education, provision of support services, and monitoring rather than an immediate referral to CPS (such as an infant with poor weight gain because of improper feeding/formula preparation).Risk Factors
Certain familial/caregiver factors place children at increased risk of experiencing neglect. These factors are essentially barriers that diminish the parent's ability to provide adequate care. When considering a diagnosis of neglect, it is crucial to assess the situation for potential barriers preventing the parent/caregiver from providing adequate care (
Jenny, 2007
). A major factor limiting the ability to provide adequate care is a lack of financial resources, which can affect nearly every aspect of care from health care to education. Poverty can affect the ability of the parents to provide adequate supervision (e.g., when the parents need to work but do not have the resources to pay for child care), housing (which can also affect the child's educational status, because a stable address is necessary for school enrollment), dental care, nutrition, clothing, and safety (car seats are expensive, and parents may not have the resources to purchase one). Clearly, familial financial resources and the lack thereof can have serious negative consequences on the ability of the parents to meet even the most basic physical needs of their child. Specific familial economic factors may be associated with an increased likelihood of child neglect. Slack and colleagues (2011) found poverty to be a strong predictor of child neglect. Specifically, receiving financial assistance from a family member and receiving food from a food pantry were associated with increased neglect, which could indicate that families who resort to these forms of assistance may be experiencing severe economic stress and struggling to get by.Some parents/caregivers may have physical health, cognitive, mental health, or substance abuse concerns that limit their ability to provide safe and adequate care for their children (
Slack et al., 2011
). Physical health problems can obviously impair caregiver ability to provide basic physical care (e.g., bathing, preparing food, and laundering clothes). Caregiver cognitive, mental health, or substance abuse concerns may affect the caregiver's ability to understand the importance of providing nearly every aspect of adequate care, from health care to love and nurturance. Parents with these concerns may honestly not know how to meet even the most basic needs of their children or may be so impaired that they are oblivious to the needs of their children.Cultural and/or religious beliefs may limit the ability of the parent/caregiver to meet their children's needs at a level that is deemed adequate by the larger society. Jehovah's Witnesses or Christian Scientists may have religious beliefs that conflict with the recognized standard of medical care for a particular diagnosis. Certain cultures also engage in folk practices to treat illness (e.g., coining or cupping) that may affect a parent's decision to seek medical care for his or her children when they are ill, and some cultures have practices to mark rites of passage (e.g., genital mutilation) that are viewed as neglectful or abusive to the larger society.
Cultural/religious beliefs can affect nearly every aspect of care given to the child. Methods of discipline used by parents are often affected by cultural and religious beliefs. Use of spanking and other forms of corporal punishment have been associated not only with physical abuse but child neglect as well (
Slack et al., 2011
). Dental care is often affected by the beliefs of a culture; a generational failure to understand the value of and to access adequate dental care can be demonstrated. Lee et al., 2012
examined the relationship between oral health literacy (OHL) and self-efficacy and oral health status and dental neglect. OHL is defined as the ability to obtain, process, and understand basic health information and services needed to make appropriate oral health decisions and act on them. Self-efficacy is a person's belief in his or her own competence. Higher OHL and self-efficacy were associated with increased oral health status and decreased dental neglect.Some families live in the culture of chaos. Their lives are so disorganized and plagued by crisis that meeting even the basic needs of their children on a consistent basis is a nearly impossible task.
Types of Neglect
Neglect can present in many different forms. Box 1 provides a list of different types of neglect, with some specific examples of neglectful situations. Medical and supervisory neglect will be discussed in some detail, because the PNP may be more likely to address these types of neglect in practice. Neglect is multifaceted, and neglect and other forms of child maltreatment rarely occur in isolation. A neglected child is at increased risk to also experience physical, sexual, or emotional abuse. A child also may experience multiple types of neglect.
Box 1
Types of child neglect
- Medical
- •Failure/delay in seeking medical care
- •Noncompliance with plan of care
- •
- Supervision/safety
- •Car seats/seat belts
- •Ingestions
- •Guns/other weapons
- •Intimate partner violence
- •
- Education
- •Truancy
- •Noncompliance
- •
- Dental
- •Failure to seek care
- •Caries
- •
- Nutrition
- •Failure to thrive
- •Obesity
- •Noncompliance to prescribed diet
- •
- Prenatal drug exposure
- Shelter/home
- •Homelessness
- •Safe
- •Clean
- •
- Hygiene/clothing
- Nurturance and affection/love
- •Abandonment
- •Ignoring/apathetic care
- •
The PNP has a high likelihood of encountering medical neglect. More than 15,000 children experienced medical neglect in 2011, representing approximately 31% of substantiated cases (
Child Welfare Information Gateway, 2012
). More than one third (34.6%) of children experiencing medical neglect were younger than 3 years, and 75.6% were younger than 12 years. PNPs will be challenged by dealing with caregivers who fail to seek appropriate medical care for their child or do not follow through with the recommended plan of care. Certain parental deviations from the recommended plan of care are clearly neglectful, resulting in certain harm to the patient, and require immediate referral to CPS to ensure the child's health and safety. Other deviations are more benign and the link to immediate and/or long-term harm are less direct, making education, supportive services, and close surveillance the most appropriate interventions. To accurately diagnose medical neglect, the following criteria are necessary: the child is harmed or at risk of harm because of lack of health care; the recommended health care offers significant benefit to the child; the anticipated benefit of the treatment is significantly greater than its negative adverse effects, ensuring that reasonable caregivers would choose treatment over nontreatment; access to health care is available but not used; and the caregiver understands the medical advice he or she has been given (Jenny, 2007
).As with any concern of neglect, it is vital for the PNP to assess for potential barriers affecting the ability of the parents to provide adequate care. Access to health care can be negatively affected by a lack of health insurance, geographical barriers, or transportation barriers. The PNP should ponder the following important questions when considering medical neglect: Do the parents have financial, cognitive, cultural, or other barriers that influenced the seeking of medical care or following through with the prescribed plan of care? Would a reasonable caregiver been capable of meeting the child's health care needs? The key aspect to consider when assessing every concern of possible medical neglect is the concept of harm: Did a lack of health care result in serious harm or threat of harm to the child? If the answer is yes, regardless of barriers to care that may exist, a report of medical neglect to CPS is warranted. It would certainly be appropriate to include in the report an explanation of barriers to care (e.g., parental mental illness, lack of financial resources/medical insurance, or parental cognitive delays). If the answer to the key question of whether the lack of medical care resulted in or had the potential to result in serious harm to the child is “No,” then a report to CPS is most likely not indicated, and instead a plan should be developed to intervene appropriately to overcome identified barriers.
The PNP will also most likely encounter dental neglect. Dental neglect is defined as the willful or persistent failure to meet a child's basic oral health needs by not seeking or following through with necessary treatment to ensure a level of oral health that allows function and freedom from pain and infection (
Bradbury-Jones et al., 2013
). PNPs play an important role in linking families with appropriate dental care. PNPs need to be familiar with local resources for dental care, especially options available for low-income families. Situations that should raise the concern of dental neglect include repeated failure to schedule or attend regular dental checkups; failure to seek dental care when a dental problem is diagnosed, such as cavities or fractures; the need for emergency dental pain relief more than once; and the need for dental extractions/care with use of a general anesthetic more than once. When children present with one or more of these criteria, the PNP should strongly consider a report of suspected dental neglect to CPS, again weighing the question of whether the lack of dental care resulted in or had the potential to result in serious harm to the child.Supervisory neglect is a serious health concern. Unintentional injury is the leading cause of death in children between the ages of 1 to 15 years (
Ruiz-Casares et al., 2012
). Whenever a child presents with an injury, two decisions must be made: Was the injury a result of an unintentional accident or the intentional actions of a caregiver (physical abuse), and if it was the result of an unintentional accident, should this injury have reasonably been prevented by adequate caregiver supervision? Caregiver supervision has been proved to decrease the incidence and severity of childhood accidents. Adequate supervision of children is important to ensure their health and well-being. In our society there is an expectation that caregivers will protect children from harmful situation or people. The American Academy of Pediatrics defines supervisory neglect as whenever a caregiver's supervisory decisions or behaviors place a child in his or her care at significant ongoing risk for physical, emotional, or psychological harm (Hymel, 2006
). Specific caregiver behaviors that are of concern for neglect include not watching a child closely enough; inadequate substitute child care (i.e., leaving a child alone); failing to protect a child from another person known to be potentially harmful (e.g., exposing the child to a known child abuser or a person engaging in illegal or inappropriate behaviors); and allowing or encouraging a child to engage in a harmful behavior (Coohey, 2008
). The PNP must remember that the definition of adequate supervision varies across cultures and circumstances. For instance, there is no universal age when it becomes acceptable to leave a child home alone; rather, other factors must be considered. When considering the potential for supervisory neglect, it is vital to consider the potential or actual harm that the child experienced as a result of the lack of supervision. A 2-year-old being left home alone while the parent is working is much different than a 10-year-old child being left for the same length of time. Even if the 2-year-old did not experience physical harm as a result of being left unsupervised, consider the psychological harm and the potential for serious physical harm. However, when assessing the 10-year-old’s need for constant supervision, the following factors must be considered. Is the 10-year-old a mature, responsible youth? Is the child comfortable with being home alone, or is he or she afraid? Does the child have access to the parent or another adult when alone? What time of day and for how long is the child alone? Is the child behaving appropriately when alone or engaging in inappropriate behaviors? When all factors are considered, it might be reasonable to leave the 10-year-old child home alone, and a concern for neglect is not warranted. It is interesting to note that in 2008, injuries were noted in only 2% of cases of supervisory neglect substantiated by CPS, and only approximately half of these injuries required medical treatment (Ruiz-Casares et al., 2012
).The PNP may also be confronted with nutritional neglect at both ends of the spectrum: failure to thrive and obesity. Both types most often result from a combination of nutritional and psychosocial factors. Failure to thrive is defined as weight falling below the 5th percentile for age (
Dubowitz, 2009
). Pediatric overweight is a problem of epidemic proportions in the United States, with more than 17% of children having a body mass index above the 95th percentile (Dubowitz, 2009
). A thorough psychosocial and nutritional assessment is crucial for both concerns. Also, the development of a detailed plan of care including linking caregivers with appropriate resources (e.g., dieticians, financial resources, exercise options, and specialized obesity or failure-to-thrive clinics) to address nutritional deficiencies is indicated. Caregivers need to understand the plan of care and verbalize agreement with the plan of care, and close monitoring of compliance is needed. Both failure to thrive and obesity can result in serious health consequences if they are untreated. Whatever the causes of the obesity or failure to thrive, neglect becomes a concern when the problems are not addressed by caregivers despite linkage to appropriate resources (Dubowitz, 2009
).Consequences of Neglect
The effects of neglect on children can be significant and long term, with children's physical and mental health and psychosocial and cognitive development affected (
Dubowitz, 2009
). The physical effects of neglect can be relatively immediate, such as injuries resulting from inadequate supervision, delay/failure to seek proper medical care, or failure to follow through with the recommended health care plan. Physical consequences of neglect can range from minor to the most severe, and can even result in death.Studies have linked neglect to negative health care consequences extending into adulthood.
Teicher et al., 2004
found differences in the brains of children who experienced neglect. Smaller sizes of the corpus callosum were noted. The Adverse Childhood Experiences Study investigators found that children who experienced neglect were more likely to experience liver disease as adults (Dong et al., 2003
), ischemic health disease (Dong et al., 2004
), and asthma and lung cancer (Brown et al., 2006
). Tietjen et al., 2009
suggested a relationship between neglect and migraines and comorbid pain conditions in adults. Specific elements of neglect were linked to adult delinquency: failure to supervise; a disorganized, chaotic family; and parental separation (Maugham and Moore, 2010
). Hayden et al., 2011
found that experiencing physical neglect as a child placed young adult women at increased risk of engaging in high-risk sexual behaviors and testing positive for sexually transmitted infections (e.g., chlamydia, gonorrhea, and trichomonas).Experiencing neglect has mental health consequences. Some psychosocial consequences can be seen in childhood. Children who experience neglect are more likely to exhibit emotional and behavioral problems. Neglected children may be withdrawn and passive or exhibit aggressive behaviors (
Dubowitz, 2009
). These children interact in less positive ways with peers and may be less self-assured. Neglected adolescents are more likely to engage in risky behaviors. Norman et al., 2012
found a causal relationship between experiencing childhood neglect and later experiencing depressive disorders, anxiety disorders, suicidal ideation and attempts, drug use, sexually transmitted infections, and risky sexual behaviors. Male adolescents who act out sexually with peers or younger children are more likely to have a history of neglect than child sexual abuse.Neglect can also result in developmental problems for children. As a result of physical and/or emotional neglect in infancy, a child can reach developmental milestones more slowly by virtue of a caregiver's failure to provide adequate opportunity and/or stimulation for the infant and then the toddler to develop. Once a child reaches preschool age and enters school, effects of neglect upon academic achievement can be seen. The academic performance of neglected children is worse than that of non-neglected children (
Dubowitz, 2009
). Neglected children have more problems with consistent school attendance, repeating grades, and poorer grades than do non-neglected peers. Children removed from their homes for neglect experienced more days in out-of-home care and were less likely to reunify than were children removed for abuse (Bundy-Fazioli et al., 2009
).Davidson-Arad et al., 2010
, in a study to compare characteristics of children assessed as neglected versus those assessed as accident victims, found that neglected children were twice as likely as accident victims to have had health problems and three times more likely to have had developmental problems. Neglected children were more likely to have had prior psychological treatment and a previous hospital referral to a community agency. Families of neglected children are more likely to live in poverty and be clients of the social services and receive state support, and their mothers are more likely to be unemployed (Davidson-Arad et al., 2010
).Implications for Practice
Decision making regarding child neglect can be very value laden, with practitioners forced to make important decisions in conditions filled with ambiguity and uncertainly (
Christiansen and Anderssen, 2010
). Carter, 2012
discussed the use of a qualitative grading scale, the Graded Care Profile (GCP), to provide an objective grading of the care given to a child by his or her caregiver (Srivastava and Polnay, 1997
). The GCP (Table) grades care on a five-point continuum from grade 1 (best possible care) to grade five (worst care) based on the caregiver's responsiveness to the child's needs (Carter, 2012
). The GCP evaluates the needs of children at different ages within four domains and dimensions within those domains: physical; safety; love; and esteem. Items within each domain are individually scored and contribute to a global score for each domain. Although developed for use by professionals, the GCP can also be used by caregivers to evaluate themselves and the care they are providing. The GCP scoring scale provides the practitioner with a tool to assist in decision making regarding neglect.TableGrade Care Profile scoring system
| Grade 1 | Grade 2 | Grade 3 | Grade 4 | Grade 5 |
|---|---|---|---|---|
| All needs met | Essential needs fully met | Some essential needs not met | Most essential needs not met | Essential needs entirely not met |
| Child first | Child priority | Child/caregiver equal priority | Child second | Child not considered |
| Best | Adequate | Equivocal | Poor | Worst |
Because of their relationships with patients and families, PNPs are in a unique position to identify child neglect. With the understanding that care exists on a continuum, the PNP must first make one essential decision: Did caregiver action or lack of action result in serious or potentially serious physical, emotional, or developmental harm to the child? If the answer to that question is “Yes,” then the PNP is obligated to report concerns of possible child neglect to CPS prior to discharging the patient from the clinic or hospital. CPS will devise a safety plan for the child and determine if it is safe to discharge the child home with the caregiver. It is always best practice to discuss your concerns of neglect with the caregiver and inform them of your need to report to CPS. This step is crucial in preserving your professional relationship with the family so you can work together to devise a plan of care to amend the neglect concern.
Important information to gather, not only to assist in your reporting decision but also, if reported, to share with CPS, includes an assessment of potential barriers affecting the caregiver's ability to provide acceptable care to his or her children. A thorough psychosocial assessment should be performed (see Box 2). Assess for a potential pattern of neglect. Is the neglect concern an isolated issue, or is it one of a series of neglectful concerns? Has suspected physical abuse, sexual abuse, or neglect previously been reported to CPS? Have caregivers previously demonstrated the inability to follow through with a recommended plan of care? If the answer to one or more of these questions is “Yes,” then most likely a referral to CPS is indicated.
Box 2
Psychosocial assessment
- Family tree
- •Maternal name and age
- •Paternal name and age
- •Sibling(s) name and age
- •Who lives with the child?
- •Visitation plan
- •Who lives where the child visits?
- •
- Previous involvement with Child Protective Services
- Previous parental/caregiver involvement with law enforcement
- Parental drug/alcohol concerns
- Parental mental health/mental retardation concerns
- Employment status
- Financial status/concerns
- Support systems
- Cultural/religious beliefs
- Intimate partner violence
If it is determined that the care of the child does not warrant a neglect referral to CPS at this time, then the PNP must work with the caregivers to develop a plan of care that will ensure that the child's needs continue to be met, optimally at a higher level. Discuss the plan of care with caregivers, ensuring that they understand the plan of care, why the plan is necessary, and what they must do to ensure that their child receives adequate care. Make sure you have caregiver buy-in and acceptance of the plan of care. Have the caregiver sign a contract stating that he or she understands and is in agreement with the plan of care. It is crucial that the PNP be aware of and link the caregiver with community resources to address identified barriers such as financial (e.g., Medicaid, food stamps, or public assistance), mental health (e.g., appropriate assessment and ongoing treatment), mental retardation (e.g., a case manager), or substance abuse concerns (e.g., an appropriate treatment program). Close follow-up with the patient and family is necessary to ensure that the child's needs are being adequately addressed. Re-education and reinforcement of the plan of care should be provided frequently. Surveillance of care can prevent potential serious harm to the child. It caregivers deviate from the agreed-upon plan of care, a referral to CPS is often necessary based on potential harm to the child. Caregivers should be given encouragement and positive reinforcement when the plan of care is followed. Surveillance can be gradually reduced as compliance is demonstrated.
It is imperative that PNPs remember the link between child neglect and other forms of child maltreatment. Children presenting with neglect concerns should also be assessed for other forms of maltreatment such as physical, sexual, or emotional abuse. Children should be asked questions about discipline and the use of corporal punishment to screen for physical abuse. Children should be asked basic screening questions about exposure to intimate partner violence. Having the child identify private parts and having a brief discussion regarding inappropriate touching are necessary. A thorough physical examination, including an external anogenital examination, is indicated with documentation of any noted injuries.
Although neglect is often a neglected form of child maltreatment, it can result in serious consequences and even death for children. PNPs must recognize child neglect and respond appropriately. Remember that a report to CPS is never a punitive action but rather an action to ensure the health and safety of the child. A clearly defined, thoroughly discussed plan of care to address an identified neglect concern of any type (e.g., health care, nutrition, emotional, or supervision) that is devised after assessment of potential barriers with implementation of interventions to address barriers does much to either alleviate concerns of neglect or can clearly demonstrate the caregiver's inability to provide adequate care. Working closely with caregivers to address potential neglect concerns often results in positive consequences for the child and caregiver, as well as the PNP. As PNPs, we must never neglect neglect.
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Biography
Gail Horner, Pediatric Nurse Practitioner, Nationwide Children's Hospital, Center for Family Safety and Healing, Columbus, OH.
Article info
Footnotes
Conflicts of interest: None to report.
Identification
Copyright
© 2014 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
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