Recognising, Assessing and Responding to Neglect - Practitioner Guidance

Contents

  1. Introduction 
  2. Policy Statement
  3. Defining Neglect 
  4. Cause of Neglect
  5. Recognising Neglect
  6. Impact of neglect
  7. Assessing and Responding to Neglect 

 

1. Introduction 

What is the purpose of this document? - The purpose of this document is to provide guidelines for the recognition, assessment of, and the response to neglect for all staff working with children and their families across Leeds, promoting a consistent child focussed approach to assessing and responding to neglect concerns. 

Why do we need this document? - It is vital that everyone in organisations and agencies working with children and families, including those who work with parents / carers, work restoratively, collaboratively, and effectively and understands the role they should play and the role of other practitioners when responding to neglect.

We must acknowledge that neglect is a difficulty concept for both practitioners and families to understand. The terminology itself is not very restorative and therefore the use of direct language which outlines concerns is easier to quantify. Neglect differs in its presentation from other forms of abuse. There is rarely a unique incident or critical event. More commonly a repetition of neglecting behaviour which causes incremental damage to the child(ren). Understanding its repercussions and the potential for both prevention and intervention is vital. 

Working within the Leeds Practice Model (One Minute Guide) which aligns itself to working restoratively with both families and colleagues, building on all aspects of professional practice and what we know to be useful when assessing, implementing and evaluating what practitioners do, the document will support practitioners in recognising, responding and appropriately supporting neglect.

Who is this document aimed at? - This guidance is aimed at practitioners from a wide range of agencies both statutory and non-statutory working with families either regularly or occasionally. 

Throughout this document reference is made to child or children, as per the legal definition this includes anyone up to their 18th Birthday.

The key contact for comments or further information about this policy is: lscp.info@leeds.gov.uk

 

2. Policy Statement 

Leeds Safeguarding Children Partnership (LSCP) are fully committed to safeguarding the welfare of children by taking all reasonable steps to protect them from neglect. 

Practitioners need to be open to recognising and working with families to respond to neglect; identifying how neglect presents and what “good enough” looks like. The development and implementation of this policy and procedures are to be seen as an integral part of our determination to provide high quality responsive services, which meet the needs of children and young people.

 

3. Defining Neglect 

Neglect can be complex and is often difficult to define clearly because most definitions are based on personal perceptions of neglect. These include what constitutes "good enough" care and what a child's needs are. Neglect often co-exists with other forms of abuse and is often a pre-condition to allowing other abuse to take place. 

Neglect is defined in Working Together to Safeguard Children (2018) as: 

The persistent failure to meet a child’s basic physical and / or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:

  • provide adequate food, clothing and shelter (including exclusion from home or abandonment);
  • protect a child from physical and emotional harm or danger;
  • ensure adequate supervision (including the use of inadequate care-givers); or
  • ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.

In addition to the Working Together 2018 definition, Horwath (2007) identified six different classifications of neglect:

  1. Medical neglect - the child’s health needs are not met, or the child is not provided with appropriate medical treatment when needed as a result of illness or accident.   
  2. Nutritional neglect - the child is given insufficient calories to meet their physical / developmental needs; this is sometimes associated with ‘failure to thrive’, though failure to thrive can occur for reasons other than neglect. The child may be given food of insufficient nutritional value (e.g. crisps, biscuits and sugary snacks in place of balanced meals); childhood obesity as a result of an unhealthy diet and lack of exercise has more recently been considered a form of neglect, given its serious long-term consequences.
  3. Emotional neglect - this involves 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.
  4. Educational neglect - The child does not receive appropriate learning experiences; they may be unstimulated, denied appropriate experiences to enhance their development and / or experience a lack of interest in their achievements. This may also include carers failing to comply with state requirements regarding school attendance, and failing to respond to any special educational needs.
  5. Physical neglect - The child has inadequate or inappropriate clothing (e.g. for the weather conditions), they experience poor levels of hygiene and cleanliness in their living conditions, or experiences poor physical care despite the availability of sufficient resources. The child may also be abandoned or excluded from home.
  6. Lack of supervision and guidance - The child may be exposed to hazards and risks, parents or caregivers are inattentive to avoidable dangers, the child is left with inappropriate caregivers, and/ or experiences a lack of appropriate supervision and guidance.  It can include failing to provide appropriate boundaries for young people about behaviours such as under-age sex and alcohol use. 

 

4. Cause of Neglect

It is not easy to say what causes a person or persons to neglect someone. Most people do not set out to purposefully neglect another. Neglect rarely manifests in a crisis that demands immediate action, it commonly occurs alongside other forms of abuse. It may be the result of other contributing factors such as parental ill-health, parental learning disabilities, substance misuse, domestic abuse, unemployment and poverty. It is the presence of one or more of these factors which impacts on the ability to parent a child and which may result in neglect. In addition neglect may be contributed to by factors which relate to the child rather than the parent / carer, but which may still impact on parenting capacity, for example illness or disability.

The relationship between poverty and neglect is problematic. It is important to separate material impoverishment and emotional impoverishment. It may be difficult to distinguish between neglect and material poverty. However when considering neglect we should do so with a ‘poverty lens’, understanding the context in which a family lives. 

Care should be taken to balance recognition of the constraints of the parents’ or carers’ ability to meet their child’s need for food, clothing and shelter with an appreciation of how people in similar circumstances have been able to meet those needs. Neglect can be viewed as a persistent failure to meet the essential needs of a child by omitting basic parenting tasks and responsibilities despite parents having the economic resources to meet the needs.

Situations of neglect can also be heightened as a result of the parent / carer’s response to those who recognise it, raise it with them and offer support. The way in which concerns about neglect are raised is vital. The term ‘neglect’ itself is not very restorative and when parent carers hear this, it may lead to them not wanting to work with the person raising concerns. When raising concerns, it is better to not use the term ‘neglect’ but to be specific and use language that directly describes what the practitioner has observed. 

In addition to the language used, the approach is important. When working restoratively with parent carers, a key feature will be to try to engage them in a conversation about what has been observed and aim to work with them to identify things that will help to form a plan.

Practitioners should seek the views of the parent carer and the children (if appropriate to age and communication) to gain a clearer understanding of the context in which the ‘neglect’ is occurring, enabling a wider view than just about individual parenting. 

When plans like this are agreed, the parent / carer is likely to be more engaged in making the changes to improve outcomes for the child because actions are likely to be ones that are most relevant to them and achievable. When plans are presented to parent / carers as a ‘fait accompli’, engagement may be reduced and success diminished. We need to move away from terms such as ‘disguised compliance’ (families seeming to ‘comply’ with others’ plans but not really believing in the plan) and ‘non-engagement’. As stated above, engagement relies on being truly involved in restorative conversations with families to help them identify the things that will make

the most difference. This engagement work lies with the practitioner and their skills in working ‘with’ families not solely relying on families to ‘engage’ with whatever we present to them.

 

5. Recognising Neglect 

To be able to recognise neglect practitioners need to understand the daily lived experience of both the child and the family as a whole. Neglect rarely manifests in a crisis that demands immediate action. Circumstances causing neglect often take years to develop and commonly occurs alongside other forms of abuse. 

Children are best protected when practitioners are clear about what is required of them individually and how they need to work together so that every child receives the support they need before a problem escalates. An effective response also requires practitioners to look beyond episodes of individual parenting and understand neglect in context.  

Neglectful parenting can manifest itself through medical, nutritional, emotional, educational, physical, and supervisory deficits. If not addressed early, parental deficits (both intentional and unintentional) are likely to become cumulatively worse over time which can have serious adverse effects on the child which will impact on their health, education, and social outcomes.  

Recognition of prenatal neglect: Whilst it is good practice that neglect should been seen through the experiences of the child, prenatal neglect can only be identified from observations of the experiences of the expectant mother and her family context, and so must be considered separately.  

Prenatal neglect may be associated with (but not exclusively): 

  • Drug use during pregnancy – which has been linked to low birth weight, premature birth, increased risk of sudden infant death syndrome (SIDS), damage to the central nervous system and physical abnormalities.  Babies may also experience neonatal abstinence syndrome at birth, which can cause irritability, tremors, respiratory distress and fluctuations in temperature.
  • Alcohol consumption during pregnancy – this can lead to foetal alcohol syndrome, which is an umbrella term to describe a spectrum of conditions caused by maternal alcohol use, including learning difficulties and an inability to connect emotionally with peers.
  • Failure to attend prenatal appointments and / or follow medical advice – prenatal support and monitoring sessions offer opportunities for problems to be identified early, and the health of mother and baby to be monitored.  Parents can also be supported to make appropriate arrangements for the birth, learn about how to care for new-borns, and ultrasounds offer early opportunities for bonding with their baby.  Both drug use and alcohol use have been linked with failure to keep prenatal appointments and failure to seek medical attention should any concerns arise during the pregnancy.
  • Smoking during pregnancy – this falls within Horwath’s working definition of prenatal neglect, as it restricts the baby’s supply of oxygen and is linked to increased risks of premature birth and low birth weight.
  • Experiencing domestic violence (or other traumatic events) during pregnancy – prenatal effects of domestic violence are not limited to the consequences of physical injuries sustained through assault.  Exposure to prenatal maternal stress or anxiety can affect the baby’s development, as heightened maternal cortisol levels are shared through the placenta which can influence foetal brain development and have implications for the emotional, behavioural, cognitive and social functioning of children. Exposure to other traumatic events during pregnancy can also have the same, or similar effects. 

 

6. Impact of Neglect

The impact and harm resulting from neglect can be wide-ranging, apparent in multiple domains of a child’s life and can manifest across the life course.

Living with neglect will have a significant impact on a child or young person, both physically and emotionally. These may differ for different children or young people, with some being more resilient than others, and some may be short term whilst others will have a longer term impact. 

Experience of neglect at different ages: children and young people experience the impact of neglect differently at different ages, it is important to remember that neglect should be seen in the context of each individual’s experiences, and consideration should be given to whether the neglect began in this age group or has in fact been ongoing for several years. Identifying different main impacts at different stages of a child or young person’s life, as shown below, will support a practitioner in assessing neglect and prioritising appropriate responses and support.

  • Infancy (birth to two years) – babies’ growth and development is linked to their interaction with the world and their caregivers.  Emotional and cognitive development can come through play, e.g. games like ‘peek-a-boo’ where actions are repeated for social and emotional reinforcement from the reactions of caregivers, and neural connections are ‘fixed’ through stimulation.  Disinterest or indifference to such actions and/ or failing to offer stimulation will limit the child’s development and growth, and damage infant attachments. 
  • Pre-school (two to four years) – most children of this age are mobile and curious, but lack understanding of danger; they need close supervision for their physical protection, which neglected children may not experience.  Children may not be appropriately toilet trained if they are in neglectful families, as this process requires patient and persistent interaction and encouragement.  Children’s language development may be delayed if their caregivers are not interacting with them sufficiently, and physical care may be inadequate, e.g. dental decay.
  • Primary age (five to eleven) – for some neglected children, school can be a place of sanctuary.  However, if their cognitive development has been delayed and they are behind their peers at school, it can also be a source of frustration and distress.  Signs of neglect, e.g. dirty or ill- fitting clothing, will be apparent to peers, teachers and to the children themselves, and may cause embarrassment and difficulties in their social interactions.  Children without clear and consistent boundaries at home can struggle to follow school rules and get into trouble.  Educational neglect can include failing to ensure that children attend school, and high levels of absence can further impair their academic achievement.  
  • Adolescence (twelve to eighteen) – neglect is likely to have an impact on the young person’s ability to form and maintain friendships and pro-social relationships, though the young person may be more reluctant to disclose their situation if they fear becoming looked after or being split up from their siblings.  Whilst adolescents can find sufficient food for themselves, they are likely to be drawn to the availability of high-fat, high-sugar convenience foods if they have never learned to prepare meals.  Adolescent risk-taking behaviour may be associated with, attributed to or exacerbated by a lack of parental supervision, which can expose neglected young people to the risk of harm through, for example, alcohol and substance misuse, risky sexual behaviour or criminal activity.  Resilience to neglectful situations does not increase with age, and can have significant consequences for young people’s emotional wellbeing; in a study of Serious Case Reviews, Brandon et al (2012) noted that ‘past neglect was a factor in eleven out of fourteen reviews conducted after a young person was believed to have committed suicide’.

Further details can be found in Appendix 1

Short term and long term effects: Living within a neglectful environment may result in short term effects for a child or young person, many of which may reduce or disappear with support and care. This may include:

  • Illness or infections
  • Nappy rash
  • Under / over weight 
  • Difficulty in establishing friendships / making friends
  • Withdrawn
  • Poor coping skills
  • Low self-esteem lack of confidence
  • Insecure attachments 
  • Lack of trust
  • Bullying
  • Acting out/aggression/impulsivity 
  • Poor problem solving skills
  • Low achievement in school

Children who have been neglected may experience long-term effects that last throughout their life including, in some cases, emerging in later adolescence or adulthood. This may include:

  • Emotional difficulties such as anger, anxiety, sadness or low self-esteem
  • Mental health problems such as depression, eating disorders, post-traumatic stress disorder (PTSD), self-harm, suicidal thoughts
  • Substance misuse and addiction 
  • Disturbing thoughts, emotions and memories that cause distress or confusion
  • Behavioural problems including anti-social behavior, criminal behavior
  • Running away
  • Poor physical health such as obesity, low weight, aches and pains
  • Struggling with parenting or relationships
  • Conflict and hostility in relationships
  • Worrying that their abuser is still a threat to themselves or others
  • Learning difficulties, lower educational attainment, difficulties in communicating

In addition children who don’t get the love and care they need from their parents may find it difficult to maintain healthy relationships with other people later in life, including their own children. They are more likely to experience mental health problems including depression and post-traumatic stress disorder, and may also engage in risk taking behaviour such as running away from home, breaking the law, abusing drugs or alcohol, or getting involved in dangerous relationships.

 

7. Assessing and responding to Neglect

Assessing
All practitioners who come in to contact with children and young people, or similarly, all those who work in some way with adults, who may be parents or carers, should:

  • Be alert to potential indicators of abuse or neglect;
  • Be alert to the risks which individual abusers or potential abusers, may pose to children;
  • Be alert to the impact on the child of any concerns of abuse or maltreatment;
  • Be able to gather and analyse information as part of an assessment of the child’s needs.

Assessment is part of a practitioners day to day work, they assess a child (or a situation) every time they see them and make judgements as to how that child is presenting and if there are any concerns. The assessment of neglect is no different, however due to the complexity of neglect and the fact that it is often a cumulative effect assessment of, and responses to neglect need to be carefully considered and well structured.

It should also be remembered that neglect cases virtually never start with an allegation from a child; invariably they are from an observation by a professional, or perhaps a member of the community.

Practitioners should discuss concerns with safeguarding leads if they are unsure about what they are identifying.

Should the outcome of any assessment identify that a child or young person is at risk of significant harm then Duty and Advice at the Front Door should be contacted in line with the practitioner’s agency procedures.

Responding
Response to the recognition of neglect is no different to how any type of abuse should be responded to. We know that a restorative approach whereby we work with families and support them to meet their own needs has positive outcomes for families, and that this approach can address child neglect as the majority of parents can be supported to change their behaviour and improve the lives of their children. 

However when working with neglect, it is important to consider the particular needs and characteristics of children, young people and their parents and carers which may make a child or young person more at risk of experiencing neglect for example:

  • There are parental risk factors (TFWF) – domestic violence or abuse, substance misuse, mental health needs, or learning disability;
  • There are issues of capacity and understanding for the parents or carers or an adolescent who is transitioning to adulthood (this may be across a wide range including capacity under the Mental Capacity Act); 
  • The child or young person is missing out on education or not achieving in education;
  • The child or young person has Complex Needs;
  • Adolescent decision making is in conflict with that which may be consistent with their welfare;
  • The young person has social, emotional or mental health needs.

In addition some situations may make the identification of neglect harder including (but not exclusively) where:

  • There are particular cultural needs;
  • English is not the first language of the child, young person or their parents or carers;
  • The child is educated through Elective Home Education; 
  • The child or young person is missing out on education or not achieving in education;
  • The child or young person has special education needs and disabilities.

When working with families, especially those where English is not their first language and / or that they have come to live in the UK from another country, practitioners should ensure that people understand the important about keeping health appointments including for dental check-ups and treatment. In some countries, it may be the norm that health and dental appointments need to be paid for by the family and we need to make clear that this is not the case.

In addition, when expecting parents to bring their children to appointments we need to consider literacy and language issues, for example, can the parent carers read appointment letters etc. 

Moreover, if there is travel involved to the appointment, we need to adopt a ‘poverty lens’ and consider the financial impact on the family – i.e. can they afford the fare to travel; if they work, can they afford or are they allowed to take time off work and are there other children who need to be cared for whilst a parent takes a child for an appointment. 

Responses to neglect should include:

a) Engagement with Family 
It is essential to understand the context in which a family lives, such as economic income, location and medical / mental health needs. Restorative conversations with parents, carers, children and other family members will provide an understanding of the lived experience for the individuals within families, and the family as a whole. It will allow the identification of who comprises the “family unit” and interaction with and between individuals, services and agencies as part of daily life.

All engagement should be child focused, ensuring that children and young people are able to speak out and that whoever they tell takes them seriously and acts on what they've been told.

Neglect needs to be understood from a child centred perspective, focusing on the child's unmet needs, and on the consequences for the child of parental behaviours e.g. is the child bullied or ostracised at school because of poor hygiene. In situations whereby external factors such as domestic violence or substance misuse are creating or impacting upon a neglectful situation, although responses should be considered within a Think Family, Work Family approach, the needs and voice of the child should not be lost. It should be explained to the child that whilst their view will be taken into account, the professional has a responsibility to take whatever action is required to ensure the child's safety and the safety of other children

b) Identification of what concerns look like
Restorative engagement will allow a practitioner to identify what concerns look like; what are they worried about; how does this present; what are the impacts (including on wider family life) and what needs to change. These should be clearly explained to the parent / carers so that they can understand what your concerns are and agree with you as to what needs to change in order to remove the concerns.

Identification of concerns isn’t necessarily about what has been done to the child, but on the standard of care provided to him or her. However to understand the impact of that standard of care it is essential that the child is spoken to, and his/her experience explored. For children who cannot verbally communicate their experiences, feelings and wishes should still be gathered using alternative methods. 

Using an outcomes focussed approach an agreed plan should be drawn up with the parents / carers about what needs to be achieved in order to overcome the concerns. Plan should be SMART and also identify any potential barriers, and how these may be overcome.

Throughout consideration should be given to involving other agencies and developing a multi-agency approach.

c) Recording
Accurate, detailed and up to date recording either through the use of agency recording sheets or single (or multi-agency) chronologies is particularly important in identifying issues of neglect. The nature of its presentation (mounting concerns and minor incidents) means that recording by all professionals, and sharing of information between professionals is crucial to the protection of the child. Apparently trivial events may assume a much greater importance when observed repeatedly through supervision and professional challenge, and an ability to analyse the picture that is building up, or put together with the observations of others.

d) Monitoring and reviewing Progress
Throughout any work with a family whereby neglect has been identified as an issue, reviewing is essential to recognise progress and identify further actions or work required. Where appropriate this should take place within the formal structures of any statutory plans in place, but can and should also occur in between formal reviews in order to maintain a current overview of progress. For situations whereby there is no statutory plan in place reviews should take place regularly to ensure oversight of progress and continuing assessment of concerns.

e) Discuss with Line Manager / supervision
The opportunity for reflection and discussion in relation to concerns regarding neglect, or ongoing work with neglect, allows for continual identification and assessment of concerns, monitoring of progress and agreement of progression. Practitioners should regularly seek the support of line managers and supervision to explore concerns about, and ongoing work with neglect.

f) Referral to Duty and Advice
Should it be identified through ongoing review of progress and reassessment of concerns that changes are not occurring and that neglect is continuing practitioners should inform Children’s Social Care by making contact with Duty and Advice at the Front Door. 

 

Appendix 1 

Experiences of neglect by age group; please note that the examples listed are intended to give an overview of what children may experience rather than provide an exhaustive list of ways in which neglect may present. 

Age group

Experiences of neglect by Horwath’s classifications 

  Medical Nutritional Emotional Educational Physical Lack of supervision 
Infancy; 0-2 years  Includes failure to notice that a baby is unwell, and failure to seek medical treatment. Not attending routine health screening appointments may be indicative. Under-nourishment leads to restricted growth and brain development.  There can be a link between neglect and obesity, e.g. if parents use sweets as ‘pacifiers’. Lack of stimulation can prevent babies from ‘fixing’ neural connections. Infant attachments are damaged by neglect, which makes learning skills more difficult Some parts of the brain, e.g. cortex, are dependent on experience and stimulation to develop. Language relies on reinforcement and feedback from carers.  Dirty home conditions may affect infant immune system; lack of changing and nappy rash; lack of encouragement may delay skill development. Babies should be supervised at all times, particularly when lying on surfaces they could fall from or in the bath. If babies feel abandoned, this can affect the development of attachments. 
Pre-school; 2-4 years  May include missed health and dental appointments, and failure to seek medical treatment following accidents or for routine conditions such as head lice or squints.  Not eating 1200 – 1500 calories per day, and/ or unregulated amounts of fat and sugar in the diet, which can lead to heart problems, obesity and tooth decay. Neglected children without a secure attachment may experience difficulties playing with their peers, sharing feelings and thoughts, coping with frustration and developing empathy. Neglect can be a significant factor in delaying a child’s language development e.g. through the amount and quality of interactions with carers.  This delay affects their education.  Child may present as dirty or malnourished, and living conditions may be poor.  Child may not have been toilet trained, sleeping sufficiently or have adequate boundaries.  Home may lack safety devices e.g. stair gates, dangerous items such as drugs or knives may be within reach, child may not have appropriate car seat, child may be left home alone. 
Primary; 5-11 years Children may have more infections and illnesses than their peers due to poor treatment, or lack of prevention e.g. through hand washing, good diet or adequate sleep.  Food isn’t provided consistently, leading to unregulated diets of biscuits and sweets. Concerns should not just focus on weight; children of normal weight could still have unhealthy diets.  Insecure attachment styles can lead to children having difficulties forming relationships, and may express their frustration at not having friends through disruptive behaviour.  Neglected children can experience a number of disadvantages at school, including low educational aspirations, lack of encouragement for learning and language stimulation. Ill-fitting, inadequate or dirty clothing, poor personal hygiene, lack of sleep, lack of routines or boundaries which can lead to frustration with school rules and boundaries. Primary school children may be left home alone after school, or expected to supervise younger children. They may be left to play outside alone or to cook meals without supervision.
Adolescent; 12+ years  Poor self-esteem and recklessness can lead to ignoring or enduring health problems rather than accessing services. There may also be risk-taking behaviour e.g. in sexual activity.  Adolescents may be able to find food, but lack of nutritious food and limited cooking experience can lead them to unhealthy snacks, which affects both health and educational outcomes.  Peer groups and independence are important at this age; young people who are isolated by neglect (e.g. through poor hygiene) will struggle. Conflict with carers may also increase.  Likely to experience cognitive impairment e.g. in managing emotion, challenging behaviour in school. Low confidence and academic failure can reinforce negative                  self-image.  Adolescents’ social development is likely to be affected by their living conditions, inadequate clothing, poor hygiene and body odour. This can affect their self-esteem. Neglected adolescents may stay out all night with carers not aware of their whereabouts, which can lead to opportunities for risk-taking behaviours that can result in serious injury.