Child Neglect: A Guide for Intervention
U.S. Department of Health and Human Services Gaudin, J. M., Jr.|
|Year Published: 1993|
Differences in definitions of child neglect in State laws and in community standards reflect the significant variations in the judgments of professionals and nonprofessionals concerning what constitutes child neglect. Some State statutes emphasize the condition of the child without any mention of parental fault; others stress the condition of the child resulting from parental actions or fault. Some communities have determined that no child under age 10 should be left at home alone, while other communities "permit" working parents to leave their children unsupervised after school.
Defining neglect is complicated by the necessity of considering the following:
- What are the indispensable, minimally adequate types of care that children require?
- What actions or failures to act on the part of the parents or other caretaker constitute neglectful behavior?
- Must the parent's or caretaker's action or inaction be intentional, willful or not?
- What are the effects of the actions or inactions on the child's health, safety, and development?
- Is the family's situation a result of poverty, or a result of parental neglect?
Legal advocates have suggested that definitions of neglect which focus only on the behavior of the parent or caretaker are inadequate.2 They strongly advocate that the parents' behavior must result in some specific physical damage or impairment or some identifiable symptoms of emotional damage to a child resulting from the parents' behavior or failure to act.3 Some researchers have also included resultant damage to the physical, emotional, or intellectual development and well-being of the child in the definitions of neglect.4 Zuravin has concluded, on the contrary, that the focus should be on the actions of the parents, not on the consequences of their behavior, nor on their intent or culpability.5 Parents who leave preschool-aged children without adult supervision for an hour or more are neglectful, regardless of their intent, or whether the child suffers serious injury or not.
Conceptual definitions of neglect vary, in part, depending on the purpose for which the definition is used. Legal advocates insist on clear evidence of serious harm to a child before court intervention to remove a child from parents. On the other hand, for caseworkers intervening with a family to prevent placement and to protect the child from further harm, the definition of neglect must focus on parental omissions in care that are likely to increase the risk of harm to the child. For researchers interested in studying the long- and short-term consequences of neglect for the child, definitions of neglect would need to focus on parental behaviors that result in harm to the child.
Polansky's conceptual definition of child neglect is widely accepted:
"A condition in which a caretaker responsible for the child, either deliberately or by extraordinary inattentiveness, permits the child to experience avoidable present suffering and/or fails to provide one or more of the ingredients generally deemed essential for developing a person's physical, intellectual, and emotional capacities."6
This definition meets the demand for inclusion of parental actions, which result in some negative consequences for the child, but fails to specify the required degree of harm to the child. The problem comes in defining what is "generally deemed essential" for a child's physical, intellectual, and emotional development. This definition is heavily dependent upon the ever-changing status of our knowledge about what is physically and psychologically essential for a child's healthy growth and development.
There is a lack of consensus among parents and even among child development researchers on what is essential for child development. Standards of what is essential continue to change as we learn more about child development and those things that impede or enhance children's physical, cognitive, emotional, and social development. For example, the legal requirement that children be restrained in car seats clearly defines a new standard for "minimally adequate care" of children while traveling in cars.
These operational definitions of neglect are highly dependent upon the standards of the local community and of the caseworker who investigates reports of neglect. However, infants and very young children left without adult supervision for hours, children who are not fed regularly, children who are not taken for necessary medical treatment when ill, chronically dirty, lice-infested children, or chronically truant children are consistently accepted as having experienced neglect.
Definitions of what is minimally adequate care or, conversely, inadequate care for children, must also take into account cultural variations in standards for adequate care of children.7 Significant differences in ratings of the severity of specific indicators of abuse and neglect among social workers, police, attorneys, and judges and among African-American, Hispanic, and white subjects were discovered in one study.8 African-American subjects rated indicators of physical neglect as significantly more severe instances of inadequate care than did whites or Hispanics. On the other hand, another study concluded that when presented with critical incidents descriptive of child neglect, there was substantial agreement among white, Hispanic, and African-American subjects on basic standards of care for children.9 Clearly, cultural variations require further consideration in practice and in research.
Poverty is a significant confounding factor in defining child neglect. Although most impoverished families manage to provide strong, nurturing care for their children, the association of child neglect with poverty is clearly supported by many studies.10 Families receiving Aid to Families with Dependent Children (AFDC) are often reported for neglect. Even among impoverished families, neglectful families are the "poorest of the poor," often lacking adequate housing, health care, and child care.11
The difficulty comes in establishing the parents' accountability for providing minimally adequate necessities for their children, such as after school supervision and medical care, in the face of inadequate income, and the absence of accessible, affordable medical and supportive social services. Some State laws specifically exempt inadequate child care because of poverty from the definition of neglect by adding the clause "in spite of availability." Working parents without health insurance may find medical care for their children beyond their resources. Nevertheless, children who are deprived of medical treatment when they are ill are being neglected, regardless of the cause.
Types of Neglect
The Study of National Incidence and Prevalence of Child Abuse and Neglect12 sought to overcome the problem of nonuniform definitions of child neglect by utilizing a standard definition of neglect. The definitions of neglect included physical neglect, child abandonment and expulsion, medical neglect, inadequate supervision, emotional neglect and educational neglect by parents, parent substitutes, and other adult caretakers of children. The NIS definitions are categorized as follows:
|Refusal of Health Care||Failure to provide or allow needed care in accord with recommendations of a competent health care professional for a physical injury, illness, medical condition, or impairment.|
|Delay in Health Care||Failure to seek timely and appropriate medical care for a serious health problem which any reasonable layman would have recognized as needing professional medical attention.|
|Abandonment||Desertion of a child without arranging for reasonable care and supervision. This category included cases in which children were not claimed within 2 days, and when children were left by parents/substitutes who gave no (or false) information about their whereabouts.|
|Expulsion||Other blatant refusals of custody, such as permanent or indefinite expulsion of a child from the home without adequate arrangement for care by others, or refusal to accept custody of a returned runaway.|
|Other Custody Issues||Custody-related forms of inattention to the child's needs other than those covered by abandonment or expulsion. For example, repeated shuttling of a child from one household to another due to apparent unwillingness to maintain custody, or chronically and repeatedly leaving a child with others for days/weeks at a time.|
|Other Physical Neglect||Conspicuous inattention to avoidable hazards in the home; inadequate nutrition, clothing, or hygiene; and other forms of reckless disregard of the child's safety and welfare, such as driving with the child while intoxicated, leaving a young child unattended in a motor vehicle, and so forth.|
|Inadequate Supervision||Child left unsupervised or inadequately supervised for extended periods of time or allowed to remain away from home overnight without the parent/substitute knowing (or attempting to determine) the child's whereabouts.|
|Marked inattention to the child's needs for affection, emotional support, attention, or competence.|
Extreme Abuse or Domestic Violence
|Chronic or extreme spouse abuse or other domestic violence in the child's presence.|
|Permitted Drug/Alcohol Abuse||Encouraging or permitting drug or alcohol use by the child; cases of the child's drug/alcohol use were included here if it appeared that the parent/guardian had been informed of the problem and had not attempted to intervene.|
|Permitted Other Maladaptive Behavior||Encouragement or permitting of other maladaptive behavior (e.g., severe assaultiveness, chronic delinquency) in circumstances in which the parent/ guardian had reason to be aware of the existence and seriousness of the problem but did not attempt to intervene.|
|Refusal of Psychological Care||Refusal to allow needed and available treatment for a child's emotional or behavioral impairment or problem in accord with competent professional recommendation.|
|Delay in Psychological Care||Failure to seek or provide needed treatment for a child's emotional or behavioral impairment or problem which any reasonable layman would have recognized as needing professional psychological attention (e.g., severe depression, suicide attempt).|
|Other Emotional Neglect||Other inattention to the child's developmental/emotional needs not classifiable under any of the above forms of emotional neglect (e.g., markedly overprotective restrictions which foster immaturity or emotional overdependence, chronically applying expectations clearly inappropriate in relation to the child's age or level of development, etc.)|
|Permitted Chronic Truancy||Habitual truancy averaging at least 5 days a month was classifiable under this form of maltreatment if the parent/guardian had been informed of the problem and had not attempted to intervene.|
|Failure to Enroll/Other Truancy||Failure to register or enroll a child of mandatory school age, causing the school-aged child to remain at home for nonlegitimate reasons (e.g., to work, to care for siblings, etc.) an average of at least 3 days a month.|
|Inattention to Special Education Need||Refusal to allow or failure to obtain recommended remedial educational services, or neglect in obtaining or following through with treatment for a child's diagnosed learning disorder or other special education need without reasonable cause.|
According to the 1988 NIS-2 study,13 almost 43 percent of the identified neglect was physical neglect, which included children living in unsafe housing, not being fed nutritionally adequate meals, being consistently without adequate clothing, and receiving grossly inadequate care for personal hygiene. The second largest category of neglect was inadequate supervision of children (36.6 percent) and failure or delay in providing health care (20.8 percent).
Large numbers of very young children are left without supervision or left in the care of only slightly older children who lack the judgment and maturity to safely provide for the infants and very young children. One study indicated that 22 percent of all first-time reports to New York's central child abuse registry during 1982-1983 contained allegations of lack of supervision.14 Often, children are left in this dangerous situation while their parents work or attend to other business. This category of neglect is difficult to define. At what age may a child be left unattended, and for what period of time? At what age is a child competent to care for a younger sibling? Much depends upon the safety of the environment and the child's level of maturity and intelligence. These criteria are highly subjective and vary significantly among ethnic and subcultural groups. Young school-aged children in Oriental, Hispanic, and low-income African-American families are often expected to care for very young siblings in the absence of parents. Yet, studies have indicated a relatively high rate of injuries to children and child fatalities due to this type of neglect.15
Thus, there are many types of child neglect and an array of contributing factors. Abandonment of the child may stem from parental alcoholism, drug abuse, or despair. Inattention to dangerous, avoidable hazards in the home, such as unprotected heaters or fireplaces, may stem from lack of knowledge, poverty, and/or apathy. A significant delay in obtaining medical treatment for serious, acute, or chronic illness or accidental injury may be the result of lack of knowledge, lack of transportation, prohibitive cost, or other barriers to seeking medical services. Sexual abuse may be the result of a parent's failure to provide adequate supervision of a young child. Alcohol and drug abuse is a factor in a rapidly increasing percentage of child neglect cases, with estimates now running as high as 70 percent in some urban areas. Some parents meet the minimal physical needs of their children, but ignore their need for critical emotional nurturance.
Withholding of Medically Indicated Treatment From Newborn Infants
The withholding of medically indicated treatment from newborn infants with serious birth defects that are life-threatening is a category of neglect that was defined in the amended Child Abuse Prevention and Treatment Act of 1984 (P.L. 98-4576). These situations have been referred to as "Baby-Doe" cases, after a 1982 Indiana court case contesting the parents' rights to withhold medical treatment, food, and water from an infant who was born with a life-threatening but surgically correctable condition that prevented oral feeding.
The 1984 amendments to the Child Abuse Prevention and Treatment Act defined as neglectful: "The failure to provide treatment (including appropriate nutrition, hydration or medication) which, in the judgment of the physician would be most likely to be effective in ameliorating or correcting the life-threatening condition." The law and the regulations issued by the Department of Health and Human Services require that States receiving Federal funds for CPS programs regard the withholding of medically indicated treatment from these disabled infants with life-threatening conditions as a form of neglect and to actively investigate reported cases. Hospitals are likewise obligated to observe the provisions of the law and to post notices in newborn wards that failure to feed and provide care for disabled infants is a violation of Federal law.
The law does make exception for withholding treatment (other than nutrition, hydration, or medication) to an infant when, in the physician's reasonable medical judgment:
- The infant is chronically and irreversibly comatose.
- The provision of such treatment would merely prolong dying, be ineffective in correcting the life-threatening condition, or be futile in terms of the survival of the infant.
- The treatment would be virtually futile in terms of the survival of the infant and the treatment itself would in such a situation be inhumane. Food and water must always be provided regardless of the extent of disabilities, and "quality of life" cannot be used as a criterion for deciding upon appropriate medical treatment.16
Decisions about minimally adequate care for these infants present difficult moral and ethical dilemmas for physicians, hospital personnel, and parents of infants born with severely disabling mental and physical handicaps.
Prenatal Exposure to Drugs
Considerable controversy surrounds the issue of prenatal exposure of infants to drugs and alcohol. Courts are still debating whether such exposure is neglectful behavior on the part of a pregnant woman. Pregnant women who abuse alcohol, however, have exposed their fetuses to the serious mental and physical disabilities known as fetal alcohol syndrome. An estimated 73 percent of pregnant 12-34-year-old women have used alcohol sometime during their pregnancy. The incidence of fetal alcohol syndrome is 1.9 births per 1,000.17 Prenatal exposure to cocaine and other drugs also results in negative developmental consequences for 30-40 percent of the estimated 500,000-740,000 drug-exposed infants in the United States.18
Failure to Thrive/Malnutrition
Children whose physical development falls below the third percentile in height and or weight for no known medical reason have been designated "nonorganic failure to thrive." Recent thinking calls for categorizing all children whose development is thus significantly impeded by inadequate nutritional intake as "acutely malnourished."19 The parents' failure to provide necessary nutritional and/or emotional nurturing, often in spite of efforts to do so, presents a challenging problem which has proven difficult to remedy beyond immediate improvements with hospitalization. Failure to thrive children respond with improved weight gain and developmental progress to inpatient hospital treatment, which includes intensive enhancement of nutritional and emotional nurturing. Normal developmental progress frequently does not continue when the children are returned home to the care of parents, and followup studies indicate continuing developmental delays in about half of the children. Outcomes of intervention appear to be related to the cause of failure to thrive and the parents' degree of awareness and cooperation with the treatment. The less chronic the developmental failure and the greater awareness and cooperation of parents, the more positive the outcomes.20
Deficits in the critical bonding and attachment process between parent and child are thought to be at least partially responsible for the significant developmental delays among children. Depression and other personality problems in the parents, lack of knowledge about child care, poverty, and other sources of social stress have been identified as contributing causes of nonorganic failure to thrive.21
Chronic vs. "New" Neglect
Recent studies have revealed significant differences in the characteristics and problems of chronically neglectful families and "new" neglectful families.22 Chronically neglecting families had more and older children, were poorer, had more problems, and less parenting knowledge than the newly neglecting families. Newly neglecting families had higher levels of stress, especially from recent serious illness or injury, and drugs were more likely to be a problem in their communities than for the chronically neglecting families.
The distinction between chronic and "new" cases of neglect may not hold up over time, however. "New" cases may actually represent the initial phase (stage) of chronic neglect. Whether this is so requires further research on the outcomes of "new" neglectful families.
To summarize, the definition of child neglect is problematic because of the lack of consensus on what is considered "minimally adequate" care of children. Although there is general agreement among professionals and the general public on what is clearly inadequate care, there are differences among professionals and ethnic groups on minimally acceptable levels of physical, psychological, and educational care and nurturing for children of different ages. Conceptual definitions of neglect differ depending upon the purpose for which they are used. Clear evidence of specific harm to a child is needed in legal proceedings for removal of a child from a parent's custody. Protective services intervention to remedy parental omissions and prevent placements may use definitions of neglect that focus on parental skills deficits and the risk of harm to a child. There are newly debated areas of neglect that present difficult moral-ethical dilemmas, for example, prenatal exposure to drugs in utero. Research studies on neglect suggest that it is important for the child protection practitioner, policy maker, and the researcher to clearly differentiate among the specific types of neglect being considered.
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