Child neglect: How health visitors identify, assess and manage neglect

Fiona Miele

Complex and multi-faceted

Distinction between different types of neglect

Influence of personal and organisational perspectives that influence how practitioners understand neglect

Medical neglect

Nutritional neglect

Emotional neglect

Educational neglect

Physical neglect

Lack of supervision and guidance (Horwath 2007)

(Horwarth 2007)

Denial of health care

Delay in health care

Indicators of poor health drowsiness, easily fatigued

puffiness under the eyes

Frequent untreated upper respiratory infections Itching, scratching, long existing skin

conditions Frequent diarrhoea

Untreated illnesses

Physical complaints not responded to by parent

Begging for or stealing food

Frequently hungry

Rummaging through rubbish bins for food

Gorging self, eating in large gulps

Hoarding food

Obesity

Overeating junk food

Disturbed self-regulation

Negative self identity

Low self-esteem

Clinical depression

Substance misuse

Have gaps in their education General learning disabilities Poor problem solving abilities Poor reading, writing and maths skills Be socially isolated Little confidence and can be Disruptive or overactive in class Be desperate for attention, or Desperate to keep out of the limelight Try too hard Blame themselves for a wide range of issues Adapted from Aggleton, Dennison & Warwick (2010)

Inadequate supervision

Inadequate guidance

Children left alone

Inappropriate boundaries e.g. Allowing under-age sex or alcohol use

Physical neglect often includes emotional neglect

Emotional neglect may not include physical neglect

To talk of physical neglect can be shorthand for both physical and emotional neglect

Physical neglect is a cognitive and emotional matter (Taylor and Daniel 2005)

Neglect is 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. It may involve a parent or carer failing to provide adequate food, shelter and clothing, to protect a child from physical harm or danger, or to ensure access to appropriate medical care or treatment’............

....’It may also include neglect of, or failure to respond to a child’s emotional needs. Neglect may also result in the child being diagnosed as suffering from ‘non-organic failure to thrive’, where they have significantly failed to reach normal weight and growth or developmental milestones and where physical and genetic reasons have been medically eliminated. In its extreme form children can be at risk from the effects of malnutrition, lack of nurturing and stimulation. This can lead to serious long-term effects such as greater susceptibility to serious childhood illnesses and reduction in potential stature. With young children in particular, the consequences may be life-threatening within a relatively short period of time

(Scottish Government 2010)

Whilst the complexity of defining neglect is acknowledged, in its simplified form practitioners, as well as members of the community know when a neglected child is living amongst them

(Stevenson 1998)

Alterations in the body’s stress response

Insecure attachments

Delayed cognitive development

Low self-esteem and confidence

Behavioural problems and poor coping abilities

Socially isolated – difficulty making friends

(Brandon et al 2014)

Depression, anxiety

Dissociation

Poor emotion regulation

ADHD symptoms

Anti-social behaviour including violence and delinquency

Substance abuse and addiction

Poor educational achievement

Social isolation

Mental health problems - suicide

Physical health problems (O’Hara et al 2015)

Cumulative harm may be caused by an accumulation of a single adverse circumstances and events

The unremitting daily impact of these experiences on the child can be profound and exponential, and diminish a child’s sense of safety, stability and wellbeing

(Bromfield & Miller 2007)

Universal service

Holistic approach to assessment of need

Named Person role

Aim and objectives

Literature review

Research Methodology

Data Collection

Sample Group

Ethical Considerations

Validity and reliability

Data Analysis

Findings

To gain an understanding about how health visitors identify, assess and manage childhood neglect within their practice

To explore the nature of health visitors understanding of childhood neglect

To explore how health visitors identify neglect and the process of assessment used to assess the nature and level of neglect

To explore when health visitors refer to social work and any barriers to this

To ascertain if the Named Person role has changed the way health visitors manage cases of neglect

To identify previous work in the area of health visitors working with childhood neglect

Qualitative study

Phenomenological approach

Semi-structured face-to face interviews

Sample group: Experience ranged from 5 years to 19 years, with an average of 10 years experience

Preparation of the data

Familiarity of the data

Interpreting the data (developing codes, categories and concepts)

Verifying the data

Representing the data

(Denscombe 2007)

Health visitors’ understanding of what constitutes childhood neglect:

Confident responses

Rich descriptions

Focus on physical signs in child and environment

“Well you would be looking at the child within the home situation as a whole. You would be looking at their physical care, whether they are being fed, clothed appropriately, given enough time to sleep in an appropriate place as well as their engagement with the parent or carer. You would be looking at he house set up as well, making sure with regard to carpet, appropriate bedding, hygiene to reduce the risk of becoming unwell and never getting out the bit with coughs, colds, flu, diarrrhoea and vomiting, that sort of thing..”

(HV1)

Hesitancy in their descriptions

Articulated difficulty with describing emotional neglect

Acknowledged difficulty dealing with issue

“I think the neglect that has the biggest impact on me is the emotional bit and that is so difficult to quantify than if you have got physical neglect which is easier to see and document....well from experience, I had a family and that little boy’s face I will remember forever” (HV 3)

Knowledge

Skills

Experience and intuition/gut feeling

The use of assessment tools

HV Training

Child protection knowledge and specifically training about neglect

Child development knowledge

Attachment

Communication skills

Interpersonal skills that include the ability to deal with challenging and difficult situations whilst maintaining a relationship with the client.

Observations skills

Listening skills

Experience informs assessment process – personal and professional

Experience and gut feeling or intuition seen as inter-related

Five of the ten HVs identified that gut feeling or intuition was the first indicator of neglect

“that gut feeling...yes, I always think it’s the first thing probably that I employ, you know, when I go into a house and look around. You either think well, yes, this is ok or you just think mmmm... Something just doesn’t feel quite right here. Then you have got to start using your other skills around you, questioning, listening, observing, to come to some sort of assessment of what might be happening with that particular family and child. So intuition plays a big part of that” (HV2)

SOGS

SHANARRI

National Risk Assessment Framework

National Practice Model

My World Triangle

Wellbeing Wheel

Action for Children Assessment tool for neglect

Allows clarification of thoughts

Used to formalise findings for reports

Helps to communicate concerns to other agencies

Gives an objective assessment of concerns

Helps to identify gaps in knowledge of family

Allows the development of a plan

Gives a fuller picture of what life is like for a child

Support

Home visiting

Practical support:

< parenting classes e.g. PEEP

< baby massage classes

< local community activities

< referral to other agencies and services

Lack of confidence in the response from SW and lack of confidence in referral system

Difference in thresholds between agencies about what constitutes neglect

Lack of confidence in making a referral

Concern that referral to SW will damage relationship with family

“sometimes I worry that Social Work may not always be receptive of the referral or the concern that you have so you sometimes have to chug away (HV 9)

“I suppose sometimes I do question myself. You

know, is it going to reach their threshold but now I tend to just think well, I don’t know if it is going to reach their threshold or not but I still think what it requires is beyond single agency so I will put request in and argue my corner over it”

(HV2)

No perceived negative impact on their role

Formalises role

Improved communication between agencies

Concern around administrative role

Use of assessment tools - particularly for emotional neglect

Referral process

Multi-agency training