noticing and helping the neglected child: towards an international research agenda

Noticing and helping the neglected child: towards aninternational research agendacfs_795 1..11

Julie Taylor*, Brigid Daniel† and Jane Scott‡*Head of Strategy and Development, National Society for the Prevention of Cruelty to Children (NSPCC), Edinburgh,

†Professor of Social Work, University of Stirling, Stirling, and ‡Implementation Coordinator, Multi-Agency Resource

Service (MARS), Scotland, UK

ABSTRACT

This systematic review examined the evidence on the extent to whichpractitioners are equipped to recognize and respond to the indica-tions that a child’s needs are likely to be, or are being neglected. Thispaper examines the methodological issues arising from the review. Asystematic process of progressive filtering yielded 112 papers repre-senting primary studies that inform the international research agendafor child neglect. A final dataset of 63 studies was of sufficient qualityand usefulness for inclusion. The review raised a number of method-ological issues of relevance for research in child protection in general,and on neglect in particular. Researchers and practitioners canbenefit from an enhanced understanding of the issues that makeneglect difficult to understand. Common issues were identified toinform future research. For example, there was a tendency for studiesto use a range of proxy measures rather than direct observation of theoutcome of interest, and a wide range of different outcome measureswas used. Many of the studies were small scale or retrospective indesign. Many studies conflated neglect and other forms of maltreat-ment, and it was often difficult to extract specific messages forneglect.

Correspondence:Julie Taylor,NSPCC, Centre for Learning in ChildProtection,1.1 Paterson’s Land, Moray House,University of Edinburgh,Holyrood Road,Edinburgh EH8 8AQ,UKE-mail: [email protected]

Keywords: child abuse (neglect),child protection, empirical research,research methods

Accepted for publication: July 2011

INTRODUCTION

A systematic literature review, commissioned by the(then) Department for Children, Schools and Fami-lies as part of their Safeguarding Children Initiative,examined the evidence on the extent to which practi-tioners are equipped to recognize and respond to theindications that a child’s needs are likely to be, or arebeing neglected. It considered published internationalevidence about the ways in which children and fami-lies signal their need for help, how those signals arerecognized and responded to and whether responsecould be swifter. While the substantive results of thestudy are published elsewhere as a research report tothe government (Daniel et al. 2009) and as issues forpractice (Daniel et al. 2010), the review raised anumber of methodological issues of direct interest to

researchers in child protection, which form the focusof this paper, specifically for those investigating childneglect. These unreported methodological issues areof relevance to both researchers and practitioners inunderstanding the complexities about child neglect.

BACKGROUND

The vision of an integrated approach for children’sservices is at the heart of government policy (DOH2000, 2003, 2004; HM Government 2006; DCSF2007a) and intent (Munro 2010, 2011). Integratedapproaches should be responsive to children’s needs,proportionate and offered on a continuum: universalsupport for all parents and children; targeted supportfor those at risk of not achieving their potential; andresponsive intervention on behalf of children with

doi:10.1111/j.1365-2206.2011.00795.x

1 Child and Family Social Work 2011 © 2011 Blackwell Publishing Ltd

urgent needs for protection (DCSF 2007b). Thecurrent economic climate in the UK is such thatswingeing cuts across the health and social caresectors are widely felt to be impacting on servicesfor those already most vulnerable. It is important toidentify as early as possible children experiencingdisadvantage such as neglect, and to deliver servicesappropriately.

Awareness of child neglect and its consequenceson the development and future well-being of childrenhas increased during the last two decades. During thistime, considerable resources have been deployed totackling the problem, but not always to best effect(Scottish Executive 2002; Berry et al. 2003). Despiteincreased public awareness, the recognition of neglectis inconsistent, and referrals to services are often trig-gered by other events or concerns about vulnerablechildren.

One recurrent manifestation of neglect is that chil-dren do not gain access to universal services – they arenot taken to vital health and dental appointments,compliance with treatment regimes is patchy and theymiss school or are consistently late. Therefore, healthand education professionals play a crucial role in rec-ognizing and responding to such signs that are indica-tive of neglect. Parents of neglected children are oftenwell known to a range of professionals, such as thepolice, staff in substance misuse support agencies,psychiatrists, learning disability advocates and peoplesupporting disabled children. Therefore, it is crucialfor professionals to be alert to indirect signals of prob-lems and to aspects of parents’ lifestyles that couldreasonably be expected to impact adversely upon theirchildren. Children who are neglected are unlikely toexpress the need for or seek help directly from statu-tory agencies (Cawson 2002). Parents of neglectedchildren are also likely to be ill equipped to seek andmake use of formal support services (Faver et al.1999).

This commissioned systematic review of the litera-ture examined the evidence on the extent to whichpractitioners are equipped to recognize and respondto the indications that a child’s needs are likely to be,or are being neglected, whatever the cause. It was onestudy (of 11) that formed the UK government’s widerSafeguarding Children Research Initiative, established tostrengthen the evidence base about child protectionand improve early recognition and intervention (seehttp://tcru.ioe.ac.uk/scri/). Our review consideredpublished evidence about the ways in which childrenand families signal their need for help, how thosesignals are recognized and responded to, and whether

response could be swifter. The operational definitionof neglect for professional practice in England 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. 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 adequate

care-givers)

• Ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s

basic emotional needs. (DCSF 2010, p. 39)

Framed in this way, the definition appears very con-crete – but all definitions are shaped by social factors,culture and values; for example, comparison with theprevious definition shows that substance misuseduring pregnancy is a recent addition, presumably inresponse to current rises in referrals associated withsubstance misuse (DOH 1999).

When undertaking an international review, thenumber of potential definitions of neglect becomeseven wider. Therefore, to keep the study as inclusiveas possible, we did not set out a specific definition ofneglect and kept as broad a definition as possible thatwas centred on the concept of unmet developmentalneed. While this paper focuses on unpacking themethodological issues to inform the internationalresearch agenda on child neglect, we start with anoverview of the study to put this in context.

THE SYSTEMATIC REVIEW

The research questions addressed in the review were:1. What is known about the ways in which childrenand families directly and indirectly signal their needfor help?2. To what extent are practitioners equipped to rec-ognize and respond to the indications that a child’sneeds are likely to be, or are being neglected, whateverthe cause?3. Does the evidence suggest that professionalresponse could be swifter?

The answers to these questions are reported else-where (Daniel et al. 2009, 2010) and are thus notrepeated here.

The method was based on systematic review guide-lines issued by the University of York NHS Centrefor Reviews and Dissemination (2007). We aimed tolocate national and international primary research

An international research agenda for neglect J Taylor, B Daniel and J Scott


studies, theoretical papers and reviews published inEnglish from 1995 to 2005. This was an interdiscipli-nary piece of research focusing on an area where adiversity of professionals such as police, paediatri-cians, social workers, nurses and speech therapistscould be involved.

Following usual review methodology and screeningstages reported in detail elsewhere (Daniel et al. 2009,2010), a total of 686 items of literature were scruti-nized independently by two members of the team.Three key judgements were made at this stage:

• Whether or not the item reported a primary study;

• If so, whether the study was of specific relevance tothe study aims, in which case it was included;

• If not, whether the material was of sufficient theo-retical or contextual value to be of interest.We adopted a broadly inclusive strategy for litera-

ture relating to professional groups that tended to beunder-represented, for example, speech therapists;and for studies involving children with disabilitiesand children of black and ethnic minority origin.We included studies that addressed parental factorsknown to be associated with neglect, such as sub-stance misuse, mental health problems and learningdisabilities. We also included studies where neglectand abuse were conflated if they appeared to be ofparticular relevance to the subject of help seeking orrecognition of need.

Each judgement was compared and discussed. Theinter-rater reliability of this filtering was 94%. Thisreduced the number of studies potentially eligible forthe final dataset to 112, and the full version of eachitem was obtained.

Final inclusion and data extraction

Each study was read in full by one member of theteam using a data extraction form to collate standard-ized information. Studies were ordered according tothe standard hierarchy of evidence for determiningthe relative methodological importance of the studiesidentified (Scharr 2006):

• Systematic review

• Randomized controlled trial (RCT)

• Quasi-experimental

• Cohort study

• Cross-sectional study

• Before-and-after study

• Case series or survey.While the funded nature of the study imposed strict

criteria regarding adherence to such hierarchies forstudies of interventions, we used these only to guide

the questions asked about the strength of the research.We recognize that there is considerable debate in childprotection regarding the primacy afforded RCTs andindeed are sympathetic to these. We were mindfulthat context is crucial throughout.

For all primary studies, judgements of researchdesign, methods and rigour were made using the guid-ance and criteria set out for each type of study. Stan-dard systematic reviews may include only RCTs orother designs deemed by many as more robust in ahierarchy of evidence. However, because of thepaucity of RCTs in this area, and the potential richmaterial in other types of studies, we chose to includegood quality studies of all types and to state the limitsof generalizability in the report (Jones 2004). Figure 1is a summary of the overall review filtering process.

Our quality ratings were based on widely availablecritical appraisal tools (NHS Public Health ResourceUnit 2009), whereby we gave a methodological scoreto all fully appraised papers (n = 112) based on astandardized assessment. A three-point scale was thenused to reflect the overall assessment: (i) we wereconfident that the research was rigorously designedand undertaken, and potential bias had beenaddressed (n = 34); (ii) we were satisfied with the

Create search terms & strategies

20,480 from 16 database searches

16,239 in Endnote library

Remove duplicates

1,532 scrutinised

Hand deletion. (100% agreement)

686 abstracts read independently by 2 reviewers (94% agreement)Details recorded on abstract filter form

574 discarded

846 discarded

Dataset: 112 met criteria. Each article rated 1-3 for methods and usefulness. Studies scoring 3 in either category rejected.Details recorded on article filter form.

Final dataset: 63

Figure 1 The filtering process.



overall design and methods, and attempts to addressbias had been taken, or at the very least, acknowledged(n = 40). Studies that were assigned a rating of 3 didnot satisfy our basic criteria of rigour, or were flawedin some other way, or bias had not been addressed(n = 8). The appraisal sheets used for each studyguided the approbation of the simple score, but weare confident that the same score would have beenreached without the use of standardized checklists.

We also used a three-point rating scale to establishhow useful a paper was in answering our researchquestion. Papers were scored: (i) extremely useful anddirectly relevant to the research question, providinginsight into practitioner recognition of and response tochild neglect (n = 28); (ii) some useful informationabout neglect, but not directly relevant (n = 35); and(iii) very little (if anything) of relevance to the researchquestion (n = 16). It should be noted that this was a verydifficult undertaking, as a number of methodologicallysound papers did not inform the research question (n =11) and had to be rejected. At the same time, many ofthe papers were extremely interesting, but were ofperipheral relevance to the specific research questions.Joint discussion of the usefulness issue was helpful inrefining the process, and we tended to err on thegenerous side for this score. Some of the includedstudies did not focus on neglect as the direct focus oftheir work, but nonetheless provided a wealth of usefuldetail and direct information about neglect.

Twenty-five per cent of the papers were blinddouble-read. Studies that were to be discardedachieved 100% inter-rater reliability.Where there wassome discrepancy between raters on the strength ofmethodology or usefulness, the paper was read by thefull team and a judgement made after discussion. Atthis stage, 14 further papers were reassigned to acategory of ‘interest but not relevant to the review’.

Table 1 shows the breakdown of ratings for the restof the studies. Any study that scored 3 for eithermethodology or usefulness was excluded (n = 19).All the remaining items with a rating of 1 or 2 onboth measures made up the final dataset to be read indetail, analysed and included in the final report. Thefinal dataset for detailed analysis was therefore 63.Information about the samples and research methodsof the 63 studies used in the final analysis are describedelsewhere (Daniel et al. 2009). The full lists of allstudies (both included and excluded) are available inthe same report. Sixteen were reassigned to ‘contextualmaterial’, and 14 to ‘tool assessments’.The pre-final 82studies are used here to shape constructively the inter-national research agenda needed for child neglect.

ISSUES OF QUALITY AND USEFULNESS

General issues

Child neglect is a truly multidisciplinary researchtopic. That is to say, many disciplines have producedexcellent research in this area. The review identifieda wide range of discipline-specific studies that wereincluded in the final dataset: medical physicians werewidely represented, including those from paediatrics,accident and emergency, general practice, psychiatryand surgery. Nurses contributed some excellentstudies, particularly those working in community set-tings. Social workers had a prominent place in thefinal dataset.There were also studies by psychologists,statisticians and epidemiologists, but very few byeducationalists. Although it was not always possible todetermine the researchers’ main affiliation, it is clearthat the topic is of concern to a wide range of profes-sional disciplines. How often the research was itselftruly multidisciplinary was not always clear; however,initial observations would suggest that this is an areathat might benefit from further development. Ouranalysis tends to suggest a monodisciplinary focus inthe main, although choice of journal for publicationwas perhaps a little more multidisciplinary. It mightbe helpful for future research to see more teams ofdoctors, social workers and nurses working together.We know that multidisciplinarity is crucial in childprotection. It seems that every analysis of errors in thesystem highlights lack of communication and collabo-ration between agencies – see, for example, the latestreport on serious case reviews (Ofsted Children’s Ser-vices and Skills 2011). This singular discipline focusseems to be repeated in research studies, and we rec-ommend adjustment to diversity in research teams toreflect the reality of neglect.

Table 1 Breakdown of the ratings for the studies beforethe final selection for the dataset

Quality rating Usefulness rating N

3 3 53 2 33 1 02 3 72 2 222 1 111 2 131 3 41 1 17



From the papers themselves, it was often difficultto ascertain the researchers’ professional discipline:psychologists may be employed in a school of nursing;sociologists may be affiliated with medical schools,and so forth. Affiliation therefore may not be a directmeasure of discipline, but does give an overall impres-sion as to where the research in this area is concen-trated. It can be seen that the majority of research inthis area that met our criteria has been undertakenin the USA or the UK. Mainland Europe also con-tributed studies from Finland, Spain, Sweden andDenmark. Despite their size, research cultures andEnglish language, there was only one Australian studyand one Canadian study. There was none from NewZealand or Hong Kong. Although we had restrictedour search to articles published in the English lan-guage, we had expected a wider international cover-age. Cultural and funding issues may explain some ofthis variance, but neglect is an issue for every country.It may be that neglect is subsumed into an overallchild welfare or joint abuse and neglect programmes.But neglect is insidious and under-researched. Sepa-rating this out and focusing specifically on it in differ-ent countries would enhance our understanding ofhow to respond to neglect earlier and more efficiently.It will also tell us more about the contextual differ-ences in welfare systems, surveillance data andresearch endeavour.

Issues of quality

The review raised a number of quality issues. Whilethese are not unusual in systematic reviews on topics

that are not concerned primarily with interventions,identifying them is important both for the conclusionsand in directing future research. Despite an initial1532 potentially relevant studies, the paucity ofexplicitly focused studies in this area was striking.

The strongest studies

The strongest studies, as might be expected, were welldesigned with sufficient detail to extrapolate both themethods of data collection and the analytic methods.Conclusions were based clearly on the data, andmethods to address bias were transparent. The stron-gest studies tended to use large samples, statisticallyderived to detect population changes at a reasonablesignificance. Angeles Cerezo & Pons-Salvador (2004),for example, included 181 staff from health and socialservices in Spain in Phase One of their study, with 251teachers in Phase Two; Lagerberg (2001) distributed1601 questionnaires, identifying 6044 children aboutwhom child health nurses ‘were anxious’. Table 2 pre-sents an analysis of the sample sizes used in thestudies. The strongest studies:

• were well-designed RCTs (only two: MacMillanet al. 2005; Barlow et al. 2007);

• used prospective longitudinal designs (for example,the studies by Dubowitz and colleagues (Dubowitzet al. 2002, 2004a, 2004b, 2005a, 2005b) as partof the Longitudinal Studies of Child Abuse andNeglect series – a consortium of five ongoing lon-gitudinal studies examining the antecedents andsequelae of child abuse and neglect; or

Table 2 Analysis of sample sizes

Population studiedless than 100

Population studied isbetween 100 and 499

Population studied isgreater than 500 Total

Children under 18 Spain 1 UK 2 Spain 1 13UK 1

USA 4 USA 4Parent(s) Canada 1 Egypt 1 USA 2 13

UK 2UK 1 USA 6

Adult(s) USA 1 UK 1 3USA 1

Families Australia 1 Canada 1 UK 1 16UK 1

UK 1 USA 9 USA 2Professionals Finland 2 Finland 1 Denmark 1 15

UK 4 Sweden 1USA 1 UK 1

USA 4Professionals and families UK 1 USA 2 3Total 13 36 14 63



• were rigorously undertaken qualitative studies(Appleton & Cowley 2004) that used clear theoreti-cal frameworks and innovative methods.

Excluded studies

Although findings from studies that scored a 3 (poor)for methodological quality were not included in ourstudy’s conclusions, we did identify some commonmethodological issues from the excluded studies thatcould help inform further research:

Secondary sources were used. There was a tendencyfor poorer studies to use a range of proxy measuresrather than direct observation of the outcome ofinterest (i.e. neglect). For example, studies typicallyaimed to capture aspects of parent and/or child char-acteristics, development and behaviour in order tolook at relationships between such factors and out-comes for children. However, in a number of studies,the primary data were social worker assessment ofthese factors. These data were sometimes collectedvia a questionnaire designed specifically for thestudy; on other occasions, the researchers extractedthe data from written case notes. Without directmeasurement of child and parent experience andcharacteristics, the resulting conclusions and practicesuggestions would need to be interpreted withcaution. If we are to enhance the quality of researchin neglect, then direct observations and accountswill likely yield more robust data than second-handaccounts. Social work notes and assessments may beinconsistent and unreliable. While it is not alwayspossible to gain first-hand access to the phenomenonunder scrutiny, it is important to make an effort,and to record why the line of least resistance hasbeen chosen.

Small studies. While child protection research can bedifficult, it is not impossible to gain adequate samplesize (as evidenced in the stronger studies). Wherestudies were reliant on statistical methods to detectsignificance, they were inadequately powered, norwere confidence intervals reported correctly. Many ofthe smaller studies were very strong studies indeed.But as a general trend, there is a tendency in theresearch that tells us about neglect to go small, or tomake statistical claims that went beyond the data.Dependent on the research question, of course, weurge larger studies where possible, and where these arelarger, to seek advice about the numbers needed todraw accurate conclusions.

Retrospective designs. Prospective designs were few, yetthese have the most likelihood of answering questionsconcerning noticing and helping the neglected child.One of our main findings is that research in this areatends to focus on children who have already beenidentified as neglected. The opportunity therefore togather meaningful information on how they are iden-tified, how they come to attention, is largely lost. Atbest, we, are reliant on good quality case notes ormemory, both of which have been found to be notalways reliable. It is difficult to be sure whether thisis an issue for research funders, who may not bewilling to commission expensive prospective longitu-dinal studies in child neglect, or whether researchersare just not applying for research grants in this area.The need for good quality prospective studies cannotbe overemphasized.

Types of studies. Studies used a range of methods,both qualitative and quantitative. For both types ofstudy, as described previously, there are criteria forrigour and validity that were often not met. As inmany systematic reviews where the focus is on widersocial issues, there are unlikely to be many RCTs(we found only three). This is to be understood, asgenerally this review was not focusing on studiesconcerned with the effectiveness of interventions.However, for intervention studies, RCTs do havemuch to offer and are often considered the gold stan-dard. Whether this is, in fact, appropriate in childprotection research is the subject of debate; nonethe-less, many of the studies that attempted to evaluateinterventions were small scale, used conveniencesamples and were retrospective. If we are to improvethe evidence base for neglect, then we need to givesome consideration at least to larger studies, andwhere appropriate, to RCTs. The limitations of ret-rospective studies are sometimes outweighed by prag-matic constraints or researcher preference. Rarely canthere be an excuse for small convenience samples. Inaddition, however, the problem might be that fundingin child protection, especially neglect, is diverted byinvesting money into processes such as inspection,rather than funding high-quality research that helpsus understand the problem. Moreover, there is a lackof coordination across the UK around such research,sometimes leading to mixed messages and certainlyleading to missed opportunities. Three small studiescould have been larger and more meaningfultogether. If we are to be serious about understandingthe issues that bring neglected children to the atten-tion of professionals, then we need to be serious



about undertaking the most rigorous research that ispossible.

Issues of usefulness

Although we found a wealth of information to informthe study’s objectives, very few studies were designeddirectly to explore how practitioners recognize childneglect, or how they then respond. This explains tosome degree the small size of the final dataset withwhich we were left. Most studies were designed withother primary objectives, and although we were ableto extrapolate useful information, there is clearly agap in the research. For example, Coohey andZhang’s (2006) study looked at the presence of menin circumstances of chronic neglect, but told us littleabout the recognition or response to neglect; May-Chahal & Cawson (2005) described the NationalSociety for Prevention of Cruelty to Children preva-lence study of maltreatment, providing helpful overalldata about the pervasiveness of abuse and neglect,but we were unable to elicit much of relevance to thequestions we wanted to answer; and Narayan et al.(2006) examined the training of paediatriciansaround neglect, which was interesting, but again, theprimary research objective was not concerned withidentification or response. We were convinced insome cases that there would have been useful infor-mation to inform our question from data collectedduring these studies, but eliciting it from publicationswith a different focus was problematic. We identifiedsome common threads in the studies that did notmake it into our final dataset because of their differ-ent focus, but were still helpful in determining thefuture research agenda on noticing and helping theneglected child.

Focus on factors associated with neglect

It appears from our findings that there is a hugeemphasis in research on exploring the factors thatare associated with neglect. Indeed, the majority ofretrospective studies were concerned with the mea-surement and examination of associated risk factors(such as maternal sensitivity, maternal mental health,alcohol and substance misuse, poverty). However,there was a gap in precise exploration of the waysin which a population risk translates into a specificrisk for a specific child and the best way for pra-ctitioners to recognize potential harm. We alsoidentified a large body of literature whose primaryobjectives were to develop and test risk-assessment

tools, sometimes for predictive purposes. While thiswork is extremely interesting, there is less attentionto the issue of which population the tools are toapplied to in practice, at what stage and by whom.There is little research into their effectivenessin leading to improved outcomes for neglectedchildren.

Conflation of categories of child maltreatment

Many studies conflated child abuse and neglect as‘maltreatment’. The findings were often reported insuch a way as to make it impossible to extract issuesrelating to child neglect separately from physical,sexual or emotional abuse. Sidebotham & Heron’s(2003) study, for example, was methodologicallystrong, but was rejected on our criteria of usefulnessbecause although the researchers were concerned withthe characteristics of children who were later mal-treated, the analysis presented in their paper did notseparate different categories of maltreatment. It wastherefore impossible to determine which characteris-tics were concerned only with neglected children.Sabol et al.’s (2004) study, another methodologicallystrong paper, used innovative methods of life tables tocompare maltreatment records with census data in theUSA. They discovered that both African-Americanfamilies and city dwellers were those most likely to beidentified as maltreating. However, the study wasrejected from our final analysis because there was noseparation of neglect in the published data, and itcould not inform our question. Spencer et al. (2006)provided interesting and pertinent information onmaltreatment of children with disabilities. Again, thestudy was scored strongly for methodology, and thepaper reported that children with disabilities are atincreased risk of abuse and neglect. Nonetheless, thestudy was excluded from the final dataset as abuse andneglect were not reported separately. A simple buthugely important recommendation is to separate(where possible) abuse from neglect when reportingfindings from research.

High degree of heterogeneity

A wide variety of outcome measures were used in the63 studies, making it difficult to undertake meaningfulcomparisons. We identified more than 70 separatemeasurement tools across the included studies, withmost studies using more than one or a battery. Themost popular of these included:



• Child Abuse Potential Inventory (CAPI) – fivestudies;

• Child Well-Being Scales (CWBS) – eight studies;

• Child Behaviour Checklist – five studies; and

• Home Observation of the Environment – sixentries.Most measures were used in a maximum of two

studies, and, in many cases, the measures used wereeither developed by the researchers themselves for thestudy, or were relatively unknown. Reliability andvalidity scores, especially on studies designed by theindividual researchers, were not given in the poorerstudies. There was heavy reliance on Child ProtectiveServices data or referrals to complete the measures,raising questions of accuracy, reliability and validity –especially across states and authorities. Even wherevalidated and reliable tools were used (e.g. CWBS),these are problematic. First of all, many of these arenot without their critics. The CAPI, for example, hasbeen highly criticized in a number of reports. Tayloret al. (2008) have argued that the CAPI has beenshown to be methodologically, theoretically andethically flawed. Second, the application of theoutcome measures was applied to different popula-tions, under different circumstances, and it wouldtherefore be disingenuous to compare the results of,for example, a study with drug-abusing parents in theUSA with one in Sweden that was focusing on chil-dren with disabilities. There is useful work that couldbe done to collate the range of child protection mea-sures that are available, and to provide criticalcomment on their validity and reliability. This hasbeen done in disease (Bowling 1995) and in quality oflife measures (Bowling 1997), for example. A similarendeavour in measures for child protection would beenormously helpful.

Meta-analysis and combined studies

Heterogeneity was not confined only to outcomemeasures. Populations varied considerably, with widevariance in sampling criteria and techniques. Somefocused on child issues, some on parental or environ-mental issues and some on professional reporting.Even within such broad groupings, there was enor-mous heterogeneity. The possibilities for statisticalmeta-analysis were therefore extremely limited. Whilemeta-analysis likewise has its critics, it would be oneway to collate a number of necessarily small studies.The wide range of outcome measures, however,means that pooling of data is not something that canbe considered.

Definitional issues

As noted earlier, there has been much debate in theliterature in recent years concerning the definitionsand subsequent operational translations of child abuseand neglect. It was not surprising, therefore, to find arange of definitions for neglect. For the purposes ofgauging methodological rigour, the use of different orunstated definitions makes comparison very difficult.There was a wide variation in the focus of neglect instudies that made it difficult to draw comparisons.For example, 17 studies were concerned with issuesregarding the child, while 28 focused on parentfactors. While 11 studies focused on broader ecologi-cal issues, 31 studies were focused on professionalissues (there was some overlap between these, withsome studies focused on more than one issue). Theevidence base for our first question (What is knownabout the ways in which children and families signalfor help?) is largely provided from studies dealing withchild, family and social characteristics. The second(How well are practitioners equipped?) and third(Could response be swifter?) questions are addressedprimarily from the largest single group of studies,those that focused on professional issues. Interest-ingly, the greater proportion of studies on professionalissues related to the health profession.

Messages from the analysis of qualityand usefulness

When interpreting the evidence from this review, it isimportant to take account of its limitations. Any fil-tering process entails discarding potentially valuableevidence.The frequent conflation of neglect and otherforms of child abuse as ‘maltreatment’ means thatstudies that touched on factors relating to the recog-nition of neglect in the context of other forms of abusemay have been missed. We deliberately chose a broadfilter and erred on the side of inclusion.We were awarethat much of the evidence was likely to emerge from abroad range of research designs, including qualitativestudies. However, a broad filter includes evidencethat may have limits of validity, reliability andgeneralizability.

Much of the evidence collated was collected incountries other than the UK, most commonly in theUSA. This raises questions about the extent to whichthe lessons are transferable to the UK because ofdifferent organizational contexts and different levelsand types of training for different professions. Ourview is that the evidence drawn from studies focusing



specifically on systems should be transferred withmore caution than the evidence that focuses more onparenting capacity and children’s development.

With these limitations in mind, a number of keyissues emerged from our analysis of the quality andusefulness of the included studies. Some of the chal-lenges of methodology mirror challenges in practice.The dilemma about whether to focus on parentbehaviour, child outcomes or a mixture of both isshared between research and practice. Across allthe studies, a vast range of standardized, customizedand proxy measures were employed, indicating thebreadth and complexity of neglect and its antecedents.The preoccupation with substantiated neglect andwith system processes also mirrors practitionerexperience.

The analysis of included studies showed that defi-nitions of neglect are slippery. Although based on theevidence about factors that impact on child develop-ment, the operational definition for England squarelylocates neglect as caregiver omission – unlike many ofthe research studies included in this review, it does notlocate the caregiver within a wider socio-economiccontext. Thus, it appears a little out of step with theemergent English policy context that has taken awider ecological perspective on safeguarding. Forexample, the Framework for Assessment (DOH 2000) isbuilt around an ecological model, and The Children’sPlan (DCSF 2007a) clearly identifies the extent towhich parenting is compromised by disadvantage andadversity and outlines strategies to provide timelysupport. The interim report of the Munro Review ofchild protection (2011) is part of a national drive toimprove the quality of child protection services, but itis unlikely that this wider perspective will change.

The child protection system should be child-centred,

recognising children and young people as individuals with

rights. . . . that the child protection system understands its

dual mandate to support families and help them provide

adequate care and to intervene authoritatively when children

and young people need protection.The general public and all

who work with children, young people, families and carers

have a responsibility for protecting children and young people

(Munro 2011, p. 19).

The strongly rated studies provide good models forthe development of further research. The limitationsin the research on neglect were that studies tended tobe monodisciplinary, to be preoccupied with profes-sional issues and formal protective systems, to use awide range of proxy measures and case records andto conflate neglect and abuse. To further the researchagenda on neglect, there is a need for more robustly

designed, prospective, multidisciplinary studies thatmove beyond a focus on formal systems towards afocus on the early indications of emergent neglect.

The evidence from the studies we analysed suggeststhat many tools developed for predicting harm cannotdiscriminate sufficiently, and that the emphasis shouldbe more upon assessment of need. Concerns havepreviously been raised about the accuracy of screeninginstruments to identify children who will be abused orneglected (Taylor et al. 2008).The problem lies not somuch with the tools themselves, but with the dangersinherent in relying on the predictive powers of suchtools. No tools can guarantee against false positives orfalse negatives, and therefore practitioners will alwaysneed the skills and knowledge to make sound profes-sional judgements, even if they make use of tools toassist with their assessments. Plans for Health Visitingset out in Facing the Future propose a role in intensivesupport for the most vulnerable children and families– again this role must be underpinned by assessmentrather than prediction (DOH 2007). Brandon et al.(2008) also suggest that assessment tools cannot ‘sub-stitute for sound professional judgement’. However,they indicate that while risk assessment tools maynot improve risk assessment, tools to assist with theanalysis of information collected in assessmentsmay be helpful. Their findings in relation to seriouscase reviews, in conjunction with the evidence in thisreport, should encourage practitioners to look beyondpresenting problems when families are in crises.

CONCLUSION

In summary, therefore, the messages for research intonoticing and responding to the neglected child are:

• There is a need for more robustly designed,prospective, multidisciplinary studies that movebeyond a focus on formal systems towards a focuson the early indications of emergent neglect.

• Further research is needed into the conditions thatsupport parents and children to seek help whenthere is a potential for neglect.

• The preponderance of research into maternalcircumstances must be complemented by moreresearch on the paternal experience.

• The research priority should move from a preoccu-pation with prediction towards examining thefeatures that contribute to accurate assessment andplanning.

• Research with children at risk of neglect should nowfocus on examining parents and children’s views,help-seeking behaviour and effective intervention,



rather than continuing to delineate the effects ofneglect.

• There is a need to build on the evidence aboutthe skills health visitors have in recognizing neglectwith research into the most effective immediate andlonger term response.

• There is a need for more research on the role of thepolice and a comprehensive programme of researchaimed at providing schools and teachers with theevidence they need to underpin the pivotal role thatis envisaged for them in safeguarding children fromneglect.

• The assertions about the importance of integratedpractice with neglect need to be supported byempirical research into the details of how best toachieve it.

• More research is required into the views, experi-ences and expectations of parents and childrenwhere there is a risk of neglect.

• There is potential for research that examines theprocesses of integrated working, rather than the largenumber of studies that focus on team structures.

• Intervention and prospective studies that focuson families where there is substance misuse couldoffer unique insights into the balance between childneglect and parenting capacity.The studies we reviewed were driven by their

authors’ commitment to producing evidence thatwould lead to a better response to neglected children.A considerable amount of intellectual and emotionaleffort has been invested by many researchers, researchparticipants and agencies hosting research. The accu-mulation of evidence as a result of this research offersa firm base for the development of more responsiveservices.There will always be a place for more researchaimed at delineating causal pathways and details ofinteractions between factors associated with neglectand child outcomes. In the meantime, there is enoughevidence to guide practice, while designing futureresearch to even more clearly help us understand howbest to recognize and respond to neglected children.

References

Angeles Cerezo, M. & Pons-Salvador, G. (2004) Improving

child maltreatment detection systems: a large-scale case study

involving health, social services, and school professionals. Child

Abuse & Neglect, 28, 1153–1170.

Appleton, J.V. & Cowley, S. (2004) The guideline contradiction:

health visitors’ use of formal guidelines for identifying and

assessing families in need. International Journal of Nursing

Studies, 41, 785–797.

Barlow, J., Davis, H., McIntosh, E., Jarrett, P., Mockford, C. &

Stewart-Brown, S. (2007) Role of home visiting in improving

parenting and health in families at risk of abuse and neglect:

results of a multicentre randomised controlled trial and eco-

nomic evaluation. Archives of Disease in Childhood, 92, 229–233.

Berry, M., Charlson, R. & Dawson, K. (2003) Promising prac-

tices in understanding and treating child neglect. Child and

Family SocialWork, 8, 13–24.

Bowling, A. (1995) Measuring Disease. Open University Press,

Buckingham.

Bowling, A. (1997) Measuring Health. A Review of Quality of Life

Measurement Scales. Open University Press, Buckingham.

Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R.,

Dodsworth, J. et al. (2008) Analysing Child Deaths and Serious

Injury through Abuse and Neglect: What CanWe Learn? A Bien-

nial Analysis of Serious Case Reviews 2003–2005. Department

for Children, Schools and Families, London.

Cawson, P. (2002) Child Maltreatment in the Family:The Experi-

ence of a National Sample ofYoung People. NSPCC, London.

Coohey, C. & Zhang, Y. (2006) The role of men in chronic

supervisory neglect. Child Maltreatment, 11, 27–33.

Daniel, B., Taylor, J. & Scott, J. (2009) Noticing and Responding to

the Neglected Child. DCSF and DH, London.

Daniel, B., Taylor, J. & Scott, J. (2010) Recognition of neglect

and early response: overview of a systematic review of the

literature. Child & Family SocialWork, 15(2), 248–257.

Department for Children, Schools and Families (DCSF)

(2007a) The Children’s Plan: Building Brighter Futures. DCSF,

London.

Department for Children, Schools and Families (DCSF)

(2007b) Staying Safe: Action Plan. DCSF, London.

Department for Children, Schools and Families (DCSF) (2010)

Working Together to Safeguard Children. A Guide to Inter-agency

Working to Safeguard and Promote theWelfare of Children (Revi-

sion). DCSF, London.

Department of Health (DOH) (1999) Working Together to Safe-

guard Children.A Guide to Inter-agencyWorking to Safeguard and

Promote theWelfare of Children. DOH, London.

Department of Health (DOH) (2000) Framework for the Assess-

ment of Children in Need and Their Families. The Stationery

Office, London.

Department of Health (DOH) (2003) Every Child Matters. TSO,

London.

Department of Health (DOH) (2004) The National Service

Framework for Children, Young People and Maternity Services.

DOH, London.

Department of Health (DOH) (2007) The Government Response

to Facing the Future: A Review of the Role of Health Visitors.

DOH, London.

Dubowitz, H., DePanfilis, D., Boyce, C.A. & Runyon, D. (2004a)

Special issue: child neglect research: initial papers from the

NIH and ACYF Neglect Projects – Issue I – Introduction.

Child Maltreatment, 9, 343–343.

Dubowitz, H., DePanfilis, D., Boyce, C.A. & Runyon, D. (2005a)

Child neglect research: initial papers from the NIH and ACYF

Neglect Projects – Issue II. Child Maltreatment, 10, 91–206.



Dubowitz, H., Newton, R.R., Litrownik, A.J., Lewis, T., Briggs,

E.C., Thompson, R. et al. (2005b) Examination of a concep-

tual model of child neglect. Child Maltreatment, 10, 173–189.

Dubowitz, H., Papas, M.A., Black, M.M. & Starr, R.H. (2002)

Child neglect: outcomes in high-risk urban preschoolers.

Pediatrics, 109, 1100–1107.

Dubowitz, H., Pitts, S.C. & Black, M.M. (2004b) Measurement

of three major subtypes of child neglect. Child Maltreatment, 9,344–356.

Faver, C.A., Crawford, S.L. & Combs-Orme, T. (1999) Services

for child maltreatment: challenges for research and practice.

Children andYouth Services Review, 21, 89–109.

HM Government (2006) Working Together to Safeguard Children:

A Guide to Inter-agency Working to Safeguard and Promote the

Welfare of Children. HM Government, London.

Jones, M.L. (2004) Application of systematic review methods

to qualitative research: practical issues. Journal of Advanced

Nursing, 48, 271–278.

Lagerberg, D. (2001) A descriptive survey of Swedish child

health nurses’ awareness of abuse and neglect. I: characteris-

tics of the nurses. Child Abuse & Neglect, 25, 1583–1601.

MacMillan, H.L., Thomas, B.H., Jamieson, E., Walsh, C.A.,

Boyle, M.H., Shannon, H.S. et al. (2005) Effectiveness of

home visitation by public-health nurses in prevention of the

recurrence of child physical abuse and neglect: a randomised

controlled trial. Lancet, 365, 1786–1793.

May-Chahal, C. & Cawson, P. (2005) Measuring child maltreat-

ment in the United Kingdom: a study of the prevalence of

child abuse and neglect. Child Abuse & Neglect, 29, 969–984.

Munro, E. (2010) The Munro Review of Child Protection.Part One:

A Systems Analysis. Department for Education, London.

Munro, E. (2011) The Munro Review of Child Protection. PartTwo:

The Child’s Journey. Department for Education, London.

Narayan, A.P., Socolar, R.R.S. & St Claire, K. (2006) Pediatric

residency training in child abuse and neglect in the United

States. Pediatrics, 117, 2215–2221.

NHS Centre for Reviews and Dissemination (2007) Review

methods and resources. Available at: http://www.york.ac.uk/

inst/crd/crdreview.htm (accessed 2 May 2008).

NHS Public Health Resource Unit (2009) Critical appraisal

skills programme [online]. Available at: http://www.sph.nhs.uk/

what-we-do/public-health-workforce/resources/critical-

appraisals-skills-programme (accessed 14 April 2009).

Office for Standards in Education (Ofsted) Children’s Services

and Skills (2011) The Voice of the Child: Learning Lessons from

Serious Case Reviews. Ofsted, London.

Sabol, W., Coulton, C. & Polousky, E. (2004) Measuring child

maltreatment risk in communities: a life table approach. Child

Abuse & Neglect, 28, 967–983.

Scharr, S. (2006) Hierarchy of evidence [online]. Available at:

http://www.shef.ac.uk/scharr/ir/units/systrev/hierarchy.htm

(accessed 9 December 2006).

Scottish Executive (2002) It’s Everyone’s Job to Make Sure I’m

Alright: Report of the Child Protection Audit and Review. TSO,

Edinburgh.

Sidebotham, P. & Heron, J. (2003) Child maltreatment in the

‘children of the nineties’: the role of the child. Child Abuse &

Neglect, 27, 337–352.

Spencer, N., Wallace, A., Sundrum, R., Bacchus, C. & Logan, S.

(2006) Child abuse registration, fetal growth, and preterm

birth: a population based study. Journal of Epidemiology and

Community Health, 60, 337–340.

Taylor, J., Baldwin, N. & Spencer, N. (2008) Predicting

child abuse and neglect: ethical, theoretical and metho-

dological challenges. Journal of Clinical Nursing, 17, 1193–

1200.



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