Understanding childhood neglect for social care services - PowerPoint Presentation

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Understanding childhood neglect for social care services

Antonia BifulcoProfessor of Lifespan Psychology & Social ScienceCentre for abuse and trauma studiesMiddlesex University, Londona.bifulco@mdx.ac.uk

Isle of Man Safeguarding Forum September 2017

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Centre for Abuse and Trauma Studies (CATS)

www.cats-rp.org.ukAn interdisciplinary research centre, spanning Psychology and Criminology.Focus on both academic and applied research.

Investigation of abuse and trauma from family, victim and perpetrator perspectives. Working with psychological, social care and forensic services.Run assessment trainings for child protection, adoption and residential care.

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Aim of session

What constitutes neglectShort and long term impacts of neglectPractice implications - multiagency working; early help; resilience Models to aid practice; what works

Key messages

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IoM Neglect pathway – issues to be addressed

(Policy document Oct 2017)How can the prevalence of neglect be established and tracked to demonstrate the impact of support and intervention?Ensure Neglect training is linked to competency framework, identified, commissioned and delivered to target professional audiences – awareness, signs, symptomsEnsure specific neglect assessment and intervention tool are available and staff trained in them.

18/11/2013`A1QA2ND22

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Neglect…. and more

Daniel Pelka was a four-year boy from the West Midlands who died in March 2012 from an acute head injury. For at least six months before his death, Daniel suffered from starvation, neglect and physical abuse. A sibling felt compelled to hide food for him while he was being starved by his parents.Daniel was denied food, force-fed salt, held under the water in a bath until unconscious and regularly beaten. He was also imprisoned in a box-room and died alone in the dark from a head injury.The mother and stepfather had a long-standing history of domestic violence and substance misuse.In August 2013, Daniel’s mother and stepfather were convicted of murder and sentenced to 30 years in prison.

18/11/2013

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Service failure…

Police were called to 26 separate incidents at the family home many involving domestic violence and alcohol abuse. Excuses made by Daniel's "controlling" mother were accepted by agencies. Professionals needed to "think the unthinkable" and act upon what they saw, rather than accept "parental versions"Daniel's "voice was not heard" because English was not his first language and he lacked confidence. No record of "any conversation" held with Daniel about his home life, his experiences outside school, or of his relationships with his siblings, mother and her partnersThere were "committed attempts" by his school and health workers to address his "health and behavioural issues" in the months before his death. But "too many opportunities were missed for more urgent and purposeful interventions"

Two of those chances were when Daniel was taken to an accident and emergency department with injuriesNone of the agencies involved could have predicted Daniel's death.18/11/2013

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What constitutes neglectPrevalenceDefinitionsSeverity

72/7/2013

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Neglect

A persistent failure to meet a child’s basic physical and/or developmental needs. Includes failing to provide for a child’s health, education, emotional development, nutrition, clothing, shelter, safety and safe living conditions, and includes exclusion of the child from the home and abandonment. Differentiated from poverty.Neglect is defined developmentally, so indicators can change by age. For unborn child neglect may occur during pregnancy as a result of maternal substance abuse.Development means physical, intellectual, emotional, social or behavioural developmentDCSF, 2010, p.38

18/11/2013

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Definition cont..

Neglect includes: • a parent’s or guardian’s failure to provide adequate food, clothing and shelter, • failure to protect a child from physical or emotional harm, or danger • failure to ensure that the child has adequate supervision • failure to ensure the child has access to appropriate medical care and treatment• unresponsiveness to a child’s basic emotional needs

18/11/2013

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Prevalence

Registrations to child protection registers England 2015-16

(n=50,310)

%

Neglect

46

Emotional abuse

35

Physical abuse

8

Sexual abuse

5

Multiple

6

Department for Education (2015) Characteristics of children in need in England, 2014-15. London: Department for Education (

DfE

).

Neglect most prevalent

maltreatment

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Registrations – comparison previous years

2002

%

2006

%

2015

Neglect

39

43

46

Emotional abuse

17

21

35

Physical abuse

19

16

8

Sexual abuse

10

8

5

DfES 2006, 2015

Neglect increasing somewhat, whilst

Other maltreatment declining

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NSPCC report – community lifetime prevalence (2011)

Maltreatment type

Total under age 11

Total age 11-17

Total age 18-24

 

Neglect

 

5% (130)13% (229)

16% (303) Emotional Abuse

4% (74)

7% (116)7% (131)

Physical violence 

1% (34)7% (119)8% (159)

Maltreatment - mixed 

7% (188)21% (358)23% (436)

Sexual abuse 

0.1% (2)0.1% (2)

1% (2)

All maltreatment 9% (229)

22% (379)

25% (465)

18/11/2013

Interviews 2,275 young people aged 11-17 years and 1,761 young adults aged 18-24 years about experiences of neglect or abuse.

Neglect also most common

maltreatment reported in

community, not accessing

services

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Assessing neglect

Practice requirementsResearch approaches

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CHILD

Safeguarding &

promoting

welfare

Assessment Framework (2000)

A map of relevant data to be collected

Health

Education

Identity

Family & Social

Relationships

Social Presentation

Emotional &

Behavioural Development

Selfcare Skills

CHILD’S DEVELOPMENTAL NEEDS

PARENTING CAPACITY

FAMILY & ENVIRONMENTAL FACTORS

Basic Care

Emotional Warmth

Stimulation

Guidance &

Boundaries

Ensuring Safety

Stability

Wider Family

Housing

Employment

Income

Family’s Social

Integration

Family History

& Functioning

Community

Resources

CHILD

Safeguarding &

promoting

welfare

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Neglect signsAppearance – smelly, dirty, not properly clothed, hungry

Health – no treatment illness, injury, poor dental careHousing and family – unsuitable housing, left alone unsupervised, taking on carer roleBehaviour – withdrawn, change behaviour, anxious, clinging, depressed, self harm, eating problems, wets bed, self harm, aggressive, nightmares.

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Research-based assessment:

The Childhood Experience of Care and Abuse (CECA) measureUsed extensively in research internationallyA version for social workers includes definitions, indicators andRatings of severity with clear examplesThe instrument has a factual and investigative orientation. High reliability and validity.

Experiences recorded chronologically and a calendar and summary report produced.

www.cecainterview.com

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CECA Neglect

Material neglect and indifference shown by parents and carers to child in relation to: material care (being fed, clothed)regular household routines

health & hygiene & medical caresocialisation & friendships, school work, career optionsemotional needs & supportThese combined in a single score.

Severity

determined by pervasiveness of neglect and number of areas of neglect

Rated:

Marked ] Severe

Moderate ] Severe

3. Mild4. Little/none ScoredFor each different parent figure

For changes in severity over time

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CECA Neglect – marked historical maltreatment

Quote:

We were basically neglected. We had to steal food from shops because we were hungry and had no money. Mum left us alone in the evening, then she would roll in drunk. It was very rare we had new clothes, the neighbours might give us some. Mum never remembered my birthday or gave me a card or present. I knew I could never go to her if I was in trouble.

No one made us breakfast – you did it yourself if there was food there. Sometimes we ‘d oversleep and it was too late to have breakfast…We bathed ourselves, with two of us in the bath. Mum never washed our clothes, we took them down to the launderette. She used to keep me off school Friday to do the washing.

Context – mother’s alcohol abuse; discordant parental relationship; father often absent; lived off benefits.

Bifulco & Moran 1998: Wednesday’s Child, Routledge

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Maltreatment scales related to poor care

(factor analysis)

CECA scales

Poor care

factor

Neglect

.80

Antipathy

.63

Role reversal

.58

Physical abuse

Psychological abuse

.47

.36

Sexual abuse

.31

Neglect is closely associated with other lack of care and abuse experiences

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Neglect and disadvantage

Disadvantage (.42)Parental loss (.35)Parental Conflict (.20)

Loneliness (.51)Helplessness (.43)Shame (.46)Felt inferiority (.22)Social

Psychological

Neglect is highly related to social disadvantage, parental relationship

and negative ‘internalising’ psychological impacts

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Long term consequences

Biological impactsPsychological impacts

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Biological findings

Cortisol – stress hormone HPA)Early adversity relates to stress habituation and difficulties in behavioural and emotional regulationBrain – restricted developmentSmaller overall brain size (smaller with earlier onset of trauma)Smaller corpus callosum (CC) – white matter in the brain controls arousal, emotion and higher cognitive abilities.Smaller hippocampus

Genetics – Maltreatment & MAOA genotype – increased risk for antisocial behaviour. Poorly regulated neural activity to threat cues with increased aggressive response.McCrory et al 201718/11/2013

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22/09/2017

Heidelberg seminar

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Long term psychological impacts

The London studies

Adult women studied over a number of years together with their adolescent offspring

Childhood neglect, physical and sexual abuse studied

Lifetime psychological disorder

Attachment framework used to conceptualise these findings.

Bifulco et al 1998; Brown et al 1990; Bifulco & Moran 2012

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Severity ratings of abuse

The more severe the neglect in childhood, the higher the association with adult depression.Grading experience is important…

Severity of neglect in childhood

% adult depression

Severe

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Adolescents: Neglect or abuse and clinical disorder

in 12 months (276 community-based young people aged 16-25)

CECA ‘severe’ experience

Odds ratio

Clinical disorder

P<

Neglect

5.27

.0001

Antipathy mother

3.16

.001

Antipathy father

2.49

.01

Physical abuse

5.03

.0001

Sexual abuse

7.88

.0001

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Neglect and deliberate self harm

- adolescent sample21% of the high risk offspring exhibited deliberate self-harm – these highly related to presence of emotional or behavioural disorder:

Suicidal ideation/plans/attempts (52%) Self mutilating (48%):DSH many times more likely with lack of care experience

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Parent maltreating & disorder in adolescents- mothers

(Odds-ratios shown)

Antipathy

From mother

Neglect from

mother

Physical abuse

from mother

Depression

in adolescent

x 4.16

x 4.08

x 2.70

Only mothers maltreatment

models depression in offspring

Antipathy

From father

Neglect

from father

Physical abuse

From father

Substance

Abuse in

Adolescent

x 3.1

x 2.1

x 2.9

Only maltreatment from father models substance abuse

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Resilience

22/09/2017

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Protective factors are those which are active in the presence of risk factors – to buffer or moderate the impact.

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22/09/2017

Palermo Conference

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Resilience factors aged 16 -adolescent sample

Support from friend - 56%

Positive peer group - 68%

Positive school characteristics - 66%

High academic attainment - 51%

High felt competence as student - 66%

Most young people (80%) had at least one

positive factor aged 16 of:

40% had at time of interview either:

Clearly Secure attachment style - 30%

Markedly high self acceptance - 14%

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Positive experience outside the home– self esteem and security

Self acceptance

Secure attachment

Support from friend

 

 

.04

.23 (**)

Positive character of peer group

 

.17 (*).19 (*)

Positive character of school 

.32 (**).21 (**)

High academic attainment .08

.17 (*)

22/09/2017** significant at the 0.01 level

* significant at the 0.05 level

Support and schoolImportant correlates ofSelf esteem and secure attachment style

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Positive experience and (absence) case disorder

% case disorder

p<.01

p<.07

p<.01

p<.001

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Practice implications

Interventions; early helpAssessment; multiagency workingCharting change

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RISK FACTORS

List actual and/or believed harm

Identify who or what is source of harm

Indicate if it is disputed

Indicate severity/pattern/ history of harm

Complicating factors such as MH/substance misuse/learning disability/domestic abuse

IMPACT ON THE CHILD

Injuries, Developmental delay, failure to thrive, Psychological/behaviour impairment – self harm, fear, distress, absconding, attachment issues

Extreme impact = permanent and enduring

Serious impact = observable and impairing functioning

Concerning impact = immediate, isolated and not

persisiting

Vulnerability factors- age, disability, awareness of risk

PROTECTIVE FACTORS

Demonstrable protective action

– removal from source of harm, compliance with intervention

Family strength and needs -belief of child, responsive carer relationship, empathy, enhanced capacity with support, motivation and competence to protect, care and change

Vulnerability factors – family networks, social and community environment, MH/substance use/DA.

Dynamic Risk analysis, Isle of Man model

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22/09/2017

Dynamic Risk analysis, Isle of Man model

cont

…

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Multiagency working

Neglect multi-causation- social deprivation; parental helplessness; emotional disorder; substance use; attachment problems; marital problems

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Parental discord

: rows, tension; threats.

A SYSTEMIC MODEL

Parental lack of care:

antipathy, neglect, lax supervision; role reversal,

CHILD DIFFICULTIES

Health, psychological, social, educational or other problem.

Describe

Father’s psychiatric

Depression, anxiety, substance abuse; psychosis PD:

Social Adversity:

Financial; housing; immigration; Legal difficulty; health/disability:

Describe:

Mother’s psychiatric

:

Depression, anxiety, substance abuse; psychosis; PD:

Parental abuse

physical, psychological,

Sexual abuse;

Incompetent parenting role:

problem i

nteraction; incompetence; hostile; helpless; lack of insight;

Parental violence

: physical attacks; hit, beaten.

Bifulco, Middlesex University

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Interventions - issues

Neglect often chronic – so no quick fix. Long term input needed; relationship with service3s offering an alternative model of relatingMultifaceted interventions individual child, family, social systems. Combination of interventions including parenting and mental health, social support and housing.Early and late: Intervention at early ages needed, but also to include teenage years. Developmental stage importantConsider protective factors – supportive relationships, school.

Involve fathers and mothers and wider kin where relevant.Attachment focusMoran, 2010, Neglect: Action for Children

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Interventions re Neglect

Care: Parenting training; Ensure care improved either through parent behaviour or another responsible adult Self-esteem: School-based initiatives; therapeutic intervention Enhance self-esteem through specific intervention, or school or leisure activity success and positive feedback Improve peer group relating – encourage friendships (school based initiatives)

Reduce child’s self-blame, over responsibility: therapeutic; school-based; social network - reduce role reversal/young carer activity, but avoid destroying the child’s sense of being needed and altruistic concern Family interventions – parental attachment, marital discord – family therapy etc

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Need for good assessment

Evidence-based tools and models for consistency and transparency. Information recorded in standardised and accessible ways, both narrative and numeric.Clarity over definitions and thresholds of ‘significant harm’ around neglect/abuse, for multi-agency professionals.

RISK FACTORS

List actual and/or believed harm

IMPACT ON THE CHILD

Injuries, Developmental delay, failure to thrive, Psychological/behaviour impairment –

PROTECTIVE FACTORS

Demonstrable protective action

– removal from source of harm, compliance

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Research-based assessments for practitioners – CATS team

Training package

ServiceProfessionShort courses

Attachment style

Interview (ASI)

Adoption/Fostering

Perinatal servicesSocial work; Psychologists CAMHS

4-day & licensingAdolescent attachment style (ASI-AD)Residential careClinical servicesForensic servicesCare workers; social workers; CAMHS psychologists4-day

Childhood Experience of Care and Abuse (CECA)Safeguarding services; Family supportForensic servicesSocial workersClinical PsychologistsForensic psychologists1-day

courses (Care: Neglect; antipathy; psychological abuse; role reversal etc)Parenting Role Interview (PRI)Family Support;Social workers, psychologists2-day

www.attachmentstyleinterview.com

;

www.parentingroleinterview.com

www.cecainterview.com

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Using research-based assessments to aid in Safeguarding

CECA – assess risk experienceParenting Role interview – future capacity

18/11/2013The ‘Case Record’ version of the CECA uses existing case material utilises and applies the definitions and scoring procedure to determine type and severity of maltreatment, relationship to perpetrator and timing. It enables a chronology to be determined.

The parent’s perception of their parenting - positive and negative

The practitioner estimate of the parents competence

The overall rating identifies parenting level.

It can be repeated to monitor change

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Case study A: CECA in CP services

Neglect from parents suspected Parents both class A drug abusers and were not compliant with efforts to stop drug use.The issue was whether the parental neglect was severe enough to consider accommodating the child. Signs in child involved- language delay, lack of

socialisation with other children, lack of stimulation, play behaviour

Previous court contact recommended family support and monitoring.

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5 year old boy – on Child Protection register since aged 3

CECA:

Neglect scores showed 2-‘moderate’ level over the past two years

- Mother did not take him to school consistently, and this meant not only that he got behind with school work, - he was not getting the additional speech therapy he needed; - evidence that they left the child unattended when the parents were drug-taking. - Lack of stimulation for child no play, toys etc.

However, no evidence of parental antipathy (hostility, criticism, rejection) and parents affectionate to child

.

CASE OUTCOME: A decision was made for kinship care

with grandparents having responsibility and the case moved to the Looked After team.

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CASE B –monitoring neglect

Young couple in their mid 20s with 16 month old son.Following a phone call from neighbours’ about smell and dirt in house, police and social services went round. The flat was found to be in a serious state – dirty, unsanitary, only use of one room due to bedroom being too messy to use, grease and dirt in kitchen and a cat and dog who messed in the flat. Bathroom door smashed in (said to be during a party). The child was naked on the floor, he slept in a cot in the sitting room with parents, few toys. No fresh food in the house, cigarette stubs everywhere etc. Rated 2-moderate neglect on CECA.Maternal Mental health: Mother suffers from depression, but won’t take medication. Has an issue with her weight and is overweight. Has lost 2 stone in 2 months which she is pleased about, but implication is that she isn’t eating.

Marital relationship seems okChild taken away and sent to grandparents on a Child Protection Plan for Neglect. 18/11/2013

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Change over 5 months with support

Review in April when parents had cleaned up substantially. Parents had signed an agreement to have place clean by 11th January. By June house better still in better shape but other issues to be resolved: Got rid of cat and dog, but have taken on a kitten. CECA 2-moderate  3 some neglectImprovements in state of hygiene of the flat – clean and tidy.Mother has been going to mother-baby group. (However stopped this week after an incident when her son knocked over a hot drink – she was upset and thought it dangerous and they shouldn’t go back).

Mother had signed up to cookery classes, goes intermittently.Agreed to go to parenting class, some reluctance because thinks she is a good parent.Has visited GP with minor complaintsChild returned to parents and taken off the plan.

18/11/2013

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CECA case B – hidden psychological abuse

‘2-Moderately’ severe Antipathy:

- mother critical, tells teachers and others that child is bad and naughty and bound to fail. She is observed shouting at him at school and by neighbours.2-‘

Moderately’ severe Psychological abuse:

child forced to be rude & swear at religious leaders against his will.

Child overhears mother tell SWs that if he is taken away she will die.

Mother made child promise to take revenge on her enemies (

incl professionals). Told him to speak Urdu instead of English at school.

Tells him his carers (in Pakistan) do not love him.

Child age 8Mother (foster carer – arranged in Pakistan) has psychosis – observed being hostile to child at school.Child dressed inappropriately; late picked up; anaemic, poor diet. 1-Marked neglect rated

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Case C Parenting improvement over lifetime – historical concerns

Couple in their 40s; New baby and new partnership; her previous children taken away (5 years ago, aged 13 and 15) due to neglect - her drinking and ex-partner’s violence and substance abuse. Previously no insight into her parenting - neglectThe relationship with the new partner was judged to be close. He is in work, and although they have rent arrears they are managing and are attempting to move away from the sink estate. Issues:(i) The mother herself has little social contact, only been to children’s centre a few times and although she takes the baby out for walks this is not for social contact.

(ii) A court case re higher contact with her teenage children, including allowing them to stay overnight. Assessment issues concerned her parenting capacity, and her emotional stability, and likelihood of staying off alcohol. The court case ruled in her favour

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Case C Parenting Role Interview – Good parenting

No difficulties with 6 month old baby; Positive interaction rated ‘1 marked’: reflected her good interaction with the baby. She described herself as an entertainer for the child and interacted well with her older children. She was probably more affectionate and closer to daughter, son more aloof. In anticipation of them coming to the home more often she had done up their bedrooms with play stations etc for them and reported looking forward to their visits. More patient now, more aware of tension in household. Negative interaction – 3 some, occasional bickering with teenage children.Competence 2- moderate:

The baby now into a routine and sleeps through the night and she is very responsive with the baby. She gives the older two as much time and affection as they need. They all eat together. The teenage children have a very good relationship with the baby and her partner makes positive comments about her parenting. Incompetence 3-some – around lack of socialising with other mother-babies due to her lack of confidence.Good insight into parenting – tendency to be rather self-critical. Overall good parenting

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Key messages

Neglect is complex due to associated harms (abuse) and its chronicityassociated risks (family and neighbourhood)It has long term psychological and social impacts. Protective factors can lessen these.Important to assess all information as accurately as possible and monitor change.Interventions help, but multiagency working needed to cover all aspects.Neglect can be overcome!

18/11/2013

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Questions?

“Thank you for your attention”

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