The CPS Response to Child Neglect

Transcription

1 The CPS Response to Child Neglect An Administrator s Guide to Theory, Policy, Program Design and Case Practice Editors Thomas D. Morton Barry Salovitz Published by National Resource Center on Child Maltreatment Operated by & ACTION For Child Protection A Service of the Children s Bureau, U.S. Department of Health and Human Services August 2001

2 The CPS Response to Child Neglect An Administrator s Guide to Theory, Policy, Program Design and Case Practice Editors Thomas D. Morton Barry Salovitz 2001 National Resource Center on Child Maltreatment 3950 Shackleford Road, Suite 175 Duluth, GA

3 Table of Contents Chapter Title Page Number I. The State of Child Neglect 1 Joann Grayson II. Issues Pertinent to Defining Child Neglect 37 Susan Zuravin III. CPS Responsibility for Child Neglect 60 Patricia Schene IV. Child Safety and Child Neglect 75 Wayne Holder Barry Salovitz V. Race, Ethnicity and Culture: Impact on Child Neglect Occurrence, Assessment and Response 93 Joyce N. Thomas VI. The Role of Social Supports in Child Neglect 108 James M. Gaudin VII. VIII. Child Neglect: The Need for Differential Program Strategies 117 Diane DePanfilis Using Research to Select Interventions and Measure Outcomes 151 Diane DePanfilis IX. The Substance Abusing Caretaker and Child Neglect 183 Joshua Nosa Okundaye X. Using What s Known and Resolving the Unknowns of Child Neglect 210 Thomas D. Morton The CPS Response to Child Neglect Page i

4 The State of Child Neglect Acknowledgments The National Resource Center on Child Maltreatment (NRCCM) gratefully acknowledges the support of the U.S. Children s Bureau. Funding to support this work was provided under grant number 90CA1579/01. A preliminary panel of experts assisted the NRCCM in identifying critical issues that child welfare agencies are facing in addressing child neglect. Members of this work group were Thomas D. Morton, Wayne Holder, Reed Holder, Todd Holder, Barry Salovitz, Elizabeth Arbet, Catherine Welsh, Terry Roe Lund, James Gaudin, Robert Hill, Kathleen Faller, Sylvia Pizzini, Michael O Farrell, Diane DePanfilis and Susan Kelly. Finally, we wish to recognize the thousands of child welfare professionals across the country who struggle to meet the challenges of child neglect. We hope that the information provided here somehow makes the journey of a child, parent, caseworker and child welfare administrator reach a safe and happy conclusion. The CPS Response to Child Neglect Page ii

5 The State of Child Neglect I. The State of Child Neglect Joann Grayson, Ph.D. Everyone in the agency knows the Smith family. The Smiths and their five children, now ages 5 to 14, first came to the agency s attention seven years ago. At that time, the family was about to be evicted due to nonpayment of rent and the oldest child was not in school. Mrs. Smith had recently had a miscarriage and the next-to-youngest child was hospitalized with bronchitis. Mr. Smith only works sporadically due to alcoholism. Mrs. Smith has resisted working due to various health problems and because she prefers to stay home with her children. Over the years, despite numerous and frequent crises, the agency has managed to keep the Smiths together. Reports of child neglect have been received intermittently from concerned school officials (the children are not attending regularly), doctors (missed appointments, immunizations not up-to-date) and recreation leaders (lack of adequate food, poor hygiene, inadequate clothing, head lice). Nearly every resource in the agency and the community has been offered and/or utilized with the family. Now, the juvenile court is involved due to vandalism and shoplifting by the two older children. Neglect, the quiet assault, can be the most damaging form of child maltreatment. Neglect is responsible for approximately half of child fatalities. Neglect affects a far greater number of children than physical or sexual abuse, and the impairments of its victims often last throughout their lifetime. Still, neglect receives less attention from researchers and policy-makers than other forms of child maltreatment (DiLeonardi & Johnson, 1992; Erickson & Egeland, 1996; Garbarino & Collins, 1999; Trainor, 1983; Wolock & Horowitz, 1984). In 1993, the National Resource Center on Child Abuse and Neglect and the National Clearinghouse on Child Abuse and Neglect Information joined in a compilation and analysis of published research in the area of child neglect for the years Only 36 research studies and 41 additional articles were found. The author notes that well over 200 journals are published in the field of social work alone. He concludes, that given the abundance of research journals in several disciplines, the limited amount of published research on child neglect is surprising (Lloyd, 1993, p.11). At the turn of the century, the situation is still similar. Writing in 1999, Garbarino and Collins note that a quick review of the listings in a popular psychology index indicated 5,848 entries for child abuse and only 559 for child neglect (p.1). Thus, it is not surprising that knowledge about child neglect has developed in a haphazard and piecemeal fashion (Melton et al., 1995). Joann Grayson, Ph.D., is a Professor in the School of Psychology at James Madison University. The CPS Response to Child Neglect Page 1

6 The State of Child Neglect Lack of attention does not imply lack of damage. Child neglect, especially emotional neglect, often has profound and long-lasting, if not permanent, consequences. Psychological consequences from emotional maltreatment may even be a unifying factor for all types of maltreatment. Lasting damage is done to the child s sense of self with resulting impairments in social, emotional, and cognitive functioning (Erickson & Egeland, 1996; Kaplan, Pelcovitz & Labruna, 1999). Defining Neglect Child neglect is typically defined as an act of omission, something that a caretaker has failed to do. Neglect is failure to provide resources needed so that a child can grow and be healthy. Neglect can be deliberate. It can also be an oversight or can arise due to lack of knowledge. Defining neglect is difficult due to differing cultural and community standards of care. Communities grapple with setting clear guidelines for a minimal acceptable level of care for children. It is also difficult because of the sheer number of subtypes of neglect. In addition, professionals disagree about whether to focus on parental behaviors, child outcomes, or both. Neglect that is chronic and ongoing may differ from neglect that is transitory, although either can cause severe harm or fatality. First, consider standards of care. Standards of care are not static. New medical discoveries or new knowledge about child development can change the standard, sometimes overnight. The availability of resources changes the standard. For example, if a medical treatment is not available in one s locality, or if it is not affordable, then use of that procedure is not expected. Attitudes can change the standard of care. Public perception is not uniform. Some view situations of neglect as unfortunate or as accidental. Others feel that the same actions are criminal negligence - not only child neglect, but a crime as well. Public opinion also changes. As part of a survey of child protective service workers (CPS workers) conducted in 1993, workers were asked to respond to scenarios and indicate whether or not they would accept the situation as a complaint and conduct an investigation. One of the scenarios involved a child who was seriously hurt while unsupervised and working with farm machinery. Few of the workers considered this a possible CPS complaint (Grayson, 1993). That opinion might be changing. In May 2001, criminal charges of child endangerment were brought against a Pennsylvania farmer in the death of his young son who was crushed by farm machinery. Nationally, in a typical year, between 175 and 300 children die in farm-related accidents, most involving machinery (Purschhwitz, 1990; Rivara, 1985). Consider, also, perceptions concerning young mothers who abandon babies. Neonaticide and abandonment of newborns have existed throughout history. Recently parents (most generally teen mothers) have been criminally prosecuted for this behavior. Other countries such as England do not regard these deaths as murder. Yet another example is leaving babies and young children in cars where they rapidly over-heat. Some children suffer brain damage. Others die. There is not agreement about whether these child deaths should be considered child neglect. The CPS Response to Child Neglect Page 2

7 The State of Child Neglect Garbarino & Collins (1999) note that standards of care evolve and change as a function of a negotiated settlement between science and professional expertise on the one hand and culture and community values on the other. They cite the example of use of child car seats. In the 1950 s there were no standards for children traveling in automobiles. By the 1980 s knowledge had stimulated changes in community values and now it is considered neglectful to permit a young child to ride in a car without a car seat. This value arose from the knowledge that more than two-thirds of injuries and 90 percent of fatalities in automotive crashes can be prevented through protective action on the part of parents (p.11). Second, consider the subtypes of neglect. In an analysis of 50 state codes, McGovern (1993) found 14 different grounds of neglect delineated. McGovern notes that each state has independently defined neglect. Some states have multiple definitions of neglect in their codes and 24 states combine abuse and neglect, listing instances together under one heading. There is no standardized way to divide neglect into subgroupings. The National Incidence Study (Sedlack & Broadhurst, 1996) utilized 17 categories of neglect. Zuravin (1991) delineates 14 subtypes. Categories of neglect reflect a number of different behaviors. It should be noted that neglect categories tell nothing about the families involved in these behaviors or the factors causing the behaviors (Daro, 1988). Thus, families exhibiting the same type of neglect may not resemble each other and there may be different factors accounting for the neglectful acts. For purposes of this chapter, the following subtypes will be considered: Physical Neglect (abandonment, inadequate supervision, inadequate clothing, inadequate shelter, inadequate personal hygiene, inadequate food, malnutrition); Medical Neglect (failure to obtain emergency care or treatment, failure to obtain necessary care or treatment, failure to obtain necessary dental care or treatment, failure to obtain necessary mental healthcare or treatment); Emotional Neglect; Failure to Thrive. Third, should one concentrate upon parental behaviors, effects on the child, or both? The same neglectful actions can result in different outcomes to the child. For example, a parent s failure to make regular meals will greatly impact greatly very young children who may fail to thrive or even die. Older children who can raid the refrigerator or get a meal at a friend s house and who receive school breakfasts and lunches may be seemingly unaffected by the parent s lack of care. If definitions rely upon impact on the child, must the impact be measurable? Brassard et al. (1987) offer a definition of mental injury as substantial, observable impairment in the child s ability to perform and behave within a normal range (cited in Erickson & Egeland, 1996, p. 6). However, others suggest that the impact of neglect may become apparent later in the child s development The CPS Response to Child Neglect Page 3

8 The State of Child Neglect rather than always showing immediate symptoms (Erickson & Egeland, 1996). Definitions that limit labeling neglect to situations where there are observable effects may discard legitimate cases. However, if effects are not apparent, is there a sufficient knowledge base to reasonably predict longterm effects of neglect? Little attention has been given to severity of neglect (Crouch & Milner, 1993). Differing community standards of care can result in variations in defining neglect. Thus, judgment of neglect is influenced by what a given community considers adequate supervision, household cleanliness, or medical care (Daro, 1988). Some literature distinguishes between acute and chronic neglect. Chronic neglect is defined as occurring over a three year or more period of time or as intergenerational. In contrast, newlyneglecting caretakers are thought to be responding to sudden stressors or changes (such as divorce, recent illness, sudden job loss). A definition offered by Hall, DeLaCruz and Russell (1984) discards newly-neglecting situations and also specifies an intensity level. Hall et al. state that neglect must either be a chronic, long-standing problem that permeates several aspects of a child s life or the neglect must be so severe that the child s life is endangered. A widely-accepted definition is offered by Polansky, Hally & Polansky. They define neglect as 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 (1975, p.5). Polansky et al. s definition, in contrast to that of Hall et al., does not specify the degree of harm to the child that is needed to fit the category of neglect. Meriwether (1988) maintains that, legally, neglect cannot be specifically defined. Instead the statutes can only set forth a standard (p.13). The question, then, is how high the standard should be set. Merriwether discusses that some states use a prudent parent standard that is higher than a necessity standard which sets only minimal requirements. Finally, should definitions of neglect focus solely on parental responsibility, ignoring social conditions and social policies that contribute to them (Gelles, 1999)? If poverty is a factor in neglect, how should it be considered when intervening? Definitions of neglect have also changed over time. Since 1980, definitions of child neglect have become narrower (Giovannoni, 1993). Rose and Meezan (1997) offer an analysis of the evolution of the concept of neglect from 1964 to Some of the changes include: evolution from considering behaviors of parents to considering mainly consequences and harm to the child; evolution from a general concern about inadequate medical care to concern about a parent s refusal of necessary medical treatment; The CPS Response to Child Neglect Page 4

9 The State of Child Neglect evolution from concern about oversight of a child s education (allowing a child to remain out of school) to concern about actively preventing a child from attending school (due to assisting with work at home) and to withholding educational opportunities; evolution from an emphasis on moral behavior to a decreased emphasis on moral fitness of the parent (again concentrating only on demonstrable harm to the child); evolution from the existence of mental or physical incapacity of the parent to considering only the direct consequences of the parent s limitations on the child; evolution from concern about the condition of the home to consideration of the cleanliness or orderliness of the home only if it presents a hazard to the child; evolution from concern about child exploitation to delegating this concern to other agencies that enforce child labor laws and mandatory school attendance. The greatest degree of consensus and consistency over time, according to Rose and Meezan (1997), is the definition of categories of inadequate food, clothing, shelter, and supervision, including abandonment. The agreement may be due to the perception that basic requirements of physical care are the responsibility of the parent and that the absence of physical care and supervision has clear consequences for children. The lack of clear definitions and the lack of consensus have profound effects on research, policy, and practice. Without agreement about definitions, it is difficult or impossible to compare research findings. Also, variability in definitions contributes to significant variability in policies and, ultimately, in the system s response to neglect. It is worth noting that public perceptions and the views of child welfare officials do not always coincide. The general public is concerned about general neglect, inadequate supervision, and emotional well-being of children. While CPS workers may share these concerns, they do not have the latitude to intervene except in cases of neglect with demonstrable harm. Cases of reported neglect are often closed immediately after investigation or even screened out and not investigated. Some evidence suggests that families reported for general neglect who do not receive services are more likely to be referred for severe neglect at a later date. By the time the situation has progressed to severe neglect, removal of the children into foster care becomes more likely (Berrick and Duerr, 1997). Ultimately, definitions of child neglect may rest on local community standards and availability of resources. As reports have risen and resources have not kept pace, neglect is less likely to be substantiated or even investigated (Giovannoni, 1993). The CPS Response to Child Neglect Page 5

10 The State of Child Neglect Incidence While there are several sources for neglect statistics, two studies are sponsored by the U.S. Department of Health and Human Services. These are Child Maltreatment: Reports for the States of the National Child Abuse and Neglect Data System (NCANDS) (National Clearinghouse on Child Abuse and Neglect, 1999) and the National Incidence Study (NIS) (Sedlak & Broadhurst, 1996). There have been three NIS studies. NIS-1 was conducted in 1980, NIS-2 occurred in 1986 and NIS- 3 in The NIS includes children investigated by child protective services (CPS) but also obtains data about children seen by community professionals who were either not reported to CPS or screened out and not investigated by CPS. The study is nationally representative and sampled 42 counties. Two sets of definitional standards are used in the NIS. The Harm Standard was developed for NIS-1 and has been used in all three studies. The Harm Standard is relatively high, requiring that an act or omission result in demonstrable harm in order to be classified as abuse or neglect. It can even exclude many children whose maltreatment is substantiated by CPS investigation. The Endangerment Standard includes all children classified as abused or neglected by the Harm Standard but also includes children who have not yet shown harm from maltreatment if CPS has substantiated maltreatment or if a non-cps sentinel (trained community professional) considers the child to be in danger. The Endangerment Standard was used as a second measure in NIS-2 and NIS- 3. According to the NIS studies, there was a 67 percent increase from NIS-2 to NIS-3 and a 149 percent increase from NIS-1 to NIS-3 for the total of all maltreated children under the more conservative Harm Standard. An estimated 1,553,800 children in the United States were abused or neglected in Neglected children were the largest category and increased from 474,800 in 1986 to 879,000 in This is a rate of 13.1 per 1,000 and accounts for 54 percent of the total child maltreatment cases. Using the Endangerment Standard, the numbers of neglected children more than doubled (a 114 percent increase) from NIS-2 (917,200) to NIS-3 (1,961,300). For both standards, physical neglect more than doubled (102 percent increase and 163 percent increase) while emotional neglect (333 percent increase and 188 percent increase) was six times greater in NIS-3 for the Harm Standard and tripled for the Endangerment Standard. The second data source, Child Maltreatment: Reports for the States to the National Child Abuse and Neglect Data System (NCANDS) presents annual national data about child abuse and neglect known to CPS in the United States. In 1992, the first NCANDS report was issued, based on data from Each state reports data. In 1999, of the estimated 2.9 million children who were subjects of CPS investigation, an estimated 826,000 were considered victims of abuse or neglect (cases were founded or considered at risk ). This represents a decline from 15.3 per 1,000 in 1993 to 11.8 per 1,000 in Of the 1999 total, 58.4 percent of victims experienced neglect, 21.3 percent were physically abused, and 11.3 percent were sexually abused. Neglect had the highest rate of victims, 6.5 per 1,000. The CPS Response to Child Neglect Page 6

11 The State of Child Neglect Thus, both studies show that neglect is the largest category of child maltreatment. Also, cases of neglect are increasing more rapidly than other forms of child maltreatment. Neglect can also kill. Statistics on child maltreatment fatalities show that neglect is almost as common a cause as abuse. Gaudin s review (1993) places the percentage of child maltreatment fatalities due to neglect in the range of 25 to 70 percent with most studies in the range of 40 to 50 percent. The NCANDS data estimate that 1,100 children died from maltreatment in Neglect was the leading cause for the maltreatment fatalities and accounted for 38.2 percent of the total. A combination of physical abuse and neglect was evident for 22.7 percent (making a total of approximately 60 percent of fatalities where neglect was a component). Physical abuse alone accounted for 26.1 percent. There is also hidden neglect, which is not documented in official reports. For example, consider the growing phenomenon of children being raised by grandparents. According to data from the American Association of Retired Persons (AARP) (Kallio, 2001), there are 4 million children living in grandparent-headed households. For 1.3 million of these children, no parent is present in the home. Compared to 1970, that is a 76 percent increase and since 1990 a 19 percent increase in children being raised by grandparents. Why are grandparents assuming care and custody of grandchildren? According to AARP data, the number one reason is parental substance abuse. Other triggers are death of the parent, child maltreatment, teen pregnancy, parent incapacitated by HIV/AIDS, unemployment of parent, parent incarceration, divorce, mental health problems (such as serious mental illness or mental retardation), family violence, and poverty. While some of the children being raised by grandparents are reflected in official child neglect statistics, in other cases, family intervention occurred early enough to avoid official investigations for child neglect. Another undercounted population may be maltreated children who witness domestic violence. The estimates of children exposed to domestic violence each year range from 3.3 to 10 million (Holden, 1998). Witnessing violence, by itself, does not generally meet criteria for CPS intervention. However, studies suggest that 30 to 60 percent of children witnessing violence are also maltreated themselves (O Keefe, 1995). There is some evidence that domestic violence program staff are uninformed about child abuse reporting or are reluctant to report children to CPS, leading to underreporting (Findlater and Kelly, 1999). There is an increasing population of homeless families as affordable housing diminishes because low and moderate-income dwelling units are stable or decreasing (Berck, 1992; Wolch & Dear, 1993). The number of children among those who are homeless is growing and more than 500,000 children may be homeless along with their parents at any one point in time (cited in Holden, Horton & Danseco, 1995). Risk of neglect, especially in areas of health, nutrition, and education, is very high (Berck, 1992) for children who are homeless. These examples of undercounted child neglect suggest that the numbers of children at risk for neglect are very high. Furthermore, at-risk populations are growing rapidly. The CPS Response to Child Neglect Page 7

12 The State of Child Neglect Influences on Incidence of Neglect Identifying factors that underlie neglect is the first step in eliminating or ameliorating these factors (Erickson & Egeland, 1996). Child neglect is generally embedded within a larger pattern of family dysfunction. Child neglect can be secondary to self-neglect on the part of the parent or secondary to debilitating conditions. These include parents who are addicted to substances, parents with serious mental illnesses, parents with clinical depression, parents with mental retardation and parents involved in domestic violence. Child factors and characteristics may contribute to the risk of neglect, but child factors alone do not account for neglect (Erickson & Egeland, 1996). Rather, child factors, in part, determine the effects of neglect. Children who are very vulnerable and dependent, such as infants or children with developmental or handicapping conditions may be seriously affected or even die from neglect whereas less vulnerable children may not show negative effects. Environmental factors can also influence the incidence of neglect. Poverty is one factor that is intricately linked to neglect. Others are parental unemployment, lack of social supports and single parent status (Erickson & Egeland, 1996). Consider first the individual parent risk factors, then factors related to the larger society and the environment. Parent Factors Ryan, age 5, was trying to explain why he was upset about his visit to his father s home. I woke up at night and was scared. I called for Daddy but no one came. I went to the living room. It was smoky and there were people there. They just sat and stared and would not talk to me. Ryan, what did you do? After awhile I went back to bed. There is a large overlap between substance abuse and child maltreatment of all types. In studies reviewed by Yoast and McIntyre (1991), the percentages of maltreatment cases where the caretaker was abusing substances ranged from 13 percent to over 60 percent. Changes in rates of substance abuse and substance addiction, then, can influence the incidence of neglect. For example, methamphetamine, popular in the 1960 s, disappeared until the 1990 s when it became the drug of choice for rural America and the working class. Some women are attracted to the drug due to its weight-loss effects. The recent popularity of crack cocaine may have profound implications for child neglect. Treatments successful with other addictions have not been effective with crack addiction, and some commentators suggest that child welfare professionals should consider this a chronic, relapsing syndrome with no cure (Besharov, 1998). The CPS Response to Child Neglect Page 9

13 The State of Child Neglect Changes in the effectiveness of treatments for substance abuse will impact the incidence of neglect. Currently abstinence and relapse rates vary in studies but average in the range of 50 percent (Landry, 1997). Recent studies have shown that after 6 months, treatment for alcoholism is successful for 40 to 70 percent, cocaine treatment is successful for 50 to 60 percent, and opiate treatment is successful for 50 to 80 percent, with success defined as a 50 percent reduction in substance use (Ericson, 2001). Treatment requires long-term (sometimes life-long) commitment. Thus, for the large number of cases of neglect where substance abuse is a factor, long-term, intensive intervention and monitoring is needed if children are to remain in their homes. Emily and John lived with their mentally ill mother after their parents divorced. Their father was a professional and child support was sufficient so that their mother did not have to work. Emily and John came into foster care after excessive school absences and minor trouble with the law. They have alternated between foster care and a grandparent, but are generally out of control at the grandparent s house. Emily and John refuse to discuss their mother s odd behaviors other than to say she probably has some kind of mental illness. Serious Mental Illness (SMI) is a term that includes the most debilitating persistent and long-term psychiatric diagnoses. These are conditions such as schizophrenia, schizoaffective disorder, major affective disorder (major depression), bipolar illness and other psychotic conditions. The label SMI is also limited to conditions that last more than a year and result in serious dysfunction in one or more life areas. Because of improvements in treatment and rehabilitation and greater emphasis upon community care, increasingly persons with SMI live in their communities. As community members, persons with SMI are more likely to become parents. Indeed, fertility rates and reproductive behavior of those with SMI are similar to the general population (Burr, et al., 1970 & 1979; Saugstad, 1989, both cited in Mowbray, Oyserman, Saunders & Rueda-Riedl., 1998). There appears to be limited literature about parenting abilities of those with SMI. For professionals working with SMI, parenting has not been a treatment focus. Indeed, a computerized literature search performed by Mowbray, Oyseman, Zemencuk & Ross (1995) for the years 1983 to 1992 found only 36 research articles involving primary data collection about parenting for women with SMI. Some studies suggest that parent psychopathology such as SMI can be an important factor in child maltreatment (Chafin, Kelleher & Hollenberg, 1996; Famularo, Kinscherff & Fenton, 1992; Taylor et al., 1991). Still, to date, there is little data about the types and extent of diagnosable pathology in the general population of those who are known to have abused or seriously neglected their children (Taylor et al., 1991). State systems are beginning to collect data about the incidence of SMI in parents whose children are in foster care or being served by child protective services (CPS). For example, studies in New York state found 16 percent of children in foster care (more than 10,000 children) and 21 percent of children in preventative services programs (an additional 8,600 children) had parents who were The CPS Response to Child Neglect Page 10

14 The State of Child Neglect mentally ill (Blanch & Purcell, 1993). Providing support services to parents with SMI is an expensive and long-term commitment. While newer medications and community support allow more individuals with this designation to live outside of institutions, many continue to experience debilitating and ongoing limitations in daily functioning. After trying to conceive for a number of years, Martha was delighted to learn she was pregnant. Although she had twice been hospitalized for depression and suicidal behavior, it never occurred to her that something she wanted so badly a pregnancy could trigger another depressive episode. After the baby was born, Martha felt unable to cope. She sat immobilized, and was sometimes oblivious to the baby s cries. Her husband was solicitous at first, but became increasingly upset as Martha failed to recover. Tension in the home was high, the baby cried and did not gain weight, and Martha alternated between extreme irritation, crying, and lethargy. Serious depression and postpartum depression have been linked to child neglect. Overall, studies conclude that depressed parents can be uninvolved and unresponsive (Goodman & Brumley, 1990; Klehr, Cohler & Musick, 1983), as well as angry and rejecting (Chaffin, Kelleher & Hollenberg, 1996; Cox, Puckering, Pund & Mills, 1987; Mammen, Shear, Jennings & Popper, 1997; Susman et al., 1985; Zuravin, 1989). Parents suffering from depression often have negative feelings (Hamilton, Jones & Hammen, 1993; Parker, 1979), have a lowered sense of self and self-worth (Culp, Culp, Soulis & Letts, 1989; Kinard, 1996; Klehr, Cohler & Musick, 1983), and show a negative interactive style with others (Klehr et al., 1983; Parker, 1979; Rivera, Rose, Futterman, Lovett & Gallagher- Thompson, 1991; Susman, Trickett, Iannotti, Hollenbeck & Zahn-Waxler, 1985). A parent s acute episode of depression can trigger significant dysfunction for the entire family. The symptoms of depression, interacting with environmental variables (such as stress, isolation, violence) and sociological variables (such as lack of support, poverty, lack of education), can contribute to the parent being the perpetrator of abuse or neglect (Culp et al., 1989; Dinwiddie & Bucholz, 1993; Famularo, Barnum, & Stone, 1986; Kinard, 1982; Susman et al, 1985; Zuravin, 1989). Maternal depression can also result in the inability to protect children from violence and abuse, both physical and sexual, perpetrated by a father or boyfriend (Dinwiddie & Bucholz, 1993; Kinard, 1996; Zuravin, 1989). Postpartum depression, in particular, can place a mother at risk for engaging in child neglect. The amount and quality of interaction an infant receives is determined in large part by the primary caretaker who is generally the mother. Characteristics that foster secure attachments and which are associated with positive outcomes include emotional availability and sensitivity to the infant s signals and needs (Jacobsen, 1999). Studies indicate mothers with postpartum depression are less responsive and less sensitive towards their infants. They are described as disorganized and inactive. Mother-child interactions are characterized as predominately negative. Mothers are described as disengaged and withdrawn and/or as interacting aggressively and in intrusive ways, while displaying few positive affective expressions (Cohn et al., 1990; Jacobsen, 1999; Milgrom & McCloud, 1996; Teti et al., 1995). The compromised functioning of the mothers with postpartum depression impacts The CPS Response to Child Neglect Page 11

15 The State of Child Neglect negatively upon their babies development. Consequences can be both long-and short-term and vary in severity (Teti, Gelfand, Messinger & Isabella, 1995). In recent years, new medications for depression, education of medical professionals and obstetricians, and public awareness campaigns such as National Depression Screening Day have resulted in earlier identification of depressive conditions and more effective treatment. These advances should lower the risk for child neglect in properly diagnosed and treated parents. Janet had planned to go to college and have a different life than her parents. She was the oldest of six children and resented her role as babysitter and caregiver. However, Janet became pregnant in the tenth grade and after bitter words with her parents, moved into her boyfriend s house. This arrangement deteriorated after the baby was born. Janet was struggling to continue school. The paternal grandparents were critical of Janet s lack of care for the baby. After repeated clashes in which her boyfriend sided with his parents, Janet left with the baby and went to a friend s house. A few days later she discovered she was pregnant again. Teen pregnancy is generally considered a situation that interrupts education, limits employment opportunities, lowers marital stability and increases poverty. Pregnancy generally marks the end of formal education for young women. Women with lower education (0-8 years) have the highest overall birth rates. They also are slower to obtain prenatal care, have poorer nutritional levels, lower weight gain, higher rates of smoking cigarettes during pregnancy, and poorer birth outcomes (Mathews & Ventura, 1997). More than 90 percent of teens who give birth elect to raise their infants (American College of Obstetricians and Gynecologists, 1995). Nationally, teen pregnancy birth rates are declining (Ventura et al., 2001). Repeat teen births (having a second baby while still a teen) are also on the decline. Lower rates of teen pregnancy should lower the incidence of child neglect. Hannah was protected while she lived at her parent s home and attended school. Diagnosed as having mild mental retardation, Hannah had been in special education classes where she was sheltered. After graduating, Hannah refused to remain with her parents. She moved in with a friend and met a man with a troubled past. Soon she was pregnant. Child Protective Services became involved after the case manager reported that Hannah had failed to keep doctor s appointments and the baby was not gaining weight. An IQ of below 60 can be a predictor of neglect (Tymchuk, 1992). Fertility rates of women with mental retardation are similar to or slightly higher than fertility rates of the general population with a mean of 2.8 children per mother with retardation (Accardo & Whitman, 1990). It has been estimated that at least 120,000 babies are born each year to mothers who have mental retardation (Keltner & Tymchuk, 1992). Deinstitutionalization and the movement toward the least restrictive alternative mean that an increasing number of persons with retardation are living in the community and having children. There are many challenges in assisting parents with mental retardation. The community commitment must be long-term, ongoing, and comprehensive throughout the child s growing up years (Booth & The CPS Response to Child Neglect Page 12

16 The State of Child Neglect Booth, 1998; Ingram, 1999; McConnell, Llewellyn & Bye, 1997). Communities without long-term supported parenting services (direct, hands-on assistance with daily living and child care tasks) are likely to experience increases in child neglect reports concerning this population as more persons with retardation become parents. Jamie and Jacob, ages 6 and 8, can t remember a time when their parents were at peace. Regular arguments erupt between the parents and sometimes the fights are physical. Twice, their mom has taken them with her to a shelter. Jamie has nightmares and wants to protect her mother. Jacob often laughs at Jamie and punches her. Jacob says he doesn t care if his parents fight. At least a third of maltreated children also witness domestic violence in their homes (Hagen, 1994; Stark & Flitcraft, 1998, both reported in Edleson, 1999). Child witnesses of domestic violence may also be homeless if they and their mother fled the household and moved to a temporary shelter. Mothers preoccupied with safety issues may have difficulty meeting children s safety needs and emotional needs. Reductions in domestic violence and/or better support services for families experiencing domestic violence will likely have some impact on the incidence and severity of child neglect. Social/Environmental Factors Social factors influence the incidence of neglect. These include, but are not limited to, poverty, social support, secure parental employment, and single parent status. The popular image of neglect is virtually synonymous with the image of poverty (Swift, 1995, p.9). Indeed, according to the National Research Council (1993), poverty is a main risk factor for child neglect. For example, in , children from families with incomes below $15,000 were 44 times more likely to experience physical neglect and were 56 times more likely to be educationally neglected than children from families with incomes above $30,000 (Sedlak and Broadhurst, 1996). While most families in poverty manage to provide adequate care for their children, the association between child neglect and poverty is clearly supported in many studies (Gaudin, 1993; Howing, Wodarski, Kurtz & Gaudin, 1993; Runyan et al., 1997). The child poverty rate has followed a curvilinear pattern over the past 35 years. The decline in poverty from the late 1950 s (when over one-fourth of children lived in poverty) into the 1970 s was in large part a product of the growth in economy (Betson & Michael, 1997). Poverty has increased since the early 1970 s from approximately 15 percent to over 20 percent in 1995 (Lewit, Terman, & Behrman, 1997). The rate has dropped slightly since then to 19 percent in 1997, then to 18 percent in 1998 (America s Children, 2000). Poverty correlates with other risk factors as well. Children living in poverty are more likely than children in middle class or affluent families to have parents who are poorly educated, relatively young or who have a disability such as mental retardation or serious mental illness. Some regard eliminating poverty as a pathway toward reducing child neglect (Pelton, 1993). Others note that child maltreatment is not synonymous with poverty and that additional factors must be considered. One advocate of this latter view is Patricia Crittenden who maintains that the association The CPS Response to Child Neglect Page 13

17 The State of Child Neglect between poverty and neglect needs to be reconsidered. Poverty may be an outcome, rather than a cause. Crittenden states, both poverty and child neglect may be the effects of learning to process information in distorted and limiting ways (p.66). Thus, parent education and assistance may be wasted on most neglectful parents. Because they are blocking out information necessary for action, teaching them new responses may be useless; they will be unlikely to identify correctly the occasions on which to use the newly learned behaviors (1999, p. 66). Garbarino (1988) has also recognized the complexity of poverty. He writes, Poverty is primarily a social, rather than a narrowly economic concept. It s not how much money you have, but how well you are able to recognize and meet basic needs (p.111). Heclo (1998) discusses attitudes towards poverty prevalent in the American public. Children are valued by Americans and there is much public sympathy for the plight of poor children who are viewed as needy and deserving of help. However, poor children are linked to poor adults and public attitudes towards poor adults differ. Adults are expected to be self-sufficient. Thus, income guarantees and cash payments to combat poverty have not been a popular alternative in the United States. The American public prefers help for those who will help themselves, aid for the deserving but no reward for vice or folly, a hand up rather than a handout (p.143). Thus, the National School Lunch Program and other similar efforts targeting children have remained in place while Aid to Families with Dependent Children (AFDC) cash payments to families have declined. There has also been a shift in attitudes towards mothers, according to Heclo. In times past, when a family lost their breadwinner (the male) because of abandonment or death, public payments to mothers were seen as a method to keep the family together and allow the mother to remain at home to concentrate on child rearing. However, between 1949 and the 1990 s, the proportion of married mothers with young children who worked outside the home shifted from 10 percent to 60 percent. Opinion surveys saw a shift in American attitudes favoring a mother s participation in the work force. This shift in attitude has made it difficult to justify cash payments to single mothers to allow them to remain at home (Heclo, 1998). While there is acknowledgment that the welfare of children and families can be significantly strengthened or weakened, depending upon what government and communities do or do not do, Americans believe in individual responsibility over collective responsibility. For example, public support for child support laws and enforcement has increased. Any child has a publicly enforceable right to material support from the two human beings who brought him or her into the world (Heclo, 1998, p. 146). Thus, parents, not government or helping agencies, are seen as primarily responsible for children. The implications of public attitudes for families with neglected children are considerable. Families where neglect is not chronic, where youth and inexperience are factors, and where lack of education and opportunity are primary causes for the neglect may respond well to programs designed to result in self-sufficiency. Conversely, neglectful families where the parent is suffering from permanent, ongoing, debilitating conditions (such as serious mental illness, mental retardation, substance addiction, serious recurring depression) are likely to fall short of the goal of self-sufficiency, even if improvements are made. For a family with chronic problems, keeping the family intact while The CPS Response to Child Neglect Page 14

18 The State of Child Neglect preventing child neglect may require a commitment of resources throughout the child s growing up years. Such a commitment is counter to public sentiment and the goals of most helping programs, managed care companies, and third-party payers of services. Since 1960, families have changed drastically. Changes include a four-fold increase in births outside of marriage, a four-fold increase in the divorce rate, and a nearly three-fold increase in the proportion of working mothers of young children (U.S. Advisory Board on Child Abuse and Neglect, 1993). Not only are there fewer adults present in families and available to children, but also their time has shrunk due to demands outside the family. Moreover, social supports are disrupted by moves. Each year, one in four young children experiences a move (U.S. Advisory Board on Child Abuse and Neglect, 1993). Although the decline in social support is apparent throughout American society, it is most evident in impoverished neighborhoods. While families and their social situations have changed, the nature of services has changed little. The decline in informal social supports has not been matched by an increase in availability, accessibility, or responsiveness of the formal service system (U.S. Advisory Board on Child Abuse and Neglect, 1993). The role of social support in child neglect is a complex one, and social support alone is unlikely to be an effective intervention. However, social support may be an essential component of successful service provision (Thompson, 1994). Gil (1970) was one of the first to notice that child maltreatment fluctuated with employment status of parents. Employment is tied to poverty and to single parent status, therefore, its use as an independent indicator of risk for maltreatment may be limited. The percentage of children living with at least one parent working full time all year was 77 percent in 1998, up slightly from 76 percent in 1997 (America s Children, 2000). Children of single parents are at higher risk of all types of neglect (as well as physical abuse) according to NIS-3. Children of single parents have an 87 percent greater risk of being harmed by physical neglect, a 74 percent greater risk of experiencing emotional neglect, and a 220 percent (more than three times) greater risk of being educationally neglected. Single parenting is on the rise. The percentage of children living with only one parent increased from 20 percent in 1980 to 27 percent in 1999 (America s Children, 2000). The rate of child support by absent parents is important for children in single-parent families. In 1995, only 33 percent of children in female-headed families received child support (KIDS COUNT, 1998). Child support in single-parent families is crucial to preventing poverty. Improved systems to collect child support should lower the risk of child neglect. Implication of Factors for Intervention Services and intervention in cases of neglect have varied as a function of the perceived cause of neglect. In the latter part of the nineteenth century and the first two decades of the twentieth, child neglect was seen as a social problem. In the 1960 s, child maltreatment was reconceptualized as an individual problem, following a medical model. Neglect was reconceptualized as due to parent The CPS Response to Child Neglect Page 15

19 The State of Child Neglect pathology, family background (learning patterns), or as a character disorder (Waldfogel, 1998). If child neglect is an individual problem, then diagnosis and treatment of family members is the preferred response. If social conditions cause or significantly contribute to neglect, then these must be remedied or the community rather than the individual must provide the needed resources and support. Neglect Factors in Fatalities Are there differences in fatalities due to neglect versus those due to abuse? While data are limited, there do appear to be differences. Margolin (1990) found that victims of fatal neglect tended to come from bigger families (4.9 for fatal neglect families versus 3.5 family members for fatal abuse families). The most common family structure for both abuse and neglect fatalities was a singleparent family where the parent was the only adult in the household. Of the neglect fatalities, 88 percent were determined to be the responsibility of a biological relative, compared to 64 percent in fatal abuse cases. Margolin found that males accounted for 15 percent of neglect fatalities while they were responsible for 57 percent of fatal abuse. The U.S. Advisory Board on Child Abuse and Neglect (1995) also reports that mothers are implicated more often in child neglect deaths than fathers. However, they suggest the mother is often held accountable in supervision-related deaths even when the father was the parent in charge of the child. Fatalities due to neglect can fall into three categories: supervision neglect, chronic physical neglect and medical neglect. In the vast majority of fatalities from neglect, a caregiver was simply not there when needed at a critical moment (Margolin, 1990, p. 314). Margolin found that the home was the most common setting for death from neglect, and the bathroom the most common room. It is there that drownings in the bathtub or jacuzzi occur. Other common sites for fatal drownings include swimming pools, garden ponds, and open waterways such as lakes or rivers or the ocean. While some drownings may be intentional, most are due to lack of supervision (DiMaio & DiMaio, 1989; Griest & Zumwalt, 1989; Kemp & Sibert, 1992). Fires can result in child fatalities when supervision is lacking. In one fatality reported by Margolin (1990), a three-year-old was playing with a lighter while her mother was at a neighbor s home making a phone call. When the fire started, the three-year-old was able to escape, but her one-yearold brother was left behind. Deaths due to lack of supervision occur in critical time periods when a caretaker is absent and a child is killed due to an acute danger, such as fire, water, or an open window (U.S. Advisory Board on Child Abuse and Neglect, 1995). The CPS Response to Child Neglect Page 16

20 The State of Child Neglect Another form of fatal neglect is chronic physical neglect. This can result in an infant s failure-tothrive (Crimes Against Children Conference, 1998; Davis, Rao, & Valdes-Dapena, 1984). This condition occurs in infants and is the result of inadequate feeding leading to malnutrition. The most common risk factor for non-organic failure-to-thrive is economic deprivation. Other risk factors for inadequate feeding due to neglect are deficits in bonding and attachment, parents who are preoccupied with other problems, substance abuse, chronic physical problems, and severe marital difficulties. Vulnerable infants are ones with minor organic problems, low birth weight, or decreased appetite (Ludwig, 1992). While most incidences of failure-to-thrive do not result in death, in cases where the child is not brought to the attention of a medical clinic, starvation and fatality can occur. Fatalities due to medical neglect can happen when a child has a serious medical condition and is not provided the necessary medical care for survival (Crimes Against Children Conference, 1998; Geffken, Johnson, Silverstein & Rosenbloom, 1992). Medical neglect may also be a result of noncompliance with medical recommendations. Some parents may simply mistrust the medical care system. Others may refuse treatment due to religious beliefs (Monopoli, 1991; Myers, 1989; Swan, 1998). Another type of medical neglect includes those situations in which a caregiver delays or fails to seek health care. These may include situations where a parent may recognize a problem but believes there is no solution for it or the parent recognizes a problem but responds inappropriately. Evolution of Child Neglect Parental behaviors, now recognized as emotional maltreatment and harmful to the child s health and development, were in earlier times acceptable and even recommended. For centuries, discipline and teaching of the infant and young child focused on breaking the child s will, which meant crushing all assertiveness and instilling complete obedience. For example, the Puritans perceived the first efforts of a toddler toward independence, which are now recognized as essential to a child s growing mastery of himself and understanding of the world, as evidence of original sin. Parents were thought to have a moral duty to use physical harshness and psychological terrorization in order to cleanse the sinful, willful nature of the small child. For example, children might be locked in dark closets for an entire day, frightened with a vast army of ghost-like figures and tales of death and hellfire, and even taken to see rotting corpses. Whole classes of children were sometimes taken to hangings, followed by whippings to make a more lasting impression (DeMause, 1980; McCoy, 1981). DeMause (1980) describes six evolutionary modes of parent-child relations from the time of antiquity to the present. The Infanticidal Mode (Antiquity) included a high incidence of infanticide; the lives of those children allowed to live were constantly threatened by severe abuse. In the Abandonment Mode (Medieval) children were often abandoned to a wet nurse, foster family, monastery, nunnery, or psychologically abandoned through severe emotional neglect. In the Ambivalent Mode (Renaissance) parents feared that the child s insides were full of evil, and expressed both love and hate to the child, often in bewildering juxtaposition. In the Intrusive Mode (18 th century) there was less parental ambivalence; the child was prayed with but not yet played with, and was disciplined as much by guilt as by beating. In the Socializing Mode (19 th century to now) the child is viewed as someone who needs continuous training and guidance in order The CPS Response to Child Neglect Page 17