Neglected Children: Controversies and Challenges

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1 Neglected Children: Controversies and Challenges Tel Aviv, Israel June 2014 Howard Dubowitz, MD, MS, FAAP University of Maryland School of Medicine, USA

2 Why is child neglect so important? It s common

3 Maltreatment Substantiated by CPS Psych Maltx. 9% Sex Abuse 9% Physical Abuse 18% Medical Neglect 2% Neglect 78% 686,000 children

4 Percent of University Students Reporting Past Neglect USA Scotland Holland India Brazil Mexico Canada Hong Kong Korea Straus & Savage, Child Maltreatment 2005;10:124

5 Why is child neglect so important? It s common Morbidity Mortality

6 Physical Health Cognitive Development Child Neglect Social Development Emotional Health

7

8 Child Neglect Associated with Smaller Corpus Callosum

9 80% US Fatalities Due to Child Maltreatment -1,640 in % 60% 50% 40% 30% 20% 10% 0% Neglect 71.1% Abuse Neglect Medical Neglect Other US DHHS. Child Maltreatment 2012, 2013

10 Adverse Childhood Experiences (ACEs) Study Emotional Abuse 1.7x Physical Abuse 1.5x Sexual Abuse 1.4x Emotional Neglect 1.3x Physical Neglect 1.4x Domestic Violence 1.4x Mental Illness 1.4x Substance Abuse 1.3x Household Criminal 1.7x Dong et al, Circulation, 2004;110:1761 ACEs increase risk of heart disease* *After correcting for age, race, education, smoking & diabetes

11 Why is child neglect so important? It s common Morbidity Mortality Our opportunity to intervene Our responsibility to intervene

12 Cost

13 A Moral Issue

14 How should we define child neglect? The definition influences our response

15 WHO Neglect Definition (1999) inattention or omission by the caregiver to provide for the child: health, education, emotional development, nutrition, shelter & safe living conditions in the context of resources reasonably available to the family or caretakers and causes, or has a high probability of causing harm to the child s health or physical, mental, spiritual, moral or social development Includes the failure to properly supervise and protect children from harm

16 Why do we want to define child neglect? To protect children and improve their well-being NOT to blame parents

17 Child Neglect: Proposed Definition Child neglect occurs when a child s basic need/right is not adequately met - resulting in actual or potential harm Basic needs/rights include: adequate food, clothing, health care, supervision, protection, education, nurturance, love, & a home

18 Adequate Health Care Reasonable efforts made to treat minor problems (e.g. cleaning a cut) Professional care obtained for moderate - severe problems (e.g. trouble breathing) Professional care meets accepted health care standards (i.e. appropriate treatment) Child receives recommended preventive health care (e.g. immunizations)

19 Advantages of a Child-focused, Broad Definition Moves us beyond the narrow focus on parents to consider other contributors Encourages a broader response, different approaches and strategies A more constructive and less blaming approach Fits with our broad interest in children s health, development & safety

20 A Broader View Societal Neglect Any act of commission or omission by individuals, institutions, government, or society, together with their resultant conditions, which deprive children of equal rights and liberties, and/or interfere with their optimal development constitute, by definition, abusive or neglectful acts or conditions. Gil, Am J Orthopsychiatry, 1975;45:346

21 U.N. CRC Article 5 Government has the responsibility to protect and assist families in fulfilling their essential role as nurturers of children.

22 Manifestations of Possible Neglect Inadequate health care Non-adherence (or non-compliance) Delay or failure in obtaining health care Drug exposed newborns Inadequate dental care Inadequate physical care Inappropriate clothing Poor hygiene, sanitation Failure to thrive, obesity (?)

23 Manifestations of Possible Neglect Inadequate supervision Recurring injuries Ingestions Truancy Inadequate emotional care Lack of emotional support Lack of mental health care

24 Children s Needs Vary Implementing a definition of neglect must take into account Age Development Mental health Physical health

25 New Forms of Neglect Exposure to tobacco smoke No car safety restraint used Access to loaded gun Lack of health insurance Exposure to domestic violence

26 How do we assess whether a need is adequately met?

27 Neglect Falls on a Continuum? Often arbitrary where we draw the line & label it neglect For situations that don t qualify as neglect - intervention often still appropriate

28 Is intentionality important?

29 How should we consider the role of different cultural values in considering neglect?

30 Cross-Cultural Definitions of Neglect Substantial agreement - in the USA Dubowitz et al Around the world UN Convention on the Rights of the Child

31

32 Why are children neglected?

33 Neglect is the Symptom Why is it occurring?

34 Risk Factors for Neglect An Ecological Framework Societal Community Family Individual Examples: Examples: Poverty Social isolation Lack of family Few resources friendly policies Examples: Examples Partner Child violence Father not disability involved Parent depression substance abuse

35 Poverty & child neglect Rate of neglect 7x higher in lowest income families compared to others Sedlak et al. 4th National Incidence Study, 2010

36 Impact of poverty on children s health & development National Center for Children in Poverty

37 What should we do about neglect?

38 Recognize the seriousness of neglect

39 Consider the advantages of a child-focused definition

40 Prevention of child maltreatment Promotion of children s health, development and safety

41 Strategies to Prevent Child Neglect An Ecological Framework Societal Community Family Individual Examples Examples Examples Example Reduce poverty Build and inequality community resources, supports Efforts Mental to address health and Foster community connections partner support violence services for Family friendly policies parents and children Encourage father involvement

42 Responding to Neglect Legal System Child Welfare Community Resources

43 Differential Response (DR) No determination of abuse or neglect Services are voluntary

44 Treatment can help

45 Severe Neglect & Resilience 111 Romanian adoptees, came to UK < 2 yrs. 52 UK children adopted < 6 mos. At time of entry to the UK, half the children: < 3 rd percentile in weight, height, head circumference, development score Rutter, J Ch Psychology Psychiatry Allied Disciplines, 1998;39:465

46 Severe Neglect & Resilience Age 4 children who arrived < 6 mos: excellent catch up children who arrived > 6 mos: good catch up Age 11 < 6 mos: normal cognitive development > 6 mos: significant impairment (15 points) Beckett et al, Child Development, 2006;77:696

47 Trickle down approach not enough Consider the child s needs - or rights

48 Advocacy Society Community Family Parents Child Professionals

49 There s one thing more important than knowledge Imagination

50 Toda Raba!

51

52 Core Elements of Differential Response Multiple responses for reports of maltreatment that are screened in Response determined by presence of imminent danger, level of risk, and legal requirements The capacity to re-assign families to a different pathway after initial investigation or assessment Families in the assessment pathway may refuse services without consequence as long as child safety is not compromised No formal determination of abuse and neglect Merkel-Holguin, Kaplan, and Kwak, 2006, p

53 Core Values for a Differential Response Non-investigative Pathway Family engagement versus an adversarial approach Services versus surveillance Labeling as in need of services/support versus perpetrator Being encouraging with families versus threatening Identification of needs versus punishment A continuum of response versus one size fits all Kaplan and Merkel-Holguin, 2008, p. 7.

54 Findings from 3 Randomized Controlled Trials Child safety maintained Fewer removals from home Better access to services Families more satisfied Cost less in the long term Siegel and Loman, 2006 Ruppel, 2011 Loman and Siegel, 2012

55 U.N. Convention on the Rights of the Child The child shall be protected against all forms of neglect, cruelty and exploitation. Child victims of abuse, neglect, exploitation and torture need and should receive physical and psychological rehabilitation and social integration www. childrightscampaign.org

56 Rights and rights

57 Maltreated children, behavior problems, and mental health care Burns, et al. J Am Acad Child Adolesc Psychiatry, 2004;43:8

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