The CPS Response to Child Neglect

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

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 30096 www.gocwi.org/nrccm

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

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

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 1988-1991. 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

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

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

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 1991. 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

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

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 1993. 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 1993. Neglected children were the largest category and increased from 474,800 in 1986 to 879,000 in 1993. 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 1990. 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 1999. 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

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 1999. 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

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

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

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

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

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 1993-94, 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

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

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

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

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

The State of Child Neglect to become civilized. In the Helping Mode (the most recent) both parents are involved in meeting the child s expanding emotional, intellectual and other needs. According to De Mause, contemporary American society includes all six modes. When psychiatrists arrange family types on a scale of decreasing health, they are actually listing historical modes of child rearing, with the lower part of the scale describing parents who behave like evolutionary arrests, psychological fossils stuck in personality modes from a previous historical period... (p.19). In some families, then, maltreatment has continued in an uninterrupted cycle, as part of the family heritage, while in other families newly acquired information from medicine, education, psychology and other fields has been utilized to improve parenting methods from one generation the next. Neglect and abandonment leading to child fatalities have also been common throughout history. Anthropologists have estimated that Paleolithic parents may have eliminated as many as 50 percent of newborn females (Hoffer & Hull, 1981). Early Roman law formalized the concept that those who create may destroy by the concept of patria potestas, a father s right to murder his children (Resnick, 1970). As late as 1600 Massachusetts adopted the Stubborn Child Act which permitted parents to put a child to death if the child was rebellious and disobedient (Bremmer, 1970, cited in Walker, Bonner & Kaufman, 1988). The idea that every child born has a right to live is a new concept (Piers, 1978). It is difficult to learn much about infanticide prior to the 1800 s as record keeping on the topic was sporadic. Whenever infanticide was an economic necessity for an entire community, it remained an unquestioned practice and, one must assume, was not considered worth recording (Piers, 1978, p.44). That infanticide did occur frequently in medieval England is beyond dispute (Damme, 1978, p.2). The recorded figures from the 1800 s are appalling. For example, in 1860, there were more than 100,000 deaths of infants under age 1 in England and Wales. In the late 1870 s the 0-1 age group was less than 3 percent of the population but represented 50 percent of the murders. By 1900, this age group had dropped to 35 percent of all murders and this percentage stayed relatively constant until the 1920 s (Rose, 1986). The death of surplus or unwanted babies was a biological necessity at a time when birth control was scarcely understood and it is only as the birth rate fell at the very end of the last century that the value of infant life correspondingly rose (Rose, 1986, p. 187). A case in point is the wet nurse system. Wet nurses were women who nursed other women s babies. Up until the 20 th century there was no way to keep an infant alive unless the mother fed it. A few women were unable to nurse because of medical problems. Many women chose not to nurse babies due to preference or pressure from husbands or friends. Some women needed to work and nursing was impossible or inconvenient. Thus, a popular alternative to nursing one s baby was to hire a wet nurse. In 1873 an ad wanting to hire a wet nurse appeared on average every six days in London. Hospitals also kept registers of wet nurses even though wet nursing was considered a quick but effectual mean of infanticide (Rose, 1986, p.52). Wet nurses took on many babies (sometimes six or more!) in order to earn a sufficient wage. Obviously, not all of the babies survived. It is estimated that 80 percent of illegitimate children The CPS Response to Child Neglect Page 18

The State of Child Neglect placed in the care of wet nurses died. In some cases, the child s death was deliberate. The wet nurses accepted the infants, collected the fee, then killed the babies (Kempe & Kempe, 1978, cited in Walker et al., 1988; Radbill, 1974). It is ironic that the development leading to the fall of the wet nurse system was not a medical concern, a moral concern, or a legal sanction. It was, instead, von Liebig s Malted Milk Extract in 1867 that gradually ousted the wet nurse system by the turn of the century. Physical neglect and lack of supervision have an equally long history. English common law identified parents as responsible for the maintenance, care, protection, and education of their children. Rather than demanding that parents promote optimal development of their children, the government should interfere only when minimal standards of care are not met. Thus, the state or government should intervene only in cases of actual or likely harm (Swift, 1995). Two historical principles still influence today s interventions. One is the principle of less eligibility which states that government assistance should be less desirable than the earnings of the lowest-paid laborer. The second principle is the perception of need. Some people are in need because of their own failings while others are the victims of natural disasters, social forces or economic factors beyond their control. The British Poor Laws legitimated the idea that there was a distinction between worthy poor and unworthy poor (Swift, 1995). The English Poor Law of 1601 placed public responsibility for the poor on local townspeople. Localities could investigate complaints of maltreatment and children of the unworthy poor could be separated from their parents through indenture or placement in institutions. In the United States, many of the original 13 colonies had laws against some forms of child maltreatment (Besharov, 1988). The volunteer charity organizations formed following the American Revolution provided an investigative function through friendly visitors who also dispensed advice and inspiration. Child protection efforts through private, non-profit agencies began in the late 1800 s. The demands of urbanization and industrialization in the late nineteenth century resulted in many children being left unattended. In 1853, Charles Loring Brace, responding to the huge number of homeless children in New York City, formed the Children s Aid Society to Rescue Children. Over the next 75 years, the Society sent more than 150,000 children by train to live with Midwest farm families. During most of the nineteenth century, destitute children were sent to institutions such as foundling hospitals or almshouses operated by private, charitable organizations. When children were 9 or 10, they were typically indentured as servants or apprenticed to learn a skill (Schene, 1998; Swift, 1995). During the second half of the nineteenth century, orphanages and children s asylums were established to keep children from being housed with needy adults and to protect them from disease and exploitation they faced in mixed almshouses. In 1877, New York passed a law to protect children and to punish those who maltreated them. Anticruelty societies then had a legal mandate to identify maltreated children. By the early twentieth century, over 300 Societies for the Prevention of Cruelty to Children (SPCC) operated under the umbrella of the American Humane Association (Schene, 1998). These agencies uncovered cases of abuse and neglect. Eventually, staff worked with law enforcement and were given the power to take custody of vulnerable children pending an investigation. The CPS Response to Child Neglect Page 19

The State of Child Neglect Gradually, ideas of family rehabilitation competed with the strategy of removing children and the Societies began to address community neglect of poor housing and harmful neighborhood conditions. In 1909, White House Conference on Children issued a policy statement that children should not be removed from their families simply for reason of poverty. The Child Welfare League of America formed in 1920, joining the American Humane Association and other organizations in stressing the need to preserve families. Private organizations began the movement into the public domain. In the 1920 s only one state, Indiana, actually had a governmental body which fulfilled the duties being covered by SPCC elsewhere. By the middle of this century, however, that changed. Public agencies were developed to take responsibility for delivering services to abused and neglected children and their families. Some humane societies and SPCCs merged with public welfare agencies so that in many of newly formed government boards, personnel long associated with SPCC tradition continued to influence policy (Farestad et al., 1995). The growing acceptance by states, counties and municipalities of responsibility for child protection symbolized a new era in the child protection movement. The Social Security Act of 1935 marked the federal government s foray into child protection. Two titles, Title IV-A and Title IV-B addressed the needs of children. Title IV-A established ADC (later AFDC) acknowledging the financial needs of children through cash payments to enable poor, single mothers to retain custody of their children. Title IV-B (Child Welfare Services) encouraged states to develop, strengthen, or expand preventative and protective services for vulnerable children by providing limited federal funding to states through formula grants (Farestad et al., 1995, p.5). Up to this point, the major goal of both private and public child protection services was the provision of services. The emphasis was casework, with the focus on enriching family life and supporting families through services. While this focus was not eliminated with the advent of the Social Security Act, there were changes. Title IV-B significantly impacted the process by providing funds for a substitute care system - foster care - but not for supportive services to families with children in the home. Still, social work casework continued an emphasis upon rehabilitation and provision of services. It was not until after World War II that the next major advance would happen. In the 1960 s Helfer & Kempe published their landmark book, The Battered Child, based on analysis of emergency room data. The development of X-rays allowed for detection of old injuries, and medical professionals were felt to be in a position to detect physical abuse. In 1963, Dr. Kempe and other physicians persuaded the United States Children s Bureau to draft a model law that required physicians to report children with serious physical injuries inflicted other than by accidental means (Besharov, 1988). Between 1963 and 1967 each state passed child abuse and neglect reporting laws, designating some professionals who work with children (primarily medical staff) as mandated reporters of suspected child abuse and neglect. In the ensuing years, many states expanded their reporting laws to make more types of maltreatment reportable and to increase the categories of required reporters, but The CPS Response to Child Neglect Page 20

The State of Child Neglect change was slow and unpredictable (Besharov, 1988). It was not until after 1974 when federal legislation broadened the definitions to include neglect and sexual abuse and encouraged states to enact reporting laws requiring a broad range of professionals to report, that the numbers of reported cases began to climb. In 1974, the Child Abuse Prevention and Treatment Act (P.L. 93-247, also called CAPTA) offered incentives to states to pass comprehensive laws for identifying, reporting, and responding to child abuse and neglect. CAPTA also established the National Center on Child Abuse and Neglect as an agency within the federal Department of Health and Human Services. CAPTA allocated approximately $60 million in federal funds to assist states in developing child protection programs. Over the next years, all 50 states enacted child abuse reporting laws. Most states revised their laws to include a wider group of mandated reporters. The early years of child protective services allowed for comprehensive responses. This included counseling and services for domestic violence. While reports were increasing, the numbers were still low enough to enable workers to offer therapeutic intervention services. In 1980, Congress passed PL96-272, the Adoption Assistance and Child Welfare Act. This was an attempt to develop a national child welfare policy. The Act tied foster care funding to the implementation of policies related to family preservation and permanency planning. It also provided that each identified child have a case plan and that the plan be followed. However, since the mid- 1980 s the full implementation of PL96-272 has been hindered by both the increasing number of children identified as abused and neglected and the serious limitations of service resources in most American communities (Farestad et al., 1995, p.6). By the late 1980 s the system had become rigid, formal, and adversarial. One response was being given to all complaints. It was an investigative system rather than a family friendly one. The CPS system developed legal overtones with evidence becoming a primary focus. Mandatory reporting, combined with heightened public awareness and ease of reporting to toll-free lines, led to extraordinary increases in the number of reports (Gelles, 1999). The American Humane Association statistics indicate that by the end of 1993 there was a 347 percent increase in reports of child maltreatment over 1976 figures. Reporting rates rose from 4 per 1,000 children in 1975 to 31 per 1,000 children in 1985 to 47 per 1,000 in 1994 (Waldfogel, 1998). While the numbers of neglected children rose (according to national studies such as NIS-3), the actual numbers of countable children investigated by CPS remained stable. Thus, the percentages of maltreated children who received a CPS investigation decreased significantly, suggesting that the CPS system had reached its capacity to respond to the maltreated child population (Sedlak & Broadhurst, 1996). Studies on reporting suggested problems with both over-reporting and under-reporting. Studies of mandatory reporting show on average, that more than 30 percent of clinicians sometimes suspect that one of their cases involves child maltreatment but fail to report it (Melton et al., 1995, p. 51). On the other hand, the requirement to report mere suspicion of maltreatment along with penalties for failure to report, establishes conditions that encourage a large number of reports. Half or more will not be substantiated. The vagueness of legal standards and definitions compounds reporting issues The CPS Response to Child Neglect Page 21

The State of Child Neglect and can lead to either over-reporting or under-reporting (Melton et al., 1995). The focus of CPS had shifted to investigation because investigation was mandated and staff was stretched too far to both investigate and to provide comprehensive services. Foster care had become a primary intervention strategy due to lack of intensive treatment. Out-of-home placements grew to 500,000 (Gelles, 1999). Education and experience requirements for child protective service staff had declined. Ninety percent of states were experiencing difficulty recruiting CPS staff. Nationwide, there was variation in policy and program implementation for child protective services. And, there was an increasing lack of public confidence in the CPS system both by those utilizing the system and by those administering it (Farestad, 1995). In 1990, the U.S. Advisory Board on Child Abuse and Neglect concluded that child abuse and neglect represented a national emergency. They found the sheer scope of the problem to be overwhelming, and reported that the CPS system was failing. They found that the nation was spending an enormous amount of money on a system based on the nation s failure to prevent abuse and neglect. It was a system focused on reporting and investigation. Too often an investigation seems to occur for its own sake, put succinctly, the system is not child-centered (Melton and Barry, 1994, p.5). At that time, the Board put forth a strategy for a new response. It suggested federal programs be: a) sufficiently intensive and diverse as to provide communities with the support they need to develop a comprehensive neighborhood-based, child-centered, and family-focused approach to child protection; and, b) sufficiently flexible so as to adapt to the needs of specific states, tribes, and communities as well as to the necessary changes as neighborhood-based strategy is tested and evolves. They suggested a specific strategy with five basic elements: 1) strengthening urban, suburban and rural neighborhoods as environments for children and families; 2) reorienting the service delivery system so that providing services to prevent child maltreatment and other forms of family disintegration is as easy as placing a child in foster care; 3) improving the role of government in child protection; 4) reorienting societal values that may contribute to child maltreatment; and 5) strengthening and broadening the knowledge base about child maltreatment. More recently, the Family Preservation and Support Initiative (PL 103-66) in 1993 provided funding for family preservation and support services to families in danger of having children removed. This Initiative has encouraged the growth of in-home services, such as Family Preservation programs and Healthy Families Programs. Home-visitation prevention programs, in general, have shown positive results if they are intensive and comprehensive. Changes in parent behaviors, home environments, and child behaviors have been documented (Olds & Kitzman, 1993). Strategies for Change Many states are facing the challenge to change child protection strategy. One suggestion has been to discontinue a dual investigative system where CPS investigates child abuse reports when the perpetrator is a caretaker and law enforcement investigates reports when the child and offender are not related (Krugman, 1997). This proposal would give law enforcement the responsibility to conduct the investigations, thus freeing millions of dollars of time for social workers who could then The CPS Response to Child Neglect Page 22

The State of Child Neglect concentrate on intervention. The social worker, then, would not have the dual role of investigator and helper. This idea has found only limited support. The assumption of reallocation of funds from investigation to intervention is not supported historically. Police, while possibly more skilled at investigative procedures, are not trained to assess family needs and begin therapeutic intervention. Additionally police are often not trained in child development, child interviewing, and specialized child abuse investigation techniques. Since assaults against children constitute a small portion of police complaints, without the influence of CPS, many child abuse or neglect cases may not receive the priority and response required for effective intervention (Hutchinson, Dattalo, & Rodwell, 1994). Furthermore, history suggests that dual relationships between CPS and law enforcement have been beneficial in the past. For example, the joint police-social work investigation teams are considered highly effective. Also, community and multidisciplinary teams with representatives from various disciplines have functioned very effectively for diagnosis and treatment planning. A second strategy is to further narrow the definitions used by CPS. This would involve stricter screening with the aim of reducing the number of complaints accepted. Only the most severe cases, involving serious physical injury, risk of imminent harm or sexual abuse would be eligible for CPS intervention (Waldfogel, 1998). What might this mean for cases of neglect? Since neglect cases are often seen as non-emergencies, it is likely that a disproportionate number would be screened out. It is not clear where these families would then receive assistance. Neglect referrals to CPS sometimes result when families fail to cooperate with or benefit from community services. Without intervention, the neglect is likely to worsen to the point that it meets criteria for CPS attention. A third strategy is to narrow the scope of CPS responsibility (Besharov, 1998; Pelton, 1998). For example, some states do not routinely investigate complaints of truancy from schools (educational neglect), but instead schools refer truant students directly to the juvenile court. Investigating fewer reports saves resources and allows more time to respond to serious neglect cases. There are several reforms suggested by Besharov (1998) to reduce the number of complaints. First, reporting laws can adopt more specific definitions about which conditions require reporting. Improvements in public and professional education can assist reporters in knowing when to report. However, since the general public has a broader definition of neglect and a lower tolerance for neglectful conditions, it will likely take considerable efforts to change public perceptions of the CPS mandate. Reports can be screened by CPS before being accepted for investigation. Feedback should be given to reporters so they become more aware of the limitations and actions of the CPS agency. Since penalties for failure to report have led to over-reporting, liability laws could be modified so that reporters who, in good faith, decide that a child has not been abused or neglected are not liable for damages to that child should they have been mistaken (Besharov, 1998). The CPS Response to Child Neglect Page 23

The State of Child Neglect A fourth strategy for change is the development of community-based, differential response systems where CPS partners with agencies and citizens to provide better services to families-at-risk or families already experiencing child maltreatment. (Waldfogel, 1998; Weber, 1998). What is a Differential Response System? Differential Response Systems have three key elements. First, a customized response, recognizing the great diversity in families, is required. Second, CPS is not a single agency acting alone in order to ensure child safety. Rather, CPS takes a lead role (especially for serious cases) but works collaboratively with the criminal justice system and with public and private agencies to provide a full range of prevention and intervention services. Third, recognizing the importance of family support, this approach uses informal and natural helpers, drawn from families and communities to be active partners with CPS and other agencies in ensuring child protection (Waldfogel, 1998). A Differential Response System encourages local departments of social services to formalize agency and community relationships that offer assistance and intervention to families at risk of child abuse and neglect. A Differential Response System also recognizes the need for formal agreements with law enforcement and the Office of the Commonwealth Attorney that support a joint response to the most serious child maltreatment reports. Examples of CPS responses available in a Differential Response System include: Referral Response - If the child protective services report does not meet the definition of abuse or neglect, the local department makes referrals as needed and appropriate. Assessment Response - If the CPS report is valid, but safety concerns for the child appear to be low, the CPS worker conducts a family needs assessment. When appropriate, families are offered services through the local department or community agencies that emphasize prevention and assistance. Investigation Response - Where safety concerns for the child appear to be high, the traditional CPS response is performed. In many instances, investigations will be conducted in cooperation with law enforcement agencies. Initial data from pilot sites in Virginia, Iowa, Missouri, and Florida using a Differential Response System suggest that investigations can be reduced by as much as 70 percent (Grayson, 1997; Grayson, 2001; Waldfogel, 1998). Since fewer cases are investigated, the percentage of founded cases is higher, while the numbers of founded cases are reduced by as much as half. Less than five percent of cases assigned to Assessment are in need of reassignment to Investigation. Assessment services are voluntary, although a family refusing services may ultimately be transferred to Investigation, which is not voluntary. Since parents are partners with professionals in the Assessment Response, workers develop closer working relationships with families. Problems are conceptualized differently, as well, with greater emphasis on underlying factors (Waldfogel, 1998). The CPS Response to Child Neglect Page 24

The State of Child Neglect A Differential Response Model has profound implications for cases of neglect. Neglect cases are likely to be assigned to Assessment rather than to Investigation Response. A Strengths-Based Model Implicit in a Differential Response System is the use of a strengths-based model for case management. Research suggests this approach results in a high level of individual goal attainment, improved vocational and independent living status, and high levels of consumer satisfaction (Virginia DSS, 1996). The strengths-based system embodies six principles which guide the intervention process. These principles are: 1. Most persons with allegations of child abuse/neglect possess the inherent capacity to learn, grow and change; 2. The focus is on individual strengths, not deficits or pathology. However, factors which may impact on safety of the child must also be identified quickly; 3. The helping process is guided by rigorous standards of consumer self-determination as long as safety of the child can be maintained; 4. The consumer-case manager relationship is primary and essential; 5. The community is viewed as an oasis of resources, not as an obstacle or a target to blame; 6. Community integration is fostered by assertive outreach. This model for case management is essential under a Differential Response system for child neglect. This collaborative and support-building approach enhances the chances of a family accepting services and, therefore, becoming better equipped to keep children safe in the future. Community Partnerships In forming community partnerships, several facets of the CPS system need to be preserved. For example, CPS needs to maintain its clear focus on child safety and resources for authoritative intervention to protect a child when necessary. Other aspects of CPS can change, such as the extent to which CPS is (or appears to be) intrusive, punitive and blaming of families. Several states have begun the process of change. In reviewing their actions, one finds that states and communities choose different starting points for change. Some have changed the investigative process, necessitating legislative action. Florida, Missouri, Hawaii, Virginia and Iowa are examples. Others have begun with the focus on service delivery at the local level rather than changing statutes and the CPS investigation process. An example can be found in Louisville, Kentucky. The CPS Response to Child Neglect Page 25

The State of Child Neglect What does it mean for the community to be responsible for protecting children? There are many possible responses, both large and small. These include: Neighbors helping neighbors. A neighbor can offer babysitting or moral support. Networking. Major helping agencies can combine efforts to provide intensive service or accomplish a specific goal. Engaging parents. Community forums, door-to-door contacts, child health fairs or other outreach can offer assistance to parents. Community planning. Local data, desires and opinions should shape the services offered. Communities can examine what is effective and what is not. Continuing Challenges Child advocates dealing with neglect have many challenges. The largest is how to promote positive, ongoing adult (preferably parental) involvement in the life of each child. For a child to develop competence requires the involvement of caring, capable adults in the child s life. Ensuring that every child has this fundamental protective system is a policy imperative (Masten & Coatsworth, 1998). Garbarino stated this challenge well. He wrote, First and foremost, children cost time and personal investment. It is the time spent listening to, talking with, caring for, playing with and responding to children that produces good child development and family well-being (1988, p.51). Child neglect is complex. It is the least well understood form of maltreatment. Cases are numerous and the variety is extreme. Often, neglect occurs along with other forms of maltreatment. Agencies and workers can easily be overwhelmed. There is much to be learned about different types of neglect and little research to consult. The attachment and bonding problems associated with failure to thrive are likely to require a somewhat different response than a complaint of lack of supervision for a preteen. The need to customize responses and the flexibility to respond in varied ways will be an ongoing challenge. Communities are challenged to provide coordinated responses to child neglect. Considering the overlap between child neglect and addictions, depression, and mental retardation, it is obvious that mental health treatments need to be available and coordinated with child protection efforts. Major decisions need to be made about the degree of support to offer families in order to keep children with biological parents. Many problems leading to child neglect are permanent or ongoing and require support until the child is grown. The value of keeping families together competes with the values of independence, self-determination and individual responsibility. If CPS is to serve fewer families, what alternative systems will support the families screened out of CPS? If CPS is to partner with other agencies, will these agencies have the resources to offer? How will a coordinated response be accomplished? If informal helpers are to be utilized, are they The CPS Response to Child Neglect Page 26

The State of Child Neglect available in impoverished neighborhoods where many children at risk for neglect live? The greatest hope of preventing further neglect is to provide effective services and supports to struggling families. Current literature suggests that long-term, multi-service, comprehensive models are the best choice for chronically neglecting families. Since neglect has proven to be a particularly damaging form of maltreatment, greater attention must be focused on developing effective interventions. The CPS Response to Child Neglect Page 27

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The State of Child Neglect Kaplan, S. J., Pelcovitz, D., & Labruna, V. (1999). Child and adolescent abuse and neglect research: A review of the past 10 years. Part I: Physical and emotional abuse and neglect. Journal of the American Academy of Child Psychiatry, 38(10), 1214-1222. Keltner, B., & Tymchuk, A. (1992). Mothers with mental retardation: New challenges facing nurses. American Journal of Maternal Child Nursing, 17, 136-140. Kemp, A., & Sibert, J. R. (1992). Drowning and near drowning in children in the United Kingdom: Lessons for prevention. British Medical Journal, 304, 1143-1146. Kids Count Data book: state profiles of child well-being, (1998). Available from Annie E. Casey Foundation, 701 ST. Paul Street, Baltimore, MD 21202, (410) 547-6624. Internet www.aecf.org. Kinard, E. M. (1982). Child abuse and depression: Cause or consequence? Child Welfare, 61(7), 403-413. Kinard, E. M. (1996). Social support, competence, and depression in mothers of abused children. American Journal of Orthopsychiatry, 66(3), 449-462. Klehr, K. B., Cohler, B. J., & Musick, J. S. (1983). Character and behavior in the mentally ill and well mother. Infant Mental Health Journal, 4, 250-271. Krugman, R. D. (1997). Three wishes for the future of child protection. APSAC Advisor, 10(10), 2-3. Landry, M. J. (1997). Overview of addiction treatment effectiveness. Rockville, MD: Substance Abuse and Mental Health Services Administration. Lewit, E. M., Terman, J. D., & Behrman, R. E. (1997). Children and poverty: Analysis and recommendations. In R. E. Behrman (Ed.), The Future of Children: Children and Poverty, Vol. 7, (pp. 4-24). Los Altos, CA: Center for the Future of Children and The David and Lucile Packard Foundation. Lloyd, D. W. (1993). A review of selected journal articles on child neglect research: 1988-1991. Symposium on Chronic Neglect, Washington, D.C.: National Center on Child Abuse and Neglect. Ludwig, S. (1992). Failure-to-thrive/starvation. In S. Ludwig & A. E. Kornerg (Eds.), Child abuse: a medical reference. (pp. 303-319). New York, NY: Churchill Livingstone, Inc. Mammen, O., Shear, K., Jennings, K., & Popper, S. (1997). Case study: Ego-dystonic anger attacks in mothers of young children. Journal of the American Academy of Child and Adolescent Psychiatry, 36(10), 1374-1377. Margolin, L. (1990). Fatal child neglect. Child Welfare, 64(4), 309-319. The CPS Response to Child Neglect Page 32

The State of Child Neglect Masten, A. S., & Coatsworth, J. D. (1998). The development of competence in favorable and unfavorable environments. American Psychologist, 53(2), 205-220. Mathews, T. J., & Ventura, S. J. (1997). Birth and fertility rates by educational attainment: United States, 1994. Monthly Vital Statistics Report, 45 (10). McConnell, D., Llewellyn, G., & Bye, R. (1997). Providing services for parents with intellectual disability: Parent needs and service constraints. Journal of Intellectual and Developmental Disability, 22(1), 5-17. McCoy, E. (1981, January). Childhood throughout the ages. Parents, 61-65. McGovern, P. J. (1993). Redefining child neglect: An American perspective. American Journal of Family Law, 7(4), 85-204. Melton, G. B., & Barry, F. D. (1994). Protecting children from abuse and neglect foundations for a new national strategy. New York: The Guilford Press. Melton, G. B., Goodman, G. S., Kalichman, S. C., Levine, M., Saywitz, K. J., & Koocher, G. P. (1995). Empirical research on child maltreatment and the law. Journal of Clinical and Child Psychology, 24(Suppl.), 47-77. Meriwether, M. H. (1988). Child abuse reporting laws: Time for a change. In J. Besharov (Ed.) Protecting children from abuse and neglect (pp. 9-45). Springfield, Illinois: Charles C. Thomas. Milgrom, J., & McCloud, P. (1996). Parenting stress and postnatal depression. Stress Medicine, 12, 177-186. Monopoli, P. A. (1991). Allocating the costs of parental free exercise: Striking a new balance between sincere religious belief and a child s right to medical treatment. Pepperdine Law Review, 18(2), 319-352. Mowbray, C. T., Oyserman, D., Zemencuk, J. K., & Ross, S. R. (1995). Motherhood for women with serious mental illness: Pregnancy, childbirth, and postpartum period. American Journal of Orthopsychiatry, 65(1), 21-38. Mowbray, C. T., Oyserman, D., Saunders, D., & Rueda-Riedle, A. (1998). Women with severe mental disorders: Issues and service needs. In B. L. Levin, A. K. Blanch, A. Jennings (Eds.) Women s mental health services. Thousands Oaks, CA: Sage Publications. Myers, J. E. B. (1989, April). The shifting boundaries of medical neglect. The ASPAC Advisor, 2(2), 5. National Clearinghouse on Child Abuse and Neglect. (1999). Highlights of findings. [Online]. Available: www.acf.dhhs.gov/programs/cb. The CPS Response to Child Neglect Page 33

The State of Child Neglect National Research Council. (1993). Understanding child abuse and neglect. Washington, DC: National Academy Press. O Keefe, M. (1995). Predictors of child abuse in maritally violent families. Journal of Interpersonal Violence, 10(1), 3-25. Olds, D. L., & Kitzman, H. (1993). Review of research on home visiting for pregnant women and parents of young children. In R. E. Behrman (Ed.), The Future of Children, Vol. 8, (pp. 53-92). Los Altos, CA: Center for the Future of Children and The David and Lucile Packard Foundation. Parker, G. (1979). Parental characteristics in relation to depression disorders. British Journal of Psychiatry, 134, 138-147. Pelton, L. (1993). The concept of child neglect and the attribution of causality. Chronic neglect symposium proceedings, (p. 13). Washington, DC: National Center on Child Abuse and Neglect. Pelton, L. (1998). Commentary three: How we can better protect children from abuse and neglect. In R. E. Behrman (Ed.), The Future of Children: Protecting Children from Abuse and Neglect, Vol. 8, (pp. 126-129). Los Altos, CA: Center for the Future of Children and The David and Lucile Packard Foundation. Piers, M. (1978). The social context of child abuse and neglect. Toronto, Canada: W. W. Norton and Company. Polansky, N. A., Hally, C., & Polansky, N. (1975). Profile of neglect: a survey of the state of knowledge of child neglect. Washington, DC: U. S. Department of Health, Education, and Welfare. Purschwitz, M. A. (1990). Fatal farm injuries in children. Marshfield, WI: Wisconsin Rural Health Center, 17. Radbill, S. (1974). A history of child abuse and infanticide. In R. Helfer & C. H. Kempe, The battered child, 2 nd Ed. (Pp. 3-21). Chicago, IL: The University Of Chicago Press. Resnick, P. (1970). Murder of the newborn: A psychiatric review of neonaticide. American Journal of Psychiatry, 126(10), 1414-1420. Rivara, F. P. (1985). Fatal and nonfatal farm injuries to children and adolescents in the United States. Pediatrics, 76(4), 567-573. Rivera, P. A., Rose, J. M., & Futterman, A., Lovett, S. B., & Gallagher-Thompson, D. (1991). Dimensions of perceived social support in clinically depressed and nondepressed female caregivers. Psychology and Aging, 6(2), 233-237. Rose, L. (1986). The massacre of the innocents. Boston, MA: Routledge and Kegan Paul. The CPS Response to Child Neglect Page 34

The State of Child Neglect Rose, S., & Meezan, W. (1997). Defining child neglect: Evolution, influences, and issues. In J. D. Berrick, R. P. Barth, & N. Gilbert (Eds.), Child Welfare Research Review, 2 (pp. 13-27). New York, NY: Columbia University Press. Runyon, D. K., Hunter, W. M., Everson, M. D., & Bangdiwala, S., et al. (April 8, 1997). Longitudinal studies of child abuse and neglect, LONGSCAN: the first 5 years at the coordinating center, North Carolina site and Seattle site, 1991-1996. Washington, DC: National Center on Child Abuse and Neglect (DHHS). Schene, P. A. (1998). Past, present, and future roles of child protective services. In R. E. Behrman (Ed.), The Future of Children: Vol. 8 (pp. 23-38). Los Altos, CA: Center for the Future of Children and The David and Lucile Packard Foundation. Sedlak, A. J., & Broadhurst, D. D. (1996). Executive summary of the third national incidence study of child abuse and neglect. Washington, DC: National Clearinghouse on Child Abuse and Neglect Information. Susman, E. J., Trickett, P. K., Iannotti, R. J., Hoellenbeck, B. E., & Zahn-Waxler, C. (1985). Child-rearing patterns in depressed, abusive, and normal mothers. American Journal of Orthopsychiatry, 55(2), 237-251, Swan, R. (1998, Spring). Religion-based medical neglect and corporal punishment must not be tolerated. The ASPAC Advisor,11(1). Swift, K. J. (1995). Manufacturing bad mothers : a critical perspective on child neglect. Toronto: University of Toronto Press. Taylor, C. G., Norman, D. K., Murphy, J. M., & Jellinek, M., et al. (1991). Diagnosed intellectual and emotional impairment among parents who seriously mistreat their children: Prevalence, type, and outcome in a court sample. Child Abuse and Neglect, 15(4), 389-341. Teti, D. M., Gelfand, D. M., Messinger, D. S., & Isabella, R. (1995). Maternal depression and the quality of early attachment: An examination of infants, preschoolers, and their mothers. Developmental Psychology, 31(3), 364-376. Thompson, R. A. (1994). Social support and the prevention of child maltreatment. In G. B. Melton & F. D. Barry (Eds.) Protecting children from abuse and neglect (pp. 40-130). New York, NY: The Guilford Press. Trainor, C. M. (1983). The dilemma of child neglect: An introduction to the problem. In C. M.. Trainor, (Ed.) The dilemma of child neglect: identification and treatment. Denver: The American Humane Association. Tymchuk, A. J. (1992). Predicting adequacy of parenting by people with mental retardation. Child Abuse and Neglect, 16(2), 165-178. The CPS Response to Child Neglect Page 35

The State of Child Neglect U. S. Advisory Board on Child Abuse and Neglect. (1990). Child abuse and neglect: critical first steps in response to a national emergency. Washington, DC: Department of Health and Human Services. U. S. Advisory Board on Child Abuse and Neglect. (1993). Neighbors helping neighbors: A new national strategy for the protection of children, 4 th report. Washington, DC: Department of Health and Human Services. U. S. Advisory Board on Child Abuse and Neglect. (1995). A nation s shame: fatal child abuse and neglect in the United States. Washington, DC: Department of Health and Human Services. Ventura, S. S., Mosher, W. D., Curtin, S. C., Abma, J. C. (2001). Trends in pregnancy rates for the United States, 1976-1997: An update. National Vital Statistics Reports, 49(4). Hyattsville, MD: National Center for Health Statistics. Virginia DSS. (1996). A report on implementing the multi-response system for child protective services in Virginia. Richmond, VA: Virginia Department of Social Services. Waldfogel, J. (1998). The future of child protection. Cambridge, MA: Harvard University Press. Walker, E., Bonner, B., & Kaufman, K. (1988). The physically and sexually abused child: evaluation and treatment. New York, NY: Pergamon Press. Weber, M. W. (1998). Commentary Four: How we can better protect children from abuse and neglect. In R. E. Behrman (Ed.), The Future of Children: Protecting Children from Abuse and Neglect, Vol. 8, (pp. 129-132). Los Altos, CA: Center for the Future of Children and The David and Lucile Packard Foundation. Wolch, J., & Dear, J. (1993). Malign neglect. San Francisco, CA: Jossey-Bass Publishers. Wolock, I., & Horowitz, B. (1984). Child maltreatment as a social problem: The neglect of neglect. American Journal of Orthopsychiatry 54(4), 530-541. Yoast, R. A., & McIntyre, K. (1991). The relationship between child maltreatment and alcohol and other drug abuse. Alcohol, other drug abuse and child abuse and neglect, 14-40. Madison, WI: Wisconsin Clearinghouse: University of Wisconsin-Madison. Zuravin, S. J. (1989). Severity of maternal depression and three types of mother-to-child aggression. American Journal of Orthopsychiatry, 59, 377-389. Zuravin, S. J. (1991). Research definitions of child physical abuse and neglect: Current problems. In R. H. Starr & D. A. Wolfe (Eds.), The effects of child abuse and neglect: issues and research. (pp. 100-128). New York: The Guilford Press. The CPS Response to Child Neglect Page 36

II. Issues Pertinent to Defining Child Neglect Susan Zuravin, Ph.D. For over two decades those whose area of interest lies in the field of child maltreatment have complained (e.g., Zigler, 1976; Besharov, 1981; Hutchinson, 1990; National Center on Child Abuse and Neglect, 1987)) about the absence of uniform and precise definitions of child maltreatment and its four subtypes: neglect, physical abuse, sexual abuse and emotional mistreatment. To illuminate current and past definitional problems, this chapter will examine selected issues regarding how to define child neglect. Neglect is a particularly important focus of attention for three reasons. First, it is the most prevalent type of all forms of maltreatment (U.S. Department of Health and Human Services, 2001). Second, it results in more harm to children than physical abuse, sexual abuse and emotional mistreatment (U.S. Department of Health and Human Services, 1996). Third, it has been the focus of less research attention, in part, because of definitional problems than physical and sexual abuse. (Wolock & Horowitz, 1984; Dubowitz, 1994) This chapter will discuss six issues that have arisen over the years with respect to defining child neglect, including failure to provide/protect, severity, chronicity, age of the child, locus of responsibility and intentionality, and harm. Overview In 1974, United States Public Law 93-247 was passed by Congress. The primary goal of this legislation, named the Child Abuse Prevention and Treatment Act (CAPTA), was to protect America s children from abuse and neglect. Specific objectives included establishment of the National Center on Child Abuse for funding of research and demonstrations on child maltreatment and the requirement that individual states have in effect a child abuse and neglect law modeled after the above federal statute to qualify for federal assistance. The definition of maltreatment embedded in CAPTA was: The physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment of a child under the age of 18, or the age specified by the child protection law of the state in question, by a person who is responsible for the child s welfare under the circumstances which indicate that the child s health or welfare is harmed or threatened thereby as determined in accordance with regulations prescribed by the Secretary (P.L. 93-247, section 2). Susan Zuravin, Ph.D., MSW, is a Professor at the University of Maryland School of Social Work. The CPS Response to Child Neglect Page 37

Issues Pertinent to Defining Child Neglect In effect, CAPTA: defines maltreatment as both acts of a caretaker and consequences for the child; places blame for the act or omission on the child s caretaker; separates neglect from other types of maltreatment, and vaguely and imprecisely defines neglect (negligent treatment), and other types of maltreatment. In other words, no guidelines or specific evidentiary criteria were identified for neglect or any other type of maltreatment. What Led Up to Passage of CAPTA? Presaging enactment of this legislation was a long period of social advocacy almost exclusively with respect to physical abuse of children. Two specific situations and their aftermath were noteworthy with respect to the child advocacy movement surrounding child abuse. In 1874, the case of Mary Ellen, a 10-year-old girl who was severely beaten and neglected by her stepparents, caught the attention of the United States public when her stepparents were adjudicated in criminal court for their treatment of this young girl. In the same year and in response to the case of Mary Ellen, the Society for Protection of Cruelty to Children (SPCC) was formed. This organization (later named the Society for the Prevention of Cruelty to Children and part of the American Humane Association) was one of the first and most vociferous to advocate strongly and vigorously for children s rights. Until the early 20 th century, it also worked in the arena of service delivery with maltreating parents and their children as well as providing advice to the courts (Cicchetti & Barnett, 1991). Perhaps most influential in the passage of CAPTA was the discovery in the late 1940 s and early 1950 s of the battered child syndrome (Caffey, 1946; Silverman, 1953). However, it was not for almost 15 years from its initial discovery that cases of infants with multiple fractures and intracranial bleeds, known as battered children, became the subject of attention and drew a vigorous response from the medical community. In 1961, Kempe and his colleagues convened a seminar on the syndrome at the annual meeting of the American Academy of Pediatrics. They followed up on this seminar in 1962 with the now noteworthy and then influential article entitled, The battered child syndrome published in the 181 st edition of the Journal of the American Medical Association. The meeting and the paper led to a flurry of statewide legislation, which, in turn, led to child maltreatment reporting laws and the establishment of Central Registries in all 50 states prior to 1970. Eventually, but not without considerable help from federal legislators, a broadened CAPTA was passed in 1974 much to the disappointment of some of its advocates. Neglect, sexual abuse, exploitation, and a catchall term of maltreatment were added to the federal definition included in CAPTA. As Cicchetti and Barnett (1991) so well note, not only was it the advocacy that led to the passage of CAPTA but also accompanying changes in mores regarding the status and needs of children and the disadvantaged in society. Children were no longer being viewed as The CPS Response to Child Neglect Page 38

Issues Pertinent to Defining Child Neglect chattel of their parents existing to gratify the needs, however pathological, of their guardians. They were seen legally as having a right to the fulfillment of their developmental needs (Cicchetti & Barnett, 1991; p. 148). Moreover, changes in attitudes about the disadvantaged as well as their needs for services led to the development and initiation of regional centers for retarded children, Project Head Start, and Medicaid (Cicchetti & Barnett, 1991; p. 147). So, in the final analysis, it was the confluence of the social advocacy on behalf of child abuse laws and the change in societal mores regarding the rights of children and the disadvantaged that led to the CAPTA legislation. Child Neglect Definitional Activity Prior to and Immediately After Passage of CAPTA As noted previously, while the vast majority of efforts regarding child maltreatment before 1974 focused on physical abuse, there was some definitional work, although not great in magnitude, on child neglect. In the 1950 s the social work professionals involved with the American Humane Association (AHA) (an organizational amalgamation of two groups, the American Society for Preventing Cruelty to Children and the American Society for Preventing Cruelty to Animals) were the first to categorize neglect as an act of omission separate and apart from physical abuse as an act of commission (Giovannoni, 1989). More than that, however, they contributed to the distinction of child abuse and neglect as diagnostic entities, situations largely demarcated by parental behavior, with assumed noxious consequences for their children (Giovannoni, 1989; p. 8). Following the work of the AHA came the publication of the very first research study in the area of child maltreatment, Leontyne Young s Wednesday s Children: A Study of Child Neglect and Abuse (1964). In this child welfare agency, case record study, Young attempted to make clear distinctions between abusive and neglectful parents using three factors: interpersonal traits, the intent of the parent to maltreat a child, and the effects of the maltreatment (Rose & Meezan, 1993, p. 281). Neglect was conceptually defined differently from physical abuse in that it involved a failure to provide adequate care to children by emotionally needy mothers that was carried out without regard to intention. In other words, unlike physical abuse, neglect did not have to be intentionally produced or non-accidental on the part of the parent to be judged as neglect and it did not have to leave injuries. Four years following Young s seminal work, Norman Polansky (and his colleagues) began a prodigious body of work on child neglect (e.g., Polansky, Borgman, & DeSaix, 1972; Polansky, DeSaix, Wing, & Patton, 1968; Polansky, Hally, & Polansky, 1975, Polansky, Chalmers, Buttenwieser, & Williams, 1981). From a conceptual point of view he defined child neglect as a condition in which a caretaker fails to provide one or more of the ingredients deemed essential for developing a person s physical, intellectual, and emotional capacities (Polansky, et al., 1975; p. 5). Giovannoni (1989) comments that in this definition the consequences for children are seen to exist along a spectrum, one which concerns the child s development. At the upper level there is optimal development; at the threshold..there is essential or normal development (p. 15). It is very important to note that unlike the narrow harm definitions of child abuse that were and had been proffered, The CPS Response to Child Neglect Page 39

Issues Pertinent to Defining Child Neglect this is a broad definition with respect to its consequences. In addition to formulating a conceptual definition, Polansky and colleagues (Polansky, Borgman, & DeSaix, 1972) were among the very first researchers to formulate an operational definition, a measurement instrument for assessing the presence and severity of neglect. This instrument called The Childhood Level of Living Scale consisted of 136 items organized into two major parts, physical care and emotional/cognitive care, for a child around the age of five. It was used to assess a child s experiences by well-trained raters. Like Young (1964), Polansky does not include parental intention or willfulness as a part of his definition because he notes that there are complications in estimating parental willfulness (p. 51). Two years following passage of CAPTA, Katz, McGrath, and Howe (1976) published Child Neglect Laws in America. This comprehensive treatise included a detailed listing of the common, specific elements of neglect and the number of states that included these factors in their legal definitions (Rose & Meezan, 1993, p. 281). It also detailed factors that were peculiar to only a few states. The statutes of all states included lack of proper parental control or guardianship as an important element of its neglect definition. This term either expressly or implicitly referred to neglect as an omission or lack of adequate food, clothing, shelter, and supervision. In addition, 42 states included abandonment and 40 included parental refusal or inability to provide necessary medical, surgical, or other special care. Less than half of the states included provisions relating to immoral environment, failure to send a child to school, and/or moral, mental, or physical unfitness of parents. As Rose & Meezan (1993) so well note, state legislation solidified the idea that the lack of adequate food, clothing, shelter, medical care, and supervision, or abandonment, were the cornerstones of a definition of neglect (p. 281). The problem, unfortunately, with these state statutory definitions was that they were vague and imprecise i.e., they did not provide explicit, well-operationalized guidance as to where on the continuum of providing food, clothing, shelter, and supervision actually become neglectful for what age of child. Child Neglect Definitions Where are We Today? Two years after passage of CAPTA, Edward Zigler, first director of the federal Office of Child Development spoke at the First National Conference on Child Abuse and Neglect. In response to his own concerns and those of others about the feasibility of investigating a phenomenon (child maltreatment) that lacks widely acceptable definition (Hutchinson, 1990, p. 61), he recommended that resolving the definitional dilemma must become the first item of business among workers and judges (Zigler, 1977, p. 30). In other words, the problem of vague and imprecise definitions of maltreatment in general and the specific types mentioned in law must be resolved before courts can render decisions, clinical case managers can investigate and treat instances of maltreatment, and researchers can integrate findings on etiology, sequelae, and treatment effectiveness across studies. The CPS Response to Child Neglect Page 40

Issues Pertinent to Defining Child Neglect Was it the first item of business? What is the status of definitions today? Are they uniform and precise? Many efforts by a wide variety of professionals from different fields medicine, law, sociology, ecology, and research-- (e.g., Kempe, et al., 1962; Giovannoni & Becerra, 1979; Polansky et al., 1972; Juvenile Justice Standards Project, 1977; Belsky, 1980; Garbarino, 1976) have been aimed both before and after the passage of CAPTA at defining child maltreatment and its various subtypes. Unfortunately, however, these efforts have led to more points of unresolved controversy than consensus. Consequently, today, definitions of maltreatment in general as well as the specific types (neglect, physical abuse, sexual abuse, and emotional mistreatment) are still vague and imprecise. Definitions differ across professional groups i.e., legal, case management, and research as well as among professionals within each group. Moreover, none of the definitions are precise, meaning that they are not operationally defined by highly specific evidentiary criteria for determining whether the elements of the conceptual definition have actually occurred. Finally, a point regarding the definition of neglect needs to be underscored. Defining neglect has never really been a priority. Over time less effort has been spent defining it than either physical abuse or sexual abuse. Consequently, neglect has received less research attention than other forms of maltreatment Literature Review Strategy Two strategies were used to identify issues and controversies as well as content regarding the definition of child neglect. First, several computerized reference databases were searched-- Social Work Research and Abstracts, Sociological Abstracts, Medline, and that of the National Clearinghouse on Child Abuse and Neglect Information as well as the Internet with the terms child neglect definition, child maltreatment definition, and child neglect laws. Second, the bibliographies of identified articles were hand-searched for relevant articles, chapters, and reports. The preponderance of the relevant material focused either directly or indirectly on issues regarding the definition of child maltreatment in general. Two articles (Dubowitz, Black, Starr, Jr., & Zuravin, 1993; Rose & Meezan, 1993) and one chapter (Gelles, 1999) specifically addressed influences and issues relevant to defining neglect. In addition, the empirical work of several others (e.g., Polansky, et al., 1982; Magura & Moses, 1986; Giovannoi & Becerra, 1979; Wolock & Horowitz, 1977; Zuravin & Taylor, 1987; Barnett, Manly, & Cicchetti, 1993) either focused in part or in whole on creating conceptual and operational definitions of neglect. While a number of issues pertinent to child neglect and controversies pertinent to child maltreatment in general were identified, those identified for discussion in this paper failure to protect/provide, severity, chronicity, developmental age of the child, harm/threatened harm, and locus of responsibility and intentionality were chosen because they either appeared most frequently in the literature or seemed to be the most important. This section discusses the six issues. The content on four of the issues - failure to provide and failure to protect, age of child, chronicity, and severity - is divided into three parts: definition of the issue, examples of the issue, opposition and recommendations for The CPS Response to Child Neglect Page 41

Issues Pertinent to Defining Child Neglect improvement relevant to the issue. The content for harm/threat of harm and locus of responsibility and intention, the two most controversial issues, is divided into four parts: definition, examples, opposition, and solution(s) to the controversy. Issue: Failure to Provide and Failure to Protect Definitions of the issues. Of the four subtypes of child maltreatment physical abuse, sexual abuse, neglect, and emotional mistreatment the two latter types are the most heterogeneous in clinical appearance. Neglect includes multiples omissions in care including, dependent upon the definer, failure to provide adequate food, shelter, clothing, supervision, and medical as well as mental health care. Additionally, and according to some, it includes failure to protect from persons who may harm the child when in the position of temporary custodian such as those who have physically and sexually abused children, those who are mentally ill, and those who abuse substances. And finally, it may include educational neglect; abandonment and desertion; and moral, mental, or physical unfitness of the parent(s). Examples of the issues. Failure to provide manifestations are not only the earliest but the most well-recognized of the omissions that are identified as definitive of neglect both conceptually and operationally. In 1964, Leontyne Young (1964) defined neglect as inadequate feeding and lack of adequate clothing among other things. In 1966, the Children s Division of the American Humane Association (1966) noted regarding neglect that it is presumed that physical, emotional, and intellectual growth and welfare are being jeopardized when, for example, the child is (1) malnourished, ill clad, dirty, without proper shelter or sleeping arrangements; (2) without supervision, unattended; (3) ill and lacking essential medical care; (5) failing to attend school regularly (p. 25). Polansky and colleagues (Polansky, Borgman, & DeSaix, 1972) following the lead of the American Humane Association included failure to provide elements in their operational definition of neglect, The Childhood Level of Living Scale (CLL). For example, they organize the CLL into two parts, physical care and emotional/cognitive care. Under physical care, they include items that operationalize feeding patterns, disease prevention, use of medical facilities, housing conditions, clothing, etc. Also solidifying failure to provide problems as a cornerstone construct are the early 1970 s child neglect laws promulgated by all 50 states (Katz, McGrath, & Howe, 1976). As noted earlier in the Overview Section of this chapter, all states included lack of proper parental control or guardianship in their statutes, implying that the lack of adequate food, clothing, shelter, and supervision was a central component of a legal definition of neglect (Rose & Meezan, 1993, p. 281). The vast majority of states, 40, also included parental refusal or inability to provide necessary medical, surgical, or other special care (Rose & Meezan, 1993, p. 281). Review of today s laws as well as more recent research efforts, both sociological and ecological in orientation, revealed that virtually all included failure to provide components The CPS Response to Child Neglect Page 42

Issues Pertinent to Defining Child Neglect in their definitions of child neglect. For example, Cicchetti and colleagues (Barnett, Manly, & Cicchetti, 1993) physical neglect type includes failure to meet nutritional, medical, cleanliness, and supervision needs. A current review of State reporting laws by the National Clearinghouse on Child Abuse and Neglect Information (2001) revealed that neglect frequently is defined by the States as deprivation of adequate food, clothing, shelter, or medical care (p. 2). Straus and colleagues (Straus, Kinard, & Williams, 1995) self-report measure called The Neglect Scale included such physical elements as failure to provide food, clothing, shelter, medical care and such supervision elements as leaving the child alone without an adult at too young an age. And finally a study (Korbin, Coulton, Lindstrom-Ufuti, & Spilsbury, 2000) from the sociological perspective found that the most frequently mentioned items defining abuse and neglect were the failure to provide elements of neglect. This group of researchers, instead of using vignettes or lists of behaviors to elicit views about what constituted maltreatment, asked the 400 study respondents to name three things that they would consider child abuse and neglect. Analysis of the data by rank order of the ten most frequently named acts of child abuse and neglect revealed that the following five were identified inadequate food, beating child, lack of supervision, lack of cleanliness, and leaving child alone (mentioned in order of their rank where inadequate food is first, beating, second, etc.). Failure to protect is a much less commonly seen component of neglect definitions. Review of the literature identified use by only two sources, some state criminal abuse and neglect laws (U.S. Department of Health and Human Services, 1999) and Zuravin and Taylor (1987) under their category substitute child care. The state of Alaska, for example, has a statute (11.51.100) which says that a person commits the crime of endangering the welfare of a child in the first degree if, being a parent, guardian, or other person legally charged with the care of the child under 16 years of age. (2) leaves the child with another person who is not a parent, guardian, or lawful custodian of the child knowing that the person is registered or required to register as a sex offender under the laws of this state or a law or ordinance in another jurisdiction with similar elements; or has been charged by complaint, information, or indictment with an attempt, solicitation, or conspiracy to commit sexual assault, sexual abuse, incest, or unlawful exploitation of a minor. Zuravin and Taylor (1987) included under substitute childcare leaving the child in the care of an inappropriate caretaker such as one who has a known history of sexual abuse, physical abuse, and/or neglect. Opposition to the issue and recommendations for improvement. The literature includes no opposition to failure to provide or its components as a definition of neglect. Virtually every definer from very early on has included such omissions in their definition. The problem is that none of the definers very precisely identify when or at what specific level on the continuum of omission in shelter, food, etc. neglect can be said to have occurred. Consensus regarding specific and precise operationalizations of these elements is definitely needed. While no opposition has been expressed in the literature on failure to protect definitions of neglect, few definers, even States, include this as an omission. This element needs more attention by definers. The CPS Response to Child Neglect Page 43

Issues Pertinent to Defining Child Neglect Issue: Actual Harm and Threat of Harm Definition of the issue. Harm definitions focus on maltreatment sequelae characterizing the victim child rather than the acts of maltreatment themselves or perpetrator characteristics. Harm, as construed by those who include it in definitions of maltreatment, exists on a continuum from actual injury, either mental or physical, to the imminent risk of harm, to the threat of harm, to no harm. Classified under harm definitions are those that include the actual physical or mental injury of the child, imminent risk of harm, and threat of harm. Obviously, the further along the continuum the broader the definition and the more difficulty operationalizing or identifying concrete evidentiary criteria. Examples of the issue. Of the five approaches to defining child maltreatment medical, legal, sociological, ecological, and research the issue of harm to the child is most closely associated with the medical and legal perspectives. The first formal definition of maltreatment, proposed by Kempe and colleagues in 1962, was a harm definition. They proposed that the radiological evidence of a history of multiple and repeated fractures to children coupled with the fact that parents could not adequately explain the cause of fractures (Aber & Zigler, 1981, p. 2) constituted child maltreatment. Thus, this first formal attempt at definition was an extremely narrow one that focused only on physical injury perpetrated by a parent(s). As such, it is a definition of physical abuse. However, it laid the foundation for future somewhat broader harm definitions involving other types of maltreatment (neglect) as well as other types of harm and positions on the continuum. Next, in the evolution of the harm definition, came the 1974 CAPTA act, which broadened the definition of harm in three ways. First, it added mental injury to the Kempe and colleagues (1962) physical injury. Second, it added threats to the child s health or welfare. Third, it added acts or omissions other than physical abuse including sexual abuse or exploitation, negligent treatment (neglect), or maltreatment to the definition. With the addition of mental injury and threat of harm as well as the other acts sexual abuse, negligent treatment, maltreatment the broader the definition. Consequently, the definition became vaguer, more imprecise, and less capable of generating uniformity across and among professionals. Noteworthy is the fact that no guidelines or operational definitions were proposed for negligent treatment, another term for child neglect. Following closely on enactment of CAPTA, the American Bar Association commissioned the Juvenile Justice Standards Project (1977). Wald (1975; 1976) and the other members of this group developed a set of harm-oriented legal definitions for child maltreatment to act as standards for legal interventions into families (Aber & Zigler, 1981). They proposed the following standard: A child has suffered or there is substantial risk that a child will imminently suffer, a physical harm or serious physical injury and a child is suffering serious emotional damage..and the child s parents are not willing to provide treatment for him/her (Juvenile Justice Standards Project, 1977, pp. 10-11). As with all harm definitions, child sequelae, rather than perpetrator characteristics or maltreatment acts, was the main focus. Like the CAPTA definition, it includes substantial risk of harm not just The CPS Response to Child Neglect Page 44

Issues Pertinent to Defining Child Neglect actual harm. Again, no guidelines or definitions are proposed specifically for child neglect or any other type of maltreatment. Today, harm definitions are seen in statutes, the 1996 federal CAPTA statute as well as state child neglect and abuse laws. Examination of definitions included in state child abuse and neglect laws (National Clearinghouse on Child Abuse and Neglect Information, 2000) reveals that laws differ with respect to where they place on the continuum of harm. About one-third of the state laws place at the highest end of the harm continuum. In other words, to meet the state definition of child abuse and neglect the child must have sustained an injury(ies) or some kind of harm. Another one-third place lower on the continuum requiring either harm or threat of harm. And, finally, some are even lower on the continuum requiring only threat of harm. The laws of all 50 states include four types of maltreatment neglect, physical abuse, sexual abuse, and emotional mental/injury as capable of leading to harm or threatened harm. Support for a serious harm standard. Strong support for restricting the definition of the various types of maltreatment to very serious harm is proffered by Wald (1975, 1981) and others (e.g., Goldstein, Freud, & Solnit, 1979). The bases of their support are predicated on three tenets. First, legal definitions serve as the basis for coercive state intervention into family life (p. 114). Second, intervention is likely to do more harm than good in less serious situations (p. 114). Third, it is inappropriate to base intervention solely on the possibility of harm because predictions..are too unreliable (p. 114) given the current state of our knowledge about children s development. Opposition to a harm/threatened harm standard for defining child maltreatment. Two definitional approaches, the research (e.g., Aber & Zigler, 1981; McGee & Wolfe, 1991) and sociological perspectives (e.g., Giovannoni & Becerra, 1979), most clearly articulate opposition to a definition based on sequelae for the child (i.e., harm). Researchers, particularly those in the field of child development (Barnett, Todd-Manly, & Cichetti, 1993) identify their goal as empirically identifying the sequelae of the various forms of maltreatment. Thus, as expressed so well by McGee and Wolfe (1991), operational definitions of..maltreatment that focuses on outcome is inherently tautological (p. 8). Instead of focusing on outcome or sequelae, definitions should involve little more than a descriptive compartmentalization of behaviors (Zigler & Phillips, 1961). Definitions should not include or be tied to a particular etiology as the medical definition does by blaming parental psychopathology, or to particular harmful consequences as exemplified by both medical and legal definitions. While this approach is superb for research, it takes a long time to consolidate information about the harm of various acts or omissions. The sociological perspectives, perhaps best exemplified by the work of Giovannoni and Becerra (1979) focuses on the acts of maltreatment themselves (Aber & Zigler, 1981). For this perspective harm is a social judgment. In other words, acts (physical and sexual abuse) and omissions (neglect) that cause harm are those that are outside the dominant parenting mores of a culture not those that cause actual physical or mental injury. Those from the sociological perspective use polls and public opinion surveys to identify acts and omissions The CPS Response to Child Neglect Page 45

Issues Pertinent to Defining Child Neglect that are considered to be maltreating. The problem with this approach, as so well noted by Barnett, Manly, & Cicchetti (1993), is that some parental acts may be detrimental to children but because they occur so frequently, they represent the norms of society s accepted parenting practices..and are therefore not considered maltreatment (p. 22). While, on the other hand, some acts are considered maltreatment because they are unacceptable to the majority of the population, even though these practices may not eventuate in harm to children (p. 22). A solution to harm/threatened harm controversy? One important solution to the controversy was first proposed by Aber and Zigler (1981). Zigler and colleagues (Aber & Zigler, 1981; Ross & Zigler, 1980) suggested that a finite number of formal definitions of child maltreatment (as well as its subtypes) be developed and that each definition should be tailored to the major social aims and objectives for which it is intended. In other words, (according to Aber & Zigler) we need to differentiate definitions by social aim and objective (p. 12). They further proposed three different definitions to meet the needs of three different social aims legal definitions, case management definitions, and research definitions. Generally supportive of this position are a number of others involved in the field of child maltreatment. Giovannoni (1991), for example, has noted that ultimately, the utility of any definition lies in the purposes for which the classification is being made.clarification of the different purposes of defining maltreatment can avoid contamination of irrelevancies pertinent to one purpose but not another (p. 51). Haugaard (1991) generally supports this position, too, when he argues that a definition of maltreatment must be relevant to those who will be using the research in which the definition is employed (p. 72). Thus, he concludes it appears proper to employ definitions.that are modified to be of relevance to one or more audiences (p. 76). Others have taken different positions generally constituting a backlash against the different definitions for different purposes solution. For example, Garbarino (1991) argued that the definition of child maltreatment should be a social judgment informed by knowledge based on research regarding the appropriateness and likely outcome of parental behavior (p. 45). Toth (1991) noted that rather than minimizing the complexity inherent in defining maltreatment by developing definitions that reinforce professional boundaries, a definitional approach designed to unify all individuals who are confronted with child maltreatment (p. 104) is appropriate. And finally, Barnett and colleagues (1991), similar to Garbarino proposed that decisions concerning which parental acts are to be termed maltreatment must be made on societal standards and not solely by researchers (p. 25). Issue: Locus of Responsibility and Intentionality Definition of the issues. Locus of responsibility refers to the etiology or cause of a phenomenon. In other words, who or what is at fault? With respect to child maltreatment and The CPS Response to Child Neglect Page 46

Issues Pertinent to Defining Child Neglect its various subtypes it translates into three alternatives: the individual caretaker, society, or the interaction between parent, child, community, and society. The medical and legal theoretical perspectives on defining child maltreatment place blame on the individual caretaker; the sociological perspective places blame on society and the way in which resources are allocated to different classes of citizens; and the ecological perspective places blame on the interaction between different forces including the society, community, individual family and parent, and victim child. The research perspective takes the position that etiology cannot be posited a priori but rather must be determined empirically. For the two perspectives that allocate blame to the caretaker, a second issue of importance arises, intentionality. In other words, were the acts or omissions the result of a desire or inclination to harm, the result of an accident, the result of ignorance of the consequences, or the result of extenuating circumstances like poverty, absence of social support, etc. Examples of the issues. The first historical mention of intention arose with respect to physical abuse. Kempe and colleagues (1962) in their article on the battered child syndrome blamed the serious injuries evident with such children on parental psychopathology. However, they qualified this focus of blame by stating that the caretaker/parent must have evidenced intent to harm before the diagnosis could be made. The next very prominent use of intent oriented definitions is in state child abuse and neglect statutes (National Clearinghouse on Child Abuse and Neglect Information, 2000). Of the 50 states, 30 currently include a statement of intent. While the wording included in the statutes generally differs from state to state, they all mean the same thing intent. Intent statements in the statutes include, to mention a few, inflicting or allowing, intentionally, knowingly, or negligently and without cause, inflicted by non-accidental means, inflicts or fails to make reasonable efforts to prevent the infliction of, infliction of injury or causing deterioration, inflicts or allows to be inflicted and creates or allows to be created etc. (pp. 2-3). Opposition to parent locus of responsibility and intent as a component of maltreatment definitions. While many child welfare professionals are silent on the issue of intent they neither use intention in their conceptual definition nor speak for or against its use-- some do take a negative stand. Of those who do take a stand, most emphasize, among other things, that intent is virtually impossible to operationally define. Dubowitz and colleagues (Dubowitz, Black, Starr, Jr., & Zuravin, 1993), for example, noted that clinical experience suggests that most neglect is not intended. For this reason and the practical difficulty of assessing intentionality, it does not seem useful to include intentionality in a conceptual definition of child neglect (p. 15). Zuravin (1991) writing in a chapter on research definitions of child abuse and neglect, also noted that it is exceptionally difficult, if not impossible, to operationalize (p. 121) intent. In addition, she noted that even if we could operationalize intent, it would be unwarranted to eliminate from the definition behaviors that are unintended, behaviors for which the parents are not responsible, or behaviors that are provoked when we are interested in determining etiology (p. 121). And, many years ago, Polansky and colleagues (Polansky, Borgman, & DeSaix, 1972) took a similar position. In The CPS Response to Child Neglect Page 47

Issues Pertinent to Defining Child Neglect addition to noting the great difficulty of operationally defining intent, they argued the sociological or community norm position. In other words, if the parent is living no better than his children and wants to keep them with him, the general attitude is that his progeny and heirs may be unlucky, but they are not neglected (p. 30). Solution to the intentionality problem? With the exception of state child abuse and neglect statutes, conceptual and operational definitions with intent components are extremely uncommon today. However, even some of the statutes provide room in their definitions of neglect for (National Clearinghouse on Child Abuse and Neglect Information, 2001) extenuating circumstances. Such circumstances typically address the family s access and response to available services that might help to alleviate the neglectful conditions.for example, if a family living in poverty was not providing adequate food for their children, it may only be considered neglect if the parents were made aware of food assistance programs but did not use them (National Clearinghouse on Child Abuse and Neglect Information, 2001, p. 5). In the past, two teams of researchers, Wolock & Horowitz (1977) and the NIS-3/NIS-2 groups (U.S. Department of Health and Human Services, 1988, 199x) devised a solution similar to that of some state statutes to the locus of responsibility/intentionality problem. For situations in which the cause of the neglect was poverty rather than parent actions or inactions the omission was not classified as neglect. More specifically, when unsanitary and inadequate housing, delay in providing health care, lack of clothing, etc. were a result of parental poverty the parent was not considered to be neglectful for purposes of the study. Issue: Age of the Child Definition of the issue. This issue refers to the ultimate dependence of classifying a particular caretaker act or omission as maltreatment based on the child s developmental capabilities at the time the act or omission occurred. In other words, given that children grow in independence and ability to care for themselves over time, there should be a changing definition of at least some conditions (Seaberg, 1990, p. 270) for maltreatment at each stage of child development (Seaberg, 1990, p. 270). This issue is one that is particularly relevant to child neglect because, as noted earlier under the issue, failure to provide, at least some of the omissions like supervision are very much dependent on children s maturity level. Examples of the issue. Age of the child has received some attention from its proponents over time, particularly those who are researchers and need to develop methods for operationally define neglect. The first mention of the need to age-grade criteria came from Polansky and colleagues (1972) early in attempts to define maltreatment subtypes. He very clearly noted that a major issue in measuring adequacy of child caring (the term he used to refer to the opposite of neglect) is the age of the child. Failure to dress a baby may be neglectful but dressing a ten-year old is infantilizing (p. 48). As a result his operational measure of adequacy of care, The Childhood Level of Living Scale, was designed to apply to children between four and seven years of age. It is important to mention, however, that he The CPS Response to Child Neglect Page 48

Issues Pertinent to Defining Child Neglect did recognize that only a few items included in the array of behaviors that constitute neglect are age-dependent. He noted that Items dealing with adequacy of housing..seem pretty universal and applicable to adults, too (p. 48). Writing eight years later in a chapter entitled, Developmental considerations in the definition of child maltreatment, Aber and Zigler (1981) strongly support the notion of developmental stage in the creation and application of child maltreatment definitions for legal, clinical management, and research purposes. They noted that there are systematic changes with developmental level in children s vulnerabilities to different types of maltreatment (p. 24). In other words, an act which may cause harm to a child at one vulnerable stage of development may not at another stage (p. 24). To support their point, they compared the effects of different types of maltreatment with respect to damage and age. They commented that vulnerability to sexual abuse seems to increase with age straight through to adolescence (p. 24) while fostering delinquency holds its greatest risk during the early school years when social standards are being internalized (p. 24) while separation and loss inflict the severest emotional damage during the child s earliest years. Zuravin, in her chapter on current problems with research definitions of child abuse and neglect (1991) concurred with Polansky and colleagues (1972) that what is considered neglect at one age can be seen as infantilization at another. Of the three operational definitions of neglect that she compared (NIS-2, U.S. Department of Health and Human Services, 1988; Wolock & Horowitz, 1977; Zuravin & Taylor, 1987), only one, Zuravin & Taylor, age-graded criteria for various types of omissions in care. Of the 14 omissions in care that are components of neglect in her definition, two are age-graded on a rationalintuitive basis, supervisory neglect and custody-related neglect. Age-grading in her operational scheme includes specific omissions for children of different ages with respect to both supervision in and outside the home. Cicchetti and colleagues (Barnett, Manly, & Cicchetti, 1991, 1993; Cicchetti & Barnett, 1991) strongly endorse considering the child s developmental and chronological age in longitudinal research aimed at identifying the sequelae of various types of maltreatment. They base their position on the important tenet of developmental psychopathology (Cicchetti & Barnett, 1991, p. 368) that similar events may have different outcomes depending on the individual s point in the life span (p. 368). Rather than age-grading particular acts and omissions a priori - i.e., prior to the beginning of the research study--they seek to establish at which developmental/chronological age(s) particular acts or omissions lead to damaging effects and when these effects first occur. To do this, they carefully document the age at which a child was maltreated and the specific act(s) and/or omission(s) s(he) experienced as well as when problems begin to evidence themselves. Opposition to the issue. While many do not include age-grading when they operationally and especially conceptually define the various types of maltreatment, the literature includes no references that oppose the age-grading of acts and omissions or even discuss any disadvantages. Zuravin (1991), a strong supporter of age-grading, believes that it is important to arrive at consensus with respect to answers to two important questions before The CPS Response to Child Neglect Page 49

Issues Pertinent to Defining Child Neglect we can advance the cause of age-grading: (1) which acts or omissions should be agegraded? and (2) what factors should drive the age-grading? To these questions, Cicchetti and colleagues, the ultimate empiricists, answer findings from longitudinal research. Issue: Chronicity Definition of the issue. Chronicity refers to patterns of the same acts or omissions that extend over time or recur over time. The opposite of chronicity is a single incident of an act or omission. The Missouri Division of Family Services (n.d.) defines chronic neglect as a persistent pattern of family functioning in which the caregiver has not sustained and/or met the basic needs of the children which results in harm to the child (p. 3). Examples of the issue. An early mention in the literature of chronicity as an important part of the definition of neglect and abuse comes with Wolock & Horowitz s operational definitions for their 1977 study. With respect to abuse, their definition is dependent on both severity of injury and chronicity. For example, if the injury is severe (causes harm), one incident is sufficient. If the injury is not severe, i.e., there are no injuries, a recurrent pattern is required to qualify the act as abuse. With respect to neglect, they use the same method that they use for abuse. Unfortunately, however, they do not specify how long an act or omission must endure or how many times it must recur before qualifying it as abuse or neglect. Zuravin and Taylor (1987) also qualify their operational definitions of abuse and neglect by chronicity. Unlike Wolock and Horowitz, their definition of physical abuse, which is dependent on evidence of physical injury no matter how severe, requires only one incident. However, definitions of various types of neglect do require chronicity. Also, unlike Wolock & Horowitz, they qualify definitions with amounts of time. For example, with respect to educational neglect a child must be absent from school for a minimum of 20 days without legitimate reason (illness) or the parent never enrolled the child in school. With respect to inappropriate caretaker-related neglect (e.g., leaving children with mentally ill, maltreating, substance-abusing, pedophiliac caretakers), time periods vary as a function of the child s age. For children under 8, the behavior is identified as neglectful regardless of the amount of time the child was left. For children 13-15, leaving the child overnight is considered neglectful. The Second National Study of Incidence and Severity (U.S. Department of Health and Human Services, 1988) used a variety of methods to operationally define chronicity. For example, to be labeled deserting or abandoning the parent must be away for at least two days without notifying the temporary caretaker of her/his whereabouts. Supervisory neglect involved leaving a child unsupervised or inadequately supervised for extended periods of time or allowing the child to remain away from home without the parent knowing (or attempting to determine) the child s whereabouts. Custody-related neglect involved repeated shuttling of a child from one household to another due to apparent unwillingness to maintain custody and/or chronically and repeatedly leaving a child with others for days or weeks at a The CPS Response to Child Neglect Page 50

Issues Pertinent to Defining Child Neglect time. Unfortunately, NIS-2, like Wolock and Horowitz (1977) do not typically identify specific periods of time that the act or omission must endure. Finally, Cicchetti and Barnett (1991) also include a chronicity measure in their system of operationally defining abuse and neglect. However, for them chronicity is not a factor that determines whether some types of acts and omissions are maltreatment but rather is a dimension on which they rate every instance of maltreatment. Chronicity is defined as the number of months the case is served by Child Protective Services. The objective is to determine if chronicity negatively impacts child outcomes. Opposition to issue and recommendations for improvement. Clearly, this issue is an important one for operational definition. To date, it has no body of opponents, yet it has not been used by many definers. However, the manner in which it is currently operationally defined by those researchers who incorporate it into their operational schemes needs some revision. First, specific time periods or number of recurrences should be defined for relevant acts and omissions. Second, researchers should strive for consensus regarding the specification of the time periods/number of recurrences needed to operationalize chronicity. If different researchers use different definitions, the findings from their studies will be difficult, if not impossible to integrate. Additionally, it is also an important issue for clinical definition. If caseworkers restrict their decisions regarding substantiation and treatment to the consequences of one incident that causes harm, situations that are chronic may go untreated and possibly result in much harm to the child. Issue: Severity Definition of issue. Severity refers to one of two meanings: degree of harm likely to result from an act or omission or the judged harshness of the act or omission with no, consideration of degree of harm likely to result (Barnett, Manly, & Cicchetti, 1993). Examples of the issue. This issue has received less attention in the literature than most of the others particularly from researchers or empiricists. On the other hand, it has received considerable attention from sociologists and anthropologists. Despite the dearth of activity on this dimension by researchers, the first attempt to define elements of neglect in terms of severity came early. Leontyne Young (1964), on the base of a rational-intuitive approach, defined severe neglect as inadequate feeding and moderate neglect as inadequate clothing or failure to provide medical care. Most recently, Cichetti and colleagues (Barnett, Manly, & Cichetti, 1993; Cicchetti & Barnett, 1991) have devised a system for operationally defining the severity of acts and omissions. Rather than using the approach of Young involving specific types of omission, they give an overall rating of severity (which they define as harshness) from one to seven to each of the five subtypes of maltreatment in their system physical abuse, sexual abuse, physical neglect, emotional maltreatment, and moral/legal/educational maltreatment. They anchor each severity rating with examples taken from actual maltreatment cases. Interestingly, to date, they have yet to find that these The CPS Response to Child Neglect Page 51

Issues Pertinent to Defining Child Neglect severity ratings, defined as harshness of the act, are correlated with victim outcomes suggesting that perhaps severity is not an important dimension. The sociological approach involves defining severity in terms of community standards. Surveys of community residents with different socioeconomic, racial, and occupational levels are the typical means of identifying the severity of a particular act or omission. Overall, there have been more of these efforts at defining severity than there have been efforts by empirical researchers. Exemplary of this type of study is that by Rose and Meezan (1996) who examined the perceptions of the seriousness of specific components of neglect held by mothers from three cultural groups Latina, African-American, and Caucasian and held by public child welfare workers in two different roles in the Chicago area (p. 139). Using items/vignettes that factored into nine types of neglect inadequate food, inadequate clothing, inadequate medical care, inadequate shelter, unwholesome circumstances, exploitation, inadequate supervision, inadequate emotional care, and inadequate education the individuals in the five groups were asked to rate the relative severity of the items included in each factor. Of the three groups of mothers, the African American and Latina were in almost total agreement. They agreed that exploitation of children, inadequate supervision of children, and raising children in unwholesome circumstances were potentially the most harmful to a child (they defined severity in terms of degree of harm likely to be incurred), and that children raised under circumstances where food, clothing, and shelter were inadequate placed them in the least amount of jeopardy. The two groups of caseworkers agreed that inadequate supervision, inadequate medical care, and exploitation were the most serious while inadequate clothing and shelter were the least serious. Opposition to the issue and recommendations for improvement. The literature includes no references that oppose the issue. However, the fact that Cicchetti and colleagues (Barnett, Manly, & Cicchetti, 1993) have found that severity defined as harshness of the act rather than harm, does not predict outcome for the child may mean that it is not an issue worth considering in definitions of child neglect. Summary of Issues and Controversies This section of the chapter examined six issues pertinent to the definition of child neglect-- failure to protect and failure to provide, severity, chronicity, age of the child, harm/threatened harm, as well as locus of responsibility and intentionality. Overall, findings reveal that currently as well as in the past neglect definitions have been neither uniform nor precise. Information from the preceding section supports this conclusion for all six issues. Following are summaries regarding findings regarding uniformity and preciseness for each issue. First, harm/threatened harm and intentionality are the most controversial of the issues. Legal and medical definers (those who discovered the battered child syndrome) strongly support The CPS Response to Child Neglect Page 52

Issues Pertinent to Defining Child Neglect harm definitions while research and sociological definers most strongly oppose it. Those who support harm definitions do not agree where on the continuum of harm an act or omission should be defined as neglect nor do those who support a strict harm definition agree how much harm has to occur before an act or omission is defined as maltreating. Caretaker intentionality, while not as vociferously opposed as harm as a criteria for defining neglect, is argued against by definers of the research, sociological, and ecological perspectives. The latter two place blame respectively on society and the interaction of child, parent, community, and societal characteristics while the former believe that intentionality shouldn t be an element of definitions because it is too difficult to operationally define. Currently, incorporation of caretaker intentionality to harm is seen in state child abuse and neglect laws; however, there is no uniformity across states with respect to inclusion of intent to harm as a part of the definition. Some include intentionality in their definition of maltreatment and others do not. Second, failure to provide is the most frequently mentioned issue in the literature regarding the core definition of neglect. From early on definers of neglect regardless of perspective (sociological, legal, research, etc.) have identified that neglect involves failure to provide such basic necessities as housing, food, clothing, supervision, and medical care. Both across time and currently definitions are uniform with respect to including these elements in definitions of neglect. Despite the uniformity, definitions of such omissions are anything but precise. To date, there are no standards for identifying where on the continuum of each basic necessity neglect can be said to have occurred. Failure to protect has received little attention by most definers of neglect. Today, it is seen mainly in the criminal neglect statutes of some but by no means, all states. Third, age of the child is a strongly supported issue by its few advocates, mainly research definers. Based on the fact that children s capabilities mature over time, the proponents of this issue believe that definitions of some elements of neglect like supervision should change with the child s developmental age. At this point the problem with incorporating this issue as a component of definitions lies in consensus among its supporters regarding the specific age or age ranges an act or omission should be defined as neglectful. Currently, age of the child is a component of very few definitions of neglect. Fourth, chronicity, which refers to patterns of the same acts or omissions that extend or recur over time, has received support as an important definitional component from a few research definers. The current problem with applying this issue, is the lack of consensus among its proponents about how to operationally define chronicity. In other words, how many times or for how long does an act or omission have to occur before it is defined as neglectful. Fifth, severity of the act or omission has received the most attention from sociologically oriented definers. Such definers are interested in determining community standards regarding the most severe forms of maltreatment and whether standards differ as a function of ethnicity and socioeconomic standards. Given the definition of severity that they use, likelihood of harm to the child, it overlaps with harm standard definitions. As a result, it doesn t seem to be as an important possible component of a neglect definition as the other issues. The CPS Response to Child Neglect Page 53

Issues Pertinent to Defining Child Neglect Implications for Clinical Program Design Clinical programs for maltreating families fall under the rubric of Child Protective Services. Such programs have two main functions: (1) to investigate and determine whether allegations of child maltreatment can be substantiated by the evidence and (2) to provide services to families who have been found to be maltreating. Uniform and precise definitions of neglect, the most prevalent type of maltreatment, are extremely relevant and important for adequately carrying out both functions. In addition, they are important for accurate reporting by mandated and non-mandated This section of the chapter focuses on two objectives: (1) identifying the adverse consequences of non-uniform and imprecise definitions and (2) recommending some solutions for the problem based on the six issues discussed in this chapter. Twenty-five years ago when Edward Zigler (1977) questioned the feasibility of investigating a phenomenon that lacks widely acceptable definition, he was right on the mark. Today, definitions of neglect not only differ between CPS agencies but also across workers in a single agency. An example on point are the findings from a study of the substantiation process for reports of physical abuse, sexual abuse, verbal and emotional maltreatment, and neglect conducted by Knudsen (1988) in an Indiana county Child Protective Service agency. The study led to two important findings. First, there was an absence of clear criteria for defining maltreatment and systematizing the investigation and substantiation process (Barnett, Todd-Manly, & Cichetti, 1993, p. 26). Second, and as a result of the lack of clear criteria, cases were frequently decided upon in an idiosyncratic fashion guided primarily by the beliefs and practices of the individual case worker (Barnett, et al., p. 26). Stein and Rzepnicki (1984) rendered a particularly pessimistic commentary on the definitional problem when they noted that except for extreme situations where the child s condition, the location of an injury, and the child s age interact so as to eliminate any doubt that abuse has been perpetrated, professionals agree that it is very difficult to determine what is and is not child maltreatment (p. 10). With respect to clinical management of maltreating families, Hutchinson (1990) comments that the definitional dilemma currently poses both ethical and technological problems for practitioners. Child welfare workers cannot ethically engage in coercive intervention into family life without a clear sense that they represent social standards rather than individual practitioner agendas. Further, practice ethics as well as practice technology require child welfare workers to inform involuntary clients of the thresholds at which coercive action will be initiated. The ambiguity in existing definitions provides insufficient guidance to child welfare workers for such case management activities. Is there a solution to the problem of imprecise and non-uniform definitions? How do the six issues considered in this chapter inform and/or confuse the effort? In the final analysis my opinion is that of Aber and Zigler. In other words, we should go with different definitions for different purposes. CPS agencies should go with a strict harm definition, one where physical injury of any severity as well as medical illness and malnutrition all due to failure to provide or failure to protect elements. As so well stated by Hutchinson (1990), broader, more imprecise definitions overload the system with nonserious cases The CPS Response to Child Neglect Page 54

Issues Pertinent to Defining Child Neglect and undermine the ability of protective workers to respond effectively to endangered children (p. 72). The advantage of such a narrow definition is that it limits the discretion and therefore the biases of decision makers (Hutchinson, 1990, p. 72). Moreover, it eliminates the need to achieve consensus regarding the specific operational criteria for such difficult-to-define issues as caretaker intentionality, developmental age of the child, and chronicity. On the other hand, researchers, particularly those who are investigating the short- and long-term sequelae of neglect should not go with a strict harm definition. For this group, as noted by McGee and Wolfe (1981), it is inherently tautological to employ the outcome in the definition. Instead, definitions are needed that descriptively compartmentalization each of the failure to provide and failure to protect elements as well as defining chronicity and identifying the developmental age at which a failure to provide or failure to protect element no longer constitutes neglect. The CPS Response to Child Neglect Page 55

The Need for Differential Program Strategies References Aber, L. & Zigler, E. (1981). Developmental considerations in the definition of child maltreatment. In R. Rizley & D. Cicchetti (Eds.), Developmental perspectives in child maltreatment: new directions for child development (pp. 1-29). San Francisco, CA: Jossey-Bass. Barnett, D., Manly, J. & Cicchetti, D. (1993). Defining child maltreatment: The interface between policy and research. In D. Cicchetti & S. Toth (Eds.), Child abuse, child development, and social policy. Norwood, NJ: Ablex Publishing Corporation. Belsky, J. (1980). Child maltreatment: An ecological integration. American Psychologist, 35, 320-335. Besharov, D. (1981). Toward better research on child abuse and neglect: Making definitional issues an explicit methodological concern. Child Abuse and Neglect, 5, 383-390. Caffey, J. (1946). Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. American Journal of Roentgenology, 56(2), 244-255. Cicchetti, D. & Barnett, D. (1991). Toward the development of a scientific nosology of child maltreatment. In W. Grove & D. Cicchetti (Eds.), Thinking clearly about psychology: essays in honor of Paul E. Meehl, volume 2: personality and psychopathology (pp. 346-377). Minneapolis, MN: University of Minnesota Press. Dubowitz, H., Black, M., Starr, Jr., R. & Zuravin, S. (1993). A conceptual definition of child neglect. Criminal Justice and Behavior, 20(1). 8-26. Dubowitz, H. (1994). Neglecting the neglect of neglect. Journal of Interpersonal Violence, 9(4), 556-560. Garbarino, J. (1976). A preliminary study of some ecological correlates of child abuse: The impact of socioeconomic stress on mothers. Child Development, 47, 178-185. Garbarino, J. (1991). Not all bad developmental outcomes are the result of child abuse. Development and Psychopathology, 3, 45-50. Gelles, R. (1998). Policy issues in child neglect. In H. Dubowitz (Ed), Neglected children: research, practice, and policy. Thousand Oaks, CA: Sage Publications. Giovannoni, J. (1989). Definitional issues in child maltreatment. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: theory and research on the causes and consequences of child abuse and neglect. (Pp. 3-37). New York: Cambridge University Press. The CPS Response to Child Neglect Page 56

The Need for Differential Program Strategies Giovannoni, J. & Becerra, R. (1979). Defining child abuse. New York: The Free Press. Giovannoni, J. (1991). Social policy considerations in defining psychological maltreatment. Development and Psychopathology, 3, 51-59. Goldstein, A., Freud, A. & Solnit, A. (1978). Before the best interests of the child. New York: Free Press. Haugaard, J. (1991). Defining psychological maltreatment: A prelude to research or an outcome of research. Development and Psychopathology, 3, 71-78. Hutchinson, E. (1990). Child maltreatment: Can it be defined? Social Service Review, 61-77. Juvenile Justice Standards Project. (1977). Standards relating to abuse and neglect. Cambridge, MA: Ballinger. Katz, S., McGrath, M. & Howe, R. (1976). Child neglect laws in America. New York: American Bar Association. Kempe, C., Silverman, F., Steele, B., Droegenmueller, W. & Silver, H. (1962). The battered child syndrome. Journal of the American Medical Association, 18(1), 17-24. Korbin, J., Coulton, C., Lindstrom-Ufuti, H. & Spilsbury, J. (2000). Neighborhood views on the definition and etiology of child maltreatment. Child Abuse and Neglect, 24(12), 1509-1527. Knudsen, D. (1988). Child protective services: discretion, decisions, dilemmas. Springfield, OH: Charles C. Thomas. Magura, S. & Moses, B. (1986). Outcome measures for child welfare services. Washington, DC: Child Welfare League of America. McGee, R. & Wolfe, D. (1981). Psychological maltreatment: Toward an operational definition. Development and Psychopathology, 3, 3-18. National Center on Child Abuse and Neglect. (1987). Proceedings of the neglect grantees meeting. Washington, DC, August 17-19. National Clearinghouse on Child Abuse and Neglect Information. (2001). Acts of omission: an overview of child neglect. Author. National Clearinghouse on Child Abuse and Neglect Information. (2000). Statutes at a glance. Author. Polansky, N., DeSaix, C., Wing, M., & Patton, J. (1968). Child neglect in a rural community. Social Casework, 49, 20-30. The CPS Response to Child Neglect Page 57

The Need for Differential Program Strategies Polansky, N., Borgman, R., & DeSaix, C. (1972). The roots of futility. London: Jossey-Bass, Inc., Publishers. Polansky, N., Hally, D., & Polansky, N. (1975). Profile of neglect: a survey of the state of knowledge of child neglect. Community Services Administration. Social and Rehabilitation Services, Department of Health, Education, and Welfare. Polansky, N., Chalmers, M., Buttenweiser, E., & Williams, D. (1981). Damaged parents: an anatomy of child neglect. Chicago, ILL: University of Chicago Press. Rose, S. & Meezan, W. (1993). Defining child neglect: Evolution, influences, and issues. Social Service Review, 280-293. Rose, S. & Meezan, W. (1996). Variations in perceptions of child neglect. Child Welfare, LXXV(2), 139-160. Ross, C. & Zigler, E. (1980). An agenda for action. In G. Gerbner, C. Ross, & E. Zigler (Eds.), Child abuse: an agenda for action (pp. 293-304). New York: Oxford University Press. Seaberg, J. (1990). Child well-being: A feasible concept. Social Work, 35, 267-272. Silverman, I. (1953). The roentgen manifestations of unrecognized skeletal trauma in infants. American Journal of Roentgenology and Radiation Therapy, 69, 413-427. Straus, M., Kinard, M., and Williams, L. (1995). The neglect scale. Paper presented to the Fourth International Conference on Family Violence Research. Durham, NH. July 23. Toth, S. (1991). Psychological maltreatment: Can an integration of research, policy, and intervention efforts be achieved? Development and Psychopathology, 3, 103-109. U.S. Department of Health and Human Services. (1988). Study findings: second national study of the incidence and severity of child abuse and neglect. Arlington, VA: National Clearinghouse on Child Abuse and Neglect Information. U.S. Department of Health and Human Services. (1996). Third national study of the incidence and severity of child abuse and neglect. Washington, DC: Author. U.S. Department of Health and Human Services. (2000). Child abuse and neglect state statute elements: Number 32, criminal neglect and abandonment. Washington, DC: Author. U.S. Department of Health and Human Services. (2001). Child maltreatment, 1999. Washington, DC: U.S. Government Printing Office. Wald, M. (1975). State intervention on the behalf of neglected children: A search for The CPS Response to Child Neglect Page 58

The Need for Differential Program Strategies realistic standards. Stanford Law Review, 27(4), 985-1040. Wald, M. (1976). State intervention on behalf of neglected children: Standards for removal of children from their homes, monitoring the status of children in foster care, and termination of parental rights. Stanford Law Review, 28, 623-707. Wald, M. (1981). Defining psychological maltreatment: The relationship between questions and answers. Development and Psychopathology, 3, 111-118. Wolock, I. & Horowitz, B. (1977). Factors relating to levels of child care among families receiving public assistance in New Jersey. Final report to the National Center on Child Abuse and Neglect (DHEW Grant 90-C-418). Washington DC: National Clearinghouse on Child Abuse and Neglect Information. Wolock, I. & Horowitz, B. (1984). Child maltreatment as a social problem: The neglect of neglect. American Journal of Orthopsychiatry. 59, 377-389. Young, L. (1964). Wednesday s children: A study of child abuse and neglect. New York: McGraw Hill. Zigler, E. & Phillips, L. (1961). Psychiatric diagnosis. Journal of Abnormal and Social Psychology, 63, 607-618. Zigler, E. (1977). Controlling child abuse in American: An effort doomed to failure. Proceedings of the First National Conference on Child Abuse and Neglect, DHEW, Publication No. OHD 77-30094. Washington, DC: Government Printing Office. Zuravin, S. & Taylor, R. (1987). Family planning behaviors and child care adequacy. Final report submitted to the U.S. Department of Health and Human Services, Office of Population Affairs (Grant FPR 000028-01-1). Zuravin, S. (1991). Research definitions of child abuse and neglect: Current problems. In R. Starr & D. Wolfe (Eds.), The effects of child abuse and neglect (pp. 100-128). New York: Guilford Press. The CPS Response to Child Neglect Page 59

III. CPS Responsibility for Child Neglect Patricia Schene, Ph.D. Introduction Neglect is recognized in all state statutes as a reportable form of child maltreatment requiring a response by the public child protective service system. Mandated reporters and concerned citizens who are aware of children who may be at risk due to neglect by their parents or caretakers have the responsibility to report those children. CPS, in turn, has the responsibility to assess the situation and determine if neglect is present, what safety concerns may be present for the child, and to learn about the family pattern of parenting as well as the ongoing risks. If the situation requires formal intervention, further exploration is undertaken of the challenges or problems the family may be experiencing that impact the care of the children, the supports or connections to extended family or community resources present, and the willingness of parents to participate in services, as well as their motivation to make necessary changes. Reporting of neglect and an adequate CPS response are essential. Although the public remains more aware of and concerned about the abuse of children, awareness of the seriousness of neglect has been growing. Neglect is more prevalent than abuse, is often fatal, and if neglect continues across the childhood years, it takes an enormous toll in all areas of child development. It has also become increasingly clear that CPS cannot operate alone in responding to child neglect. The immediate and extended family must recognize the need for change; formal service providers must be enlisted to deal with the myriad of family problems normally present in neglect; community resources and supports, including more informal connections for parents and children must all be pursued in order to make a lasting impact on the patterns of parenting in cases of neglect. This chapter focuses primarily on the CPS role in child neglect; the range of situations presented under the neglect rubric; the actual process of case intervention in terms of assessment, service planning and provision, ongoing case monitoring responsibilities, and the criteria and process for case closing; and, lastly, the administrative and policy issues impacting CPS response to neglect. Patricia Schene, Ph.D., has worked in the field of children and family services for 25 years as a state administrator, private agency director, researcher, writer and educator. The CPS Response to Child Neglect Page 60

CPS Responsibility for Child Neglect Range of Situations Encompassed Under Neglect The complexity of definitions of neglect has been addressed in previous chapters in this monograph. These can serve as a context for understanding the variety of situations reported to CPS and the factors influencing the response of CPS. In summary, it must be understood that the CPS response occurs within the parameters of the reporting statutes in every state and can vary considerably among jurisdictions within and across states due to current interpretations of statute, resources available for CPS response, and the level of training and capacity of individual caseworkers and supervisors to assess and respond to neglect. The most common categories of neglect include physical neglect, lack of supervision, educational neglect, medical neglect, emotional neglect, and failure to thrive. In reality these categories often occur together, but can be described separately. Physical Neglect This is the category of neglect that is most clearly understood and commonly addressed in state statutes. It includes failure to provide for the child s basic physical needs including adequate shelter, food, or clothing. It also can include the failure to protect a child from harm or danger. Lack of Supervision This could be considered closely related to physical neglect and is the most common form of maltreatment identified in official reports of child neglect. It covers situations when the child is left unsupervised or inadequately supervised for extended periods of time. The age of the child is, of course, a major factor in determining the CPS response to lack of supervision. Educational Neglect This covers situations where the parents or caretakers do not make the level of effort necessary for their child to attend school or arrange for an alternative way to pursue their education. Permitting chronic truancy, causing children to remain out of school to care for other siblings or to work, or refusing to obtain recommended remedial educational services have been reportable situations. It is clearly a societal expectation that parents make it possible for children to be educated. At the same time, there has been some concern around having educational neglect be a responsibility of CPS. Some states have dropped educational neglect as reportable to CPS, believing it is the responsibility of the educational system to assure that children attend school or are home-schooled. Others take the position that educational neglect is normally combined with other forms of neglect and will be responded to by CPS when it occurs in combination. The CPS Response to Child Neglect Page 61

CPS Responsibility for Child Neglect Medical Neglect When parents fail to provide needed medical treatment for their children, or other interventions in cases of serious disease or injury, it is considered medical neglect. Although somewhat controversial in cases where needed medical care clashes with parental religious beliefs, the courts in recent years have decided that the child s need for medical care must prevail particularly in situations where the lack of medical attention is likely to cause severe or long-term effects. A related category of neglect the withholding of medically indicated treatment from newborns is related to medical neglect. CPS is required to respond to those situations by federal law; parents cannot choose to withhold medical treatment or sustenance from an infant born with a life-threatening but potentially correctable condition. Emotional Neglect Serious inattention to the child s need for affection, support, nurturing, or emotional development has been labeled emotional neglect. This type of neglect is more difficult to document as it seldom leaves physical evidence, its harmful manifestations cannot always be tied to parental neglect, and it often occurs in privacy or when children are too young to even know they are being neglected. The term psychologically unavailable (Erickson and Egeland, 1996) has been used to describe parents who overlook their children s needs for warmth and comfort. These can have serious long-term consequences. This category is sometimes used when parents permit drug or alcohol use by their children. It is also used when parents refuse to allow treatment for a child s emotional or behavioral impairment or parents who clearly and chronically impose unrealistic expectations on their children. Failure to Thrive Children whose physical development falls below the third percentile in height or weight for no known medical reason are designated nonorganic failure to thrive, and reflect the parents failure to provide necessary nutrition or nurturing. Normally the child needs to be hospitalized which results in weight gain and developmental progress. Response to these cases is often problematic unless parents can sustain the progress made in the hospital. Chronic Neglect In addition to the categories of neglect, one of the dimensions of the CPS response is the issue of chronicity. There are a host of known factors associated with chronic neglect that are not present in all neglect cases. These cases are normally defined by the presence of multiple reports on the same family in spite of CPS interventions and even services to address the underlying problems. Somehow the necessary changes to keep the children safe and adequately cared for do not persist. Cases of chronic neglect are quite prevalent and very challenging to individual caseworkers as well as challenging to the normal process of CPS intervention. Continually assessing the situation, developing a case plan, providing services, closing the case only to re-open it and begin the cycle over again does not make sense in cases of chronic neglect. It is hard, however, for CPS agencies to vary the response to a category of cases. The CPS Response to Child Neglect Page 62

CPS Responsibility for Child Neglect Substance Abuse in Neglect The abuse of drugs or alcohol on the part of a parent almost always presents the danger of child neglect, particularly for infants or young children. Unless there is a non-using caretaker in the home, the abuse commonly leads to the neglect of the child s basic needs. This has been a problematic area for CPS in that there is no legal authority to intervene just because of the use or even abuse of substances; there must be some evidence of neglect or abuse of the children. Removing children from these homes may secure their safety, but is normally very traumatic for the children as well as the parents. This issue elevates the importance of a careful assessment by CPS and some clear assurance that protective arrangements are in place for the child. The Case Process A. Assessment Screening and Gatekeeping When a report of neglect is made, the initial CPS response is usually to make sure the conditions being reported meet the statutory definitions of neglect. At that first call, it is also important to ascertain the location of the child, the parent or caretaker, and the urgency of the situation. About 40 percent of all reports are screened out at intake by CPS agencies nationwide. That means that only 60 percent received an investigation or an assessment. (Child Maltreatment,1999:1) Neglect reports are more likely to be screened out than are reports of physical or sexual abuse. Within the group of reports that do result in an investigation or assessment, neglect constitutes at least 58.4 percent. (Child Maltreatment, 1999:20) This does not include psychological maltreatment, another category that would also contain an unreported number of additional neglect reports. Although statutes differ, the criteria for neglect are normally the absence of minimally adequate care, not the absence of an ideal level of care. The range of situations presented above combined with the reported ages of the children as well as the presence of consistent protective supports are all factors that influence whether the report of neglect is initially investigated and whether the case is open for ongoing services. Investigation/Assessment This requires a visit to the home as well as the exploration of information from those who know the child, parents, and the family. The home visit provides vital information on the living conditions cleanliness, adequacy of food, space, -- the health of the children, the patterns of supervision, the methods of discipline and interaction with the children, and the explanation for any recent school absences or missed medical appointments. This initial visit is the opportunity to engage the parents by trying to understand their view of the problems, The CPS Response to Child Neglect Page 63

CPS Responsibility for Child Neglect their capacities to provide minimally adequate care, their support system, and their sense of what they need to do a good job of parenting. The presence and severity of neglect for all children in the home is ascertained from the initial information gathering and home visit. A foundation for developing a helping relationship with the parents has begun and some clarity emerges on what is needed to secure the safety and protection of the child. Assessing Strengths and Risks Based on the initial findings, as assessment is made of the current safety of the children and the ongoing risks and strengths of the family. Initial decisions have to be made about out-ofhome placement, immediate medical attention, securing a support person for the parents who can assure the protection of the children, or to decide no further intervention is necessary. Most CPS systems have formal, written protocols for the assessment of safety, risks, and strengths. The presence of a social network of supports is known through research to be a vital element in the assessment of neglect, as is the capacity and motivation of the parent to protect the child. A factor present in many cases of neglect is depression on the part of the major caretaker; its presence and severity needs to be assessed. Parental patterns of problem solving are also known to be relevant to assessment. If parents have had success using their own approaches to problem solving in any area of their lives, they have more of a chance to use those approaches in caring for their children. The entire process of assessment is directed toward: understanding the nature and severity of the neglect, its impact on the safety and wellbeing of the children, the family dynamics and patterns of parenting, the motivation to change and the willingness to utilize services; the needs of the family as a whole for services and supports, the availability of extended family to help care for the children, and the risks and strengths present that will inform CPS intervention; engaging the parents and other family members to become involved in a process of change, leading to greater safety for the children and sustainable patterns of protection and nurturance; making decisions to assure child safety and to connect the family to the needed services and supports as well as to determine the course of continued intervention including the involvement of the court. These three processes are not linear each informs and supports the other and can overlap in time. B. Service Provision If the results of the assessment indicate the need to provide services, CPS would normally move the case to an ongoing services unit within the agency or refer the family to The CPS Response to Child Neglect Page 64

CPS Responsibility for Child Neglect community services and supports. If the latter course is chosen, CPS normally stays involved at least long enough to assure the connections are made, and sometimes sets up some form of consultation or partnership with the community agency or support for a period of time. Some public CPS agencies purchase the community services for the family and remain involved to monitor the provision of services and get reports on their effectiveness. The services most commonly provided in neglect cases include childcare, homemaker services, domestic violence shelter and counseling, parenting support groups, mental health counseling, and substance abuse evaluation and treatment. CPS would develop a service plan with the family specifying the services, time periods, anticipated outcomes, and the responsibilities of the parents. CPS would normally make the arrangements for service provision, discuss the needs of the family with the providers, identify the particular outcomes agreed upon, clarify the expectations related to services coordination and reporting on client progress. Particularly in neglect cases, CPS would work with the family to identify and mobilize whatever natural connections exist or could be formed to extended family members, faith communities, and social networks. By promoting and facilitating parents connections to the larger network of formal and informal community services and supports, the underlying factors present in most neglect cases have a better chance to be addressed. These resources can be considered a partner with CPS is helping to achieve the outcomes in the case plan. In cases where it is unlikely that the safety and well-being of the child can be assured if left at home with the parents or caretakers, even with services, CPS has the responsibility to file the neglect and dependency petition with the court, explore placement with family members or people the child is familiar with, or place the child in foster care. For some children, particularly failure to thrive situations, immediate hospitalization is required. It is always advisable for CPS to obtain the cooperation of the parents whenever placement out of the home is pursued. A clear plan for reunification with timetables and necessary steps to be made by the parents needs to be discussed in detail. The requirements of the Adoption and Safe Families Act necessitate CPS informing parents of the time frames for permanency and the importance of working toward timely reunification. In all cases where CPS remains involved, the role of the caseworker and the agency in arranging for the services and supports, coordinating interventions, reviewing progress, and assuring the continued safety of the child must be explained to the family. The CPS Response to Child Neglect Page 65

CPS Responsibility for Child Neglect C. Case Monitoring CPS has the responsibility to obtain information from the parents, service providers, and supports to the child and family about the progress in achieving the outcomes agreed to in the case plan. This information needs to be integrated into decision-making related to reunification, possible changes in the service plan, potential need for placement, and determining the next steps. Parents and family members need to be a vital part of discussions related to preparing for reunification, exploration of alternative permanency arrangements, perceptions of progress, and the need for additional or alternative services and supports. Monitoring should be ongoing, but set periods of time for decision-making need to be present in the case plan. These time frames have to be supported by progress reports from providers; caseworker visits to the family, and discussions with parents. If a child is in outof-home placement, the court sets up timeframes for decision-making that are an additional requirement; these also must be supported by information on progress. D. Case Closure The key criterion for case closure is the judgment on the part of the CPS caseworker and supervisor that the protective considerations that initially brought this case forward have been adequately resolved. This decision is not made in a vacuum; the family, the service providers, and the other supportive resources all have a role in this. It must be clear, however, that the judgment is made by CPS, the agency given formal responsibility by society to organize the interventions that protect children from neglect and abuse. Achieving the outcomes initially specified in the case plan is key. It is not enough that the parent, for example, participated in services; the outcomes much have been achieved. Many a neglecting parent will dutifully attend parenting classes, for example, but not change her pattern of parenting. Attendance is not the outcome; change is essential if change did not occur in spite of attendance, there may be an underlying issue such as depression, domestic violence, or substance abuse that is not being addressed. This would call for a revised service plan, not case closure. Discussions with parents should result in demonstrated awareness of the supports and services they can draw upon on an ongoing basis to assure the protection of their children. CPS must indicate the ways such help can be engaged. It is also essential to inform parents and family members of the way to contact CPS if they see renewed or additional risks to the children or believe they are not able to sustain the protective level of parenting needed. In cases of chronic neglect, it is particularly important that case closure is not just one more step in a revolving door of family involvement with CPS, and, more importantly, one more failed effort to assure the ongoing safety and well-being of the children. If the neglect case is The CPS Response to Child Neglect Page 66

CPS Responsibility for Child Neglect chronic, the criterion for case closure has to involve sustained change for at least six months. Decisions about additional services, or alternative permanency arrangements for the children need to loom large in chronic neglect cases where sustained levels of adequate parenting cannot be assured. The cumulative harm to children growing up in homes characterized by chronic neglect has to inform decision-making in these cases. When the decision is made to close the case, CPS should plan for at least one follow-up visit with the family to assure the safety and well-being of the children and to respond to concerns voiced by the parents. E. Documentation The case record must be clearly documented and information transferred to computerized information systems or other resources for accountability. At minimum, the record needs to include the initial report, a summary of what was learned through the assessment process, and what level of parental acceptance and motivation was present. The case plan and any revisions in the plan need to be a part of that documentation. Services and supports provided to the child and the family, the involvement of particular providers and supportive resources need to be identified. Records of family team meetings should be included. All the court forms and decisions have to be a part of the case record. Results of case monitoring of progress toward outcomes need to be included. The reasons to close the case should be specified along with the ongoing supports in place for the parents and children. With the focus on accountability turning more and more to outcomes as opposed to processes, both at the state and federal levels, it is important that case records address the work done to achieve the outcomes as well as the level of success. Documentation is particularly important in cases of neglect that are more likely to be reported again. Any additional involvement by CPS with the family should build from what was done in the past, rather than go automatically through the same paces. There has to be some understanding of what was tried before, what did and did not work, and what new commitments or approaches should be pursued with the family. In chronic neglect, it is important that the cumulative harm to the children be weighed along with the immediate safety concerns, particularly around issues of permanency. Administrative and Policy Issues Impacting CPS Response to Neglect Neglect cases are challenging to administrators as well as to caseworkers. There are a number of issues that arise for policy makers that present a particular need to look through the lens of neglect as distinct from the lens of abuse. The ones to be discussed here include: Screening and Assessing Reports of Neglect Chronic Neglect The CPS Response to Child Neglect Page 67

CPS Responsibility for Child Neglect Differential Response to Reports Service Availability Training Building Community Partnerships Outcome Focused Intervention Workforce Issues A. Screening and Assessing Reports of Neglect Reports of child neglect are intuitively seen as less severe than reports of abuse and are screened out at intake more often. Although the proportion of neglect cases resulting in serious harm or child fatalities is lower than the proportion of abuse cases, about half the fatalities due to child maltreatment each year are related to neglect. The obvious explanation is that there are more cases of neglect than of abuse on CPS caseloads. This is also illustrative of the variation among neglect cases in actual severity and, more to the point, the greater difficulty in neglect compared to abuse to identify the cases that really require the attention of CPS. In making policy decisions relating to screening and opening cases for services, administrators must also recognize that the majority of children who are recognized as abused or neglected by mandated reporters do not enter the CPS report base, according to consistent findings of the National Incidence Studies. This means they either were not reported or they were screened out at intake. Careful decision-making needs to occur around the criteria for screening; we are clearly missing opportunities to help. The common characteristics associated with parents who neglect their children do not lend themselves to change. These include: Unstable, insufficient income Social isolation Substance abuse Low self-esteem Depression Lack of ability to form or sustain healthy relationships The CPS Response to Child Neglect Page 68

CPS Responsibility for Child Neglect These characteristics are likely to be present to some degree in most neglect families. Yet the severity of their manifestation on parenting and the parents receptivity to allow services and supports to impact their lives varies a great deal. This underscores the importance of careful assessment in neglect. It might be easy to dismiss a reporter s concerns by indicating that they do not reach the level of statutory authority to intervene, but it is particularly necessary in neglect to probe more deeply. Some policymakers recommend screening more cases in for initial assessment or investigation to more fully understand the level of risk to the children. Our responses to reports of child maltreatment have rested largely upon an assumed focus on incidents of abuse or neglect. The expectation is that the reporter is identifying a particular behavior or act that they find actually or potentially harmful to the child. The CPS response has been to investigate the incident, determine if it took place, who is responsible, and what must be done to protect the child. In neglect, the focus should be more on a pattern of behavior that dangerously neglects the child s needs or well-being. A focus on incidents makes much less sense. The purpose of the assessment or investigation should be understanding whether or not there is a pattern of neglect, not whether any particular incident can be substantiated. Of course, the immediacy of the current risks has to be addressed and steps taken to protect the child. The point is that decision-making on whether this case should be open and, if so, what services and supports should be given, has to look at the larger pattern. Neglect often serves as an early warning of a situation that might escalate into more serious maltreatment. Many of the children who are known to CPS and subsequently die of maltreatment were originally reported to CPS for neglect. B. Chronic Neglect One could argue that most neglect is chronic. There are, of course, situations where parents use poor judgment and leave children unsupervised but do not make a habit of that behavior. There are other situations of neglect that occur early enough in parenting and do not become chronic because they are addressed by the parent with the help of her support system and/or the intervention of CPS. CPS tends to define chronic neglect as a particular number of reports within a defined time period. But, in fact, there are usually many unreported situations of neglect occurring in that same family that are not counted or countable. Chronic neglect is characterized by a persistent pattern of parenting where the parent consistently does not meet the basic needs of the child. CPS must consider the accumulation of harm to children involved in chronic neglect as well as their immediate safety. Chronically neglected children are physically, medically, educationally, and emotionally at a disadvantage. This can result in long-term, negative consequences for the child. The CPS Response to Child Neglect Page 69

CPS Responsibility for Child Neglect When the State of Missouri developed policy on chronic neglect (DSS, DFS, Memorandum, January 12, 1998), they directed staff to look beyond each incident and include in the safety assessment a review of the family s history, concerns from the community and mandated reporters, the findings of prior child abuse/neglect reports and concerns documented in reports that did not rise to the level of child abuse and neglect. Staff are directed to keep the case open until the family demonstrated their ability to sustain change over a period of time. They are urged to ensure that some long-term, preferably informal support is in place when they close the case. Administrators may find it difficult to accommodate a set of decisions on the assessment process as well as on the time a case has to remain open and the criteria for case closure that differ from what is normally done in CPS. Chronic neglect cases really make the argument for that level of focus and flexibility in time lines if cumulative harm to children is to be addressed. C. Differential Response to Reports Many states have implemented a dual-track of differential response system to reports of child maltreatment. This usually entails an investigative track as well as an assessment track. The reports of more serious maltreatments go on the investigative track and are essentially handled in the more traditional way investigation and substantiation of maltreatment, identification of the person responsible, entering the name of the alleged perpetrator in the state central registry, and the involvement of law enforcement and/or the courts if criminal charges are to be filed or the child is to be removed from the home. The assessment track response is less focused on confirming the maltreatment and more focused on identifying if there is a need for services. If parents can voluntarily participate in services, they are immediately made available, no names are entered in the central registry, and usually no decision on substantiation is made. The experience so far is that at least 75 percent of the cases go to the assessment track. The proportion of neglect cases that go on the assessment track is at least that high. This is becoming the main way of responding to neglect cases in these states. There are many positives empirically documented in evaluative research on differential response. The assessment track is very appropriate for most neglect cases in that parents do not have to be labeled and listed in the central registry in order to receive assistance. The time period between the report and initial service provision is much shorter. The family has to voluntarily accept services in this track, so more efforts go into assessment and engagement than was formerly the case. (If the parent does not accept services, the caseworker can move the case to the other track if she felt the risk warranted that action.) Often the provision of services is through community agencies, not just CPS. For neglectful families, that connects them to a resource they feel more comfortable with. Some of the problems arise with families accessing community agencies that are not accustomed to ensuring resistive clients participate in services, nor experienced in continually assessing overall risks. This is very important in the dynamics of neglect and The CPS Response to Child Neglect Page 70

CPS Responsibility for Child Neglect some CPS agencies have worked effectively with community agencies to build these practices into their programs. To have CPS decision-making rest on the need for services, not primarily on substantiation, as the gatekeeper to services is an important policy change that has particular relevance for neglect. The State of Michigan implemented a five-category disposition system for child abuse and neglect reports in 1999. Only the first two categories require entering the responsible perpetrator in the state s central registry. CPS, however, must be involved in all but the last category (services not needed) to assist the family in participating in services. D. Service Availability The availability of the array of services needed by parents and children involved in neglect is an area of needed development. In many communities there is an insufficiency of mental health services, substance abuse treatment services (particularly programs that accommodate children), assistance with affordable, sanitary housing, and support groups for parents. Children who have experienced neglect are often in need of sustained assistance to attain or maintain grade level due to lack of consistent attendance or competing responsibilities. There are usually untreated emotional and mental health problems, as well as chronic health problems due to the lack of adequate care. CPS systems typically do not have the resources to evaluate all of the needs of the parents and children in any of their cases. Even if evaluated, the service resource may be unavailable, have large waiting lists, or be inaccessible to parents without reliable transportation. There are more opportunities for being creative and flexible with existing funding resources and more ways to draw on the resources of the larger community in finding the services parents and children need. Leadership has to be provided by agency administrators to make progress in this area. Training of supervisors and caseworkers to access unfamiliar resources is essential for accessing what families need. E. Training Although a great deal of progress has been made in recent years in providing training for CPS staff and supervisors in many parts of the country, there is still a long way to go especially in areas of understanding the dynamics of neglecting families, the impacts of neglect on children, specific practices and interventions that are helpful, and how outcomes can be established and pursued in case practice with neglect families. Supervisors need to be involved in clinical supervision, actually helping caseworkers make decisions on cases through guidance and the transfer of knowledge about the cases, the resources in the community, and the patterns of interaction with parents that elicit change. The CPS Response to Child Neglect Page 71

CPS Responsibility for Child Neglect They need to be trained for that set of responsibilities. In all parts of the country, the tenure of CPS staffs is very short; the positions experience a great deal of turnover, and new staff are often not adequately prepared to deal with the complexities of child neglect. Administrators could contribute greatly by having a training needs assessment study be conducted, documenting what relevant competencies are present on staff, where the gaps are, and then develop a system of initial and ongoing training to address the important needs. F. Building Community Partnerships for the Protection of Children The field has always pointed out that CPS cannot do the job of protecting children all alone. Traditionally partnerships have been formed with law enforcement and the coordination with the courts has been a necessary part of case practice. CPS has also purchased services for its families from a number of community agencies. In recent years, however, the concept of community partnerships has been extended to pull in a broader array of community agencies, schools, domestic violence shelters, childcare centers, faith communities, and concerned citizens into a partnership with CPS to better protect children. Not only is the set of partners expanded, but the roles for partners are also changing. One role is to be more involved with prevention and early intervention, working with CPS to identify the conditions that might require a formal report and those that would not. Another role is when CPS decides to screen out a case at intake or to close after initial assessment because the situation did not meet the criteria for CPS. The case can be referred to a community agency for services or follow-up. Another role is to serve with CPS on integrated service teams to bring all agencies and resources together to plan for providing services and supports to a family. In some communities CPS actually transfers the initial assessment to a community agency, such as a childcare center, which might be known to the family and in a better position to assess the problems, risks, and strengths. One major change has been to involve the non-formal system of supports, people who are concerned about children/families but do not hold any professional responsibility for their case. These could be the community of concerned neighbors; the faith community the parent is a part of, or a group of volunteers who would be willing to provide support. Mechanisms such as family team meetings or family group conferences often bring both formal and nonformal resources together to help CPS and the family make decisions about next steps. From initial experience, it is clear that building these community partnerships cannot move forward without the leadership and active involvement of the public child welfare agency. There are particular mechanisms that the agency can implement to foster these partnerships. One is to outstation CPS staff in the community. Another is to regularly meet with concerned community organizations and faith communities to explore ways to respond to vulnerable children and families, even if CPS does not primarily initiate the response. An additional The CPS Response to Child Neglect Page 72

CPS Responsibility for Child Neglect mechanism is to put together systems of governance that formalizes shared needs assessment responsibilities, resource allocation, and case decision-making. G. Outcome Focused Intervention Over the past several years, many child welfare agencies have actively sought ways to identify outcomes and measure their achievement. This effort has been greatly accelerated by the federal government s move toward outcome accountability in their Child and Family Service Reviews. The three federal outcomes are safety, permanency, and child and family well-being. Within each of the three outcomes are sub-outcomes that states need to address in the reviews. All are relevant to neglect cases, but the sub-outcomes related to child and family well-being are particularly relevant. Agencies are asked to report on the enhanced capacity of families to provide for their children s needs. The second sub-outcome under child and family well-being is that children receive appropriate services to meet their educational needs. The last suboutcome in this area is that children receive adequate services to meet their physical and mental health needs, requires more comprehensive assessment of these needs as well as reliable information on the provision and adequacy of the services to children. Although meant for and appropriate for all cases of child maltreatment, these outcomes are particularly relevant for neglect cases. They clearly go beyond the capacity of most public agencies to both document and, more importantly, provide what is needed to identify levels of outcome achievement. This is an area of need that administrators are actively addressing. All involved agree that obtaining good outcome data is a developmental process. Leadership is needed to understand the outcomes and ensure case practice addresses and documents achievements. Assisting supervisors to readily and routinely utilize information on outcomes residing in their information systems - to guide casework practice on specific cases - is an additional administrative responsibility. Attention to the attainment and utilization of outcome data will go far to assure more effective services to neglect cases. H. Workforce Issues One of the major administrative challenges in child welfare is to ensure a sufficient number of qualified staff that remain in their jobs for reasonable time periods. This, of course, is a challenge impacting the quality of services provided on all cases, not just neglect. It is particularly challenging in neglect, however, because of the common characteristics of neglecting parents. To be effective in engaging these parents, in connecting them to needed services, and in supporting the focus on sustainable change, requires considerable and consistent time from caseworkers. Moreover, the ratio of caseworkers to supervisors has to be low enough (the standard is 5-1) to permit clinical supervision actual support for decision-making on neglect cases. Unreasonably high caseloads work against time being spent with neglecting parents and their The CPS Response to Child Neglect Page 73

CPS Responsibility for Child Neglect children. Agency administrators have a role to play in advocating for the workload standards that allow for effective practice. There are many examples of approaches to workload management, the setting of workload standards, and the development of the needed resources that can be drawn upon in addressing this important challenge. Retention of qualified staff is again a challenge for administrators regardless of the type of case. A recent report (May 2001) of a study done by APHSA, CWLA, and the Alliance for Children and Families on workforce issues involving 43 states indicated that annual staff turnover rates are quite high. CPS averaged 22 percent annual turnover. The turnover rate for CPS workers is 76 percent higher than the rate for total agency staff. Furthermore, the preventable turnover rates are also quite high and again higher for CPS workers compared to other direct service workers. Neglect cases are particularly impacted by turnover. Many studies have pointed to the importance of developing a relationship with a helping professional if these challenging cases are to experience progress and changed patterns of parenting. Strategies for addressing preventable turnover have been studied. Important factors are increased salaries, reduced caseloads, and the provision of educational support. There are less costly factors that make a difference: valuing of workers, training, better access to supervisors, mentoring programs, and flextimes are examples. Administrators often face intractable barriers in addressing workforce issues, yet they are key to the provision of effective services. The administrative and policy issues discussed above are really a mix of the type of challenges faced. They include both broad conceptual changes in approaches to serving neglecting families, as well as practical issues faced by administrators in the management of their agencies. As a group, they are not comprehensive, but are illustrative of the range of important challenges as well as the important role played by administrators in forming and improving the CPS response to neglect The CPS Response to Child Neglect Page 74

IV. Child Safety and Child Neglect Wayne Holder, MSW & Barry Salovitz, MSW Introduction Many people may believe that within child neglect cases, child safety is often overlooked. That is a curious belief given that the prototype safety assessment model being implemented nationally predominantly focuses on threats of harm associated with neglect cases. Therefore, what is the basis for the belief that in child neglect cases, child safety is minimized? Conversely, since safety models apparently are being formed around neglect kinds of case circumstances, why do physical abuse and sexual abuse continue to receive the highest priority, including having intervention models that are designed with greater rigor accorded the abuse related referrals? This chapter seeks to sort out the myths and truths about child safety and child neglect so that CPS administrators can develop child safety policies and strategies for these cases. Child Safety The National Resource Center on Child Maltreatment provided essential definitions with respect to child safety that comprise a foundation for discussing child safety in child neglect cases (1999). A child is unsafe when the present and emerging threats of harm that exist cannot be managed by the family s protective capacities, in which case agency intervention is needed to supplement those protective capacities. Threats of harm are conditions/actions within the family that represent potential for serious injury or trauma to the child. Harm refers to the nature of the injury or trauma affecting the child. Severity refers to the extent of harm that could occur from the threat to safety. Vulnerability concerns the child s capacity for self-protection. Wayne Holder, MSW, is Co-Director of the National Resource Center on Child Maltreatment. Barry Salovitz, MSW, is Director of Program Development for the National Resource Center on Child Maltreatment. The CPS Response to Child Neglect Page 75

Child Safety and Child Neglect Imminence refers to both the time frame for harm resulting from threats of harm and the certainty of harm s occurrence. Protective capacities are factors or resources within the family that can or do promote the child s safety. Child safety can be considered to be in jeopardy when the following exists (Holder, 1987): Conditions, situations, behaviors or circumstances within a family are out of control; The harm resulting from the family being out of control is likely to occur immediately, which includes from the present to the next several days; The harm is likely to be severe; and There is a vulnerable child in the family. For safety to be an issue in a neglect case, one must determine that the neglectful behavior needs to be controlled and is serious enough to cause severe harm immediately or in the near future. The severe effects can include trauma, impairment, disfigurement, injury or even death. Here emphasis is given to the distinction between conditions that threaten child safety and those that affect the quality of life and child well-being. Certainly quality of life and child well-being are issues apparent to all who work with chronic neglect cases. To explain, there is little doubt that neglect has long-reaching effects on children related to their development and well-being. It is generally recognized that the long-standing deprivation occurring in neglect cases can result in children growing up with serious emotional and physical deficiencies. The point is, however, the dynamics that are destructive to a child s general or long-term well-being do not fit the criteria presented here regarding safety. Dynamics that are destructive to a child s well-being in neglect cases do not usually have an immediate severe effect. The harm from such dynamics does not occur in a present or near future time perspective that is consistent with a child being unsafe. With respect to child neglect cases, CPS decision makers need to recognize that threats to safety occur in two dimensions: 1) the present or right now and 2) emerging or within the next days and up to a few weeks. This delineation is critical. While some neglect referrals contain vivid, easily identifiable threats of harm that are occurring at the time of the referral - such as a young child left unattended - many neglect referrals are more insidious, although threats of harm can often be less obvious upon the first encounter. Many neglect referrals do not possess threats of harm (threatening conditions, behaviors or circumstances) that are currently active. As one continues working with a neglecting family, case dynamics become apparent, indicating that threats of harm do exist or may soon emerge and become active. As an example, consider the depressed mother who significantly wavers in her basic parenting responsibilities for her infant. To further illustrate the idea of emerging safety threats, as this chapter was being written, a very grisly case appeared in the national media. It involved an 8-year-old girl who was kept The CPS Response to Child Neglect Page 76

Child Safety and Child Neglect locked in a filthy closet for months by her mother and stepfather. Barely alive when found, the little girl weighed only 25 pounds. Although the girl s three sisters and two brothers were placed in foster care when the case came to light, apparently their conditions were not nearly as severe. This sad case situation helps us to see the difference between present and emerging threats of harm. Certainly, when authorities were advised about the little girl s condition and living circumstances, we can conclude that she was in present danger. The harm was obvious, active and current. However, what if the family had been referred to CPS six months earlier, when the girl was 7 ½ years old? There may have been no present danger threats of harm evident. But, surely, what led to the current unthinkable situation existed back then. We can reasonably believe that family and caregiver behaviors, emotions, perceptions, conditions and situations that eventually led to the present danger existed six months ago. The threats of harm were emerging. The vulnerability of this child, who easily could have died, illustrates for us in vivid ways: 1) why understanding the distinction between present and emerging danger is critical and, 2) how ongoing safety assessments must be sufficient to examine family life and functioning in ways that probe beneath a family s initial allegations and presentation. Caregiver Characteristics In child neglect referrals and neglect cases, threats of harm are mostly associated with caregiver characteristics that play out in their behavior. Here are some real-life family situations that illustrate this point: Capacity Cognitive A developmentally disabled mother lights candles in her infant s bedroom because she does not want her to sleep in the dark. The curtains catch on fire and the child dies in a burning house. A parent s perceptions about threatening conditions within the home are unrealistic. The parent allows the children to play on a trampoline situated on a second floor balcony. A child falls one story and miraculously is not injured. Mental Health A mother is distraught over her divorce and lapses into a depression that causes her to retreat from her parenting responsibilities for her toddler. The child fails to develop and eventually malnourishment threatens his life. Physical Disabilities A wheelchair bound father living in an isolated rural area is the sole caregiver of twin three-year-olds. The twins become seriously malnourished. The CPS Response to Child Neglect Page 77

CPS Responsibility for Child Neglect Physical Health A loving and caring mother with muscular dystrophy allows her 5-year-old daughter to play at the school playground across the street while she watches from the living room window. She doesn t want her illness to keep the child housebound or deprive her from a normal childhood. The mother admits that occasionally she loses sight of the child while she is playing and that she is physically unable to respond quickly if required. Nothing serious had occurred at the point of the initial investigation. Mobility An obese mother allows her children to play in an unfenced front yard that borders a busy street. Although she supervises her children, her inability to move easily or quickly limits her ability to intervene to protect her children. The youngest child was nearly hit by a car while chasing after his dog. The mother was ineffective when she pursued the child. Focus and Attentiveness The Internet consumes a mother s attention. She is oblivious to her surrounding circumstances and what threats to her children s safety may be present in the home. Both pre-school children regularly roam the neighborhood unattended. Needs The parents pleasure-seeking needs are paramount compared to the needs of their children, leading them to often involve their children with threatening individuals and situations. The parents regularly leave their kids with people who they hardly know. On the last occasion, they reportedly left their daughter with a known sex offender. Motivation A parent did not want the child and is not satisfied with the parenting experience. While the parent does not wish ill will on her 11-year-old child, there is a propensity to not attend to the child or the child s needs. The child has become involved in neighborhood gang activity. Self-Indulgence and Egocentricity The mother is consumed with her own needs related to male relationships. She regularly has elevated her needs and the interests of her male companions beyond her 6-year-old son. As a result of the mother s needs, the child has been locked out of the house, left alone frequently at night, and left in the care of a disabled senior citizen who is unable to provide basic care for the child. The CPS Response to Child Neglect Page 78

CPS Responsibility for Child Neglect Overwhelmed An overweight mother has four children ranging from one year of age to five. She has housing and financial problems, lacks transportation and is socially isolated. The household is chaotic. The stress she experiences limits her protective capacities. There is a history of a child death involving a child being smothered underneath the mom while the two slept together. Judgment A mother bathes her three children together. The ages of the children are 4 years old, 2 years old and 9 months old. The infant drowns when the mother leaves the room to answer the phone. Knowledge and Skill A new mother believes that her infant cries because she wants to be spoiled. The mother refuses to attend to the child and will not let anyone else, including the father. This parenting behavior limits detection and fulfillment of the child s most basic needs. A father believes and expects that his 6-year-old daughter is capable of taking care of her 2-year-old sister for long periods of time. The 6-year-old is seriously burned while trying to cook for her sister. Choice of Living Arrangements This family lives in a dilapidated trailer in a rural area. The trailer lacks heat during an extremely cold winter. An infant dies of exposure to the cold. Another family lives in a crack house. In addition to drugs and drug paraphernalia, the children are exposed daily to drug dealers and users. This home has all kinds of hazards, including exposed wiring, broken windows and loose ceiling sheetrock. The dad indicates that he is repairing the house and refuses to see that the conditions of the home are threats to his children s safety. Substance Abuse and Addiction Getting and using drugs compromise this mother s capacities, judgment, motivation and involvement with her three children. The mother exposes the children to dangerous people. She leaves them alone to fend for themselves while getting and using drugs. She passes out and is unable to provide for their needs and protect them. She is so preoccupied with getting high that she fails to supervise her children. Sometimes she is so sick from withdrawal that she is unable to provide basic care and protection. The CPS Response to Child Neglect Page 79

CPS Responsibility for Child Neglect Values and Beliefs These parents religious beliefs prevent an acutely ill child from receiving necessary medical care. Three critical elements are noticeable in all these neglectful situations: 1) the presence of a parental condition that reduces or obviates parenting quality, responsibility and protective capacities at a very fundamental level (safety), 2) a vulnerable child and 3) the absence of any other responsible adult to care for the child. Threats of Harm Work that has been done in recent years to develop safety models has resulted in indications of threats of harm that can be associated with neglecting families (Holder, 2000.) Keeping with the delineation of present and impending danger, let us begin with consideration of neglect related present danger threats of harm referred to CPS and requiring immediate intervention: Failure to thrive (of any child); Health or life threatening current living arrangements with vulnerable child(ren); Young child observed to be unsupervised or alone now; Child is fearful/anxious about home situation as related to home conditions and general threats (as compared to threats emanating from the parent); Child needs immediate attention for an acute medical need, the lack of which could result in severe effects; One or both parents is not controlling or cannot control their (nonviolent) behaviors (such as mental disorders or developmentally disabled) that could reduce their parenting capacity with vulnerable child(ren); Unrealistic parental viewpoint or expectations of a young child related to self-care and self-protection; Child has exceptional disabling or life-threatening needs that the parents cannot meet; Parents observed to be unable to provide basic childcare in the immediate present with vulnerable child(ren); Parents observed to be under the influence of substances (e.g., inebriated, passed out, etc.) now with vulnerable child(ren); The CPS Response to Child Neglect Page 80

CPS Responsibility for Child Neglect Parents whereabouts unknown with vulnerable child(ren); A vulnerable child with serious needs or conditions and the family is geographically or socially isolated; Family is hiding the child; The family currently does not have basic resources (e.g., food, clothing, shelter) at a safety level. The above influences may not be present upon first encounter with the neglectful family, but through further assessment, the strong possibility of such conditions arising becomes apparent. However, keeping in mind the distinction between present and emerging threats of harm, neglected children may still not be safe. In the following list of emerging threats of harm, you will find some repetition with the above list on present danger. However, careful reading and consideration will reveal different insight based on additional time and exposure to the family. So, consider the following list of emerging threats of harm that may have been reported, unconfirmed at the first encounter with the family, but ultimately confirmed by the end of the investigation/assessment or even further along the CPS process. Developmentally delayed child, showing signs of failing to thrive. Health or life-threatening living arrangements. Young child observed to be occasionally or routinely left unsupervised or alone as an expression of parental planning and judgment. Child fearful/anxious about home situation as related to home conditions and general threats (as compared to threats emanating from the parent). Child needs immediate attention for an acute medical need, the lack of which could result in severe effects. It is not clear whether there is or will be an adult in the home who will perform parental duties and there are vulnerable child(ren). One or both parents does not or cannot control their (nonviolent) behaviors (such as mental disorders or developmentally disabled) that could reduce their parenting capacity with vulnerable child(ren). Unrealistic parental viewpoint or expectations of a young child related to self-care and self-protection. Child has exceptional needs that the parents cannot meet that could become disabling or life threatening. The CPS Response to Child Neglect Page 81

CPS Responsibility for Child Neglect Parents determined to be unable or unwilling to provide basic childcare on a routine basis with vulnerable child(ren). Parents determined to be addicted or abuse substances resulting in the inability to assure a child s safety. Parents whereabouts continue to be unknown. Vulnerable child with serious needs or conditions, and the family is geographically or socially isolated. Family hides the child or avoids allowing others to see the child or know about the condition of the child. Family does not have basic resources (e.g., food, clothing, shelter). One or both parents lack knowledge, skill or motivation to meet the safety needs of a vulnerable child. Parents have been found to be insensitive to the child s needs and limitations that may lead to placing him/her in threatening situations. It has been determined that the parents unrealistic expectation is placing or will likely place a vulnerable child in threatening situations. Child is perceived in extremely negative terms by one or both parents. One or both parents express a dislike for a child and say they do not want to parent the child or request placement. Child is seen by either parent as responsible for the parent s problems or situation. Parents show no remorse or empathy for the child s condition or circumstances. One or both neglectful parents has failed to benefit from previous professional help that was associated with neglectful safety concerns. Safety Instruments Safety assessment instruments have been successfully used to guide practitioner decisionmaking with respect to identifying threats of harm. However, these instruments have not been developed to distinguish between neglect threats of harm and threats of harm from other forms of maltreatment. A review of the most popularly specified threats of harm (Illinois, 1999) reveals that workers are often being guided to consider threats of harm The CPS Response to Child Neglect Page 82

CPS Responsibility for Child Neglect that can be related to neglect situations. Caretaker s behavior is violent or out of control. Obviously violence does not apply to neglect cases. As mentioned previously, being out of control emotionally and behaviorally with respect to being able to fulfill one s parenting responsibilities does apply to neglect. In the context of a vulnerable child, the state of being out of control emotionally or behaviorally represents a threat of harm. So, an instrument that lists this as a threat of harm would be more effective by separating violence or aggressive behavior from out of control (including non-aggressive behavior or emotion). Caretaker describes or acts toward child in predominantly negative terms or has extremely unrealistic expectations. Certainly this threat of harm can be used with neglect cases. However, training, guidelines and other prompts are necessary to assure that worker bias is not toward physical abuse indicators. Previously, it was mentioned that neglecting parents might avoid parenting responsibilities at a very basic level (including safety) because of attitudes toward the child or beliefs about the child s capacity. Caretaker caused moderate to severe harm or has made a plausible threat of moderate to severe harm to the child. For this to apply to safety within neglecting families, it would seem that the impairment, trauma, etc. having occurred would be evidenced in the history of neglect. While it is unlikely that a caretaker would threaten to neglect a child, one might suppose that a caretaker could impulsively threaten to leave the child alone or unsupervised. Of course, a parent might say they refuse to get medical care for a child based on medical beliefs. While this may not be a threat in so many words, the character of the communication and potential effects are similar. Child s whereabouts cannot be ascertained and/or there is reason to believe that the family is about to flee or refuse access to the child. This threat is not necessarily specific to a particular maltreatment. It really is about not being able to evaluate a child s condition that could be related to neglect, abuse or neither. Caretaker has not, will not, or is unable to provide sufficient supervision to protect the child from potentially moderate to severe harm. This is obviously a threat of harm that is strictly related to neglect. This is the second time, in the list of threats of harm that are the most popular in the CPS field today, that we find moderate to severe harm mentioned. This poses a question as to how one is to understand how moderate harm rises to the safety The CPS Response to Child Neglect Page 83

CPS Responsibility for Child Neglect threshold. As mentioned in the definitions earlier, threat of harm is defined with reference to serious injury or trauma. Harm refers to the nature of the injury or trauma. Severity refers to the extent of harm; presumably in the same fashion that moderate refers to the extent of harm. However, in the National Resource Center on Child Maltreatment monograph, Designing a Comprehensive Approach to Child Safety, severity is qualified as being consistent with serious injury, death, permanent disablement and long-term damage to development. Many of us will agree with the qualification related to serious, but would have difficulty understanding what the qualification for moderate would be in order for family conditions, behaviors, emotions, motives and so forth to rise to the safety threshold. The inclusion of moderate within threats of harm may be a mistake in facilitating effective safety assessments by workers and in distinguishing between that which is a risk factor and that which is a safety factor. Caretaker has not, will not, or is unable to meet the child s medical care needs that may result in moderate to severe health care problems if left unattended. This is obviously a threat of harm that is strictly related to neglect. Caretaker has previously or may have previously abused or neglected a child and the severity of the maltreatment, or the caretaker s response to the prior incident, suggests that child safety may be an urgent and immediate concern. Neglect is even mentioned in this threat of harm. Guidance through training, guidelines, supervision, etc., can support increased worker understanding of what sorts of response by neglectful caretakers fit this threat of harm. Presumably the previous severe neglect could fit our definition for severity described above. Child is fearful of people living in or frequenting the home. This is a threat of harm related to neglect. It embodies both questions about protective supervision and threatening living arrangements. Caretaker has not, will not, or is unable to meet the child s immediate needs for food, clothing and/or shelter, the child s physical living conditions are hazardous and may cause moderate to severe harm. Here again is another threat of harm that is devoted to neglect. Other than having the problem related to moderate harm that has already been mentioned, this threat of harm is rather specific concerning the daily life experience associated with basic needs at a safety level. Child sexual abuse is suspected and circumstance suggest that child safety may be an immediate concern. The CPS Response to Child Neglect Page 84

CPS Responsibility for Child Neglect This appears not to be related to neglect. However, neglect could be operating when primary caretakers know that a child is vulnerable to being sexually abused and do not provide supervision and protection. Non-sexually abusing caretakers in the home may be neglectful if they fail to acknowledge the threat of sexual abuse. Caretaker s alleged or observed drug or alcohol use may seriously affect his/her ability to supervise, protect or care for the child. This is clearly neglect. Caretaker s alleged mental illness or developmental disability may seriously affect his/her ability to supervise, protect or care for the child. What is apparent in this threat of harm, and the one that precedes it, is the apparent lack of reference to substance abuse, mental illness or developmental disability that results in aggression toward the child. That is what makes these threats distinctively neglect oriented. Besides, in this list, aggression and acting out toward the child is adequately addressed in the first threat of harm. Caretaker may be a victim of domestic violence that affects caretaker s ability to care for and/or protect the child from imminent, moderate to severe harm. This also is a threat of harm related to neglect. This is not solely about domestic violence, but the capacity of the victimized caretaker. In that sense, this threat of harm is very closely related to other threats listed here. In fact, it could be that this threat is a duplication, provided in order to emphasize to workers the need to be cautious with domestic violence cases. The caution expressed here is whether the victimized parent has the capacity to protect his or her children from the violent partner. In this review of (what could be considered) the state of the art concerning threats of harm contained in the most commonly used (or adapted) safety assessment instrument, it is obvious that child neglect is well represented. In fact, depending on the emphasis provided on a couple of threats of harm, the entire list could be judged to relate to or include child neglect. It is reasonable to conclude that the orientation of safety instrumentation focuses on child neglect conditions that represent threats of harm. This is curious since traditionally the tendency, when considering whether children are safe, is to focus on physical and sexual abuse. Is this not born out by the popularity of dual tracking, in which more serious cases (involving forms of abuse) are investigated while neglect is usually diverted for a family assessment (which is softer and may minimize safety assessment)? The CPS Response to Child Neglect Page 85

CPS Responsibility for Child Neglect The Leman Case Example The following case example helps to bring this discussion to several conclusion points about child neglect, child safety, safety assessment and intervention and emerging safety threats. Referral The Leman family was referred by a school counselor for suspected emotional and physical neglect. The family consists of Berlinda age 32, Danny age 15, and Bobby age 3. The father, Brent Leman, has been absent from the family for some time. The mother has a sister living in the area. The school counselor had knowledge of the family for about a year and has been in the home upon one occasion. The mother was described as taking no interest in the children. Danny was described as depressed, failing in school, constantly truant, insecure and predelinquent. Bobby was described as unusually docile, withdrawn and developmentally behind. The counselor said the home was rundown, dirty and smelly. Family Information The family resides in a small, two-bedroom home that is messy, but is not filthy or dirty. There are no serious health problems in the home and mainly things have been left lying around. The kitchen is somewhat picked up, but not clean. Shades are pulled, and two small lamps furnish the only light. The family rents the house. Bobby's crib is in his mother's room while Danny stays in the other bedroom. Berlinda is 32 years old, medium height and slightly overweight. She has rounded shoulders and a slump-like appearance. She wears no makeup and her hair is unkempt. Her face is often expressionless. Her skin is pale, maybe even yellowish and she has dark lines or shadows under her eyes. She dresses in a disheveled manner. She keeps her hands either held together or fiddles with her fingers. Berlinda is slow to talk and avoids communicating freely. She avoids eye contact and her eyes are almost always directed at her hands. Berlinda was the oldest child from a large family in Arkansas. She married a serviceman when she was 17 and was pregnant at the time of the marriage. Danny was born during that same year. The family located to this area nine years ago. The father was shipped overseas shortly after coming to this area and returned five years later. Bobby was born a year after the father s return. Shortly after Bobby s birth, the father went AWOL The CPS Response to Child Neglect Page 86

CPS Responsibility for Child Neglect and deserted the family. His whereabouts is unknown and the family has remained in this area on public assistance. Berlinda describes herself as not much of a mother. She indicates she has no friends. She says she does not have the energy to give the boys attention. She describes herself as being very lonely. She says she has little contact with her sister. Berlinda has little to say positively about herself or her life. She remarks that people don t have much control over their lives. She says things just happen to people. She has little to say about her own family or her absent husband. She indicates that she just tries to make it one day at a time. She says that Danny misses his father. She indicates that neither Danny nor Bobby is a problem. She says Danny is on his own a lot. She describes Danny as very sad sometimes. She isn t sure how Danny is doing in school. When asked to describe Bobby she says that he is a quiet child. She says he is not toilet-trained and tends to sleep most of the day. She says he is shy and afraid of strangers. She says he hardly talks, seldom cries and often rocks. Berlinda views him as no trouble. When asked about working with the agency or receiving services, Berlinda says she doesn t really care. She believes the schools could take care of what Danny needs. When asked about needs that she or her family has, she shrugs her shoulders. When asked if there was anything the agency could do to assist her, she shakes her head no. When asked about problems she or the children are encountering she seems resigned and says things are fine. Bobby appears slightly thinner and shorter than normal. His skin color is pale. He is generally unresponsive, will not play and looks blankly at the worker. He does not cry or smile. He does not reach for his mother. He will not talk or respond to prompts to talk. Interview with Danny Danny is a well-groomed 15-year-old. He is generally willing and able to respond during the interview. He reports that he has no interest in school these days and hasn't for most of the year. He says his mother doesn't really care how he does in school so why should he. Danny says he would rather just quit school and move out and marry his girlfriend. He hasn't thought at all about how he would live if he did such a thing. The CPS Response to Child Neglect Page 87

CPS Responsibility for Child Neglect He says he is pretty much allowed to do whatever he wants at home. He doesn't have a curfew or any rules. He hates being at home and mostly stays to himself, in his room when he is home. Danny has not seen his father since before Bobby was born. He appears to feel a sense of loss about this, perhaps anger as well. He does not know where his father is. He describes Bobby as just a baby. He says Bobby is very quiet and never plays or cries or makes noise. Danny seems to realize that Bobby is not behaving as most 3-year-olds do because he asks if it is normal for Bobby not to play or cry. He says his mother doesn t even get Bobby out of the crib most days, except to feed him or change his diaper. He says his mother has become more and more sad over the past couple of years. He doesn t know of any friends that his mother has. The only things they do as a family is eat meals together now and then. Interview with Danny s Teachers Danny is progressively doing worse in school, acts depressed most of the time, and tends to imagine (daydream) things as being better for him, including fantasizing about leaving school and marrying his girlfriend. Danny is very likable and teachers and counselors seem to take a personal interest in Danny. He takes pride in his appearance, is generally shy, and avoids engaging with teachers about his feelings and concerns. He does not try to justify his performance or behavior. He is not ordinarily communicative. Danny has recently been involved in some concerning behaviors at school, including minor vandalism to the science lab with several other classmates. Danny appears to have gone along with the other boys and the teachers are concerned that he is following a bad group. One of the boys is known to be an active member of a local gang. Medical Exam A medical exam reveals that Bobby is under-stimulated physically, socially and emotionally. He is smaller than normal and frail. Indications are that Bobby is not intellectually limited, but more likely is intellectually thwarted due to emotional/social deprivation. While he is well behind developmentally, Bobby appears to be experiencing no immediate health threat. The CPS Response to Child Neglect Page 88

CPS Responsibility for Child Neglect Examination of Leman Family Referral The referral from the school is deceptive, as many neglect referrals often are. The school reported primarily on behalf of a truant, troubled teenager. The fact that anything at all was mentioned about the home or other family members could be considered to be unusual. What is provided about the family and home is general and, regretfully, is tainted by the dreaded dirty house prejudice that often allows such referrals to be dismissed as low risk. In some jurisdictions this kind of referral, if not screened out, would be tracked to assessment. It would not receive a full investigation. The assessment likely would inform the family that a report had been received and then would primarily focus on the family s strengths and needs. The intervention might include a review of various family domains, inquiring into whether the family or individual family members might have unmet needs. How extensive the assessment may be - with respect to considering risk of maltreatment, threats of harm, or the quality, nature and significance of family member functioning - depends on the program design, the competence of the worker and specific expectations concerning information collection and analysis. In other jurisdictions a referral like the Leman family, if not screened out, might be assigned for an investigation which presumably would result in a fuller examination of the family and its condition. However, often investigations focus strictly on alleged events and effects. In other words, it is common for an investigation to be directed at parental acts and aggression that results in the manifestation of abuse in the form of bruises, breaks and/or burns. Certainly, the exception to the abuse orientation would include parental omission that results in serious and obvious effects in a child (such as starvation or a lack of protection and supervision). The point to be made is that often investigations end up considering only the most vivid, severe situations. An investigation conducted on the Leman family might very well end up with an unsubstantiated finding and a case closure following the investigation. To adequately respond to a case like this, a number of decisions are warranted. First, this referral should not be screened out. Information gathering and decision-making at intake should be thorough and sufficient to assure that loss leaders such as truancy and dirty houses do not sway judgment. Credence and weight must be given to key information items, such as a mother s disinterest in her children and the presence of a vulnerable child. Without the validation that comes from face to face examination available through a quality assessment or investigation, care should be taken when screening referrals, so as to avoid downgrading the significance of neglect related referrals as merely low risk. Second, regardless whether an investigation or assessment occurs, the evaluation of such a family should include a full consideration of the presence of threats of harm, the functioning of all children in the home, the functioning of adults, general parenting practices of the parents and the disciplinary practices of the parents. The evaluation should be objective in the sense of not being biased one way or the other concerning The CPS Response to Child Neglect Page 89

CPS Responsibility for Child Neglect strengths or deficits. Gaining an accurate, realistic picture of exactly what is going on in the family, in so far as possible, should be the objective of the evaluation. Third, after an investigation or assessment occurs, a case like the Leman family should be offered continuing child protective services. A review of the threats of harm covered earlier suggests that no present danger exists for Bobby, clearly the most vulnerable child in this family. However, there are a number of concerns that seem relevant with respect to the question of emerging threats of harm. There is an indication that Berlinda s depressed condition is worsening. Her mental health is already diminishing her parenting responsibilities, resulting in negative effects for both children. Although it is confirmed that Bobby is not in immediate danger right at this moment, it seems reasonable that without intervention, his condition will likely worsen and become acute. If the agency remained involved with Berlinda, a clearer understanding could be gained concerning family functioning and its relationship to emerging threats of harm. Drawing off of the threats of harm lists identified earlier in this chapter, the following questions should be raised: To what extent is Berlinda able to control her emotions in order to function as a parent? Is her self-control as influenced by her depression progressively worsening? How realistic are Berlinda s expectations concerning Bobby and his needs? What level of supervision is needed for Bobby and what capacity does Berlinda have now or will she have in the future given her current condition and what might be expected about her future condition? Is there another responsible adult who can be relied on to provide basic care and supervision of Bobby if Berlinda s emotional state continues to worsen? If Bobby s physical or medical needs became acute, what capacity and resource does Berlinda have to assure that those needs are met promptly and appropriately? How serious is Berlinda s emotional condition? Is her condition situational or does it exist as a mental disorder? Is it in fact worsening? What treatment or intervention options are available and helpful for Berlinda to assure her capacity to perform her parental responsibilities? What are the dynamics and dimensions associated with Berlinda s motivation to parent, sensitivity to Bobby s needs and empathy for Bobby s condition that could influence his eventual safety? By remaining involved, emerging threats of harm could be fully considered. Additionally, a deeper understanding of the needs in this case could lead to treatment so that current conditions could be addressed, offset or remedied, prior to becoming threats of harm. It should be clear that current information does not indicate the immediate need for a safety The CPS Response to Child Neglect Page 90

CPS Responsibility for Child Neglect intervention. However, if this case was closed following an assessment/investigation and no treatment services were rendered, then it can be reasonably concluded that 1) conditions within the family will worsen and rise to the safety threshold; 2) the Leman family may not be referred again since the gravest concerns (related to Bobby) are not visible within the community and 3) Bobby could end up seriously impaired or even dead. This scenario is not inconsistent with many neglect fatalities. Final Thoughts Child neglect cases are dangerous because we are fooled by the low-grade concerns that are simply eating away at family life until, eventually, it can be too late to do anything. Child neglect cases are often not severe during early encounters. Additionally, child neglect referrals and subsequent investigations often do not determine that kids are in present danger, and decisions occur that obviate considering whether kids are in an emerging danger context. The good news is that safety assessment instruments containing standardized threats of harm seem to adequately cover the vast majority of neglectful family conditions. However, more emphasis is needed to understand the difference between present and emerging danger, particularly with respect to neglect. It could be that safety assessments give too much prominence to the initial encounter with a family and examine only safety threats that are currently active and severe. It would be interesting to know more clearly what relationship an alleged event (e.g., beating a child) and a child s condition (e.g., bruises) have to safety assessments since neglect referrals often do not contain either. Reports concerning neglect are often based on general circumstances (e.g., children are not being cared for, parents use poor judgment, home conditions are unsatisfactory) rather than a specific event related parental behavior (e.g., disciplinary approach, intentional aggression, hitting). It is curious whether or not this fact tends to reduce CPS concern. Does the potential severity in neglect referrals get lost in the vagueness and generality of what is going on in a family compared to the present severity and vividness often apparent in physical and sexual abuse cases? Is insufficient attention being given to understanding the vulnerability of children within the context of family conditions and parental capacity? We could agree that what is at stake for the children in many of these cases (e.g., physical abuse victims versus physical neglect victims) is not different with the exception of time: Is the child in present danger versus is the child in emerging danger? The conclusion that can be reached is that the CPS response to child neglect must be sufficiently efficacious in its assessment and intervention to effectively identify neglected children who are unsafe at the first CPS encounter, but also those neglected children that gradually and eventually become unsafe. The CPS Response to Child Neglect Page 91

Child Safety and Child Neglect References Holder, W. and Morton, T. (1999). Designing a comprehensive approach to child safety. The National Resource Center On Child Maltreatment. Duluth, GA. Holder, W. and Corey, M. (1987) The child at risk decision-making system. ACTION for Child Protection, Inc. Charlotte, NC. Holder, W. et al. (2000) SAFE: Safety assessment and family evaluation. ACTION for Child Protection, Inc. Charlotte, NC. Morton, T. and Salovitz, B. (2001) Ideas in Action Safety Planning at Reunification. Child Welfare Institute. Duluth. GA. State of Illinois. (1999) Child Endangerment Risk Assessment Protocol. Springfield IL. (Note: The CERAP model was used in this paper as the prototype safety assessment instrument since a large number of states nationally are employing the same or modified versions of the threats of harm contained on this form.) The CPS Response to Child Neglect Page 92

V. Race, Ethnicity and Culture: Impact on Child Neglect Occurrence, Assessment and Response Joyce N. Thomas, RN, MPH Introduction Although it may be a common belief that everybody knows what child neglect is and that it is easily identified regardless of cultural factors, variations in child rearing beliefs and behaviors make it difficult if not impossible to establish a universal definition of child neglect. Cultural values and practices play important roles in shaping the definition and interpretation of child neglect; however, providing culturally competent definitions of child neglect is difficult because perceptions of what constitutes neglect are complex and can vary across cultures (Korbin, J. & Spilsbury, J. 1999). Uncertainty about how to define child neglect, coupled with beliefs and traditions that vary across cultures and ethnicities, can spell misunderstandings and even poor practice. This article will examine the relationship between child neglect and issues of race, ethnicity and culture, and how the child welfare field has defined and integrated cultural competency into policy, practice and research. A critical task for child welfare administrators is encouraging workers to gain a better understanding of variations in child rearing patterns to establish an unbiased perspective about child maltreatment while avoiding stereotyped judgments of individual families who may be identified with a specific ethnic population. Defining Cultural Competence The term cultural competence is used in this article because cultural competence goes beyond being aware of issues of race, ethnicity, and/or sensitivity to cultural differences. Typically, culture is demonstrated in the rules and mores that guide relationships. The word competence signifies the capacity to be skilled and achieve a level of mastery. The term cultural competence refers to the set of congruent behaviors, attitudes, structures and policies that comes together in a system, agency, or among individuals to enable that system, agency or those individuals to work effectively in cross-cultural situations (Cross, Bazron, Dennis, & Isaacs, 1989). Culturally competent services, supports, or other assistance are provided in a manner that respects and is responsive to the beliefs, interpersonal styles, attitudes, languages and behaviors of clients, and therefore provide the greatest likelihood that a successful outcome will be achieved. Joyce N. Thomas, RN, MPH, is the President and Co-Founder of the Center for Child Protection and Family Support of Washington, D.C. Ms. Thomas is also the Director of the People of Color Leadership Institute and the former Director of the Division of Child Protection, Children s National Medical Center, Washington, D.C. The CPS Response to Child Neglect Page 93

Impact of Race, Ethnicity and Culture The Range of Cultural Competence In the monograph, Toward a Culturally Competent System of Care, strategies were presented on the process of achieving cultural competence (Cross, Bazron, Dennis, Isaacs, 1989). According to the model by Cross et. al, in order to move in the direction of becoming culturally competent, individuals and agencies should engage in a process of self-assessment and goal-setting, which can be facilitated through the use of a cultural continuum. The continuum ranges from (1) cultural destructiveness, (2) cultural incapacity, (3) cultural blindness, (4) cultural pre-competence, (5) cultural competence, and (6) cultural proficiency, or advanced cultural competence. At the extreme negative end of the continuum is cultural destructiveness, which represents the attitude that one race or culture is superior to another and as such the lesser race or culture should be controlled or eradicated because of their perceived inferiority. If and when such beliefs are acted upon in cases of child neglect, they can lead to destructive practices as evidenced by the outlawing of Native American rituals and the passage of laws that give priority to placement of dependent children outside their cultural community. Another example is the unjustified termination of parental rights of African American, low-income, single mothers without evidence of reasonable efforts or culturally appropriate service plans for the family. The next level of the continuum is cultural incapacity, whereby extreme bias and racial stereotyping are common. An example of cultural incapacity is the assumption that all low-income, single parent, ethnic-minorities families should be suspected of child neglect based on their general appearance. In the cultural incapacity stage, families are often threatened and harassed without justification. The midpoint on the continuum is cultural blindness in which one adheres to the notion that ethnicity, race or culture make no difference, and that all people are the same. Cultural blindness assumes the belief that child welfare workers do not have biases or predispositions about certain groups of people. The problem with this behavior is that as a nation of immigrants and diverse cultural groups, there are likely to be differences in child rearing practices, family dynamics and communication styles, which if misunderstood or not appreciated, could hamper the relationship between the worker and the client, thus negatively impacting the information-gathering process. In these situations, the strengths, qualities and cultural values of children and families tend to become overlooked. The fourth point on the continuum is that of cultural pre-competence, which reflects movement toward the positive end of the continuum. This could include activities by child welfare administrators to recruit and hire culturally diverse staff, or provide culturally diverse training to staff. The fifth point on the continuum is cultural competence, which is characterized by acceptance and respect for differences; an ability to conduct cultural self-assessments; careful attention to the dynamics of difference; acquisition of cultural knowledge, and adaptations to diversity. There is a strong demonstrated commitment by the individual, the agency and the system to value the differences of others. Finally, the sixth point and most positive end of the continuum is cultural proficiency, or advanced The CPS Response to Child Neglect Page 94

Impact of Race, Ethnicity and Culture cultural competence in which cultural competency is seen as an important and valued aspect of best practice. Agencies can demonstrate cultural proficiency by retaining consultants who are experts in cultural competence and by advocating and implementing culturally competent practices and policies. Importance of Consistent Terminology Developing cultural competence within an organization requires clear, consistent terminology. In fact, the need for greater clarity of terminology is the most critical cultural competency issue in child welfare, according to the participants in a 1999 think tank on cultural competence. This think tank, which was held in Washington, D.C., focused on cultural competency accomplishments in the child welfare field; gaps in services, and critical issues that must be addressed. Participants identified two critical issues in the child welfare field: (1) the need for greater clarity of terminology, and (2) the need for continuous quality training to assist workers and child welfare agencies in better understanding unique aspects of the various subcultures (National Call to Action, 2000). 1 Maintaining a clear and consistent understanding of the terminology used to define cultural factors and the terminology used to refer to individuals is often problematic. In the neglect literature, many terms are used to describe cultural differences. Sometimes researchers identify participants by race such as white, non-white, and other times they identify participants by ethnicity, such as national origin - except in the case of Blacks, who almost always are identified by race. This interchangeable use of terms has created confusion and misinterpretation of research findings across various studies. The problem of terminology is further complicated by the abundance of generalized terms such as people of color, minority population, communities of color, ethnic-minorities, diverse communities, or ethnic-diverse families, which are often used interchangeably to refer to any or all ethnic and cultural groups such as African Americans, Asian/Pacific Islanders, Latinos and Native Americans. Inconsistency in terminology often leads to misunderstandings in discussions that link child neglect with cross-cultural factors. Rather than make generalized statements, child welfare research should provide a more accurate interpretation of research findings and specify the target population or race, ethnic or cultural group that is the focus of a particular study. Racial, Ethnic and Cultural Variables Most of the studies on child neglect that are published in the professional literature fail to specify which characteristics are most prevalent in a particular ethnic or cultural group. Research conclusions are often based on very small samples of children who have been reported and substantiated for neglect. There is no clear distinction in the consequences of different types of neglect, the level of severity, or the acute versus chronic circumstances of ethnic-minority families. The clarity of the relationship between child neglect and cultural factors is further complicated by the reality of poverty in many reported and substantiated cases. 1 The National Call to Action hosted a Think Tank Forum involving professionals of color in the field of child welfare to identify critical issues related to race, ethnicity and culture. This forum was held in Washington, D.C. on September 21,2000 and was sponsored by the Children s Hospital of San Diego, California. The CPS Response to Child Neglect Page 95

Impact of Race, Ethnicity and Culture According to Urquiza & Wyatt (1994), clinical research on child neglect has failed to address important socioeconomic, cultural and racial factors. They assert that distinctions in the literature that focus only on race are minimally useful because these distinctions only identify differences based on common ancestry and genetic physical characteristics while obscuring the enormous variability within and between groups. Ethnicity is typically used to refer to both the race and land of origin, but does not explicitly encompass the influence of culture. To identify subjects as Latino or Hispanic is to identify them by ethnicity, but not by culture. Individuals of Latino or Hispanic origin are more accurately described by terms such as Mexican, Cuban, Puerto Rican, Dominican and Guatemalan. All of these ethnic groups have unique and highly structured cultural traditions. The word culture refers to the set of integrated patterns of human behavior that encompasses customs, beliefs, values and practices. Differences among racial, ethnic and social groups can be seen in such human institutions as family, marriage practices, language, religion, communication traditions, play, art/music and food cultivation and consumption (Abney & Gunn, 1993). Korbin and Spilsbury (1999) indicate that culture is central to the understanding of handling child neglect. Thomas (1995) suggests that culture not only shapes the ideas and behavior of parents and children but also of professionals who are involved in the intervention process. Differentiating between neglect and what are considered to be common cultural or religious practices can sometimes be difficult. Confusion occurs when trying to decide whether the behavior is harmful or neglectful, how to intervene, what is normal or acceptable within the culture and how to deal with the potential conflict of cultural practices with the laws of the state (Thomas and Benjamin, unpublished). These decisions are at the core of the difficulties in assessing child neglect within the context of cultural competency. Cultural Factors in Child Rearing Patterns The family is the basic sociocultural unit for the growth and development of children, the resource for social support, and the institution through which culture is transmitted. Child rearing patterns vary greatly among different cultural groups, therefore it is essential for child welfare workers to understand and appreciate cultural aspect of family systems, as well as the norms, functions, and strengths of the family. Culture is transmitted through generations and maintained over a period of time even though it may be subject to modification and change in the course of history. Different cultural groups may experience different kinds of family-related stress, discomfort, tension or frustrations that impact child-rearing practices (i.e., living arrangements, financial matters, marital relations, family transition, etc.) which could result in the neglect of children (Tseng and Spiegel, 1990). In addition to the stress factors, perception of the stress, and the existing resources for coping with the stress also affect the nature and severity of the stress on the parenting process. For example, in Asian-American families, issues such as immigration/refugee experience, acculturation levels and socioeconomic levels all impact family dynamics and parenting practices (Philips, 1996). Child rearing among Asian families is greatly influenced by values that arise from traditional cultural The CPS Response to Child Neglect Page 96

Impact of Race, Ethnicity and Culture principles of Confucianism 2, Taoism 3, and Buddhism 4 philosophies, which focus on family orientation, seeking harmony with others, and establishing a strong spiritual structure. In a 1991 study by Hong & Hong that focused on child abuse and neglect, findings suggest that Chinese- Americans were much more tolerant to parental conduct and behaviors and less likely to ask for investigation in a potential case of child maltreatment. The pioneering work of Robert Hill in the 1972 landmark book, Strengths of Black Families, identified five assets of African American families: strong achievements orientation, strong work orientation, flexible family roles, strong kinship bonds, and strong religious orientation. Despite these strengths, the history of slavery and racial oppression has taken a toll on parenting practices of African Americans (Comer & Poussaint, 1992). Numerous studies (Hampton, 1991; Zuravin & Starre, 1991; Dubowitz, 1993) of low-income African American families have documented child rearing practices that increase the risks of reports of child neglect. Structural problems such as economic stress, single parenthood, substance abuse and racism are all factors that contribute to high numbers of African American children in the child welfare system. In The Black Parenting Book, Beal, Villarosa, and Abner identify four parenting styles of African Americans: authoritarian 5, lax 6, neglectful and authoritative 7. Child neglect occurs when parents are unable or unwilling to assume proper responsibilities for their children. For example, research has documented how racism and other forms of discrimination against African Americans undermine a family s ability to support their children both financially and emotionally (Pinderhughes, 1989). In Latino families, fathers are considered responsible for the welfare, honor, dignity and protection of the family, and mothers are in charge of overseeing and nurturing the home life, especially regarding the children. When Latino children disobey, parents often respond harshly. According to Lisa Fontes, low-income, immigrant Latino families are vulnerable to charges of child neglect that stem from lack of acculturation to norms in the United States (Fontes, 2000). The above statements about parenting are not intended to be a comprehensive view of child rearing practices among various racial and ethnic groups. It is important to remember that there are many subcultures within each major ethnic group, and workers need to individually assess families in a culturally competent manner in order to respond appropriately respond to issues of child neglect. 2 Confucianism defines specific rules of conduct in social relationships and places a tremendous value on the family as a whole. 3 Taoism refers to the importance of maintaining balance and harmony. 4 Buddhism is the spiritual structure of many Asian families in which time is circular. 5 Authoritarian is a style of parenting based on many rules with few explanations and no challenges to the authority of the parents. 6 Lax is a parenting style in which there are little to no demands on the child and this leads to chaotic lives that lack direction and clear purpose. 7 Authoritative parents demand responsible behavior from their children by setting high yet reasonable standards according to their cultural expectations, child s personality and development. The CPS Response to Child Neglect Page 97

Impact of Race, Ethnicity and Culture Conducting A Culturally Competent Assessment of Child Neglect Cultural competency is an ongoing and developmental process. It is important to recognize that individual workers and child welfare agencies may be at different points on the cultural competency continuum. In order to understand adequately how race, ethnicity and culture are factors in cases of child neglect, child welfare workers must be aware of personal biases and feelings about serving ethnic-diverse families. Information gathering and assessment of a family s level of functioning require an understanding of the family s core values. The assessment process and the determination of the nature of intervention or service needs are highly variable. The specific approach will depend on the purpose of the assessment, role of the worker, nature of the circumstances and the mandate of the agency (English, 1991). In each situation it is important to pay specific attention to issues of risk assessments (i.e., safety concerns), parental factors, child s response to the environment and the family dynamics and communications. Risk assessment and consideration of safety factors help identify potentially harmful situations and determine the degree to which harm or neglect is found. Risk assessment instruments or tools are used prospectively in child neglect cases to determine the probability, frequency and severity of the potential for harm of children (Cicchinelli, 1995). Risk assessment has brought into sharp focus the reality that many of the factors that are considered when making judgments and decisions about child neglect cases may or may not be reliably applied across case types, clinicians and caseworkers and culturally diverse client groups (English, 1991). Case factors are filtered through the lens of the worker s personal characteristics such as their gender, parenthood status, attitudes about parenting (Ashton, 2001), and perceptions about ethnic and racial issues. The family s ethnicity can play an important role in the assessment and intervention process. For example, 73 percent of the respondents in a recent survey of 200 child abuse investigative police officers and child welfare social workers acknowledged that decisionmaking within their agency is influenced by the client s ethnic/cultural background (Thomas & Benjamin, unpublished). If the individual worker s perception of the situation is biased and judgmental, this can translate into stereotypes that obstruct accurate assessments of risk. Too often, cultural biases directly interfere with the assessment process of certain types of clients and result in premature assumptions, inaccurate determinations of risks and an inability to appreciate the actual needs of the client (Brooks, 1997). To conduct an adequate assessment, workers must concentrate on the specific issues of history, family structure, values, beliefs and customs of the population to be served. In addition, it is important to gather information regarding specific ethnic background, language, immigration/ refugee experience, intergenerational conflicts, cultural strengths, and community support systems. For example, understanding that the extended family is the primary unit of reference for many Asian (e.g., Chinese, Japanese, Korean, Vietnamese, Cambodian, Laos, East Indian, Filipino and Pacific Islander), Hispanic (e.g., Mexican-American, Puerto Rican, Cuban) and Native American (Alaskan Natives) families is a key to understanding much of their individual behavior, motivations and goals. The importance of maintaining family lineage is demonstrated through practices that ensure filial piety, or binding children to their parents and requiring respect and loyalty. The CPS Response to Child Neglect Page 98

Impact of Race, Ethnicity and Culture In communicating with diverse ethnic cultural group family members about possible child neglect, child welfare workers should use simple words and avoid jargon or slang; listen carefully; avoid interrupting the family member; allow extra time to communicate with the family; think through the situation before a decision is made; adapt the style of communications to the purpose of the assessment; dialogue with other professionals regarding views and interpretations of the family; never make jokes about the situation (especially with other professionals), and be aware of personal biases. In general, steps in the assessment process should include identifying the family s strengths; identifying environmental factors that might serve as barriers for families; identifying the various patterns of family systems communication; recognizing the family s cultural views toward mainstream society; determining and identifying the family s cultural beliefs in natural support systems and/or alternative practices; demonstrating an appreciation of indigenous community leaders to enhance cultural knowledge; determining whether the family is involved with a neighborhood church and/or community healers. When appropriate, workers can provide materials and other information in the family s primary language. Also, bilingual and bi-cultural staff should be enlisted to aid in assessments of families. Agency Self-Assessment Process Child welfare agencies should conduct self-studies to examine the specific policies, practices, activities and actions that are used to serve ethnic-diverse populations. Self-assessments will help determine an agency s ability to provide culturally appropriate services and to review how policies and practice govern service delivery. There are several guiding principles for cultural competency that should be considered by child welfare agencies, including: a visible ethnic-diverse presence in the agency; articulation of cultural competency in the mission statement, objectives, philosophy and policies of the organization; delivery of multi-cultural services (i.e., rites of passage, bi-lingual/bi-cultural celebrations, etc.); demonstrations of an emphasis on strengthening the family in the context of their culture; conducting an agency self-assessment on cultural competency; development of a specific plan to recruit and retain a multi-cultural professional staff in percentages and types that are relevant to the clients being served; provision of ongoing service education, training and forums on cultural issues; and advocating on behalf of all children who may be from disadvantaged and vulnerable families. Delivering culturally competent services is a process and a product. On an ongoing basis, policy makers and program administrators must make the necessary time and resources available to help workers gain a better understanding of the dimensions of race, ethnicity and culture and their impact on the child welfare system. The CPS Response to Child Neglect Page 99

Impact of Race, Ethnicity and Culture Conclusion Understanding the relationship between cultural competency and child neglect is complicated by several formidable obstacles such as inaccurate use and confusion about terminology, contradictions in the research literature, and the tensions of racism in society which spill over to how the child welfare system is viewed by clients and workers. In a study of child welfare workers, it was found that most of the respondents (73 percent) were unable to describe the social conditions of the ethnic/culturally diverse families in the communities that they currently serve (Thomas & Benjamin, unpublished). To provide culturally competent services, agencies must sanction - and in some instances mandate - the incorporation of cultural knowledge into their service delivery framework. This knowledge must be available at every level within the system. Based on different cultural systems the child rearing practices may vary tremendously, therefore it is essential to know the cultural background of the family so that within the cultural context, the child welfare worker has a meaningful understanding of the behavior, function, and relations of the family in order to conduct an appropriate assessment. Culturally competent practices help workers evaluate the nature of stress and recognize mechanisms used by the family to cope or problem solve. Cultural competency is an ongoing and developmental process that agencies and child welfare professionals can ill afford to neglect. The CPS Response to Child Neglect Page 100

Impact of Race, Ethnicity and Culture References Abney, V., Gunn, K, (1993), Culture: A Rationale for Cultural Competency, American Professional Society on the Abuse of Children, Advisor, 6 (3). Ard, S., Chung, C., & Myers, S., (1998.) The Effects of Sample Selection Bias on Racial Differences in Child Abuse Reporting, Child Abuse & Neglect, Vol. 22, No.2 pp 103-115. Ashton, V., (2001.) The relationship between attitudes toward corporal punishment and the perception and reporting of child maltreatment. Child Abuse & Neglect, Vol. 25, pp 389-399. Beal, A., Villarosa, L., & Abner, A., (1999) Ain t Misbehavin : Discipline and Parenting in The black parenting book, Chapter 5, page 103-107. Bellamy, N., (1998), Parenting Practices in African American and European Americans, University of Utah, Salt Lake City, Utah. Unpublished paper. Bonner, B., Crow, S., Logue, M., (1999) Fatal Child Neglect in Neglected children: research, practice, and policy, Sage Publications, Thousand Oaks, Calif. Boyd-Franklin, N., (1989) Black, Afro-American Families: The Cultural Context, Black families in therapy: a multisystems approach, The Guilford Press, New York. Brooks, P., (1997) Domestic Violence Risk and Program Assessment: Concerning Black Communities in conference proceedings of the Institute on Domestic Violence in the African American Community, Atlanta, Georgia. Carreon, V & Jameson, W. (1993.) School-linked service integration in action: lessons drawn from seven California communities, California Research Institute, San Francisco State University, San Francisco, California. Center for Social Policy Studies, (2000.) LaShawn Receiver: Progress Report as of December 31, 1999, Washington, D.C. Chalk, R., King, P., (1998.) editors Violence in families: assessing prevention and treatment programs, Committee on the Assessment of Family Violence Interventions Board on Children, Youth, and Families, National Research Council, National Academy Press, Washington, D.C. Child and Family Services Agency, (1999.) Annual Report LaShawn receivership, Washington, D.C. Cicchinelli, L., (1995.) Risk Assessment: Expectations and Realities in American Professional Society on the Abuse of Children, Advisor Vol. 8, No. 4. Collier, A., McClure, F., 1999. Culture-Specific Views of Child Maltreatment and Parenting Styles in the Pacific-Island Community Child Abuse & Neglect, Vol. 23, No. 3, pp 229-244. The CPS Response to Child Neglect Page 101

Impact of Race, Ethnicity and Culture Courtney, M., (1994). Factors Associated with the Reunification of Foster Children with Their Families. Social Services Review, 68 (1): 81-108. Coohey, C. (1995) Neglectful Mother, Their Mothers, and Partners: The Significance of Mutual Aid, Child Abuse & Neglect, Vol. 19, No.8 pp 885-895. Coolbaugh, K., Hansel, C. (1999.)The Comprehensive Strategy : Lessons Learned From the Pilot Sites, Juvenile Justice Bulletin, U.S. Department of Justice, OJP, Office of Juvenile Justice and Delinquency Prevention FY 2000, Washington, D.C. Crittenden, P., (1999.) Child Neglect: Causes and Contributors in Neglected children: research, practice, and policy, Sage Publication, Thousand Oaks, Calif. Cross, T., Bazron, B., Dennis, K., and Isaacs, M., (1989) Toward A Culturally Competent System of Care, Volume 1, in A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed, CASSP Technical Assistance Center, Georgetown University Child Development Center, Washington, D.C. Duquette, D., Hardin, M., (1999) Guidelines for public policy and state legislation governing permanence For children, Department of Health and Human Services, Administration for Children and Families, Children s Bureau, Washington, D.C. English, D., (1991.) Cultural issues related to the assessment of child abuse and neglect. In T.Tara (Ed.) Fourth National Roundtable on CPS Risk Assessment: Summary of Highlights (pp. 211-215). Washington, D.C. American Public Welfare Association. English, D., (1998.) The Extent and Consequences of Child Maltreatment, in the Future of Children, Protecting Children From Abuse and Neglect, Vol. 8. No.1, Spring 1998. English, D., (1999.) Evaluation and Risk Assessment of Child Neglect in Public Child Protection Services, in Neglected children: research, practice and policy, Sage Publications, Thousand Oaks, Calif. Fantuzzo, J., Mohr, W., (1999.) Prevalence and Effects of Child Exposure to Domestic Violence, in The Future of Children Domestic Violence and Children, Vol.9. No.3- Winter, pg. 21-32. Feig, K. (1995.) Drug exposed infants and children: Service needs and policy questions, Working paper, Office of Social Services Policy, Division of Youth and Family Policy, Office of the Assistant Secretary for Planning and Evaluation, Washington, D.C. DHHS. Fontes, L., (1997.) Conducting Ethical Cross-Cultural Research on Family Violence, Chapter in Out of the darkness: contemporary perspectives on family violence, Sage Publication, Thousand Oaks, California pg 296-312. Fontes, L., (2000.) Working with Latino Families on Issues of Child Abuse and Neglect, The national child advocate, Huntsville, Alabama. Ford,D., Racusin, R., Ellis, C., Daviss, W., Reiser, J., Fleischer, A., Thomas, J., (2000.) Child The CPS Response to Child Neglect Page 102

Impact of Race, Ethnicity and Culture Maltreatment, Other Trauma Exposure, and Posttraumatic Symptomatology Among Children With Oppositional Defiant and Attention Deficit Hyperactivity Disorders, in Child Maltreatment, Vol. 5, No. 3, Sage Publications Inc. Thousand Oaks, Calif. Gaudin, J., (1995.), Evaluation and Treatment: Defining and Differentiating Child Neglect in American Professional Society on the Abuse of Children, Advisor, Vol. 8, No. 2, Summer. Gaudin, J., (1999.). Child Neglect: Short-Term and Long-Term Outcomes, in Neglected children: research, practice and policy, Sage Publications, Thousand Oaks, Calif. Gershater-Molko, R., Lutzer, J., (1992.) Child Neglect Types of family violence. Giovannoi, J., Billingsley, A. (1970.) Child Neglect Among the Poor: A Study of Parental Adequacy in Families of Three Ethnic Groups, in Child Welfare, pp 48, 199. Hampton, R., Gelles, R.,(1991.). A Profile of Violence Toward Black Children, chapter in the book Black family violence, current research and theory, Lexington Books, Lexington, MA. Hill, R. (1993.) Building on Cultural Strengths to Support African American Families in Family Resource Coalition Report, Volume 12, Number 1, Spring. Hill, R., (2001.) The Role of Race in Parental Reunification unpublished paper, Race Matter Forum, Washington, D.C. Holton, J., (1992.). African American s Needs and Participation in Child Maltreatment Prevention Services: Toward a Community Response to Child Abuse and Neglect, Urban Research Review 14 (1): 1-5. Holder, W., Nabor, L., (1999.) The prevention of Child Neglect in Neglected children: research, practice and policy (Ed.) Dubowitz, H., Sage Publications, Thousand Oaks, CA Hong, G., Hong, L., (1991.) Comparative Perspectives on Child Abuse and Neglect: Chinese Versus Hispanics and Whites, Child Welfare, 70 (4): 463-475, July-August 1991. Horejsi, C, Craig, B., Pablo, J., (1991.) Reactions by Native American Parents to Child Protection Agencies: A Look at Cultural and Community Factors, unpublished paper, distributed by the University of Montana Department of Social Work, Missoula, Montana, pp14. Ima, K., Hohm, C. (1991.) Child Maltreatment Among Asian and Pacific Islanders Refugees and Immigrants, Journal of Interpersonal Violence, 6(3): 267-285. Kendall-Trackett, K., Eckenrode, J., (1996.) The Effects of Neglect on Academic Achievement and Disciplinary Problems: A Developmental Perspective. Child Abuse & Neglect, Vol. 20. No. 3, pp 161-169. Kerr, M., Black, M., Krishnakumar, A., (2000.) Failure-To-Thrive, Maltreatment and the Behavior and Development of 6-Year-Old Children From Low-Income, Urban Families: A Cumulative Risk Model, in Child Abuse and Neglect, Vol. 24, No.5, pp 587-598. The CPS Response to Child Neglect Page 103

Impact of Race, Ethnicity and Culture Kotch, J., Browne, D., Duport, V., and Winsor, J., (1999.) Predicting Child Maltreatment in the First 4 Years of Life From Characteristics Assessed in the Neonatal Period, Child Abuse & Neglect, Vol. 23, No. 4, pp 305-319. Korbin, J., Spilsbury, J., (1999.) Cultural Competence and Child Neglect in Neglected children, research, practice, and policy, Sage Publication, Thousand Oaks, Calif. Kumpfer, K., Alvarado, R., (1999.) Effective Family Strengthening Interventions, Juvenile Justice Bulletin, U.S. Department of Justice, OJP, OJJDP, Washington, D.C. Lassiter, R., (1987.) Child Rearing in Black Families: Child. Laurel, L., Landsverk, J., Ezzet-Lofstom, R., Tschann, J., Sylment, D., & Garland, A., (2000.) Children in Foster Care: Factors Influencing Outpatient Mental Health Services Use, Child Abuse and Neglect, Vol.24, No.4, pp 465-476. Leslie, B. (1993.) Parental crack use: Demographic, familial and child welfare perspectives. A Toronto study. North York, Ontario: Children s Aide Society of Metropolitan Toronto. Levesque, R., (2000.) Cultural Evidence, Child Maltreatment, and the Law, Child Maltreatment, Vol. 5, No.2, Sage Publication, Inc. Lutzker, J., Bigelow, K., Doctor, R., Kessler, M., 1998, Safety, Health Care, and Bonding With and Eco-behavioral Approach to Treating and Preventing Child Abuse and Neglect, Journal of Family Violence, Vol. 13, No. 2, pg 163-185. Morton, T., (1999.) The Increasing Colorization of America s Child Welfare System: The Over Representation of African-American Children, Policy and Practice 57 (4): 23-30. Morin, R., (2001.) Misperceptions Cloud Whites Views of Blacks, a survey project conducted jointly by The Washington Post, the Henry J. Kaiser Foundation, and Harvard University. July 11, 2001. National Council of Juvenile and Family Court Judges, (1995.) Improving court practice in child abuse & neglect, Resource Guidelines, Reno, Nevada. National Research Council, (1993.). Understanding child abuse and neglect, Panel on Research on Child Abuse and Neglect, Commission on Behavioral and Social Sciences and Education, National Academy Press, Washington, D.C. Needell, B, Barth, R., (1998.) Infants Entering Foster Care Compared To Other Infants Using Birth Status Indicators, in Child Abuse & Neglect, Vol. 22, no. 12 pp 1179-1187. Osofsky, J., (1999.) The Impact of Violence on Children, in The Future of Children Domestic Violence and Children, Vol. 9, No.3- Winter, pg 33-48. Philips, W., (1996.) Cultural Competent Practice Understanding Asian Family Values in the Roundtable a Journal of the National Resource Center for Special Needs Adoption, Volume The CPS Response to Child Neglect Page 104

Impact of Race, Ethnicity and Culture 10, No. 1. Pinderhuges, E., (1989.) Understanding Race, Ethnicity, and Power. The Free Press, New York. Pierce, R. & Pierce, L., (1991.) The Need for Cultural Competencies in Child Protective Service Work, chapter in book, Black family violence: current research and theory, Lexington Books, Lexington, MA. Ramos, M., Runner, M., (1999) Defining Culture and Achieving Competence, Cultural considerations in domestic violence cases, Family Violence Prevention Fund, San Francisco, CA. Richie, B., (1996.) Compelled to crime: the gender entrapment of battered black women, Routledge, New York. Richie, J., & Richie, J. (1981.) Child Rearing and Child Abuse: The Polynesian Context in. J. Korbin (Ed.), Child abuse and neglect: cross-cultural perspectives (pp. 186-204). Berkeley, CA: University of California Press. Roer-Strier, D., (2001.) Reducing risk of children in change cultural contexts: recommendation for intervention and training, Child Abuse and Neglect, Vol. 23, pp 23-248. Sagatun-Edwards, I., Saylor, S., (2000.) Drug-Exposed Infants Cases in Juvenile Court: Risk Factors and Court Outcomes Child Abuse & Neglect, Vol. 24, No. 7, pp 925-937. Schechter, S., Edleson, J., (1999.) Effective intervention in domestic violence & child maltreatment, Guidelines for Policy and Practice, Recommendations from the National Council of Juvenile and Family Court Judges, Reno, Nevada. Sedlak, A., (1993.) Study of High Risk Child Abuse and Neglect Groups, National Incidence Study- 2 Re-analysis: Report to Congress. Appendix C. Sue, D., (1990.) Counseling Specific Populations, in Counseling the culturally different: theory & practice, Second Edition, A Wiley-Inter-science Publication, New York. Thomas, J., (1998.) Triple Jeopardy: Child Abuse, Drug Abuse And The Minority Client, Journal Of Interpersonal Violence, September. Thomas, J., (1990.) Drug Abuse and Child Maltreatment: A Clear and Present Danger, American Human Association, Protecting Children, Winter. Thomas, J., (1989.) Breeding Grounds for Multi-Cultural Conflicts, School Safety, Vol. 23, Winter. Thomas, J. (1991.) Cultural Competency: Organizational Responsibilities, American Professional Society On The Abuse Of Children, Advisor, Spring. Thomas, J. (1995.) Violence, Conflict and Challenges: A Nursing Perspective, Nursing Debates the Issues. Proceedings: American Journal Of Nursing, Washington, D.C. The CPS Response to Child Neglect Page 105

Impact of Race, Ethnicity and Culture Thomas, J. (1995.) Child Protective Services Responses to Child Maltreatment. Service Provider Perspectives on Family Violence Interventions. Proceedings of a Workshop, Committee on the Assessment of Family Violence Intervention, Washington, D.C. National Academy Press. Thomas, J., & Benjamin, M., (unpublished) Cross Cultural Factors in the Investigation of Child Maltreatment Cases funded by the Department of Justice, Office of Juvenile Justice and Delinquency Prevention, Washington, D.C. Thomas, J., Wilks, T., Holley, F., (1997.) State of Children of the District of Columbia: Community Ethos, Special Report of the Center for Child Protection and Family Support, funded by the D.C. Children s Trust Fund, Washington, D.C. Thomas, J., (1998.) Community Partnerships: A Movement With a Mission, APSAC Advisor, American Professional Society on the Abuse of Children, Volume 11 Number 3. Chicago, Illinois. Thomas, J.,( 2000.) State of the Children of the District of Columbia: Domestic Violence and Child Maltreatment, Special Report of the Center for Child Protection and Family Support, Washington, D.C. Urguiza, A., Wyatt, G., (1994.) Culturally Relevant Violence Research with Children of Color in the American Professional Society on the Abuse of Children s, Advisor, Vol. 7, No. 3 Fall. Urquiza, A.J.; Wu, J; Borrego, J., (1999.) Foster Care and the Special Needs of Minority Children. in: Curtis, P.A.; Dale, G.; Kendal, J.C. (Editors). The Foster Care Crisis; Translating Research Into Policy and Practice. Child, youth, and family services. University of Nebraska Press, Lincoln. Weiss, C., Minsy, S., (1994.) Program self-assessment survey for cultural competence: a manual, New Jersey Division of Mental Health and Hospitals, Trenton, New Jersey. Wells, K., Shenyang, G., (1999.) Reunification and Re-entry of Foster Children, Children and Youth Services Review, 21(4): 273-294. Wen-Shing, T., & Spiegel, J., (1992.) Family and Culture in Family, culture and psychobiology edited by Eliot Sorel, Legas, New York. Zuravin, S., & Starr, R., (1991.) Psychosocial Characteristics of Mothers of Physically Abused and Neglected Children: Do They Differ by Race? chapter in book, Black family violence: current research and theory, Lexington Books, Lexington, MA. Zuravin, D., & DiBlasio, F., (1996.) The Correlates of Child Physical Abuse and Neglect By Adolescent Mothers, Journal of Family Violence, 11, 149-166. The CPS Response to Child Neglect Page 106

VI. The Role of Social Supports in Child Neglect James M. Gaudin, Ph.D. Brenda Elliott is a 20-year-old single mother of two toddlers, age 4 and 3, and a six-month-old infant daughter. Jamiel, age 4 has been diagnosed with sickle cell disease. Brenda was reported for neglect last year when she left her children in the care of her chronically alcoholic neighbor, Sally K., while she was away with her boyfriend for a drunken weekend with friends. She was reported again last month when she left the children with Sally overnight while she began working the evening shift at a nursing home as an aide. Ms. Elliott moved to the city from rural south Georgia two years ago, following her current livein boyfriend, Carl, who is employed periodically as a day laborer, but is often fired because of his abuse of alcohol and sometimes crack. He provides little financial and inconsistent emotional support for Brenda, who has abused alcohol and other drugs in the past, but not over the past six months, after completing a 30-day residential treatment program and getting her children back from foster care. Brenda lives in a public housing apartment complex on the west side of Atlanta where violence, gunfire, and drug dealing are frequent. Other than the alcoholic Sally, she has only one neighbor, an 18-year-old single parent with an infant, LaKeisha, with whom she is friendly and feels she has something in common. LaKeisha also sometimes drinks too much, but only on occasion. Brenda has one friend at work who lives in public housing across town and is also a single parent with two small children. Brenda comes from a large extended family, all of who live 200 miles away in rural southeast Georgia. Her mother and father are still angry with her for moving to Atlanta with her new boyfriend, who was a known substance abuser in the small town of Alma. Brenda has not talked with them since she left for Atlanta last year. She has heard only twice from one older sister. Brenda has not attended church since coming to Atlanta and is not involved with any social or community group. Her social activity is limited to visits with her young neighbor, Lakeisha, and sometimes with Sally, who is frequently intoxicated and often offers a beer to Brenda. As the case of Brenda indicates, the neglect of children does not take place within the confines of a discrete family system removed from the environment that surrounds it. Thorough assessments of neglectful families must include an examination of the linkages of the family members with surrounding ecological systems, i.e., relationships with neighbors, friends, extended family, the neighborhood, and formally organized services and organizations in the larger community that offer critical support and assistance to most parents. James M. Gaudin, Ph.D., is Professor Emeritus at the University of Georgia School of Social Work. The CPS Response to Child Neglect Page 107

The Role of Social Supports Research on Social Support and Neglect Beginning with the early studies into the phenomenon of child abuse and neglect in the 1960 s and 70 s the relative social isolation or lack of strong formal and informal social supports for parenting was identified as a significant characteristic of maltreating mothers (Elmer and Gregg, 1967; Giovannoni and Billingsley, 1970; Newberger, et al., 1977; Polansky et al., 1981; Wolock & Horrowitz, 1979; Young, 1964). However, some more recent comparison studies between maltreating and non-maltreating families have affirmed the relationship between neglect and weak formal and informal social supports, but not for physically abusive families (Coohey, 1995; Corse et al., 1990; Lovell & Hawkins, 1988; Seagull, 1987; Starr, 1982). Research on social supports of neglecting and abusing families has focused almost exclusively on the social networks of mothers. Unfortunately, little attention and research have been directed toward the fathers or male figures in neglecting families. Nothing is known of their social connections and supports, beyond the fact that they are most often the most critical, though often only potential support for the neglecting mother and child. The peer supports for children in neglecting families has received no attention, yet is a powerful factor in the lives of the child victims of neglect. The term social isolation which infers a lack of social embeddedness in the community or an absence of linkages with formal and informal social networks has been found to be not characteristic of either neglectful or abusive families (Polansky, Gaudin, Ammons, and Davis, 1985; Polansky, Ammons, & Gaudin, 1985; Crittenden, 1985; Coohey, 1996). The studies have revealed that both neglectful and abusive families have at least one or two potentially supportive relatives, friends, or neighbors. However, these sparse linkages vary greatly in the amount of support they offer the maltreating family, the amount of stress they cause for the family, and the family s satisfaction with the support offered. Complexity of Definitions The conflicting findings from the studies of social supports available to maltreating families over the past 35 years is partially explained by differences in the definitions of social support and the measures used to assess it. Early studies most often assessed the structural characteristics of the parent s (usually the mother s) informal network of neighbors, relatives, and friends and linkages with formally organized groups (Young, 1964; Giovannoni and Billingsley, 1970; Elmer and Gregg, 1967; Altameier, et al., 1984; Garbarino & Sherman, 1980; Starr, 1982). The number of people or organizations identified, the frequency of contact with these, and the proximity to these potentially helping resources were emphasized. The term used to encompass these characteristics is social embeddedness. In more recent studies no significant differences were found between neglecting and non-neglecting families on these more structural, quantitative characteristics of their social networks (Beeman, 1997; Crittenden, 1985; Nelson, Landsman, Cross, Tyler, & Twohig, 1993) while others have supported significant differences (Polansky, Ammons, & Gaudin, 1985; Polansky, Gaudin, Ammons, & Davis, 1985; Coohey, 1995, 1996). The CPS Response to Child Neglect Page 108

The Role of Social Supports Qualitative Dimensions of Social Networks The number of identified persons in one s social support network is not the most critical measure of social support. There are also critically important qualitative characteristics of the linkages with members of the parent s support network that require consideration. One may have many relatives and have frequent telephone interactions, but how much help can or will they offer? The content of the linkages is critical. From some network members the parent can expect emotional support, patient listening, helpful advice, but not babysitting, the loan of $10, or a ride to the health clinic. Others will provide the more tangible aid, but not emotional support. Some network members identified by a parent as potentially helpful will actually be unwilling to provide either form of help. Close ties with relatives usually offer more extensive support, but may also be the source of criticism, additional demands and increased stress. Neighbors are more likely to provide babysitting for an hour or two than relatives living at some distance. Highly inter-connected social networks provide more consistent monitoring and feedback, but less diversity or heterogeneity among network members means less diversity of resources to call upon. This becomes a critical factor when one is living in poverty, looking for a job, or advice about how to handle a sick child. Relatively homogeneous social networks are also less likely to provide models for more adequate childcare and feedback to challenge the neglectful childcare practices of parents. Frequency of contact and geographical proximity with network members is also a critical factor when a parent needs temporary childcare, after-school supervision or some emergency loan of cash or food. Duration of the linkage often translates into consistency and reliability of help available, which is also related to the amount of reciprocity there is in the helping. Helping linkages often break down for neglectful parents because of their failure to reciprocate the helping. The satisfaction of the parent with the amount of support that is available is also an important consideration, since the amount of help desired from others varies with the parent. The most frequently employed way of assessing the parents informal support system is to ask the parent for their perception of the support they feel is at least potentially available to them from identified neighbors, friends, and relatives. Since it is our own perception of support that most clearly influences behavior, the parent s perception of the support potentially available to them is critical. Studies have found that this perceived support is what most clearly distinguishes maltreating parents from nonmaltreating parents (Altameier, et al., 1984; Garbarino & Sherman, 1980; Polansky Buttenweiser, Williams, 1981; Gaudin & Pollane, 1983; Polansky, Gaudin, Ammons, & Davis, 1985; Egelund & Brunquell, 1979; Moncher, 1995). When studies have thus measured the informal social support of neglectful vs. non-neglectful families, the results have most often concluded that the neglectful families perceive significantly less physical and emotional support available to them from their neighbors, friends, and relatives ( Egelund & Brunquell, 1979; Garbarino & Sherman, 1980; Polansky Buttenweiser, & Williams, 1981; Gaudin & Pollane, 1983; Daniel, Hampton, & The CPS Response to Child Neglect Page 109

The Role of Social Supports Newberger, 1983; Polansky, Ammons, & Gaudin, 1985; Polansky, Gaudin, Ammons, & Davis, 1985; Coohey, 1995, 1996; Wolock & Horowitz, 1979). However, some studies have not supported this relationship (Kinard, 1996; Nelson et al., 1995). The amount of actual support received by a parent over a defined period of time is the measure of enacted support. A much more limited number of studies of families who abuse or neglect children has used this operational definition of social support. An early study of neglectful vs. non-maltreating mothers by Giovannoni & Billingsley (1970) reported that the adequate African American mothers received more help with babysitting and housework from kin than the neglectful African American mothers, but the same was not true for the white mothers. Crittenden s study (1985) of maltreating and adequate mothers revealed that the adequate mothers actually received more childcare and listening from friends and more money from relatives over a 30-day period than the maltreating mothers, but neglectful mothers received more help with household tasks from relatives than the adequate mothers. These studies highlight the complexity of the nature of social support, depending upon the type of maltreatment, ethnicity, and the type of support received (and recalled) over time. Sampling Differences The conflicting findings from studies of the relationship between child maltreatment and weak social supports are also partially related to the wide differences in the size and composition of the study populations. Often the studies failed to differentiate between abusive families and neglectful families, not to mention those who both abuse and neglect (Young, 1964). When this critical distinction has been made, the neglectful parents, who have most often been mothers, have been found to have relatively weak informal social supports (Giovannoni & Billingsley, 1970; Crittenden, 1985; Polansky, Ammons, et al., 1985; Polansky, Gaudin, et al., 1985; Coohey, 1996). Most often the study samples have been small and limited to reported and substantiated neglect, thus reducing the potential for finding significant differences. Studies utilizing larger samples have found significant differences (Polansky, Ammons, et al., 1985; Polansky, Gaudin, et al., 1985: Coohey, 1996). The measures used for social support have varied widely and are most often not comparable. Some have focused on social embeddedness, others on enacted support, but most often widely differing measures of perceived support have been used. So where does this leave us in terms of social support and neglect? Whether measured as enacted or perceived support, the weight of the early and more recent research clearly indicates that neglectful families anticipate and receive less support from neighbors and friends than do comparison families or abusive families, but frequency of contact with and support from relatives is similar. Similarly, families that both abuse and neglect feel less available support than do non-maltreating or those that only abuse children (Crittenden, 1985; Coohey, 1996). The relationship between perceived informal social support and child neglect is supported by the research, but what has not been established is a causal relationship. Indeed the The CPS Response to Child Neglect Page 110

The Role of Social Supports process of being reported, investigated, and accused of child neglect undoubtedly contributes to the parent s sense of stigmatization, isolation, and social disconnectedness (Gaudin & Polansky, 1986; Polansky et al., 1985). Interventions to Enhance Social Supports If neglectful families lack strong informal supportive networks, and this is a contributing factor in their failure to provide adequate care for their children, are there interventions that have been successful in remedying this relative absence of support and thus preventing neglect or improving the adequacy of parenting by neglectful families? Do we have research that supports the effectiveness of these interventions? A review of social support assessment and intervention models with neglectful families conducted by Diane DePanfilis (1996) concluded that the effectiveness of social support interventions is supported by published studies to only a limited degree. Each family is unique, so no intervention is effective with all neglectful families, and multi-service interventions are required for most. Because neglecting families differ so greatly in type of neglect, the characteristics of the families, and their ecologies, the practice research challenge is to identify the salient characteristics of neglectful families who benefit from interventions to enhance informal social supports and those for whom other interventions are more helpful. Assessment of Neglectful Families Effective intervention with a neglectful family begins with skillful, ongoing assessment focused on the family system in its unique ecological setting, identification of both strengths and barriers to adequate child caring, mutually agreed upon goals and objectives, and careful documentation of interventions and outcomes. Assessments should include a brief history of the parents own developmental history, health, use of addictive substances, the developmental history of the children. Complete family assessments must include the extended family and close friends, who are at least potentially, the most critical sources of tangible and emotional support, feedback, modeling of positive childcare norms. They can also be the source of great stress for the parent if the communication is largely criticism and negative feedback without concomitant emotional and tangible support. The assessment should also include linkages with formally organized services and groups that can supply necessary tangible and emotional support. An adequate initial assessment and related plan for intervention usually requires several sessions. Since critical issues and circumstances emerge and change over time, assessment with neglectful families must be an on-going, continuing process during intervention. A wide variety of standardized self-report measures have proven useful for assessing the social support networks of families. These include measures for perceived support: Eco-Map (Hartman, 1978); the Index of Social Network Strength (Gaudin, 1979); the Social Network Map and Social Network Assessment Guide (Gaudin, et al The CPS Response to Child Neglect Page 111

The Role of Social Supports 1990/91) the Social Network Map (Tracey & Whittaker, 1990); the Personal Assessment of Social Support, (Dunst, & Trivette, 1988), and for enacted support (support received recently) the Community Interaction Checklist, (Wahler, Lesky & Rogers, 1979) Maternal Social Support Index, ( Pascoe, Ialongo, Horn, Reinhart & Perradatto, 1988) Index of Socially Supportive Behaviors, (Barrera, Sandler, Ramsey, 1981); Parenting Social Support Index (Telleen, 1985). Others have used more unstructured, subjective interviews, global rating scales, or case record reviews to assess social embeddedness and the qualitative dimensions of social support. Intervention with Neglect The review by DePanfilis (1996) identified a range of assessment and intervention models designed to enhance both formally organized parent support services and informal social supports for neglectful families. The social support assessments included assessment of social embeddedness, quantitative/structural and qualitative dimensions of neglectful parent s social supports. The intervention models reviewed broadly included parent education/support programs, multi-service interventions, in-home individual support, self-help groups, social skills training, and therapeutic day care. All of these types of interventions have been utilized with neglectful families to increase the formal and informal supports for parents and to thus improve the quality of parenting. The evaluations of these types of programs vary greatly in the validity and reliability of their designs and thus the confidence that can be placed in their effectiveness. The conclusions from most of the evaluations are limited by significant limitations in the size and composition of the samples used and by the reliability and validity of the social support measures used and other design features. However, the weight of the evidence from the studies supports the effectiveness of social support interventions with many neglectful families, most often when used as a component of multi-service models. In 1988 the National Center on Child Abuse and Neglect funded six demonstration grants to develop and evaluated ways to intervene with chronically neglectful families. The lack of strong social supports was assumed to be a major contributing factor to the parents inadequate parenting. The projects employed family empowerment strategies, group interventions, childcare, and remedial services for children. The goals were to reduce social isolation, strengthen social supports and improve parenting adequacy. Services were received for an average of 18 months. DiLeonardi s published report (1988) on the outcomes of the six intervention projects indicated that many of these multi-problem, chronically neglectful families improved in the areas of family socialization or activities, household cleanliness, and appropriate child discipline (p. 561) and reached the minimum adequacy level during the course of the services 1 However, although the average scores on the Childhood Level of Living Scale (Polansky et al, 1981) increased 1 As indicated by scores on the Childhood Level of Living Scale (Polansky, et al., 1981) The CPS Response to Child Neglect Page 112

The Role of Social Supports by 11 points at termination over the pretest scores, the average remained at only 82 percent of minimum adequacy on the measure. Improvements in the families functioning were attributed to the wide range of services provided, an empowerment approach, and the ability to individual services to the families based upon assessed needs. Social skills training along with parenting classes have been employed as the interventions with neglect families by several projects. One effort with a limited sample of parents who were at risk for physically, sexually, or emotionally abusing or neglecting their children (Lovell & Richey, 1997). The goal was to improve the quantity and quality of social interactions with potentially supportive formal and informal resources in their communities. Results indicated few differences between the maltreating families who received the services and a comparison group involved in a more traditional group program. The failure of the program to demonstrate significantly greater improvements was partially attributed to the limited power of a small sample (N = 38) and the inability to isolate the outcomes of the program from the influence of other interventions being received concurrently by both the 22 experimental group and the 16 comparison group participants. A successful home-based family support program with chronically neglecting families offered social skills-building and parenting classes, supplemented by in-home modeling of parenting skills, a monthly support group and environmental interventions to improve housing, increase employment, and to develop or enhance social supports (Mugridge, 1991). A one-year follow-up of the initial 12 families completing the program indicated substantial improvement in parenting attitudes. There were no new neglect complaints up to two years after completion of the program. Characteristics of the interventions which contributed to the successful outcomes of the project were: consistent positive reinforcement of the skills learned and decreasing social isolation of the parent, along with limiting workers to one chronically neglecting family at a time, 24-hour availability, intensive contact of at least two hours per week (Mugridge, 1991). A family treatment approach has been successfully utilized to increase the social supports of abusive and neglectful families. Preventing child abuse and neglect by enhancing social networks was one of the objectives of a multi-family group therapy intervention with 42 abusive or neglecting families (Meezan & O Keefe, 1998). The families involved in the 34 week multi-family group treatment program significantly increased the amount of support received from both formal and informal sources. Though the comparison group families also increased the amount of support utilized over the same time span, the increases were significantly less than those for the families who received the multi-group treatment. The maltreating families involved in the multi-family treatment group also scored lower on the Child Abuse Potential Inventory (Milner, 1989,1990) and improved in a larger number of areas on a measure of family functioning. One program which provided neighborhood-based support centers offering parenting groups, activity and discussion groups to abusing families and neglectful families reported increased neighborhood involvement in less than half of the participants (Downs The CPS Response to Child Neglect Page 113

The Role of Social Supports & Nahan, 1990). But developing parent education and support groups for parents whose children are involved in neighborhood-based therapeutic childcare programs has been utilized to enhance informal social supports for parents at risk for abuse or neglect (Miller & Whitaker, 1988). One highly successful project specifically targeted the impoverished social networks of neglectful families utilized a variety of interventive strategies. The Social Network Intervention Project with neglectful families (Gaudin, Wodarski, Arkinson, and Avery, 1990/91) is one controlled, but small sample (N = 52) study, which demonstrated the effectiveness of interventions that targeted the informal linkages between neglectful families and neighbors, friends, and relatives. Network interventions were combined with intensive case management and in-home counseling, social skills training, group and inhome instruction in childcare and child management skills to (a) enhance informal support, and (b) improve the quality of parenting for a group of families reported and substantiated for child neglect. Each worker was limited to working with 15 neglecting families at one time. The social network interventions included the following services: 1. Direct network interventions included: brainstorming with parents to identify potential helpers, convening existing networks, redefining linkages to include specific helping, problem solving, conflict resolution, mediation and consultation with network members. 2. Natural neighborhood helpers were identified, recruited, linked with neglectful parents, provided with professional consultation and support. 3. Parent aides were recruited, trained, employed part time to assist neglectful parents with tangible aid, offering advice and support, and help with obtaining services from agencies and organizations. 4. Parent training/support groups were held weekly to teach parenting skills and social skills and to enhance friendship linkages. 5. Individual and family counseling to reduce barriers to social linking, resolve family conflicts, offer information and referral for services, and encouragement to parents and children. Neglectful families received these intensive services for an average 12 months. Families who received the services for 12 months developed significantly stronger informal support networks and significantly improved the quality of care for their children. Over 80 percent of the families who received at least 9 months of SNIP interventions improved on ratings of their parenting practices on the Childhood level of Living Scale (Polansky et al., 1981) from neglectful or severely neglectful to at least adequate. Almost 60 percent of the cases were closed after nine months of service. A comparison group of neglectful families who received regular CPS case management services from the same two agencies did not improve significantly in the adequacy of their informal support networks The CPS Response to Child Neglect Page 114

The Role of Social Supports or in the quality of their parenting. The conclusion of this controlled study was that social network interventions can be effective in remedying neglectful parenting and developing adequate informal support networks under the following conditions: (a) when offered along with intensive case management, social skills training, parent training, and counseling services from a professionally qualified social worker, who (b) a caseload limited to 15 families, and (c) the services are provided to a family for at least one year. Interventions to strengthen the informal social support networks alone are not effective in remedying neglect. The needs of most neglectful families require the combination of formally organized, professionally provided services and informal support services for effective intervention. Short-term services are not effective, and for many chronically neglectful families, continuation for at least 18 months is required to achieve adequate parenting. Follow-up reviews of the neglectful families served through this demonstration project were not completed. However, anecdotal information indicated that many of the families served whose cases were closed at the termination of the project, regressed to neglectful parenting and were again confirmed as neglectful. Implications for Interventions The evidence to support the effectiveness of programs that have been developed to remedy the relatively weak supports from neighbors, friends, and relatives available to neglectful families is not strong. There have been very few programs specifically targeting neglecting as opposed to abusive families. Most of the published research and demonstration projects have targeted mixed samples of abusive and neglectful families, and have not reported differential results for neglect families. Those that have done so are few, and only a few of those have reported significant improvements in the informal social supports for neglecting families. Frequently the limited size of the samples does not offer sufficient power to detect significant differences if results for the neglect families are reported separately. Most often the interventions are only generally described without the detail needed for the replication with larger samples that is needed to confirm the effectiveness of the intervention with neglecting families. The modest results of the interventions targeting the enhancement of social supports require research that differentiates between characteristics of neglectful families for whom the interventions are successful in (a) enhancing social supports and (b) improving the adequacy of parenting practices. It is evident that none of the strategies reported are successful with a majority of neglectful families. The challenge is to identify the characteristics of neglecting families for whom the intervention is successful. This will require larger samples of neglecting families and theory and practice-based isolation of independent variables that appear to make a difference in the outcomes. Careful specification and measurement of the intervention itself is missing from most of the studies reported. This kind of careful research is necessary for replication with additional, larger samples to validate interventions that effectively enhance social supports and improve parenting adequacy of neglectful families. The CPS Response to Child Neglect Page 115

The Role of Social Supports Meanwhile, the existing research clearly indicates that successful interventions to develop, strengthen, and enhance the informal supports and also improve the adequacy of parenting by neglectful parents cannot successfully stand-alone. They must be one component of multi-service programs that offer the range of tangible and therapeutic services that respond to the individually-assessed needs of multi-problem neglectful families. The poverty that characterizes the majority of neglectful families leaves them with multiple tangible needs that must be addressed first. Again we must conclude that there is no silver bullet, and no one size that fits all! Interventions to enhance the critical social supports for vulnerable neglectful parents must utilize a variety of strategies that: (1) provide new opportunities for supportive, affirming social interactions (2) utilize modeling, coaching, encouraging, reinforcing the development of social skills, (3) empower the parents by identifying and developing their strengths (4) teach reciprocity in helping to maintain vital social linkages. The research suggests the use of group methods to improve social supports, recognizing however, the obstacles of fear and poor social skills are significant barriers to be overcome to involve neglectful parents in groups. Some skilled one-to-one work to build up some trust in the social-worker to family relationship and teach social skills is necessary prior to group involvement. The provision of transportation, childcare, a welcoming, non-judgmental atmosphere, and some light refreshments are also necessities for successful involvement of neglectful parents in groups. Successful involvement of fathers or other males in neglecting families requires males involved in group leadership. The relative absence of strong, enduring, mutual supportive relationships with families, friends, and neighbors are a significant contributing factor to the neglect of children. Neglecting parents also lack knowledge of and effective helping linkages with formally organized agencies and services that offer essential financial and therapeutic supports. The multiple needs of most neglectful families require multi-service interventions. Interventions that only target linkages with potential informal supports will not be successful. However, interventions with neglectful families that fail to assess and target these critical supports for parenting ignore an essential, effective, culturally sensitive source of helping that most families, across cultures, utilize to successfully cope with the always challenging task of parenting happy, healthy children who will become the happy, productive adults and successful parents to the next generation of children. The CPS Response to Child Neglect Page 116

VII. Child Neglect: The Need For Differential Program Strategies Diane DePanfilis, Ph.D. Introduction Child neglect, the most common form of child maltreatment, has many dimensions, multiple causative factors, and may result in adverse physical, emotional, psychological, and developmental outcomes (DePanfilis, Swanson-Ernst, Dubowitz, and Ting, under review 2001). As a result, the field has reached some consensus that efforts to target single risk factors are not likely to be as effective in preventing or responding to neglect as are programs based on an ecological-developmental model (National Research Council, 1993). Further, due to the multiple causes of neglect and the various forms in which it is observed, it is agreed that intervention and prevention programs must be individualized and offer multiple services (DePanfilis, 1996; Gaudin, 1993b; Wolfe, 1993; Cohn and Daro, 1987). The purposes of this paper are to briefly describe the various ways in which children s basic needs are unmet, briefly review what is known about the consequences and causes of child neglect, and discuss the implications for program strategies for child protective services (CPS) agencies and community based programs. Definitions Child neglect is the most common and the least understood form of child maltreatment. Experts have struggled with the best way to define the problem when the basic needs of a child are unmet. (Dubowitz, 2000; Dubowitz, Black, Starr, and Zuravin, 1993; Zuravin, 1991, 1999). However, while there could still be debate about when conditions or consequences cross the threshold of inadequacy, some researchers suggest that neglect (1) refers to acts of omission of care to meet a child s basic needs that (2) result in harm or a threat of harm to children (DePanfilis, 1996; Dubowitz, Black, Starr, Zuravin, 1993). This definition infers that neglectful conditions are not always due to omission of care by caregivers alone, but may also be due to ecological factors. Since the focus of this paper is on strategies for both prevention and intervention, this broader definition of neglect is used, thus incorporating situations that sometimes involve Child Protective Services (CPS) and those situations that do not yet involve CPS. Diane DePanfilis, Ph.D., is an Associate Professor at the University of Maryland School of Social Work and is Co-Director of the University of Maryland Center for Families. The CPS Response to Child Neglect Page 117

The Need for Differential Program Strategies In order to develop strategies to increase safety and well-being for neglected children or children at risk for neglect, it is important to consider the various ways in which a child s basic needs may be unmet, as it is likely that the contributors to these possible consequences are different, and thus the strategies also need to differ. However, when one begins to define the specific subtypes of neglect, there is overlap but not consensus (Barnett, Manly, and Cicchetti, 1993; Magura and Moses, 1986; Trocme, 1996; U.S. DHHS, 1988; Zuravin and DePanfilis, 1996). For example, some researchers divide their neglect definitions into dimensions (e.g., supervisory neglect, physical neglect, educational neglect, etc.) and the dimensions are sometimes further divided into subtypes (Zuravin, 1999). In other words, the number and type of dimensions, the number and identity of each subtype, whether frequency and severity of each subtype is included in the definition, and the operational translations proposed by the various definers differ across models (Harrington, Zuravin, DePanfilis, Dubowitz, and Ting, under review-2001). For example, the NIS-3 (DHHS, 1996) addressed three types of neglect physical, educational, and emotional. Each of these three dimensions was then subdivided into subtypes. For example, physical neglect included seven different subtypes. In contrast, Erickson (1996) used five categories physical, emotional, medical, mental health, and educational and Zuravin and DePanfilis (1996) divided neglect into 14 dimensions with subtypes under most. In the past 30 years, a few researchers have tried to improve our understanding of the types of neglect by developing research measures (Magura and Moses, 1986; Magura and Moses, 1987; McGee, Wolfe, Yuen, and Wilson, 1995; Polansky, Borgman, and DeSaiz, 1972; Polansky, Cabral, Magura, and Phillips, 1983; Polansky, Chalmers, Buttenweiser, & Williams, 1981; Straus, Kinard, and Williams, 1995; Trocme, 1996). (These measures are described in Chapter 4). However to date, these efforts have not resulted in any consensus. To address this gap, the Federal Interagency Task Force on Child Abuse and Neglect through its research committee began a series of meetings in 1994 to address research definitions of all forms of child maltreatment. By 1999, the group had developed an instrument to categorize types of maltreatment described as the Child Maltreatment Log (CLL). This instrument is being field tested in two 17- month pilot projects that were initiated in September 2000 by the Children s Bureau in collaboration with the National Institute of Child Health and Development (NICHD) at NIH. 1 Following this pilot, researchers and practitioners may be able to look to the CML as another source for categorizing the types of neglect. Lacking a consensus in the field, this paper conceptualizes basic needs into categories and subtypes thought to be most helpful to administrators, program planners, and practitioners who may try to construct different strategies based on the ways in which a child s basic needs may be unmet. The structure for categorizing basic needs relies on the shift toward child welfare outcomes influenced by the passage of the Adoption and Safe Families Act of 1997 (ASFA), P.L. 105-89. Using this framework, it is possible to see how some outcomes are more directly 1 Information about this initiative can be obtained from Kathleen Sternberg, PhD, at NICHD by email at Kathleen_sternberg@nih.gov or by phone at 301-496-0420. The CPS Response to Child Neglect Page 118

The Need for Differential Program Strategies related to the mission of the CPS agency (i.e., child safety and permanency) while other outcomes may be most related to the broader mission of the community child protection system (i.e., child well-being and family well-being). However as emphasized by Courtney (2000), the child welfare system must also be concerned about child well-being for children in out-of-home care. It is recognized that the presence of some of the conditions below affects more than one outcome. Child Safety Meeting a child s physical and supervision needs will most directly increase the likelihood that a child is safe from conditions that would be defined as neglect in many state laws. Sub-types of unmet needs that could jeopardize a child s safety follow. It is recognized that some of these subtypes are more concerning for younger children and that the more severe the condition, the less safe a child is likely to be. For each of the definitions that follow, it should be assumed that in most state laws, to classify these conditions as neglect, the condition needs to be seriously inadequate and result in harm or a risk of harm as a result of the condition. Inadequate/delayed health care: failure of a child to receive needed care for physical injury, acute illnesses, physical disabilities, or chronic condition or impairment that if left untreated could result in negative consequences for the child (Adapted from: Magura and Moses, 1986; U.S. Department of Health and Human Services, 1996; Zuravin and DePanfilis, 1996). Inadequate nutrition: failure to provide a child with regular and ample meals that meet basic nutritional requirements or when a caregiver fails to provide the necessary rehabilitative diet to a child with particular types of physical health problems. At the seriously inadequate level, caregivers may intentionally withhold food or water from children and/or children are observed as malnourished or dehydrated. (Adapted from: Magura and Moses, 1986; Trocme, 1996; Zuravin and DePanfilis, 1996). Poor personal hygiene: failure to attend to cleanliness of the child s hair, skin, teeth, and clothes. At the seriously inadequate level, a child has suffered consequences such as physical illness. (Adapted from Magura and Moses, 1986; Zuravin and DePanfilis, 1996). Inadequate clothing: chronic inappropriate clothing for the weather or conditions. At the seriously inadequate level, a child has suffered consequences such as illness or threat of illness. (Adapted from Magura and Moses, 1986). Unsafe household conditions: presence of obvious hazardous physical conditions in the home that could result in negative consequences for the child(ren). Examples include leaking gas from stove or heating unit, peeling lead-based paint, dangerous substances or objects in unlocked lower shelves or cabinets; no guards on open windows; broken or missing windows; needles and other drug paraphernalia available to children). At the seriously inadequate level, there are multiple household hazards that have resulted in physical injury to a child. (Adapted from Magura and Moses, 1986; Zuravin and DePanfilis, 1996). The CPS Response to Child Neglect Page 119

The Need for Differential Program Strategies Unsanitary household conditions: presence of obvious hazardous unsanitary conditions in the home. Examples include: heavy rodent infestation; rotting food and garbage left out for days; urine soaked mattresses; feces and other excrement rotting within household; home smells overwhelmingly of urine/feces/spoilage). At the severely inadequate level, a child is physically ill as a result of unsanitary conditions. (Adapted from Magura and Moses, 1986; Zuravin and DePanfilis, 1996). Availability of utilities: family has been without at least one essential utility for several days or more (e.g., heat, water). At the seriously inadequate level, children suffer physical consequences due to lack of heat, no indoor plumbing, etc. (Adapted from Magura and Moses, 1986). Inadequate supervision: child left unsupervised or inadequately supervised for extended periods of time or allowed to remain away from home overnight without the caregiver knowing the child s whereabouts. At the seriously inadequate level, the lack of supervision includes exposing the child to dangerous conditions, which may have resulted in negative consequences (Adapted from Trocme, 1996; U.S. Department of Health and Human Services, 1996). Inappropriate substitute caregiver: failure to arrange for safe and appropriate substitute childcare when the caregiver leaves child with an inappropriate caregiver. At the seriously inadequate level, the child may experience other forms of maltreatment as a result of being left with an inappropriate caregiver. (Adapted from Magura and Moses, 1986; Zuravin and DePanfilis, 1996). Witnessing violence: a child witnesses violence in the home, e.g., partner abuse or violence between other persons who visit the home on a regular basis. At the seriously inadequate level, the level of violence is escalating and occurring frequently thereby increasing concern for the child s safety. (Adapted from U.S. Department of Health and Human Services, 1996). Drug exposed newborn: a newborn infant has been exposed to drugs because the mother has used one or more illegal substances during her pregnancy. Exposure may have resulted in negative physical consequences to the infant s health. At the seriously inadequate level, the caregivers are unable or unwilling to meet the special needs of the infant at birth. (Adapted from National Council of Juvenile and Family Court Judges, 1992). Permitting alcohol or drug use: encouraging or permitting of drug or alcohol use by a child. At the seriously inadequate level, there is a pattern of this condition and the child has suffered physical or emotional consequences. (Adapted from U.S. Department of Health and Human Services, 1996). Permitting other maladaptive behavior: encouraging or permitting of other maladaptive behavior (e.g., severe assaultiveness, chronic delinquency) under circumstances where the caregiver had reason to be aware of the existence and seriousness of the problem but did not attempt to intervene. At the seriously inadequate level, the child has suffered physical or emotional consequences. (Adapted from U.S. Department of Health and Human Services, 1996). The CPS Response to Child Neglect Page 120

The Need for Differential Program Strategies Permanency Children who have experienced permanency have stability in their living situations and continuity of family relationships and connections (U.S. Department of Health and Human Services, 2000). The conditions that follow could jeopardize a child achieving an outcome of permanency. Abandonment: desertion of a child without arranging for reasonable care and supervision in situations when children are not claimed within 2 days and when children are left by caregivers who give no (or false) information about their whereabouts. At the seriously inadequate level, a child has suffered negative consequences. Besides affecting permanency, this condition also affects the safety of the child and may eventually also affect the child and family well-being. (Adapted from U.S. Department of Health and Human Services, 1996). Expulsion: blatant refusals of custody without adequate arrangements for care by others or refusal to accept custody of a returned runaway. At the seriously inadequate level, a child has suffered negative consequences. (Adapted from U.S. Department of Health and Human Services, 1996). Unstable living conditions: moves of residence due to eviction or lack of planning at least three times within a six month period or homelessness due to the lack of available, affordable housing or the caregiver s inability to manage finances. At the seriously inadequate level, a child has suffered negative consequences. (Adapted from Zuravin and DePanfilis, 1996). Shuttling and Lack of Continuity of Parenting the child is repeatedly left at one household or another due to apparent unwillingness to maintain custody, or chronically and repeatedly leaving a child with others for days/weeks at a time. At the seriously inadequate level, a child has suffered negative consequences. (Adapted from Magura and Moses, 1986; U.S. Department of Health and Human Services, 1996; Zuravin and DePanfilis, 1996). Parental capacity for childcare: Parent or caregiver may be unable to meet the basic needs of children because of a significant physical, mental-emotional, or behavioral limitation that interferes with his/her ability to care for children. These impairments may result in hospitalization, institutionalization, or incarceration. This affects the permanency of the family and may also affect child safety, child well-being, and family well-being. (Adapted from: Magura and Moses, 1986). Child Well-Being Children who have achieved well-being are functioning within normal bounds in the following areas: physical health, mental health, behavior, peer relationships, supportive relationships with adults, school attendance and performance, daily living skills (depending on age) (Courtney, 2000). Children have difficulty functioning normally when certain conditions exist, including those that follow. The CPS Response to Child Neglect Page 121

The Need for Differential Program Strategies Inadequate nurturance or affection: marked inattention to the child s needs for affection, emotional support, attention, or competence; being detached or uninvolved, interacting only when absolutely necessary, failing to express affection, caring, and love for the child. This includes cases of nonorganic failure to thrive as well as other instances of passive emotional rejection of a child or apparent lack of concern for a child s emotional well-being or development. (Adapted from American Professional Society on the Abuse of Children, 1995; Magura and Moses, 1986; U.S. Department of Health and Human Services, 1996). Inadequate parental teaching/stimulating: children have few if any games, toys, or play materials; parents may ignore children or think children a bother, children may have no place to do their homework and may not be exposed to natural opportunities to learn within the home. Consequences may include academic school performance problems or acting out or participating in status offences or more serious criminal behavior, as the child gets older. (Adapted from Magura and Moses, 1986). Isolating: the child is consistently denied opportunities to meet needs for interacting/communicating with peers or adults inside or outside the home; markedly overprotective restrictions which foster immaturity or emotional over-dependency; chronically applying expectations clearly inappropriate in relation to the child s age or level of development; inattention to the child s developmental/emotional needs (Adapted from American Professional Society on the Abuse of Children, 1995; U.S. Department of Health and Human Services, 1996). Delay in obtaining needed mental health care: a child is not provided needed treatment for an emotional or behavioral impairment (Adapted from Magura and Moses, 1986; Trocme, 1996; U.S. Department of Health and Human Services, 1996; Zuravin and DePanfilis, 1996). Chronic truancy: habitual truancy (minimum of 20 days) without a legitimate reason. At the seriously inadequate level, the child has experienced negative consequences, which could have long-standing effects. (Adapted from: U.S. Department of Health and Human Services, 1996; Zuravin and DePanfilis, 1996). Failure to enroll/other truancy: a child (age 6) is not enrolled in school or a pattern of keeping a school-age child home for no legitimate reasons (e.g., to work, to care for siblings, etc.) an average of at least 3 days a month. (Adapted from: U.S. Department of Health and Human Services, 1996). Unmet special education needs: a child fails to receive recommended remedial educational services, or treatment for a child s diagnosed learning disorder or other special educational needs or problems of the child (Adapted from American Professional Society on the Abuse of Children, 1995; U.S. Department of Health and Human Services, 1996). Lack of parental approval of children: a child experiences criticism or disapproval without justification and a child s faults and shortcomings are clearly overemphasized. Parent rarely rewards positive behavior or praises the child. Parent has difficulty conveying empathy for the child s circumstances. (Adapted from Bavolek, 1984; Magura and Moses, 1986). The CPS Response to Child Neglect Page 122

The Need for Differential Program Strategies Family Well-Being Family well-being encompasses various aspects of family functioning (communication, roles, relationships), methods for resolving conflict, parenting knowledge and skills, ability of family members to use formal and informal supports, and the ability of the family to be self-sufficient in terms of income, basic housing, access to health care, and so on (Courtney, 2000). Often enhancing family well-being will also lead to increased achievement of child safety, child wellbeing, and permanency. The conditions that follow could jeopardize a family achieving an outcome of family-well-being. Unrealistic parental expectations: Parent or caregiver has very poor understanding of ageappropriate behaviors or makes unrealistic demands of children, may punish child for inability to meet unrealistic expectations. (Adapted from: Bavolek, 1984; Magura and Moses, 1986). Insufficient household furnishings: Family lacks certain essential household and sanitary functions, e.g., no working sink, no beds for sleeping, no table for holding family meals, etc. and the absence of these essential items strains the relationships in the family and could eventually jeopardize a child s safety as well as the well-being of the family. (Adapted from: Magura and Moses, 1986). Overcrowding: The space in the household is inadequate for the number of household members. There is no segregation of sleeping areas; children and adults of any ages may be found sharing the same bed. There is no space to move around which can lead to fights and arguments about space. These conditions can jeopardize family well-being and could eventually also lead to negative effects in child well-being. (Adapted from Magura and Moses, 1986). Money management: Family has chronic monetary crises, which threaten the stability of the household and may result in running out of food and other essentials for meeting the basic needs of children. In some circumstances alcohol or drug abuse/addiction may make it difficult for the parent or caregiver to prioritize financial needs with resources. In other circumstances, the level of income for the number of household members may make it very difficult to successfully manage and maintain a household budget. Finally, in other circumstances, parents may lack the necessary skills to develop and maintain a household budget. In any of these examples, the consequence is a strain on family well-being that could also affect the safety and well-being of children. (Adapted from Magura and Moses, 1986). Adult relationships in household: There may be a pattern of discord within the family that results in frequent conflict, physical violence, separations and instability, and children may be caught in the middle of these conflicts. These conditions not only affect family well-being but also may also eventually affect child safety, child well-being, and permanency. (Adapted from Magura and Moses, 1986). Parental/caregiver recognition of problems: Parent or caregiver accepts little to no responsibility for children s unmet needs; is not open to working with CPS or a community agency to change conditions that may jeopardize the family well-being and/or child safety, child The CPS Response to Child Neglect Page 123

The Need for Differential Program Strategies well-being, and/or permanency. Efforts to engage the caregiver in a partnership are resisted (Adapted from Magura and Moses, 1986). Parental/caregiver motivation to solve problems: Parent or caregiver actively rejects parental role, taking a hostile attitude toward child care responsibilities; believes that child care is an imposition. This condition not only affects the family well-being but, depending upon other conditions, may also affect child safety, child well-being, and permanency. (Adapted from Magura and Moses, 1986). Parental/caregiver cooperation with case planning/services: Parent or caregiver may actively reject services or work to sabotage service planning. The family may be difficult to contact (not answering the door, slamming the door), may threaten service providers, or may move frequently to avoid contact. Depending on the other conditions in the family, this condition will not only jeopardize family well-being but may also affect child safety, child well-being, and permanency. (Adapted from Magura and Moses, 1986). Support for principal caregiver and/or other family members: The family well-being may be threatened because the caregiver and/or other family members are socially isolated, have no one to turn to for emotional or instrumental support (Adapted from Magura and Moses, 1986). Definitions in Perspective The complexity of grouping together a group of conditions that create concern for a child s basic needs being unmet cannot be underestimated. However, if our purposes are to identify families who need some form of intervention (e.g., CPS or family support), for the purposes of helping families more adequately meet the basic needs of children, then a broader more inclusive definition of neglect is desirable. As emphasized by Rose and Meezan (1997), if neglect is defined more broadly, access to services should be granted to a greater number of children and families, including those at risk of harm and those minimally harmed (p. 24). And if we consider the responsibility for the protection, safety, and well-being of children to be the responsibility of the community, then we (the community) need to provide individually tailored services to a wider range of at-risk families (Farrow, 1996; Larner, Stevenson, & Behrman, 1998; Shirk, 1998; U.S. DHHS, 2001; U.S. GAO, 1997; Waldfogel, 1998a, 1998b, 2000) in order to improve the overall safety and well-being of children. Consequences of Neglect As emphasized by Gaudin (1999) and Erickson and Egeland (1995), no child is invulnerable or unaffected by inattention to basic needs, but there is variability in developmental outcomes depending on the complex interplay of both risk and protective factors (explained below). Nevertheless, neglect is a complex, multifaceted problem that can have profound effects on children (Black and Dubowitz, 1999, p. 274). While these effects may vary depending on the age of the child, circumstances surrounding the conditions, severity of neglect, and many other factors, it is important that our interventions and treatment target these effects as well as risks that neglect will continue. The CPS Response to Child Neglect Page 124

The Need for Differential Program Strategies Compared with physically abused children and non-maltreated children, neglected children may suffer the most concerning short and long term consequences (Youngblade and Belsky, 1990). For infants and toddlers, researchers have reported that neglected children have the worst delays in expressive and receptive language (Allen & Oliver, 1982; Culp, Watkins, Lawrence, Letts, Kelly, and Rice, 1991; Fox, Long, and Langlois, 1988) compared with abused and nonmaltreated children and in another study (Gowan, 1993), physically neglected children had significantly lower IQ scores at 24 and 36 months. Pre-school and school aged neglected children have been reported to experience behavioral and mental health problems and peer and school relationship problems. Specific presentation of problems varies by study. In one study of school-age maltreated children, 70% of whom were neglected, mothers rated them as having more behavior problems and being more depressed and socially withdrawn than did mothers of comparison group of non-maltreated, poor children (Aber, Allen, Carlson, and Cicchetti, 1989). Some results suggest that neglected children are observed as more passive and withdrawn compared to abused children who were noted to be more aggressive (Bousha and Twentyman, 1984; Crittenden, 1992; Hoffman-Plotkin, and Twentyman, 1984). In contrast, other studies have reported that both abused and neglected children to be more aggressive in their peer interactions than non-maltreated children (George and Main, 1979; Herrenkohl, Herrenkohl, Egolf, and Wu, 1991; Reidy, 1977 and in one study, teachers reported that neglected children were alternately withdrawn and aggressive (Erickson, Egeland, and Pianta, 1989). Longer term, there is evidence from several prospective and retrospective studies that older school-age neglected children experience cognitive and academic deficits that impair their development (Eckenrode, Laird, and Doris, 1993; Erickson, Egeland, and Pianta, 1989; Herrenkohl, et. al., 1991; Perez and Widom, 1994; Wodarski, Kurtz, Gaudin, and Howing, 1990). Taken in combination, children within families identified with neglect risks are likely to present with their own treatment needs related to behavior, mental health, and or school problems. Based on preliminary findings from a neglect demonstration program ((DePanfilis, Swanson-Ernst, Dubowitz, and Ting, under review 2001), sixty-six percent of families were referred for intervention partially because children were observed with behavioral or emotional problems either at school, home, or both. In addition, twenty percent were referred partly because of a learning disability and eleven percent were referred partly because of a developmental disability. Risk and Protective Factors For at least 20 years, the child maltreatment field at large has recognized the complex interplay between forces at work within the child, the individual parent or caregiver, the family as a system, and the broader neighborhood, community, and society (Belsky, 1980; Belsky and Vondra, 1989; Cicchetti and Rizley, 1980; Maccoby and Martin, 1983; National Research Council, 1993). Given the multiple forms in which neglect occurs and the complex etiology, the field is far from reaching a consensus on a causal model of neglect (Azar, Povilaitis, Lauretti, and Pouquette, 1998). Similar to early theories about child abuse, Polansky was among the first to propose a theory of neglect suggesting that the majority of neglectful mothers behavior resulted from their own early histories of inadequate care and resulted in personality disorders, The CPS Response to Child Neglect Page 125

The Need for Differential Program Strategies the most frequent of which was labeled the apathetic-futile type (Polansky, et. al, 1981). Also partially pointing to early childhood experiences, Crittenden (1993) has proposed a four stage information-processing model of neglect: (1) perception of essential aspects of children s states, (2) accurate interpretation of the meaning of these perceptions; (3) selection of adaptive responses, and (4) responding in ways that meet children s needs. Crittenden (1993) suggests that failure to accomplish one or more of these stages can result in different levels of neglect consequences, which has its roots in parental attachment relationships where the parent failed to have their own needs met in childhood. Gaudin and colleagues (1993) and Garbarino (1977) take a more transactional view and argue for models that take into account the interrelationship of societal and parental views about children, poverty, stress, and social isolation. In the absence of any unifying theory, researchers have tended to identify risk factors by comparing characteristics of neglectful families to families not known with neglectful problems (Schumacher, Slep, and Heyman, 2001). Some of the elements most consistently associated with child neglect include parental drug or alcohol abuse or addiction (Herskowitz, Seck, & Fogg, 1989; MacMurray, 1979; Magura and Laudet, 1996; Zuravin and Greif, 1989; USDHHS, 1993a; Wolock and Horowitz, 1979); parental depression, apathy, or low self-esteem (Christianson, et. al., 1994; Culp, Culp, Soulis, & Letts, 1989; Polansky, Chalmers, Williams, & Buttenweiser, 1981; Wolock and Horowitz, 1979; Zuravin, 1988a) social isolation and housing instability (Crittendon, 1985; DePanfilis, 1996; Garbarino and Crouter, 1979; Garbarino and Sherman, 1980; Gaudin, Polansky, Kilpatrick, and Shilton, 1993; Nelson, Saunders, and Landsman, 1993; Polansky, 1985; Zuravin, 1989); stress associated with challenges such as single parenthood, large family size, family interactional problems and disorganization (Burgess and Conger, 1977; Chaffin, Kelleher, and Hollenberg, 1996; Pianta, Egeland, and Erickson, 1989; Polansky, Chalmers, Williams, & Buttenweiser, 1981; Steinberg, Catalan, and Dooley, 1981; Williamson, Borduin, and Howe, 1991; Wolfe, Jaffe, Wilson, and Zak, 1985; Zuravin, 1987, 1988a); and family poverty and its correlates (Chaffin, Kelleher, and Hollenberg, 1996; Drake and Pandey, 1996; Dubowitz, 1999; Giovannoni and Billingsley, 1970; Martin and Walters, 1982; Nelson, Saunders, and Landsman, 1993; Pelton, 1994; Sedlak, 1997; U.S. DHHS, 1998; Wolock and Horowitz, 1979; Zuravin, 1987). There has been far less attention to protective factors that may mediate or buffer the effects of multiple risk factors for neglect. Broader research however has identified a core set of protective factors that may help families at risk for neglect to offset stress and other risk factors. For example, social support can have both stress-preventive and stress-buffering features (Thompson, 1995). After reviewing the evidence on the beneficial impacts of social support on both psychological and physical health, Belsky and Vondra (1989) concluded that both formal and informal supports enable individuals to cope with stress and thereby both lessen the risk of ill health and mental health and facilitate a more optimal recovery from illness. In this review, they also found evidence of the positive impact of social support on parenting. A similar literature on the strengths of black families point to the positive benefits of different aspects of social support, e.g., religious affiliation; active extended family that provides material resources, child care, supervision, parenting, emotional support to child and family; and mutual aid and social supports within the community (Hill, 1971, 1999; Lewis and Looney, 1983). The CPS Response to Child Neglect Page 126

The Need for Differential Program Strategies As we search for areas of protective factors in families at risk for neglect, it is helpful that we understand what the broader family strengths research field has learned. This literature (see for example: Deal, Trivette, and Dunst, 1988; Olson, McCubbin, Barnes, Larsen, Muxem, and Wilson, 1983; and Stinnett and DeFrain, 1985) has identified core themes about the strengths that help families cope with stress and adversity in their lives. Some examples of these findings suggest family strengths in the following areas: marital communication; shared orientation to child rearing; financial management skills; ability to deal with crises; appreciation and commitment to each other within the family; good communication patterns; high degree of spiritual orientation; sense of purpose for going on during good and bad times; sense of congruence about family goals, needs, projects, functions; family rules, values, and beliefs; positive coping strategies; problem solving competencies; ability to be positive; effort to spend time together; flexibility and adaptability in roles; a balance between the use of internal and external family resources for coping and adapting to life events and planning for the future. Other research with families of color (e.g., see Hill, 1971, 1999; Lewis and Looney, 1983) have also highlighted the following: identification of family with community of color, e.g., religious, media, political, neighborhood, or recreational affiliations; positive racial identity; biculturalism (possess values, beliefs, attitudes, customs, language and behaviors of at least two cultures); family maintains and transmits cultural or family traditions (e.g., celebrations, rituals, food, clothing); ethnic identity of neighborhood is present and positive; and the family demonstrates leadership in community. As we contrast these protective factors, different scenarios can be created to hypothesize how protective factors interact with risk factors. Cicchetti and Rizley (1981) suggest that parenting outcomes are determined by the relative balance of potentiating (risk) factors and compensating (protective) factors experienced by a given family. They further suggest that some risk factors are transient or situational and others are more chronic and enduring. Then, child maltreatment occurs when risk factors outweigh protective factors. Building on this theoretical model, the following conceptual model of neglect derived from a working model proposed by DePanfilis and Koverola (2001) will be used for the purposes of conceptualizing strategies for preventing neglect and intervening when child neglect has already been observed. The CPS Response to Child Neglect Page 127

The Need for Differential Program Strategies Figure 1 Working Conceptual Model of Child Neglect* Situational Risk Factors Acute Life Stress Acute Mental Health & Physical Health Crisis Acute School Problems Acute Family Relationship Conflict Enduring Risk Factors Child Behavior, Mental Health, or Physical Health Problems Caregiver Mental Health or Physical Health Problems Impaired Caregiver-Child Relationship Substance Abuse Enduring Protective Factors Family System Strengths Supportive Caregiver- Child Relationship Coping Strategies Social Support R di f Ch Underlying Risk Factors Poverty Caregiver Childhood Adversity Racism Violence in Community Underlying Protective Factors Spirituality Cultural Roots Community Connections Economic Stability * Developed by DePanfilis, D. & Koverola, C. (2001) University of Maryland, Baltimore Center for Families The CPS Response to Child Neglect Page 128

The Need for Differential Program Strategies This working conceptual model of neglect identifies both risk and protective factors. Risk factors are identified at three levels: (1) situational (factors that may present short term risks which in turn threaten the child s basic needs and possibly safety), enduring (risks that have been present over time and will require change oriented interventions to reduce the risk of neglect), and underlying (factors at the level of society and community that contribute to the enduring risk factors). The model depicts a bi-directional arrow between each level of risk factor, illustrating that an increase in situational risk factors will increase enduring risk factors, which can also increase underlying risk factors. The reverse direction is also true. With respect to protective factors, the model specifies two levels, namely enduring and underlying. The model depicts a bidirectional arrow between enduring and underlying factors indicating that an increase in enduring protective factors will result in an increase in underlying protective factors, and vice versa at their respective levels. The model also postulates that there is a bi-directional relationship between risk factors and protective factors, such that an increase in enduring protective factors will decrease enduring risk factors and ultimately may decrease underlying risk factors. Situational Risk Factors are defined as those factors that impinge upon the lives of families, creating demands that are experienced as stressful. These events are episodic and typically result in a crisis in the family that threatens the basic needs of children, and safety of children if the conditions are severe. Situational Risk Factors can be categorized as falling into several different categories, based on the focus of the demand. The model of neglect depicted in Figure 1 includes the following: (1) Acute life stress: Family has inadequate financial resources or other recent events challenge the capacity of the family to address basic needs such as housing, transportation, food, clothing or other essential need. (2) Acute Mental Health and Physical Health Crises: Family has at least one member who is experiencing an acute mental health crisis such as suicidality, gravely emotionally disabled, a psychotic episode, child threatening to harm another, or health related crisis such as recently diagnosed AIDS, high-risk pregnancy, cancer, lead poisoning. (3) Acute School Problems: Family has a child who is experiencing severe problems at school such as impending or actual suspension or expulsion, dangerous acting out behavior, serious academic performance problems. (4) Acute Family Relationship Conflict: Family is experiencing open conflict such as acute domestic violence, violence between siblings, high conflict divorce, need for ex parte order. Enduring Risk Factors are those factors that are identified as long term and of an enduring nature; the family has an ongoing struggle with addressing these issues. These are risk factors associated with child neglect. These factors include the following: The CPS Response to Child Neglect Page 129

The Need for Differential Program Strategies (1) Child Behavioral, Mental Health, or Health Problems: Family in which there is at least one child with chronic and ongoing externalizing or internalizing behavioral problems, mental health problems, and/or health problems that affects functioning at home, school, and/or in the community. (2) Caregiver Mental Health or Health Problems: Family in which the caregiver or another adult household family member has a chronic health or mental health problem, which affects the person s performance in fulfilling the caregiver role. (3) Impaired Parent-Child Relationship: Family in which the parent-child relationship is impaired and characterized by a long-standing pattern of coercive interaction or detachment/rejection of the child. (4) Substance Abuse: Family in which there is a member who has a pattern of active substance abuse. (5) Family Conflict: Family in which there is an ongoing pattern of conflict that impairs family functioning and may culminate in chronic or episodic violence between members. (6) Social Isolation: Family members have a pattern of lacking others to turn to for emotional support, instrumental or tangible support, cognitive aid, appraisal support, and social companionship. (7) Everyday stress: Caregivers and other family members experience chronic stress due to disorganized daily lives and experience frequent crises that affect basic needs. Underlying Risk Factors are those that are embedded within the societal context and have profound negative implications for families. These factors are typically intergenerational and they are deeply resistant to change. (1) Poverty: Families who often struggle to have sufficient resources to meet the basic needs of their members. (2) Caregiver Childhood Adversity: Families in which a parent or other caregiver comes from a background of childhood adversity, for example experienced neglect, abuse, insecure attachment with caregiver, or deprivation during childhood. (3) Racism in our society deeply affects choices that families have for where they live and the opportunities that may not be available to them for helping their children be healthy, safe, and achieve well-being. (4) Violence within the community. The CPS Response to Child Neglect Page 130

The Need for Differential Program Strategies Enduring Protective Factors are conceptualized as those factors of longer duration that support and enhance a family s capacity to nurture its members and successfully resolve threats to healthy functioning. (1) Family System Strengths: The internal characteristics and skills that families have to help them cope with multiple adversities, (e.g., interactional patterns and connections to one another, coping strategies, family values, capacity to access and use community resources, commitment to each other, family health, family cohesion). (2) Supportive Parent-Child Relationships: The ability of families to embrace attitudes that are positive about children, use positive discipline strategies, and indicate that the relationship between the parent and child is characterized as supportive of the child and his/her development. (3) Coping Strategies: Families capacity to implement general coping strategies to, deal with the needs and demands of the child and family, manage financial and other resources, problem solve stressful events, feel satisfied in the parenting role. (4) Social Support: Network of supports that families have within the neighborhood and community (family, friends, informal/formal connections) to meet basic social support functions, e.g., emotional support, child care, instrumental support, and financial support. (5) Readiness for Change: Primarily where the caregiver expresses a readiness and motivation to change behaviors and conditions that would otherwise increase risk for child neglect. Underlying Protective Factors are conceptualized as those factors that provide a solid foundation and basis to strengthen families and help them cope with adversity. (1) Spirituality: The family expression of a connection to spirituality, for example, by participation in the faith-based community or some other outward manifestation of embracing a spiritual dimension to family or individual life. (2) Cultural roots: The family having a connectedness and pride in their own heritage and roots, manifested in celebrations or other overt behaviors that are characteristic of the integration of cultural roots in family life. (3) Community connections: The family has a long-standing connectedness to others (individuals, organizations, informal and formal entities) to support the parenting role. (4) Economic stability: The family experiences a degree of economic stability and viability such that financial concerns are not focused on the meeting of basic needs and responding to crises. The CPS Response to Child Neglect Page 131

The Need for Differential Program Strategies This model posits that IF families experience an increase in risk factors (situational, enduring, and/or underlying) together with a decrease in protective factors (enduring and/or underlying) THEN there is a NEED FOR HELP by some aspect of the community. Implications for Program Strategies Considering the multiple pathways that can lead to neglect and the many ways in which a child s basic needs may be unmet, the field is far from reaching a consensus that provides clear support for one intervention approach versus another. However, while there may be much more that we need to learn, findings from recent reviews (DePanfilis, 1999; DePanfilis, 1996; Gaudin, 1988; Gaudin, 1993a; Gaudin, Wodarski, Arkinson, and Avery, 1990/91; Howing, Wodarski, Gaudin, and Kurtz, 1989; Smokowski and Wodarski, 1996) do suggest some basic principles for practitioners who intervene with families when children s basic needs are unmet. Ecological-Developmental Framework Intervention is more likely to be effective if it operates from a conceptual framework that views neglect within a system of risk and protective factors interacting across four levels: (1) the individual or ontogenic level; (2) the family microsystems; (3) the exosystem; and (4) the social macro system (Belsky, 1980). Whether one uses a conceptual model similar to the one presented in Figure 1 or another conceptualization, to be most effective, intervention may be directed at multiple levels (ontogenic, family microsystem, and exosystem) depending on the specific needs of the family. In addition, over the long term, community systems should consider strategies to also address the social macro system. Policy initiatives must be targeted at social conditions that continue to oppress large segments of the population, especially the poorest of the poor and families of color, including families who are unable to provide minimally adequate care for their children (Nelson, Saunders, and Landsman, 1993). Examples suggested by Nelson and colleagues (1993) include the availability of affordable childcare, increased education and employment opportunities, adequate low-income housing and rent subsidies, and large scale drug prevention and treatment initiatives. Polices further need to ensure that both family preservation and support services are integrated into community institutions such as schools, churches, and recreational organizations serving families (Thomlison, 1997). Thomlison (1997) suggests that risk-focused programming should prevent the accumulation of risk factors; establish and maintain pro-social situations and opportunities; focus on resilience and adaptation; facilitate active involvement of parents, children, and others in planning; ensure that services to at-risk populations are both necessary and sufficient; provide timely, careful, and expert evaluation, assessment, and follow-up services throughout the formative childhood years; and build safe, stable environments to permit families to establish structure, routines, rituals, and organization. The CPS Response to Child Neglect Page 132

The Need for Differential Program Strategies Attention to Basic, Concrete and Emergency Needs Whether the target population is families with children who are already determined to have experienced neglect or families who are assessed as at risk for neglect, the first response to families needs to consider situational risks that may be creating immediate concern for the safety and well-being of children. In the conceptual framework presented in Figure 1, these situational risks are identified at the first level. In the lists of definitions, those that are most concerning are listed under child safety. An initial risk assessment and evaluation of safety should assess whether children are at risk for immediate harm because of these situational risks. If identified, an immediate response must address these basic, concrete, or emergency needs before one can assume the family will be ready to address more enduring risks for neglect. This means that programs must have flexible funds and access to other such funds in the community to address these very basic needs of families. Examples of minimal investments that can increase the safety and well-being of children and families include: bus tokens to help family members get to health care appointments, parent teacher conferences, or other community agencies; basic household furniture, e.g., beds, linens, a table; a security deposit to move to better housing and away from a drug and crime ridden block; household improvements to repair safety hazards; registration fees for GED programs, birth certificates, camp, sports programs, etc. all which would support an intervention plan; school supplies such as uniforms, pencils, books, notebooks; temporary child care assistance to support a caregiver in going for job interviews, a personal health appointment, or drug treatment counseling; help with utility bills; emergency food and pampers, particularly during the first weeks of a employment when a pay check has not yet arrived. Importance of Outreach and Community Families who have children whose basic needs may be unmet are typically poor and lack access to resources (Gaudin, 1993a; Smale, 1995). Further, as indicated above, these families are more likely to be socially isolated, experience loneliness, and lack social support in both rural and urban areas than non-neglecting comparison groups (DePanfilis, 1996). To reach these families, services must be based in the community and concerted efforts must be made to engage families in services. Traditional, in-office, one-to-one counseling by professionals has proven to be ineffective with neglect (Cohn and Daro, 1987). Intervention therefore must include aggressive outreach and advocacy and be designed to mobilize concrete formal and informal helping resources. Services provided in the home and within the neighborhood and community are therefore essential. The helper is in a much better position to understand the family in their daily environment and to break down and manage the natural resistance of the family to change (Anderson and Stewart, 1983; DePanfilis, 2000a; Miller and Rollnick, 1991; Prochasca and DeClemente, 1982). To be most effective, interventions must be a collaborative process between the family and the community. Strategies should encourage an inclusive process that allows people from schools, churches, health centers, businesses, day care, and other sectors to come The CPS Response to Child Neglect Page 133

The Need for Differential Program Strategies together to plan and carry out goals for strengthening their neighborhood (Zuravin and Shay, 1992). In turn, people will be linked to people and informal helping relationships will be built. The movement toward developing community based child protection systems with differential response systems holds promise as an approach to implement these principles (Farrow, 1996; Shirk, 1998). Importance of Culturally Competent Intervention Risk and protective factors for child neglect may differ according to race, culture, and ethnicity. It is also well documented that, children from African American, Hispanic, and other racial and ethnic backgrounds are subject to the direct and indirect effects of discrimination, compounding and exacerbating their risk for many kinds of problems (Fraser and Galinsky, 1997, p. 272). Experts have emphasized that families of color, and especially African American families, are disproportionately represented in the child welfare system (Gould, 1991; Leashore, Chipungu, and Everett, 1991; National Black Child Development Institute, 1990); have been provided differential treatment within the child welfare system (Stehno, 1982; Albers, Reilly, and Rittner, 1993); that children of color enter the foster care system in increased numbers, partially influenced by poverty and by conversion of informal kinship arrangements to formal foster placements (Danzy and Jackson, 1997); and that once in the system, remain in the system longer than Caucasian children, do not receive as many in-home support services as Caucasian children, and have a disproportionate number of undesirable experiences (Gould, 1991; Mech, 1985; Billingsley and Giovannoni, 1972). Most often these families are poor, poorly educated, and are disadvantaged in the economic mainstream of the larger society (Brissett-Chapman, 1997). Since neglected children and their families continue to represent over half of the caseload of our child welfare agencies (U.S. DHHS, 2001b), it is imperative that we work to increase the cultural competence of service providers. At the last symposium on neglect, Abney (USDHHS, 1993b) outlined needs of neglectful families that a culturally competent system should address. At the micro-level, families need opportunities to build empowerment skills and to be involved in the advocacy process and peer support groups. At the macro level, families need access to financial assistance; housing acquisition programs; training focused on job retention; income augmentation to promote economic self-sufficiency; child care and health care; culturally and racially unbiased research; substance abuse prevention and treatment programs; services that are geographically accessible, bilingual, and culturally sensitive; and greater participation in program planning and implementation by professionals of color and community representatives (USDHHS, 1993b). We must also build bridges to engage families across culture (Abney, 2000) and incorporate what we know about families of color in our assessment of risk and safety (Brissett-Chapman, 2000). Finally, our family assessments can be informed by what we know about the strengths of specific cultural groups. Importance of a Helping Alliance and Partnership with the Family Families at risk for neglect may not have had positive experiences with formal systems. A key component of many effective programs is to create a helping alliance and partnership with the family (DePanfilis, 2000c; Dore and Alexander, 1996; Kenemore, 1993). This requirement is especially challenging because some caregivers with neglect problems have difficulty forming The CPS Response to Child Neglect Page 134

The Need for Differential Program Strategies and sustaining mutually supportive interpersonal relationships (Dore and Alexander, 1996; Gaudin and Polansky, 1986; Gaudin, Polansky, Kilpatrick, and Shilton, 1993). One of the key challenges for practitioners, whether in public child welfare or a community based agency, is to form positive connections and partnerships with families so that they will have an opportunity to tackle the difficult challenges in their lives (McCurdy, Hurvis, and Clark, 1996). Successful engagement with families, who may be resistant to intervention, requires an ability to feel and demonstrate empathy with caregivers (Siu and Hogan, 1989) despite their initial resistance to intervention. Importance of Family Assessment Effective intervention to remedy child neglect must be based on a comprehensive assessment of the family, with attention to the type of neglect that may be apparent and to the specific contributing risk factors (situational, enduring, underlying) (DePanfilis, 1999; Gaudin, 1988; 1993a). When available, this assessment should be undertaken in conjunction with other service providers to form a comprehensive picture of the individual, interpersonal, and societal pressures on the family members - individually and as a group. For both practice accountability and empirical usefulness, practitioners should consider using standardized clinical measures of risk and protective factors as well as parenting attitudes, knowledge, and skill for assessment and recording information. (Smokowski, and Wodarski, 1996). Because the complex interplay of risk and protective factors for each family is unique and families with neglect problems are heterogeneous, no particular method of intervention will lead to desirable outcomes for even a majority of families (National Research Council, 1993; Wolfe, 1993). Interventions must be tailored to the specific needs of individual families and programs must be flexible to accommodate differences. There are significant differences between families who have experienced chronic multiple problems that lead to neglect compared to families who may have experienced a recent situational crisis, for example, homelessness or unemployment which has led to a child s basic needs being unmet (Nelson, Saunders, and Landsman, 1993). Further, because of the many different types of family systems, it is important that intervention be geared to the family s own definition of family and to culturally based differences and strengths (Lloyd and Sallee, 1994). Mainstream efforts with families in the past have had too exclusive of a focus on mothers and have not explored the roles of fathers and other primary caregivers. (Dubowitz, Black, Kerr, Starr, and Harrington, 2000). Importance of Empowerment Based-Practice Several neglect-focused demonstration projects have reported on the importance of using empowerment approaches (Lee, 1994; Solomon, 1976) in their work with families (DiLeonardi, 1993; Mugridge, 1991; Landsman, Nelson, Allen, & Tyler, 1992; Witt, Dayton, and Sheinvald, 1992; Zuravin and Shay, 1991; U.S. DHHS, 1993b). Empowering families means carrying out interventions in a manner in which family members acquire a sense of control over their lives as a result of their efforts to meet their needs (Dunst, et. al., 1988, p. 88). To decrease the risk of neglect, interventions must help families learn to effectively manage the multiple stresses and conditions within the family and in their neighborhoods. Family members should be empowered to resolve their own problems and avoid dependence upon the social service system (Lloyd and The CPS Response to Child Neglect Page 135

The Need for Differential Program Strategies Sallee, 1994). The role of the helper becomes one of partner, guide, mediator, advocate, coach, and enabler. Applying the Strengths Perspective The strengths perspective is being increasingly applied with diverse populations (Saleeby, 1997; Saleeby, 1996; Trivette, Dunst, Deal, Hamer, and Prompst, 1990) and has particular relevance to families at risk for neglect and other forms of maltreatment (DePanfilis and Wilson, 1996). A strengths-based orientation provides the opportunity to build on a family s existing competencies to respond to crises and stress, to meet needs, and to promote, enhance, and strengthen the functioning of the family system. Strengths-based practice involves a paradigmatic shift from a deficit approach that emphasizes problems and pathology, to a positive partnership with the family. The focus of assessments (described above) is on the complex interplay of risks and strengths related to individual family members, the family as a unit, and the broader neighborhood and environment. This is not to suggest that a practitioner avoids specification of needs of families, because it is when a need is desired but lacking that families are identified because of child neglect. A child s most basic needs for food, clothing, shelter, health care, nurturance, stimulation, and safety may be unmet and as a result, helping practitioners become involved. When a child s basic needs are unmet, we must understand what conditions within and outside the family may be contributing as well as what resources exist within and outside the family to enable the family to improve the well-being of all its members. The focus of intervention however is not on correction of a problem but on enabling caregivers to meet the needs of all family members because they in turn will be better able to have the time, energy, and resources necessary for enhancing the well-being and development of the family as a whole (Dunst, Trivette, and Deale, 1988). This focus on the enduring and underlying protective factors, along with the risks optimizes a better match of interventions (DePanfilis, 2000b). The Need for Individualized Tailored Interventions Because of the complex interrelationships between risk and protective factors, the levels of risk and protective factors, and the many different ways in which children s basic needs may be unmet, it is impossible to provide a formula to always apply in specific cases of neglect. However, the conceptual model presented in Figure 1 suggests some differences in the types of risk factors that may be present and therefore, the types of intervention responses that may be most appropriate. For example, sending a family to a parenting skills class when they are experiencing acute life stress and may have received a recent eviction notice will only increase resistance and decrease the likelihood that the basic needs of children in this family will be met. The first response to families must consider whether situational or enduring risks are presenting immediate risk of serious harm to children. This could mean that the family is homeless and living on the street in winter or that toddlers have been left unsupervised because the drugaddicted caregiver is unable to provide daily care. Other chapters in this monograph that address the assessment of safety (Chapter 10), the caregiver with serious mental health or cognitive The CPS Response to Child Neglect Page 136

The Need for Differential Program Strategies deficits (Chapter 7), and the substance abusing caregiver (Chapter 8) provide more guidance about these issues. Since neglect is of a more chronic nature than other types of maltreatment and more likely to recur (DePanfilis and Zuravin, 1998; 1999), it is important that we develop an intervention response in conjunction with the community that will try to reach families early and avoid more severe consequences for children. Thus, our initial safety plan should target the specific risks that may present concern for an immediate risk of harm. Services could range from the provision of concrete services to address serious household safety problems to the assessment and treatment for a six-year-old child who is setting fires in a family that has been unwilling or unable to access needed mental health services. The goal of initial intervention should be to address safety and other emergency needs and to increase readiness for change oriented interventions. Next, a comprehensive family assessment (described earlier) should help to uncover the most concerning risk factors that will increase the likelihood of neglect in the future and identify the effects of past neglect that may indicate the need for treatment (e.g., child related behavioral or mental health problems). Specific intervention components should then be matched to address the most pressing needs of each individual family and to target individualized family outcomes, that if achieved will increase protective factors and reduce the risk of neglect. In her review of promising interventions related to neglect, DePanfilis (1999) suggested that the goal of intervention, to help families within communities meet the basic needs of their children, is to provide the mix and intensity of services appropriate to each family s need. Interventions are geared to increase the ability of families to successfully nurture their children by enabling families to use resources and opportunities in the community that will help them alleviate stress, overcome knowledge and skill deficits, and build and maintain care giving competencies. Since the contributors to neglect are varied, interventions may be directed to developing and/or providing (1) concrete resources; (2) social support; (3) developmental remediation; (4) cognitive or behavioral interventions; (5) individually oriented interventions; and/or (5) family focused interventions (p. 220). Examples of interventions that may match the specific needs of families are depicted in Table 1. The CPS Response to Child Neglect Page 137

The Need for Differential Program Strategies Table 1. Alternative Interventions When Children are Neglected. 1 Ecological (Concrete) Ecological (Social Support) Developmental Cognitive/ Behavioral Individual Family System - housing assistance - emergency financial, food, or other assistance - clothing, household items - advocacy for availability or accessibility to community resources - hands-on assistance to increase safety and sanitation of home (home management aides) -transportation -free or low-cost medical care - low cost quality child care - individual social support (parent aide, volunteer) - connections to church activities - mentor involvement - social support groups - development of neighborhood child care co-op - neighborhood center activities - social networking - recreation programs - cultural festivals and other activities - therapeutic day care - individual assistance with developmental role achievement, e.g., parenting, - public health visiting with focus on developmental including attachment needs of family members - peer groups (often at schools) geared to developmental tasks, -mentors to provide nurturing, cultural enrichment, recreation, role modeling - social skills training - communication skill building -teach home management, parent-child interaction, meal preparation skills and other life skills - teach new thought processes; e.g., regarding childhood history - parenting education - employment counseling and/or training - financial management counseling -problem solving training -AOD in-patient and out-patient counseling, - detoxification - 12 Step programs - mental health in-patient and out-patient counseling - crisis intervention - stress management counseling -play therapy - home based family centered counseling regarding family functioning, communication skills, home management, roles and responsibilities - center based family therapy - mobilizing family strengths - nurturing family camps - family sculpting 1 Reprinted with permission from DePanfilis, D. (1999). Intervening with families when children are neglected. In H. Dubowitz (Ed.). Neglected children research and practice (pp. 211-236). Thousand Oaks, CA: Sage Publications. The CPS Response to Child Neglect Page 138

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The Role of Social Supports Wolock, I. & Horowitz, B. (1979.) Child maltreatment and material deprivation among AFDC-recipient families. Social Service Review, 53, 175-194. Youngblade, L. M., & Belsky, J. (1990.) Social and emotional consequences of child maltreatment. In R. T. Ammerman & M. Hersen (Eds.), Children at risk: An evaluation of factors contributing to child abuse and neglect, (pp. 109-146). New York: Plenum Press. Zuravin, S. J. (1987.) Unplanned pregnancies, family planning problems, and child maltreatment. Family Relations, 36, 135-139. Zuravin, S. (1988a.) Child abuse, child neglect, and maternal depression. Is there a connection? In Child neglect monograph: Proceedings from a symposium (pp. 20-43). Washington, DC: U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect. Zuravin, S. (1988b.) Fertility patterns: Their relationship to child abuse and neglect. Journal of Marriage and the Family, 50, 983-993. Zuravin, S. (1999.) Child neglect: A review of definitions and measurement research. In H. Dubowitz (ed), Neglected children: Research, practice, and policy (pp. 24-46). Thousand Oaks, CA: Sage Publications. Zuravin, S. J. (1991.) Research definitions of child physical abuse and neglect: Current problems. In R. H. Starr, Jr. and D. A. Wolfe (Eds.). The effects of child abuse and neglect. New York: The Guilford Press. Zuravin, S. J. (1989.) The ecology of child abuse and neglect: Review of the literature and presentation of data. Violence and Victims, 4, 101-120. Zuravin, S. J., & DePanfilis, D. (1996.) Child maltreatment recurrences among families served by Child Protective Services final report (National Center on Child Abuse and Neglect Grant # 90CA1497). Baltimore: University of Maryland School of Social Work. Zuravin, S., & Greif, J. L. (1989.) Normative and child maltreating AFDC mothers. Social Casework, 70, 76-84. Zuravin, S., & Shay, S. (1991.) Preventing child neglect. In D. DePanfilis and T. Birch (Eds.). Proceedings National Child Maltreatment Prevention Symposium (pp. 41-51). Washington, DC: National Center on Child Abuse and Neglect, June 6-7, 1991. The CPS Response to Child Neglect Page 150

VIII. Using Research to Select Interventions and Measure Outcomes Diane DePanfilis, Ph.D Introduction The primary purpose of this chapter is to synthesize what is known about the efficacy of prevention and intervention strategies in reducing the risk of neglect. As has been emphasized in other chapters in this monograph, neglect has had much less research attention than other forms of child maltreatment. This is particularly true with respect to research on prevention and intervention. For the purposes of this chapter, promising practice strategies were selected for review if they had some research evidence of success with high-risk families, including those identified for neglect. In addition, since it is difficult to discuss practice strategies without first discussing assessment, methods for assessing and measuring neglect and risk and protective factors that contribute to it will be highlighted first. Given the increased emphasis on the need for outcome based child welfare practice (U.S. DHHS, 2000) and the need to make decisions early to increase safety and permanency for children, it is important that we identify tools for assessment and measurement of outcomes and then strategically match interventions that will most likely assist families in achieving successful outcomes. Assessing and Measuring Neglect Other chapters in this monograph have focused on defining neglect and discussed the complexities of measuring and categorizing its subtypes. In the past 30 years, a few researchers have tried to improve our understanding of the types of neglect by developing research measures. One of the first such efforts was undertaken by Polansky and colleagues (1972) in the development of the Childhood Level of Living Scale (CLL) and was later validated in several studies (Polansky, Cabral, Magura, and Phillips, 1983; Polansky, Chalmers, Buttenweiser, & Williams, 1978). Polansky and colleagues (1972) categorized neglect into two types: physical care and emotional/cognitive care and then further broke each of these categories into sub-types. Despite this groundbreaking work more than thirty years ago, most practitioners have not used the CLL. The CLL scale s usefulness in the field has been criticized because of its length and level of detail (99 items) and because it was designed for use with preschool children only (Gaudin, Polansky, and Kilpatrick, 1992; Trocme, 1996). Diane DePanfilis, Ph.D., is an Associate Professor at the University of Maryland School of Social Work and is Co-Director of the University of Maryland Center for Families. The CPS Response to Child Neglect Page 151

Using Research to Select Interventions and Measure Outcomes The most widely accepted measure of the degree to which a child s needs are met, may be the Child Well Being Scales (CWB) (Magura and Moses, 1986; Magura and Moses, 1987). The CWB scales were originally developed as a set of standardized client outcome measures to evaluate child welfare services. This observational instrument was constructed for use by workers in child welfare agencies in the assessment of four areas: parenting role performance, familial capacities, child role performance, and child capacities. Each of forty-three separate scales is related to one or more physical, psychological, or social needs of children. Each scale has anchoring points that are clearly described and to those familiar with neglect, the anchoring definitions lend face validity (Gaudin, Polansky, and Kilpatrick, 1992). Each scale is weighted in terms of a common dimension the seriousness of the condition so that certain conditions and their likely consequences are given differential ratings. In a validation study of a subset of twenty-three of the CWB scales, Gaudin and colleagues (1992) found these scales to discriminate between neglectful and non-neglectful low-income families. Again, while used more often than the CLL scale, the CWB scales have not been used extensively in the field by practitioners and some have critiqued the use of the scales suggesting that while these measures could be useful to researchers, they are less practical for use by practitioners (Seaberg, 1988; 1990; Doueck, 1991). For comparison purposes, current neglect demonstration project grantees funded by the US DHHS, Children s Bureau have committed to using the twenty-three CWB subscales evaluated by Gaudin and colleagues (1992). In an effort to construct a measure that could be used by workers to help guide the substantiation decision, Trocme (1996) constructed the Child Neglect Index (CNI). The CNI is a single-page instrument divided into four dimensions, some with sub-types supervision, physical care (food and nutrition, clothing and hygiene), and provision of health care (physical health care, mental health care, and developmental educational care). Similar to the CWB scales, the CNI is an observational measure structured to be rated on a severity scale ranging from adequate to seriously inadequate. It is designed to answer two questions: What do child welfare practitioners mean when they say that a child has been neglected? What do they mean by serious as opposed to mild neglect? (Trocme, 1996, p. 145). The simple scoring of the CNI involves combining the score on the scale receiving the highest severity rating with an age score, thereby addressing the fact that certain types of neglect are of higher concern when children are younger. Evaluation of the psychometric properties of the CNI has revealed acceptable levels of validity and reliability. With respect to concurrent validity, the CNI scores proved to be significantly related to the National Incidence Study (NIS) definitions and to scores on the CWB scales. Ratings from the CNI scores also predicted which cases were likely to be kept open for ongoing services suggesting that the scale correlated well with independent assessments made by child welfare workers. Test-retest reliability scores based on having intake workers complete the CNI twice within a 2-week period suggest acceptable ranges from.83 (developmental/ educational care) to.91 (supervision) and an average of.86 (N=127, weighted kappa) (Trocme, 1996, p. 149). Interrater reliability scores on individual CNI scales were also acceptable. On average, case readers (supervisors and investigators) were in agreement 93% of the time in making neglect/noneglect classifications (Trocme, 1996). Overall, this measure is very promising for use within child welfare agencies and for research based on definitions of neglect that are usually classified within state child abuse and neglect laws. This measure would be less useful for family support The CPS Response to Child Neglect Page 152

Using Research to Select Interventions and Measure Outcomes or other community systems that may focus on prevention of neglect or lower threshold types of neglect. A recent effort by Straus, Kinard, and Williams (1995) has been to develop a brief self-report measure of neglect. The 20-item version of the Straus, et al. (1995) Neglect Scale conceptually divided neglect into four dimensions supervisory, physical, cognitive, and emotional needs. Each dimension was operationally defined by a set of five items. Research conducted by Straus and colleagues (1995) with college students indicates that this scale has a high level of internal consistency reliability and moderate construct validity. To develop the measure, a pool of sixtythree items was generated based on expertise in the area of child abuse and neglect and existing measures of child maltreatment and then forty items were selected for the test development version. Positive items (e.g., kept the house clean ) were reverse coded prior to conducting psychometric analyses and item analyses were conducted to select a subset of 20 items by eliminating the half of the items least highly correlated with the total score of the respective scales (Straus, et al., 1995, p. 5). Initial examination of this measure in this study suggested that internal consistency reliability was very good, with alphas of.80 to.89 for the four subscales and.93 for the full 20-item scale. A more recent test with 150 maternal caregivers of children identified as at risk for neglect, indicated that internal consistency reliability for the 40 item version was very high (alpha =.96) and was moderate for the four five-item subscales identified by Straus et al. (1995), with alpha =.85 for emotional,.82 for physical,.78 for cognitive, and.81 for supervisory (Harrington, Zuravin, DePanfilis, Dubowitz, and Ting, 2001). Further research on the reliability and validity of this measure with different populations is needed before recommending either the twenty-item or forty-item version for use by practitioners. Assessing and Measuring Risk and Protective Factors The conceptual model of neglect introduced in Chapter 7 is used here as framework for identifying examples of assessment measures that may be useful for assessing risk and protective factors. See Figure 1 and refer to Chapter 7 for a more complete presentation of the model. The CPS Response to Child Neglect Page 153

Using Research to Select Interventions and Measure Outcomes Figure 1 Working Conceptual Model of Child Neglect * Situational Risk Factors Acute Life Stress Acute Mental Health & Physical Health Crisis Acute School Problems Acute Family Relationship Conflict Enduring Risk Factors Child Behavior, Mental Health, or Physical Health Problems Caregiver Mental Health or Physical Health Problems Impaired Caregiver-Child Relationship Substance Abuse Family Conflict Social Isolation Every Day Stress Enduring Protective Factors Family System Strengths Supportive Caregiver- Child Relationship Coping Strategies Social Support Readiness for Change Underlying Risk Factors Poverty Caregiver Childhood Adversity Racism Violence in Community Underlying Protective Factors Spirituality Cultural Roots Community Connections Economic Stability * Developed by DePanfilis, D. & Koverola, C. (2001) University of Maryland, Baltimore Center for Families The CPS Response to Child Neglect Page 154

Using Research to Select Interventions and Measure Outcomes This model suggests that neglect is the consequence of a complex interplay between risk and protective factors and that we need to respond differently to risk factors that present as situational risks from those that present as enduring risks. Situational Risk Factors are defined as those factors that impinge upon the lives of families, creating demands that are experienced as stressful. These events are episodic and typically result in a crisis in the family that threatens the basic needs of children, and safety of children if the conditions are severe. Situational risk factors may be categorized as (1) acute life stress, e.g., recent events challenge the capacity of the family to meet basic needs such as housing, transportation, food, clothing or other essential need; (2) acute mental health and physical health crises that suggest the need for medical or mental health assessment; (3) acute school problems that have resulted in a crisis for the child or family; and (4) acute family relationship conflict, e.g., domestic violence. Many CPS agencies already have methods for assessing the risk of maltreatment and evaluating the safety of the child. However, in families at risk for neglect or those already substantiated for neglect, often the opportunity for engagement arises out of the initial crisis. It is crucial that we develop opportunities to quickly assess these situational risk factors and develop interventions that respond to an accurate assessment. To assess families experiencing acute life stress, it doesn t take a measure or scale to know what to do, e.g., family is without any food so an emergency food resource is located. However, families who are experiencing these types of crises may live in chronic circumstances of one crisis or another. If we are going to help the family meet the basic needs of children, it will be important to not only respond to the immediate crisis but to try to understand what is leading to the crisis in the first place. Carefully assessing and documenting these circumstances will help to look more broadly at all of the ecological and personal factors that may impinge on the safety and well being of the child and family. Certain subscales of the CWB (Magura and Moses, 1986) scales discussed earlier can be used for this purpose (e.g., security of residence, availability of utilities) and other CWB scales may document changes that will lead to reduction of life stress related crises (e.g., money management). Certain sections of another observational instrument, the Family Assessment Form (FAF) (Children s Bureau of Southern California, 1997), may also be useful both for assessing situational risk factors and also for documenting changes in these over time. For example, sections of the FAF about the living and financial conditions provide useful targets for interventions. Strength of this tool is that its results could lead to planning interventions both with the family and with other systems. For example, if serious health hazards within a household are identified that are outside the family s control, advocacy with the landlord or housing authority may be needed on behalf of a family in order to increase safety for children. Inter-rater reliability of this measure is acceptable (McCroskey, Nishimoto, Subramanian (1991) and the authors suggest that ratings have been the same or within on-half step of each other about 75-80% of the time (Children s Bureau of Southern California, 1997). Other sections of this measure can also be used to assess interactions between adults as well as between adults and children that could be creating acute crises, e.g., domestic violence. The CPS Response to Child Neglect Page 155

Using Research to Select Interventions and Measure Outcomes Specific to household safety, the Home Accident Prevention Inventory (HAPI-R) (Tertinger, Greene, and Lutzker, 1984) was developed to help practitioners or parents assess the hazards in their homes. Hazards are categorized as fire and electrical, suffocation by ingested object, firearms, solid and liquid poisons, suffocation by mechanical objects, falling, and drowning. Based on this household hazard assessment, the practitioner and family can work together to develop a safety plan to address the hazards. Developed within the same eco-behavioral homebased intervention, the Checklist for Living Environments (CLEAN) is also useful in cases of neglect to help professionals or parents count items around a home that represent clutter and to assess filth such as decaying food (Lutzker, 2000; Rosenfield-Schlickter, Sarber, Bueno, Greene, & Lutzker, 1983; Watson-Perczel, Lutzker, Greene, and McGimpsey, 1988). Two self-report measures developed by Dunst and colleagues (1988), the Family Needs Scale and the Family Resource Scale are tools that be can used with families either via interviews or paper and pencil report to identify both the needs and resources in the family. For example, the Family Needs Scale asks families to identify the degree to which they need help with such things as, having clean water to drink and having plumbing, lighting, and heat. Similarly constructed, the Family Resource Scale measures the adequacy of different resources in households with children. The scale includes 31 items rated on a five-point scale ranging from not at all adequate (1) to almost always adequate (5). The scale items are roughly ordered from the most to least basic. The hierarchy is derived from a conceptual framework that predicts that inadequacy of resources necessary to meet individually identified needs will negatively affect both personal well-being and parental commitment to carrying out professionally prescribed regimes unrelated to identified needs. For example, the first item asks caregivers to rate the extent to which resources are adequate in the family to provide food for two meals a day. The last item relates to having time and money for travel and vacation. Both measures have adequate internal consistency reliability (i.e., Coefficient alpha =.92 computed from average correlation among 30 items; Coefficient alpha =.97 computed from average correlation of 30 items with total score for the Family Resource Scale (Dunst, Trivette, and Deal, 1994). The measures also correlate well with other measures of health and well-being and to parental commitment to child and family level interventions. Another measure that has proven to be very relevant to families at risk for neglect (DePanfilis, Dubowitz, and Kelley, 2001) is the Daily Hassles Scale, specifically the subscales: financial concerns, role overload, employment problems, parental worries and interpersonal problems (Kanner, Coyne, Schaefer, & Lazurus, 1981). For families with acute mental health and physical health crises, this means collaborating with mental health and health providers to respond to circumstances quickly in order to avoid possible life-threatening circumstances. For children who are experiencing serious and acute school problems (often with similar problems also occurring at home), it will require a complete professional assessment to develop correct solutions to these presenting concerns. The CPS Response to Child Neglect Page 156

Using Research to Select Interventions and Measure Outcomes Enduring Risk Factors are those factors that are identified as long term and of an enduring nature; the family has an ongoing struggle with addressing these issues. Enduring Protective Factors are conceptualized as those factors of longer duration that support and enhance a family s capacity to nurture its members and successfully resolve threats to healthy functioning. Family assessments should be driven to understand both risk and protective factors so that interventions can be tailored to both reduce risks and increase protective factors. The number of standardized clinical assessment measures available for informing this assessment are too numerous to review in the context of this chapter however several will be selected as illustrations of how standardized measures may inform the achievement of outcomes over time. The Family Assessment Form (FAF) (Children s Bureau of Southern California, 1997), discussed above, was designed to assess strengths and needs in six areas of family functioning: living conditions; financial conditions; interactions between the adult caregivers; interactions between caregivers and children; support available to the family; and developmental stimulation available to children. Intended as a comprehensive assessment, the measure captures both risk and protective factors and is structured so that case plans can be directly derived from sections of the assessment that indicate high ratings. The North Carolina Family Assessment Scale (NCFAS) (Reed-Ashcraft, Kirk, and Fraser, 2001) is an instrument designed for family assessment and outcome measurement in family preservation services and child welfare. The domains included in this assessment are derived from ecological theory (Bronfenbrenner, 1979): (1) environment including housing stability, safety, financial management, etc.; (2) social support including social relationships and formal services; (3) family/caregiver characteristics including parenting skills, domestic violence, etc.; (4) family interactions including bonding, communications with child, etc.; and (5) child well being including the child s physical health, mental health, substance abuse, etc. The reliability and validity of the NCFAS was examined with data on 419 families who received intensive family services in North Carolina. Although caution is warranted regarding the generalizability of the findings, results of this study support the internal consistency reliability and construct validity of the instrument (Reed-Ashcraft, Kirk, and Fraser, 2001). A useful source for identifying protective as well as risk factors are the assessment instruments developed by Dunst and colleagues (1988; 1994). Two of these measures have already been identified, the Family Needs and Family Resource Scale. Other instruments are useful for assessing social support and strengths in family functioning. The Support Functions Scale (Dunst, Trivette, and Deal 1988) measures parents (caregivers ) needs for different types of help and assistance. The twenty-item scale identifies the degree to which families have people in their lives to meet five social support functions: (1) emotional support (e.g., someone to talk to); (2) child support (e.g., cares for child regularly or in emergencies); (3) financial support (e.g., has someone to lend them money); (4) instrumental support (e.g., someone to fix things around the house); and (5) agency support (e.g., obtains services for child). The Family Support Scale (Dunst, Trivette, and Deal, 1988) measures the helpfulness of sources of support to families with children. The scale has been used in a number of studies examining the effect of social support on parent health and well-being, family integrity, parental perceptions of child functioning, and styles of parent-child interaction (Dunst, 1985). Since social isolation is an important The CPS Response to Child Neglect Page 157

Using Research to Select Interventions and Measure Outcomes risk factor for neglect (DePanfilis, 1996), it is important for us to understand with whom the family is connected, and the degree to which these connections are perceived by the caregiver as helpful to providing care to children in the family. The brief instrument (18 items) is an opportunity for the caregiver to identify which of six groups of people are helpful to them: (1) informal kinship; (2) social organization; (3) formal kinship; (4) immediate family; (5) child related professional services; and (6) generic professional services. The Inventory of Social Support (Dunst, Trivette, and Deal, 1988) provides a way of determining the types of help and assistance that are provided to a respondent by different individuals and agencies that make up a person s personal social network. The types of individuals they are asked about are identical to the categories in the Support Functions Scale. The Family Functioning Style Scale (Deal, Trivette, and Dunst, 1988) is an instrument for measuring two aspects of family strengths: (1) the extent to which a family is characterized by different qualities and (2) the manner in which different combinations of strengths define a family s unique functioning style. The scale items are organized into three categories that are believed to represent distinct (but not independent) aspects of family functioning style: family identity, information sharing, and coping resource mobilization. The 12 qualities of strong families comprising the content of these categories are based on an extensive review and integration of the family strengths literature. The family-identity category measures five aspects of family strengths: (1) commitment toward promoting the well-being and growth of individual family members as well as that of the family unit; (2) appreciation for the small and large things that individual family members do well and encouragement to do better; (3) allocation of time for family members to do things together (no matter how formal or informal the activity or event), (4) sense of purpose that permeates the reasons and basis for going on in both bad and good times,; and (5) congruence among family members regarding the importance of assigning time and energy to meet needs. The information-sharing category measures two aspects of family strengths: (1) communication among family members in a way that emphasizes positive interactions and (2) rules and values that establish expectations about acceptable and desired behavior. The coping/resource mobilization category measures five aspects of family strengths: coping strategies that promote positive functioning in dealing with both normative and non-normative life events; (2) problem-solving abilities employed to meet needs and procure resources; (3) positivism in most aspects of living, including the ability to see crises and problems as an opportunity to learn and grow; (4) flexibility and adaptability in the roles necessary to procure resources to meet needs; and (5) balance between the use of intra- and extra-family resources for meeting needs. This scale includes 26 items and can be completed either by the primary caregiver (for the family) or the practitioner can use it in a family meeting and have them complete it together. Each scale item is rated on a five-point scale varying from not at all like my family to almost always like my family. Several measures of family strengths are obtained from the respondent s scores. First, sub-scale scores are derived from each of the 12 family strengths areas. Second, overall family strengths scores are derived by adding the sub-scale scores for the family-identity, information sharing, and coping/resource-mobilization categories. Both sets of scores can be plotted on a profile form to The CPS Response to Child Neglect Page 158

Using Research to Select Interventions and Measure Outcomes discern the family s unique functioning style. All of the Dunst and colleagues (1988) measures are available for reproduction without cost. To assess parenting attitudes, knowledge, and skill; parenting stress, parent-child relationships, and family functioning, there are numerous measures that have been used in past research with neglect (e.g., the Adult-Adolescent Parenting Inventory (AAPI) with subscales of inappropriate parental expectations of the child, lack of empathy towards children s needs, parental value of physical punishment, and parent-child role reversal (Bavolek, 1984); Parenting Stress Index (PSI), subscales of parental distress, parent-child dysfunctional interaction, difficult child (Abidin, 1983); Parenting Scale (Arnold, O Leary, Wolff, and Acker, 1993); Self-Report Family Instrument (SFI) (Beavers, Hampson, and Hulgus, 1985; Index of Family Relations (Hudson, 1992); Home Observation for the Measurement of the Environment (HOME) (Caldwell and Bradley, 1984). There are increased resources for locating these and other measures that could be useful for conducting family assessments and targeting and measuring outcomes over time (e.g., Azar, 2000; Early, 2001; Fisher and Corcoran, 2001; Rothman and Thomas, 1994; McCubbin, Thompson, and McCubbin, 1996; Pecora, Fraser, Nelson, McCroskey, and Meezan, 1995; Weiss and Jacobs, 1988; Wells and Biegel, 1991). Promising Interventions 1 While not yet applied specifically to neglect intervention or prevention research, there has been a recent interest in developing classification systems for establishing the level of evidence about the efficacy and effectiveness of specific treatments with specific client populations (e.g., Becker, et. al., 1995; Saunders, Berliner, and Hanson, 2001). This chapter does not attempt such a review. Instead, interventions that that have targeted or include families at risk for neglect or that appear to address conditions that could be a consequence of neglect, and that appear to be based on accepted theory or practice principles and have some level of research support, will be briefly summarized. In most cases, the review is based on published research however some preliminary findings from currently funded demonstration studies are also identified. As emphasized in chapter 7, effective intervention to remedy child neglect must be based on a comprehensive assessment of the family, with attention to the type of neglect that may be apparent and to the specific contributing risk factors (situational, enduring, underlying) (DePanfilis, 1999; Gaudin, 1988; 1993a). Thus, it would be inappropriate to assume that all interventions identified here would always be appropriate for all families at risk for neglect. The specific selection of interventions must be matched to the individualized assessment. General principles however may apply to most situations of neglect (see chapter 7). 1 NOTE: parts of this section are based on a review initially completed for an updated edition to DePanfilis, D., & Salus, M. (1992). Child Protective Services: A guide for caseworkers. [U.S. Government Printing Office No. 1992-625-670/60577]. Washington, D.C.: National Center on Child Abuse and Neglect. The CPS Response to Child Neglect Page 159

Using Research to Select Interventions and Measure Outcomes Services for Children There is a substantial body of research literature that suggests that neglect is a complex, multifaceted problem that can have profound effects on children. While these effects may vary depending on the age of the child, circumstances surrounding the conditions, severity of neglect, and many other factors, it is important that our interventions and treatment target these effects as well as risks that neglect will continue. Thus, the goal of services and treatment for neglected children is to increase child well-being as well as child safety. Early childhood programs provide children at risk with time away from a stressful home situation, needed structure, limit setting, stimulation, an opportunity to interact with adults and children who serve as models for appropriate actions, and an alternative to foster care when continual presence in the home places the children at risk and jeopardizes the children s safety. Child care in particular has been suggested to provide opportunities for children to interact with adult role models who are warm and caring and offer a safe environment with a clear structure, predictable experiences, and developmentally appropriate opportunities to develop self-esteem and coping skills through academic and/or social achievement (Garbarino, Dubrow, Kostelny, and Pardo, 1992). In a recent review of the effectiveness of child care programs, Roditti (2001c) suggested that the use and effectiveness of quality day care as an important service for high-risk children has been demonstrated by the Yale Child Welfare Research Program (Seitz, Rosenbaum, and Apfel, 1983) and the Kempe Early Education Project Serving Abuse Families (KEEPSAFE) (Oats, Grey, Schweitzer, Kempe, and Harmon, 1995). Because these services are often provided in conjunction with other treatment, there has yet to be research that by design can provide information about the benefits of different components of these programs. When childcare is used for maltreated or at-risk children however, it is very important that quality childcare be located. After a review of the evidence, Roditti (2001a, 2001b) suggests that higher-quality center-based childcare programs result in favorable benefits for children, including improved cognitive skills in language development and pre-math, enhanced socio-emotional development, and better teacher-child relations. Characteristics of higher quality include high staff-to child ratios (1:4 for infants and 1:5 for toddlers), well trained and higher-paid staff, experienced administrators, and a safe, clean, and stimulating physical environment. Because of the association between poverty and child maltreatment, many maltreated and at-risk children are eligible for programs like Head Start. While the duration of effects for Head Start programs have not been consistently promising (Schnur and Belanger, 2001), children in Head Start programs have demonstrated significant gains on measures of cognitive ability at one year post-head Start (Lee, Brooks-Gunn, and Schnur, 1988; improved health care (Washington, 1985), and higher levels of social competence than children who did not attend preschool (Lee, Brooks-Gunn, Schnur, and Liaw, 1990). Out-of-home placement in family foster care should be considered when a child is unsafe because the risk of imminent harm to the child is great and/or when the child s behavioral and emotional needs cannot be addressed at home. A nurturing placement for children can provide them with an opportunity to develop trust in adults, enhance self-esteem, and learn appropriate methods for communicating with others. When there is a need to place children in out-of-home care, the risk of disrupting the family must be considered and weighed against the risk of harm to The CPS Response to Child Neglect Page 160

Using Research to Select Interventions and Measure Outcomes the children. Some experts suggest that when children need to be placed out of the home that kinship foster care be considered first as it may be less traumatic for children (Child Welfare League of America, 1994). Kinship foster care can promote one of the fundamental goals of the child welfare services system to support families in their efforts to protect children (Berrick, 2001, p. 132). However, although some research suggests more positive experiences for children placed in kinship care, others have expressed concern about the absence of services to these families. Berrick s (2001) review of the evidence suggested that kinship foster care encourages more visitation and contact with birth parents (Berrick, Barth, and Needell, 1994; LeProhn, 1994), fewer placement changes for children during their stays in foster care, and more successful reunifications compared to other types of foster care (Berrick, Needell, Barth, Johnson-Reid, 1998). Studies also suggest that when children need to be moved, children in kinship care are more likely to transfer to another relative (Courtney and Needell, 1997) and that children in kinship foster care are generally happy with their caregivers (Wilson, 1995). On the other side, Berrick (2001) says that although kinship care may provide a variety of benefits to children in care, there is significant evidence to suggest that many of these children may be treated inequitably by the child welfare services system. Kinship foster parents receive less support, fewer services, and less contact with child welfare workers than unrelated foster families (p. 130) (Berrick, Barth, and Needell, 1994; Dubowitz, 1990; Meyer and Link, 1990; Zwas, 1993). Supportive services can provide adjunctive assistance for neglected children who may also be receiving other forms of treatment or intervention. Services such as Big Brothers, Big Sisters, YMCA, and Foster Grandparents can provide neglected children with a consistent role model, support, nurturance, and a safe place. Community and church activities can also benefit maltreated children. These programs provide support to the children, help overcome problems associated with loneliness, and broaden the children s range of social contact. In situations where supportive services are used, it is imperative that consultation and training be provided to the service providers on a regular and consistent basis. While these programs have been used with maltreated children for some time, the empirical evidence of the efficacy of these programs has varied and sometimes been difficult to determine since these programs have often been used in combination with other treatment. Based on a recent review of the evidence, Tierney and Grossman (2001) suggest that the most effective of these programs achieve goals of improved academic performance, attitudes, and attendance (Cave and Quint 1990; Johnson, 1998; Tierney, Grossman, and Resch, 1995), decreased risk for substance abuse (LoSciuto, Rajal, Townsend, and Taylor, 1996; Tierney, Grossman, and Resch, 1995), reduced likelihood to hit someone, improved relationships with their parents, improved peer relationships, and increased self-esteem (Tierney, Grossman, and Resch, 1995) compared to a control group. Therapeutic Child Development Program (Sheehan, 2001; Childhaven, undated). This treatment is a milieu based intervention for maltreated preschool children that seeks to reduce risk factors and enhance protective factors by providing children with positive nurturing interactions with adults and a consistent, safe, monitored environment. This therapeutic child development approach is based on research by expert child practitioners and scientists showing that early life experiences and brain development affect later-life functioning. Children attend a milieu-based program during the day and parents are provided with educational and supportive services. In a long-term follow-up, treated children were significantly less aggressive, had fewer The CPS Response to Child Neglect Page 161

Using Research to Select Interventions and Measure Outcomes internalizing behavior problems, were less frequently arrested for violent and non-violent crimes, and were less often identified as violent by caregivers (Moore, Armsden, & Gogerty, 1998). Treatment Foster Care is a family-based alternative to residential, institutional, and group care for children and adolescents with significant behavioral, emotional, and mental health problems (Chamberlain, 2001). When neglected children are unsafe and they suffer significant behavioral, emotional, or mental health problems, treatment foster care is usually the preferred option since these programs serve children and adolescents who have problems similar to those served in more intrusive settings and the majority of treatment foster care placements are completed as planned, suggesting this as a viable placement alternative (Meadowcroft, Thomlinson, and Chamberlain, 1994). While in treatment foster care settings, studies have suggested that youth improve on behavioral indicators of adjustment (Clark, Boyd, Redditt, Foster-Johnson, Hardy, Kuhns, Lee, and Stewart (1993) and have shown greater stability of living situation than youth in congregate care settings (Chamberlain and Reid, 1998; Hawkins, Almeida, and Samet, 1989). Services for Families, Parents, Parents and Children Services to families, parents, and/or parents and children are directed to reducing risk factors and increasing protective factors. Results from six federally funded neglect demonstration projects point out promising results for families who receive empowerment based intervention however results also indicate the challenges inherent in engaging families who struggle with complex social problems (DiLeonardi, 1993). Services need to be tailored to the unique circumstances of each family and motivational strategies need to be employed to engage families in the change process. These services may be directed to increase child safety, child well-being, family wellbeing, and/or permanency. Behavioral Parent Training Interventions for Conduct-Disordered Children (Barkely, 1997; Breston and Payne, 2001; Forehand and McMahon, 1981; Patterson, 1976; Patterson and Gillion, 1968) has a long-standing record of success for the treatment of conduct disorders in children. This treatment should be considered when neglected children display disruptive behaviors that may be the result of neglect and/or stem from disordered family interactions. Treatments targeting behavior-disordered children and their families typically use a short-term child focused behavioral intervention and teach parents specific skills that are designed to increase child compliance, decrease child disruptive behavior, and minimize coercive interactions between parent and child at home and in other settings. These interventions differ from didactic parenting classes in that they are based on established principles of behavior change and involve teaching skills in addition to conveying information. Approximately 40% of such interventions are manualized treatments and a recent review suggested that several of these models have empirical support for their efficacy (Breston and Payne 2001). Some longstanding approaches have met stringent criteria of the American Psychological Association and been judged as wellestablished psychosocial interventions for childhood disorders and others have been identified as probably efficacious psychosocial interventions for childhood disorders (e.g., Alexander and Parsons, 1973: Barkley, et al., 1992; Bernal, et al., 1980; Hughes and Wilson, 1989; Kazdin, et al., 1987; Kazdin, Siegel, and Bass, 1992). The primary child welfare outcome that these interventions are geared to is child well-being. The CPS Response to Child Neglect Page 162

Using Research to Select Interventions and Measure Outcomes The Family Connections Program (FCP) (DePanfilis, Glazer-Semmel, Farr, and Meek, 1999) is a University of Maryland, Baltimore affiliated program that promotes safety and well-being for children and families through community and clinical services, education and training of graduate social workers, and research and evaluation of program outcomes. Services are partially funded by the School of Social Work, the U.S. DHHS, Children s Bureau, the USDHHS, Center for Substance Abuse Prevention, the Title IVE Education for Child Welfare program, the Jimmie Swartz Endowment Fund, and the Annie E. Casey Foundation. Individualized, tailored outcomebased intervention is delivered through the provision of emergency assistance and concrete resources, crisis intervention, home-based supportive services, individual and family counseling, advocacy and case management, and parent groups. Services target child safety and well-being, caregiver well-being, and family well-being program outcomes. Client level outcomes may address: achievement of family maintenance and safety; caregiver psychological functioning; child developmental achievement; family functioning; social support; problem solving skills; and care giving attitudes and behavior. A factorial design is examining whether length of service and parent groups in addition to home-based intervention increase achievement of client outcomes. Preliminary results (DePanfilis, Dubowitz, and Kelley, 2001) suggest improvement in a number of outcomes from baseline to case closure: reduction in housing related problems; decrease in caregiver depressive symptoms; decease in life stress and parental stress; an increase in parenting satisfaction; and an increase in the perception of the capacity of the family to manage conflict. The Family Enhancement Program (Nelson, Smith, and Tompkins, 2001) is a five-year funded neglect demonstration project funded by the U.S. DHHS, Children s Bureau designed to provide early intervention and extended aftercare to African-American families at risk of child neglect through a community-based family preservation program. The program provides comprehensive in-home services; counseling and concrete services; parenting education and support groups; flexible funds for needed goods and services; a culturally-responsive empowering approach; and informal supports in the community to families referred by CPS for placement prevention and reunification services. The project is still in process but preliminary results (Nelson and colleagues, 2001) were reported for 33 families referred from the community and 95 families referred by CPS who completed 4-8 weeks of intensive services. It also compared 20 community-referred and 49 CPS-referred families who completed aftercare services. In these preliminary analyses, both community-referred and CPSreferred families increased in self-reported resources and social support over the 4-8 week intervention period, but community-referred families with prior CPS involvement showed the least change in child well-being. Both community-referred and CPS families showed more change during aftercare if they attended religious services and did not have a history of substance abuse problems. Family Focused Treatment Interventions (FTI) (Lipovsky, Swenson, Ralston, and Saunders, 1998; Ralston, 1998; Ralston and Swenson, 1996) is a protocol of sequential treatment interventions focused on increasing child safety, reducing risk, and clarifying responsibility in child maltreatment cases. This intervention is designed for use in a coordinated multidisciplinary community system of care. The guiding principles of FTI support beliefs that the safety of the child is paramount; that family strengthening and reunification are the desired outcomes of community interventions; the safety of the child is a precondition to family reunification; adults are accountable for any abusive and/or neglectful behaviors toward their children; and acknowledgement of responsibility for protection and safety is required from the adult caregivers. Family strengths and resources in support of safety and protection are the primary focus of interventions and each family is involved in a uniform assessment that The CPS Response to Child Neglect Page 163

Using Research to Select Interventions and Measure Outcomes focuses on identification of family strengths, risk factors for child safety, and the impact of abuse or neglect which guides the focused interventions in support of family reunification. Barriers to future safety and protection must be identified and overcome in support of family reunification and community resources are key to supporting the family in overcoming any identified barriers to safety and protection of the child. When the goal of family reunification is not possible, early permanency planning is in the best interest of the child. Initial results of this comprehensive approach are promising (Swenson and Ralston, 1997). Family preservation services are designed to allow children to remain safely in their own homes by building on family strengths and overcoming deficits (Nelson, 2000). Family preservation services are: provided frequently (at least once a week), individually tailored to meet the family s stated needs, oriented toward specific goals developed collaboratively by the worker and the family, and are respectful of the family members as the experts on their own situation and needs (Nelson, 2000). It is generally agreed that there are three types of family preservation services: (1) intensive family preservation services (see below), (2) family centered casework services, and (3) family resource, support, and education services (discussed in a separate user manual insert title of community based user manual). Family-centered casework services are generally not in response to a specific crisis but provided to families with longer term, more chronic problems such as neglect (Nelson, 2000). These services may last up to 18 months and provide a comprehensive response to the families needs. In some communities, these services are available to families who have been stabilized with intensive family preservation services but still need longer-term intervention to keep children safe and reduce the risk of maltreatment and placement. Some of these programs are based on family systems theory (Walton and Denby, 1997) and employ family therapy interventions from the communication, strategic, structural, and brief schools (Barth, 1988, 1990). Others may rely most heavily on ecological theory (Bronfenbrenner, 1979) and therefore extends intervention beyond the family to the numerous systems in which the child and family are embedded. These programs emphasize case management and service coordination as methods by which both concrete and therapeutic services are delivered so that risk factors associated with out-of-home placement of children are reduced (Berry, 1991, 1992; Grigsby, 1993). Most evaluations of family preservation services have focused on intensive family preservation services (see below). In general, programs target both prevention of placement and other outcomes such as improvement of family functioning, reduction of stress, improvement in living conditions, and increase of social support. For these longer term programs, prevention of placement (at least in the short term) may not be an appropriate outcome as most of these families are probably not experiencing imminent risks that may lead to the need for placement in out-of-home care. Prevention of future maltreatment however would be an appropriate outcome, however programs have not routinely reported on rates of recidivism. With implementation of outcome measurement strategies prompted by the Adoption and Safe Families Act (ASFA), this is expected to change. The primary outcomes that are likely to be achieved through these services are child safety and family well-being. The Focus on Families Program (Haggerty, Mills, and Catalano, 1991) targets parents who are participating in substance abuse treatment. The target age of the children is 3 to 14. The program has two key goals: to decrease drug use among parents and to increase parenting skills. Four sessions are designed to address relapse, five sessions deal with communication, eleven sessions focus on family management, seven sessions address teaching children skills, and the last five sessions aim to help parents to promote their children s success in school. This program is one The CPS Response to Child Neglect Page 164

Using Research to Select Interventions and Measure Outcomes of the science-based family strengthening programs supported by the U.S. DHHS, Center for Substance Abuse (CSAP) and the Office of Juvenile Justice and Delinquency (OJJDP) (Kumpfer, 1999). The program was rated as a Model program because it has been tested by a quasi-experimental research design and demonstrated positive findings. Parent outcomes showed that experimental parents, at all time points for all skill measures (problem solving, self efficacy, social support, family factors, etc.), had significantly higher scores than control group parents and displayed greater self-efficacy than controls at each of the three follow-up time points (Catalano, Haggerty, Flemming, and Brewer, 1996). Due to the relationship between substance abuse and neglect, it is expected that this program is relevant for families identified with neglect problems. Intensive Family Preservation Services usually target families when children have been identified as at risk for placement. These services are a brief, home-based multiple component intervention designed to prevent out-of-home placement and reduce the risk for child maltreatment by changing behaviors and increasing skills. Treatment components are primarily cognitive-behavioral and matched to identified problem areas (Booth, 2001). The HOMEBUILDERS program (Kinney, Haapala, and Booth, 1991) and similar programs (Tracy, Haapala, Kinney, and Pecora, 1991; Whittaker, Kinney, Tracy, and Booth, 1990) provide services intensively (several times a week) over a 4-6 week or 3-4 month time period, depending on the model. Typically, workers serve only two or three families at a time. Services may include family and individual therapy, skill building, and concrete services (Nelson, 2000). Booth (2001) suggests that research has supported the effectiveness of intensive, time-limited, in-home services for preventing out-of-home placement and other family disruptions; reducing child abuse/neglect and family violence; improving parenting skills, family functioning and children s behavioral problems; and enhancing social and community supports (Feldman, 1991; Fraser, Pecora, and Haapala, 1991; Fraser, Walton, Lewis, Pecora, and Walton, 1996; Yuan and Struckman-Johnson, 1991). Corcoran (2000) also reports similar promising findings however points out that the majority of earliest studies relied on pretest, posttest-only designs and some studies were compromised because not all families served may have been at imminent risk of placement. Results of quasi-experimental studies do not report as consistent and promising results and in at least one study (Schuerman, Rzepnicki, and Littell, 1994), families receiving family preservation services versus casework as usual were more likely to experience placement. Critiques of intensive family preservation services have suggested that this short term intervention may be insufficient to overcome the effects of poverty, substance abuse, and poor parenting that are associated and that many evaluations have observed significant variation in the implementation of services by practitioners (Blythe, Salley, and Jayaratne, 1994; Heneghan, Horwitz, and Leventhal, 1996; Rossi, 1992). The Homebuilders program is one of the family strengthening programs supported by the U.S. DHHS, Center for Substance Abuse (CSAP) and the Office of Juvenile Justice and Delinquency (OJJDP) (Kumpfer, 1999). The program was rated as a Model program because it has been tested by a quasi-experimental research design and demonstrated positive findings. The Local Efforts to Address and Reduce Neglect (LEARN) program (Berrick and Duerr, 1997) operated in seven sites in California and was designed to reduce physical neglect among children by reducing family poverty, increasing parenting skills, and improving family functioning. Services included voluntary (1) in-home assistance (assessment, referrals, and The CPS Response to Child Neglect Page 165

Using Research to Select Interventions and Measure Outcomes direct intervention within the home); (2) intervention at school with client children through group or one-on-one self-esteem and/or skills-building sessions; (2) parent support or education groups; and (3) parent or family counseling. On average, families received fourteen hours of inhome assistance, ten hours of service to children, seven hours of parent group intervention, and three hours of counseling over twenty to thirty weeks. Over two years, 1,752 clients were referred to the program and data was collected on 479 families. Another 575 target families were never engaged in program services despite repeated efforts by program staff. Another 197 target families were engaged in service for a time but dropped out of the program or moved before post-test assessments were completed. Using an author derived measure of neglect, participating families showed improvement in problems with hunger but did not demonstrate improvement in items such as falling asleep, inappropriate dress, poor hygiene or head lice. No changes were also noted in the child behavior between served children and a control group at post test as measured by the Behavior Problems Index (BPI) (Zill and Peterson (1989). Finally, no statistically significant differences were noted between treatment and control groups with respect to school absences or new reports of abuse or neglect. The authors (Berrick and Duerr, 1997) hypothesize that the absence of positive findings may be due to a relatively low level of risk for neglect among the families targeted for intervention. The Nurturing Parenting Programs (Bavolek, 1983) are family-centered programs that teach nurturing skills to parents and children while reinforcing positive family values. This program is one of the science-based family strengthening programs supported by the U.S. DHHS, Center for Substance Abuse (CSAP) and the Office of Juvenile Justice and Delinquency (OJJDP) (Kumpfer, 1999). The program was rated as a Model program because it has been tested by a quasi-experimental research design and demonstrated positive findings. The Nurturing Parenting Programs are widely used with families: at risk for abuse and neglect, identified by local CPS agencies for abuse and neglect, and/or seeking to become adoptive or foster parents. The Nurturing Parenting Program (Bavolek, 1983) is a group-based intervention designed specifically for families at risk of child physical abuse or neglect. The program is family-based, with both parents and children participating in separate group sessions and together in family activities. The three main components of the program are: discipline, nurturing, and communication. Thirteen different Nurturing Parenting Programs are available for different target populations based on child s age (prenatal, birth to 5 years, 5-11 years, adolescence), family s culture (Hmong, African American, Hispanic), and special issues (substance abuse, teenage parents, foster and adoptive families, special learning needs). The initial Nurturing Program for Parents and Children 5-11 years has been extensively field-tested. (Bavolek, Comstock, and McLaughlin, 1983). The research included 121 abusive adults and 150 abused children. Significant increases were found: in parenting attitudes of both parents and children; personality characteristics of both parents and children; and family interaction patterns. The subsequent development and validation of additional Nurturing Programs have shown similar results. Participants show significant pre-post changes in parenting attitudes and child rearing practices. Project 12-Ways (Lutzker and Rice, 1984) is an eco behavioral program that delivers 12 services in the homes of families who have been reported for child abuse and neglect or are considered at risk for maltreatment. This program, originally developed in 1979, delivers: parent-child training, stress reduction for parents, basic skill training for the children, money The CPS Response to Child Neglect Page 166

Using Research to Select Interventions and Measure Outcomes management training, social support, home safety training, multiple setting behavior management, health and nutrition, problem solving marital counseling, alcohol abuse referral, and single mother services. Program evaluation data have consistently shown that when compared to a matched comparison group in the same region, families who receive services from Project 12-Ways are significantly less likely to be reported again for child abuse and neglect up to four years after services (Lutzker and Rice, 1984, however the differences between the groups decreased over time (Lutzker and Rice, 1987). Data from single-case research designs have documented the effectiveness of the eco behavioral approach to child maltreatment by showing skill development in parent training (Dachman, Halasz, Bickett, and Lutzker, 1984), stress reduction (Campbell O Brien, Bickett, and Lutzker, 1983), home safety assessment and hazard reduction (Tertinger, Greene, and Lutzker, 1984), infant stimulation and health care skills (Lutzker, Lutzker, Braunling-McMorrow, and Eddleman, 1987, and home cleanliness and nutrition (Sarber, Halasz, Messmer, Bickett, and Lutzker, 1983). It is unclear whether this Illinois-based program, could be successfully replicated in other states and communities (Lutzker, Bigelow, Doctor, Gershater, and Greene, 1998). Project Healthy Grandparents (PHG) (Kelley, Yorker, Whitley, and Sipe, 2001; Whitley, White, Kelley, and Yorker, 1999), sponsored in part by Georgia State University, the US DHHS Children s Bureau, and the Georgia Department of Human Services, PHG works to strengthen intergenerational families and to improve their quality of life by providing grandparents and grandchildren with comprehensive services and improved access to community resources. Service interventions are designed to ameliorate the effects of child neglect and provide grandparents with resources needed to prevent subsequent neglect. Social workers and registered nurses perform monthly home-based case management duties. Third-year law students, supervised by the attorney faculty member, conduct assessments regarding the legal relationships between grandparents and their grandchildren and help grandparents explore their legal options for increasing the permanency for their grandchildren. Families also participate in parent education and support groups. Services are available for twelve months and some grandparents opt to continue attending monthly support groups after form services have ended. Targeted outcomes include: decrease in grandparent psychological distress, increase in family resources, increase in social support, improvement of physical health, and increase in family coping behaviors. Preliminary multivariate analysis of variance (MANOVA) results with 120 families from pre- to post-test indicate reduction in psychological distress, increase in family resources, increase in social support, improvement of physical health, and an increase in family coping behaviors (DePanfilis, Dubowitz, and Kelley, 2001). The Self-Sufficiency Project (SSP) (Landsman, Nelson, Allen, and Tyler, 1992) was a USDHHS, Children s Bureau funded neglect demonstration project. The services were developed based on a philosophy of empowerment and the primary interventions were group services for parents, child groups organized by age ranges, multiple family therapy sessions, and parent support groups. Additional services such as in-home parent training and family therapy, and alcohol/drug counseling were also offered to individual families. Thirty-one families received services and the project outcomes were evaluated with self-report and observational measures. For the SSP participants as a whole, only self-report measured changed significantly from intake to termination. Paired t-tests comparing mean scores at intake and termination found caregiver s scores on the Generalized Contentment Scale (Hudson, 1982) and the Index of Self The CPS Response to Child Neglect Page 167

Using Research to Select Interventions and Measure Outcomes Esteem (Hudson, 1982) to have improved. One of the subscales of the AAPI (Bavolek, 1984) (reversal of parent and child roles) also improved. Neither of the observational measures, the Child Well-Being Scales (Magura and Moses, 1986) or the Childhood Level of Living Scale (Polansky and colleagues, 1972) indicated significant change for the SSP families as a group. The Social Network Intervention Project (SNIP) (Gaudin, Wodarski, Arkinson, and Avery, 1990-91) was designed to provide personal network interventions services to 30 families. The intervention consisted of personal networking, mutual aid groups, volunteer linking, employing neighborhood helpers and social skills training. After six months of intervention, 34 SNIP families scored significantly more positively than the control families on three measures of parenting adequacy. Paired t-tests revealed that the means on the Childhood Level of Living Scale (CLL) (Polansky et. al, 1972) and the Indicators of the Caretaking Environments for Children Scale (ICECS) (Halper and Jones, 1981) increased significantly, and the means on the Child Neglect Severity Scale (CNSS) (Edgington, Hall, and Rosser, 1980) decreased significantly for the SNIP families but not for the control families. After six months of intervention SNIP parents had significantly more appropriate expectations of their children and were less reliant on corporal punishment than at baseline but there were only small, insignificant improvements on the other two measures of parental attitudes using the AAPI (Bavolek, 1984). On average, the SNIP families also reported significantly larger, more supportive networks than at baseline. The reported size of their social networks increased by almost 27% and network support increased by 25%. The changes in network size and supportiveness for the controls were insignificant. At 12 months of intervention there were highly significant changes on the three measures of parenting adequacy for the SNIPO families, but no significant changes for the control families on these same measures. By 12 months, there were also significant changes in the SNIP families as measured on all four subscales of the AAPI (i.e., appropriate expectations, empathic understanding, corporal punishment, and role reversal attitudes). The positive effects for social networks also endured at 12 months. The Strengthening Families Program (Kumpfer, 1998) is a research-based familystrengthening program coordinated by the University of Utah s Health Promotion and Education Department in Salt Lake City, Utah. SFP targets the families of children age 6 through 11 who are at risk of substance abuse. The program focuses on family attachment and bonding, family supervision, family communication of values, and no drug use expectations. SFP interventions consist of parent training, social and life skills training curriculums for elementary-aged children, and family practice sessions. This program is one of the science-based family strengthening programs supported by the U.S. DHHS, Center for Substance Abuse (CSAP) and the Office of Juvenile Justice and Delinquency (OJJDP) (Kumpfer, 1999). It is rated at the highest level, termed exemplary because it has been evaluated with an experimental design and yielded positive findings. Because of the strong connection between substance abuse and child maltreatment, this program is a viable option for families involved with CPS agencies. The Strengthening Families Program has been evaluated in as many as 15 research studies by independent evaluators. The original NIDA study (Kumpfer, 1998) involved a true pretest, posttest, and follow-up experimental design with random assignment of families to one of four experimental groups: (1) parent training only; (2) parent training plus children s skills training; (3) the complete three-component SFP program, including the family relational skills component; or (4) no treatment (drug treatment as usual with no parent or child training). The CPS Response to Child Neglect Page 168

Using Research to Select Interventions and Measure Outcomes Because of positive results, SFP was then replicated and evaluated on five CSAP High Risk Youth Program grants with diverse ethnic groups by independent evaluators using quasiexperimental, pre-, post-, and 6-, 12-, 18-, and 24-month follow-up statistical control group designs comparing drug-abusing families with non-drug-abusing families and has been used extensively throughout the U.S. Outcome results are consistent across replications and modifications for ethnic families. Pre-test, post-test, and 6-month to 5-year follow-up measures demonstrate that relative to controls: (1) The Parent Training (PT) program was very effective in reducing the children s antisocial behaviors, aggression, and conduct disorders by improving the parents effective discipline, family management skills, and supervision of the child; (2) The Children s Skills Training (CT) program improved the children s social and life skills, including improved peer resistance; problem solving; communication; and ability to make positive friends, identify feelings, and control anger; (3) The Family Skills Training (FT) program improved the family s time together, communication, cohesion, planning, and organization, and reduced their high levels of family conflict; and (4) The full Strengthening Families Program (SFP) (including the complete three-component program) is the most powerful because it has an impact on more risk and protective factors predictive of later problem behaviors (Kumpfer, 1998). This program has viability with families with substance abuse problems or risks for substance abuse and neglect. Strengthening Multi-Ethnic Families and Communities is a strength-based family skills training program designed to decrease risk factors related to violence against self (drugs/alcohol), violence against family (child abuse, domestic violence), and violence against others (juvenile delinquency, crime, gangs) (Steele & Marigna, 1999). The program targets parents of children between the ages of 3 and 18 from diverse ethnic and cultural backgrounds. The program is divided into five main components: cultural/spiritual, enhancing relationships, positive discipline, rites of passage, and community involvement. This program is one of the science-based family strengthening programs supported by the U.S. DHHS, Center for Substance Abuse (CSAP) and the Office of Juvenile Justice and Delinquency (OJJDP) (Kumpfer, 1999). It is rated as promising because it has been tested with a non-experimental design, demonstrated positive findings, and has substantial qualitative data suggesting its promise as an effective program. All evaluation results are based on pre-post test designs. The SMEFC program has been implemented in the U.S. and internationally. Two outcome evaluations suggest (Steele and Marigna, 2000; Steele, 2001) suggest the viability of this program for families involved with CPS agencies. In the first evaluation of 665 parents participating in the program in Washington State, the evaluation assessed the impact of the program in three areas: (1) parent sense of competence; (2) family/parent child interactions; and (3) child competence. The program positively impacted all three of these areas with at least some individual items (in each area) reaching statistically significant improvements from baseline to graduation. Evaluation results also showed that parents felt more confident in their ability to manage child behavior at home and at school, and more comfortable interacting with teachers. A second program evaluation based on work with caregivers in the Los Angeles area (Steele, 2001) revealed statistically significant improvements at post-test in the following domains: parental competence in child management skills, anger management & problem solving skills, and with relationships with children and others. Similarly, there were statistically significant improvements in child competence with regard to child self-esteem and self-discipline, child problem solving and choices. Finally, at post-test there was significant improvement in parent-child interactions, and The CPS Response to Child Neglect Page 169

Using Research to Select Interventions and Measure Outcomes family activities as well as parental involvement in other supportive activities. This program was selected for replication by the Family Connections program in Baltimore (DePanfilis, Glazer- Semmel, Farr, and Meek (1999) as the group component of this neglect prevention program. Conclusions Given the complex nature of neglect, we have much more to learn before suggesting the types of intervention that best match specific contributing risk factors. Future research needs to be long term given the chronic nature of neglect and the conditions that are associated with it. Since many programs have experienced difficulty with engagement in services, research also needs to evaluate efforts for engagement and retention in services. Careful attention to description of population and the nature and depth of intervention and using common definitions and measures is also important so that results between programs can be more easily compared. Given the shift toward community based child protection, it is important that CPS agencies and community based agencies develop partnerships to better understand which families can be best served in the community and which families need the authority of the CPS system. In the words of Nicholas Scoppetta, Commissioner, New York City Administration for Children s Services (Policy and Practice, 2001), The keys to future success but also our biggest challenges are training and partnership. No single approach to children s services will protect all children and support all families. And no single public or private agency can do it. Only when we balance child protection and preventive services, and combine proper assessment of a family needs with community partnerships that effectively meet them, will we have a truly effective system. (p. 40). The CPS Response to Child Neglect Page 170

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Using Research to Select Interventions and Measure Outcomes Kumpfer, K.L. (1999). Strengthening America s families: exemplary parenting and family strategies for delinquency prevention. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention User s Guide. Landsman, M. J., Nelson, K., Allen, M., & Tyler, M. (1992). The self-sufficiency project final report. Iowa City, IA: National Resource Center on Family Based Services. Lee, V., Brooks-Gunn, J., Schnur, E., & Liaw, F.R. (1990). Are Head Start effects sustained? A longitudinal follow-up comparison of disadvantaged children attending Head Start, no preschool, and other preschool programs. Child Development, 61, 495-507. LeProhn, N.S. (1994). The role of the kinship foster parent: A comparison of the role conceptions of relative and non-relative foster parents. Children and Youth Services Review, 16, 107-122. Lipovsky, J., Swenson, C.C., Ralston, M.E., & Saunders, V.E. (1998). The abuse clarification process in the treatment of intrafamilial child abuse. Child Abuse and Neglect, 22, 729-741. LoSciuto, L., Rajal, A.K., Townsend, T.N., & Taylor, A.S. (1996). An out-come evaluation across ages: An intergenerational mentoring approach to drug prevention. Journal of Adolescent Research 11(1), 116-129. Lutzker, J. R. (2000). How do I protect children from hazardous home conditions and other poverty-related conditions? In Dubowtiz, H., & DePanfilis (D.). (Eds.), Handbook for child protection practice (pp. 254-256). Thousand Oaks, CA: Sage Publications. Lutzker, J. R., Bigelow, K. M., Doctor, R. M., Gershater, R. M., & Greene, B. F. (1998). An ecobehavioral model for the prevention and treatment of child abuse and neglect. In Lutzker, J. R. (Ed.). (1998), Handbook of child abuse research and treatment (pp. 239-266). New York: Plenum Press. Lutzker, J.R., & Rice, J.M. (1984). Project 12-Ways: Measuring outcome of a large-scale inhome service for the treatment and prevention of child abuse and neglect. Child Abuse and Neglect, 8, 519-524. Lutzker, J.R., & Rice, J. M. (1987). Using recidivism data to evaluate Project 12-Ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect. Journal of Family Violence, 2, 283-290. Lutzker, S.Z., Lutzker, J.R., Braunling-McMorrow, D., & Eddleman, J. (1987). Prompting to increase mother-baby stimulation with single mothers. Journal of Child and Adolescent Psychotherapy, 4, 3-12. Magura, S., & Moses, B.S. (1987). The Child Well-Being Scales. Washington, DC: Child Welfare League of America. The CPS Response to Child Neglect Page 177

Using Research to Select Interventions and Measure Outcomes Magura, S., & Moses, B.S. (1986). Outcome measures for child welfare services. Washington, DC: Child Welfare League of America. McCubbin, H., Thompson, A., & McCubbin, M. (1996) Family assessment: resiliency, coping and adaptation, inventories for research and practice. Madison: University of Wisconsin Systems. Meadowcroft, P., Thomlinson, B., & Chamberlain, P. (1994). Treatment foster care services: A research agenda for child welfare. Child Welfare, 33, 565-581. McCroskey, J., Nishimoto, R., & Subramanian, K. (1991). Assessment in family support programs: Initial reliability and validity testing of the Family Assessment Form. Child Welfare, 70, 19-33. Meyer. B.S., & Link, M.K. (1990). Kinship foster care: The double-edged dilemma. Rochester, NY: Task Force on Permanency Planning for Foster Children, Inc. Moore, E., Armsden, G., & Gogerty, P. L. (1998). A twelve-year follow-up study of maltreated and at-risk children who received early therapeutic care. Child Maltreatment, 3, 3-16. Nelson, K. (2000). When do family preservation services make sense, and when should other permanency plans be explored. In. H. Dubowitz and D. DePanfilis (Eds.), Handbook for child protection practice (pp. 257-266). Thousand Oaks, CA: Sage Publications. Nelson, K., Smith, P., & Tompkins, M. (2001). Innovative family preservation services for African-American families. Presentation at Faces of Change: Embracing diverse cultures and alternative approaches. 13 th National Conference on Child Abuse and Neglect. Albuquerque, April 23-28, 2001. Oats, R.K., Grey, J., Schweitzer, L., Kempe, R.S., & Harmon, R.J. (1995). A therapeutic preschool for abused children: The KEEPSAFE Project. Child Abuse and Neglect, 19, 1379-1386. Patterson, G. R. (1976). Living with children: New methods for parents and teachers. Champaign, IL: Research Press. Patterson, G. R., & Gillion, M.E. (1968). Living with children: New methods for parents and teachers. Champaign, IL: Research Press. Pecora, P., Fraser, M. Nelson, K., McCroskey, J., & Meezan, W. (1995). Evaluating family-based services. Hawthorne, NY: Aldine. Polansky, N.A., Borgman, R. D., & DeSaiz, C. (1972). Roots of futility. San Francisco: CA: Jossey- Bass, Inc. Polansky, N.A., Cabral, R. J., Magura, S., & Phillips, M.H. (1983). Comparative norms for the Childhood Level of Living Scale. Journal of Social Service Research, 6, (3/4), 45-55. The CPS Response to Child Neglect Page 178

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IX. The Substance Abusing Caretaker And Child Neglect Joshua Nosa Okundaye, Ph.D. Introduction Parental substance abuse and child neglect interact in several ways with complex and debilitating impact on families, substance abuse treatment providers and the child welfare system. The child welfare system incorporates the dilemma of the substance abuse as a disease theory. Due to the expectation of personal responsibility for minimally acceptable parenting, ASFA timeframes, relapse expectations and implications for safety and permanency, any efforts to significantly impact this problem must begin with a working refinement of key issues to be addressed and best treatment service models to be considered. 4This chapter presents key issues to be addressed, assessment and retention strategies, and a proposed intervention that is strengths-based, individualized, and outcomes supportive. The Problem Parental substance abuse is associated with a large percentage of child maltreatment and neglect cases. In fact, the major reason for the increase in children entering foster care is believed to be parental substance abuse. (Azzi-Lessing, & Olsen, 1996; Olsen, Allen, & Azzi-Lessing, 1996; Dore & Doris, 1998; Dore, Doris, Wright, 1995). In many cases, while the reason for referral is almost always neglect, abuse, (sexual and/or physical), or abandonment, the role of substance abuse in these cases has caused significant concerns in the field. Parental substance abuse is reported by child welfare workers in anywhere from 20 percent to 90 percent of cases (Jaudes, Ekwo, Voorhis, 1995). A 1999 report by Advocates for Children and Youth states that in Maryland parental substance abuse is associated with at least two-thirds of maltreatment cases. 2 Parental substance abuse is also associated with two-thirds of all foster care cases as a reason for removal and a key barrier to reunification for many of the children who reside in foster care for extended periods. 3 Joshua Nosa Okundaye, Ph.D., LCSW-C, is a Professor at the University of Maryland School of Social of Social Work. 1 Protecting Our Children: 1999 Report on Maryland s Child welfare System, Advocates for Children and Youth, Baltimore, MD December 9, 1999. p. 5. 2 U.S. General Accounting Office referenced in HHS, 1999, p. 46. The CPS Response to Child Neglect Page 183

Substance Abuse and Child Neglect The association of parental substance abuse and child neglect has been documented by multiple data sources. For example, studies quoted in Blending Perspectives and Building Common Ground found that families with identified substance abuse problems were significantly more troubled than other families in the child welfare system. SAMHSA s evaluation of grant initiatives to provide residential substance abuse treatment for pregnant women and women with children indicates that female substance abuse treatment clients who have never had children removed from the home by child protective services tend to be older than other clients, have more children, and have more additional problems such as having been homeless and unemployed, than do other clients entering these substance abuse treatment programs. The complexity of these families often makes it difficult for child protective services workers to determine the extent to which substance abuse presents a risk to children. Danger to a child may or may not be the direct result of a parent s substance abuse. 4 However, untreated parental substance abuse can be a factor in child drug and alcohol problems. Children could either use substances or be prenatally exposed to substances. Unfortunately, despite the seriousness of the interactions between these two social problems, child welfare and substance abuse treatment services and staff have different vantage points on the problem, definitions of the problem, client identification, definitions of success, and even different timelines. As the recent DHHS report to Congress on substance abuse and child protection Blending Perspectives and Building Common Ground states, addiction is a complex illness. Multiple treatment attempts may be required before significant improvement is seen. Relapse is common, particularly in the early stages of recovery. The long terms needed for recovery for many women with multiple problems may conflict with shorter timelines associated with child welfare decision making. Federal child welfare law now requires that permanency hearings to determine the long-term plan for a child be held within 12 months of a child s entry into foster care, and that a petition to terminate parental rights be filed after a child has resided in foster care for 15 of 22 months. 5 Thus, although it appears that parental substance abuse treatment is one of the keys to carrying out the child welfare mission, local departments of social services do not usually provide substance abuse treatment services. Rarely are child welfare workers experts on key questions such as: Why do substance abusers fail to follow through on treatment goals? How does parental progress on substance abuse treatment goals translate into children s safety? Conversely, substance abuse treatment providers are not experts on this key question either. These are only a few of the numerous challenges of providing services to families of substance abusers. Importantly, a challenge that cuts across both child welfare and substance abuse treatment is the problem of retention by agencies that serve these clients and the problem of definition and monitoring of outcomes. It is the contention of this article that these are perhaps two of the most critical assessment and treatment variables and as such, deserve immediate attention from policy makers, service providers and researchers. The complexity of the interactions between child neglect and substance abuse can be captured most clearly at the point of entrance into both 3 4 HHS, 1999, pp. 52-62. HHS, 1999, pp 74-75. The CPS Response to Child Neglect Page 184

Substance Abuse and Child Neglect systems by emphasizing the importance of improving the problem of recruitment and retention by agencies that serve these clients. Retention of the Substance Abusing Caretaker The problem of what to do about clients who drop out of treatment is perhaps one of the first challenges that must be addressed by the substance abuse health and child welfare field. For purposes of this chapter, the terms retention problems and dropout relate to how to improve follow-up after intake or the initial contact. Reviews of psychotherapy dropout literature (Baekeland & Lundwall, 1975; Eduson, 1968; Garfield, 1986; Clinton, 1996; National Institute of Mental Health [NIMH], 1981, Pekarik, 1992) indicate that between 30 percent and 60 percent of psychotherapy outpatients terminate prematurely. In mental health agencies, 20-57 percent of outpatients terminate against their therapists advice after the first session (Deane, 1991; Dodd, 1971; McNair, Lorr, & Callahan, 1963; Noonan, 1973; Overall & Aronson, 1963; Waller, 1997). According to Miller and Rosnick (1991), the risk of a client s dropping out of treatment is highest following the first session. Because 20 to 57 percent of patients do not return after the first visit and 37 to 45 percent attend only one or two sessions (Ciarlo, 1979; Fiester & Rudestam, 1975; Pekarik, 1983), the early phase of psychotherapy seems crucial for continuation, as unilateral termination rates level off after that (Baekeland & Lundwall, 1975; Pollack, Mordecai, & Gumpert, 1992). Patients appear to decide whether to return at the end of the intake interview (Anderson, Hogg, & Magoon, 1987). One study of substance abuse treatment reports that only 42 percent of the clients that were referred for substance abuse treatment came in for an initial interview and only 24 percent of the clients that were referred for substance abuse treatment stayed in treatment for six or more sessions (Kleinman, 1992). Having fewer economic resources, being unable to pay bills and having a higher level of psychological distress were correlated with early attrition from substance abuse treatment (Roffman, 1993). The ability of the clinician to address the ambivalence of the patient regarding seeking treatment (Rofman 1993), their perceptions of social isolation (Gainey, 1993), and their motivation to seek treatment (Simpson, 1997) were correlated with treatment retention. In addition, outreach following the treatment process is important to re-engage people into substance abuse treatment (Zanis, 1996). Enrollment in drug treatment programs is related to improvements in the areas of employment, criminal behavior, HIV related risk behaviors, family relations, and psychological health (Watkins, 1992; Milby, 1996; McLellan, 1986). Drug abuse treatment, especially treatment that is longer than three months, has been associated with declines in post-treatment drug use (Metzger, 1998; Hubbard, 1988). This phenomenon is also of particular interest to practitioners interested in carrying out prevention and intervention programs with families at risk for child neglect. Risk and protective factors for child neglect may differ according to race, ethnicity and socio-economic status. It is well established that families of color, and especially African American families, are disproportionately represented in the child welfare system (Leashore, Chipungu, and Everett, 1991; Children s Defense Fund, 1990; National Black Child Development Institute, 1990). Most often these families are low-income, poorly educated, and are disadvantaged in the economic mainstream of the larger society (Brisett-Chapman, 1997). Further, it is well documented that The CPS Response to Child Neglect Page 185

Substance Abuse and Child Neglect children from African American, Hispanic, and other racial and ethnic backgrounds are subject to the direct and indirect effects of discrimination, compounding and exacerbating their risk for many kinds of problems (Fraser and Galinsky, 1997, p. 272). Thus, for low-income minority and urban families at-risk for child neglect, dropout variables at play can be expected to cause significant problems for prevention and intervention efforts. The problem of what to do about dropout is a significant problem for family interventions (Spoth & Rednond, 1995 in BFT). For these hard-to-serve families, it may be more appropriate to examine what services should be offered with family interventions, as well as how, when, and where to offer such services (Taylor & Biglan, 1998). We must also acknowledge that therapy is a collaborative endeavor and as such, more attention should be paid to the role of the service provider in discussions about treatment resistance and dropouts. Unfortunately, what service providers often do in response to resistance is to become less effective in helping the family (Patterson & Chamberlain, 1994, in BFT). Another reason current treatments fall short of their intended goal may be due, in part, to the fact that they involve the application of a single treatment to all individuals with the disorder (Levy, 1997). A substantial body of research has developed in the treatment of other problem behaviors suggesting that treatment outcome is much improved when treatment is tailored to the individual. In particular, it seems that tailoring treatments to an individual s readiness or stage of change greatly improves treatment outcome (Ockene, Ockene, & Kristellar, 1988; Levy, 1997). It is possible that a number of interventions like those of the transtheoretical model could be used to reduce dropouts. Service providers could match their interventions to the client s stage of change (Prochaska & DiClemente, 1982, 1984, 1992; Prochaska, Rossi, & Wilcox, 1991). Dropout can also be reduced by attending to the client s informational needs around treatment. Clients decisions about therapy can be balanced by helping them to appreciate the potential benefits while trying to reduce the perceived costs of therapy (Brogan et al., 1999). This article proposes the integration of a stage of change model into a dropout prevention strategy within neglect and substance abuse prevention and treatment efforts. Key Issues & Outcomes Because of the dilemma incorporated in the substance abuse and child maltreatment arena, and the need for a successful CPS response, any efforts to significantly impact this problem must begin with a working refinement of key issues to be addressed and best treatment service models to be considered. Examples of key issues that must be commonly resolved include: What role does the addiction/substance abuse play in the neglect/maltreatment of the child/ren? Does it need to be the primary reason for neglect or is its presence as an ancillary factor sufficient? How is the substance abuse/addiction to be established as a treatment condition or illness? In short, is it a disease? If it is a disease, how much of the signs and symptoms is needed to classify the illness or who determines the course of the illness? Should the progression be the same for all those afflicted with the illness? The CPS Response to Child Neglect Page 186

Substance Abuse and Child Neglect Are some types/levels of addiction/substance abuse to be excluded? Does a particular level of functional impairment caused by the substance abuse/ addiction need to exist? Are some types/levels of maltreatment so extreme or trivial or unrelated that they should be excluded? Should any child factors, such as age be weighted as factors? What will be the procedure for identifying and exchanging information about drug treatment and non-compliance without violation of legal rights? This includes where in the agency or court will names be found or when in the child protection process will potential names be found? Who will do the screening and assessment at key entrance points to the system? Are they to be addictions specialists or child welfare specialists? What about treatment matching? Who will determine motivation for and stage of change? What about the family? How do we determine family needs, which must also include the extent of the substance abuse problem and the impact on the mother s ability to provide adequate care and safety for her child (ren)? What is standard or best treatment? How do we ensure that current practice standard treatment and services is client specific and culturally sensitive? While the preceding seems like a long list of competing alternatives, it is important for any future discussions to include a strategy to track the impact of any integrated services on substance abuse and child neglect. Therefore, the following outcomes are offered as significant and measurable: a. Reduce reinvestigation for child abuse/neglect. b. Place fewer children in foster care after participation in treatment. c. Reduce length of stay in foster care for children of treatment participants. d. Reduce dropout from substance abuse treatment. e. Mothers will stay clean longer than previously noted. f. Mothers will develop more positive social networks. g. Mothers will have a greater success in starting new jobs, enrolling in classes or finding support groups. h. Mothers will report a lower level of mental health stressors. i. Mothers who receive services will have a lower cost of foster care social services. j. Mothers who receive treatment services will be less likely to require cost intensive follow up substance abuse services. k. Children of treated mothers will have greater levels of well-being. The CPS Response to Child Neglect Page 187

Substance Abuse and Child Neglect This chapter does not intend to propose answers to these questions or solutions to these key issues. What this chapter seeks to achieve is to highlight a few of the significant issues and offer a treatment approach that is measurable and promotes child safety, permanency, and well-being. The paper concludes by presenting components of a strength based motivationally sensitive intervention model that represents an innovative substance abuse treatment and intensive family services in a wrap-around, integrated package of services. We must begin by answering this question: What do we know about the variable? In this case, the variable is addiction and neglect which is indeed a fusion of two variables. For practitioners who interface with both variables, one common question or dilemma is what to do about clients who do not show for intake appointments or follow up after initial visits. In other words, what do we know about retention in treatment that impacts both addiction and child neglect? The families with whom child welfare and substance abuse treatment providers are most likely to work, in general, are often challenged by a unique, complex and overwhelming set of circumstances that make it exceedingly difficult to easily accept the helping partnership that we are offering. Despite the fact that they said yes, in words, it is another thing altogether to find the time, strength and courage to follow through with the behavior that supports a new, ongoing relationship. It is precisely because of this that this chapter presents the motivationally based model of intervention that is located within an urban community (Okundaye & DePanfilis, Unpublished Manuscript). First let us examine the conceptual framework that guides this program. Conceptual Framework and the Stages of Change Model While there is much more to be known about substance abuse treatment and the prevention of neglect, current evidence suggests that an individualized family-focused intervention with multiple services is required to increase parental competence. Importantly, little is known about which service components are required or for what length to improve outcomes and prevent neglect. Effective intervention to reduce the risk of child neglect must be based on a comprehensive individualized assessment of the family. The assessment must consider the type of neglect that may result without intervention and the specific contributing causes at the individual, family, neighborhood, and community levels (Gaudin, 1988; 1993a). This is also true of services to the substance-abusing caretaker. Services are provided in the home and within the neighborhood and community and offices are neighborhood based. Applying this principle, service providers are in a good position to understand the family in their daily environment and to break down and manage the natural resistance of the family to change (Anderson and Stewart, 1983). When available, this individualized assessment is undertaken in conjunction with other service providers to form a comprehensive picture of the individual, interpersonal, and societal pressures on the family members - individually and as a group. This holistic approach takes both client competencies and environment into consideration (Whittaker, Schinke, and Gilchrist, 1986) and views the environment as both a source of and solution to families problems (Bronfenbrenner, 1979; Garbarino, 1982). For both practice accountability and empirical usefulness, providers should consider incorporating the use of standardized clinical measures of The CPS Response to Child Neglect Page 188

Substance Abuse and Child Neglect risk and protective factors (Dunst, Trivette, and Deal, 1988; Magura and Moses, 1986; Magura, Moses, and Jones, 1987) in their assessment of specific family needs and problems. These identified needs are then translated into specific intervention outcomes that form the basis of time-limited, individualized service plans. This process involves tailoring services to the unique needs of each family. Providers should also consider the inclusion of the stages of change instruments (Assessment of a Client s Readiness to Change Measure; Demographics and General Information Questionnaire for Therapists; Demographics and General Information Questionnaire for Clients; Stages of Change Questionnaire; Processes of Change Questionnaire; Therapist s Assessment of Client s Termination Status. Development of a helping alliance and partnership with the family can be expected to be challenging because some caregivers, whose children may be at risk of neglect, may have difficulty forming and sustaining mutually supportive interpersonal relationships (Dore and Alexander, 1996; Gaudin and Polansky, 1986; Gaudin, Polansky, Kilpatrick, and Shilton, 1993). One of the essential challenges for practitioners is to form positive connections and partnerships with families so that they will have an opportunity to tackle the difficult challenges in their lives (McCurdy, Hurvis, and Clark, 1996). Successful engagement with families, who may be resistant to intervention, requires an ability to feel and demonstrate empathy with caregivers (Siu and Hogan, 1989) despite their initial resistance to intervention and the change process. Moving from recruitment rates to treatment outcomes, studies have found that the amount of progress clients make following intervention tends to be a function of their pretreatment stage of change (see Prochaska & DiClemente, 1992; Prochaska, Norcross, Fowler, Follick, & Abrams, 1992). The important lesson from these studies is that interventionists who treat all clients as if they are in the same stage are destined to fail. Professionals frequently design excellent actionoriented treatment and self-help programs but then are disappointed when only a small percentage register, or when large numbers drop out of the program after registering (Prochaska, DiClemente & Norcross, 1992). Regardless of how effective 12-step programs are for some people, they re not for everyone (Marlatt, 2001, p.25). Often, the 12-step program is designed for people who have already come to terms with their problem and are ready to take action. But many people with substance abuse problems are nowhere near that point and benefit more from the gentler, more empathic approach (Washton, 2001, p.25). We cannot treat clients in the precontemplation stage as if they are in the same place as those in the action stage and expect them to complete therapy. We can drive them away and then blame them for being resistant, not motivated, or not ready for therapy. Historically it has been us who were not ready for them (Brogan et al., 1999, p. 111). The vast majority of addicted people are not in the action stage. Aggregating across studies and populations (Abrams, Follick, & Biener, 1988; Gottleib, Galavotti, McCuan, & McAlister, 1990), 10 percent-15 percent of smokers are prepared for action, approximately 30 percent-40 percent are in the contemplation stage, and 50 percent-60 percent are in the precontemplation stage. If these data hold for other populations and problems, then professionals approaching communities and work sites with only action-oriented programs are likely to underserve, misserve, or not serve the majority of their target population (Prochaska, DiClemente & Norcross, 1992). Essentially, after 30 years of research, the constructs that seem to survive different types of analysis and methodologies are SES, minority racial status, low-education and psychological variables such as stages of change. Since one cannot manipulate static variables, The CPS Response to Child Neglect Page 189

Substance Abuse and Child Neglect more attention should be paid to the role of variables such as stages of change in the client and perceptions of clients potential to change by the therapist. This paper proposes the integration of a stage model into substance abuse and neglect prevention programs. It is expected that program administrators who plan similar programs or clinicians who work primarily with at-risk low SES clients will find the principles useful. Stages of Change All human beings are motivated to meet basic needs. However, clients frequently differ in their state of readiness or eagerness to change. And, their readiness to change may fluctuate from one time or situation to another. Inadequate motivation, resistance to therapy, defensiveness, and inability to relate are client variables frequently invoked to account for the imperfect outcomes of the change enterprise. In short, application of the stages of change principles to the substance abusing caretaker and neglect prevention will improve outcomes. Each stage of change represents a period of time as well as a set of tasks needed for movement to the next stage. Although the time an individual spends in each stage may vary, the tasks to be accomplished are assumed to be invariant (Prochaska, DiClemente & Norcross, 1992). Individuals in the Pre-contemplation stage do not see any need to change. They are not adequately aware of their problems and do not intend to change their behavior in the foreseeable future. Resistance to recognizing or modifying a problem is the hallmark of pre-contemplation (Prochaska, DiClemente & Norcross, 1992). People in pre-contemplation are resistant to change and are likely to drop out of treatment (Beitman et al., 1994; O Hare, 1996; Prochaska & DiClemente, 1984). Individuals in the Contemplation stage are considering change but also rejecting it. People are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Contemplation is knowing where you want to go but are not quite ready yet. An important aspect of this stage is that individuals struggle with the pros and cons of the problem along with the energy required to overcome it. Serious consideration of problem resolution is the central element of contemplation (Prochaska, DiClemente & Norcross, 1992). Individuals in the Preparation stage are intending to take action in the next month and have unsuccessfully taken action in the past year (Prochaska, DiClemente & Norcross, 1992). Originally called the decision making stage, the preparation stage can be considered as the early stirring of the action stage. Because this stage combines the intention and behavioral criteria, individuals in this stage score very high on the contemplation and action stage (Prochaska, DiClemente & Norcross, 1992). In the Action stage, the individual takes steps to change. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Individuals are classified in the action stage if they have successfully altered the behavior for a period of from one day to six months (Prochaska, DiClemente & Norcross, 1992). In the Maintenance stage, the individual maintains goal achievement. Individuals struggle to prevent relapse and to consolidate or continue the gains they have achieved. Maintenance is a The CPS Response to Child Neglect Page 190

Substance Abuse and Child Neglect continuation, not an absence, of change. Stabilizing behavior change and avoiding relapse are the hallmarks of maintenance (Prochaska, DiClemente & Norcross, 1992). Processes of Change The processes of change enable us to understand how shifts in the stages of change occur. Change processes are overt and covert experiences that individuals engage in when they attempt to modify problem behaviors. Each process is a broad category encompassing multiple techniques, methods, and interventions traditionally associated with disparate theoretical orientations. Change processes are independent variables that measure the overt or covert activities that individuals use to change behaviors (Prochaska, Velicer, DiClemente, & Fava, 1988). These change processes can be used within therapy sessions, between therapy sessions, or without therapy sessions. Prochaska, Norcross, Fowler, Follick, and Abrams (1992) found that attendance in behavior therapy was predicted by stages of change as well as by processes of change used by clients between sessions during the beginning phase of therapy. Change processes surpassed demographics, socioeconomic status, severity, duration of the problem, goals and expectations, self-efficacy, social support, and stages of change as predictors of weight loss on treatment (Prochaska et al., 1992). It appears that processes of change used by individuals vary as a function of their readiness for change (Levy, 1997). Ten change processes receiving the most theoretical and empirical support, along with their definitions and representative examples of specific interventions are presented by Prochaska, DiClemente & Norcross (1992) and summarized by Levy (1997) as follows: 1. Consciousness raising: increasing information about oneself and one s problem. Interventions: observations, diplomatic confrontations, interpretations, bibliotherapy. 2. Self-liberation: choosing and committing to act, and belief in one s ability to change. Interventions: decision making therapy, New Year s resolutions, logotherapy techniques, commitment enhancing techniques. 3. Dramatic relief: experiencing and expressing feelings about one s problems and their solutions. Interventions: psychodrama, grieving losses, role playing. 4. Counterconditioning: substituting alternatives for the given problem behavior. Interventions: relaxation, desensitization, assertion, positive self-statements. 5. Stimulus control: avoiding or countering stimuli that elicit problem behaviors. Interventions: restructuring one s environment (e.g., removing alcohol or fattening foods), avoiding high-risk cues, fading techniques. 6. Helping relationships: being open and trusting about problems with someone who cares. Interventions: therapeutic alliance, social support, self-help groups. 7. Environmental reevaluation: assessing how one s problem affects the environment. Interventions: empathy training, documentaries. 8. Social liberation: increasing alternatives to nonproblem behaviors available in society. Interventions: advocating for rights of repressed, empowering, policy interventions. 9. Self-reevaluation: assessing how one feels and thinks about oneself with respect to a given problem. Interventions: value clarification, imagery, corrective The CPS Response to Child Neglect Page 191

Substance Abuse and Child Neglect emotional experience. 10. Reinforcement management: rewarding oneself or being rewarded by others for making changes. Interventions: contingency contracts, overt and covert reinforcement, self-reward. Improving Retention of Substance Abusing Caretakers: Some Practice Innovations While engagement and retention are important issues for child maltreatment prevention programs (McCurdy, Hurvis, and Clark, 1996), few if any programs have actually incorporated the Stages of Change Model in their program design. Importantly, not only are there only a few programs that coordinate services for neglect and substance abuse, there are even only a few among these who integrate the stage of change model and drop out prevention strategies in their program planning and implementation. The project that is described in the following section will refine our understanding of how the model can be applied and how best to prepare administrators and practitioners to use it effectively. Outreach to the Community For any community based human service program to be successful, one has to first reach out to the community to let them know that the program exists. At any point in time, for any particular community and any specific program, the marketing plan is unique. Program staff has a role in helping to recruit potential families to the program. They also have an opportunity to contribute to the development and implementation strategies to reach out to the community and to encourage both professional and self-referrals. Outreach to Potential Clients at Intake Under most circumstances, by the time a family enters the agency door, the family would have already been screened and the primary caregiver has completed the intake protocol and accepted services. Trained substance abuse and child welfare staff should be in place after intake to reach out and engage the family in a helping alliance. In other instances, a family may have been referred but need some extra coaching before they may feel comfortable accepting services. After acceptance of a referral, staff should make contact with the family and help them understand more about the Program. Manipulating client expectations include a variety of different procedures, including interviews, films, audiotapes, videotapes, and brochures. Essentially, they teach prospective clients about program characteristics, describe and explain expected patient and therapist behaviors, and describe certain phenomena that may occur (e.g., negative feelings toward service provider) with suggestions about dealing with them (Reis & Brown, 1999). Pre-treatment preparation procedures that provide clients with information and address their expectations have reduced unilateral termination rates. Patients are likely to remain and participate in a process they know about (Reis & Brown, 1999). If the staff has been unsuccessful in talking with the primary caregiver by phone or if the primary caregiver has not shown for several intake appointments, the next step should be outreach to the potential client. The primary purposes of these outreach visits are to: (1) provide information The CPS Response to Child Neglect Page 192

Substance Abuse and Child Neglect to the family about the services available and (2) provide information about what the primary caregiver can expect about the program. In some situations, it may take several visits before the family is comfortable with proceeding with the process. How many visits and contacts deemed appropriate for a particular family will vary depending on individual contexts. After talking with an outreach staff, if a family expresses interest in accepting services, the staff helps them schedule an intake appointment as soon as possible, in order to maximize their motivation to continue. Outreach after Assignment In most cases, by the time a referral has been received, the program has had some contact with the family and/or reviewed information about the family. They will have each incorporated information and impressions into their initial snapshot of who the family is and what their strengths and needs are. The program staff then needs to identify the dyad, nuclear or extended family system with whom they will likely be working over time, and identify which individual or group to whom direct initial outreach efforts will be made. It is crucial that the staff takes the time to deliberately decide who is the client system with whom they are trying to connect. Multiple Methods of Outreach The strongest antidote to unilateral termination administratively appears to be appointment reminders (Reis & Brown, 1999). Simple follow-through contact has been shown to increase significantly the rate of client s returning for further treatment (Miller & Rosnick, 1991). Sometimes, a particular strategy is obviously the one that is most likely to work with a particular client. The referring provider may give a "head's up" that the client is never at home, so a letter is best or that the client has difficulty reading, so a brief visit is experienced as welcoming and nurturing. Most times, however, it's a bit of a guessing game. In those situations, it is recommended that staff initiate a variety of strategies simultaneously so that they are most likely to effectively connect with at least one of them. If a client has a telephone, this is the most obvious, time-effective strategy to make a first contact. Confidentiality considerations, which are always important, are no less so here. In leaving a message, one must consider with whom to leave it and how much to say. If it is before the staff has talked with the client, perhaps only their name and number should be given. In those first-time situations, it may also be advisable to block Caller I.D. (by entering *67, and then the number being called) so that others in the household may not call back. When writing a letter, it is obviously important to consider the client's literacy level. Staff may find out this information by asking the provider who facilitated the referral or the intake specialist who assisted with the intake protocol. If there is no information, a brief letter with simple words and short sentences is probably advisable. It is important to decide whether or not to use letterhead (again, for reasons of confidentiality). It is recommended that staff read the letter as though he/she is the client -- is the reaction the one being sought? If not, the letter needs to be rewritten. Stopping by the client's home, at different times of the day, is more time-consuming but may be the only way to make the contact. It is important to go at times when staff can stay for at least 30 minutes in case the client indicates that s/he wants to spontaneously begin. However, it is crucial that staff expect only to stay for a minute or two (perhaps, on the front steps) to schedule a The CPS Response to Child Neglect Page 193

Substance Abuse and Child Neglect mutually convenient time and place to meet. For some new clients, unexpected presence is experienced as a caring gesture that signals willingness to go out of one s way to help. For others, it is experienced as an intrusion that suggests that the program is trying to "catch" them engaging in an "unacceptable" behavior. It is important to read the verbal and nonverbal cues that they send. Sometimes, the provider who facilitated the referral is able to help staff connect with the client. If the provider continues to have a relationship with the client, s/he may be willing to plan a joint meeting, write an introductory or joint letter, or have the client call from his/her office. These are desirable options when the originating relationship was a positive one, when the good feelings and positive expectations may be generalized to a new relationship with the client. Obviously, if the originating relationship was a negative or adversarial one, staff should focus on other outreach strategies. When one or more of these techniques is successful, staff needs to "start where the client is" -- literally. Staff must begin to model the partnership that will characterize their working relationship throughout the intervention by encouraging the client to help identify convenient, realistic, and safe meeting times and places. Whenever possible, clients are empowered to make the final choice. For some (perhaps many) of the clients, this may be an unusual experience. They may need help in learning how to make a good choice and express it. Staff should consider the many possible places to meet. Offices (at the program or somewhere else), clinic waiting rooms, church basements, school conference rooms, recreation centers, home, work place, or the park are only some of the opportunities to join with the client. Staff should be encouraged and instructed to remember that the most important thing to do in that first contact is CONNECT! A "perfect" assessment supported by all the right forms is next to useless if the program won't be seeing the client again. Also, staff must remember that a good program is one that has clients. In order to have a successful program, staff has to improve the rate of follow through after the initial contact and intake. Treatment Matching This process begins with treatment plan negotiation. There must be a genuine willingness on the part of the service provider to view the client as a partner with unique and legitimate perspectives on the treatment process (Reis & Brown, 1999). This involves conducting individualized family centered assessments to help families define strengths and needs and match specific needs to positive, measurable outcomes which, when achieved, will reduce the risk of neglect to their children (DePanfilis, Glazer-Semmel, Farr, and Ferretto-Meek, 1999). For both practice accountability and empirical usefulness, programs should incorporate the use of standardized clinical measures of risk and protective factors (Dunst, Trivette, and Deal, 1988; Magura and Moses, 1986) in their assessment of specific family strengths, needs, and problems. Standardized substance abuse screening and assessment instruments (Michigan Alcoholism Screening Test- MAST; Addiction Severity Index-ASI) should be included in the assessment package. Finally, as a first step to engaging the family, staff should be trained to employ the stages of change instruments. Adherence or compliance with a particular treatment regimen may reflect The CPS Response to Child Neglect Page 194

Substance Abuse and Child Neglect problems associated with a particular stage rather than with the type of treatment employed. Clients may be more willing to stick with treatment, regardless of format, if they are given assistance or guidance to help them overcome their motivational conflicts and uncertainties. Once a detailed assessment has been made, a number of motivation-enhancing strategies can be matched to the individual s particular deficit. For some, education and information about the positive consequences of a behavior change may be essential, whereas for others, resolving an underlying conflict may be the key. Still others may benefit from rallying social support (Curry, Marlatt, Peterson, & Lutton, 1988). Based on the identification of the stage of change, staff should be trained to employ methods suggested earlier to foster motivation and readiness for the change process. When convergence between the family and staff is reached, standardized outcomes are selected by family members and staff as the target of intervention for every family. From the list of outcomes presented earlier, selected outcomes (including substance use and abuse) are then translated into timelimited, individualized service plans. This process involves tailoring services to the unique needs of each family based on goals that the family believes are most important. When available, this individualized assessment is undertaken in conjunction with other service providers to form a comprehensive picture of the individual, interpersonal, and societal pressures on the family members - individually and as a group. This holistic approach takes both client competencies and environment into consideration (Whittaker, Schinke, and Gilchrist, 1986) and views the environment as both a source of and solution to families problems (Bronfenbrenner, 1979; Garbarino, 1982). Because each family is unique and families who may be at risk of child neglect are heterogeneous, no particular method of intervention will lead to desirable outcomes for even a majority of families (DePanfilis, 1999; National Research Council, 1993; Wolfe, 1993). Further, because of the many different types of family systems, it is important that intervention be geared to the family s own definition of family and to culturally based differences and strengths (Lloyd and Sallee, 1994). Interventions must also be geared towards the family s readiness for change and their perceived readiness by the therapist to engage in the change process. Helping Alliance Development of a helping alliance and partnership with the family can be challenging because some caregivers, whose children may be at risk of neglect, may have difficulty forming and sustaining mutually supportive interpersonal relationships (Dore and Alexander, 1996; Gaudin and Polansky, 1986; Gaudin, Polansky, Kilpatrick, and Shilton, 1993). One of the essential challenges for practitioners is to form positive connections and partnerships with families so that they will have an opportunity to tackle the difficult challenges in their lives (McCurdy, Hurvis, and Clark, 1996). Successful engagement with families, who may be resistant to intervention, requires an ability to feel and demonstrate empathy with caregivers (Siu and Hogan, 1989) despite their initial resistance to intervention and the change process. Intervention will be successful if family members are enabled to become better able to solve problems, meet needs, or achieve aspirations, and achieve a greater sense of control over stressful life events. The CPS Response to Child Neglect Page 195

Substance Abuse and Child Neglect Attitude and Paradigm Shift The program should be geared to develop effective ways of helping by enabling staff to develop: a skillful use of self; flexible and caring attitudes with clients; an interest in and ability to engage clients and form meaningful relationships with families; and a profound belief in a family's ability to change. Staff should be further coached to use empowerment skills to develop client behaviors that improve the use of personal power, foster self-esteem, take care of personal problems, and set and pursue personal goals. Other essential components include: tolerance/acceptance of race, ethnicity, and gender; serve as a role model for respect and tolerance of diversity; skills that involve the family in planning and in every stage of the process; and the ability to advocate for clients to obtain needed resources from community institutions. As staff will begin to experience, effective helpers possess specific qualities: concern for others; commitment and obligation; acceptance and expectation; empathy; genuineness; comfort with authority and power; and purpose (Cournoyer, 2000). An important component of any neglect and substance abusing caretaker program is the development of beginning social workers that are effective helpers. Hence we not only recommend that the client s readiness for change be integrated into the assessment process but we also believe that a strengths based perspective instead of a deficit model be used. For example, rather than viewing the SES phenomenon as a function of deficits in the client, it makes more sense to view it as an interpersonal phenomenon. Client and therapist both approach the therapeutic enterprise with a whole host of expectations which, if not met, are likely to result in a less than optimal experience at high risk for unilateral termination (Reis & Brown, 1999). Therapists must acknowledge perspective divergence and take to heart the idea that treatment is a collaborative endeavor. Openness to modifying their perspectives, as they expect patients to modify theirs, will enhance treatment and reduce unilateral terminations. Just as service providers expect clients to come in with problems, they should expect them to bring different perspectives. Just as providers training and experience provide them with expertise about treatment, clients unique experiences provide them expertise about their lives. Unilateral termination is minimized when perspective divergence is expected, recognized, acknowledged, and incorporated into the process (Reis & Brown, 1999). Summary and Conclusions To begin to find answers that would increase our success in this area, we must begin by acknowledge that that there was a need for substance abuse treatment for the caretakers. They have difficulty getting treatment resources in a timely manner and especially for those people who do not have medical insurance or assistance it is usually virtually impossible. We have to begin expanding slots in terms of programs to meet the needs of substance impacted families. To meet treatment needs that are appropriate for this population, child welfare must begin a relationship with the substance abuse field that does not currently exist. The substance abuse field must work closely with child welfare staff to educate them about addictions. The child welfare field must sensitize the substance abuse field to the issues of child welfare and the child welfare field to the issues of substance abuse and parenting. The CPS Response to Child Neglect Page 196

Substance Abuse and Child Neglect While in treatment, caretakers must be provided the environment to facilitate a conducive type of visitation process, whether as outpatients or inpatients. Like a neutral ground, the treatment program would set aside some time for the process of visitations. The treatment focuses on the parents and does not the isolate the family. This gives them the opportunity to do family therapy, child therapy, so that all parts of the family could be treated together. Many of these parents become so dysfunctional that they do not even have the skills to get themselves up in the morning to get to a program. Here is where the outreach becomes a critical component. In some situations, staff could for the first couple of weeks of treatment go to the person s home and say, It s time to get up. Let s go. That might increase the number of people who remain with the program. The other issue that this section is how to we define success. If we are defining success by completion of treatment or total abstinence for six months to one year, we may have difficulties with success. What is completion of treatment? Here we are talking about families, children, and visitation, so success needs to be defined contextually. The client may be visiting the child for the first time. While a mother may have dropped out of treatment, they did spend time with their children. Did the visits provide an unfavorable or favorable outcome for the family? Another important factor is that there is not enough presence of addictions expertise at the forefront - in terms of personnel at child welfare agencies. Positions need to be funded or workers trained to do bio-psycho-socials and have a worker as the gatekeeper who can incorporate the bio-psycho-social into the service plan. One of the greatest challenges that social workers and other mental health clinicians face is the successful engagement of clients in the intervention and treatment process. Application of the Stages of Change Model to identify the client s readiness for change and employment of specific strategies to enhance motivation depending on the stage of readiness, has been demonstrated successful with numerous populations and as such, should be adopted and researched for programs that serve maltreating families, particularly families with a substance abusing caretaker. Substance abuse crosses every field of human services especially social work. You cannot serve any type of population without considering the role of substance abuse. The educational system that trains social workers and other human service providers need to recognize this. Social workers and other human service providers coming out of school need to have taken at least 1-3 credit hours of substance abuse course work. At the present time, we have many workers who are unprepared to address this issue. While a few addictions specialists could make a difference if located at key points of assessment, everyone working with these caretakers and their children need to have some level of substance abuse training. Students being trained for clinical practice are often trained to work with voluntary clients and little effort is made help them develop skills to successfully engage clients who may be less ready to make changes in their lives. Preparing human service providers to develop skills in outreach and engagement will increase the likelihood of successful intervention and best practice. This paper reviewed the literature on the stages of change model and demonstrated how one program that combines pre-treatment education of clients and service to the community has The CPS Response to Child Neglect Page 197

Substance Abuse and Child Neglect integrated these useful concepts into a model of service delivery with families at risk for neglect. The paper is limited in that employing these strategies is just being demonstrated. However, given the fact that an extensive literature review of the child maltreatment literature could find no published account of the model being used in either child maltreatment prevention or intervention programs, we believe that this chapter contributes a conceptual foundation to others who may be entertaining application of the model with similar populations. The CPS Response to Child Neglect Page 198

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Substance Abuse and Child Neglect U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect (1996). Child maltreatment 1994: Reports from the states to the National Center on Child Abuse and Neglect. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect (1999). Child maltreatment 1997: Reports from the states to the National Child Abuse and Neglect Data System. Washington, DC: U.S. Government Printing Office. U. S. Department of Health and Human Services, National Center on Child Abuse and Neglect. (1988). Study findings: Study of national incidence and prevalence of child abuse and neglect: 1988. Washington, D.C.: U. S. Government Printing Office. Vlahov D, Anthony JC, Celentano D, Solomon L, Chowdhury N. Trends of HIV-1 risk reduction among initiates into intravenous drug use 1982-1987. Am J Drug Alcohol Abuse. 1991; 17(1): 39-48 Waller, G. (1997). Drop-out and failure to engage in individual outpatient cognitive behavior therapy for bulimic disorders. International Journal of Eating Disorders, 22, 35-41. Watkins KE, Metzger D, Woody G, McLellan AT. High-risk sexual behaviors of intravenous drug users in- and out-of-treatment: implications for the spread of HIV infection. Am J Drug Alcohol Abuse. 1992; 18(4): 389-98. Wells, S. J., & Anderson, T. L. (1992). Model building in child protective services intake and investigation final report. (National Center on Child Abuse and Neglect Grant # 90CA1407). Washington, DC: American Bar Association. Whittaker, J., Schinke, S., & Gilchrist, L. (1986). The ecological paradigm in child, youth, and family services: Implications for policy and practice. Social Service Review, 60, 483-503. Witt, C., Dayton, C., & Sheinvald, J. K. (1992). The family empowerment program: A social group work model of long term, intensive, and innovative strategies to reduce the incidence of chronic neglect for at risk parents. (National Center on Child Abuse and Neglect, Grant # 90CA1392). Pontiac, MI: Oakland Family Services. Wodarsky, J. S., Kurtz, P. D., Gaudin, J. M., & Howing, P. T. (1990). Maltreatment and the school age child: Major academic, socioemotional, and adaptive outcomes. Social Work, 35, 506-513. Wolfe, D. A. (1993). Prevention of child neglect emerging issues. Criminal Justice and Behavior, 20, 90-111. Zanis DA, McLellan AT, Alterman AI, Cnaan RA. Efficacy of enhanced outreach counseling to reenroll high-risk drug users 1 year after discharge from treatment. Am J Psychiatry. 1996 Aug; 153(8): 1095-6. The CPS Response to Child Neglect Page 208

Substance Abuse and Child Neglect Zuravin, S., & Shay, S. (1991). Preventing child neglect. In D. DePanfilis and T. Birch (Eds.). Proceedings National Child Maltreatment Prevention Symposium. Washington, DC: National Center on Child Abuse and Neglect, June 6-7, 1991. Zuravin, S. J. (1991). Research definitions of child physical abuse and neglect: Current problems. In R. H. Starr, Jr. and D. A. Wolfe (Eds.). The effects of child abuse and neglect. New York: The Guilford Press. Zuravin, S. J., & DePanfilis, D. (1996). Child maltreatment recurrences among families served by Child Protective Services final report (National Center on Child Abuse and Neglect Grant # 90CA1497). Baltimore: University of Maryland at Baltimore, School of Social Work. The CPS Response to Child Neglect Page 209

X. Using What s Known and Resolving the Unknowns of Child Neglect Thomas D. Morton, MSW As Garbarino and Collins (1999) appropriately observe, professional journal s attention to neglect as a phenomenon in the broad context of child maltreatment is far less than that given to physical abuse and sexual abuse. This is the case even though more children die from neglect than any other form of child maltreatment and neglect is substantiated more frequently. Though there has been considerable research conducted since Leontine Young s early work, this research has not filtered into practice or program design in significant and identifiable ways. Perhaps the appearance of a strong observed link between poverty and neglect has left both program managers and practitioners feeling that their inability to resolve the family resource issue leaves them ill-equipped to address neglect successfully. As well, overly simplistic interpretation of studies establishing correlations between poverty and neglect, as well as between neglect and other variables, may have led to equally simplistic and erroneous programmatic responses. The preceding chapters identified a number of issues that must be addressed for child welfare service agencies to advance their effectiveness in resolving issues of neglect within families. Addressing these issues presents significant challenges. Agencies do not generally have the internal research capacities needed to refine their own practices and program designs. Under pressures of limited and often insufficient resources, agency budgets can ill afford to reallocate funds from services to research. Unlike medicine where pharmaceutical and medical technology industries motivated by profit augment the advancement of science, no such infrastructure exists for child welfare. This leaves much research to investment by foundations and the federal government. Where foundations have been willing to invest in medical research, this is far less true of child welfare research. By default, federal funds remain the main source of funding for child welfare research. It also means that most research on child welfare issues will be conducted either by institutions of higher education or under federal contracts to research firms. While research firms are specifically responsive to federal research interests, institutions of higher education must necessarily depend on the match between faculty research interests and the research needs of child welfare agencies. In 2000, the National Association of Public Child Welfare Administrators Thomas D. Morton, MSW, is Co-Director of the National Resource Center on Child Maltreatment and President & CEO of the Child Welfare Institute in Atlanta, Georgia. The CPS Response to Child Neglect Page 210

Resolving the Unknowns of Child Neglect (NAPCWA) assisted by the National Resource Center on Child Maltreatment, sought to improve communication between state child welfare systems and child welfare researchers. NAPCWA convened five regional meetings and identified approximately 50 research priorities. Though the effort has generated a continuing dialogue between NAPCWA and the National Association of Deans and Directors, little real action can occur without expanded research finding. The limited availability of research funds continues to paint a dismal future for resolving the challenges faced in effectively responding to child neglect. However, these limitations do not impede responsible action to assimilate knowledge from current research and theory and guide its application in current practice, policy and program design. There are many areas in which the collective expertise of the field could make progress based on what is known, and in doing so, better inform future efforts to unlock the unknown. The Search for Definition As several authors in this monograph have noted, the ambiguity and lack of agreement about the definition of neglect both make interpretation of prior findings difficult and the application of these findings illusive. States legal definitions vary, as do local interpretations of a state s definition in day-to-day practice. For example, Oregon added threat of harm to their statute as a separate condition. It is likely that circumstances may be substantiated as neglect in Oregon that would not be substantiated in other states. This implies an additional population added to the pool of families observed to have neglected their children. Given this, if one conducts research aimed at demystifying the etiology of neglect in Oregon, can the results be generalized to states in which this additional pool of families is not included? It is unlikely that standard legal definitions are going to be achieved across states. Nor is it likely that community standards for interpreting state statutes will achieve a high degree of similarity. It is possible that researchers and agencies could adopt more consistent operational definitions of neglect. However, to be meaningful, several definitions may be necessary. Dynamically, are educational neglect and medical neglect born of a predominantly common etiology? If the answer is no, then different operational definitions may be necessary for each. Current child protection agency practice makes little distinction in assessment and intervention among the major forms of child abuse and neglect, let alone different forms of neglect. As well, the further refinement of different forms of neglect into separate etiological phenomenon runs contrary to current efforts in child welfare agencies to develop simple assessment tools that can be used universally with all families and all forms of neglect. To alter this situation, child welfare agencies would need to abandon present practices that attempt to simplify practice to match the limited training of an available workforce and build practice on the actual requirements of families entering the system. Great political will is necessary to reverse a trend toward declassifying child welfare positions that began in the 1970 s and early 1980 s, although there is evidence that several states are attempting to do so. Complicating the definitional issue is the ambivalence of the public and child welfare agencies around whether the primary agenda of the child protection agency is social control or treatment. The strategy of child protection systems is deeply rooted in a legalistic law enforcement role. The CPS Response to Child Neglect Page 211

Resolving the Unknowns of Child Neglect Families are investigated for potential wrong doing (violation of state statutes) by caretakers. Once substantiated, families are placed on a type of probation that requires them to participate in services under the implied or real threat of losing their children. This framework is consistent with America s approach to criminal (anti-social) behavior in which the implied or actual threat of loss or incarceration is used as an incentive to conform to societal laws. But is neglect anti-social or just asocial? Although neglect presents a threat to a child, it may not constitute a direct threat to society in the same way that criminal behavior is traditionally considered. There is no doubt about public opinion surrounding neglect that results in severe harm or death to a child, particularly in instances where there is evidence of parental intent to harm the child (e.g., locking a child in a closet and depriving the child of food). But several authors (Zuravin, 1999) have argued against intent as a relevant construct in considering most neglect. Under criminal law, proving negligence usually involves proving that the action, or in this case omission, was done consciously for the purpose of causing harm or that harm would result and that the harm was an imminent consequence to the negligent act. While harms do occur from neglect they are not necessarily always subsequent occurrences to the neglect. A parent may leave a child unattended dozens of times without harm occurring. If neglect is most frequently not an intentional act to harm a child, why should the response to neglect be based on a criminal justice model? Richard Matt, former president of NAPCWA and former director of child welfare in Missouri, has commented frequently that he hopes that within his lifetime people will stop using child abuse and neglect in the same sentence. Doing so, he asserts, suggests that they are essentially similar phenomena. There is substantial basis for his perception given that child welfare agencies commonly use the same assessment protocols regardless of whether neglect or abuse is present. It is largely a paradox that child welfare agencies have implemented assessment and intervention approaches without ever stating an explicit operational definition of neglect. The NRCCM has observed in a number of instances, caseworkers cannot articulate why a certain service is being used or why a case plan can be expected to resolve neglect beyond, That s what we do in these cases. While case plans are supposed to be individualized to a family, they are often cookie cutter copies. Yet one might not expect to find individualized plans where one does not find any distinction among the forms of abuse or neglect being presented. For practice and research to function well together, agreement is needed on the operational definition of neglect. Meaningful application of research findings to practice can only realistically occur where practitioners and researchers agree about the phenomenon they are addressing. The means of reaching such agreement does not presently exist. One early goal of the National Center on Child Abuse and Neglect (NCCAN) was to synthesize research and to support the development of coordinated and congruent approaches. However, NCCAN has substantially fewer resources with which to pursue this task. National organizations such as NAPCWA or the Child Welfare League of America (CWLA) could take on such a task, but substantial funding would be required. The CPS Response to Child Neglect Page 212

Resolving the Unknowns of Child Neglect The Ambiguity of Science Much of the existing research involves studies that correlate variables with neglect. The inconsistent results of studies may stem either from inconsistency in defining neglect or from a present inability to truly understand the interaction of the many variables presumably associated with neglect. Given the extremely complex nature of human behavior, predicting its exact future may be a futile pursuit. Yet, child welfare systems are duty-bound to intervene and to attempt changes in human social behavior. Some degree of science is necessary and justified. Epidemiological approaches have often relied on repeated studies to build a case for assuming causation where direct causal links cannot be established, e.g. smoking and cancer. With human behavior the paths between cause and effect are confounded by many variables which may not interact the same way from person to person or family to family. Repeated studies may offer a way to build a sufficient case. Child welfare agencies are seemingly left in a situation where existing science must be carefully evaluated and resulting agency actions based on judgment rather than completely left to empiricism. Recent history has witnessed considerable discussion regarding research-based versus clinical judgment models in risk assessment. One must be careful to separate the issue of decision-making about whether to intervene from decision-making about where and how to intervene. Clinical judgment cannot be totally eliminated in aspects of interventions to change human behavior. How should these judgments be made and upon what evidence should they be based? These are critical decisions that must be addressed by the field as a whole, but principally by researchers and practitioners working together. A forum is desperately needed that brings agency administrators, practitioners and researchers together to jointly evaluate what is known and how to use it. This approach should include discussions of correlation effects and implications for causation versus a variance relationship based on other possible impacting variables. Guidance is needed about how variables are addressed in assessment and what is know about intervention relative to both individual variables and combinations of variables. Nowhere is this needed more than in understanding the true relationship between poverty and neglect. The Potentiating Effects of Multiple Variables Researchers at Portland State University have observed that the interaction effects among variables is more highly predictive of re-maltreatment than the effects of variables considered independently. This would be consistent with recent ecological theories of child maltreatment. Yet practice has little means to presently consider these interaction effects either in predicting future maltreatment or in modifying interventions to take into account the multiple presence of linked variables in a case. For example, how is the intervention strategy different for a mother who is developmentally disabled, depressed, abusing alcohol and with three children under the age of seven, from a similar mother of normal intellectual capacity? Are the services and expectations the same? The CPS Response to Child Neglect Page 213

Resolving the Unknowns of Child Neglect Present service strategy in most child welfare agencies appears to suggest treating each identified variable independently of the others that have been identified. To some extent, this is a reflection of categorical and specialized services. Further, the breadth of conditions, which may be associated with neglect and their possible multiple combinations makes the development of, services specialized around potential multiple combinations numerically nearly impossible. The recognition of this situation is partially the reason that case management evolved. For case management to be effective under assumptions that include multiple independent contributions from various sources, only coordination of services may be required. Where variables interact, effective case management necessarily may also require assessment and management of the interaction effects of the various interventions. Neither science nor theory is quite this far along. This suggests that a next look at neglect as a family system issue should focus on these interactions among variables so that more robust intervention strategies can evolve. A second evolution in addressing the reality of multiple factors seems to be service saturation. Simultaneous application of multiple services represents another root in the evolution of case management. With regard to neglect, this strategy seems suspect. Neglectful caretakers frequently report feeling overwhelmed by the demands of the child. Where service interventions increase demands on an already overwhelmed caretaker, a positive outcome seems less likely. This may suggest the need for a phased strategy of change in neglect where certain core or foundational capacities are addressed before direct intervention steps are taken with caretaker behavior. Polansky noted that verbally accessing some mothers around any topic was often a precondition to having focused discussions about a family s neglect of its children. Similarly, frequently noted issues around problem solving skills and impulsive behavior may need to be addressed before focusing on direct care giving skills. Matching Strategy with Dynamics Child welfare administrators are increasingly challenging three aspects of current CPS strategy relative to neglect. The first concerns the role of the CPS agency relative to the community. The second concerns the need for a formal investigative response. The third is the timing of the CPS response. Toward the end of the last decade, increased attention focused on community partnerships. NAPCWA strengthened its perspective on the role of the community in revising its guidelines for the administration of CPS programs. The Edna McConnell Clark Foundation funded pilot projects in four communities focusing on under-resourced communities and the development of the means for earlier identification of at-risk children and families and offering a service response that might preclude formal CPS involvement. Many national organizations, e.g. CWLA, APHSA, have expressed strong support for this strategy. The Annie E. Casey Foundation has invested significant resources in support of community-based strategies. While scatter plots of cases reveal high concentrations of cases in certain neighborhoods, the dynamics of neighborhood in relationship to neglect remain uncertain. The cost of housing and historical strategies around housing assistance to the poor are likely to concentrate poor families The CPS Response to Child Neglect Page 214

Resolving the Unknowns of Child Neglect in certain neighborhoods. Presumed effects of poverty upon neglectful behavior would be more likely concentrated in these neighborhoods. To the extent that social isolation, and more specifically a diminished capability for reciprocity that might accompany poverty, are a dynamic then these conditions might be exacerbated. Whether this is the case or not remains uncertain. Community-based efforts seem directed toward increasing social embeddedness in the size and activity of social networks. Issues confronting the poor in accessing services are well documented. Locating services within neighborhoods seems to counter this problem. In many instances it may be too early to tell how such strategies will succeed. As well, it is always helpful to remember that in the realm of social interventions, experimentation and learning generally occur before success. A second major change in the CPS response has been the elimination of the investigative response for some or all of the CPS population. North Dakota eliminated investigations for all non-criminal cases. Missouri developed a dual-track approach, eliminating investigations for non-serious (primarily neglect) cases. Other states are considering or have experimented with the idea of multiple response systems. The premises behind such approaches stem from at least two observations. The first is that the investigation is alienating and thereby a deterrent to families accepting voluntary services. Since CPS agencies cannot legally mandate intervention except in the more serious cases, this was perceived to be a hindrance to earlier intervention with families. The other is that the investigative process is time consuming and potentially unnecessary where criminal prosecution or court action is not indicated. States altering their response systems indicate no decline in child safety and a greater willingness of families to accept services. It is unclear whether this increased willingness to accept services is actually resulting in diversion of families from the system and ultimately reducing the need for more stringent interventions later. Toward the end of the century, CPS agencies found themselves with a potential service population that exceeded resources available to respond. As the number of reports increased, resources were reallocated to mandated functions, e.g. investigation, at the expense of reducing non-mandated functions such as services to less serious cases. Risk assessment blossomed as a means of triage and assuring that CPS agencies were working with the most needy cases. At the same time, CPS administrators began to speak more frequently about the number of cases seen at intake and investigation that came back with multiple reports and possibly even multiple findings before a case was actually opened. Unlike abuse, neglect in many cases is a pattern of family life. While it can be observed as an apparent incident, e.g. absence of supervision, other forms such as the failure to provide adequate food, shelter or clothing may be pervasive in family life. While the condition can be observed on a given day, it may not really be an incident so much as an observed point in a pattern of neglect. It is here that the incident driven culture of the legalistic or criminal justice approach potentially conflicts with the dynamic of neglect. The progression to severity is not completely clear in many forms of child maltreatment. This is true whether one considers the act of the caretaker or the consequence to the child. It may be that The CPS Response to Child Neglect Page 215

Resolving the Unknowns of Child Neglect physical abuse begins with acts of physical intimidation and proceeds to physical assault. However, it is less clear that it begins with milder forms of physical assault and proceeds along a continuum to severe injury or death, though child death cases often reveal a history of non-lethal injuries. Similarly, sexual abuse may begin with sexual overtures that precede acts involving penetration. However, it is less clear where the most harm is experienced by the child. It may come from the first sexual assault, from cumulative assaults or from the failure of the family to recognize what is happening to the child and stop it. In neglect, effects are often cumulative. A child dying from failure to thrive does not die from a single incident of withholding food but rather from this act being repeated over time. Similarly brain development is not necessarily arrested by a single incident of a parent not responding to a child s crying, but from the cumulative effect of rarely being held and comforted or actively stimulated. This implies that by the time the effects of neglect become serious enough to notice, some forms of harm may be irreversible. Consequently, one must ask whether the decision to intervene should be based more on the observed present effect on the child or the strength of the caregiver s pattern. Patterns of behavior are not easily determined in the context of present investigative strategies. Present strategies are inherently incident driven. The questions raised are more based on did it occur and is the caretaker responsible than on what is the nature of this pattern in family life. Safety assessments have been constructed to detect present danger more so than emerging danger. As Holder and Salovitz note in Chapter 4, neglect requires equal consideration of emerging danger. As well, it may be the case that intervention timed to meet the legal and risk thresholds of seriousness may be too late to be effective. In a conversation with Diane DePanfilis, she commented on her research in Baltimore and observed that at intervention the first call is more likely to be accepted by the family and be effective than interventions occurring after a higher threshold of seriousness is met. If these observations hold up, risk assessment and current screening practices may actually eliminate interventions in families at the time when we can most likely succeed. To some extent this discussion suggests the need to de-link abuse and neglect. While they may co-occur, their intrinsic dynamics may suggest different assessment foci and intervention strategies. The Role of Change Versus Compensating Interventions Safety interventions are predominantly compensating interventions. They provide protective factors not present or present at insufficient levels within a family. Similarly, there are other interventions that might compensate for risk elements within a family. Homemaker services might be an example. Permanency planning has tended to emphasize resolving the family s problems within a defined period of time or moving on to other permanency options. But what if certain contributing factors cannot be changed and they are not directly within the cognitive control of the caregiver? Consider a developmentally disabled caregiver with an I.Q. The CPS Response to Child Neglect Page 216

Resolving the Unknowns of Child Neglect of 70. The caretaker is capable (in this instance) of selected tasks of self-maintenance, but has difficulty remembering to give the child medication and to feed the child regularly. Perhaps the principal contributing factor, mental retardation, will never be corrected. Should this caretaker lose her child to permanency planning by her inability to make progress toward assuring safety within the home? Many states statutes include provisions for terminating parental rights where these conditions preclude permanency within the birth family. But should they? A person in need of kidney dialysis who is Medicaid eligible is not expected to repair her kidney within 15 of the next 22 months or face losing her kidney or access to treatment. Though not exactly the same, the comparison invites discussion. Some advocates might argue that the child s developmental needs can never be adequately met in this environment. But what if the developmentally disabled mother had access to homemaker services 18-24 hours a day? Suppose this supplement to her family would permit the child to grow up with his or her mother? Comparatively, homemaker services are relatively cheap compared to kidney dialysis. The assumption that all maltreatment constitutes some degree of moral failure on the part of parents may be the single biggest factor prohibiting long-term supplemental assistance to families. Authors such as Dubowitz (1993) have asserted that intention is not a relevant construct in defining neglect. If this is so, then one must also question whether there can be moral turpitude without intention. While some may successfully argue that certain qualities of life may not be afforded in the home of a mentally ill or developmentally disabled caretaker, do these qualities rise to the safety threshold that has been more firmly stated by ASFA if supplemental services can maintain safety within the home? Dealing with Accrued Harm If, as evidence suggests, the harm from neglect is more likely accrued in many instances rather than the result of a single incident, the CPS agency faces a challenge in regard to the timing of intervention. Where agencies closely tie seriousness to the severity of current harm and base the need for intervention on the combination of these two elements, a number of children are likely to be left exposed to forms of neglect that will over time result in cumulative severe effects. Far less attention has been devoted to the risk of cumulative effects than to the risk of incidences of re-maltreatment. Similarly, a strong focus on risk of re-maltreatment, where incidences of maltreatment are a determining variable rather than cumulative exposure to chronic neglect conditions may well allow low risk situations that are really high risk situations. Nowhere is this more obvious than in current concerns about early brain development. The parental omissions in this case, taken as single incidences would rarely qualify as an incident of neglect. Yet, exposure over time to these parental responses can lead to severe consequences relative to brain development. This represents another area where the application of assumptions and beliefs about abuse to neglect may be faulty. It is difficult to measure what did not occur and to relate quantities of nonoccurring events to specific levels of outcomes. The early stages of exposure to physical neglect may look quite similar to normal family life due to the fact that the omissions are small in The CPS Response to Child Neglect Page 217

Resolving the Unknowns of Child Neglect relation to quantities expected. Over time these omissions may become more noticeable or they may simply accumulate in effect. In the latter cases they may remain unnoticeable until the harm to the child becomes visible. The Etiology and Ecology of Child Neglect Researchers and theorists have traveled a road from viewing neglect as primarily a matter of a parent s psychological functioning (Polansky et. al., 1981) to viewing neglect as a byproduct of factors in the exo-system and macro system (Pelton, 1981). While most theorists have moved toward an ecological framework that embraces contexts within the caregiver, family, community and macro system, practice has tended to leave behind assessment of specific cognitive processes of the caregiver. Although risk assessment scales may contain items such as caregiver perception of the child, even where identified, the experience of the author and several colleagues is that direct intervention to change parental perception, beliefs and cognitive processes is rarely reflected in case plans. Directly addressing these aspects of neglect might be considered treatment. General perceptions hold that the present child welfare workforce is neither trained nor resourced to do treatment and that such work should be left to mental health and other clinicians. Informal and anecdotal data question whether these considerations are actually addressed in mental health treatment or if the focus in mental health services is on more classically defined mental health issues. In a somewhat related vein, Coulborn Faller and Bellamy (2000) have suggested that the four personality disorders occur with higher prevalence among maltreating parents. For the most part, these conditions suggest a poor prognosis for treatment. At the same time, parents are rarely screened for these conditions nor the implications of their presence considered in intervention strategies. In the past decade, child welfare agencies have declared a strong commitment to moving toward family-centered practice. The defining elements of this approach remain vague. One commonly cited characteristic is viewing the family as a system and seeing the maltreatment in the context of family interactions, not just perpetrator and child interactions. Although family systems theory in no way ignores the psychological functioning of individual members, child welfare applications frequently focuses on stress, power and closeness or distance in relationships. The author s review of several states training curricula has found that where factors these are observed, the related implications for individual or family level interventions remain less clear. The focus seems to remain on referring for family counseling or parenting skills training. Case Management and Child Neglect Case management has become the predominant means by which public child welfare agencies approach all child maltreatment cases that are opened for ongoing services. In a survey conducted by the National Resource Center on Child Maltreatment, the majority of states responding conveyed that their primary approach assessment and case planning involved problem identification and matching problems to community services. The caseworker s role primarily is to coordinate services and make referrals. The CPS Response to Child Neglect Page 218

Resolving the Unknowns of Child Neglect This suggests that much of the field has adopted an operational definition of neglect that suggests neglect is a consequence of co-occurring family problems such as substance abuse, unemployment, mental health issues, etc. While considerable research supports the cooccurrence of such variables, other research and theory, e.g. Polansky, et. al. (1981) and Crittenden (1999), suggest that a parent s cognitive processing plays a significant role in much of neglect. If this is the case, and if the problems in processing are not directly related to these other problems, case management in itself is not likely to be effective. Crittenden suggests that parenting skills training is unlikely to be successful with parents whose cognitive and affective processes are impaired until these processes are altered. Though this situation may not be exclusively related to neglect, it seems particularly relevant to neglect. Neglectful parents often report feeling overwhelmed by their child s needs and as lacking the capacity to meet them. Further, they frequently show evidence that they are unable to form and maintain relationships. Given the disorganization and chaos that often accompany such families, the idea of presenting a neglectful parent with an array of services seems somehow contradictory to both the parent s present capacity and abilities. Though not intended necessarily to do so, the lowest common denominator of case management can be a scenario where the case manager s primary relationship with the family is built around monitoring the use of services. Unless other providers, e.g. the substance abuse counselor, is handling the issues of parental capacities to recognize and respond to the child s needs and how the parent relates to the child, case management alone seems an inadequate response to neglectful families. Blaming the environment has popular support and potentially frees the child welfare agency of responsibility for change. Viewing the causes of child neglect as external to the parent and the child welfare directs the focus to the quality of community services and the availability of resources to purchase them. As well, it may be a convenient accommodation to an under-trained workforce, since identifying problems and referring them to someone else is presumably easier than fixing them. Ending Acts of Omission in CPS Much has been made of the neglect of neglect. The phenomenon seems well supported by available evidence. A number of factors seem to contribute to this situation. Foremost among these is the absence of an infrastructure that continuously supports analysis of emerging evidence and the real time exchange of information among those concerned with advancing the state of the art in addressing neglect. The issues discussed earlier in this and other chapters have no real forum in which to continue and will remain words floating on the wind with no place to land unless this situation is changed. The consequences of failing to alter this situation are enormous. Practitioners skimming the literature may extract variables out of context and over generalize their meaning. Conversely, they may neglect variables that should be considered and ruled in or out in every case. To the extent that this continues, families and children will continue to be exposed to interventions reflective more of individual practitioner beliefs than the considerable base of information that The CPS Response to Child Neglect Page 219

Resolving the Unknowns of Child Neglect does exist. Such an approach to CPS practice can hardly be said to be consistent with national goals of safety and well-being. The CPS Response to Child Neglect Page 220

Resolving the Unknowns of Child Neglect References Coulborn Faller, K. and Bellamy, C. (2000). Mental health problems and child maltreatment, National Resource Center on Child Maltreatment. Crittenden, P. (1999). Child neglect: causes and contributors, in Neglected children Dubowitz, H., Ed., Sage Publications, Thousand Oaks. Dubowitz, H., Black, M., Starr, R., and Zuravin, S., (1993) A conceptual definition of child neglect. Criminal Justice and Behavior, 20(1), 8-26. Garbarino, J. and Collins, C. (1999). child neglect: the family with a hole in the middle, in Neglected children, Dubowitz, H. Ed., Sage Publications, Thousand Oaks. Pelton, L. (1981). The Social Context of Child Abuse and Neglect. New York: Human Sciences Press. Polansky, N., Chalmers, M., Buttenweiser, E. and Williams, D., Damaged parents: an anatomy of child neglect. Chicago, University Press. Zuravin, S., (1999). Child neglect: a review of definitions and measurement research, in Neglected children, Dubowitz, H. Ed., Sage Publications, Thousand Oaks. The CPS Response to Child Neglect Page 221

National Resource Center on Child Maltreatment 3950 Shackleford Road, Suite 175 Duluth, GA 30096 www.gocwi.org/nrccm