Introduction

Today as we embark upon a new pediatric subspecialty, Child Abuse Pediatrics, it is impressive to look back and realize that Dr. C. Henry Kempe first acknowledged the existence of child abuse as a medical problem less than five decades ago. With today’s worldview, it is difficult to understand that many physicians questioned the validity of child maltreatment as a diagnosis when Kempe wrote his landmark paper. Since then, significant advances have been made in the field of Child Abuse Pediatrics. These advances include the definition of various types of maltreatment such as physical abuse, sexual abuse, and psychological abuse. Child neglect remains less well defined, making effective research in prevention and treatment difficult.

Neglect is the most common form of child maltreatment. Child neglect accounts for over 50% of all reported child maltreatment cases, and at least half of all child maltreatment fatalities. Despite its prevalence, there is a dearth of clear definitions of neglect and research dedicated to neglect. Although there is consensus that a clear definition of neglect is necessary, the task of defining neglect is daunting.

As an example of a well-defined form of child maltreatment, physical abuse is defined as acts of commission that result in injuries. These injuries can be visualized, they can be related to plausible mechanisms, and physicians can describe anticipated immediate and long-term outcomes based on the injury the child sustained. On the contrary, neglect is defined by acts of omission that often result in no clear injury. This lack of injury occurs within a context of multiple factors, and physicians can only describe potential immediate and long-term outcomes with marginal accuracy. Creating and applying a neglect definition to clinical situations is significantly more difficult than it is in other forms of child maltreatment.

A clear definition of neglect is necessary to end inconsistencies in policies, practice, and research. Various neglect definitions have been proposed for over a decade and each has failed to gain universal acceptance. Many of the definitions place the blame for child neglect on the child’s caretakers alone. For example, the definition of child abuse and neglect in the U.S. Government’s Child Abuse Prevention and Treatment Act (CAPTA) is, “The physical or mental injury, sexual abuse, negligent treatment, or maltreatment of a child under the age of eighteen by a person who is responsible for the child’s welfare under circumstances which indicate that the child’s health or welfare is harmed or threatened.” Other caretaker-blaming definitions used by states and agencies include, “An omission in care by caregivers that results in significant harm or the risk of significant harm,” and, “A type of maltreatment that refers to the failure by the caregiver to provide needed, age-appropriate care although financially able to do so or offered financial or other means to do so.” A broader definition is that neglect occurs, “… when children’s basic needs are not adequately met.” This definition avoids blaming parents alone, and instead attributes neglect to child, parent, family, and community factors.

Despite several attempts to clearly define neglect , clinicians are often left saying, “We know neglect when we see it!” The failure to establish a clear operational definition of neglect has resulted in a self-fulfilling prophecy of “the neglect of neglect.” ^,

Neglect is multifactorial and multidimensional, encompassing a wide range of causes and consequences. Understandably, it is a challenge to create a universal definition that can be applied to the extremely diverse set of clinical situations in which child neglect occurs, such as infants exposed to drugs in utero, infants failing to thrive based on lack of appropriate nutrition, young children left alone without age-appropriate and developmentally appropriate supervision, and children exposed to drugs and domestic violence, all of which must fit within the definition of neglect. A universally accepted definition of neglect needs to address every possible facet of the topic.

One obstacle in defining neglect is the question of perspective. Should a neglect definition be based on the perspective of the child and focus on specific unmet needs, or should a neglect definition be based on the perspective of the parents and focus on their responsibility for failing to meet the child’s needs? Perspective differences in the definition of neglect are often based on two conceptual models proposed in the 1980s. Belsky described a framework for understanding the etiology of child maltreatment based on the view that child maltreatment is a social-psychological phenomenon. This model identified specific factors for the individual, the family, and the community and the culture that allow all forms of child maltreatment to occur. On the other hand, Cicchetti and Rizley developed a transactional model to address the causes, consequences, and mechanisms of child maltreatment. This model describes risk factors as either potentiating (increasing the probability of maltreatment) or compensatory (decreasing the probability of maltreatment). Child maltreatment occurs when potentiating factors outweigh compensatory factors.

Multiple factors influence the occurrence and outcome of child neglect on an individual, family, and community level ( Figure 55-1 ). Individual factors are divided between those of the caregiver and those of the child victim. Neglectful caregivers can be influenced by inadequate parenting role models, mental health problems, physical health problems, alcohol and substance abuse, cognitive limitations, lack of education, domestic violence, impulsivity, poor anger control, unemployment, limited knowledge of the basic needs of a child, and social isolation. Factors that affect children that might lead to their neglect include age, physical and mental health, special needs, history of abuse, level of education, lack of resilience, temperament, and behavior. These intrinsic child risk factors can make child care more difficult, creating a cycle of neglect, since the failure to fulfill their needs results in increasingly difficult behaviors and inadequate bonding, which are identified as family risk factors. Other important family factors to consider include: single-parent homes, larger families, limited financial resources, inadequate food, and domestic violence. Societal influences have been identified as: poverty, unsafe neighborhoods, frequent moves, poor access to mental health and general health care, and lack of long-term community resources.

Factors influencing the occurrence and outcome of child neglect.

There are compensatory factors to consider at each level as well. Compensatory factors include caregivers that have positive parenting role models, gainful employment, adequate support systems, and resilient children. Ideally, the balance between the potentiating and compensatory factors will identify the probability that neglect will occur.

A significant limitation of conceptual models is that although the presence of a particular factor is important to note, it does not always result in the occurrence of child maltreatment. For example, poverty has been identified as a significant risk factor for child neglect. Yet not all impoverished families neglect their children, and children that live within affluent families can be victims of neglect despite adequate available resources.

Many of the same factors influence the occurrence of other forms of child maltreatment and have not interfered with the defining of maltreatment. For example, a child that is physically abused by a caregiver within the context of poor parenting models, poverty, substance abuse, and other stressors is still diagnosed as a victim of child physical abuse. The influencing factors are taken into account to determine what intervention is most appropriate for the safety and well-being of the child. The same standard should apply for neglect. The influencing factors should be identified and used to determine the intervention necessary when neglect occurs, but these factors should not interfere with making the diagnosis of neglect.

Conceptual models allow a broader and richer understanding of the numerous complex, interwoven factors influencing the occurrence of neglect to foster a better understanding of a child’s situation and to improve methods of prevention and strategies for intervention. These conceptual models, however, should not impede the establishment of a clear and consistent definition of neglect, which is needed to improve clinical assessments, research, and prevention efforts. A conceptual model cannot replace a neglect definition. Cicchetti and Lynch demonstrated this by applying an ecological-transactional model to understanding the effect of community violence on the occurrence of child maltreatment. They concluded that the model provided a framework to target prevention and intervention efforts, but that violence itself needed to be defined more clearly.

The Child Protection Program at Hasbro Children’s Hospital has promulgated a definition of neglect that incorporates a “multi-dimensional” approach inspired by the system used to diagnose mental illness in the DSM-IV. This definitional tool looks at various aspects of neglect (the axes). The three axes are the type of neglect, the degree of neglect, and the outcome of neglect.