How Much Care is Adequate? Neglect and a Continuum of Care

The adequacy of care a child receives exists on a continuum from optimal to grossly inadequate, without natural cut points. A crude categorization of situations as “neglect” or “no neglect” is often simplistic. Seldom is a need met perfectly or not at all; cut-points are usually quite arbitrary. It is difficult to determine at what point inadequate household sanitation, for example, is associated with harmful outcomes. And, with relatively few extreme situations, the gray zone is large. Even a relatively concrete area such as establishing the daily requirement for key nutrients is not straightforward, and, it is difficult to measure the extent to which these are met.

Examples of adequate health care include: Reasonable efforts made for minor problems (e.g., cleaning a cut), professional care obtained for moderate to severe problems (e.g., trouble breathing), child receives adequate treatment to optimize outcome and limit complications (i.e., adequate adherence to treatment regimen), child receives recommended preventive health care (e.g., immunizations), and professional care meets accepted health care standards (i.e., appropriate treatment). The last example illustrates how deficits in care are not always due to parents. In keeping with the quality of care being on a continuum, it may be useful to categorize care, for example, as “excellent” (infant seat always used), “moderate” (infant seat usually used), or “inadequate” (seat seldom used).

The Quest for an Evidence-Based Definition

Ideally, a definition of neglect would be based on empirical data demonstrating the actual or probable harm associated with certain circumstances (e.g., not receiving adequate emotional support). Although evidence-based definitions are a good goal, they are difficult to achieve for most types of neglect.

Children’s health, safety, and development occur within a complex ecology with many and interacting influences, making it difficult to study the impact of a single risk factor, such as inadequate emotional support. The context of children’s experiences also influences the possible impact of a given circumstance; a mature 9-year-old, for example, may do well alone at home for a few hours, whereas an unsupervised child with a fire-setting problem is a scary proposition. In some areas, it is probably not necessary to have evidence documenting harm (e.g., hunger, homelessness, abandonment). It is very clear that these conditions impair children’s safety, health, and development.

In practice, we need to apply the best available knowledge, albeit often less than we would like, to clarify whether a certain circumstance or pattern of experiences jeopardizes a child’s wellbeing. Situations where the likelihood of harm is equivocal are best not considered to be neglect, although that should not preclude efforts to improve care. Research may help elucidate whether such circumstances should warrant concern.

Actual vs. Potential Harm

Most state legal definitions of neglect include circumstances of potential harm in addition to actual harm. However, approximately one third of states restrict their practice to circumstances involving actual harm. Potential harm is of special concern because the impact of neglect may be apparent only years later. In addition, the goal of prevention may be served by addressing neglect even if no harm is yet apparent. However, it is often difficult to predict the likelihood and nature of future harm. In some instances, epidemiological data are useful. For example, we can estimate the increased risk of a serious head injury from a fall off a bicycle when not wearing a helmet compared with being protected. In contrast, predicting the likelihood of harm when an 8-year-old is left home alone for a few hours is difficult. Such circumstances may come to light only if actual harm ensues. Even when we can estimate risks, opinions may vary as to how seriously to weigh a risk. In addition to the likelihood of harm, the nature of the potential harm should be considered. Even a high likelihood of minor harm (e.g., bruising from a short fall) might be acceptable. Life is not risk free. Indeed, children’s development requires taking risks (e.g., learning to walk and falling). In contrast, even a low likelihood of severe harm (e.g., drowning) is unacceptable.

Further Refining the Definition of Neglect: A Heterogeneous Phenomenon

The different types of neglect children may experience represent a wide range of circumstances. In addition to characterizing different types of neglect—physical, emotional, supervisory, educational, etc. —it is useful to describe other aspects of neglect: the severity, the duration (or chronicity), number of incidents (frequency), intentionality, and the context in which neglect occurs.

Severity is viewed in terms of the likelihood and seriousness of harm. Simply put, severe neglect occurs when the unmet need is associated with serious harm, actual or potential. And, the greater the likelihood of such harm, the more severe is the neglect.

Several researchers have pursued different strategies to rate the severity of neglect. These approaches have limited clinical usefulness.

Chronicity , a pattern of needs not being met over time, is important albeit challenging to assess. One study found that chronicity of maltreatment was related to child outcomes. Some experiences of neglect are usually only worrisome when they occur repeatedly (e.g., poor hygiene). The challenge to assessing chronicity is clear; caregivers seldom disclose socially undesirable information. Older children, however, may be helpful. A crude proxy of chronicity is the duration of child protective services (CPS) involvement, or the time between the first and most recent reports. The problem is clear. A CPS report reflects only when problems were identified; it is highly speculative to assume what transpired before and between reports.

Frequency is similarly difficult to assess. Caregivers or older children may disclose the information. The number of CPS reports again offers a crude proxy.

Intentionality is a question that arises regarding neglect—implicitly or explicitly. Intentionality may not apply to most neglectful situations. The Merriam-Webster dictionary defines intentional as “done by intention or design.” In most cases, parents do not intend to neglect their children’s needs. Rather, problems impair their ability to adequately meet these needs. Even the most egregious cases, such as those where parents appear to willfully deny their children food, probably involve significant parental psychopathology; labeling such instances “intentional” may be simplistic. In clinical practice, as we strive to strengthen families, viewing their shortcomings as intentional may be counterproductive, especially if it fosters a negative stance toward parents. Finally, as a practical matter, it is very difficult to assess intentionality.

Cultural context is relevant to defining neglect. For example, in many cultures, young children help care for younger siblings. This is both a necessity and considered important in learning to be responsible. Others may view the practice as unreasonably burdensome for the child caregiver and too risky an arrangement. There is no easy resolution to such differences, and there can be dilemmas concerning new immigrants to the United States. Clearly, the risks here might be very different from those in the country of origin. We need to recognize the importance of cultural context and how it influences child rearing practices and the meaning and consequences of experiences for children. It is, however, also important to recognize that just because a certain practice is normative within a culture does not preclude possible harm. One needs to be careful to avoid glibly accepting all culturally accepted practices; some may be clearly harmful and should not be sanctioned. At the same time, good practice should always involve understanding the culture and engaging the family respectfully.

Poverty is strongly linked with child neglect. For example, in the Third National Incidence Study (NIS-3), neglect was 44 more times likely to be identified in families earning less than $15,000 a year compared with those earning over $30,000. There are also ample data demonstrating that poverty per se jeopardizes children’s health, development, and safety. Poverty can thus be construed as a form of societal neglect, particularly in a country with enormous resources. The child welfare system, however, focuses narrowly on parental or caregiver omissions in care (i.e., fault); 11 states and Washington, D.C., laws explicitly exclude circumstances attributable to poverty in their neglect definitions.

Individual Level

Family Level

Problems in parent-child relationships have been found among families of neglected children. Research on dyadic interactions indicates less mutual engagement by both mother and child and disturbances in attachment between mother and infant. ^, Compared to parents of abused and nonmaltreated children, parents of neglected children had the most negative interactions with their children. Bousha and Twentyman found that mothers of neglected children interacted least with their children compared with mothers of abused and nonmaltreated children.

Although mothers of neglected children may have unrealistic expectations of their young children compared with matched controls, a lack of knowledge concerning child developmental milestones (e.g., when should an infant be able to sit unsupported) has not been clearly associated with neglect. However, deficient parental problem-solving skills, poor parenting skills, and inadequate knowledge of children’s developmental needs have been associated with neglect. ^–

In his work with neglected children, Kadushin described chaotic families with impulsive mothers, who repeatedly demonstrated poor planning and judgment, coupled with either father absence (often abandonment or incarceration) or negative mother-father relationships. Neglect has been associated with social isolation. ^, Single parenthood without support from a spouse, family, or friends poses a risk for neglect. In one study, mothers of neglected children perceived themselves as isolated and as living in unfriendly neighborhoods. Their neighbors saw them as deviant and avoided social contact with them. Mothers of neglected children may have less help with child care and fewer enjoyable social contacts compared with those where neglect was not a concern. Another study found that maltreating parents showed lower levels of community integration, participation in community social activities, and use of formal and informal organizations than did parents providing adequate care.

Giovannoni and Billingsley described a pattern of estrangement from kin among mothers of neglected children that included a lack of supportive relationships. Seagull asked whether social isolation is a contributory factor to neglect or a symptom of underlying dysfunction. In either case, social isolation appears to be strongly associated with child maltreatment, and particularly with neglect.

Stress also has been strongly associated with child maltreatment. In one study, the highest level of stress, reflecting concerns about unemployment, illness, eviction, and arrest was noted among families of neglected children compared with abusive and control families. Lapp found stress was frequent among parents reported to CPS for neglect, particularly regarding family, financial, and health problems.

Crittenden described how distortions in information processing can lead to neglect. She described three types of neglect associated with deficits in cognitive processing, affective processing, or both: (1) disorganized, (2) emotionally neglecting, and (3) depressed. The first type, “disorganized,” is characterized by families who respond impulsively and emotionally. The family operates in a crisis mode and appears chaotic and disorganized. Children may be caught in the midst of this crisis, and their needs are not met. The second type, “emotionally neglecting,” includes families who are minimally attentive to their child’s emotional needs. Parents may handle the demands of daily living (e.g., ensure food and clothing), but ignore how the child feels. The third type, “depressed,” is the classic presentation of neglect. Parents are depressed and therefore unable to process either cognitive or affective information. Children may be left to fend for themselves emotionally and physically.

Community/Neighborhood Level

The community context and its resources, or social capital, influence parent-child relationships and are strongly associated with child maltreatment. A community with much social capital, such as family-centered activities, quality and affordable child care, and a good transportation system, enhances the ability of families to nurture and protect their children. Informal support networks, safety, and recreational facilities also support healthy family functioning. Garbarino and Crouter described the feedback process whereby neighbors may monitor each other’s behavior, recognize difficulties, and intervene. This feedback can be supportive, diminish social isolation, and help families obtain services.

A comparison of neighborhoods with low and high rates for child maltreatment showed that families with the most needs tended to cluster in areas, often those with the least social services. In addition to the role of personal histories, the authors attribute the formation of high-risk neighborhoods to political and economic forces. Families in a high-risk environment are less able to give and share and may be mistrustful of neighborly exchanges. In this way, a family’s problems may be compounded rather than ameliorated by the neighborhood context, if dominated by other needy families. Garbarino and Crouter found that parents’ negative perceptions of the quality of life in the neighborhood were related to increased child maltreatment. In summary, communities can serve as valuable sources of support to families, or they may add to the stresses that families are experiencing.

Societal Level

Many factors at the broader societal level compromise the abilities of families to care adequately for their children. In addition, these societal or institutional problems can be directly neglectful of children. “More than a dozen blue-ribbon commissions and task forces over the past decade have warned of the inadequacy of America’s educational system and urged reform.” Only 70% of youth complete high school. In a national study, 70% of children with learning disabilities received special education services according to their parents; fewer than 20% of children receive needed mental health care.

Poverty is defined as living in families with incomes below the federal poverty line ($21,200 for a family of four in 2008). Poverty appears to be strongly associated with neglect, “…these families are the poorest of the poor.” The harmful effects of poverty on the health and development of children are pervasive. In addition to its influence on family functioning, poverty directly threatens and harms children’s health, development, and safety. Children in poor families lag behind children in wealthier families in health insurance and in academic performance. For many children, living in poverty means exposure to environmental hazards (e.g., lead, violence), hunger, few recreational opportunities, and inferior health and health care. According to the National Center for Children in Poverty , 20% of children under age 6 in America live in poverty, a rate two to three times higher than that of other major industrial nations. Of all the risk factors known to impair the health and well-being of children, poverty is clearly very important. It should be noted, however, that most low-income families are not neglectful of their children. Conversely, neglect is hardly limited to poor families.

The child welfare system, the very system intended to assist children in need of care and protection, is another example of societal neglect. “If the nation had deliberately designed a system that would frustrate the professionals who staff it, anger the public who finance it, and abandon the children who depend on it, it could not have done a better job than the present child welfare system.” Inadequately financed, with staff who are generally undertrained and overwhelmed, and with poorly coordinated services, CPS are often unable to fulfill their mandate of protecting children.

Professional Level

As mentioned earlier, professionals may contribute to neglect in different ways. Problematic communication with parents not understanding their child’s condition or treatment plan is pervasive. Pediatricians sometimes do not comply with recommended procedures and treatments, thereby compromising children’s health. Pediatricians may fail to identify children’s medical or psychosocial needs, perhaps contributing to their neglect.