Recognizing and Responding to Child Neglect

Child neglect is a toxic stress with harmful outcomes. It is the most prevalent form of child maltreatment with continued trends for underreporting due to a lack of a widely accepted definition. Given this reality, pediatric clinicians may rely on subjective thresholds for its diagnosis. There are risk factors for neglect countered by protective factors that builds resilience in families. Pediatric clinicians are positioned to prevent neglect through their relationships with families across the life span. Currently, there are evidence-based screening tools available to ensure the skillful differentiation between the signs and symptoms attributable to neglect versus poverty.

Key points

  • Clinicians should be familiar with the common and subtle signs of all subtypes of child neglect.

  • There are similarities between the presentation of child neglect and poverty. It is imperative to differentiate between the two using evidence-based screening tools.

  • Understanding the history of racism and its role in child maltreatment, clinicians are encouraged to engage in training to recognize and address implicit biases.

  • Upon identifying unmet material needs, clinicians should refer and connect families to resources and services addressing all possible contributors to neglect.

Abbreviations

BIPOC Black, Indigenous, and People of Color
CPS child protective services
SAMSHA Substance Abuse and Mental Health Services Administration
SDH social determinants of health
SEEK PQ-R SEEK Parent Questionnaire-R
SEEK Safe Environment for Every Kid
WE CARE Well Childcare visit, Evaluation, Community Resources, Advocacy, Referral, Education

Introduction

Child neglect is a toxic stress resulting in physical and psychological harm. , In 2022, there were 558,899 victims of reported child abuse and neglect in the United States. This equates to a national rate of 7.7 per 1000 children in the population that were victims of maltreatment. Of the different types of child maltreatment, neglect is the most prevalent with approximately three-quarters (74.3%) of substantiated victims having experienced this form of abuse. Although the effects of neglect are equally detrimental to boys and girls, data reveal a child’s age and gender may be a determinant of vulnerability, with slight differences. For boys, birth through the age of 10 years is identified as a vulnerable period. For girls, this period of vulnerability begins at age 11 and peaks at age 17.

Child neglect can also serve as a facilitator for other forms of child maltreatment. With respect to victims of neglect that have also experienced sexual abuse, boys and girls are affected relatively evenly at 50.0% and 49.6%, respectively. As it relates to child fatalities, approximately 1990 children died from abuse and neglect at a rate of 2.73 per 100,000 children in the United States in 2022. Of these deaths, 76.4% suffered neglect, while 42.1% suffered physical abuse either exclusively or in combination with another maltreatment type. In terms of child torture, neglect, specifically medical neglect, remains a major player.

Scope of the problem

Definition of Child Neglect

Child neglect is underreported. , Neglect can be especially difficult to report due to the lack of a clear and widely accepted definition. , Adding to the complexity, child neglect encompasses multiple subtypes with pediatric clinicians relying on subjective thresholds largely influenced by unconscious biases for what they consider acts of neglect. In lieu of a standard definition, an accepted definition of child neglect is an act of omission by a caregiver that results in actual or potential harm to the child. , This definition focused on the failure of a caregiver, is commonly applied by the legal system in civil and criminal courts. As the household of all children may not be represented by a nuclear family structure, with children living with their biological parents, the term “caregiver” refers to all adults functioning in a caregiving capacity on behalf of a child. Neglect can be active or passive. Active neglect is the failure to fulfill caregiving responsibilities despite having all resources; while, passive neglect is the failure of the caregiver to fulfill their responsibilities because of deficits in knowledge, health, mental abilities, or resources. Despite, the elusive nature of a perfect definition, pediatric clinicians should not confuse signs of neglect with signs of poverty.

Types of Child Neglect

Neglect has multiple subtypes with some overlap between types encountered in clinical practice and in the child maltreatment literature. Subtypes focus on the deliberate withholding of material items, services, nurturing behaviors essential to the well-being of their children, or safe environment. Neglect subtypes of withholding material items include physical and nutritional neglect. Physical neglect results when a child’s need for clothing and shelter are not been met as well as not tending to a child’s hygiene. , Poor hygiene can lead to avoidable disease, such as infections, diarrhea, or skin infestations, while dental caries can affect a child’s ability to eat. Nutritional neglect is the withholding of food from a child resulting in actual or potential harm with presentations ranging from extreme failure to thrive to obesity. ,

Deliberate withholding of services include denial of access to medical or educational services. Medical neglect is the failure to seek medical, mental, or dental health interventions in a timely manner. , Educational neglect is when a child’s need for adequate school-related services are withheld. This includes caregivers not enrolling a child in school, failing to provide a validated home education curriculum, noncompliance with recommended special education classes or services or condoning chronic truancy. , Homeschooling can be a powerful tool in the hand of abusive caregivers given minimal contact with mandated reporters. Although a majority of homeschooled children do not grow up in abusive families, the lack of a standardized curriculum deserves scrutiny.

Supervisory and emotional neglect are not responding to a child’s need for nurturing. , Supervisory neglect is when a child’s need for age-appropriate supervision is not met, placing a child at a significant risk for physical, psychological, or emotional harm. , Emotional neglect focuses solely on affection and psychological support. It also includes permitting a child’s engagement in risk behaviors, including but not limited to illicit substance use. , In living situations affected by family violence, including intimate partner violence, the dysfunction between caregivers can result in a lack of prioritization of the needs of their children in their care. ,

Environmental neglect is failing to provide a safe living environment as eliminating mitigatable hazards should be a priority for every caregiver. Hazards include, but are not limited to, exposure to illicit or prescription drugs, or associated paraphernalia. Children living in homes with a colocated methamphetamine laboratory are also at high risk with serious negative consequences. This includes poisoning, drug-related homicides, accidental deaths and burns from laboratory fires or explosions. Unsafe hoarding can also create unsafe conditions with associated fire hazards, lack of clear pathways, risk of falling, limited functional space for meal preparation, showering, playing, doing homework, or socializing. The exposure of children to sexually explicit materials in their living environment is also unsafe. Used as a deliberate strategy to undermine children’s abilities to avoid, resist, or escape abuse, it increases children’s vulnerability to sexual abuse.

Risk Factors for Neglect

The risk factors for child neglect occur at the level of the child, the caregiver, the family, and the community. The presence of these risk factors should not be considered pathognomonic to make a diagnosis of neglect; instead, they should be used to inform preventative strategies.

Child-level risk factors are age of the child, the child’s physical and mental health, as well as the child’s developmental capabilities. , Infants aged under 1 year are at highest risk as they are completely dependent on their caregivers. Similarly, children with medical or mental health challenges, or developmental delays, require an incredible time investment for their care. Time-intensive obligations may include frequent appointments, complex medication regimens, and infrequent opportunities for respite. Requiring a higher level of care at home and additional service requirements in school may overwhelm caregivers resulting in denial of school-based services in their stressed state. ,

Caregiver-level risk factors include low educational attainment, mental illness, and substance use. , Educational attainment can affect health literacy, which may diminish caregiver comprehension of a child’s illness, of the role of medications, follow-up appointments, or services to ensure best outcomes for the child. Additionally, this lack of understanding can result in unrealistic expectations for children at different stages of development leading to frustration and resultant neglect. , , Caregiver mental illness and substance use left untreated can cause a caregiver to be emotionally unavailable to provide the nurturing, love, and guidance a child requires. , Caretaking activities such as feeding, bathing, or clothing the child are also affected further impacting the well-being of the child. ,

Family-level risk factors include the presence of family violence and social isolation. , Children in large families with finite resources are at particularly high risk. Social isolation further limits the support available to caregivers to care for themselves or their children. These supports whether in the form of other family members or friends can provide respite to alleviate caregiver stress, a prominent risk factor and predictor for the occurrence of child maltreatment. ,

Community-level factors are primarily due to access. The absence of facilities catering to family well-being, community building, or the learning and socialization of children are fundamental resources for the prevention of neglect. , Poor access to medical care and mental health services or lack of neighborhood resources can negatively affect family health outcomes. , , A lack of community centers, public libraries, green spaces, and religious institutions can increase the perception of isolation and limited socialization. These spaces provide opportunities for families and community members to connect allowing a sense of belonging and trust for resource sharing that can address the needs of the family that may be unique to each community, further reducing a sense of isolation.

Protective Factors for Neglect

Protective factors support resiliency among families; however, their presence does not preclude a child from ever being a victim of neglect. , Protective child factors include a child being in good health, enjoys school, and is engaged in extracurricular activities. , Caregiver protective factors are engagement in learning about their child’s development, needs and management of their illness as needed. , The foundation of family protective factors is a social support system that include friends and other family members willing to help when the family is overwhelmed. Community protective factors are based on the availability of programs that will support the health, well-being, and quality of life of families in communities by addressing safe housing, transportation, community violence, education, job opportunities, and literacy skills as well as food pantries. Protective factors can be identified using the only peer-reviewed and validated tool of multiple family-level protective factors, the Protective Factors Survey. This self-report measure, focused on prevention, is organized by domains: emotional support, concrete support, nurturing and attachment, family functioning, and knowledge of parenting and child development.

Screening tools for child neglect

Pediatric clinicians must be attentive to the varied signs of neglect, which may include inadequate health care, recurring injuries, school absenteeism, and emotional issues (ie, depression and anxiety). , , For younger children, close attention to milestones are important as neglect can present as developmental delay. Screening for social determinants of health (SDH) to identify unmet needs can be used when there are only subtle signs of child neglect. Screening tools to identify families include the Safe Environment for Every Kid (SEEK) Parent Questionnaire-R (SEEK PQ-R) or the Well Childcare visit, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) screening tool.

The SEEK PQ-R is an evidence-informed approach to address specific risk factors including parental depression, major stress, unhealthy substance use, domestic violence, food insecurity, and the use of harsh punishment in families. , This screening tool specifically caters to families with children aged 0 to 5 years for the primary prevention of child maltreatment. , Findings from 2 large randomized controlled trials found that SEEK resulted in significantly lower rates of child maltreatment in all identified outcome measures. , This approach to strengthening families through strategies to increase good parenting practices, learning how to increase their young child(ren)’s health, development, and safety made a significant impact by decreasing child protective services (CPS) reports. , Decreases were also noted for nonadherence to medical care, delayed immunizations, and rates of harsh punishment clearly demonstrating the effectiveness of this model. ,

Another approach utilizes the 10 item, the WE CARE questionnaire. Similarly, this approach recognizes family strengths and incorporates the development of written family support plans to ensure understanding for implementation. Domains are economic stability, education, neighborhood/physical environment, and food. This screening tool has been incorporated at multiple health care centers across the country relying on existing clinical processes, infrastructure, and social service resources, thereby making implementation and sustainability feasible. , The WE CARE intervention is similar to SEEK in that it requires training of pediatric clinicians, a short screening tool for patients, and access to a directory containing community-based resource listings for provider referral of families. ,

Diagnosis and management of neglect

The etiology of neglect is multifactorial with all children at risk no matter race, ethnicity, education, or socioeconomic status. An effective response must be comprehensive with a focus on 3 key elements: (1) the needs of the child, (2) the caregiver’s access to resources and their efforts to provide, and (3) the consideration of all options to ensure the best possible outcomes. Pediatric clinicians should obtain a comprehensive history from the parent and child, if they are developmentally able to participate. This engagement is instrumental in understanding the family dynamics. After the interaction with the family, if there are suspicions of neglect, a candid discussion among members of the medical team, the family, and identified family support will promote an informed plan for best outcomes.

Discussion

Poverty as a Mimicker of Child Neglect

Poverty, defined as the lack of financial resources for an acceptable standard of living, has a strong correlation with child neglect. The supplemental poverty measure quantifies this lack of resources and is stratified at the level of the individual or family, by assets and income, recipients of public benefits and government-sponsored insurance, zip code, and the percentage of parents living below the poverty line. In 2022, the official poverty rate in the United States was 11.5%, with 37.9 million people in poverty. For children, the supplemental poverty measure reflects that the child poverty rate has more than doubled, from 5.2% in 2021 to 12.4% in 2022. Although neglect can coincide with poverty, poverty itself does not cause neglect; therefore, identifying the attributes of both is imperative to avoid trauma to the family when they are not differentiated.

Cognitive biases can result in the premature labeling of the caregiver as abusive during patient encounters where children present with visible signs of a lack of financial resources. As concerns about neglect do not automatically require a referral to CPS, the acknowledgment that child poverty can mimic child neglect is important. Studies describe the evaluation process by CPS as rife with disrespectful treatment, cultural misunderstandings, and harsh judgments of differing parenting styles resulting in lack of culturally appropriate services. A lack of stable or safe housing, transportation, steady employment, childcare, and community support can present as neglectful caregivers when, in fact, this is not the case. It is well documented that poverty indicators (material hardship and unemployment) and parenting behaviors (low warmth, physical discipline, and frequent TV viewing) have been shown to be predictive of child neglect. Taking into consideration the duality of these indicators as symptoms of poverty and known predictors of neglect, the benefits of government spending programs and their role in decreasing neglect cannot be overstated.

In 2020, Congress allocated US$56 million to Community-Based Child Abuse Prevention services—the largest dedicated federal source for primary prevention funding for child abuse and neglect. However, in 2018, the estimated lifetime economic burden of substantiated child abuse and neglect cases and child fatalities was approximately US$592 billion nationwide. Despite the increased funding, the realities of child maltreatment trends from 2018 to 2020 reflects a misalignment of funding allocation and the goals of Healthy People 2030.

There are several programs currently sponsored by the federal government to address food insecurity, mental health needs, and caregiver empowerment for families in need. Programs include the Supplemental Nutrition Assistance Program ( https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program ) to provide nutrition benefits to low-income families with field offices nationwide. , Another program is the Supplemental Nutrition Program for Women, Infants and Children ( https://www.fns.usda.gov/wic ) to help women and children aged up to 5 years with free healthy food, nutritional advice, and referrals to wrap around services such as health, welfare, and social services. , A mental health and treatment services resource sponsored by the federal government is Substance Abuse and Mental Health Services Administration (SAMSHA) Treatment Locator ( https://findtreatment.samhsa.gov/ ). The SAMSHA locator can be used to link families to resources using their address and zip code. Resources to support child development includes the Early Head Start Program ( https://eclkc.ohs.acf.hhs.gov/center-locator ). This program lays the foundations for healthy parent–child interactions through supporting child development and caregiver understanding of the child’s developmental needs.

Social Determinants of Health and Structural Racism

The World Health Organization defines social determinants of health (SDH) as “the conditions, in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” Growing up in poverty is a powerful social determinant of health because it can affect children’s access to health-promoting conditions. So, addressing poverty as an approach to eradicating child neglect cannot be overstated. Despite poverty being offered as the ubiquitous explanation for multiple dysfunctions of our society, including child neglect, the role of structural racism remains a key player.

Structural racism refers specifically to the public policies, laws, institutional practices, cultural representations, and other norms that work in various, often reinforcing, ways to systematically disenfranchise people based on race. These policies negatively affect the financial and social well-being of the families by the denial of access to services and opportunities with profound and detrimental health effects on predominantly Black, Indigenous, and People of Color (BIPOC) communities. As a result, children from these communities, from single-parent households, and from immigrant families are more likely to live below the poverty line. To address SDH and child neglect, pediatric clinicians must acknowledge structural racism as a major driver behind these trends. ,

Pediatric clinicians may be met with some defensive posturing by families from targeted communities in the offering of resources. The realities of the history of BIPOC peoples in the United States can often impede the process of connecting families to service offerings despite being overwhelmed by poverty and other vulnerabilities unique to marginalized communities. Many families may be uncomfortable with what they perceive to be an amplified exposure to social services systems (ie, financial assistance, food stamps, and housing assistance). For these families, this social service exposure cause increased visibility to mandated reporters—a phenomenon referred to as surveillance bias. This increase in the number of entities surveilling families may foster apprehension derailing service engagement as the offered services envisioned as needed aid, may be viewed as burdensome.

The Role of the Clinician and the Medical Home

The United States Preventive Services Task Force found inadequate evidence that primary care interventions can prevent maltreatment among children who do not already have signs or symptoms of such maltreatment. Several states have identified poverty as a major factor for some families in the child welfare system and are implementing strategies to provide supports, such as financial assistance to reduce the risk associated with children entering the child welfare system. In addition to these state level interventions, the pediatric medical home remains the gateway to all levels of prevention. The American Academy of Pediatrics strongly recommends pediatric clinician involvement in preventing child maltreatment because of their relationships with families across the life span. This approach to care facilitates relationship building with families allowing for an in depth understanding of their needs and by extension the attributes unique to each family. Routine child health supervision visits can be used to explore psychosocial issues and can aid in risk assessment. , Given the sensitive nature of the conversation, this established rapport between the pediatric clinician and the family is essential in the primary prevention of child neglect.

There are specific recommendations identifying opportunities to incorporate child prevention strategies for neglect. These recommendations guide anticipatory guidance priorities and screening approaches during health supervision visits using a proactive approach to identifying children at risk for neglect. , The well child visit can provide the platform for not only rapport building but also to discuss behavioral and developmental challenges for families spanning the continuum from infancy to adolescence. , It is strongly recommended that pediatric clinicians screen for changes in SDH, caregiver support systems, and mental health stressors, especially postpartum depression at health supervision visits. Pediatric clinicians should also consider mental health stressors that are specific to families in BIPOC communities. The experience of racial stressors across the life course can contribute to the accelerated deterioration in health and mental health in these communities. One such stressor is weathering. Weathering occurs as a consequence of the cumulative physiologic burden on biological systems by repeated experiences with discrimination, stigma, economic adversity, and political marginalization. Another mental health stressor specific to BIPOC communities is racial battle fatigue . Racial battle fatigue is the chronic experiences of racism and microaggressions resulting in constant anxiety and worry, hypervigilance, elevated heart rate and blood pressure, extreme fatigue, and other physical and psychological symptoms. The experience of these stressors related to enduring racial discrimination and their impact on mental health may contribute to adverse consequences on caregiver capacity and similarly neglect risks for children in BIPOC communities, so they must be addressed by pediatric clinicians during the health supervision visits.

In the prevention of neglect, there are anticipatory guidance priorities specific to each age group. Topics of each visit builds on the topics from previous visits to facilitate the rapport building instrumental to the accurate identification of risk factors. , For the prenatal visit, questions around the planning of the pregnancy is recommended to assess the impact of the impending birth. This is also an opportune time to explore parental experiences with trauma, explore how the parents were parented and disciplined, and understand the envisioned support system. The subsequent newborn visit builds on discussions from the previous visit to continue to establish trust with their provider. This visit is a great time to explore parental feelings around infant crying and techniques for calming the infant, eliciting and adjusting their perspective on positive parent-newborn interactions, and encouraging the identification of trusted individuals to provide respite from the care of the newborn. For the rest of the visits for the next few months of life, it is important to continue to discuss infant crying and attachment, the realities of sleep deprivation for parents, and postpartum depression. Any misinformation about normal development and expectations around sleeping, waking, and feeding demands for this infant should be addressed during these visits. , ,

The scope of the problem of child neglect, when the responsibility of this neglect is expanded beyond that of the parents or guardians, extends to inadequate health care, poor education, inadequate housing, the ineffectiveness of the social selection policies, and other adversities resulting from constructs made or not made adversely affect a select group of children, thereby expanding the number of children suffering from neglect. Neglect can have substantial and long-term effects on children’s physical and mental health as well as on their psychosocial and cognitive development including, but not limited to, physical effects, cognitive/academic effects, and psychosocial effects. These effects only compound without effective interventions as the Adverse Childhood Experiences study has shown increased risk for depression and suicidality decades later with the added risk for involvement in the criminal justice system. ,

Summary

Child neglect, the most prevalent form of child maltreatment, is a toxic stress with harmful results affecting children of all socioeconomic classes. , , Given the similarities in presentation between child neglect and poverty, children from communities impacted by structural racism are at increased risk at the hands of both of these SDH. Pediatric clinicians are in an optimal position to engage with families in ways that will differentiate the two to ensure the appropriate unmasking of unmet needs of families they serve while being mindful of the role of implicit bias in hampering this process. There are evidence-based approaches to screening for neglect coupled with programs sponsored by the federal government to address SDH and contributors to neglect at the level of the child, caregiver, and communities. With available tools pediatric clinicians, social workers, and mental health providers can not only play a role in the prevention and early detection of child neglect but also play the role of an advocate when the effects of poverty and structural racism thwarts collective efforts.

Clinics care points

  • Clinicians should be familiar with the common and subtle signs of all subtypes of child neglect.

  • Clinicians should be aware of the similarities between the presentation of child neglect and poverty as it is imperative to differentiate between the two using evidence-based screening tools.

  • Understanding the history of racism and its role in child maltreatment, clinicians are encouraged to engage in training to recognize and address implicit biases.

  • Prevention of child neglect should be prioritized. Upon identifying unmet material needs, clinicians should refer and connect families to resources and services addressing all possible contributors.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

May 20, 2025 | Posted by in PEDIATRICS | Comments Off on Recognizing and Responding to Child Neglect

Full access? Get Clinical Tree

Get Clinical Tree app for offline access