Child Neglect: Guidance for Pediatricians

Abstract

After completing this article, readers should be able to:Child neglect is the most common form of child maltreatment,accounting for more than 50% of all cases reported to child protection services(CPS). The 1993 National Incidence Study of Child Abuse and Neglect,based on the identification of maltreatment by community professionals, identified 30 cases of neglect per 1,000 children in the population,a very conservative estimate. The morbidity and mortality associated with neglect also are substantial. Physical problems include injuries,ingestions, inadequately treated illnesses, dental problems,malnutrition, neurologic deficits, and the approximately 50% of the estimated 2,000 annual fatalities that are attributed to child maltreatment. Psychological problems include difficulties with attachment in infancy, impaired cognitive development and learning difficulties, emotional and behavior problems, and delinquent and criminal behavior. Addressing child neglect falls well within the broad mission of pediatrics to protect children and enhance their health and well-being. Pediatricians have many opportunities to identify child neglect and to intervene. Finally, all 50 states have laws requiring physicians (and others) to report child neglect to CPS.Child neglect usually is defined as parental omissions in care that result in actual or potential harm to the child. In general, CPS requires clear evidence of harm, unless the risks are obviously serious, such as when young children are left unattended. Some states exclude situations attributed to poverty.We suggest a richer and more constructive framework for defining neglect. If our purpose is to enhance children’s safety and health, not to blame parents, neglect can be defined as occurring when children’s basic needs are not adequately met. Using this definition, neglect may be attributed to child, parent, family, or community factors, and the response(including whether to report to CPS)can be guided by an understanding of the etiology of the problem, the severity of the neglect, and the availability of different options. Basic needs include adequate food,health care, clothing, nurturance,protection, supervision, education,and a home. Parents are primarily responsible for ensuring that these basic needs are met, but other important factors beyond parental behavior contribute to their ability to do so. A broad, child-focused definition identifies basic needs of children that are not met and suggests interventions that might be appropriate (eg, a visiting nurse) regardless of whether CPS criteria are met.The following points pertain to this definition of neglect: Pediatricians may encounter a variety of forms of neglect. The goal of this article is to provide practical information for the brief assessment and initial management of different types of neglect. Some of these require screening(eg, hunger); others may be observed (eg, failure to thrive). We first offer “core issues”or general principles for assessing and managing all of the types of neglect,followed by a brief description of each form of neglect, adding specific issues pertaining to its assessment and management. Systematic screening is recommended during child health supervision visits to help prevent neglect or to detect problems that may not be apparent. It is beyond the scope of this article to detail the assessment and management of all the issues raised.By employing a systematic approach, the clinician usually can provide the most thorough assessment and management of child neglect. Health-care recommendations are not implemented, resulting in actual or potential significant harm (eg, a child who has severe asthma is not getting/taking prescribed treatment).Screen: “Do you have trouble getting medical care or medicines for your child?” Delay or failure in getting health care resulting in actual or probable significant harm (eg, infant who has protracted symptoms presents with severe dehydration, child who has serious mental health problems is not receiving help).Screen: “Do you have trouble getting medical care or medicines for your child?” nadequate food may present as failure to thrive (FTT) or “growth deficiency” or as repeated hunger. FTT usually is defined as growth that is less than expected, reflected by the weight for age or height for age falling below the 5th percentile, the weight for height falling below the 10th percentile, or the weight for age falling across two major percentiles. Severe and chronic undernutrition impedes brain growth, as reflected by the head circumference. Poor growth raises concern about the adequacy of the diet, especially if there is no other explanation (eg,Down syndrome). However, children can experience significant hunger and still grow normally.Screen: “Do you sometimes have trouble getting enough food for your family?” Review growth pattern,note possible trend toward FTT. A nutritionist or dietitian is recommended if poor growth persists or if there is moderate FTT. A comprehensive approach to managing FTT is listed in the Suggested Reading. A few issues will be highlighted: In utero exposure to illegal drugs is a form of neglect, as is direct and indirect (ie, passive inhalation)exposure of older children. In addition, exposure to alcohol and tobacco can harm the fetus,constituting neglect.Screen (during pregnancy): “Have you been smoking? Have you ever felt that you ought to cut down on your drinking? Have you been using any drugs?” After the newborn period: “Does anyone at home smoke or use drugs or alcohol?” Consider using one of the brief standardized measures to screen for alcoholism(eg, CAGE). Avoidable exposure to well-known environmental hazards, in and out of the home, is a form of child neglect. Examples include: poisonous substances within reach of young children, smoking around children who have pulmonary conditions,exposure to domestic violence, riding a bike without a helmet, failure to use a car seat or seat belt, and access to a loaded gun.Screen: “Are all poisons and other dangerous items out of reach? If your child rides a bike, does he or she wear a helmet? Do you have a smoke alarm that is in working condition? Does anyone smoke at home? Is there a gun in your home?Is anyone harassing you, making you afraid, or physically hurting you?” Neglect occurs when children are not supervised in accordance with their developmental needs, resulting in clear risks to their health and well-being (eg, an infant left unattended in a bath tub, a preschooler left home alone, a teenager out overnight without parental approval). Abandonment is the extreme form and has been defined as occurring when children are not “claimed”within 2 days; teenagers may be forced to leave the home.Screen: “Are there times when you need to leave your child alone or you’re not sure where he or she is?” The child does not receive adequate affection, nurturance, love; the child does not have a secure sense that parent feels positively about him or her and that the paren clearly cares about or is able to care for him or her (eg, infant of a depressed mother comforted is often unmet, preschooler whose parents abuse drugs and who seldom receives positive attention from them, teenager who receives little parental supervision and feels that her parents are uninterested in her and not supportive of her emotionally).Screen: “Do you often feel down,depressed, or hopeless? How are you managing with the kids?” A child’s educational needs are neglected when the child is not enrolled in school, when a child fails to attend without a satisfactory reason (>2 d/mo), and when special educational needs are not adequately met. “Home schooling,” if organized appropriately, appears to be an acceptable alternative.Screen: “How are things going at school?” Ask about behavior,learning, and peer relations. Child repeatedly does not meet basic standards of hygiene (eg, child is obviously smelly or filthy, not just scruffy).Child repeatedly wears clothing that is obviously unsuitable for the weather or poorly fitting (eg, lack of jacket in very cold weather,painfully small shoes).The family is forced to sleep in a homeless shelter, on the street, or in a car.Screen: “Have you been homeless in the last year?” Refer to appropriate resources for housing assistance.Our approach to child neglect focuses on basic needs of children that may not be met. In view of the overlap that often exists among different types of neglect, we offer“core” guiding principles for assessing and managing those issues. The guidance in this article must be adapted to the individual clinician’s circumstances.This work originated at the Child Abuse and Neglect Leadership Conference in Chicago, June 1997. We would like to acknowledge the contribution of others in our working group: Sara Schuh, MD, Wendy Wright, MD, and Lavdena Orr, MD.