Re-examining child neglect in the changing policy landscape

Frances Gunn and Duncan Helm (University of Stirling)

November 2023

Acknowledgements

This Insight was reviewed by Graham Hall (North East Locality Children and Families Team), Caroline McDonald (Glasgow City Health and Social Care), Jane Scott (Independent Consultant), and Scottish Government colleagues across the Directorate for Children and Families and paediatrics policy team.

Comments represent the views of reviewers and do not necessarily represent those of their organisations. Iriss would like to thank the reviewers for taking the time to reflect and provide feedback on this publication.

Key points

- Child neglect remains a prevalent and pressing challenge across Scotland.

- Messages from research and practice suggest that ensuring consistent assessment of neglect remains problematic in practice.

- Findings from Significant Case Reviews (now Learning Reviews) highlight that consideration of thresholds regarding escalating neglect concerns is indicated.

- The complexity of chronic or severe neglect requires a co-ordinated multi-disciplinary approach, rooted in local communities.

- Recent policy emphasises the relationship between neglect, poverty and other systemic stressors, providing an opportunity to review and reflect on best practice.

Introduction

This Insight explores the evidence on child neglect in the context of the refreshed Scottish definition of neglect published in the National Guidance for Child Protection (Scottish Government, 2021). Throughout this work, the word ‘child’ is used to include infants, children, and young people up to the age of 18, and the word ‘caregiver’ is used to include parents, legal guardians and others who care for children.

In the 2014 National Child Protection Guidelines, neglect was defined as ‘...the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development’ (Scottish Government, 2014, p12). With the publication of the 2021 National Child Protection Guidelines, this definition has been refreshed and expanded to acknowledge that: ‘neglect can arise in the context of systemic stressors such as poverty and is an indicator of both support and protection need’ (Scottish Government, 2021, p13). This emphasis on structural inequality and recognition of the links between need for support and need for protection presents both challenges and opportunities in practice which we will examine in this Insight.

Daniel (2015) reflected on a child’s experience of neglect as hunger or being left alone for lengthy periods, or being ignored when distressed, excited or happy and having no opportunity to have fun with caregivers or other children, or lack of support to attend school or health care services. This demonstrates the breadth and complexity of how neglect affects children. Our developing understanding of the impact of child neglect throughout the life course shows that due to its chronic and cumulative presentation, neglect in childhood can interrupt social, emotional and physical development resulting in long term consequences including poor physical and mental health, reduced educational attainment and subsequent lower earning potential, disrupted attachment impacting on expectations of healthy relationships, evidencing it as one of the most damaging manifestations of abuse (Blaisdell and colleagues, 2019; Chandan 2019; Kumari, 2020).

GIRFEC (Getting It Right for Every Child) underpins all professional work with children in Scotland. In this Iriss Insight, the five GIRFEC questions are used to guide exploration of policy, research and practice around working with neglect. This Insight is therefore relevant to all professionals who work with children.

The prevalence of child neglect

In the year 01/04/2022 to 31/03/2023, The Scottish Children’s Reporter Administration (SCRA) received 4087 referrals in respect of 3208 children under grounds of a ‘lack of parental care’ (s67 (2)(a) Children’s Hearings (Scotland) Act (2011). While the number of referrals to SCRA under ‘offence’ ground 1j CH(S)A 2011 was higher at 6498, these referrals were in respect of 2637 children highlighting that lack of parental care is the most common reason for referral into the Children’s Hearings System. Although lack of parental care is not an exact definition of neglect, the data give a fuller picture of the numbers of children who may be experiencing some form of neglect.

This trend is echoed in the Scottish Government statistics on child protection registration: in the year 01/08/2021 to 31/07/2022, 1397 children whose names were placed on the child protection register in Scotland had neglect identified as an area of concern, making it second only to exposure to domestic abuse. The two most recent Triennial Reviews of Initial Case Reviews (ICR) and Significant Reviews (SCR) in Scotland (Care Inspectorate 2022 and Care Inspectorate 2019) both also highlight that neglect continues to feature prominently. In the triennium 2018-2021 neglect was noted as a contributory factor in 18 of the 32 SCR’s analysed, while in the triennium 2015-2018 of the 25 SCR’s analysed, 13 identified neglect as a cause of harm. This means that since 2015 in Scotland within SCR’s, neglect remains the most common familial non-fatal category of harm that children have been subjected to. It is clear therefore, that neglect continues to be a significant area of challenge for practitioners in Scotland.

Working with neglect: current policy landscape

Within the literature between the 1980s and 2000s, there was felt to be a ‘neglect of neglect’ (Wolock and Horowitz, 1984; McSherry, 2007) meaning that, although neglect was commonly observed in practice, it was under researched and not viewed as a priority in service provision. Several seminal research papers have been published since then in Scotland, (Daniel and colleagues, 2010; Daniel and colleagues, 2014, Burgess and colleagues, 2013; Daniel, 2015; Scott and Daniel, 2018) and the focus on neglect within the Child Protection Improvement Programme (Scottish Government, 2016) has undoubtedly driven policy and guidance to inform practice. The statistics above however confirm that levels of neglect remain both high and static, which indicates a need to consider new ways of working with neglect.

Research suggests that a high proportion of children who are looked after away from home on more than one occasion have experienced neglect (Cusworth and colleagues, 2019). This relationship between neglect and care experience evidences the significance of the impact of neglect, and challenges the perspective noted within the research that professionals view neglect as less serious than other forms of abuse (Stokes and Taylor, 2016). The findings of the Independent Care Review (2020) enabled policy makers and practitioners to hear the voices, perspectives and lived experiences of care experienced children and young people, including some who had been subject to neglect, and led to development of The Promise (2020) which was created to support the ambition for children in Scotland to grow up loved, safe, and respected. That these findings are influencing policy development provides some evidence of the Scottish Government commitment to public input in shaping policy development outlined in the Participation Framework (Scottish Government, 2023).

Driven by this ambition, research and lived perspective, the policy landscape in Scotland is shifting to encompass an ethos of more rights-based and relationship-based ways of working. The United Nations Convention on the Rights of the Child (1989) (UNCRC) underpins our key policy driver GIRFEC, and both recognises and values the fundamental roles played by caregivers in meeting the needs of children. Parental responsibilities are crucial in the context of child neglect as, neglect occurs when caregivers have not, for any reason, fully fulfilled their responsibilities to care for the child, and this lack of parental care results in impairment to the child’s health or development. The UNCRC places responsibility on State Parties to provide appropriate assistance to help caregivers in performing their parental responsibilities to guarantee and promote the rights set out in the Convention. The Family Foundation within The Promise emphasises the need for State Parties to provide supports to families when required (The Promise, 2021). To support State Parties to effectively provide this appropriate assistance, Children’s Services Planning (CSP) is set out in legislation in Part 3 of the Children and Young People (Scotland) Act 2014. This approach requires services and support to be delivered through a whole family, whole-system cross-sector approach which spans prevention, universal services, early intervention and targeted/intensive/crisis support.

The GIRFEC framework encompasses the cumulative analysis of research, reviews and practice experience. It is the overarching influence guiding work with children and families to support the Scottish Government’s ambition of making Scotland ‘the best place in the world to grow up’. The refreshed definition of neglect as an indicator of both support and protection need, emphasises that the GIRFEC principles remain applicable throughout all work with children and families, including work under the auspices of child protection. GIRFEC therefore is described as a ‘continuum of services including prevention and early intervention’ (Scottish Government, 2021, p15). This provides an important reminder that professionals working in universal services are privileged to remain with children across that continuum, whereas targeted services may only become part of the Team Around the Child (TAC) when more intense assessment and support is required. Coles and colleagues (2016, p336) argue that GIRFEC is ‘a universal children’s well-being policy framework that embodies a holistic approach to understanding children’s needs with an aspirational commitment to all of Scotland’s children’. Given GIRFEC’s universality, the role of universal services in identifying concerns about neglect is crucial, as most children will be visible to universal services. The challenges and opportunities in working with neglect will now be explored in the context of the five GIRFEC questions.

What is getting in the way of this child or young person’s wellbeing?

A lack of shared understanding?

In the context of neglect, this question often focuses on caregivers not meeting the child’s needs. However, this framing suggests implicit assumptions in the way that professionals, families, and children construct and understand neglect. Without a shared understanding between families and professionals about what neglect is and its impact, a trusting relationship and shared outcomes and goals cannot truly exist. And without trust, potential for partnership working to achieve genuine and sustained change is reduced (Ingram and colleagues, 2015; Pecora and colleagues, 2014). The impact of past trauma on caregivers' ability to form the trusting relationships that enables partnership working is widely acknowledged and underpins the National Trauma Training Programme (NTTP) which aims to support practitioners in adopting a trauma skilled approach to work with families.

UNCRC Article 12 sets out the child’s right to express their views on matters affecting them and for those views to be taken seriously. However, research suggests that a child’s young age and lack of comparisons might make it harder for them to understand or recognise their own experiences of care as neglectful (Cossar and colleagues, 2013). UNCRC Article 19 requires state parties to do all they can to protect children from neglect, but a child may lack the ability to articulate their experience of neglect (Burgess and colleagues, 2014) and experiences may manifest in challenging behaviours (Cossar and colleagues,2013). It is therefore vital that professionals have the knowledge and skills to really hear what children are saying about their experiences. For a rights-based approach to be fully embedded into practice, it is necessary to empower children to understand what safe care looks like and to ensure that their expectations are in line with professional evidence-based perspectives of ‘good enough’ care.

Horwath and Tarr (2015) argue comprehensively that professionals working with child neglect, more so than other types of abuse, are at greater risk of losing sight of the experiences of the individual child thereby resulting in assessment and intervention that are not child focused. They argue that this is due to how professionals relate to the social construction of the neglected child as opposed to a more holistic ethos of a child who has experienced neglect and been impacted by this.

Do I have all the information I need to help this child or young person?

Given that neglect can span across all dimensions of a child’s life, is it unlikely that one professional will be in possession of all the information?

The definition of child neglect in policy encompasses physical, emotional, educational and health neglect, therefore several agencies may hold information indicative of neglect (NSPCC, 2022). This means that joint working, information sharing, and analysis is crucial when considering child neglect. Munro (2008) likened multi-agency assessment to completing a jigsaw puzzle, with different people holding different pieces of the puzzle. However, this assumes we have all the pieces of the puzzle and an idea of what the completed puzzle looks like (Helm, 2010). If we remove these assumptions, the challenging reality for practitioners becomes clearer. Key information is often missing and there can be a lack of clarity about what outcomes professionals are trying to attain. The need for multi-agency working, underpinned by shared understanding, is crucial. GIRFEC provides a necessary framework for multi-agency responses through Team Around the Child (TAC) processes.

What can I do now to help this child or young person?

How can I ‘own my concerns’ and work in partnership with the family to address the neglect?

Colin Anderson, Chair of Glasgow Child Protection Committee (CPC) urged all agencies ‘to own their concerns’ when reflecting on the findings of the SCR into the death of Lauren Wade in 2015 (Glasgow CPC, 2016) which concluded that she had died due to severe neglect. This important call reminds us of the message within the seminal report ‘It's Everyone’s Job to make sure I’m Alright.’ (Scottish Executive, 2002) emphasising shared responsibility for reporting concerns about both abuse and neglect.

Although the individual roles of all practitioners are clearly outlined in policy, in practice this can be complicated by factors including lack of understanding of the remit and responsibilities of other agencies. Thomson (2011) notes that, in practice, information flows from other agencies towards social work creating a hierarchy and inferring that social work, as Lead Professional, are the agency required to have the ‘full picture’. However, with the Scottish Government investment in health visiting and school nursing, the role of universal health services is strengthened, and alongside education staff, these universal services have a crucial role in identifying neglect as they are often the professionals who have consistent contact with the child for the longest periods of time (Sommerfield, 2019). Therefore, following the GIRFEC questions, when universal services identify neglect, they should begin to assess and provide initial support, unless the neglect at the point of identification is such that there is an immediate risk of significant harm requiring assessment by social work. There may not therefore always be a role for social work as Lead Professional during initial assessment of neglect and subsequent intervention as another agency may be best placed to adopt this role.

Scott and Daniel (2018) emphasise that, for interventions to address neglect to have maximum impact, professionals need to engage effectively with families by forming trusting and respectful professional relationships. However, when professionals identify that caregiver reporting does not match professional assessment, or cannot be evidenced, professional curiosity and respectful challenge are both essential. Muirden and Appleton (2022) confirm the value of professional curiosity across both health and social care which is helpful in the context of multi-agency working, as the body of research since inception of the term ‘professional curiosity’ in 2013 has focussed on its role in social work practice.

What can my agency do to help this child or young person?

How can teams and organisations be better equipped to work effectively with neglect?

Professionals work in the context of their employing organisation, and this must be recognised when exploring work with child neglect. A decade ago, Brandon and colleagues (2013) described some children who were subject to neglect as ‘hidden’ and, in Scotland we saw the most severe outcome of hidden neglect in the case of Declan Hainey who died in 2009. Learning extrapolated from SCRs across Scotland suggests the term ‘hidden’ remains unfortunately apt for neglect. There is a disconnect between these missed intervention opportunities and the GIRFEC principles of early intervention, which confirms that recognition of child neglect continues to be challenging. While GIRFEC has at its core an ethos of maximising wellbeing, it does not claim to have been specifically designed to identify risk of child abuse or neglect (Vincent, 2011). In practice, this has been noted as a repeated point of concern for practitioners who feel the need to employ specific tools over and above those within the National Practice Model (NPM) to ensure robust assessment and management of child neglect.

Across Scotland, there are differing approaches to assessment of neglect. In some areas this is underpinned by a broad approach to work with children and families via the NPM, in others a specific framework like Signs of Safety (Turnell, 2011) is in use and some areas have adopted specific child neglect assessment tools (CNAT) eg, the Graded Care Profile 2 (NSPCC, 2015; Srivastava and Hodson, 2020).Within the Triennial Review of Learning from SCRs in Scotland 2018-2021, Glasgow Child Protection Committee highlight their relaunch of use of a standardised CNAT as an example of practice change. They suggest that this, in combination with other initiatives supporting working with neglect, is demonstrating early indications of increased confidence in identification of neglect (Care Inspectorate, 2022).

While acknowledging the research highlighting the value of use of CNAT (Barlow and colleagues, 2012), a disconnect relating to the use of simplistic tools to score a phenomenon as complex as neglect may exist. Although CNAT have been developed to bring objective and consistent assessment of the impact on children living with neglect, this appears at odds with the more individualised GIRFEC approach. Horwath and Tarr (2015) also warn that use of generalised assessments can result in professionals having only a limited understanding of the impact of neglect on each individual child. They argue that use of CNAT, rather than increasing a child-centred approach, are instead focused on making parenting more effective without acknowledging the role of social stressors, and that due to individual factors and resilience, the impact of the neglect has the potential to be different for each individual child.

Research suggests that professionals can become desensitised to neglect over time and this can impact on thresholds and prioritisation of workload (Doherty, 2017). Organisational factors like resource availability can also have a significant impact on threshold judgements and decision-making (Platt and Turney, 2014). When coupled with the complexity of understanding neglect, these factors can result in a form of assessment ‘paralysis’ in practitioners (Brandon and colleagues, 2008) that can result in missed opportunities to support and protect neglected children.

Where neglect is chronic or where threshold judgements are challenging, supervision should always be considered. Supervision should support reflection on complex and chronic neglect cases (McGregor and Devaney, 2020) and is an important conduit to escalation. However, Ravalier and colleagues (2023) question the quality and consistency of delivery of supervision in practice and it is acknowledged that organisational pressures can shift the focus of supervision away from reflection and learning towards accountability and managerial functions (Wilkins and colleagues, 2017). These barriers to the effective delivery of supervision should be addressed locally, to ensure that practitioners consistently have access to the reflective supervision that is known to be the ‘cornerstone of good practice’ (Laming, 2003, p11).

Where neglect is chronic or where challenges around thresholds exist, supervision should always be considered. McGregor and Devaney (2020) highlight the role of those providing supervision in emphasising the value of reflecting on chronic neglect cases and given the role of supervision in bringing a more objective perspective and reflection on complex cases, it is suggested that supervision is an important conduit to escalation. However, Ravalier and colleagues (2023) question the quality and consistency of delivery of supervision in practice, and Wilkins and colleagues (2017) highlight the organisational pressures which can lead to the focus of supervision shifting towards accountability and managerial functions rather than reflection and learning. These barriers to the effective delivery of supervision should be addressed locally, to ensure that practitioners consistently have access to the reflective supervision that Laming (2003, p11) hailed as the ‘cornerstone of good practice’.

What additional help, if any, may be needed from others?

It takes a village to raise a child … scaffolding and the relationship between the community and child neglect

It can be argued that neglect is abuse by omission rather than commission (Taylor and Hoyano, 2012; Gill, 2014) and that neglect is therefore more heavily dependent on, or influenced by, external and community factors and social stressors than other forms of abuse.

A most pressing social stressor is poverty. Bywaters and colleagues (2016) have provided evidence establishing that ‘poverty is a contributory causal factor in child abuse and neglect’ (Bywaters and colleagues, 2016a, p33) and in their updated review in 2022, they confirm that ‘family poverty and inequality are key drivers of harm to children’ (Bywaters and colleagues, 2022, p7). The evidence supports the argument that unemployment and lack of access to money makes it more difficult to meet a child’s needs effectively even when the secure attachment and motivation to meet the child’s needs is present. Given our post-pandemic landscape, and cost of living crisis, the impact of financial issues is increasing sharply. In Scotland most Health and Social Care Partnerships (HSCP) have robust income maximisation services, which effectively address some material consequences of poverty, but this is a narrow perspective and cannot support the longer term, sustainable changes required to mitigate the more complex impacts of poverty on the ability of caregivers to meet the needs of their children. All the evidence outlined has identified that this is a structural factor which cannot be changed easily in the scope of 1:1 practitioner intervention, yet it strongly impacts on the ability of families and caregivers to effectively meet the needs of their children. Featherstone and colleagues (2019) highlight the challenges for practitioners in working with families in the context of austerity and cuts to services, and argue that to maximise impact within their sphere of influence, practitioners need to work more effectively within the communities and wider contexts in which neglect occurs.

Saar-Heiman and Gupta (2020) introduce a poverty aware paradigm for child protection (PAPCP) and suggest that risk within traditional child protection discourses focuses on harm deemed to be caused by actions or inactions of caregivers, with an absence of attention to harms because of structural inequalities like poverty. This approach fits well with an approach to working with neglect based on lived circumstances, rather than professional aspiration. Poverty is a context that places constraints on decision-making also because it alters the psychological, social, and cultural factors that influence the decision-making process, and the way people view the world around them. Bramley and colleagues (2019) within their Hard Edges reports also note the potential value of a whole systems approach rather than intervention on an individual level. Their findings give a window of insight into the holistic impact of living in deprived areas with severe or multiple disadvantages. They suggest that there is likely to be an area effect which, when considered in the context of child neglect, confirms that the communities in which we live have an impact on shaping our expectations of care and need by providing a local baseline of acceptable and expected behaviours. They also highlight a ‘selection effect’ whereby families who have experienced adversity and/or low income are more likely to end up in areas of high deprivation through housing allocation processes. They argue that social support has potential to prevent stress from developing into depression, but there are indications that it is less effective in low socio-economic-status neighbourhoods. It is not known exactly why, but one hypothesis is that other members of the same neighbourhood are also stressed, therefore linking back to the idea that social stressors are community level problems and should be addressed as such, rather than on an individual level (Bramley and colleagues, 2019).

The benefits of services rooted within and shaped by local communities is echoed by Turbett (2020) in a previous Iriss Insight advocating a community social work (CSW) model. CSW is described as preventative early intervention which is led by local need with an ethos of shared responsibility between the community and the service. There are several examples of this model or similar being successfully trialled in Scotland at the time of writing, including the Help Everyone At the Right Time (HEART) model in East Ayrshire, CSW in Fife, and the Centre for Excellence for Looked after Children in Scotland (CELCIS) Addressing Neglect and Enhancing Wellbeing (ANEW) programme, all of which share an ethos of community led early intervention.

The need to escalate

The Care Inspectorate (2019) has consistently noted a small number of children who have been exposed to neglect for lengthy periods of time before professional intervention, including where caregivers were described as highly resistant to working with professionals. This resulted in challenges for the professionals in timeously identifying and responding to neglect that had demonstrable poor outcomes for the child. Lauren Wade’s death provides a stark reminder that, while the impact of neglect is a continuum of harm, it can, in the most significant cases, result in death. The SCR completed following Lauren’s death noted that ‘although there were a number of indicators of neglect, there was…no clear assessment of needs’ (Glasgow CPC, 2016, p10). This reminds us that, when indicators or concerns regarding neglect are noted or reported, timely and robust assessment of need is essential. Should a family decline to enable this, statutory measures to enable assessment should be considered (NSPCC, 2022).

The findings from SCRs confirm that, where neglect coexists with resistance or non-engagement, the cumulative effect of these can result in significant harm and therefore the threshold for escalation should always be considered. Due to the complexity and chronic nature of neglect, there can be challenges in evidencing the need for legal measures to reduce risk (Dickens, 2007). Values and beliefs are significant influences in threshold judgements, yet the findings of SCRs exclude the detail of the interactions between professionals, agencies and families (Ferguson, 2016) which are an important source of learning. Complexities and tensions in relationships can be present even when professionals endeavour to follow the principles of partnership working. To effectively support and protect neglected children, practitioners need to demonstrate respect and empathy for caregivers' choice to decline assessment (Frederick and colleagues, 2021) but without losing sight of the child’s lived experience and potential need for escalation.

The key practice messages

- Timeous identification of neglect is important and there is some evidence suggesting use of structured assessment tools can support practitioners to confidently identify neglect, however these must be used critically and in conjunction with professional holistic assessment and judgement.

- Where there are concerns or indicators of neglect, a full assessment of need is crucial, and if the family declines to engage in this, supervision and consideration of statutory measures is key to avoid drift.

- Access to consistent high-quality supervision is also important when professionals have been working with chronic neglect to challenge complacency.

- Despite the prevalence and the growing body of evidence highlighting the magnitude of harm resulting from neglect, it continues to be viewed as less severe than other forms of abuse. This must always be challenged, and where neglect coexists with resistance, timeous consideration of escalation to ensure ongoing assessment is facilitated is crucial.

- Given the complexity of neglect, multi-agency working, and information sharing is key to obtaining a full and holistic understanding of the presentation and impact of the neglect. Neglect is not solely a social work issue to address, and all professionals have a crucial role in identification of neglect and working to improve outcomes for children.

- Social stressors including poverty can underpin neglect, and where contributory factors are noted to be outwith the family’s control this must be acknowledged and reflected in planning.

- Given the clear links between poverty and neglect, there is a compelling argument for continuing to emphasise the whole family approach, whilst simultaneously targeting CSP and subsequent intervention on a community level, rather than on an individual level. Partnership working with third sector colleagues to enable this is essential.

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About the authors

Frances Gunn is a Service Manager in Universal Early Years. She is a registered midwife and health visitor, and has experience as a child protection advisor. Frances is also a part time PhD student at the University of Stirling. Her PhD research study is an exploration of professionals and families’ understanding of child neglect using an ecological framework perspective, with data from Ayrshire & Arran providing a geographic case study and context to the findings.

Duncan Helm is a Senior Lecturer in Social Work at the University of Stirling. He is a registered social worker with practice experience and subject expertise in child and family social work. Duncan’s research interests are in professional judgement and decision making. He has published on topics including analysis in assessment, sensemaking and peer-aided judgement.

This work is licensed under the Creative Commons Attribution-Non Commercial-Share Alike 2.5 UK: Scotland Licence.To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-sa/2.5/scotland/ Copyright © November 2023

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