Neglect

Neglect is defined in Working Together to Safeguard Children 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. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:

• Provide adequate food, clothing and shelter (including exclusion from home or abandonment);
• Protect the child from physical and emotional harm or danger;
• Ensure adequate supervision (including the use of inadequate caregivers); or
• Ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.

The impact of Neglect during the first two years of a child's life can have profound and lasting effects on the development of the brain, leading to later problems with self-esteem, emotional regulation and relationships.

Neglect during the first five years of a child's life is likely to damage all aspects of the child's development. A neglected child may have difficulties with:

• Basic trust;
• Self-esteem;
• Ability to control their behaviour;
• Social interaction;
• Educational attainment; and
• Problem-solving.

Neglect in childhood can also lead to problems during adulthood, including:

• Living independently in the community;
• Accepting adult responsibilities;
• Anti-social behaviour such as criminality, substance misuse;
• Increased vulnerability to being in abusive relationships (including the risk of sexual exploitation, criminal exploitation and being trafficked);
• Life chances and opportunities such as employment and education;
• Parenting - children who experience neglect lack a role model for good parenting, and so are vulnerable to becoming neglectful or abusive parents; and
• Self-care - for example, nutrition, general health, risk-taking behaviour;
• Mental ill health, including dissociative disorder, PTSD and depression.

Risk factors that could impact the parents' ability to provide appropriate and safe care include:

• Having children with disabilities, complex health needs or who were born prematurely;
• Social isolation;
• Poverty, housing issues, unemployment;
• Young parents;
• Care leavers;
• Substance misuse;
• Domestic abuse;
• Mental ill health;
• Learning disabilities.

A particularly damaging combination for children is growing up in an environment of low emotional warmth and high criticism - that is, parents/carers who switch unpredictably between helpless (neglectful) and hostile (abusive) care.

Neglect can affect children of all ages, including adolescents and older children.

When parents/carers hold specific beliefs that may influence their views on how the child receives health care and treatment, or on general nutrition, the child's health and well-being can be dangerously compromised.

It is important to remember that neglect can be fatal to the child.

"The majority of neglect related deaths of very young children involve accidental deaths and sudden unexpected deaths in infancy where there are pre-existing concerns about poor quality parenting and poor supervision and dangerous, sometimes unsanitary, living circumstances which compromise the children's safety . . . these issues include the risks of accidents such as fires and the dangers of co-sleeping with a baby where parents have substance and/or alcohol misuse problems." (Brandon et al., 2013).

Neglect differs from other forms of abuse in that there is rarely a single incident or crisis that draws attention to the family. Rather, it is repeated, persistent neglectful behaviour that causes incremental damage over time.

It is important to avoid 'start again' syndrome. Neglect should not only be measured by the most recent set of events but should be judged by the cumulative impact on the child of any previous incidents.

There is no set pattern of signs indicating neglect other than the child's basic needs not being adequately met. In this context:

• The child's basic needs are for food, shelter, clothing, warmth, safety, stimulation, protection, nurture, medical care, education, identity and play;
• Adequately means sufficient to avoid harm or the likelihood of Significant Harm;
• Failure to meet the child's needs does not necessarily mean that the parents/carers are intentionally neglectful, but it points to the need for intervention;
• It is essential to monitor the outcome of intervention - are the child's needs being adequately met after the intervention, and is there a sustainable improvement?

The essential factors in demonstrating that a child is being neglected are:

• The child is suffering, or is likely to suffer, Significant Harm;
• The harm, or risk of harm, arises because of the failure of parents or carers to meet the child's needs;
• Over time, the harm or risk of harm has become worse, or has not improved to the point at which the child is consistently receiving a "good enough" standard of care;
• Persistent, severe neglect indicates a breakdown or a failure in the relationship between parent and child.

Where there are concerns about standards of care, a Safeguarding Children Partnership approved tool may be used for assessment, planning, intervention and review. This would provide an objective measure of the child's care across all areas of need, highlighting both strengths and weaknesses. Improvement and/or deterioration can be tracked over the intervention period. It allows professionals to target work as it highlights areas in which the child's needs are, and are not, being met. It may also help parents/carers who may have experienced neglect themselves to understand why such behaviours are harmful.

It can be challenging to identify neglect in very young children, which can lead to a delay in recognition and intervention. Practitioners should remain vigilant and exercise professional curiosity.

Babies and young children could:

• Fail to seek comfort from caregivers;
• Fail to thrive. For example, not growing at an appropriate rate for their age or not reaching developmental milestones;
• Have frequent and untreated nappy rash;
• Have ingrained dirt and unclean fingernails;
• Have inappropriate clothing for the weather;
• Have repeated episodes of headlice;
• Have unexplained bruising;
• Display signs of hunger such as smacking their lips and putting their hands to their mouth, clenching fists and crying; 
• Have faltering growth or weight gain;
• Become angry when performing problem-solving tasks; 
• Interact with their caregiver in an avoidant, passive, withdrawn or angry way;
• Have poor speech delay;
• Have gross motor skill delay;
• Have accidental injuries;
• Formal assessments should be carried out if there is any suspicion of developmental delay. 

Older children could:

• Have anxiety, withdrawal and /or depression;
• Show signs of self-harm;
• Display changes in eating habits;
• Be continuously exhausted;
• Be under or overweight;
• Have dirty or inadequate clothing;
• Steal food or money for food;
• Have a decline in school attendance;
• Have poor social, language or communication skills;
• Partake in substance misuse;
• Want to be constantly close to their trusted adult or caregiver;
• Have difficulty in concentrating;
• Being aggressive; and 
• Display obsessive behaviour.

Professional Curiosity

It is important to establish a shared definition of professional curiosity and its meaning across a multiagency audience. Expectations of competence in this area vary between agencies; one might expect the Police, with their training in investigation, to be more practised than other professionals. However, this review demonstrates that it is equally essential for GPs, Social Workers, and Health Visitors to have skills in challenging and probing information.

The Munro Review of Child Protection recognised that professional curiosity needs to be embedded in the practice mindset of those working with families and is, in part, how a worker exercises the "respectful uncertainty" advocated by Lord Laming following his review into the death of Victoria Climbie in the 1980s. 

"Respectful Uncertainty" is generally recognised to mean the process of corroborating and validating information provided by a service user to establish that it is truthful and has been correctly understood. Laming was directing his comments specifically to social workers, but the principle applies equally to other professions:

"The concept of 'respectful uncertainty' should lie at the heart of the relationship between the social worker and the family. It does not require social workers to constantly interrogate the people they work with, but it does involve the critical evaluation of the information they are given. People who abuse their children are unlikely to inform social workers of the fact. For this reason, at least, social workers must keep an open mind."

The key aspects of professional curiosity:

• Questioning and challenging: it means asking direct, open questions and being willing to respectfully challenge the person's or family's account if it doesn't align with other observations or other information;
• Looking beyond the obvious: social workers are encouraged to see past immediate, surface-level explanations and actively look for subtle signs or indicators of vulnerability, abuse, neglect, or harm;
• Triangulating information: this is the critical process of seeking and comparing information from multiple sources - the individual, family members, other professionals like teachers, doctors, police, and case history - to build a comprehensive and accurate understanding;
• Maintaining respectful uncertainty: this involves taking what people say seriously but applying a critical eye and not taking their word as the definitive truth without corroboration or exploration;
• Observing and reflecting: it includes carefully observing interactions, the home environment, and non-verbal cues. Reflection, often done in professional supervision, is used to test out initial hypotheses and consider alternative explanations;
• Awareness of bias: recognising and setting aside one's own professional assumptions and biases that could influence judgement or assessment.

The need to develop skills in professional curiosity has arisen alongside an increased awareness of issues such as disguised compliance, in which cooperation is superficial and follows the path of least resistance, yet without meaningful engagement. Consequently, the desired change is not achieved, and seemingly cooperative parents continue to place their children at risk.

Professional curiosity may describe the tenor of the relationship with the service user. Still, to develop the necessary skills and an open, questioning mindset, workers need regular, effective supervision to test the strength of their assessments, and highly developed interpersonal skills to challenge families and other service users in a way that does not lead to a breakdown in the working relationship with a family.

In supporting a family in which neglect is an issue, the greatest of care must be taken to resist the pressure to focus on the needs of the parents/carers: intervention should concentrate on ensuring that the child's needs are being met. This may require action to ensure that parents/carers have access to specialist (and, if necessary, independent) advice and assistance, including support in communicating with professionals.

Neglect may arise from lack of knowledge, competing priorities, stress or deprivation. It may also be linked to parents/carers who retain cultural behaviours which are inappropriate in the context in which the family is living.

When a child's needs are unmet because the parents/carers lack knowledge or skills, the first choice for intervention should generally be the provision of Early Help services such as information, training and support services. If there is no progress and professionals assess that progress is unlikely without more proactive intervention, a referral to Children's Services, in line with the Referrals Procedure, should be considered.

Neglect often occurs in a context in which parents/carers are dealing with a range of other problems such as substance misuse, mental ill-health, learning disability, domestic violence, and lack of suitable accommodation.

When a family is affected by poverty, professionals should have specific consideration of the family's socioeconomic circumstances and its impact and connection to other familial current or historic factors and subsequent interpretation of neglect and abuse. (Please see in the additional resources, The Relationship between Poverty and Child Abuse and Neglect: New Evidence).

On many occasions, the birth of an additional child may add to the pressure on the family. The parents/carers may provide an acceptable standard of care until a new pressure or an unexpected crisis arises, at which point they lose sight of their child's needs. In this situation, the first choice for intervention should be to provide support in dealing with the competing pressures. This may require referral to appropriate adult services or family support services.

Neglect is characterised by a cumulative pattern rather than discrete incidents or crises, and so drift is always a potential problem. Drift may result in a loss of focus on the child's needs and a shift in professional expectations regarding an acceptable level of care.

Accurate, detailed and contemporaneous recording by all professionals, and sharing of this information, are crucial to the protection of the child. In any service, professionals should work from a single set of records for each child. All entries in case notes should:

• Be factual and evidence-based;
• Rigorously separate fact and opinion;
• Be dated and timed;
• Give names and agencies in full; and
• State agreed responses and outcomes.

Records should include a detailed chronology of what has been tried and to what effect.

There is a risk of confusion between the style of care and the standard of care. Styles of appropriate care vary widely, influenced by factors such as gender, class, culture, religion, and age. The common factor across all appropriate care styles is that they address the child's needs. Neglectful care may share common characteristics with appropriate care styles, but it fails to address the child's needs and falls below an acceptable standard.

Non-attendance at or repeated cancellations of appointments, and the lack of access to the child during visits, are indicators that should increase concern about the child's welfare and should be escalated for discussion with your supervisor.

The term 'disguised compliance' is sometimes used to describe the behaviour of parents or carers who appear to co-operate with professionals to allay concerns and end professional engagement. The National Guidance for Child Protection in Scotland 2021- updated 2023 outlines that this term implies the responsibility for this block lies with families and children. It outlines how failures in engagement are a shared responsibility and how solution- and strength-based approaches may be optimal. Professionals should continue to build strong relationships, remain curious, and maintain a culture of healthy scepticism. They should ask questions, cross-check information and seek and be open to information from other sources and professionals.

All agencies should be aware of the need for supervision of staff who are monitoring cases of chronic neglect:

• Professionals often want to think the best of the families with whom they work, and interpret events accordingly;
• Familiarity with the family's lifestyle may cause professionals to minimise concerns and accept that the observed standards are normal for this family;
• Changing the worker also carries risks, as it takes time to see the pattern of events that identifies care as neglectful.

Supervision must provide an independent review, keeping the focus on the child's needs and the adequacy of parenting over time.

If the child appears resilient, professionals should not accept this at face value but should check for evidence of unmet needs and impaired health and development.

When reviewing progress in cases of neglect, it is important to look for evidence of sustained improvement in the child's health and development. Where there is a pattern of short-lived improvements, the overall situation remains unsatisfactory. If adequate standards of care cannot be sustained, the child remains at risk of significant harm.

Professionals must resist the temptation to "start again" at key points such as the birth of a new child or a change of worker. It is important to view current events in the context of the full history of safeguarding and child protection, including previous responses to support. The family histories of neglectful families are often complex and confusing, and professionals may be tempted to set them aside and concentrate on the present. This can lead to an overly optimistic approach to a family with deeply entrenched problems.

As noted above, neglectful adults are often enmeshed in a complex network of problems. The clamour of parents'/carers' needs tends to draw professional attention away from children's unmet needs. When addressing the needs of neglectful parents/carers, it is necessary to ask repeatedly:

• Do they understand what action is needed and within what timescales?
• Are they able and willing to meet the child's needs?
• Are they doing so?
• Are they able to access appropriate support services?
• Is anything changing for the child? Is the change sufficient to raise the standard of care to an acceptable level?

If adult services are supporting the parents/carers, it is essential to stress the need for them to notify children's practitioners if the parents/carers fail to engage with the services offered.

If there is a vulnerable adult living in the same household as a child whose needs are neglected, then their needs may also be neglected or unmet. Practitioners should report any concerns about the welfare of vulnerable adults to adult social care.

LLR SCP Neglect Strategy Toolkit

Missed Opportunities; Indicators of Neglect – What is Ignored, Why, and What Can be Done? November 2014

The Relationship Between Poverty and Child Abuse and Neglect: New Evidence - University of Huddersfield

Understanding Adolescent Neglect: Troubled Teens | The Children's Society

Safeguarding children in affluent families | Goldsmiths, University of London

'Disguised compliance': learning from case reviews