Interventions in Chronic and Severe Neglect: What Works?

In 1984, a paper published by Wolock and Horowitz in the American Journal of Orthopsychiatry drew attention to what they described as ‘the neglect of neglect’ in the prevailing understandings of and responses to child maltreatment. Thirty years on, this expression still resonates even though child neglect has moved out of the shadows and become a central concern for child welfare practitioners and policy makers, and the focus of much research activity. But, while considerably more is now known about the aetiology, identification and assessment of neglect, effective interventions have proved harder to develop. Why is this so, and what can we do about it? The papers in this special issue help us to consider these two questions in more detail. ‘Effective interventions have proved harder to develop’ We take as a starting point that child neglect is a complex phenomenon with a range of possible inter-connecting ‘causes’, and that continuing chronic neglect has been shown to have a range of adverse effects on children's health, development and wellbeing. These effects are wide-ranging, cumulative and damaging over the long-term. If neglect is unlikely to be mono-causal, it seems equally unlikely that any one intervention is going to be successful across the board. Therefore, a variety of intervention responses will be needed, including early intervention strategies that attempt to engage families as soon as neglect is identified, but also encompassing later intervention responses that can be used with families where early identification has not been possible and/or where neglect has become entrenched. This special issue gives us a chance to draw together some reflections on current knowledge and some new ideas about ‘what works’ in practice with families where neglect is a feature of family dynamics. ‘Some reflections on current knowledge and some new ideas about ‘what works’ in practice’ The challenges of developing appropriate responses to neglect are perhaps most usefully understood from a transactional ecological perspective (Brandon et al., 2008) that recognises the complex interplay of factors that can compromise parents' abilities to offer satisfactory care to their children. Such an approach can also help to make sense of the relational difficulties of this work, in terms of engaging parents in the intervention process. While we know that the long-term effects of neglect are pernicious, practitioners need also to be aware that neglect can be fatal. In the paper that opens this special issue, Brandon et al. (2014) present the results of a study that re-analysed data from 800 serious case reviews (where deaths or very serious maltreatment are examined in detail) in England, interrogating in-depth anonymised information on 46 of these. Using an ecological transactional framework, as previously described, they tease out the interplay of factors in a neglected child's life that result in catastrophe. They push further our knowledge about neglect, demonstrating six categories of neglect where practitioners need support to make well-reasoned judgments. These categories include deprivational neglect, medical neglect, accidents with elements of forewarning, sudden unexpected deaths in infancy, physical abuse combined with neglect, and young suicide. Brandon et al. (2014) emphasise that practitioners require compassion and sensitivity in order to be attuned to the relationship between parents and children. ‘Practitioners need also to be aware that neglect can be fatal’ ‘Practitioners require compassion and sensitivity in order to be attuned to the relationship between parents and children’ The next paper remains firmly in the ecological transactional frame and reflects on the significance of social resources in buffering the adverse effects of maternal depression in families where there is neglect. LONGSCAN was a longitudinal study of the risks and consequences of child abuse and neglect conducted between 1992 and 2012 in five sites across the USA. Kotch and colleagues (2014) report on analyses undertaken on the effects of different aspects of what they define as social capital on neglected children. They note that social cohesion and trust significantly reduced the impact of caregiver depression on externalising behaviours and alcohol use of neglected children at age 18. We know that neglect has a significant effect on adolescent health risk behaviours and we also know that caregiver depression increases the risk of neglect. This study clearly demonstrates that addressing depression, along with supporting community cohesion and neighbourhood trust, can ameliorate negative outcomes for children and young people. We need to be looking for community-wide interventions and building social capital as we begin to tackle neglect more effectively. ‘We need to be looking for community-wide interventions and building social capital’ This study is also of interest because of its focus on adolescents, a group whose experiences of neglect have perhaps been downplayed in the past. Recent work by Rees et al. (2011), Brandon et al. (2013, 2014) and others has started to shed light on the significant negative impacts that neglect has on older young people. The paper by Kotch and colleagues (2014) provides food for thought about the value of neighbourhood-based approaches in working with this often ‘hard to reach’ group. ‘The value of neighbourhood-based approaches in working with this often ‘hard to reach’ group’ Farmer and Lutman (2014) report on a recent study undertaken in England as part of a wider government-funded series of studies within the Safeguarding Research Initiative (Davies and Ward, 2012). The sample in this study consisted of 138 neglected children who had been returned to their parents following an episode of care and followed up after five years to examine how risks were managed over time. The authors note that there is a need to counteract or deliberately interrupt what they describe as the otherwise ‘inevitable errors’ that occur in case management over time, as a result of various processes. For example, parents were difficult to engage and the neglect was often minimised to the extent that sufficient protective action was not taken. Case files lacked information about the child's development and parents were given too many opportunities to change. Farmer and Lutman call for written contracts with parents that would allow practitioners to better understand capacity to change. They reiterate the concern expressed by Stevenson (2007) that an incident-based child protection system does not allow a helpful or effective response to neglect, which typically builds over time, often without an identifiable ‘trigger’ event of the sort that would lead to protective action. Farmer and Lutman argue that the current approach is not ‘fit for purpose’ and that a new approach is needed that supports practitioners to discern and understand patterns of behaviour that build up over time, and that captures developmental information better over time, evidenced in such a way that it can be used in care proceedings if required. ‘An incident-based child protection system does not allow a helpful or effective response to neglect’ Daniel and colleagues (2014) set out the messages from Action on Neglect, a knowledge exchange project that followed up on the extent to which current practice equates with research evidence. Through a process of co-production, the project looked at the ways in which neglected children are currently helped and what might be done to improve recognition and response. The project outputs included a detailed pack of working examples highlighting improved pathways to help neglected children and their families. Particularly poignant are the voices of neglected children and young people, who emphasise that ‘love is a doing word’ and who write a letter to practitioners with messages for teachers, social workers and mental health services. ‘Particularly poignant are the voices of neglected children and young people’ Staying with models of intervention, Lacharité (2014) offers a description of an approach to working with neglect that is being used in Quebec, with apparent success. The Ecosystemic and Development Intervention Program for Children and Families – Second Generation (EDIP-CF2) provides the framework for integrated child neglect services across the province and focuses on the child and family in context. While not losing sight of the difficulties that ‘neglecting families’ experience in terms of parenting and providing satisfactory levels of care to support their children's development, the approach developed within the EDIP-CF2 also pays attention to the ‘social organisation’ of the family and the context within which parenting takes place, emphasising the significance of family and community relationships. In this, it perhaps echoes Wolock and Horowitz's earlier analysis of neglect as a ‘social problem’. Indeed, the EDIP-CF2 approach identifies the need to focus on the broader social environment within which parents have to exercise their responsibilities, to try and reconfigure the ‘world of neglect’ that the family currently inhabit, and build stronger social connections and supports. ‘To try and reconfigure the ‘world of neglect’ that the family currently inhabit, and build stronger social connections and supports’ The last article focuses directly on another specific intervention model – this time, one developed in the US. The short report by Gardner et al. (2014) focuses on how the NSPCC has been using the SafeCare® parenting programme with neglected children and their families. SafeCare® is a structured, manualised programme that has been well evaluated in the US. Transporting it to a UK context has had challenges that Gardner and colleagues unpack. The ongoing evaluation focuses on outcomes for children, transportation to and sustainability within a UK context, patterning of participation and attrition, and outcomes for practitioners. ‘Transporting it to a UK context has had challenges’ This special issue concludes with a training update (Armitage, 2014) and a book review (Galluccio, 2014), both reviewing recently published materials that can assist practitioners in understanding the complexities of neglect and support the development of effective responses.

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