Preventing Child Maltreatment: How is Neglect Different?

(Originally published April 2014)

I recently attended a Strengthening Families prevention conference in Idaho where a social entrepreneur gave a talk on the need for organizations to commit to “big, hairy, audacious goals (BHAGs).” His organization had made a commitment to eliminating child sexual abuse in the U.S., and to this end has been enlisting corporations to train their employees in practical steps that would initially reduce, and ultimately eliminate, the sexual abuse of children. A discussion of eliminating child maltreatment may seem foolish given that public child welfare agencies annually investigate/assess almost two million reports of child abuse or neglect involving 3.3 million children. However, BHAGs invite bold thinking and a careful consideration of the causes of undesirable social phenomena which can inspire thought experiments and initiatives ruled out by realistic appraisals of the likely course of events. Why, indeed, are possibly 4% or more of children in the U.S. abused or neglected every year when the great majority of Americans view children as precious and are deeply upset by stories of severe child maltreatment?

 

During the past 20 years, there have been surprisingly large reductions in violent crime and juvenile crime, as well as declines in some forms of child maltreatment and a number of other social problems. It is clearly possible for deviant social behavior to dramatically increase or decrease within a decade or two as a result of poorly understood social causes. The number of sexual abuse victims substantiated in NCANDS (the federal government’s data base on child abuse and neglect) has declined almost 60% since the mid-1990s, and large reductions in substantiated physical abuse have also occurred during this same time period. In addition, the Fourth National Incidence Study (NIS-4) found large reductions in both sexual abuse and physical abuse between 1993 (NIS-3) and 2005-06, the years on which NIS-4 analyzes were based. NCANDS is based on information regarding CPS reports submitted by state child welfare systems. The four NIS reports used a different methodology in which “sentinel” reporters around the country provided information regarding abuse and neglect incidents of which they were aware, independent of CPS reports.

 

During the past few years, there have been a few studies of hospitalizations resulting from physical abuse that have found increases in severe physical abuse cases since onset of the Great Recession in 2008-09. These studies have raised doubts about NCANDS data which reflect a continuing decline in physical abuse victims through 2011.  However, NCANDS lacks a severity measure of child maltreatment, and so is not a sensitive indicator of increases or decreases in severe physical abuse, a low base-rate phenomenon. It is possible that severe physical abuse of very young children increased during the recession while the much more common excessive spanking of school age children continued to decline. The steady expansion of differential response systems in which CPS cases assigned to family assessment tracks are not subject to “findings” such as substantiated or unsubstantiated may also account for some of the more recent declines in physical abuse victims in NCANDS data.  

 

Finkelhor and his colleague, Lisa Jones, have carefully considered possible explanations for the reduction of sexual abuse and physical abuse in NCANDS and NIS data, which include the use of criminal investigation and prosecution for these types of child maltreatment, widespread implementation of sex abuse prevention programs in the public schools, changes in the way CPS programs classify reports at intake, and even the increased use of anti-depressants, among others. It has proven to be surprisingly difficult to pin down the exact causes of the decline in child maltreatment in yearly NCANDS reports and NIS-4, or, for that matter, the causes of the decline in violent crime and a variety of other social problems. Nevertheless, this is an academic discussion/debate which should matter a great deal to child maltreatment prevention advocates. Once the causes of a 60% decline in child sexual abuse are better understood, then governments and philanthropic entities can build on whatever has already proven to be effective, rather than proceeding through trial and error or based on logic models that may prove questionable.

 

Why is Neglect Different?

 

There has been a small decline in substantiated victims of neglect (in NCANDS) since the mid-1990s, but far less than the large declines in physical abuse and sexual abuse. The decline in physical neglect in NIS-4 was not statistically significant. Furthermore, in some states, 90-100% of substantiated victims of child maltreated have been neglected in recent years. Clearly, there is something different about neglect that scholars attempting to explain the decline in child maltreatment have not (in my view) identified.

Anyone who has worked in public child welfare agencies as a caseworker, supervisor or manager is likely to have encountered families with 10, 20, 30, 40, even 50 or more CPS reports, most of which allege various forms of neglect. Neglect is more recurrent than physical abuse or sexual abuse and, in its chronic forms, much more resistant to therapeutic interventions. Nevertheless, neglect even in its extreme forms is tolerated in CPS programs and by mandated reporters to a far greater extent than physical abuse or child sexual abuse. Concerned citizens who have had little or no contact with maltreated children may lack a concrete understanding of what neglect even is, e.g., lack of supervision, erratic feeding of children and poor hygiene, medical and educational neglect, dangerous persons in the home, dirty houses, hazards in the home, deprivation of nurturance and extreme lack of attention to children, or all of the above?

 

My view is that the social tolerance for neglect, even when severe and/or chronic, and the lack of effective interventions for chronic neglect that accounts for the lack of a decline in neglect comparable to the declines in sexual abuse and physical abuse since the mid-1990s. Arguably, communities and societies cannot achieve large reductions in types of child maltreatment concerned citizens, child advocates and community professionals are willing to tolerate. Political communities mobilized by outraged public opinion are more likely to invest significant resources in developing, evaluating and implementing innovative prevention and early intervention programs, as well as effective therapeutic interventions to stop specific forms of child maltreatment when they occur. Furthermore, prevention programs are likely to be better funded and delivered in more systematic ways when public opinion is unequivocally and strongly disapproving of a type of child maltreatment. Neglect prevention has not had the public support sex abuse prevention has received except when children, mostly babies and toddlers, have died as a result of parental negligence.

 

During the past few years, dissemination of research regarding the effects of childhood adversities on early brain development has begun to change social attitudes regarding the neglect of infants and toddlers. It has become possible in many states to have serious discussions with legislators and governors regarding investments in prevention/ early intervention programs for at-risk children.  New federal investments in home visiting and early childhood education has increased the potential for states to develop more comprehensive prevention programs for very young children; but it will take at least a few years before the effects of these new programs on prevention of child maltreatment are well understood. However, the effects of the federally funded expansion of home visiting programs are likely to have a modest effect (at best) on the incidence of child abuse and neglect for a variety of reasons, in part because many high risk families are not recruited into the programs; and because, even when prevention programs are effective, much of the effect on child maltreatment rates is gradual and extends over a period of 15 years or more. Contrary to the view of many child advocates, implementation of evidenced based programs is not likely to be the royal road to child maltreatment prevention. Programs are one piece of a larger puzzle, important, but not the end all/be all of effective prevention initiatives.    

 

There is another way in which neglect is different than other types of maltreatment:

neglect is enmeshed with poverty to a greater extent than with physical abuse or

sexual abuse. A 2009 Partners for Our Children (POC) survey of parents with open child welfare cases in Washington State found that almost half of these parents had annual an incomes of less than $10,000, and one-fifth of parents had no apparent source of income whatsoever. Almost 60% of parents with children in foster care had an annual income of less than $10,000.  Child welfare agencies in the U.S. are serving a large population of families who are not just poor – many of these families are on the verge of destitution. They are one small step away from homelessness and hunger; and the everyday life of destitute parents is likely to be a struggle for survival. One of the possible reasons public child welfare agencies tolerate chronic neglect may be that child protection staff have an intimate feel for the enmeshment of severe poverty and neglect, and do not believe it is reasonable to expect the same parenting standards in severely poor families as in more affluent families. However, efforts to articulate a minimal standard of care acceptable in most neighborhoods and communities (including impoverished communities) have not been successful. Any articulation of a minimal standard of care likely to be accepted outside public agencies will likely raise the unarticulated parenting standards actually being applied by CPS programs in chronic neglect cases.  

The U.S. child poverty rate is approaching 25%, and exceeds 25% in 15 states. Child poverty rates are higher in families with young children and in African-American, Native American and Latino families. Depending on the measure used, 9-12% of children in the U.S. are living in severely poor families, and many of these families live in neighborhoods or communities in which poor families are concentrated. In addition, in the U.S. the psychological dimension of poverty is exacerbated by extreme income inequality. Concretely, this means that poverty is often experienced as demeaning and shameful. Extreme income inequality leads to anger, resentment and to social tensions that affect parenting, for example through harsh disciplinary practices, parental depression and hopelessness. Poverty in its various dimensions, i.e., chronicity, severity, concentration in poor neighborhoods and demeaning attributions regarding the poor, is associated with family breakdown resulting from substance abuse, mental health problems, trauma histories and family violence. 

 

Any serious attempt to dramatically reduce the incidence of neglect (almost 80% of substantiated child maltreatment in the U.S.) would include a determined effort to reduce child poverty, especially severe, chronic and/or concentrated poverty. In the absence of such efforts which seem unlikely (to put it mildly) in the current political environment, neglect prevention must focus on developing a wide array of family support services – not a single evidenced based program or two – for low income families, and invigorating neighborhoods and communities through initiatives that create hope in poor parents of a better future for their children.

 

There is another public health approach to prevention that has the potential to reduce

fatal child neglect, i.e., the targeting of specific parenting practices such as sleeping arrangements for infants, inadequate supervision around swimming pools or large bodies of water, use of car seats, etc. Injury prevention programs targeted at specific behaviors, e.g, use of bike helmets, have been among the most successful public health initiatives during the past couple of decades. Programs intended to influence whole

populations, rather than a small number of high risk families, have the potential to reduce serious injuries and child deaths resulting from parental negligence. Unfortunately, these programs are unlikely to have much of an effect on chronically neglecting families in which inadequate parenting affects multiple parenting domains, and is more like a condition in which children are being raised than a discrete set of parenting practices. 

Lessons for Advocates and Practitioners

 

The large decline in child sexual abuse, and possibly physical abuse (but not neglect) during the past two decades suggests that large reductions in child maltreatment are possible when (a) social attitudes will not tolerate a specific form of child maltreatment, regardless of the perpetrators, for example priests or coaches or other esteemed professional groups, (b) an effective intervention has been identified to address a specific form of maltreatment (c) there are potentially negative consequences (for example, criminal prosecutions or lawsuits) for abusing children, and (d) the conditions that are known to increase the likelihood of maltreatment have been significantly reduced, for example, secrecy and shaming in sexual abuse, acceptance of severe corporal punishment of children in physical abuse. None of these conditions have been met for child neglect:  (1) severe and or chronic neglect is often tolerated, both in agencies and communities, (2) effective interventions for chronic neglect are still being developed while inadequate services with strict time limits continue to be provided in most agencies and communities, (3) neglect is not criminalized (nor should it be), nor are there other community sanctions unless children die due to parental negligence (and often not even then), and (4) governments are largely unwilling to take steps to reduce child poverty, severe poverty or income inequality.

 

The current focus of policymakers and advocates on implementing a few evidenced based prevention programs may eventually have modest effects on the incidence of neglect, and potentially large effects on fatal neglect, but will not come close to eliminating child neglect and (in its chronic forms) the devastating effect on child health and development.

 

References

 

Child Maltreatment 2012, U.S. Department of Health & Human Services, Administration for Children and Families, 2013.

 

Child Maltreatment 2000, U.S. Department of Health & Human Services, Administration for Children and Families, 2000.

 

David Finkelhor and Lisa Jones (2006) .   “Why have Child Maltreatment and Child Victimization Declined.”  Journal of Social Issues, 62(4).

Lisa Jones and David Finkelhor (2009).  Updated Trends in Child Maltreatment, 2007. Durham, NH. Crimes against Children Research Center.

Lisa M. Jones, David Finkelhor and Stephanie Halter

“Child Maltreatment Trends in the 1990s: Why Does Neglect Differ from Sexual and Physical Abuse?”  Child Maltreatment , 2006; 11; 107.

 

The Fourth National Incidence Study of Child Abuse and Neglect (NIS-4): Report to Congress

(http://www.acf.hhs.gov/programs/opre/abuse_neglect/natl_incid/index.html)

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