Neglect

The majority of annual substantiated reports to Child Protective Services include issues of neglect. Precise statutory definitions of neglect vary by state, though common principles include the real or potential harm to a child’s health, safety, or well-being related to insufficient provision of basic needs by caregivers.

Child neglect can be manifest in any area of basic need, including physical, medical, educational, supervisory, and emotional. Reports of neglect disproportionately affect impoverished families and families of color, and although poverty is a risk factor for neglect, they are not equivalent. Poverty can challenge parents’ abilities to meet certain needs for their children and simultaneously increase parental stress, which drives many reports of neglect to child welfare agencies. Addressing underlying issues related to economic stress for low- to middle-income families, including expanding Medicaid access and providing earned income and housing tax credits and other concrete financial support to impoverished families are effective approaches to reducing rates of child neglect and entry into foster care.

When neglect is considered in a medical setting, evaluation and collaboration with the family should be child-centered yet recognize multiple possible contributors, including child, family, household, community, and environmental factors.

Manifestations

Almost any presentation to medical care could be related to primary or secondary manifestations of neglect because neglect can manifest in any area of basic need. Aspects of neglect can include physical, nutritional, emotional, educational, supervisory, and medical neglect. The presentation of child neglect varies depending on the child’s age, developmental needs and stage, and comorbid medical conditions or type of child maltreatment. Examples of diagnoses and associated potential for neglect include:

• Failure to gain weight as expected may indicate physical or nutritional neglect in young infants or children who are otherwise well, medical neglect in children with known medical needs, emotional neglect in settings of behavioral health struggles, or supervisory neglect if children are inappropriately independent.

• Developmental delay may indicate inadequate support of any basic need, including physical, medical, educational, or emotional neglect.

• Physical injuries may indicate supervisory neglect if harm results from inadequate or inappropriate supervision.

• Critical illness or uncontrolled complications of medical diagnoses such as recurrent preventable complications or illness progression outside the typical course expected may indicate physical, medical, or supervisory neglect depending on the child's age and abilities.

Evaluation

The level of concern for neglect should be based on history, physical examination, and pattern of medical care. As with all medical evaluations, a differential diagnosis should be developed and investigated.

• For example, while failure to gain weight in a young infant may indicate inadequate caloric intake related to neglect, it could similarly be related to an undiagnosed underlying medical condition resulting in increased metabolic demand, such as congenital heart disease.

Multifactorial contributors to neglect should be considered, including cultural and socioeconomic factors related to the child, caregivers, environment, and resources.

• In the example of inadequate weight gain in a young infant, physicians should ensure adequate attention to parental education regarding normal feeding in infants and plans for close monitoring of infant weight should be made.

• Issues at the child, family, and community level should all be explored with the child and caregivers to assess potential interventions.

  • For example, physicians could collaborate with families to schedule appointments to accommodate parents’ work schedules, making it more feasible for families to receive appropriate medical care for their children.

• Efforts should be made to provide supportive services to ensure that neglect is not solely related to issues of poverty.

  • Physicians should be aware of available local services and partner with social workers or local prevention services when available to connect families to appropriate public services, including nutritional support such as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

If possible, efforts should be made to include the patient’s medical home in the ongoing evaluation of neglect to provide insight into the above contributors and facilitate collaboration with the family.

Prevention and Interventions

According to the CDC, prevention strategies and interventions require addressing factors at all levels of the social ecology — the individual, relational, community, and societal levels. Some examples include:

• strengthening financial security

• changing social norms

• providing quality health care and early education

• improving parenting skills