The Neglected Child

Patrick Ayre

email: pga@patrickayre.co.uk

web: http://patrickayre.co.uk

Graham Hopkins

email: office@rightthing.co.ukweb http://www.rightthing.co.uk/

With Elli Mackenzie and Adrian Pleater

The neglected child

In March 2014, Ofsted reported that

“One third of long-term cases examined on this inspection were characterised by drift and delay, resulting in failure to protect children from continued neglect and poor planning in respect of their needs and future care”.

Family history not attended to

Lack of focus on the child

Little evidence of long term support to enable lasting change

Non-compliance not addressed

LSCBs lacked data and strategic plan

Sir Walter Monckton

“I have pointed out where I think that the two authorities failed separately in their duty to take adequate care of these two children. There was also a lamentable failure of communication of material facts between the two.”

Sir Walter Monckton – “Report on the circumstances which led to the boarding out of Dennis and Terence O’Neill…”

May 1945

Terry O’Neill

NEGLECT

Neglect is 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 protect from physical and emotional harm or danger ensure adequate supervision ensure access to medical care or treatment.

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

NEGLECT

Neglect is 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 protect from physical and emotional harm or danger ensure adequate supervision ensure access to medical care or treatment.

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

NEGLECT

Neglect is 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 protect from physical and emotional harm or danger ensure adequate supervision ensure access to medical care or treatment.

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

NEGLECT

Neglect is 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 protect from physical and emotional harm or danger ensure adequate supervision ensure access to medical care or treatment.

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

NEGLECT

Parents who neglect their children basically just don’t know any better because of their own poor upbringings. If we send them to a family centre for Parental Skills training, all will be well.

NEGLECT

Parents who neglect their children basically just don’t know any better because of their own poor upbringings. If we send them to a family centre for Parental Skills training, all will be well.

IF ONLY!!....

NEGLECT

So neglected children who come into care may be a bit thin, a bit dirty, badly in need of seeing a doctor or dentist, maybe a bit wild.

But we can place them with foster carers for a bit of looking after, a bit of TLC, a bit of structure and everything will be fine. The children will absolutely love it and will immediately start to thrive. Simple really!

NEGLECT

So neglected children who come into care may be a bit thin, a bit dirty, badly in need of seeing a doctor or dentist, maybe a bit wild.

But we can place them with foster carers for a bit of looking after, a bit of TLC, a bit of structure and everything will be fine. The children will absolutely love it and will immediately start to thrive. Simple really!

IF ONLY!!....

Neglect

Behavioural

Constant hunger

Constant tiredness

Frequent lateness or non-attendance at school

Destructive tendencies

Neglect

Low self-esteem

Neurotic behaviour

No social relationships

Running away

Compulsive stealing or scavenging

Neglect

Physical

Poor personal hygiene

Poor state of clothing

Emaciation, pot belly, short stature

Poor skin and hair tone

Untreated medical problems

Significant harm

Harm is defined by Children Act 1989:

ill-treatment (including sexual abuse and, by implication, physical abuse)

impairment of health (physical or mental) or development (physical, intellectual, emotional, social or behavioural)

The child's basic needs

basic physical care

affection

security

stimulation of innate potential

guidance and control

responsibility

independence

Why do parents neglect?

We need to understand the interaction between:

3 Ns: Nurture, Nature, Now

Circumstantial factors and fundamental factors

Why do parents neglect?

Circumstantial Poverty

Particular relationships

Lack of skill/knowledge

Temporary illness

Lack of support

Environmental factors

Fundamental

Lack of parenting capacity

Deep seated attitudinal/behavioural/ psychological problems

Long term health issues

Entrenched problematical drug /alcohol use

Forms of neglectHowe identifies 4 types of neglect

Emotional neglect

Disorganised neglect

Depressed or passive neglect

Severe deprivation

Each is associated with different effects and implications for intervention

(Howe, D (2005) Child Abuse and Neglect, Basingstoke: Palgrave Macmillan)

Emotional neglect Sins of commission and omission

‘Closure’ and ‘flight’: avoid contact, ignore advice, miss appointments, deride professionals, children unavailable

However, may seek help with a child who needs to be ‘cured’

Intervention often delayed

Associated with avoidant/defended patterns of attachment

Emotional neglect: parents Can’t cope with children’s demands:

avoid/disengage from child in need; dismissive or punitive response

Children provided for materially but there is a failure to connect emotionally

More rules; everyone has a role and knows what to do.

Parents may feel awkward & tense when alone with their children.

Emotional neglect: children

When attachment behaviour rejected: Learns that caregiver’s physical and emotional

availability is reduced when emotional demands are made;

Caregiver most available when child is showing positive affect, being self-sufficient, undemanding and compliant;

Reverse roles, “false brightness” to care for/ reassure parent.

Emotional neglect: children

Frightened, unhappy, anxious, low self-esteem

Withdrawn, isolated, fear intimacy and dependence

Precocious, ‘streetwise’, self-reliant

Emotional neglect: children

May show compliance to dominant caregivers but anger and aggression in situations where they feel more dominant.

May learn that power and aggression are how relationships work and you get your needs met

Behaviour increasingly anti-social and oppositional

Brain development affected: difficulties in processing and regulating emotional arousal

Disorganised neglect Classic ‘problem families’

Thick case files

Can annoy and frustrate but endear and amuse

Chaos and disruption

Reasoning minimised, affect is dominant

Feelings drive behaviour and social interaction

Worker may feel agenda co-opted by family’s immediate needs

Disorganised neglect: carers Feelings of being undervalued or emotionally

deprived in childhood so need to be centre of attention/affection

Demanding and dependant with respect to professionals

May be regarded as overwhelmed but amenable to services

Crisis is a necessary not a contingent state

Associated with ambivalent/coercive patterns of attachment

Disorganised neglect: carers

Cope with babies (babies need them) but then…

Parental responses to children

– unpredictable and insensitive (though not necessarily hostile or rejecting).

– driven by how the parent is feeling, not the needs of the child

Lack of ‘attunement’ and ‘synchronicity’

Disorganised neglect: children Anxious and demanding

Infants: fractious, fretful, clinging, hard to soothe

Young children: attention seeking; exaggerated affect; poor confidence and concentration; jealous; show off; go to far

Teens: immature, impulsive; need to be noticed leads to trouble at school and in community

Neglectful parents feel angry and helpless: reject the child; to grandparents, care or gangs

Depressed neglect

Classic neglect

Material and emotional poverty

Homes and children dirty and smelly

Urine soaked matresses, dog faeces, filthy plates, rags at the windows

A sense of hopelessness and despair (can be reflected in workers)

Depressed neglect: carers Often severely abused/neglected: own parents

depressed or sexually or physically abusive

May seem unmotivated, mild learning disability

Learned helplessness in response to demands of family life;

Stubborn negativism; passive-aggressive Have given up both thinking and feeling

Depressed neglect: carers Listless and unresponsive to children’s needs

and demands, limited interaction

Lack of pleasure or anger in dealings with children and professionals

No smacks, no shouting, no deliberate harm but no hugs, no warmth, no emotional involvement

No structure; poor supervision, care and food

Depressed neglect: children

Younger the child, more debilitating the effects

Lack interaction with parents required for mental and emotional development

Infant: Incurious and unresponsive; moan and whimper but don’t cry or laugh

At school: isolated, aimless, lacking in concentration, drive, confidence and self-esteem but do not show anti-social behaviour

Severe deprivation

Eastern European orphanages, parents with serious issues of depression, learning disabilities, drug addiction, care system at its worst

Children left in cot or ‘serial caregiving’

Combination of severe neglect and absence of selective attachment: child is essentially alone

Severe deprivation: children Infants: lack pre-attachment behaviours of smiling,

crying, eye contact

Children: impulsivity, hyperactivity, attention deficits, cognitive impairment and developmental delay, aggressive and coercive behaviour, eating problems, poor relationships

Inhibited: withdrawn passive, rarely smile, autistic-type behaviour and self-soothing

Disinhibited: attention-seeking, clingy, over-friendly; relationships shallow, lack reciprocity

Emotional neglect: case management

Help parents to learn to use others for support.

Teach parents to engage emotionally with their children.

Must be highly structured as neither parent or child know how to interact normally & spontaneously.

Fear of affect – need clear rules & roles

Disorganised neglect: case management

Logic would argue for warding off crises for a while so that families can be taught to organise their lives, but…

Family may want to have needs met, but cannot delay gratification or trust logic and planning;

Without intense demands associated with crises, have no way of being important to others;

Will CREATE new crises.

Disorganised neglect: case management

Feelings must be addressed

Need a structured, predictable environment with no surprises where:

– There are rewards for clear, direct, and undistorted communication of feelings and accurate cognitive information about future outcomes

– Family can learn the value of compromise

Teach parents how to use cognitive information to regulate feelings (without denying them)

Depressed neglect: case management

Involves much more than teaching appropriate parenting

All family members must learn that their behaviour has predictable and meaningful consequences

Teach that it helps to share feelings with empathetic others.

Depressed neglect: case management Our standard approaches don’t work Threats / punitive approaches particularly

ineffective:– Parents don’t believe they can change so don’t

even try.– Even most reasonable pressure results in “shutting

down” / blocking out all info. Parent education – may be ineffective because

judgment impaired and gains not transferable.

Depressed neglect: case management

These families need: Long term involvement Supportive approach Responsiveness to family’s signals and needs BUT these need to be balanced with a

recognition of the children’s needs. (How long is too long? How much is too much?)

Depressed neglect: infants and children

Must experience responsive and stimulating environments that also provide human comfort for a few hours each day.

The longer the child is exposed to helplessness, the more intense and longer the intervention needed to remedy the situation.

Depressed neglect: parents

Must learn appropriate ways to show their feelings– Practice smiling, laughing, soothing– May be mechanical at first– Genuine feelings will emerge with repetition

As parents learn to show their feelings, the child’s responsiveness will increase; virtuous spiral

Severe deprivation: case management

Highly unlikely to be in the child’s best interests to remain in the environment which caused the harm;

It is probable that the child and new carers will require substantial therapeutic and emotional support;

Significant challenges often persist despite a move to a caring and predictable environment.

Chronologies

Chronologies:

as a

matter

of

fact

Hamzah Khan

11 September 1970

Amanda Hutton is born

1986/87

Hutton begins her long relationship with Aftab Khan, Hamzah’s father.

13 February 1989

Tariq Khan born - Hutton and Khan’s first child.

…and so begins the pattern of avoiding contact with health services.

28 May 1996

First record of police being called to a domestic violence incident involving Hutton being attacked by Khan.

Early 2005

Hutton misses an ultrasound scan at hospital arranged for Hamzah

June 17, 2005Hamza Khan born. Nothing reported to cause concern

June 23, 2005 Hamzah seen by a midwife at home. Nothing to cause concern

July 7, 2005 Hamzah is seen by health visitor for “birth visit”. Nothing to cause concern

 6 October 2005 Hutton discusses options for getting away from Aftab Khan with PC Whittaker, an experienced domestic violence officer with West Yorkshire Police. 11 October 2005Hutton is diagnosed with post-natal depression. She is prescribed anti-depressants.

October 2005Health visitor sees Hutton after three unsuccessful attempts. Health Visitor says the door was slammed in her face.

24 December 2005Hutton’s mother dies.

15 February 2006The health visitor again attempts to visit Hutton and leaves a calling card

August 2006

Following further attempts by the health visitor to see Hutton. Health visitor contacts the social services – child protection team - for advice

October 2005Health visitor sees Hutton after three unsuccessful attempts.

15 February 2006The health visitor again attempts to visit Hutton and leaves a calling card

August 2006Following further attempts by the health visitor to see Hutton. Health visitor contacts the social services

August 2006

A registrar of births visits Hutton at home and notes Hutton had a “puffed up” eye and smelt of alcohol.

7 September 2006Hutton goes to her GP – needs drink to cope 19 September 2006 Hamzah is registered with a GP 15 months after his birth but never attends the practice or gets any of his jabs. 23 November 2006 - A social worker attends Hutton’s house and speaks to her.

December 2006

One of the children reports domestic violence to police, saying both Hutton and Khan have assaulted him.

Police try and arrange accommodation with Children’s Social Care who are unable to find a placement. The child returns home.

Shortly after this Amanda Hutton calls police for help but by the time they arrive, Aftab Khan has left the house.

February 2007Amanda Hutton attends A&E with bruising and chest pains following an assault at home. She says she has separated from Aftab Khan.

She would attend A&E on three further occasions – once being taken there by ambulance after it had been called to the house by one of the children.

22 February 2007 Hutton attends GP surgery for last time

April 2007Hutton’s social worker contacts health visitor to say Hutton has had a “change of heart”

May 2007Older child makes another complaint of physical and emotional abuse. Social Care Services interpret this as “teenage angst”.

He is accommodated for two nights in an emergency accommodation but returns home to the family.

May to November 2007Appointments are made for a range of immunisations for Hamzah. Not one is kept.

7 December 2007 Police call to Hutton’s house after a “dropped” 999 call. Hutton also requests to see a specific police officer whom had previously supported her. But by the time the officer makes contact Hutton says she no longer wants to meet.

13 June 2008Hutton and her family are the subject of a Multi-Agency Risk Assessment Conference (MARAC). A health visitor contacts school about attendance issues with some of Hutton’s children August 2008 Another MARAC discusses Hutton’s refusal to engage with an organisation that supports women affected by domestic violence

4 December 2008

Aftab Khan assaults Hutton.

A police officer visits and notes nothing of concern relating to children in the house. The police officer told the court she had a list of all the children in her notebook but could not remember whether this meant she had actually seen all of them.

This incident leads to Khan’s only conviction for attacking Hutton and the couple split.

9 December 2008

Aftab Khan is interviewed by police about the incident on 4 December. He admits assault. But he also raises concerns about the welfare of Hamzah – says police should check on him as he is being neglected. Khan claims he will contact social services.

December 2008

Hutton and all her children except Qaiser, who is now 22, move house in Bradford following her split from Khan. A judge grants a no-contact order, forcing Aftab Khan to stay away from Hutton

January 2009Another MARAC meeting hears that Hutton is now working with a domestic violence support charity. Notes that Hamzah has not seen a GP since birth.

19 January 2009A worker for a domestic abuse support charity visits Hutton in her new home and reports nothing of concern.

17 February 2009PC Whittaker visits Hutton at home in connection with the ongoing prosecution of Aftab Khan.

16 March 2009Hutton and her children move to a larger house in Bradford.

21 April 2009A different police officer conducts a “welfare check” on Hutton’s house after some of the children are not picked up after school.

9 June 2009Aftab Khan given a community order by magistrates after admitting battery following the incident on 4 December 2008.

September 2009Hamzah would normally have started school (although there is no legal requirement until his fifth birthday in June 2010). Hutton answers questions about his absence by claiming he is in Portsmouth with an Uncle

October 2009The children and Amanda Hutton are removed from the register of the GP practice.

14 December 2009Hutton said Hamzah has been taken ill but describes him as poorly rather than seriously unwell. 15 December 2009Hamzah dies at a time unknown while Hutton is at Morrison’s supermarket. At 11.05pm a call is made from Hutton’s phone to Pizza Hut. At 11.07pm a call is made from Hutton’s phone to the Spicy Delight Indian take-away.

2010

Correspondence in 2010 between health visitors, early childhood services, children’s social care and education centres on the difficulties in seeing the children. The health visitor realises that the younger children have not been in contact with health services or registered with a GP.

Amanda Hutton again says the children are living elsewhere.

11 March 2011

One of Hutton's neighbours alerted social services to her concerns about the family.

21 September 2011Uniformed police officers gain access to Amanda Hutton’s home. Hamzah’s decomposed body is found in a cot in Hutton’s bedroom.

Five of his siblings, aged between five and 13, are removed from the house, which is described as being in “appalling squalor”.

6 March 2013

Hutton is charged with the manslaughter of Hamzah.

24 July 2013Hutton admits child cruelty in respect to five of her children and preventing the burial of a corpse at Bradford Crown Court. Her son, Tariq, admits preventing the burial of a corpse. • 18 September 2013 Hutton goes on trial at Bradford Crown Court accused of manslaughter. • 30 September 2013Hutton is brought to court by police but is too drunk to give evidence and her defence is delayed.

October 2014

Hutton is convicted of manslaughter and is sentenced to 12 years in prison, and three years for child cruelty – to run concurrently.

Capturing chronic abuse

Judging the quality of care is an essential component of any assessment but how well do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event

The pattern of neglect: atypical

The pattern of neglect: typical

Intervention Intervention

The pattern of neglect

'G ood enough' level

Intervention Intervention

The pattern of neglect

Intervention Intervention

'G ood enough' level

Intervention ceases

The pattern of neglect

Cumulativeness

T h r es h o ld f o rin te r v en tio n

SEXUAL

ABUSE

PHYSICAL

ABUSE N

EGLECT

NEGLECT

NEGLECT

Failure of cumulativeness

T h r es h o ld f o rin te r v en tio n

SEXUAL

ABUSE

PHYSICAL

ABUSE

NEGLECT

NEGLECT

NEGLECT

NEGLECT

What’s the problem?

Chronic abuse and the principle of cumulativenessFiles very long and badly structured

Patterns missed and ‘chronic abuse’ overlooked

The problem of proportionality

Acclimatisation (case, agency and geographical)

More assessment issues Picking out the important from a mass of data Interpretation Decoyed by another problem False certainty; undue faith in a ‘known fact’ Discarding information which does not fit First impressions/assumptions Too trusting/insufficiently critical Distinguishing fact/opinion

Department of Health (1991) Child abuse: A study of inquiry reports, 1980-1989,

HMSO

Assessment Pitfalls

When faced with an aggressive or frightening family, professionals are reluctant to discuss fears for their own safety and ask for help

Attention is focused on the most visible or pressing problems and other warning signs are not appreciated

Parents’ behaviour, whether co-operative or uncooperative, is often misinterpreted

Not enough weight to information from family friends and neighbours

Not enough attention is paid to what children say, how they look and how they behave

In Cleaver, H, Wattam, C and Cawson, P Assessing Risk in Child Protection, NSPCC, 1998

Child centred assessment

The purpose of assessment is to understand what it is like to be that child or young person (and what it will be like in the future if nothing changes)

Assessment pitfalls

Rule of optimism

Start again syndrome

Natural love

Cultural relativism

Too much

not enough

Brain development

At birth our brains are only 25% developed By age 3, a child’s brain has reached almost 90%

of its adult size and has accomplished 80% of its total development.

The growth in each region of the brain largely depends on receiving stimulation.

This stimulation provides the foundation for learning.

Experience Affects the Structure of the Brain

Brain development is “activity-dependent” Every experience excites some neural

circuits and leaves others alone Neural circuits used over and over

strengthen, those that are not used are dropped resulting in “pruning”

Poor integration of hemispheres and underdevelopment of the orbitofrontal cortex

Difficulty regulating emotion, Lack of cause-effect thinking, Inability to recognize emotions in others, Inability to articulate own emotions, Incoherent sense of self and

autobiographical history Lack of conscience.

Other physiological issues

Serotonin: emotional stability and feeling good

Malnutrition: cognitive and motor delays, anxiety, depression, social problems, and attention problems

MyelinationSensitive periods (infancy & attachment)

Emotional development

Sensitive period for emotional development: up to 18 months

Shaped primarily by the way in which the prime carer interacts with the child

Emotional deficits harder to overcome once the sensitive window has passed.

How often do we intervene assertively at this point?

Building a child

Building a child is like building a house, each new level built on the one below. If the lower levels are unsound, no amount of tinkering with the upper floors will make it stable.

A final thought

“We are guilty of many errors and many faults but the worst of our crimes is abandoning our children, neglecting the fountain of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him we cannot answer 'Tomorrow.' His name is 'Today.'”

Gabriela Mistral (Chilean poet, 1889-1957)