Childhood neglect: Why it matters and how to identify it earlier

1. Childhood neglect:Why it mattersandhow to identify it earlier The doctor’s view Dr Sarah Steel and Dr Sarah Maxwell

2. Objectives • What is neglect? • The impact on the developing brain • Attachment • How do children present? • Long term consequences • evidence from systematic reviews

3. Failure to provide: Comfort Protection Love Discipline Encouragement Physical Neglect Emotional Neglect • Failure to provide: • Food • Clothing • Shelter • Medical care • Educational provision

4. Recognition of risk factors • Social and environmental risk factors • Poverty, social isolation, poor housing • Care giver risk factors • Mental ill-health, domestic violence, parental conflict, substance misuse, parental history of abuse • Persistent harmful caregiver-child interaction • Symptoms and signs in the child's functioning

5. What is the impact of neglect on child development?

6. Structural brain differences

7. Brain development • Learning starts in the fetus • Brain size more than doubles in first year of life • 40,000 new synapses formed every second in the infant’s brain • Influenced by social forces and so is ‘experience-dependent’ • Male brain more vulnerable as matures more slowly

8. Anatomy of brain

9. Parent-infant interaction

10. Still face experiment • Still face

11. Attachment • Attachment = interactive regulation of emotion • Infants seek closeness and comfort from an attachment figure, especially in danger through display of distress signal (crying/ clinging) • Learn to develop strategies for internal regulation of distress • Right brain to right brain • Especially at night

12. The arousal-relaxation cycle Trust Security Attachment Fahlberg (1988)

14. The positive interaction cycle Self worth Self esteem Fahlberg (1988)

15. Positive interaction cycle • serve and return Responsiveness

16. Attachment • First year of life – right brain development • Visual, acoustic communication • Emotional and social processing • Response to danger • Second year of life – left brain develops • Father important- stimulation, regulation of aggression • Cognitive development, speech • Down regulates negative emotional states AND up regulates positive emotions

17. Gender implications • Typically mothers are calming and fathers more arousing and energetic • Suggests contact with parents may be important at different times • 1st year Mum and 2nd year Dad? • Mother essential for fear regulation in 1st year and father for aggression regulation later • Implications for contact decisions? • Night time contact?

18. Things to consider • Who can fill the role of predictable, consistent & emotionally available primary caregiver • Who will be intuitively sensitive to child’s emotional needs • Who can act as regulator of child’s emotional states • At what points of time are these needed

19. Stress!

20. Hypothalamic-pituitary-adrenal axis • Core stress response system • Stress leads to (CRH) hormone release from hypothalamus • Stimulates ACTH secretion acts on adrenal gland to produce cortisol • Maltreatment may lead to atypical responsiveness of HPA axis to stress that predisposes to psychiatric vulnerability later in life

23. Presentation of child

24. Core–info: Cardiff child protection systematic reviews • Systematic review 2013 • 180 articles reviewed 41 answered question • Mixture of case control and cohort studies • Age from 0-6 years • Further school age and teenager review as well

25. Features in the childPreschool

26. Emotional behavioural development • Attachment pattern • 12 months ambivalent-insecure • 18 months avoidant, however some are classified as ‘secure’ • If anxiously attached by two years of age • angry, frustrated and non-compliant • negative affect • Poor coping skills

27. Infant • Feeding difficulties, crying, poor sleep patterns, delayed development • Irritable, non cuddly, apathetic, non-demanding baby • ‘difficult baby’, ‘does not belong to me’, ‘does not love me’, ‘spoiled’, ‘greedy’, ‘attention seeking’, ‘lazy’

28. Toddler • Head banging, rocking, bad temper • ‘Violent’, clingy • Overactive-apathetic, noisy to quiet • Immobile and silent • Developmental delay • Language delay • Poor social skills

29. Features in the childInfant school age

30. Minnesota study:developmental sequelae • More self-destructive, inattentive and overactive behaviour. • Anxious, withdrawn, unpopular, aggressive and obsessive-compulsive • Lacking humour, • Little sensitivity and empathy • Poorer at following directions and expressing themselves. 

31. Physical examination • Underweight and or stunted growth • Sad, withdrawn, over affectionate, angry, apathetic • Restless, frozen and non moving, destructive, over active, distant, over friendly • Developmental signs: failure to achieve milestones, failure to thrive, academic failure, under achievement

32. School age

33. Behaviour • Soiling and wetting • Present as aggressive and hostile • More impulsive • Poor concentration • May be particularly quiet or withdrawn

34. Relationships with other children: • Difficulty with friendships • Problems socialising, • Few friends • Perceived as more likely to be aggressive or disruptive

35. Emotional or self-perception issues: • Little self-confidence • Low self esteem • Experience symptoms of depression • Difficulty interpreting emotions, such as anger or sadness • Mood swings • Show levels of affection towards others, which are inappropriate for the situation

36. Emotional or self-perception issues • Worthless to others • What happens is beyond their control • Anxiety and helplessness • Fewer effective coping skills • Angry, or restrict their emotional displays • Consider suicide

37. School performance • Poor performance in school • Poor attendance • Difficulty carrying out complex task • Lower IQ than their classmates • May be better at problem solving, planning and abstract thinking

38. Relationships with parents • Family members lonely • Little exchange of information • Lack of emotional warmth • Parents are more negative • Make demands of their children • Children come to expect less support from their mothers

39. Implications Early recognition vital Recovery potential 1st year Significant 2nd year Some recovery 3rd year Less recovery 4th year No change (need school support and public funding) Long term consequences significant for health education and social care

40. Challenges • Once children are showing the signs of neglect we have missed the oppourtunity to prevent significant harm thus need to act quickly • Waiting until the harm has happened means life long consequences for these children • Need to identify those families at risk and improve assessments of parents ability to nurture their child • Work intensively for limited period but child’s time frame is SHORT • To maximize child's potential need to remove early

41. Summary • Early neglect causes long term irreparable brain ‘damage’ • Features in child are on a continuum • Neglect more damaging than a single episode of physical harm but physical harm still triggers a response when neglect does not • Health need to work intensively with families at risk • Children's services need to become involved early • The legal system need to understand the urgency in managing neglect

42. References • ‘Family Law and the Neuroscience of attachment, Part 1, Allan Schore & Jennifer Mcintosh, Family Court Review, Vol 49 No 3, 2011 • Child protection companion 2013: Royal college of paediatrics and child health • Welsh systematic reviews • http://www.core-info.cardiff.ac.uk