What is Chronic Neglect?

(Originally published November 2020)

Every child welfare office is familiar with families who have 20, 30, 40, 50, 60 or more CPS reports over many years, most with allegations of neglect but with an increasing admixture of physical abuse and sexual abuse allegations as the number of reports increases. The description of these families as “frequently encountered”  or “chronically referring” may have contributed to the mistaken idea that it’s the number of CPS reports that defines chronic neglect. The number of CPS reports is a proxy for families in which neglect of children is pervasive, i.e., includes multiple childcare domains such as feeding, supervision, hygiene, etc., and which includes deprivation of nurturance and other types of emotional neglect. A main reason chronic neglect has such devastating effects on child development in young children is that parental omission in meeting the basic physical and emotional needs of children begins early in life and undermines the necessary elements of positive child development such as emotionally responsive parenting of infants and toddlers, development of secure attachment of babies with caregivers and the capacity of young children to use a trusted adult to calm down. In extreme cases, young children in chronically neglecting families are barely socialized (see The Boy Who Was Raised as a Dog, 2006).  

 

Chronic neglect is not the same as situational neglect or sporadic neglect in which incidents of child neglect are unusual or infrequent, or (in sporadic neglect) associated with reappearance of a chronically relapsing condition such as drug/alcohol abuse, a mood disorder, or an incident of domestic violence. Chronic neglect has become embedded in family life, is rarely interrupted by periods of positive parenting, and is not necessarily the immediate effect of parental drug/ alcohol misuse or episodes of mental illness, though these conditions often plague a family’s life.  Furthermore, chronic neglect often evolves into chronic maltreatment in which neglect is combined with instances of physical abuse and/or sexual abuse.

 

Chronic maltreatment is the most difficult therapeutic challenge facing public child welfare agencies, more difficult, by far, than chronic neglect alone. In chronically maltreating families, social norms around parenting have eroded or collapsed, sometimes to the extent that just about any kind of mistreatment of children is possible. In other families, parents are fully cognizant of effective parenting practices, but are unable to engage in nurturing parenting due to drug addiction or severe depression. In other words, all chronically neglecting families and chronically maltreating families are not the same. It is important for helping professionals and judicial decision makers to recognize important differences in parents’ capacity for emotionally responsive parenting, and in the motivation and capacity to seek help for chronically relapsing conditions and/or for domestic violence.  

 

Research regarding chronic neglect and chronic maltreatment

 

There has been much outstanding research regarding chronic neglect and its effects on children published in the U.S. in recent decades. Anthony Loman, Melissa Jonson-Reid and Brett Drake, Diana English and Kristi Slack have produced a rich and detailed profile of chronic neglect: 

 

  • In frequently encountered families, each CPS report regardless of its disposition increases the likelihood of a future substantiated report.  (Loman, 2006)

  • A single specific allegation of neglect contained in a CPS report is like the “tip of an iceberg,” or “ a single frame in a lengthy film; ” (Loman, 2006), indicating that a focus on specific allegations or reports is likely to be misleading.

  • Following an initial report of neglect, allegations of physical abuse and/or sexual abuse begin to appear by the third CPS report on a chronically referring family (Jonson-Reid, et al, 2010); similarly, the more CPS reports on a  neglecting family, the more likely some of these reports will allege physical abuse or sexual abuse. (Jonson- Reid, et al, 2003, Loman, 2006)          

  • As children become older, information regarding parent-child conflict becomes more common in subsequent CPS reports. (Loman, 2006)

  • Chronically referring families often take their children to emergency rooms due to children’s mental health crises ( Jonson- Reid, et al, 2010 )

  • Co-occurring substance abuse and mental health disorders are common among chronically neglectful and chronically maltreating families (Wilson & Horner, 2005, Laslet, et al , 2014)

  • Caseworkers and other professionals should not assume that chronically referring families have received whatever services public agencies have to offer.  (Jonson-Reid, et al, 2010)  Many families with multiple reports receive no services until a caseworker identifies a safety threat, or unless a family is rated “high risk” on a standardized risk assessment tool.  

 

These research findings suggest that early incidents of child neglect often develop into patterns of pervasive neglect, sometimes combined with physical abuse, as children become oppositional and difficult to manage or more profoundly emotionally disturbed. I have consulted on cases in recent years in which children as young as 3 or 4 had attacked a parent with a weapon! The psychologist, Steven Gold, has developed a proposed mental health diagnosis of “prolonged child abuse trauma” (PCA) to refer to “growing up in a household where many of the most foundational needs for adaptive child development are sorely lacking.”  The Science of Neglect from the Center for the Developing Child at Harvard describes the effects of ‘severe neglect in a family context’ as a “wide range of adverse impacts from big developmental impacts to immediate threats to health or survival.” (2012)

 

Some psychologists and trauma experts distinguish the effects of severe early neglect and trauma on theoretical grounds, though this distinction matters little when children have been both severely neglected and physically harmed, as well as sexually abused in some families. Both severely neglected children and children who have been assaulted are likely to suffer from “meltdowns,” i.e., the inability to control emotional reactions to perceived threats, to struggle with a sense of shame and inferiority, to have impaired impulse control and other executive functions; and to have difficulty making friends, along with serious cognitive impairments.

 

Children who have grown up with lack of nurturance are likely to have difficulty with intimacy in adolescence and young adulthood. The recent movie, Kajillionaire, is about a young woman who is emotionally stunted due to her parents’ inability to express affection. There is a painful scene in the movie when this young woman (played by Evan Rachel Wood) offers her mother a large amount of money to call her “hon,” a term the mother has just used to refer to a young woman who has become part of the family’s  scams. The mother cannot say the word to her daughter for any amount of money!

 

It is difficult for many severely neglected youth or adults to believe that they are worthy of love, or that anyone would ever notice them except when irritated or angry. Marilynn Robinson’s novel, Lila, is about a young woman, abandoned by her mother and raised by a drifter, who marries an elderly minister only to experience excruciating (and unfounded) fears of rejection and abandonment. Some young people who have never been loved or nurtured may feel shame for being alive and look for a way to vanish from the sight of others.    

 

Parents’ trauma histories              

 

 In 2004, two scholars, Joy Newmann and Jolanda Sallman, published an outstanding study of women with co-occurring mental health disorders who had received publicly funded substance abuse and or mental health treatment in a Wisconsin community.   Many of these women had lost custody of their child or children, and the study’s findings regarding these women’s trauma histories apply to many chronically neglectful parents:

 

  • Seventy-five percent of the women had been both physically and sexually abused in childhood.

  • Women in the sample had an annual income one-third of the average for all women in the county; “economic adversity continues to loom large in their lives.”

  • “Many women who enter the ADM ( i.e., publicly funded treatment) system have been exposed to an epidemic of interpersonal violence across the life span,” beginning in childhood and continuing in detention facilities or prison and in intimate relationships.

  • These women had been hospitalized for psychiatric conditions an average of 7.6 times.

 

Newmann and Sallman assert that “studies … suggest that in the vast majority of cases mental disorders do precede the onset of addictive disorders.”  A study of women in Washington State who had received services from the Parent Child Assistance Program (PCAP) found that a key difference among women in the program (all of whom had histories of substance abuse) who retained custody of their child vs. women who lost custody permanently was the severity of psychiatric problems. (Grant, et al, 2011) In this study, 60% of women retained custody of their child at exit from PCAP.  Women who lost custody of their child permanently had more psychiatric diagnoses, were often severely depressed at the time of exit from the program and had more unmet needs for housing, legal assistance, and domestic violence services, “signaling that they had very difficult life circumstances.”  

 

Co-occurring substance abuse and mental health disorders are strongly associated with histories of early trauma and of elevated levels of interpersonal violence. Desperately needy parents often engage in stubborn resistance to  offers of help and to entering treatment programs, in part because they don’t trust professionals who reach out to them, and because they may have given up on themselves.  Engaging parents who present as hopeless/helpless (“whatever you have to offer will not help me”) is the initial therapeutic challenge. Engagement skills can be developed in training programs based on the Social Work 101 principle, “join to need”, for all ages, all IQ’s. However, engagement skills must be combined with non-judgmental attitudes and with genuine curiosity regarding the backgrounds of troubled parents. Some parents have never had a relationship with anyone who was curious about them in a disinterested, non-exploitative way. Curiosity and genuine concern are powerful therapies for some parents; ditto for the ability of caseworkers  to recognize and meet the concrete poverty related needs of families.   

 

The goal of parental engagement in its early stages is to motivate a parent to take small concrete steps to help herself, and to recognize their children’s needs even when they are unable to meet them. The Three Houses tool which I have described in other commentaries is a useful approach to overcoming  denial of parents regarding the effects of drug/alcohol misuse and domestic violence on their children. In addition, chronically neglecting parents will need assistance in rebuilding a parenting structure, i.e., a daily routine that serves the needs of children. One of the first indications that situational neglect or sporadic neglect has crossed the boundary to chronic neglect is the loss of a reliable parenting structure, including times for feeding, bathing, naptime, playing with or reading to children, after school supervision, etc. The inability to maintain a daily structure of childcare activities is often followed by the appearance of rationalizations or beliefs justifying the lack of a parenting structure, or of the need for any kind of positive parenting.  Beliefs develop to excuse bad habits and dysfunctional parenting.  These beliefs and attitudes must be identified and skillfully challenged by caseworkers and therapists. 

 

Everyone in child welfare, judicial officers and CASA’s should read (and reread) Judith Hermann’s inspired book, Trauma and Recovery (1992), arguably still the greatest book in trauma studies.  Herman outlines a recovery process that begins with establishing safety, includes time for mourning of losses, and evolves into reconnection of the traumatized person with the community. Herman offers several cautionary warnings regarding the use of coercion in the treatment of trauma victims, given that the use of coercion for therapeutic ends reenacts the powerlessness of victims during traumatic events.

 

The idea that trauma victims are healed when they become clean and sober, or when obvious symptoms of depression or PTSD vanish, is mistaken and can lead to premature termination of treatment and/or reunification with a child in foster care.  Parental sobriety must be translated into a greatly increased ability to take initiative on one’s own behalf and the behalf of other family members, to recognize and respond to the needs of children, and to sustain intimate relationships and/or friendships. Recovery from chronic or complex trauma is a rocky road with many reversals, including but not limited to relapse.  This can only occur in the context of supportive relationships.

 

What to do about chronic neglect

 

  1. First and foremost, every effort should be made to prevent situational neglect or sporadic neglect from developing into chronic neglect. Per Anthony Loman’s suggestion, every CPS report should be viewed as “an occasion of assistance.” Poverty related services and skill-based parenting programs are far more likely to be effective as early interventions than as  responses to chronic neglect. 

  2. Every large child welfare office should develop a multi-disciplinary case management team that includes a CPS caseworker, substance abuse treatment specialist, mental health therapist and parent advocate who work with 20-25 chronically neglecting families at any one time. The team brings specialized expertise to family problems; and provides a degree of immunity among helpers to the hopeless/helpless attitudes of parents. Leaving a single overworked caseworker with near total responsibility for case management with a multi-problem neglecting family is a formula for failure. There was a time in past decades when Oregon had several of these case management teams funded with family preservation dollars. This is a model that could possibly be funded through Family First. 

  3. A ‘present danger’ orientation in child protection is poorly suited to the challenges of chronic neglect, in which much of the harm to children resulting is cumulative and may not be accompanied by safety threats.

  4. Developmental screening and developmental testing of children should be standardized practice in CPS assessment of chronically referring families.  Chronically neglected children who remain in the home (and most do) should be enrolled in therapeutic child-care programs on the model of Seattle’s Childhaven at the earliest possible age.  

  5. Children who have early onset mental health conditions should receive evidence-based treatment; and school age children will usually need tutoring and  emotional support to stay in school.   

  6. Every parent who receives post- investigation services of any type should be assigned a paid mentor/coach with a budget of concrete services funds to assist the family.   

  7. Supported housing and financial assistance for community college or job training should be available for parents seeking reunification. 

 

Public child welfare agencies have been slow to develop adaptive responses to chronic neglect and chronic maltreatment, in part due to lack of adequate staffing and services, but also because chronically referring families present daunting challenges that are overwhelming without strong collaboration among several community agencies. Enlightened child welfare leaders and managers will create these collaborations in every community,  and will reach out to philanthropists as well to support the combination of substance abuse and mental health treatments, crisis intervention (as needed) and poverty related services needed for effective interventions.      

 

References

 

English, D., Marshall, D, Brummel, S. & Orme, M. , “Characteristics of repeated referrals to child protective services in Washington state,” (1999) Child Maltreatment, 4 (4) , 297-307.

 

Grant, T., Huggins, J., Graham, C., Ernst, C., Whitney, N. & Wilson, D., (2011), Maternal substance abuse and disrupted parenting: distinguishing mothers who keep their children from those who do not,” Children and Youth Services Review, vol. 33, 11, 2176-2185.      

 

Gold, S. “Escaping a toxic childhood,” Aeon, April 2020; available online.   

 

Herman, J., Trauma and Recovery (1992), Basic Books, New York City.

 

Jonson-Reid, M., Emery, C. , Drake, B. & Stahlschmidt, M.  “Understanding chronically reported families” (2010), Child Maltreatment, 15 (4), pp. 271-281.

 

Jonson-Reid, Drake, B., Chung, S. & Way, I., “Cross-type recidivism among child maltreatment victims and perpetrators,” (2003) Child Abuse and Neglect , 27, (8), pp.  899-917.

 

Laslet, A.L., Room, R. & Dietze, P., “Substance misuse, mental health problems and recurrent child maltreatment” (2014), Advances in Dual Diagnosis, vol. 7, 1, pp. 15-23.     

 

Loman, A., "Families frequently encountered by child protective services: A report on chronic abuse and neglect" (2006), Institute for Applied Research, St. Louis, Mo. 

 

Newmann, J. & Sallman, J.  “Women, Trauma Histories and Co-occurring Disorders: Assessing the Scope of the Problem,” (2004), Social Service Review, 78 (3), 446-499.

 

Perry, B. & Salovitz, M., "The Boy Who Was Raised as a Dog And Other Stories from a Child Psychiatrist’s Notebook: What Traumatized Children Can Tell Us about Loss," Love and Healing ( 2007), Basic Books, New York City.  

 

"The science of neglect: the persistent absence of responsive care disrupts the developing brain, Working Paper #12" (2012), The Center for the Developing Child at Harvard, Cambridge, Mass.   

 

Wilson, D. & Horner, W., “ Chronic Child Neglect: Needed Developments in Theory and Practice,” (2005), Families in Society , vol. 86, 4, pp. 471-81.  

 

Dee Wilson©           

 

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