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What If Child Protection Was Organized Around Neglect?

(Originally published February 2012)

Barbara Nelson’s Making An Issue of Child Abuse (1984) is still the most compelling and incisive account of the legislative development of the modern child protection system in the United States. Nelson maintains that mandatory reporting laws passed in all 50 states between 1963 and 1968 were a response to widespread media stories regarding battered child syndrome and other types of severe abuse perpetrated by parents. A number of states (but not all) included definitions of neglect in their mandatory reporting statutes either as an afterthought or because they used model statutes developed by advocacy groups; nevertheless, discussions of neglect hardly entered into the rationale for new unprecedented child protection laws.

Federal CAPTA legislation passed in 1974 contained a broad definition of child maltreatment. However, Nelson comments that “The definition of child abuse found in CAPTA provides a more comprehensive statement of the problem than one might expect after reading transcripts of the legislative hearings. In the public debate over the congressional legislation, comprehensive definitions were actively suppressed in order to enhance the noncontroversial nature of the issue,” in particular “the connection between poverty and maltreatment was purposely blurred”, Nelson asserts, as “part of a conscious strategy to dissociate efforts against abuse from unpopular poverty programs.”

Standard elements of CPS systems such as mandatory reporting, investigations of screened in reports, coordination with law enforcement agencies, substantiation of child maltreatment, central registries, emergency removal of children from the home and use of court structure, i.e., dependency actions, in serious cases, are not family friendly nor were they intended to be. Rather, child protection systems were designed to protect severely physically abused children by giving public agencies legal authority to intervene in families’ lives; and then adapted to respond to sexual abuse in the late 1970s and early 1980s. The question of whether this model is a good framework for protecting neglected children and working with neglecting parents was hardly discussed in the early years of modern child protection systems given the often mentioned ‘neglect of neglect’, and the two decades of denial (i.e., 1970-1990) by many policymakers and scholars that poverty and child maltreatment are strongly associated.

However, since the mid-1970s reports to CPS of child neglect have far outnumbered reports of physical abuse and sexual abuse; and the percentage of child victims substantiated for neglect increased from 60% in 2002 to almost 80% in 2010, according to National Child Abuse and Neglect Data Systems (NCANDS) reports. Less than 20% of substantiated child victims were physically abused and 9.2% were sexually abused in 2010. In some states, for example, New York, Connecticut and Massachusetts, virtually all substantiated child victims in 2010 were neglected, though some of these children were physically abused, sexually abused or psychologically maltreated as well.

A recent study published in Pediatrics (Leventhal, et al, 2012), found that there were 4569 children admitted to U.S. hospitals due to injuries resulting from physical abuse in 2006, a year in which public child welfare agencies substantiated more than 900,000 cases of child maltreatment. Obviously, many other children with serious inflicted physical injuries were not hospitalized or perhaps even reported to CPS. Nevertheless, intervening to protect children with life endangering non-accidental injuries is a small part of child protection in the U.S.

Here is a peculiar feature of child welfare in America: state and county child protection systems designed to protect seriously physically abused and sexually abused children, who represent a tiny percentage of maltreated children, are being used to respond to a huge number of reports of child neglect that include a large percentage (80%) of children found to be maltreated. These systems were not designed for neglected children; therefore it should not be a surprise that child welfare systems are doing a poor job of meeting their needs. Of course, there is a group of children reported to CPS who have been physically abused and/ or sexually abused as well as neglected. I refer to these children as chronically maltreated; they present difficult challenges to CPS caseworkers, professionals who work in various helping roles and courts. It is highly questionable whether child welfare agencies have found effective approaches to protecting children in these families.

Before considering alternative approaches, it is worth reviewing the differences among confirmed cases of physical abuse, sexual abuse and neglect cases that come to CPS attention. Most neglected children (even severely neglected children) are not injured at the time of CPS investigation / assessment, though a few have experienced neglect related accidents or medical neglect of serious illness / injuries. Severe neglect includes children who have been pervasively neglected, i.e., inadequately supervised, erratically fed and bathed, poorly clothed, deprived of nurturance, left in the care of dangerous persons, etc., in addition to children who have been injured or become ill as a result of neglect.

Neglected children are, on average, younger than other maltreated children. Perhaps a fourth to a third of children reported for neglect have been chronically neglected and been reported to CPS several times. Referral histories that include up to 30 or more CPS reports are not uncommon in Washington State. Some of these families have also been reported for physical abuse and / or sexual abuse, but neglect reports tend to predominate in chronically referring families. It is the chronicity of neglect, as well as its severity, that results in developmental harm to children. For this reason, patterns of neglect (and referral histories) are usually more important than specific incidents in understanding the effects of neglect on children.

While fatal neglect related accidents occasionally occur in neglecting families, the most common damage experienced by chronically neglected children is developmental and emotional; and these developmental impacts include cognitive impairments, attachment issues, impaired social skills and capacity for emotional regulation. Chronically neglected children usually have a difficult time in school, and they often develop early onset internalizing or externalizing behavioral problems that impair social development. Parenting issues in these families related to child safety and well-being are intimately connected. It is not true (as some experts claim) that these children are either safe or unsafe. Children can be physically safe in some families, but remain profoundly at risk for developmental harm and emotional harm related to maltreatment, substance abuse, mental health problems of parents and family violence. Furthermore, Anthony Loman, the author of one of the best studies of chronically referring families, has found that these families are no more likely to be referred for conditions viewed by intake units as presenting risk of imminent harm than other children with open CPS cases.

Neglecting families are poorer on average than physically abusing or sexually abusing families; and chronically referring families are often severely poor, i.e., have incomes less than half the median income of all poor families. A recent study of parents with open child welfare cases in Washington State found that almost half of the parents had annual incomes of $10,000 or less. Neglect is thoroughly enmeshed with poverty, in part because many of these families are headed by single parent women with low levels of education. Lawrence Berger, a child welfare scholar with expertise in economics, has found that economic deprivation has a more direct impact on risk of violence toward children in single parent families than in two parent families in which the emotional climate resulting from the relationship between the mother and father has a larger effect on rates of violence than economic deprivation per se. It is plausible that the poverty of single parent families is especially impactful on a broad range of parenting behaviors when combined with lack of intimate social support.

Chronic neglect and chronic maltreatment are almost always found in combination with substance abuse, mental health conditions, domestic violence and / or parental cognitive impairment. For this reason, chronic neglect and chronic maltreatment are difficult therapeutic challenges that can lead helping professionals to feel as hopeless / helpless, i.e., demoralized, as family members. I occasionally find in training or community presentations that some professionals begin to feel defeated merely by listening to a candid description of the families. Child welfare agencies need to be concerned with developing approaches to intervention that will sustain the morale of professionals (and para professionals) who work with these troubled families.

How would a child protection system organized around neglecting families be different from CPS systems described above?

Poverty related services would be greatly expanded; and would include:

Educational and job training programs that offer families the prospect of improving their economic condition.
CPS investigations / assessments would be more interested in patterns of neglect, and referral histories, than in alleged incidents of neglect.
Child welfare interventions would have a child development focus and would be as concerned with developmental harms to children as with risk of physical injuries.
Evidenced based programs that coach parents in recognizing and responding to young children’s non-verbal cues would be widely available.
Prevention and early intervention would be emphasized, especially when parents are engaged in substance abuse, have serious or chronic mental health problems, or have been reported to law enforcement agencies for domestic violence. Parenting assistance would be offered to parents receiving publicly funded substance abuse or mental health treatment prior to a CPS report.
Early education programs such as Chicago Parent Child Centers would be available to low income children and their families.
Therapeutic child care programs such as ChildHaven in Seattle would become a core in–home service for young children at risk for neglect.
Chronically referring families would be served by 3-4 person case management teams that include a child welfare caseworker, a family advocate, a mental health or substance abuse specialist, and for families with babies or toddlers, a public health nurse.
Brief depression screening tools would be routinely used by child welfare caseworkers and public health nurses in assessing parental functioning.
Free respite care and crisis nurseries would be available to low income families. Some percentage of foster parents would be used to mentor and support birth parents, especially single parent women.
A small percentage of cognitively impaired and/ or mentally ill parents with children would receive long term (i.e., for several years) case management services on the model used by some mental health agencies for chronically mentally ill individuals.
Child welfare workforces would be better educated and trained in child development, either by hiring a cadre of public health nurses in casework positions, and /or by offering certification programs in child development that qualify caseworkers for a small increase in salary.

Child welfare systems need to be able to serve four different groups of neglecting families:

1. Families engaged in situational neglect that can be helped with brief poverty related services.

2. Families who can benefit from a combination of poverty related services and skill based parenting programs that include hands on coaching of parents in their interactions with babies and other pre–school children

3. Families with caregivers who are abusing drugs or alcohol, and/or have severe or chronic mental health problems, and/or are involved in domestic violence

4. Parents with severe cognitive impairments or chronic mental illness (often including neuropsychiatric problems) who need ongoing case management services for several years, perhaps indefinitely, in order to parent children.

The steady increase in states’ use of differential response (DR) during the past dozen years has been a step in the right direction, especially when modest funding for poverty related services has been added for families receiving an assessment (with no investigative findings) rather than an investigation. However, DR systems, like a business as usual CPS investigative approach, need to be more fully adapted to the needs of neglected children and their families. Effects of child maltreatment on child development has not been a fundamental concern of child protection in the U.S., in part because of flawed conceptions of child safety and well-being, and also due to workload pressures on CPS investigative units. For too many children and families, CPS interventions have been too little, too late, incident focused, concerned mostly with imminent safety threats and unconcerned with emotional and developmental harms to children, often lacking any poverty related services or lacking help with housing / homelessness or child care, provided by caseworkers with weak educational backgrounds and superficial training in child development, and offering ineffective didactic parent training programs as a core service. Fortunately, this sad state of affairs has begun to change as child welfare agencies around the country search for more effective family support services and in response to enlightened federal leadership from the Administration for Children, Youth and Families.

Child advocates and policymakers sometimes frame reform agendas as the need for bigger investments in prevention and early intervention programs; and it is true that these investments are urgently needed. However, adapting child welfare programs to the needs of neglected children and their families also requires a thorough reorientation of child welfare practice around the needs and challenges of neglecting families following CPS investigations or out-of-home placements. This has been hard to achieve without concentrated public policy attention on neglect; but the widespread interest in early brain development and the impact of adverse childhood experiences (ACES) on health and mortality across the life span has generated a spark of public interest that can (hopefully) be fanned into a full blown public policy agenda once the implications for practice are clearly articulated to those who care about child welfare reform.

References

Berger, Lawrence, “Income, family characteristics, and physical violence toward children,” Child Abuse and Neglect, 29, 2005.

Child Maltreatment 2002, Child Maltreatment 2006 and Child Maltreatment 2010 \; Administration for Children, Youth and Families, U.S. Department of Health and Human Services, Washington D.C.

Leventhal, John, Martin, Kimberly and Gaither, Julie, “Using U.S. Data to Estimate the Incidence of Serious Physical Abuse in Children,” Pediatrics, published on line February 6, 2012.

Loman, Anthony, “Families Frequently Encountered by Child Protective Services:

A Report on Chronic Child Abuse and Neglect,” Institute of Applied Research, St. Louis, Missouri, 2006; available at http://www.iarstl.org

Marcenko, Maureen, Lyons, Sandra, Courtney, Mark, “Mothers’ experiences, resources and needs: the context for reunification,” Children and Youth Services Review, 33, March, 2011.

Nelson, Barbara, Making an Issue of Child Abuse: Political Agenda Setting for Social Problems , University of Chicago Press, 1984.

Wilson, Dee and Horner, William, “Chronic Child Neglect: Needed Developments in Theory and Practice,” Families in Society, Volume 86, #4, 2005.

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