Cracking the Code of Chronic Neglect
(Originally published April 2015)
Dr. Kristine Nelson, formerly the Dean of the School of Social work at Portland State University and an outstanding child welfare scholar, before her retirement, used to talk about “breaking the code of chronic neglect.” It is common for child welfare scholars who write about neglect to note the poverty (P), substance abuse (SA), mental health conditions (MH) and domestic violence (DV) of families with multiple CPS reports for neglect and, sometimes, for physical abuse or sexual abuse as well, as if these chronically relapsing conditions adequately explain the neglect of children. PSAMHDV is an awkward acronym for the conditions that cause chronic neglect, not a code to be broken, in these scholarly accounts of chronic neglect.
Child welfare practitioners may notice other characteristics of chronically neglecting families: the filthy homes (an understatement in many cases), the pervasive neglect of children across multiple child care domains (e.g., supervision, hygiene, medical and dental care, protection from dangerous persons, nurturance), the hopeless/helpless attitudes of parents that often leave them unreceptive to offers of help. What can be done to help families who have so many serious problems but who often seem so uninterested in help, even help with extreme poverty related basic needs?
Code breakers look for patterns that make codes intelligible. The proof that a code has been broken is the ability to discern what are frequently simple to understand messages. In my view, the pattern suggested by the scholarly account of neglect, i.e., poverty, substance abuse, mood disorders (especially depression) and domestic violence, is disempowerment. The pattern suggested the experience of caseworkers and other helping professionals with parents who have difficulty consistently responding to children’s basic needs and who seem resistant to help, is incapacity.
Chronically neglecting parents usually have lengthy histories of disempowerment which often begin with early trauma and gradually progresses to co-occurring substance abuse and mental health disorders, along with family violence. Disempowerment may be compared to a river with a few major tributaries and several minor ones, including severe cognitive impairments, other physical and mental disabilities (involving both parents and children), histories of incarceration, low levels of education and a generalized hopelessness I refer to as demoralization. In addition, these disempowering conditions are massively compounded by poverty, often long term severe poverty, in cases of chronic neglect and chronic maltreatment, i.e., neglect combined with physical abuse and/or sexual abuse.
Poverty and Chronic Neglect
Poverty has an extraordinary influence on U.S. child welfare systems through its influence on rates of child maltreatment (especially neglect), out-of-home placement decisions, in-home safety planning and the timing of reunification, and in other less obvious ways as well. A large survey (2009) of parents with open child welfare cases in Washington State found that half of the parents had an annual incomes of less than $10,000, and one-fifth of parents in the sample had no identified source of income, and were not living with another adult whose income exceeded $20,000 per year. Families whose incomes are less than half the poverty standard set by the federal government are not just poor, they are destitute and at high risk for homelessness.
Scholarly explanations of the powerful association between poverty and child abuse and neglect, adamantly denied by many academic experts until about 1990, usually reference the stresses of poverty, a superficial (though not false) explanation for a wide range of maladies.
There is an explanation of the relationship between stress and health (both physical health and mental health) that sheds light on the functioning of parents with extensive child welfare involvement, especially chronically neglecting and maltreating families. A considerable amount of stress can be energizing and motivating when individuals, groups and communities have the talents, habits and confidence to take on tough challenges and some control over critical resources. Chronic and acute stress begins to break down parents and families when they lack access to and control of essential resources and the skills and talents needed to overcome formidable challenges. A formula for damaging the physical health and mental health of adults is a large scope of responsibility but with little or no authority or power over resources, working conditions, policies, etc. Arguably, it is not stress, per se, that damages physical and mental health, but stress resulting from lack of power and control over life circumstances and essential resources.
Michael Marmot’s The Status Syndrome (2004) contains a valuable in-depth discussion of how poverty, especially persistent poverty, damages physical and mental health. Marmot writes (p. 30) that “What characterizes being poor, and lower in the (social) hierarchy, is a great sense of helplessness, or … lack of control over life’s circumstances.” Concretely, this means that poor people may be unable to afford safe housing, timely medical and dental care, reliable transportation, their children’s educational costs and other necessities, and also lack opportunities for social participation and employment that does more than pay the bills. In addition, impoverished parents are likely to have jobs that put them at the bottom of a pecking order and subject them to daily slights and instances of micro-aggression.
Marmot maintains that “ the lower the social position, the higher the risk of heart disease, stroke, lung diseases, diseases of the digestive track, kidney diseases, HIV-related disease, tuberculosis, suicide, (and) other “accidental” and violent deaths.” Persons living in poverty are 2-3 times more likely (depending on the measure) to experience depression. Depression is so common among low income populations that it is sometimes viewed as a minor irritant like the common cold, and referred to as “the blues” or “being in the dumps”. However, major depression is to the common experience of minor depression as a serious case of the flu is to a common cold, not a condition which should be ignored or minimized.
Here then is a plausible pathway from long term poverty, often beginning in childhood, to early onset mood disorders: depression and anxiety leading to (a) substance abuse to help both manage a chronic mental health condition and provide a “high” that is unavailable in other ways; (b) to intimate partner violence in late adolescence and early adulthood; (c) to chronic neglect, or worse, chronic child maltreatment. The inability to control life circumstances resulting from low levels of education and limited employment opportunities, or no employment history, leads to chronically relapsing mental health conditions with the potential to immobilize individuals for lengthy periods of time followed by substance dependence, in which a craving for drugs takes precedence over every other need, to domestic violence from which there is no easy, or safe escape. Persons affected by this causal pathway gradually lose control of their circumstances, their capacity for self-care and the care of their children, their bodies, their interpersonal relationships and their capacity to regulate emotional reactions. Even experienced helping professionals will often turn away from parents in this predicament without attempting to understand how parents have come to this point. Mental health labels such as personality disorder may be employed to suggest that parents cannot be helped.
Another Pathway: Effects of Untreated Early Trauma
Retrospective studies of women with co-occurring substance abuse and mental health disorders
have found histories of early trauma, usually including both physical and sexual abuse, as well as recurrent episodes of violence in interpersonal relationships and in both correctional facilities and psychiatric facilities. These women are almost always poor, often severely poor, but early trauma may have preceded living in dire poverty. As Judith Herman and many other trauma experts have pointed out, the most common mental health condition resulting from trauma is depression,
often combined with PTSD, and various somatic ailments, some of which cannot even be named or easily described to medical experts, are also common.
In staffing chronic neglect cases over the past few years, I have noticed that caseworkers’ initial impression of mothers is often that they have serious cognitive impairments and do not seem able to learn or generalize from their experiences, or understand what is said to them. However, when I have inquired about the mothers’ early histories, I was sometimes informed that these women experienced early trauma that was described in vague terms, and that has been virtually ignored by helping professionals. In addition, mothers may have sustained neurological damage from fetal alcohol syndrome or other unidentified causes. Several years ago, I consulted on a chronic neglect case in which children had experienced profound developmental harm throughout their childhoods, yet the parents had no discernable substance abuse problem or mental health diagnoses. When I read the child welfare office’s voluminous case file on this family, I discovered that the mother had been severely battered by male partners, including the father, for more than 15 years. Somehow, the case plan did not reflect an understanding of this history.
Victims of chronic, complex trauma may recover to some extent and may be able to work and to raise children (usually with some help from relatives), but maintain their sense of safety by living constricted lives that depend on predictable routines, limited social contacts and avoidance of unexpected challenges. Professionals may be viewed as threatening, even when they’re not CPS caseworkers. Highly functional professionals with trauma histories may also have unexpected dependencies and sometimes be using “learned helplessness” to cope with some of life’s challenges.
The Message of Chronic Neglect
Poverty, combined with the chronically relapsing conditions commonly found in chronic neglect and chronic maltreatment, has the effect of steadily disempowering parents to the point where they may no longer believe that they can be helped. Arguably, the resistance of extremely needy individuals to help is a resistance to the renewal of hope, and the likelihood that the parent’s worst fears will be reconfirmed.
The chronic and pervasive neglect of children, poor self-care, deplorable living conditions and the seeming inability to access available resources, is an indicator of incapacity, i.e., lack of self -efficacy.
The point of breaking a code is to read the message: What is the message of chronic neglect? Some possible answers include:
I cannot ...
I no longer care about …
Neither you nor anyone else can help me.
Leave me alone.
These are not necessarily hostile messages; despair is deeper than anger, harder to access or combat. Helping professionals, relatives and/or friends (if any are still around) must communicate different messages and do so repeatedly:
I care about what happens to you, your children and your family.
I’ll help you with your immediate basic needs.
I’ll be back.
You can do more than you think you can.
You have choices.
There’s a way out of …
I’m curious about …
Chronic neglect and chronic maltreatment are the result of a long process of disempowerment that has multiple dimensions. The challenges posed by chronic neglect cannot be effectively remedied with a few weeks or few months of therapeutic interventions, though it’s true that not every chronically referring family is in the dire straits described above. Families will be best served by family teams with several different types of expertise that immunizes professionals against the despair of parents.
Referral to substance abuse treatment programs and mental health agencies is a necessary but not sufficient adequate child welfare response to chronic neglect. One or more persons who combine compassion for parents with a persistent concern for child safety and child well-being need to develop a therapeutic relationship with family members, and these persons will need the active support of others. Concern for parents should not end with termination of parental rights, if this occurs. Many of these parents are young and will have more children. Furthermore, it is a harsh child welfare system that is willing to remove one child after another from parents while making no more than token efforts to help. Earlier intervention in the lives of troubled families can head off a process whose end state is likely to be an immobilized and despairing parent who has given up on herself and everyone else, and whose remaining emotional protection is numbness and a lack of interest in what others think of her.
Herman, Judith, Trauma and Recovery, 1992.
Marmot, Michael, The Status Syndrome , Henry Holt and Company, 2004.