Dr Sarah Steel and Dr Sarah Maxwell

ObjectivesWhat is neglect?

The impact on the developing brain

Attachment

How do children present?

Long term consequences evidence from systematic reviews

Physical Neglect

Emotional Neglect

Failure to provide: Food Clothing Shelter Medical care Educational provision

Failure to provide: Comfort Protection Love Discipline Encouragement

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

What is the impact of neglect on child development?

Structural brain differences

Brain developmentLearning 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

Anatomy of brain

Parent-infant interaction

Still face experimentStill face

AttachmentAttachment = 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

TrustSecurityAttachment

The arousal-relaxation cycle

Fahlberg (1988)

Self worthSelf esteem

The positive interaction cycle

Fahlberg (1988)

Positive interaction cycle serve and return

Responsiveness

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

Gender implicationsTypically 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?

Things to considerWho 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

Stress!

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

Presentation of child

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

Features in the childPreschool

0-20 months(7 studies,349 cases,237 controls)

20-30 months(3 studies, 125 cases, 113 contols)

3-4 years(4 studies, 86 cases, 125 controls)

Description

Avoidant and disorganised insecure attachment

During play demonstrated greater negativity

Greater negative affect during play

Developmental delay and Language delay

less positive social interaction

Developmental delay, in particular language delay

Passive and withdrawn behaviour

Greater memory deficits

Less ability to discriminate emotions

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

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’

ToddlerHead banging, rocking, bad temper

‘Violent’, clingy

Overactive-apathetic, noisy to quiet

Immobile and silent

Developmental delay Language delay Poor social skills

Features in the childInfant school age4-5 years (6 studies,110 cases, 128 controls)

5-6 years(5 studies, 155 cases, 155 controls)

Description

Language delay becomes more evident

Insecure avoidant attachment

Problems discriminating emotional expressions (particularly between angry, sad and fearful expressions) , poor emotional regulation

Poor peer relationships, rate self as angry oppositional

Poor peer relations, less social interactions , more aggressive, conduct problems

Low self esteem

Helpless outlook, view ‘others’ nit as source of help

Less moral more inclined to break rules and cheat

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. 

Physical examinationUnderweight 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

School age

Behaviour

Soiling and wetting

Present as aggressive and hostile

More impulsive

Poor concentration

May be particularly quiet or withdrawn

Relationships with other children:

Difficulty with friendships

Problems socialising,

Few friends

Perceived as more likely to be aggressive or disruptive

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

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

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

Relationships with parents

Family members lonely Little exchange of informationLack of emotional warmth Parents are more negativeMake demands of their childrenChildren come to expect less support

from their mothers

ImplicationsEarly recognition vital

Recovery potential

1st year Significant

2nd year Some recovery

3rd year Less recovery4th year No change (need school support and public funding)

Long term consequences significant for health education and social care

ChallengesOnce 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

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

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