child neglect: assessment and intervention
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Child Neglect: Assessment and Intervention
Ibis Kinnart, MSW, APSW
Children’s Hospital of WI
Child Advocacy Program
Learning Objectives:Define neglect and describe primary
manifestationsDescribe stages of change and motivation
enhancement techniquesDescribe psychosocial assessment of cases
and resources to ameliorate barriers to careDescribe best practices when working with
families where medical neglect or noncompliance issues exist
Identify criteria warranting referral to Child Protective Services and how to collaborate
Chapter 48.13(10)His/Her/Their parent, guardian or legal custodian
neglects, refuses or is unable for reasons otherthan poverty to provide necessary care, food,clothing, medical or dental care or shelter so as toseriously endanger the physical health of the child,within the meaning of s.48.13(10), stats.
Pursuant to s. 48.13(10m), stats., His/Her/Theirparent, guardian or legal custodian is at substantialrisk of neglecting, refusing or being unable forreasons other than poverty to provide necessarycare. . ., based on reliable and credible informationthe child/ren’s parent, guardian or legal custodianhas neglected. . . another child in the home.
ManifestationsSafety/Supervision: ingestions, falls, pedestrian vs.
motor vehicle collision, exposure to other hazards, parent frequently unavailable, fatigue
Medical: Delay/failure to seeking medical care, nonadherence to medical recommendations, poorly controlled asthma, diabetics, seizures etc.
Physical: frost bite, respiratory infection, hunger, non-organic failure-to-thrive, inadequately clothed
Hygiene: Rashes, lice/scabies, odor, matted hair, rejection from peers
Educational: untreated developmental delays, truancy--reading problems, repeating grade, taunting by peers. “Homeschoolers” not being educated.
Psychosocial ContributorsLack of
transportationLack of appropriate
child care &/or support system;many siblings
Language barrierNo phoneco-pay/insurance
issuesTransient/housing
issues
Poor understanding of medical condition, treatment or child development
Parent cognitively delayed, unperceptive
Parent apathy, disbelief, mood disturbance or defensiveness
Child factors: temperament, special needs, uncooperative
Provider barriers Inconvenient
appointment timesLong wait times--on
the phone & in the office
Short visits, not enough time for questions/discussion
Providers with foreign accents--difficult to understand
Poor communication amongst providers
Incomplete information provided re: diagnosis, prognosis, treatment
Provider makes decisions versus shared decision-making with parents
Don’t believe what families tell them; “tunnel vision”
Too busy, can’t track patients
Maslow’s Hierarchy of Needs-- Deficiency Needs
1. Physiological/Body Needs: Hunger, thirst, bodily comforts (health, sleep)
2. Safety/Security Needs: Out of danger, safety planning and emergency preparedness
3. Belongingness and Love/Social Needs: acceptance, affiliated with other
4. Esteem/Ego Needs: competency, mastery, receiving recognition and admiration
Resources: Transportation T19 HMO cab Straight T-19 wheelchair van script bus tickets/cab vouchers Red Cross reimbursement for Badger Bus/Coach Line Medical mileage reimbursement (414-289-
6223) Disabled Loading Zone (414-286-8677)
Resources: Casemanagement & Parenting programs
Public Health Department Prenatal or Child Care Coordination, T-19 benefit;
offered in-home or clinic based Birth to Three (center or home based) Health Care Connections (414-266-6966), T-19
benefit for children with complex medical needs; clinic based, some home visiting
Special Needs Family Center, service coordination Family resource centers, Children’s Trust Fund
(608-266-6871) has a statewide directory Parenting classes
Resources: Child Care Crisis nurseries like La Causa (414-647-5990) and
Family Support Project (262-544-0633) WI SHARES, day care funding (888-713-5437) Child care referral services ex. 4C’s (562-2676) Respite programs offered by La Causa (414-647-
5960), Children’s Service Society (414-453-1400), United Cerebral Palsy (329-4500)
Affordable recreational programs/camps--MPS, YMCA, Boys/Girls Clubs, Salvation Army.
Headstart programs Sick child care--Memorial Hospital of Oconomowoc
(262-569-0256) TLC (St.Luke’s) (414-647-3080)
Resources: Interpreters Contact HMO customer service re: bilingual
providers or translator service AT&T translation line Multilingual staff, Spanish classes Language Source (414-607-8766) Referral to ESL classes, Literacy Services
(414-344-5878), La Causa (414-647-5960), council for the Spanish Speaking (414-384-3700), La Casa de Esperanza (262-547-0887)
Resources: Utilities Pay as you go cell phone or alternate phone
service provider Ameritech Telephone Assistance Program
(800-924-1000) Call customer service & set up payment plan Energy assistance program (800-842-4565) Wisconsin Gas Medical Emergency, restores
service for up to 21days If lack of air conditioning, visit shopping
center, grocery store, library other public places
Resources: Housing A-Call (414-302-633); Access to Shelter
System (262-547-3388)emergency housing assistance
Building Inspector, Lead Abatement Programs
Housing Authority, low-income housing, rent assistance programs
Landlord/Tenant hotlines (800-772-2295), 272-MYLA, (414-674-6767)
Community Advocates (414-449-4777) Runaway shelters (414-271-1560) or
Waukesha(262-544-5333)
Resources: Mental Health Mental Health Association (414-276-3122)
Waukesha (262-546-0769) Milw Co. Crisis Line and Mobile Team (414-
257-7222), Crisis Walk-in Center (414-257-7665); MUTT (414-257-7621)
Nat’l Alliance for the Mentally Ill (769-0447) Protective Payee for SSI payments Counseling programs with sliding-scale fees:
Catholic Charities (414-771-2881), Family Service (414-342-4560), Counseling Center of Milw. (414-271-4610), WI School of Professional Psychology (414-466-9777)
Task force on Family Violence
Resources: Special Needs Children with Special Needs Center (414-
266-6333). Parent mentors, information and referral.
Wisconsin First Step (800-642-7837). March of Dimes Southeast WI ARC Milw (774-6255) Racine (262-634-6303) United Cerebral Palsy (414-329-4500),
Racine (262-639-9595). Info. & referral Katie Beckett: Milwaukee/Waukesha (414-
266-2193), Racine/Kenosha (262-637-2707) W-2 Disabilities Hotine (888-400-8455) Parent-to-parent programs: MUMS, Family
Village web sites
Resources: Financial Foodline (414-773-0211), food stamps Maternal & Child Health Hotline (800-772-
2295)--Healthy Start, Badgercare, PNCC, WIC
Kinship Care (414-297-9370) Paternity establishment & Child Support
Enforcement Services hotline for Women, Children &
Families (877-855-7296)--W2, Child Support Community Information Line (414-733-0211) Social Security Disability (800-772-1213),
Family Support Program (414-289-6799)
Resources: Legal/AdvocacyLegal Aid Society (414-765-0600), family, housing,
consumer, public benefits, civil and rights laws, domestic violence victims
Legal Action of WI (414-278-7722), family law, landlord/tenant, social security, public assistance
Centro Legal (414-384-7900)Community Advocates (414-449-4777), housing
and HMO advocacyCommunity Insurance Info. Center 414-291-5360Milwaukee 9 to 5 (414-272-7795) advocacy for
working women, family/medical leaveABC for Health--legal advocacy re: health care &
insurance disputes (608-261-6939 or 261-6938)
Resources: Web Sites ABC for Heath: www.safetyweb.org Children’s Health Alliance:
www.chawisconsin.org WI First Step: www.mch-hotlines.org Dept of Health & Family Services:
www.dhfs.state.wi.us NORD: www.raredisease.org NICHY: www.nichy.org Exceptional Parent: www.eparent.com National Health Information Center:
www.nhic-nt.health.org
Resources: Dental issues a) WI Donated Dental Services (888-338-6852) b) Marquette Pediatric Dentistry Clinic (288-
7273); c) Madre Angela Dental Clinic (383-3220); d) Healthy Smiles for WI
c) WCTC dental hygiene clinic (262-691-5561) lack of Pediatric dentists and lack of providers
accepting T-19, appointment dates months away:
a) Dental Lack of Insurance: helpline (800-364-7646) b) Dental referral service (800-922-6588) c) 800-DENTIST
Life Change
Think of a time that you changed something in your life…How long did it take? Where did the ideas for
change come from? Who did/did not provide support?
Motivational Enhancement Therapy
How can we help people increase their motivation to change?
What prevents people from being motivated to change?
How do people get motivated to change on their own?
How do we hinder people from being motivated to change?
Stages of Change Theory (Prochaska & DiClemente)Pre-contemplation:
Consciousness raising: Learning new ideas that support the healthy behavioral change
Engagement: Experiencing empathy Dramatic relief : Experience the negative
emotions that go along with the unhealthy behavioral risks
Environmental evaluation: Realizing the negative impact of the unhealthy behavior or the positive impact of the healthy behavior on one’s social and physical environment
Stages of Change Theory
Contemplation: Self reevaluation. Realizing the change is an important part of one’s identity as a person.
Determination/Preparation: Making a firm commitment to change. Self liberation.
Action (3-6 months). Social liberation.
Stages of Change TheoryMaintenance (3-6 months)
Reinforcement: Increasing the rewards for the positive behavioral change and decreasing the rewards of the unhealthy behavior.
Helping Relationships. Seeking and using social support for the healthy behavioral change.
Counter Conditioning. Substituting healthier alternative behaviors and cognitions for the unhealthy behaviors.
Stimulus Control: Removing reminders/cues to do the unhealthy behavior & adding cues or reminders to engage in the healthy behavior.
Stages of Change Theory
TerminationRelapse (efforts fail or regress to a previous
stage) Is very common.
But I’m a _____, not a Therapist!
Let’s be realistic. Most of our clients have neither the time nor the interest in pursuing counseling. If we have a
relationship with them, it can be therapeutic.
Motivational Principles: Phase I: Building Motivation for ChangeExpress empathy: Reflective listening, neutral
but warm. Builds a positive relationship. Respect the person, see their framework. Summarize the client’s perceptions of the problem and ambivalence. Assess family’s understanding and personal,
religious, or cultural beliefs about the child’s condition. Were parents aware of the expected outcome? Provide additional education and instruction, liason with religious or cultural leaders if indicated.
Building Motivation to Change
Develop discrepancy: Increase the perceived benefits of change and slowly decrease the perceived costs/difficulty of change. Provide practical assistance to remove barriers, go over and question the pros/cons of change vs. staying the same. Review risks and problems and give clear advice to change.
Building Motivation to Change Avoid Argumentation. Family will be
defensive, damages the relationship and often burns out the helper.
Roll with resistance. Re-frame, redirect topic, emphasize personal responsibility for change.
Support self-efficacy. Send the optimistic message that they can make changes and take control. What have they overcome before? How did they do it? Identify strengths and affirm the parent. Elicit from the parent a self-motivational statement. Restate their openness to change and concerns.
Phase II: Strengthening Commitment to Change
Discuss consequences of actions and inactions. Convey concerns regarding improving
child’s well-being in a kind, but forthright way. Families are more receptive if they don’t feel judged or blamed. Provide information and advice.
Strengthening Commitment to Change
Discuss a plan. Set clear, realistic expectations and priorities. Express an interest in helping & work to
build a trusting and respectful relationship. Good communication is a major determinant of compliance. (ex. long waits on hold, speaking with office staff vs. MD)
Strengthening Commitment to Change
Deal with resistance. Identify and address underlying issues
contributing to the neglect. Acknowledge stressors and be empathetic.
Asking for a commitmentCommunicate free choice, (but possible
consequence of CPS referral if concerned) Involve a significant other(s); Explain goals
for the support person’s involvement & role
Evaluation and Intervention
Avoid “he said, she said” situations. Good documentation up front will make for a more effective CPS referral later if needed.
Consult with providers to see if a compromise, simplification or prioritization in the treatment plan occur. Document what is negotiable versus necessary, and explain the reasons why.
Consider doing joint visits with other providers It reduces the number of appointments and can improve information/messages sent. Avoid overkill—role is to foster self sufficiency.
Evaluation and Intervention cont.
Refer to community resources to address barriers/psychosocial contributors to the problem. Praise and build on family strengths, include involved extended family or friends. Document parent’s receptiveness and follow through on specific referrals.
Obtain appropriate releases so as to coordinate care with core people. Document collateral contacts and relevant information.
When efforts fall short: ContractingProvider should compose a letter (or gather
notes) to be used as a contract that outlines: child’s needs and treatment plan,
including the main benefits and risks possible health consequences if plan not
followed, including severity and chronicity
language should be easily understood by non-medical professionals and families
Contracting-State the Problem a description of past actions or omissions
that led to harm or potential harm for the child, suggesting a pattern of neglect
a description of referrals and prior efforts, and their impact on remedying barriers to care
indicate failure to meet basic needs could require a referral to child protective services
Care Conference: Conflict Resolution
Arrange for a meeting with caregivers and other core people who have been involved.
Present the information to the parents and again solicit their understanding and viewpoints. Clarify what you would like to see happen. Incorporate motivation enhancement techniques into the discussion.
Do not make any threats/promises regarding how CPS would respond a referral-- especially regarding removal of the child.
Seek parent input on anything they would like added or changed or don’t agree with.
Care conference cont.After reviewing letter and making any
changes, ask the parent to sign the document affirming they understand what has been presented.
If refuses to sign, document parent declined and reasons why, if offered.
If unable to speak with family or no shows, letter can be sent certified return receipt mail. Request the parent either sign that they understand and agree or call to schedule an appointment to discuss this further.
Do I really Need to Do All This?
No.
You can make a report at ANY time.
When to report to Child Protective Services
Actual or potential harm is serious (and due to a basic need not being met). . . OR
Less intrusive efforts have failed and harm or endangerment persists. The recommended health care offers a significant net benefit, outweighing the costs, side effects, and risks.
48.981(2) Mandated ReportingPersons required to report do so when--- they
have reasonable cause to suspect or have reason to believe that a child seen in the course of professional duties has been abused or neglected or has been threatened with an injury and that abuse of the child will occur.
Report shall be immediate to the county agency (or local law enforcement after hours). Failure to report could result in fines &/or jail time. Provider could also be reported to Licensing and Certification.
Making the ReferralContact the county in which the child
resides, and provide information regarding: names, ages/birthdays for child and other
family members home & work address & phone numbers, factual description of suspected neglect
and condition of the child/ren fax over pertinent records (consent not
needed in child abuse or neglect investigations)
Reasons for reluctance to reportDon’t want to cause conflict with the family
and jeopardize ongoing relationship and care. Don’t want to be a “bad guy” or “betray” the client.
Fear for the future welfare of the child--parents will not seek care, child is blamed by parents for report. Believe reporting will make things worse.
Fear for personal safety.Limited monitoring/tracking of patients--not
aware a patient is not following up as recommended.
Reasons for reluctance to report Lack of confidence in CPS. Think case will
not be dealt with appropriately, or provider can do a better job themselves.
Lack of knowledge/training regarding mandated reporting or indicators of neglect.
Unsure if neglect truly exists, perceived lack of evidence to support suspicion.
Too much work/effort required on their part. Emotionally drained/frustrated.
Fear will have to testify.
Liason with CPSWhen making a report, include additional
information regarding abuse/neglect issues. If you are the reporter, call to request to speak
with the investigator if one has been assigned. Be nice. Don’t take your frustration out on the worker. Give them time to investigate.
If the case is not assigned for investigation, ask to speak with an intake supervisor.
Speak/explain the information in basic, layman terms. Focus on the harm or serious, potential/likely harm. Provide additional educational materials regarding the illness.
Liason with CPS
Speak with the worker’s supervisor if appropriate. Workers must consult with their supervisor regularly on cases and supervisor should be abreast of case status. If not satisfied, speak to manager. As a LAST resort, consult with DA if serious concerns for the child’s safety remain.
Inform worker of new information that develops after initial report. If case already closed, make a new referral to intake.
Be nice, be patient, and have realistic expectations for investigation.
Liason with CPS
Even if neglect is substantiated, case may not meet legal criteria for removal. May offer services and close monitoring. You may be back to square one when the “voluntary” services back out.
Sometimes the barrier is at the DA/court level. The worker may be as concerned as you, but not enough grounds for more aggressive measures.
Don’t forget about Care for the Caregiver
Be mindful of professional boundaries, your emotions and signs of burnout. Utilize your support people and resources (EAP, debriefing, case staffing).
Have realistic expectations for yourself. Don’t burden yourself by thinking maybe there’s more you could have done. Watch out for “rescue” fantasies, anger and hopelessness.
Defining Medical Neglect
Actual and potential harm to a child due to a lack of health care, whatever
the reason.
(Dubowitz, 1999)
Major manifestations of medical neglect, (Dubowitz, 1999)Failure, or delay in obtaining health care.
The problem is: Not recognized. Recognized but the parent thinks there is
no treatment for it. Recognized, but the response is
inappropriate. Recognized, but the parents thought it
would get better without medical care.
Manifestations cont.
Refusal of health care Mistrust of medical providers or
adversarial relationship. Disbelief regarding illness’ severity and
treatment. Religious beliefs/expectations of miraculous healing.
Manifestations of Medical Neglect
Non-adherance to health care recommendations, inadequate care Neglect only if actual or probable harm
exists Neglect only if significant benefit from
treatment is probable Neglect even if a single or rare event Neglect even if an excuse exists
Manifestations cont.Nonorganic failure to thrive. Inadequate growth
where the primary contributors are psychosocial problems rather than medical or genetic (ex. reflux, poor oral/motor skills, GI etc). Examples: May eat well and gain weight in the
hospital, parent doesn’t wake for night-time feedings, not mixing formula correctly, doesn’t respond to cries or interact with child, breastfeeding with poor diet or routines
Incidence
According to National Child Abuse and Neglect Data System, 2% of all maltreatment reports were for medical neglect. Of the 8,611 children identified, 50% were under 4 years of age
(U.S. Department of Health & Human Services, 1996)
Withholding medical care based on religious grounds
Between 1975 and 1995, there have been 172 known deaths of children where medical care was withheld. In most of these cases, the prognosis would have been excellent had the children received medical care. (Asser & Swan, 1998)
American Academy of Pediatrics and others have put forth position statements calling for the repeal of religious exemption laws.
Defining Medical Neglect
Actual and potential harm to a child due to a lack of health care, whatever
the reason.
(Dubowitz, 1999)
Convey concerns regarding child’s health needs not being met
in a kind, but forthright way. Families are more receptive if they
don’t feel judged or blamed. Information and advice.
Failure, or delay in obtaining health care. The problem is:
Not recognized.
Recognized but the parent thinks there is no treatment for it.
Recognized, but the response is inappropriate.
Recognized, but the parents thought it would get better without
medical care.
Manifestations cont.
Refusal of health care Mistrust of medical providers or
adversarial relationship. Disbelief regarding illness’ severity and
treatment. Religious beliefs/expectations of miraculous healing.
Examples of actual harmAsthmatics not taking medications &/or not
getting prescriptions filled. Exacerbation with delay in care can require frequent admissions, intubation.
Severely developmentally delayed. Poor hygiene, infected g-tube site. Left alone or in care of siblings. Quality of life issues: truancy--educational neglect and not receiving therapies, diminished physical and social functioning, and independence.
Examples of actual harmPoor dental hygiene and eating habits: tooth
abscess, facial cellulitis, dental caries, numerous teeth extractions, gum necrosis, untreated pain.
Seizure disorder patients not receiving medicine. Status epilepticus resulting in anoxic brain injury. Severe brain injury, requiring g-tube.
FTT:Malnutrition, dehydration can lead to seizure and multi-organ dysfunction if delay in care.
Examples of actual harmPoorly treated wounds that become infected
and develop cellulitis or drainage, delay in seeking medical care. Macerated/ulcerated skin, gangrene, necrosis, grafting.
Diabetics: blood sugars not tested, insulin not being given, not following diet. Child expected to self manage, family not coming in for teaching. Recurrent hospitalizations. Delay in seeking care when symptomatic. DKA--vomiting, seizures, close to coma.