SPECIAL FEATURES OF NEGLECT

Only the person responsible for supplying the child’s needs can be neglectful; in contrast, anyone can be abusive. However, total failure of the responsible individual does not necessarily result in neglect as someone else may supply the need; in contrast, other people cannot negate abuse, although its effects may be ameliorated.

Neglect depends critically on determination of the needs of a normal child and what constitutes an adequate supply of those needs. This will be much more comprehensively understood by the expert in child development than the parent or civil society; each level of knowledge may have quite a different view of what constitutes neglect. Further, these views will change with advancing knowledge and are likely to be different from one society to another. It may have an absolute meaning for those basic needs that we all recognise as essential, and a relative meaning for those needs that lead to acceptance and integration within a particular culture or society.

It is probably rare for a parent to know precisely what all the needs of a child are at a particular time in its development and to know that these are not being supplied. Neglect is thus much more common than abuse and directly related to the education and awareness of the caretaker. With the exception of feeding, warmth, basic cleanliness, and human interaction most parents are unaware of the other needs for development. In contrast, to know that hitting a child is hurtful is common knowledge to all (even if some might argue that the hurt itself is in some way beneficial to “learning”, the actual hurt is always acknowledged).

If a child was considered to be neglected when she/he has any needs that are not being met, no matter how trivial, the definition would apply to most children and lose meaning. We have therefore to invoke what a reasonable person from the society in question would consider constitutes the needs. There is universally some degree of failure to supply all the needs of children by all caretakers. All parents know that they innocently forget, or neglect, their children when there is competition for their attention and time. This may even be beneficial when it teaches children that in real life there are competing interests and priorities; indeed, part of the child’s needs include learning to enter and live within their society. This might include learning realities, such as not to have everything immediately available and to experience hunger, thirst, and loneliness. Unlike abuse, a certain degree of “neglect”, using the term in a lay sense, is essential to normal development—but becomes damaging when repeated or sustained.

We can “identify” with the idea of neglect and wonder about our own parental performance. If such concepts are not presented carefully, we can even imagine being accused or the subject of investigation; a real fear when neglect is categorised as a form of abuse with its connotations of deliberate harm. Such considerations may lead to unjustified fear and reticence on the part of parents and agencies to support actions against the really harmful and criminal abuse described in the accompanying paper by Southall et al in this issue.

If the parent is unaware of the needs of the child, through lack of education, there can still be neglect. We would argue that the child is neglected, without the parent being neglectful; such a confusing idea shows the complexity of the concept of neglect and how it needs to be refined and explored, without the burden of being linked to abuse.

An independent person cannot be neglected—they can certainly be abused. Neglect is related to the degree of dependency on others to supply needs. Abuse, on the other hand, is not reliant on the degree of dependency but on the degree of significant harm undertaken.

However, even though parents who neglect are, by definition, innocent of any deliberate deprivation that they conceive will bring harm to their children, such unknowing or thoughtless neglect can be damaging or even fatal. This is partly because the parent, being partially or completely unaware of the neglect, does not take any steps to correct the situation, so the neglect becomes longstanding. Indeed, neglect over a long time is particularly harmful.^4,5 For instance, children from “low warmth–high criticism” families may fare worse than those experiencing assaults.

Severe neglect requires intervention by child protection agencies. It nearly always results from the impoverished circumstances and life stresses affecting the family. These are not deliberate acts of omission by the caretaker. The caretaker, although aware that their care of the child is not good, is usually unaware of the extent of actual harm being done. The mother’s time, energy, and thoughts are concentrated elsewhere in an effort to cope. In this respect the neglected child is part of the family and “shares” its distress and deprivation. A common example of this situation includes a young and unsupported mother without training in family life, left alone with several young children, overburdened by circumstances, disorganised, at the end of her tether, who fails to feed and clothe her children adequately, fails to get them to school regularly, and seriously fails to provide sufficient love and attention.

Even when the parent is aware of the needs, there may be constraints that prevent those needs being met by the “neglecting” parent. The stressed parent has to prioritise, and part of the compromise leads to neglect of the child. The working mother who cannot make adequate provision for her absence (latchkey child) and is forced to stop breast feeding in order to go to work are examples of neglect because of societal pressures. Not infrequently, substitute inputs are given by the well intentioned parent—the expensive toy instead of loving interaction. The parent believes the substitute mitigates the neglect.

Neglect is usually the result of a continuous pattern of parental behaviour and the effect, which is cumulative, becomes apparent slowly. The effect of a single deprivation, a missed hug or meal, or a period left alone, will not have a significant effect on development. However, cumulatively there can be serious long term effects.

Neglect can also result from a failure of a child to signal needs to the parent; as when the child is passive and does not demand attention. In contrast, abuse and active ill treatment tend to occur when such strong demands (shouting, screaming) are made by the child that the parent becomes frustrated. With abuse the child becomes the focus of attention; whereas with neglect the child is the opposite—an ignored “nonentity”.

Some children who are neglected may seek attention and love elsewhere. They may even precipitate ill treatment rather than be neglected. These learned attention seeking or affection seeking behaviours may lead some children into abusive sexual relationships. In this way neglect by the primary provider can lead directly to abuse. Although abuse can have its antecedents in neglect, it may be that neglect amounting to rejection may be much more damaging for some children than active ill treatment. This is in direct contrast to the seriousness with which emotional neglect versus sexual abuse is viewed by society. This is the “Lolita” who seeks adults for sex because of neglect (lack of love, care, and attention) in the home.

THE CONUNDRUM OF CHILD MALNUTRITION WITH LOVING AND CARING PARENTS—AN EXAMPLE ILLUSTRATING SOME OF THE ABOVE CONCEPTS

Thirty five per cent of the children of the world are nutritionally stunted⁶ and many more suffer from other forms of nutritional deprivation. Malnutrition involves neglect since nutritional needs have not been met. This neglect, one of the commonest severe insults suffered by children, is a critical example of why we need to understand neglect and differentiate it from abuse.

Nearly all mothers of malnourished children think they have been looking after their children well. They are perplexed when their child becomes ill. The mother is astonished to find that her child has needs that she has not given. For example, she may not realise that a monotonous diet of cheap weaning food is insufficient. When the child cries, some nutritionally inadequate low quality diet is given until the child starts to become malnourished and loses his/her appetite (type II nutrient deficiency); the mother thinks she is feeding the child well as food is offered frequently, but the child does not want to eat it! It is perceived as the child’s fault for not taking what the mother thinks is perfectly good food. There is little point in the child crying for he cannot signal that it is not more but better food that he needs. The resulting passivity leads from mild malnutrition to severe malnutrition and possibly to death.

One of the main features of severe malnutrition is passivity. Children do not cry or complain; they have a “flat affect”. The cry is one of the most important attributes of a healthy child. It signals to the carer that something is wrong that needs interpretation and attention. The critical corollary is that, if the child does not cry, a mother may think that her child’s needs are being met and that she is doing a good job. If the child does not cry appropriately, then half of the communication between child and mother is broken. Once the child fails to communicate its needs, sustained neglect becomes inevitable. The lack of willfulness by the mother is amply confirmed when, following admission to hospital, many of the nursing staff also neglect the malnourished child. Nurses also respond to a cry—and if there is no cry then some nurses think that the child is not hungry or distressed. Nurses attend acutely ill but well nourished children while the malnourished is ignored in the next bed. The smiling child who responds to talk, laughter, and attention is also attended; these are the children the nurses pick up and fuss over. The child with the “flat affect” is left alone and becomes more isolated and neglected. The malnourished child improves in hospital partly because the special diets lead to an improved affect so that adults no longer neglect the child; one of the reasons why relapse from malnutrition is much less common than usually supposed.

Neglect, by parents and nurses, is not anyone’s fault as such. It is a question of education and demonstration. When neglect is linked with the term “abuse”, there is less hope that attendants or parents will be receptive.

Thus, neglect can represent a failure to appreciate the child’s needs or a failure of communication between the child and the caregiver. From the flat affect of the child we could say that she/he appears to be “resigned to fate”; what is not often appreciated is that the parent has often reached exactly the same conclusion. Such a tragedy must be differentiated from wilful abuse.

Similar neglect can be shown to other children when they do not seem to be distressed: the premature infant, the child with a terminal illness, the child who has suffered psychological trauma, and even the grossly abused child. The child who feels abandoned, thinks that nobody loves him, and reacts by withdrawal may become less noticed and is in danger of being neglected.

THE WIDER CONTEXT

This definition of neglect as a failure to supply needs has its parallel in the construct of Human Rights legislation and international agreements.⁷ Individuals have the right to basic human needs and carers have corresponding duties of care. It is not only individuals that can neglect, but also societies, governments, and organisations. The same constructs developed for families apply with equal force to anyone who has a duty of care and fails to supply the needs of those under their care, be that a non-governmental organisation (civil society), government, or a United Nations organisation. From a global perspective, societal neglect is as common as familial neglect and includes the unethical inequalities in healthcare and social support that result in, and from, poverty.^8,9 However, we would argue that when individuals with power, or even states deliberately foster poverty for gain or as part of a political strategy, they are guilty of abuse rather than neglect. Where an organisation deliberately fails to act in a situation where it is mandated to intervene, this is abuse (of power) and not neglect.

The cultural dimension to needs is clearly illustrated when an abusive act is viewed as supplying a cultural need of the individual. It is critical for each of us to be part of “our” culture and accepted by the society in which we live. The arguments surrounding circumcision illustrates this. Nearly everyone from the West would regard female genital mutilation as a barbaric abusive act; but to fail to prepare a child to be accepted into its culture, and therefore risk ostracism, could also be viewed as parental neglect. This particular conundrum raises strong passions on both sides—a debate we do not wish to enter here except to point out that concepts of neglect can lead to completely opposite conclusions from ideas of abuse and that individuals have relative as well as absolute needs that are defined by the culture in which they live. To tackle such problems as genital mutilation, society as a whole has to change so that it is no longer a neglect to omit the “abuse”.

WHAT TO DO ABOUT NEGLECT?

Social services are the appropriate agency to deal with severe forms of neglect, for the whole family needs help. In our view criminal proceedings against neglect may be detrimental.

Most forms of neglect, however, should be addressed through education of both carers and society, often through religious, or other community initiatives. There should also be a more general debate on the needs of the child and how belonging to a particular culture moulds these needs. What constitutes abuse is fairly clear. What constitutes neglect will change, as our knowledge of child development and of children’s needs advances; what is the province of the expert today may become common knowledge tomorrow.