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Child Neglect: A Guide for Intervention
Author(s):
U.S. Department of Health and Human Services
Gaudin, J. M., Jr. |
Year Published: 1993 |
5. Assessment of Neglect
Effective intervention to prevent or remedy child neglect is dependent on accurate and continuing assessment. Assessment is an ongoing process that begins with the first contact and continues throughout the life of a case. To gain an understanding of the causes of neglect in a family, the assessment should include consideration of the areas outlined in Figure 2.
Indicators of Neglect
The assessment process begins with identification of the indicators of neglect; that is, the specific parental inadequacies resulting in the unmet basic needs of the child. For example, a toddler left unsupervised outside daily for an hour or more at a time; severely unsanitary or dangerous conditions in the home; failure to keep medical appointments for a child's serious health problem; nonorganic failure to thrive; or, chronic, unexplained absences from school are specific indicators of neglect. It is also important to determine whether the condition is chronic or a recent change.
Helping professionals must always remember that neglect means lack of minimally adequate care and be aware of cultural and social class differences and norms affecting child care. For example, the minimum age at which a child is expected to be able to care for a toddler varies among Hispanics, lower income African-Americans, and middle class whites. Older children in these families are trained to care for younger siblings and have learned basic safety skills, including who to contact in emergency situations. Child care and supervision is a responsibility shared by extended family members, neighbors, or friends in lower income African-American, Native American, and Hispanic families. Assessment of adequacy of supervision in these families must include these substitute or supplemental care providers.109
Similarly, assessment of the adequacy of the size, structure, and physical condition of housing and household furniture and appliances must be considered in the context of the limited housing options that conditions of poverty allow many families of color. The unavailability of adequate low-rent housing becomes a question of community neglect, rather than child neglect on the part of parents who are denied access to more adequate housing by reason of economics or discrimination.
Problems Identified by the Parents
Obtaining the parent's own perspectives on the family's problems and their causes is essential. Parents' perceptions of problems and priorities may be quite different from that of professional helpers. Chronically neglectful families are typically poor, with multiple problems. Therefore, it is important to identify and set priorities among the family's neglect-related problems. A mother's concern about money to keep utilities on or to forestall eviction must come before the caseworker's concerns about teaching nonabusive approaches to disciplining children.
Gaining the cooperation of neglectful parents is often difficult, but necessary for effective intervention.110 Recognizing and giving attention and assistance to the problems identified by the parents are critical to obtaining parental cooperation and commitment to improved parenting.111
Causes/Barriers to Provision of Adequate Care
To change a pattern of neglect, the helping professional must address the causes rather than the symptoms. For example, if an infant is malnourished due to parent neglect, CPS intervention would be very different for a mother who lacked knowledge about how and what to feed her baby than for a mother whose abuse of alcohol resulted in the baby's malnourishment.
Assessments should include examination of problems, causes, and barriers at all system levels, that is, individual, family, organizational/community, and cultural. It is equally important to identify and acknowledge the strengths, coping skills, and resources of parents and other family members that may be mobilized to reduce the risk of further maltreatment. The availability and accessibility of informal social network supports and formally organized supportive services should also be considered in the assessment.112
Understanding the interaction of stressful life circumstances, lack of environmental supports, and deficits in personal resources is the first step in developing a plan for intervention. The following factors should be considered in that assessment:
Individual Personality Factors
- Strengths, e.g., motivation, concern for the children, willingness to learn, and resourcefulness.
- Mental Status (while examples represent deficits, opposite assessment findings should be noted as strengths in mental status).
- Diagnosis of serious mental illness or hospitalizations for mental illness.
- Impaired intelligence level, e.g., evidence of mental disability or illiteracy.
- Poor reality orientation, e.g., noticeable distortions of reality, disorientation to time, place, or circumstances.
- Inappropriateness of affect, e.g., unusual elation or unhappiness.
- Symptoms of depression, e.g., previous hospitalization for depression, loss of appetite, unexplained weight loss, restricted affect, listlessness, sleep disturbances, suicidal thoughts, poor self concept, or low self-esteem.
- Poor judgment, especially in relation to care of children, use of money, etc.
- Poor impulse control, e.g., difficulty in handling anger and controlling sexual urges, misspending money.
- Substance abuse, e.g., abuse of alcohol or other drugs or addictions.
- Overstressed, e.g., overwhelming feelings of helplessness, fears, and confusion resulting from a crisis with the report of neglect often exacerbating the stress.
- Parenting knowledge and skills, e.g., age-appropriate expectations of children, empathic ability with children, knowledge of children's medical needs, or safety consciousness.
- Interpersonal skills, e.g., verbal and written communication, ability to maintain social relationships, stability of intimate relationships, handling of conflict, and problem-solving skills.
- Physical health.
- Cooperation, motivation for accepting help, improving adequacy of parenting, and willingness to engage in a helping relationship.
Family System Factors
- Family strengths, e.g., concern for children, stable relationships, family cohesion, and assertiveness in problem-solving.
- Income, e.g., employment of head of household and adequacy of income.
- Size of household, number and spacing of children, and other dependent adults in home.
- Stability and supportiveness of marital relationship or relationship with significant intimate partner.
- Children with special needs, e.g., a physical or mental disability, serious behavioral problems, developmental delays, or learning problems.
- Stability of family membership, e.g., recent deaths, divorces, separations, births, children removed or replaced, or assuming care for children of relatives or friends.
- Degree of structure and organization of family, e.g., explicitness of family rules, discipline, roles, generational boundaries, and role reversals.
- Family interaction patterns, e.g., observed verbal and nonverbal communication between parents and children and between adults, attention to children, handling of conflict, balance of negative versus positive parent'child communications, amount of positive physical contact between parental figures and children, children's display of aggressive or withdrawing behaviors.
- Family boundaries, e.g., openness of the family to outside influences; amount of interaction across family boundaries with individuals, organizations, and the community; and knowledge of and use of formal and informal helping resources in community.
Environmental/Community Factors
- Housing, e.g., adequacy of space for family size; condition of housing; safe conditions for children; and availability of stable, affordable housing.
- Neighborhood supports for parenting, e.g., safety of neighborhood and recreational facilities; safety of play areas for children; level of neighborhood organization; and communicative, mutually supportive networks.
- Supportiveness of informal social networks, e.g., availability of relatives, neighbors, friends, pastors, etc. to provide tangible aid, advice, guidance, and emotional support to assist parents.
- Availability of organized parenting support services, e.g., availability of affordable child care, emergency assistance, after-school programs, recreational programs, parks, high-quality school programs for children with special needs, mental health, and health care, family counseling, parent education, and peer support groups.
Cultural Factors
- Cultural strengths
- Strong loyalty to "family," family cohesiveness and family ownership of children's problems in Native American, African-American, Hispanic, and Asian families.113
- Strong, supportive extended family linkages and sharing in child care tasks by family, friends, and neighbors in families of color.114
- Cultural emphasis on discipline, obedience to rules, and respect for elders who are sources of advice for child rearing.
- Bicultural competence of children and adults, which permits preserving cultural identity while negotiating the dominant culture.
- The use of humor as a means of coping for African-Americans.
- Cultural emphasis on independence of children in Native American families and interdependence of siblings in Hispanic families.
- Strong religious values, customs, rituals, and institutions that provide spiritual support and reinforce strong, ethical values for life decisions, respect for elders, and give meaning to life. Churches provide group socialization activities and supplementary child care for children.
- Value placed on education of children, who are seen as the hope for the future by African-Americans and Asians.115
- Strong ethnic community representatives and organizations that help people of color to bargain, negotiate, and obtain resources from the larger societal systems.
- Cultural Barriers
- Language differences between immigrant groups and larger culture. Use of "Black English" by some lower-SES African-Americans in larger white-oriented society.116
- Differences in styles of communication, e.g., avoidance of eye contact with whites by Native Americans, African-Americans, and norms that prohibit sharing of strong feelings with nonfamily members by Asians and Hispanics.
- Discrimination, bias by majority Anglo-whites against immigrant minorities or people of color.
- Child-rearing norms that are at variance with dominant culture norms, e.g., use of folk remedies to treat illnesses or expecting young school-aged children to care for toddlers.
- Social status differences and conflicts within Hispanic, Asian, African-American groups.
- Lack of knowledge about how the larger social systems operate in the dominant culture, i.e., how to cope with complex bureaucracies and political processes.
- Distrust of authority figures from majority culture or assumption of punishment rather than help.
- Resources to Overcome Obstacles
- Crosscultural competence of professional helpers, who are informed about diverse cultural heritages, values, customs, child rearing norms and practices, communication styles, and aware of their own cultural heritage and biases.
- Culturally sensitive and responsive outreach to people of color by organizations and communities.
A complete assessment of neglectful families includes consideration of all factors that may be contributing to the child's neglect as well as factors that may contribute to problem resolution. The diagnostic assessment and service/treatment plan is based on this information with revisions occurring as additional information about the family is obtained.
Setting Priorities
The professional helper works with the family to assign priorities in problem resolution, identifying the top two to five mutually agreed upon priorities for action. The priorities then become the first problems addressed in the service/treatment plan. For example, Goal #1obtain immunizations for preschool child; Goal #2obtain safe housing for family. Breaking goals down into manageable achievable subgoals helps neglectful families' problem solving, and achievement of small goals increases the family's motivation to improve.
Structured Assessment Measures
Structured assessment measures have been used in both research and intervention projects with neglectful families to learn about the characteristics of neglect; provide a clearly defined, limited focus for interventions; and provide a means for systematically assessing intervention outcomes.
Measures of Quality of Parenting
- Polanksy's Childhood Level of Living Scale (CLL) was developed to provide a quantifiable measure of the quality of physical and emotional/cognitive care for young children.117 The scale consists of 99 items, which were selected as observable indicators of the quality of care to be used in discriminating between neglectful care and high-quality care of children. The responses to the items are a simple "yes/no" to each item, indicating the presence or absence of the behavior of the parent toward the child. The scale must be completed by a caseworker or someone else who is familiar with the parent's patterns of behavior toward the child for whom quality of care is being assessed. It yields a total score on a scale of 1'99, with higher scores indicating better quality of care. Scores can also be calculated separately for physical care, emotional/cognitive care, and nine subscales. Reliability and validity are well established, and norms have been empirically established for neglectful, severely neglectful, marginally adequate, adequate, and excellent levels of care.118 A caseworker or volunteer familiar with the family can complete the scale in 15 minutes or less. It can be a useful tool for systematically assessing the quality of physical and emotional/cognitive care being provided by a parent and for measuring improvements in quality of care over time.119
- The Child Well-Being Scale is a more recently developed scale for measuring adequacy of child care.120 The scale, like the CLL, is completed by a person familiar with the family's patterns of child care. Quality of child care is assessed on 43 separate dimensions, which range from provision of nutritious meals and physical safety of the home to the appropriateness of the parent or other care provider's expectations for the child. Each anchored scale proposes to measure a dimension of care related to one or more physical, psychological, or social needs of children. The assumption is that the degree to which these needs are met defines the status of the child's overall well-being. Three primary factors are measuredhousehold adequacy, parental disposition, and child performance. The latter factor is assessed on the basis of anchored ratings on four of the subscales applied to each child in the family. The subscales assess educational status and performance and delinquent behavior and are thus applicable only to school-aged children. Recent application of this measure with neglectful families support its reliability and validity.121
- The HOME Inventory is a structured observation/interview instrument that assesses the quality of the child-rearing (home) environment.122 Separate rating scales are available for infants (birth to age 1), toddlers (age 1'3), and 3'6 year olds. Items cover parental interactions and activities with the child to provide intellectual stimulation, the safety and quality of the physical home environment, and the discipline and emotional nurturing of the child. Many of the scale items assess the presence in the home of age-appropriate books and toys for the children that would be found most often in middle class homes. These items appear to bias the scale toward middle- and upper-income groups and indeed, the scale does correlate significantly with measures of SES.
- The CLEAN Checklist (Checklist for Living Environments to Assess Neglect) was created by Watson-Perczel to assess home cleanliness.123 The checklist divides each room into "item areas" such as furnishings, surface areas, fixtures, and appliances. Each item area is inspected to determine whether the item area is clean or dirty, the number of clothes or linens in direct contact with an item area, and the number of items not belonging in contact with a particular area. The CLEAN produces a composite percentage score reflecting the condition of the home along three dimensionsclean/dirty, clothes/linens, and items not belonging.124 This structured assessment measure enables the professional helper or volunteer to identify specific, measurable, and achievable goals for improving the cleanliness of the physical environment when this has been identified as less than adequate or neglectful. Program evaluation using single subject designs and feedback from CPS caseworkers indicates that the use of this instrument with a very structured, behavioral home cleanliness program resulted in lasting changes in the home conditions.125
- The Home Accident Prevention Inventory (HAPI) has been used similarly to assess the safety of the home environment and to provide a measure for assessing outcomes of behavioral interventions to remedy unsafe home conditions for children. The HAPI includes five categories of safety hazards in the homefire and electrical, mechanical-suffocation, ingested object suffocation, firearms, and solid and liquid poisons. The measure was used to assess improvements in home safety resulting from a structured, behavioral intervention program. Neglectful families were provided detailed instructions for remedying the unsafe conditions and feedback regarding the number and location of the safety hazards in the home. Subsequent assessments of the hazardous categories in each home after the interventions indicated large decreases in seriously hazardous conditions over several months.126
Social Network Assessment Measures
A number of structured assessment instruments can be used to assess the quantity and quality of a family's linkages with formal and informal supportive resources outside the family system.
- The Eco-Map is one of the simplest and most widely used measures.127 Information about the family members' relationships with agencies, employers, church, school, other organizations, relatives, friends, and neighbors is plotted on a one-page circular chart. The lines from family members to outside individuals and groups are drawn to indicate supportive or conflictual relationships. A graphic picture of the family's support system or lack of supports is illustrated. This can be used to identify problematic relationships that could be improved to become supportive or to identify the need for making new supportive relationships.
- The Social Network Map and Social Network Assessment Guide are examples of structured measures designed to assess the size, intensity, composition, and supportiveness of the parent's informal social network.128 These measures yield a picture of the social network as perceived by the parent and provide direction for interventions to assist neglectful parents to increase the size, composition, and supportiveness of the network.
Observational Measures
Structured observational guides have also been used by researchers and practitioners to assess the quality of parent'child interactions in neglectful families and to assess outcomes of interventions to improve the quality of those interactions.129
- For use with parents of young children, Crittenden has developed the 52-item CARE-Index as an observational measure of the quality of parent'child interactions.130 The measure focuses on seven aspects of dyadic parent'child behavior:
- facial expression,
- vocal expression,
- position and body contact,
- expression of affection,
- pacing, and
- control and choice of activity.
For each aspect of behavior, there are three items describing the quality of the adult care provider's behavior and four items describing the child's behavior. The scored items describing each quality are added up to provide three scale scores for adults, that is, "sensitivity, controllingness, and unresponsiveness," and four for children.131 Parents and children are observed playing as naturally as possible in the home on a small blanket spread on the floor and in a "Strange Situation" laboratory setting. Observations may also be videotaped for coding and later comparison.
The use of the CARE-Index for research purposes requires structured situations and intensive training of observers to achieve acceptable levels of reliability. However, the measures do provide guidelines that can be used by professional helpers to aid in the assessment of specific parent'child behaviors that require modification to improve the quality of child care. For example, observation of the relative absence of physical holding, eye contact, or positive verbal messages by a parent indicates the need to teach nurturing behaviors, as appropriate to the parent's ethnic or cultural background.
Risk Assessment Measures
Over the past 10 years, public child welfare agencies have increasingly turned to structured risk assessment instruments in an effort to standardize assessment and decision making, set service priorities, manage the large numbers of referrals, and help identify family problems and strengths. The risk assessment instruments range from simple rating scales to highly complex rating systems, which yield weighted numerical scores for categorizing families by degree of assessed risk for future maltreatment.
Most of the risk assessment measures do not differentiate neglect from abuse. Alaska's risk assessment instrument is an exception. It yields a separate risk score for neglect and for physical abuse.132 The neglect scale is designed to assess the likelihood for continued neglect for cases reported to an agency for child maltreatment. The factors were empirically determined through a study of 550 families referred for child maltreatment over a 12-month period. The nine factors selected to predict the likelihood of child neglect include:
- previous referrals for neglect,
- number of previous out-of-home placements,
- caretaker neglected as a child,
- single caretaker in home at time of referral,
- caretaker history of drug/alcohol abuse,
- age of youngest caretaker at time of referral,
- number of children in home,
- caretaker involved in primarily negative social relationships, and
- motivation for change on part of caretaker.
Weighted risk scores derived from the workers ratings on these nine factors have proved to be reliable predictors for subsequent neglect.133
Risk assessment rating scales are very useful for training new CPS caseworkers. The scales provide a framework for understanding and recognizing critical case factors. However, as Wald has pointed out, these rating scales, which are most often not based on empirical research, should not be used to replace clinical judgment by trained professionals about individual child neglect situations.134 They can be used with an awareness of their limitations, as useful tools to guide and supplement clinical judgment, but never as rigidly applied criteria for decision making.135
Appropriate allowances must also be made for cultural differences on risk indicators. The State of Washington has developed a risk assessment matrix and checklist for family and community strengths and resources that provides guidelines for multicultural assessment.136
In summary, the assessment process in cases of child neglect requires several steps and sets the stage for subsequent intervention. The helping professional must be particularly sensitive to the need to involve the neglectful family in the process. Further, distinctions in cases must be made with regard to cultural norms and SES. Structured assessment measures are useful supplements to professional judgment about areas in need of remediation.
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