Child Neglect Article Review

O R I G I N A L P A P E R

Unintentional Child Neglect: Literature Review and Observational Study

Emily Friedman • Stephen B. Billick

Published online: 15 November 2014 � Springer Science+Business Media New York 2014

Abstract Child abuse is a problem that affects over six million children in the United States each year. Child neglect accounts for 78 % of those cases. Despite this, the issue of

child neglect is still not well understood, partially because child neglect does not have a

consistent, universally accepted definition. Some researchers consider child neglect and

child abuse to be one in the same, while other researchers consider them to be conceptually

different. Factors that make child neglect difficult to define include: (1) Cultural differ-

ences; motives must be taken into account because parents may believe they are acting in

the child’s best interests based on cultural beliefs (2) the fact that the effect of child abuse

is not always immediately visible; the effects of emotional neglect specifically may not be

apparent until later in the child’s development, and (3) the large spectrum of actions that

fall under the category of child abuse. Some of the risk factors for increased child neglect

and maltreatment have been identified. These risk factors include socioeconomic status,

education level, family composition, and the presence of dysfunction family characteris-

tics. Studies have found that children from poorer families and children of less educated

parents are more likely to sustain fatal unintentional injuries than children of wealthier,

better educated parents. Studies have also found that children living with adults unrelated

to them are at increased risk for unintentional injuries and maltreatment. Dysfunctional

family characteristics may even be more indicative of child neglect. Parental alcohol or

drug abuse, parental personal history of neglect, and parental stress greatly increase the

odds of neglect. Parental depression doubles the odds of child neglect. However, more

research needs to be done to better understand these risk factors and to identify others.

Having a clearer understanding of the risk factors could lead to prevention and treatment,

as it would allow for health care personnel to screen for high-risk children and intervene

before it is too late. Screening could also be done in the schools and organized after school

E. Friedman (&) Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, USA e-mail: emilybeth.friedman@gmail.com

S. B. Billick NYU School of Medicine, 901 5th Avenue, New York, NY 10021, USA e-mail: stephen@billick.com

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Psychiatr Q (2015) 86:253–259 DOI 10.1007/s11126-014-9328-0

activities. Parenting classes have been shown to be an effective intervention strategy by

decreasing parental stress and potential for abuse, but there has been limited research done

on this approach. Parenting classes can be part of the corrective actions for parents found to

be neglectful or abusive, but parenting classes may also be useful as a preventative

measure, being taught in schools or readily available in higher-risk communities. More

research has to be done to better define child abuse and neglect so that it can be effectively

addressed and treated.

Keywords Child neglect � Unintentional injuries � Child abuse � Maltreatment

Introduction

Definition

There is some ambiguity and debate over the definition of child neglect. What lack of

action leads to neglect? Some researchers believe that child neglect and child abuse are one

in the same, while others believe that there is a conceptual difference between the two.

In a study done by Putman-Hornstein, Cleves, Licht, and Needell (2013), they broadly

defined neglect as ‘‘acts of parental omission that endanger children’’ [9]. In this study,

they compared instances of fatal injuries for children referred to child protective services

for allegations of physical abuse compared with those referred for neglect. It was deter-

mined that children referred for physical abuse sustained fatal injuries at a rate 1.7 times

more frequently than those referred for neglect. Because of this, Putnam-Hornstein et al.

suggest that there is a conceptual difference between abuse and neglect [9].

Others disagree. In an article published by Single Parent Advocate, Cedrick Tardy

(2012) writes, ‘‘abuse and neglect are one in the same’’ [12]. He defines unintentional

neglect as an instance when a parent decides to put a priority of lower value over the

ultimate well being of his or her child. Parents may even believe, he says, that they are

acting in the child’s best interest.

Other factors that make neglect hard to precisely define are long-term effects and

cultural differences. In the chapter on Child Neglect in the APSAC Handbook on Child

Maltreatment, Erickson and Egeland (2002) point out that actions can be considered

neglectful regardless of their immediate observable impact on the child’s functioning.

Sometimes, the impact of neglect may not become apparent until later in the child’s

development [3]. For example, emotional neglect can cause children to be socially with-

drawn, have problems with peers, and exhibit anxious avoidant attachment patterns.

Studies have even suggested that consequences of emotional neglect can be more profound

than physical neglect and other types of maltreatment [3].

Cultural differences and motives must be taken into account when determining if an

action is neglectful. For example, some Hispanic parents sometimes do not use car seats for

their children because they think the child will feel abandoned if they are not in their arms

[3]. While this is unsafe and could be considered neglect, culture and motives put this

action in a gray area.

A broad spectrum of circumstances falls under the categories of child abuse or neglect.

According to Karageorge and Kendall (2008) in the Child Abuse and Neglect User Manual

Series, ‘‘it may be a single incident, such as a caregiver shaking an infant to try to stop its

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crying, or a pattern of behavior, such as a parent providing inadequate supervision or

sexually abusing a child over several months or years’’ [6].

Because neglect is multiply determined, it has both immediate and gradual effects, and

covers a wide range of behaviors, it is a more intractable form of maltreatment than

physical abuse [7]. In fact, child and family services supervisor Michelle Selinger, with

Carver County Community Social Services in Minnesota, said, ‘‘Being able to wrap a

safety plan around physical abuse is almost easier than wrapping a plan around chronic

neglect’’ [5]. According to Selinger, cases of neglect are more complicated and often more

fatal than cases of clear-cut abuse [5].

Statistics

According to the National Child Abuse Statistics, every year in the United States more than

three million reports of child abuse are made, involving more than six million children. In

2012, 78.3 % of those abuse reports were for child neglect [2].

Associations and Risk Factors for Increased Child Neglect and Maltreatment

Studies have found multiple factors that increase the risk of child neglect and maltreat-

ment. Such factors include socioeconomic status, education level, family composition, and

the presence of dysfunctional family characteristics.

A study done by Mooney (2010) found that socioeconomic status has a significant

correlation with instances of child maltreatment [8]. This study found that children under

the age of one from poor families are 17 times more likely to die from unintentional injury

than those born to parents in professional roles. Additionally, non-working, unemployed,

poor parents are 12 times more likely to have a child die under the age of 15 from an

assault [8]. The greatest discrepancy between the classes was in deaths caused by fires,

pedestrian accidents, unintentional suffocation, and drowning. Myer Glickman, ONS

(Office for National Statistics) head of health analysis, said: ‘‘The study shows that chil-

dren in the most disadvantaged families��� have a risk of accidental or violent death around five times that of children with at least one parent in a professional or managerial job. The

difference between socio-economic classes in child death rates is more than 15 times for

deaths from fires and more than eight times for fatal pedestrian accidents’’ [8]. It is clear

from this study that socioeconomic inequalities have a marked effect on a child’s likeli-

hood of being neglected or abused.

Studies done on parental education level and neglect rates have also shown a causal

relationship. A study performed in Sweden by Beiki, Karimi, and Mohammadi (2014)

followed 907,335 children between 1961 and 2007 to assess whether or not fatal and non-

fatal unintentional injuries among foreign-born children were similar across parental

education levels [1]. It was found that the risk of death and hospitalization was signifi-

cantly higher among children with lowest parental education level compared with those

with highest parental education level. Risk of death was 1.48 times higher and risk of

hospitalization was 1.10 times higher in the low parental education group as compared with

the high parental education group. It was also found that injury prevention education was

less effective for helping children with parents who had low education levels [1].

According to Schnitzer and Ewigman (2008), family composition is also an independent

risk factor in the occurrence of child neglect. Their study looked at data from the Missouri

Child Fatality Review Program from 1992 to 1999. Children who died under the age of five

were eligible for the study, and controls were selected from children who died of natural

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causes. Cases were defined as children who died of unintentional injury when the caregiver

was (1) not present, (2) present but not capable of protecting the child, (3) placed the child

in an unsafe sleeping environment, or (4) failed to use legally mandated safety devices. A

total of 380 cases met these criteria [11]. Household composition was assessed based on

the relationship of the adults living in the household with the deceased child. They found

that children living with adults not related to them were six times more likely to die of

maltreatment related unintentional injury than those living with two biological parents

[11]. Similarly, children living with related adults who were not parents, such as aunts,

uncles, and grandparents, had an elevated risk twice that of children living with biological

parents [11]. Interestingly, risk was not elevated in single parent households in which no

other adults lived [11].

In addition to caregiver makeup, birth order may also be a risk factor. More than 70 %

of children who died of unintentional injuries were born second or later, according to an

article written by Heimpel (2013) in The Chronicle of Social Change [5].

A study done by Lee (2013) found that the presence of dysfunctional family charac-

teristics such as alcohol or drug abuse, parental personal history of neglect, and parenting

stress all increase the odds of neglect. Parental depression doubles the odds [7]. Occurrence

of neglect was measured through revised Parent–Child Conflict Tactics Scales and

instances of Child Protective Services involvement. The study also found that there was a

higher probability of neglect in African American and Hispanic families. This association

was no longer significant in African American fathers after accounting for economic

hardship, but compared with Caucasian, the study did find a 58 % increase in the odds of

child neglect in the Hispanic ethnicity group [7].

Depression was also identified as a variable leading to maltreatment in the APSAC

handbook. Erickson and Egeland (2002) state that maltreating parents have been found to

have a high incidence of depression [3]. They also note that social cognitive and affective

processes tied to parent’s perceptions of their children can lead to maltreatment. More

specifically, maltreatment can occur when parents lack understanding of the emotional

complexity of human relationship, have difficulty seeing things from the child’s per-

spective or have trouble understanding their developmental level. These parents tend to

think in all-or-nothing terms, or have unresolved issues with trust, dependency and

autonomy of their own. These factors can cause parents to try to seek to satisfy their own

individual personal needs through the child–parent relationship, rather than focusing on the

needs of the child [3].

Prevention and Treatment

There is evidence to suggest that parenting classes could be effective in preventing and

treating instances of unintentional neglect. In a study conducted by Gorzka (1999),

homeless parents were invited to participate in parenting education courses for three one-

hour sessions for a total of three weeks. Researchers measured potential for abuse using the

Adults Adolescent Parenting Inventory. They measured parental stress using the Parenting

Stress Index before and after the course. A significant decrease was shown in the post-test

scores [4]. This study provides evidence for parenting courses as a useful intervention

strategy.

However, perhaps an even more important way to prevent and treat child abuse and

neglect is to research it further so as to better define it and understand its causes. In one

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study, Schnitzer, Covington, and Kruse (2011) tried to assess caregiver responsibility in

unintentional child injury deaths. However, it was hard to reach a consensus on caregiver

responsibility and child neglect because of changing social norms and lack of standards of

minimally adequate care [10]. The definition of child neglect differs across states, disci-

plines, agencies and purpose [10]. Having a more clear and widespread definition could

potentially lead to less ambiguity and fewer instances of neglect.

Furthermore, having a clearer understanding of the risk factors could be immensely

beneficial. Knowing the risk factors will allow for nurses and other health care personnel to

better identify high-risk children [11]. Identification of risk factors could also lead to the

development of an evidence based intervention strategy [11]. A better understanding of

unintentional neglect and its causes could potentially greatly reduce its prevalence.

Methods

Participants

A total of 170 care-giving situations were observed. Some situations were simply one

caregiver and one child, while others included multiple caregivers and multiple children,

one caregiver and multiple children, and multiple caregivers and one child.

Procedure

Participants were observed on the Upper East Side of Manhattan. Observations were made

on the corner of East 72nd Street and 5th Avenue, and in the surrounding ten-block radius.

Observations were made at various times of day and days of the week.

None of the participants knew that they were being observed.

The following factors were noted about the children and their caregivers:

1. How many children and how many caregivers?

2. Is the caregiver the probable child’s parent?

3. Is the caregiver talking or texting on a cell phone?

4. Is the caregiver engaged in a conversation and not paying adequate attention to

the child?

5. Did the caregiver wait for the walk signal to cross the street?

6. Is a small child holding the caregiver’s hand while crossing the street?

7. Is the child walking behind the caregiver, not in full view?

8. Is the child struggling to keep up with the caregiver’s pace?

9. Is the child properly strapped in the stroller?

10. If the child is on a bicycle or scooter, are they wearing proper protective gear like

a helmet?

Results

Refer Table 1 for number of times each neglectful act was observed. The Percentage of

neglectful act with each care-giving team is shown in Table 2.

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Conclusion

While observing children and their caregivers on the Upper East Side of Manhattan, there

were a number of instances in which the caregiver unintentionally neglected the child.

These acts ranged from unintentionally putting the child in danger to not understanding the

child’s needs. Examples of unintentionally putting the child in danger include crossing the

street either at the end of the walk signal with not enough time to complete the crossing

legally, or crossing the street before the signal had changed to walk. Examples of not

understanding the child’s needs include walking too fast for the child’s smaller gait. Most

commonly, caregivers were simply not proving adequate supervision or taking adequate

safety precautions by being inattentive on a cell phone, allowing the child to walk behind

them out of clear view, allowing the child to ride a scooter or bike without a helmet, and

not holding a small child’s hand while crossing the street.

The fact that an average of 28.5 % of caregivers displayed some form of neglect even in

an affluent, well-educated area of New York City seems to suggest that caregivers may be

unaware of the potential danger to the child and the child’s needs. Perhaps the best way to

address the issue of unintentional child neglect is to make parenting classes an integral part

of the high school curriculum. This way, every high school student would be required to

learn about the needs and limitations of children and learn how to prevent any uninten-

tional harm to the child.

Additional education in the adult parental developmental period would reinforce the

previously acquired high school education. A child-specialist could come into talk to all

parents on the maternity wards of hospitals. This too would ensure that every parent be

schooled in how to care for their child and prevent unintentional harm or neglect. As

demonstrated by Gorzka’s (1999) study, parenting classes have proven to be effective in

Table 1 Number of times each neglectful act was observed

Neglectful act Number of times observed

Crossing the street at the end of or before the walk signal 12

Caregiver walking too fast for the child 6

Child walking behind the caregiver 6

Inattentive caregiver on cell phone 11

Caregiver not holding small child’s hand to cross the street 2

Child not wearing a helmet while riding a scooter (N = 28 children on scooters) 12

Child not secure in their stroller 1

Caregiver not providing adequate supervision 1

Table 2 Percentage of neglect- ful act with each care-giving team

Caregiver Percentage of neglectful act (%)

Two or more caregivers 27

Mother 25

Father 33

Nanny 29

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reducing potential for abuse [4]. Increasing access to parenting classes could be immensely

beneficial to reducing the problem.

Parenting classes, both in adolescence and in adulthood, together with more research on

the issue of child neglect are important next steps on the road to reducing and eventually

eliminating the problems of child abuse and child neglect.

References

1. Beiki O, Karimi N, Mohammadi R: Parental education level and injury incidence and mortality among foreign-born children: A cohort study with 46 years follow-up. Journal of Injury and Violence Research 6(1):37–43, 2014.

2. Child Abuse in America. National Child Abuse Statistics. Retrieved 6 May 2014. From http://www. childhelp.org/pages/statistics.

3. Erickson MF, Egeland B: Child Neglect. In: Myers JEB, Berliner L, Briere J, Hendrix CT, Jenny C, Reid TA (Eds) APSAC Handbook on Child Maltreatment, 2nd edn., Thousand Oaks, CA: Sage Pub- lications Inc, 2002.

4. Gorzka PA. Homeless parents: Parenting education to prevent abusive behaviors. Journal of Child and Adolescent Psychiatric nursing 12(3):101–109, 1999.

5. Heimpel D: 2013 New Study points to Danger of Child Neglect. The Chronicle of Social Change. Retrived 6 May 2014. From https://chronicleofsocialchange.org/news/new-study-points-to-danger-of- child-neglect/3934.

6. Karageorge K, Kendall R: The role of professional child care providers in preventing and responding to child abuse and neglect. Child abuse and neglect user manual series. U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau, 2008.

7. Lee SJ: Paternal and household characteristics associated with child neglect and child protective ser- vices involvement. Journal of Social Services Research 39(2):171–187, 2013.

8. Mooney H: Less advantaged children are 17 times more at risk of unintentional or violent death than more advantaged peers. British Medical Journal 2101 341:c6795, 2010.

9. Putnam-Hornstein E, Cleves MA, Licht R, Needell B: Risk of fatal injury in children following abuse allegations: Evidence from a prospective, population based study. American Journal of Public Health 103(10):e39–e44, 2013.

10. Schnitzer PG, Covington TM, Kruse RL: Assessment of caregiver responsibility in unintentional child injury deaths: Challenges for injury prevention. British Medical Journal 17(Suppl 1):i45–i54, 2011.

11. Schnitzer PG, Ewigman BG: Household composition and fatal unintentional injuries related to child maltreatment. Journal of Nursing Scholarship 40(1):91–97, 2008.

12. Tardy C: 2012. The effects of unintentional child abuse (Neglect). Single parent advocate: Coping (Self- Care)—Parents, Parenting. Retrieved 6 May 2014. From http://singleparentadvocate.org/get-advice/ item/the-effects-of-unintentional-child-abuse.

Emily Friedman, BS received a BS from Tufts University and is currently a first year medical student at the Sidney Kimmel Medical College at Thomas Jefferson University.

Stephen B. Billick, MD is a psychiatrist in the Upper East Side of Manhattan. He received his MD from the University of North Carolina in Chapel Hill. He is a Clinical Professor in the Department of Psychiatry at NYU School of Medicine.

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