Taking neglect seriously

 

 

Some interesting research about children’s timescales and the Court process, which has been conducted by the Childhood Wellbeing Research Council. It is the first piece of the research that was commissioned under the Family Justice Review, and therefore worthy of attention.  (More attention than it has received)

 

It is heavy, and I can’t say yet whether its conclusions will necessarily be unchallenged, but it is, I think, for the first time, a proper drawing together of all of the important research on delay, decision-making, impact of neglect on children and attachment issues.  If the other pieces of FJR research are going to be as important as this, I will be a very happy law geek.

 

 

http://www.cwrc.ac.uk/news/documents/Decision_making_within_a_childs_timeframe_Oct_2012_CWRC_WP_16.pdf

 

 

It is long and detailed, so my cursory summary of it is absolutely no substitute for reading it.  It also contains some important research about the impact of child abuse, particularly neglect, on children.  A lot of it is pulling together of research that is already out there, but might be less widely known than it should be.

 

 

 

1.1 This overview of research evidence has been commissioned in response to the Family Justice Review recommendation for consistent training and development for family justice professionals, including a greater emphasis on child development. It aims to bring together key research evidence to facilitate understanding among professionals working in the family justice system in areas relating to:

• · neuroscience perspectives on children’s cognitive, social and emotional development;
• · the implications of maltreatment on childhood and adulthood wellbeing;
• · evidence concerning the outcomes of interventions by the courts and children’s social care; and
• · timeframes for intervening and why they are out of kilter with those for children.

 

 

I am hoping to whet your appetite to read the research, because this is some big important stuff.  (I will stop nudging you in the ribs at some point, but really, this needs to be read)

 

 1.19 While the issues covered in this chapter are intended to help the reader develop a critical approach to the understanding of research findings they should not detract from the value of the research itself. The following chapters consider robust findings from a number of well received research studies into parents’ problems and the impact of abuse on early childhood development; family justice professionals need to be aware of this research, particularly because it points to the importance of making timely decisions when children are suffering, or likely to suffer, significant harm.

 

 

We start with some basic principles  (the first few are of the “no-s*** Sherlock variety, but the last two are perhaps startling to see in such stark form)

 

 

Summary points

• · Children growing up with parents who experience problems such as mental illness, learning disability, substance misuse and domestic violence are at greater risk of being maltreated.

 

• · Not all parents with these problems will abuse or neglect their children; however these factors interlock in complex combinations which substantially increase the likelihood of maltreatment.

 

• · Protective factors such as the presence of a non-abusive partner and/or a supportive extended family, parents’ ability to understand and overcome the consequences of their own experiences of childhood abuse, their recognition that their adverse behaviour patterns constitute a problem and their willingness to engage with services can substantially reduce the likelihood of maltreatment.

 

• · Where insufficient protective factors are present, parents’ problems can undermine their ability to meet the needs of their children and inhibit the child’s capacity to form secure attachments.

 

• · Healthy child development depends on the child’s relationships, and particularly their attachment to the primary caregiver.

 

• · The process of attachment formation begins at birth. The four basic attachment styles: secure, insecure ambivalent, insecure avoidant and disorganised illustrate different adaptive strategies in response to different types of caregiving.

 

• · Up to 80% of children brought up in neglectful or abusive environments develop disorganised attachment styles. These children behave unpredictably and have difficulty regulating their emotions.

 

• · Disorganised attachment is strongly associated with later psychopathology.

 

 

 

 

 

This is interesting :-

 

 

The risk of recurrence (of child abuse) was reduced when medical and/or legal services were involved.

 

So the PLO may have been onto something, when they wanted to draw lawyers for parents into the process earlier – it is just a shame that the funding system means that they really can’t come in until proceedings are almost inevitable, rather than at the Initial Assessment process, when legal advice could make a real difference.

 

  

The mitigating value of protective factors

2.10 There is substantial evidence that certain protective factors can interact positively with parental problems to mitigate their impact, thus reducing the likelihood of maltreatment and improving the chances of better long-term outcomes for children. Jones and colleaguesidentified the following factors to be particularly pertinent: the presence of a non-abusive partner; the presence of a supportive extended family; parents’ adaptation to their own experience of childhood abuse; parents’ recognition that there is a problem and their willingness to take responsibility for it; and parents’ willingness to engage with services.

 

 

Whilst these are all things that we intuitively look at in care proceedings, it is helpful to see that the things we take for granted as common sense protective factors actually are.  And the phrase ‘insight’, which we hear so often, really is instrinsically bundled up in this.

 

 

[I do wonder, on a 26 week timetable, how the “Ostriches”  – those parents who bury their heads in the sand and pretend none of this awful situation is happening to them, before finally realising, will fare.  I suspect that there will no longer be enough time to turn the Ostrich cases around to a positive outcome]

 

2.11 Cleaver and colleagues40 have provided a comprehensive analysis of the manner in which, where there are insufficient protective factors, parents’ problems can impact on parenting capacity and trigger maltreatment and poor child outcomes. To summarise:

 

• · Parental mental illness can seriously affect functioning. For example someone suffering from schizophrenia can experience delusions and hallucinations and be preoccupied with a private world. A person who is depressed can have feelings of gloom, worthlessness and hopelessness, which may mean that everyday activities are not carried out. Mental illness can blunt parents’ emotions and feelings towards their children, cause them to be emotionally unavailable or behave unpredictably, or occasionally cause them to be violent.

 

• · Learning disability can affect parents’ capacity to learn and retain the new skills that are necessary to parent a child. Parents with a learning disability may also have had a negative experience of their own childhood which can leave them with low self-esteem and a poor sense of self-worth. Consequently, parents with learning disabilities and their children are vulnerable to financial and sexual exploitation, domestic violence, harassment and bullying.

 

• · Parents who abuse drugs and/or alcohol can be subject to erratic mood swings, paranoia and hallucinations, or feelings of elation and calm, diminished concentration, memory impairment and a loss of consciousness. This can leave them unable to: meet the basic needs of their children, be emotionally available to them or at times keep them safe.

 

• · Being the victim of domestic violence is likely to undermine parents’ self-esteem and confidence in their parenting skills. Such parents may have their attention focussed on the necessity to placate the perpetrator rather than on their children’s needs. They may not be able to protect those of their children who get caught up in or witness an attack from physical abuse and emotional trauma. Perpetrators of domestic violence are likely to cause physical and emotional harm to their children as well as to their partners.

 

2.12 Behaviour patterns such as these undermine a parent’s ability to meet their children’s needs. They have a particularly damaging impact on the child’s emerging capacity to form attachments.

 

 

The report then goes on to specifically look at attachment issues – I think lawyers (and perhaps some others in the family justice system) are often a bit muddled about attachment, and what the significance or otherwise of it is.  I often see it being conflated with an concept of whether the parent loves the child and vice versa. If you know a bit about attachment theory, not much of this is new, but it is helpful to have it pulled into one place and be able to take the Courts to this one document.

 

 

The importance of a secure attachment base for healthy child Development

 

Young children experience their world as an environment of relationships, and these relationships affect virtually all aspects of their development – intellectual, social, emotional, physical, behavioural, and moral.

 

 

2.13 Healthy child development depends on the establishment of these relationships. Early secure attachments contribute to the growth of a broad range of competencies, which can include: a love of learning; a comfortable sense of oneself; positive social skills; multiple successful relationships at later ages; and a sophisticated understanding of emotions, commitment, morality, and other aspects of human relationships.

 

2.14 Howe asserts that, biologically, attachment is a means of survival. It is defined as proximity seeking behaviour to an attachment figure, the primary caregiver, by a baby or child when he or she experiences discomfort such as pain, fear, cold or hunger.This behaviour is instinctive and is based on the assumption that the primary caregiver will be able to reduce the discomfort.

 

The baby gradually constructs an internal working model of themselves and of their primary caregiver on the basis of their caregiver’s responses to their attachment needs:

These mental representations refer to the kind of memories, experiences, outcomes, feelings and knowledge about what tends to happen in relationships, particularly with attachment figures at times of need.

 

2.15 Thus, the primary purpose of an internal working model is to help regulate the negative emotions of fear, distress and anxiety triggered when a child feels insecure.

 

2.16 The process of attachment formation begins at birth. A newborn infant seeks care and protection through proximity to their attachment figures. Following birth, a baby is instantly alert to messages they receive about the world around them, such as those reflected in the face of their caregiver(s) and the way in which their urgent needs are met. From about the age of three months a baby is increasingly selective and begins to smile less readily for strangers, tending to target their attachment behaviours more accurately towards their significant carers. By the age of six to seven months, an infant can generally show a clear cut attachment to their primary caregiver(s), and will show distress and anxiety about being separated from them. For instance, infants of this age become less likely to tolerate being held by strangers. However, from this point onwards a securely attached infant is able to use their caregiver as a secure base for exploration.

 

2.17 During toddler and pre-school years children learn to define themselves and others in increasingly sophisticated ways. They develop their locomotive skills, their cognitive capacity, their communicating and negotiating abilities, and increase their knowledge and understanding of the perspectives of others. A child’s secure foundations from infancy help them to achieve these developments.

 

2.18 Researchers have identified four basic attachment styles, each relating to the type of caregiving received. These are: secure, insecure ambivalent, insecure avoidant and disorganised. Each of these styles of attachment illustrates different adaptive strategies in response to different types of caregiving, and are developed by children to enable them to ‘stay close and connected to their attachment figures at times of intense negative arousal’.

 

Whilst these categories are very useful in facilitating understanding of different attachment styles, it should be noted that in real life they are not entirely discrete entities; whilst some children will fall exclusively into one category, many children will show a mixed pattern of attachment behaviours, with elements of several styles present.

 

2.19 Children who are securely attached to their caregiver(s) have a relationship that is characterised by sensitive, loving, responsive, attuned, consistent, available and accepting care.51 Securely attached children have the ability to regulate their distress, either by themselves or by the knowledge that they can get help from their attachment figure should they need it.

 

2.20 These children develop internal working models in which they see other people as positively available and themselves as loved and likeable, valued and socially effective.Secure attachment styles are found in about 55% of a non-clinical population.

 

2.21 Conversely, insecurely attached children experience anxiety about the location of their caregiver at times of need, as well as uncertainty about the type and sensitivity of the response they will receive.55 There are three types of insecure attachment patterns, the avoidant, the ambivalent and the disorganised.

 

2.22 Children who develop an insecure, ambivalent pattern of  Attachment experience inconsistent caregiving. Their caregiver(s) tend to be preoccupied with their own emotional needs and uncertainties, and can be unreliable and emotionally neglectful. These children will exaggerate their attachment behaviour in an attempt to be noticed; in this they are not always successful, and their ambivalence reflects their simultaneous need for and anger with their attachment figures.56 About 8% of children in a non-clinical population display insecure ambivalent attachments.

 

2.23 About 23% of children develop insecure, avoidant attachment patterns.These children tend to experience parenting that is hostile, rejecting andcontrolling. They come to see themselves as neither loved nor loveable.They adapt to their caregivers’ rejection by over-regulating their emotions,and are anxious that any display of need, longing, vulnerability or emotionmight drive their caregiver(s) away.59

 

2.24 Some caregivers cannot regulate their child’s responses to stressful circumstances; as a result, their children experience feelings of danger and psychological abandonment.60 Children who are cared for by people who are frightening, dangerous and/or frightened develop disorganised attachments.61 These children may be fearful of approaching their caregivers because they cannot predict the response: sometimes they may be picked up and cuddled, but at other times they may be shouted at or smacked. As a result, these children are not able to ‘organise’ their own behaviour, and have difficulty regulating their emotions. Like their parents they may behave unpredictably. They develop highly negative and inconsistent internal working models in which they see other people as not to be trusted.

 

Disorganised attachment is strongly associated with later psychopathology.

 

There is consistent evidence that up to 80% of children brought up in neglectful or abusive environments develop disorganised attachments, although these are evident in only 15% of a non-clinical population.The effects of maltreatment on attachment behaviour will be discussed further in Chapters Three and Four.

 

 

 

Chapter 3 gets stuck into the neuroscience – what is happening with a child’s brain during early years and what are the effects of neglect upon child development?     I’ve felt for a while now that neglect is the poor cousin of child abuse  – it is really easy to understand and grasp the risks of sexual abuse, or a fractured skull, but neglect is so easy to minimise and belittle and so hard to get a firm grasp on  ‘what will happen to the child if this situation persists rather than improves?’

 

A lot of the neuroscience bit may be a bit fresher than the attachment theory previously discussed, and I think it is very important in the way we look at neglect. It may help Courts take neglect as seriously as it needs to be taken.

 

How the child’s relationships shape the development of the brain and the stress response system

Summary points

• · Much of the development of the brain and central nervous system takes place after a child is born, within the first three years of life.

 

• · The child’s environment of relationships – and in particular the relationship with the primary caregiver – plays a critical role in shaping the development of the overall brain architecture.

 

• · Negative experiences, and in particular insufficient stimulation, adversely impact on the construction of neural connections which form the basis for cognitive and social development.

 

• · By the time children are two, the foundations for their ability to speak and understand language, to reason and make plans have already been laid.

 

• · Executive function skills, necessary for both learning and social interaction, begin to develop shortly after birth, with dramatic growth occurring between the ages of three and five years.

 

• · There is a short window of opportunity for certain types of development. If the types of experience upon which they depend do not occur within a predetermined timeframe, children will not move on to the next stage of development and their long-term wellbeing will be compromised.

 

• · Early interactions between the primary caregiver and the baby play a significant role in establishing the normal range of emotional arousal and in setting the thermostat for later control of the stress response.

 

• · Both very high and very low levels of cortisol are indicative of abnormal development of the stress response and can cause long-term physiological and psychological damage.

 

 

[This last one is interesting, because it raises the possiblility of a biological/chemical test for neglect, that there’s a chemical which can be measured and considered whether it is in normal parameters – and I suspect Trimega and Trichotech are already contemplating the marketing for their Cortisol tests…  Are we ready for neglect to be determined by science?  There’s an entire blog post all on its own, I think]

 

3.14 The process of creating and strengthening or discarding synapses is the brain’s means of learning and the way in which a child responds to their environment. This process is often referred to as ‘plasticity’, a term that indicates the brain’s ability to change in response to repeated stimulation.

 

These repeated adaptations are made in response to a combination of genetics and experience. The brain is genetically pre-programmed to expect certain experiences and forms certain neural pathways to respond to them; the more the child is exposed to these experiences, the stronger the pathways become. For example, a baby’s brain is genetically preprogrammed to respond to voices. When a baby is spoken to the neural systems which are responsible for their speech and language receive the necessary stimulation to strengthen. If, however, they are not exposed to adequate stimulation through exposure to speech, the pathways which have been developed in anticipation of this exposure will be discarded:

 

All children need stimulation and nurturance for healthy development. If these are lacking – if a child’s caretakers are indifferent or hostile – the child’s brain development may be impaired. Because the brain adapts to its environment, it will adapt to a negative environment just as readily as it will adapt to a positive one.83

 

3.15 A child’s experiences greatly shape the quality of the architecture of the developing brain. Positive experiences, particularly in the first year of life, produce more richly networked brains. More neuronal connections produce better performance and more ability to use particular areas of the brain.

 

Conversely, as Chapter Four shows, negative experiences, and in particular insufficient stimulation, adversely affect the development of neural connections and have a negative impact on children’s cognitive and social development, their speech development and their learning and memory.

 

3.18 The sequence of brain development follows a logical pattern. Development of the higher regions does not commence before the connections in the lower regions have been completed.92 This is because the higher levels in the hierarchy depend on reliable information from the lower levels in order to accomplish their functions.93 Impaired development in the lower regions of the brain will therefore have a negative impact on the development of the functions of the higher regions, such as language, empathy, regulation of emotions and reasoning.

 

 

This, for me, is a big deal.  The research establishes that a major part of the formation of basic brain structure happens in the first few years of life, that positive experiences enhance this and negative ones hinder it, and that higher brain functions don’t get formed until the basic ones are completed.  So a baby that is being understimulated or mistreated will have serious consequences on that emotional development in later life.

 

This next bit also interested me

 

3.24 There are specific periods when the development of a child’s brain is more strongly affected by a certain type of experience than at other times. These periods are widely referred to as sensitive periods. At certain times the impact of experience on development can be irreversible: these are a special class of sensitive period known as critical periods.

 

 

This is then the pulling together of research on the impact of stress and how it affects children. It is sciency but important

 

 

3.34 Everyday life involves responding and reacting to varying degrees of stress.

 

When an individual experiences stressful events, their body responds physiologically to restore a condition of equilibrium, or homeostasis.114 The body’s stress response activates several interlocking biological systems designed to prepare an individual for events that may threaten their wellbeing.The hypothalamus, which is located in the centre of the brain, is involved in maintaining homeostasis, including responding to stressful events which upset regulatory rhythms. The amygdala reacts to social situations that generate uncertainty or fear by releasing chemical messages in various directions. The hypothalamus is activated by these messages, and in turn triggers the hypothalamus-pituitary-adrenal (HPA) axis: the core stress response system.

 

3.35 The stress response involves activation of the pituitary, which in turn triggers the adrenal glands to produce extra cortisol. This allows the body to generate extra energy to focus on the stress and to put other bodily systems ‘on hold’ while this is being dealt with.

 

3.36 Chronically high levels of cortisol have detrimental effects on health. Therefore feedback loops are present to modulate the responsiveness of the HPA axis which returns the system to homeostasis. This feedback loop is mediated by receptors located, in the main, in the hippocampus. The purpose of this regulation is to produce adaptive responses to social and psychological stressors. These prepare the body to anticipate and respond optimally to threat but return efficiently to a homeostatic balance once the body is no longer challenged.

 

3.37 The stress response system is not fully mature at birth. It requires an extended period of development whereby experience plays a crucial role.

 

An important component of this development is a baby’s attachment to their caregivers.When babies express feelings of distress or discomfort, they are dependent on their caregivers to notice these signals and to respond by providing the type of care which maintains their equilibrium, such as sensitive touch, feeding and rocking.122 A baby’s stress response system is unstable and reactive; it will produce high levels of cortisol if the baby’s needs are not being met, or if the baby is in an environment which is aggressive or hostile. Persistent and unrelieved chronic stress in infancy results in the baby’s brain being flooded by cortisol for prolonged periods.

This can have a toxic effect on the developing brain, with detrimental consequences for future health and behaviour. Please see Chapter Four paragraphs 4.38 to 4.44 for further discussion relating to the toxic consequences of chronic stress.

 

3.38 In some children, however, prolonged exposure to stress may be linked to abnormally low levels of cortisol. This is particularly evident in those who have experienced low-grade, frequent emotional (and sometimes physical) abuse and neglect in very early childhood and is associated with early indications of anti-social behaviour in boys.

 

3.39 Both very high and very low levels of cortisol are indicative of abnormal development of the stress response, and cause long-term physiological and psychological damage.

3.40 A normal adult pattern of cortisol production is highest in the morning, and then gradually declines through the day to be at its lowest in the evening.

Babies who have secure attachments to their caregiver(s) will begin to form this pattern between three to six months old; however it takes until about the age of four years before it is fully established.126 Early interactions between primary caregiver and baby therefore play a significant role in how a child develops the capacity to respond appropriately to stressful circumstances and the ability to regulate their own negative emotions if and when these occur, such as following an immunisation injection, an injury, or on the first day at school.

 

3.41 This chapter has shown how the brain and stress response systems develop in early childhood and are shaped by the relationship with the primary caregiver. There are indications that when the caregiver does not respond appropriately to the child’s needs, development can be impaired

 

 

 

Chapter Four then gets heavily stuck into the impact of child abuse on children and their development. Traditionally, this has been a difficult area, because there are obvious ethical reasons why you can’t get a bunch of children and mistreat them under scientific conditions to see what happens, and you can never be certain when looking at children you suspect have been neglected exactly what did happen to them. But there was a group of children who we knew exactly how neglected they were, and those were the babies who grew up in Romanian orphanages that were effectively given very minimal care and no stimulation.

 

So some of the research is drawn from that. I haven’t really discussed any of that, because it involves palpably worse neglect than we are used to seeing in a family court environment  – the Romanian orphanages had a staffing ratio of 1 carer to every 20 children, and it is clear that one twentieth of a carers time (or 1 hour 12 mins per child per day), even if they are very dedicated and devoted and hardworking, isn’t going to be enough for a baby, and even the worst of our neglectful parents must spend more than an hour and twelve minutes a day interacting with their baby.

 

Here is the summary for chapter four – note the last point about the correlation between childhood neglect and adult dysfunction.  [To be balanced, no doubt a parallel could be drawn about children in the care system and adult dysfunction…]

 

 

Summary points

• · Exposure to domestic violence and/or parental substance misuse in utero can have a long-term negative impact on the unborn child.
• · High quality care can determine the extent to which children who are genetically predisposed to mental illness or learning disability, or who are exposed to abusive or neglectful parental behaviours, are affected.
• · Chronic exposure to trauma through aggressive, hostile or neglectful parenting can lead to stress system deregulation. Exposure to toxic stress in early childhood can cause permanent damage to the brain and have severe and long-term consequences for all aspects of future learning, behaviour and health.
• · Neglected children may experience chronic exposure to toxic stress as their needs fail to be met. This is compounded by a lack of stimulation and social deprivation.
• · Severe global neglect (i.e. severe neglect in more than one domain) during the first three years of life stunts the growth of the brain.
• · Adults who have been physically abused in childhood show poorer physical and intellectual development, more difficult and aggressive behaviour, poorer social relationships and are more frequently arrested for violent crimes than their peers.
• · Children who have been sexually abused may experience sleep problems, bedwetting or soiling, problems with school work or missing school, and risk taking behaviour in adolescence including multiple sexual relationships.
• · Adolescents who have experienced abusive or neglectful parenting in childhood are more likely to engage in risk-taking behaviours such as substance misuse and criminal activity.

 

 

 

There’s a discussion on emotional abuse which (perhaps appositely) is the most emotive form of reasons for State intervention in family life and the one which gets people hot under the collar, and is the one which opponents of the Family Justice system consider to be a trivial and unwarranted justification for State intervention.   Note my underlining.

 

Emotional abuse and neglect

4.17 Emotional abuse is described as:

The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or making fun of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber-bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.

 

4.18 Emotional abuse is often considered to be the most damaging of all forms of maltreatment in early childhood because the perpetrator is almost always the primary caregiver, and their abusive behaviour represents a direct negation of the child’s ‘need for safety, love, belonging and self esteem’.

The chapter discusses the professional difficulties in determining when neglect or emotional abuse reaches the stage when intervention is required. There are some big strong statements in here, which I have underlined.

 

 

4.20 Findings from the studies in the Safeguarding Research Initiative154 showed that practitioners found it difficult to identify emotional abuse and neglect and to decide when a threshold for action had been reached. These difficulties arose for a number of reasons:

• Both types of maltreatment are heterogeneous classifications that cover a wide range of issues.

• Both emotional abuse and neglect are chronic conditions that can persist over months and years. Professionals can become accustomed to their manifestations and accepting of the lack of positive change.

• Both types of maltreatment can persist for many years without leading to the type of crisis that demands immediate, authoritative action.

Without such a crisis it can be difficult to argue that a threshold for a child protection plan or court action has been reached.

• Both types of maltreatment are also closer to normative parental behaviour patterns than physical or sexual abuse, in that most parents will, on occasion, neglect or emotionally maltreat their children to a greater or lesser degree. It is the persistence, the frequency, the enormity and the pervasiveness of these behaviours that make them abusive.

 

4.21 Two systematic reviews of literaturethat explored the evidence in relation to neglect and emotional abuse concluded that these types of abuse are associated with the most damaging long-term consequences, yet they are also the most difficult to identify. Furthermore, relative to physically abused children, neglected children have more severe cognitive and academic deficits, social withdrawal and limited peer interactions, and internalising (as opposed to externalising) problems.

 

4.22 Child maltreatment is a public health issue, in that its prevalence has a negative impact not only on the individuals concerned, but also on the welfare of society as a whole. The consequences of child maltreatment can last over the course of a life time and negatively affect parenting capacity, with detrimental consequences for the next generation.

 

A consideration of when changes would be made is the next discussion

 

4.30 Ward and colleaguesstudied the life pathways of 43 infants who had been identified as likely to suffer significant harm before their first birthdays; two thirds of them had been identified before birth. This study found that those parents who were able to overcome issues affecting parenting capacity, such as substance misuse and domestic violence, had begun to address these during the pregnancy. This was often as a result of a revelatory moment when they realised they needed to make substantial changes to their lifestyles in order to protect their unborn child, and indeed to prevent the local authority from removing the baby from their care immediately following the birth. Those parents who were able to address all of their difficulties before their child was six months old were able to maintain these changes in the longer term – up to at least their child’s third birthday. Parents who were interviewed as part of the evaluation of the Family Drug and Alcohol Court pilot also identified the birth of a child as a catalyst for overcoming adverse behaviour patterns.176 The findings from these studies suggest that there is a window of opportunity for social work and legal interventions during pregnancy and in the first few months following birth when parents may be more open to address adverse behaviour patterns.

The portions on “Toxic Stress” are interesting  – this is a new term to me, and I suspect I will be hearing it more in the future.   I’m starting to wonder whether paediatric neuroscience is going to be an expert discipline which has much more to tell us about neglect than the traditional psychological assessment that tells you nothing at great expense and delay.

 

 

Toxic stress

4.38 In addition, if inadequate or damaging parent-infant interactions persist, a child’s stress response system can be activated over prolonged periods, producing chronically high levels of the stress hormone cortisol. Brief periods of moderate, predictable stress are not problematic. In fact, they are protective and essential for survival. However excessively high levels of stress and prolonged exposure to raised cortisol levels are harmful and have toxic consequences for the developing child’s brain.186 A child’s stress response system can be activated over prolonged periods if they continually feel threatened by aggressive or hostile parenting, including witnessing or hearing violence between caregivers, or if, as a result of neglectful parenting, their basic needs for food, warmth, nurture, care and affection are not met.

The stress response system starts to self-regulate at around six months, and persistent maltreatment may lead to poor emotional regulation and a maladaptive response to stress. 

Toxic stress can result from strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive adult relationship.

 

4.39 Brain development can be altered by this type of stress, resulting in negativeconsequences for children’s physical, cognitive, emotional, and socialgrowth.The ability of a child’s brain to adapt to its environment,particularly during the first three years of life (and especially during the firstyear) makes it particularly sensitive to chemical changes. Therefore,persistently high levels of stress hormones, such as cortisol, can disrupt itsdeveloping architecture.190 Because the brain develops in certain setsequences (see paragraphs 3.16 to 3.18) early development impacts uponlater brain development. Therefore stress exposure early in life has thehighest potential for long-term dysfunction in neurobehavioral systems that mediate emotional responses, abstract thinking, and social interaction.

 

4.40 As Chapter Three has shown, the amygdala, hippocampus and prefrontal cortex regions of the brain are particularly sensitive to chronic stress (see paragraphs 3.34 to 3.41). This is because they contain an abundance of stress hormone receptors.Exposure to high levels of cortisol can cause cell damage which is reversible when exposure is brief, however when exposure is prolonged it can lead to cell death. Therefore permanent damage can be caused to these areas of the brain when a child is exposed to toxic stress.

 

4.41 Damage to the hippocampus can lead to impairments in memory and mood related functions, and limit the ability of the hippocampus to promote contextual learning, ‘making it more difficult to discriminate conditions for which there may be danger versus safety, as is common in post-traumatic stress disorder’.It can also lead to problems in the development of linguistic, cognitive and social-emotional skills.

 

4.42 Chronic stress is also associated with over activity in the amygdala which then activates the stress response system. This can result in an increase in the potential for fear and anxiety. One task of the prefrontal cortex is to suppress amygdala activity, allowing for more adaptive responses to threatening or stressful experiences. However exposure to chronically elevated cortisol levels can damage the neural pathways between the prefrontal cortex and amygdala, limiting the ability of the prefrontal cortex to inhibit amygdala activity. As a result, children may appear, ‘to be both more reactive to even mildly adverse experiences and less capable of effectively coping with future stress’.

 

 

 

The brain scans comparing a neglected child with a non-neglected child are staggering. I can’t reproduce them here, but go and look at them.

 

The last sentence of this next section is also staggering. I had never contemplated childhood neglect having a correlation with the  serious adult illnesses described here

 

Impact of maltreatment in later childhood and adolescence

4.50 Child abuse and neglect typically begin early in childhood; however the damage these experiences cause to all areas of development can have a cumulative effect on subsequent behaviour and health in later childhood and adolescence. Unsurprisingly, socially, emotionally and behaviourally impeded development attributed to abuse and neglect in the early years continues into middle and later childhood. Maltreated children may experience difficulties in coping with the social and academic demands of school and neglected children in particular may fall behind in their language and reading skills.Because subsequent development builds on previous milestones, abused and neglected children can continue to be challenged by normal developmental tasks.

 

4.51 During middle to late childhood caregiver(s) need to be good role-models and actively encourage sociable behaviour alongside firm and calm limit setting to promote good adjustment.212 Parenting which is harsh, rejecting or inconsistent is associated with poorer outcomes.213

 

4.52 Adolescence is a period of preparation for adulthood, when several key developmental tasks are encountered. These include physical and sexual maturation; movement towards social and economic independence; the development of identity; the acquisition of skills needed to carry out adult relationships and roles; and the capacity for abstract reasoning.

 

Adolescence can be a time of tremendous emotional, social and physical growth and potential, however for young people who have experienced abuse and neglect either in their past or present, this is a time of particular vulnerability.

 

4.53 The neglect of adolescents is a major issue that frequently goes unnoticed.Adolescents can be neglected by services as well as by their families. It is clear that neglect is age-related, and as children grow older it is defined not only by parental behaviours but also by the way in which young people experience them. Davies and Ward216 argue that some fundamental questions have barely been considered. For instance, there is little public debate or consensus as to what constitutes an acceptable level of supervision as children grow older. Furthermore, teenagers are the second most likely group of children to be the subject of a serious case review.

 

4.54 As children grow and develop into young adults, the cumulative effects of child abuse and neglect can have detrimental consequences for their health and welfare. Growth in the frontal lobe of the brain may be under developed in young people who have experienced abusive or neglectful parenting during their childhood. This may mean that they are more likely to engage in risk taking behaviour and live a generally unhealthy life style (see paragraph 3.17). For instance, abused and neglected adolescents are more likely to start drinking alcohol at a younger age and more likely to use alcohol as a way of coping with stress than for other social reasons.Exposure to maltreatment during childhood is also associated with tobacco use, illicit drug use, obesity and promiscuity in adolescence.

 

4.55 Young people who have been maltreated in childhood are also more likely to have trouble maintaining supportive social networks and are at a higher risk of school failure, gang membership, unemployment, poverty, homelessness, violent crime, incarceration, and becoming single parents.Additionally, if they become parents themselves, they are less likely to be able to provide a stable and supportive environment for their children. This creates an intergenerational cycle of adversity.221

 

4.56 There may also be physiological disruptions in later life as a consequence of abuse and neglect during childhood. For example, the manifestations of toxic stress can cause alterations to the body’s immune system and increases in inflammatory markers which are known to be linked to poor health outcomes.These include cardiovascular disease; viral hepatitis; liver cancer; asthma; chronic obstructive pulmonary disease; autoimmune disease; poor dental health; and depression.

 

 

The fifth chapter deals with Timely decision-making.  This is the first time that the Pro 26 week evidence has been properly set out, and in this context, it becomes more compelling  (I remain troubled by what it means for justice – I think Judges should decide on what the right timeframe for decision-making is, based on the case before them)

 

Summary points

• · One of the most important issues to confront in promoting better outcomes for abused and neglected children is a mismatch between three timeframes: those of the developing child; those of the courts and those of the local authority.
• · The birth of a baby is often a catalyst for change. Children who remain with parents who have not made substantial progress in overcoming adverse behaviour patterns and providing a nurturing home within a few months of their birth may continue to experience maltreatment for lengthy periods.

 

• · Social work decisions concerning permanence are made after lengthy and meticulous deliberations. There is a tendency for delays to occur once a temporary solution has been found and the pressure to resolve a crisis has been relaxed.

 

• · The Children Act 1989 embodies the principle enshrined in human rights legislation and policy that children are best brought up by their own families. Identifying the very few children whose parents will not be able to meet their needs within an appropriate timeframe requires professionals to set aside much of the culture of their training and practice.

 

• · On average, care proceedings take a year to complete; data collected between 2008 and 2011 indicate that courts in only eleven local authority areas meet the previous target of 40 weeks.

 

• · Factors that contribute to delays in completing care proceedings include: resource issues; waiting for parenting assessments and the results of attempted placements with parents; resolution of disputes and changes of plan.

 

• · Repeated assessments of birth parents are a major source of delay, as are sequential assessments of different groups of relatives. These are sometimes undertaken in spite of obvious contraindications. There is a stark contrast between the frequency of parenting assessments and the paucity of paediatric assessments to ascertain the impact of abuse and neglect on children’s development.

 

• · The more complex the case, the greater the proliferation of expert assessments and the longer the delay.

 

• · Professionals encounter numerous difficulties in trying to retain a focus on the best interests of the child: attempts to ensure that parents’ rights and needs are respected can conflict with those of their children.

 

• · Most children placed for adoption are aged two or older before they reach their adoptive families. This timeframe is at odds with research evidence that indicates that babies who are placed early for adoption are most likely to form secure attachments with new carers.

 

• · Delayed decisions mean that children experience the cumulative jeopardy of lengthy exposure to abuse and neglect; disruption of attachments with temporary carers; unstable placements at home or in care; and prolonged uncertainty about their future.

 

• · There is a relatively short window of opportunity in which decisive actions should be taken to ensure that children at risk of future harm are adequately safeguarded. Delays close off those opportunities

 

 

 

This is interesting, gathering some research on when and how interventions work  – the importance of gripping neglect cases early and avoiding drift is really apparent from this  – the longer the neglect has gone on, the less chance there is on intervention making a difference.

 

 

In families where children are abused or neglected, social work interventions can be effective if they are decisive and proactive and if they fit in with children’s developmental timescales.230 Actions reinforced by court orders can be more effective than those that are less intrusive, particularly where parents are reluctant to engage with support services or social workers have competing priorities.231 Where parents do not have the capacity to overcome entrenched, adverse behaviour patterns that damage their children’s welfare, placement in the care of the local authority is generally more beneficial for children than remaining at home (or returning there),232 and adoption is likely to lead to the best outcomes for very young children.233 A number of intensive, evidence-based interventions have been shown to be effective in other countries and the results of some UK pilots look promising.234

  However one of the key messages from this wide body of research is that the longer that children experience abuse and neglect without sufficient action being taken, the less effective are even the most intensive and intrusive interventions in promoting their long-term wellbeing.

 

 

 

 

5.7 The prospective study of infants suffering significant harm also showed that 93% (13/14) of the parents who were able to overcome adverse behaviour patterns sufficiently to provide a nurturing home did so within the first six months of the birth. Where children remained with birth parents who had not made substantial progress within this timeframe (12 cases), concerns about maltreatment persisted and were still evident at the child’s third birthday.

 

 This finding has obvious implications for timescales for decision-making and for intensive interventions. However it is drawn from the experiences of a very small number of children in what is already a relatively small study. It needs testing out with a larger sample

 

 

 

The research is interested in a concept called Cumulative jeopardy, where the child development, already harmed by poor parenting, is compounded by the legal process aimed at protecting them

 

Conclusion: Cumulative jeopardy

5.26 There is a complex interaction between child development timeframes and delayed actions by local authorities and the courts. Firstly, research on child development and the consequences of abuse shows that the longer children are left inadequately protected from all forms of maltreatment (emotional abuse and neglect, as well as physical and sexual abuse) the greater the chance that their long-term wellbeing will be compromised. Three recent English studies that explored the consequences of professional decision making in neglectful and/or abusive families all found that a high proportion of maltreated children are left in very damaging circumstances with inadequate action being taken to safeguard them, and with adverse consequences for their health and development.

 

Intensive interventions such as the Family Drug and Alcohol Courtscan make a difference in families, prevent recurrence of abuse and neglect and enable children to remain safely at home. They are also able to show where parents are not able to change within a child’s timeframe, so that decisions concerning alternative routes to permanence can be made in a timely fashion. However such interventions are not yet widely available in this country.

 

5.27 Secondly, a number of studies have shown that, once children are removed from abusive families they often spend lengthy periods in temporary placements before long-term plans are made for their future.Young children can become closely attached to interim carers, only to experience further loss when this attachment is disrupted as they move to a permanent home. Ward, Brown and Maskell Grahamfound that infants who had experienced this double jeopardy (six months or more in an abusive environment followed by a short period of stability and then a disrupted attachment) were showing severe developmental and behavioural difficulties by the time they were three, and that these persisted as they entered formal education. Again, evidence based interventions were not available for these children, and indeed some carers had difficulty in accessing any psychotherapeutic or behavioural support for them.

 

5.28 The long-term wellbeing of abused and neglected children can be jeopardised in other ways. Frequent changes of placements are one of the most problematic aspects of the current care system in England, as each change can have a negative impact on children’s developmental progress, and particularly their capacity to form secure attachments. Studies by Masson and colleagues284 and Ward, Munro and Deardenboth identified a relationship between delayed decisions and placement instability when children are looked after away from home. Masson and colleagues found that ‘the longer the case lasted the more likely it was that the child would move’:children moved during the proceedings in over 80% of the cases in this study. Ward, Munro and Deardenfound that very young children move at least as frequently as teenagers, and that instability is closely related to the provisional nature of decisions, as children move back and forwards between temporary, short-term foster homes and placements with own parents or new carers while they wait for permanence plans to be made.

 

5.29 Finally, there is also a relatively short window of opportunity in which decisive actions can be taken to ensure that children are adequately safeguarded. Delays close off these opportunities. If children are to remain at home, proactive engagement with social workers needs to begin early, particularly in view of evidence that case management becomes less active after they reach their sixth birthdays. There is a body of research evidence to show that if abuse and neglect are not adequately addressed at an early stage, as children grow older they may benefit less both from specialist interventions to address its consequences and from separation to prevent its recurrence.Early intervention is also urgently necessary where there are concerns that a child might need to be placed for adoption, for not only do children become increasingly difficult to place as the consequences of long-term exposure to abuse and neglect become more entrenched, but also adoptive carers are harder to find for older children.

 

 

5.30 The following timeline, showing best and worst case scenarios related to child development timescales where children remain with their birth parents and where adoption is the conclusion illustrates how these issues intertwine.

 

 

[I can’t reproduce that timeline, but it is well worth seeing, and probably having a copy at Court for most hearings. It has the potential to be extremely helpful and might actually start making that god-awful phrase “The timetable for the child” have some actual meaning]