neglect, resilience and resistance patrick ayre department of applied social studies university of...

Neglect, Resilience and Resistance

Patrick Ayre

Department of Applied Social Studies

University of Bedfordshire

Park Square, Luton

email: [email protected]

web: http://patrickayre.co.uk

NEGLECTNeglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: provide adequate food, clothing and shelter protect from physical and emotional harm or danger ensure adequate supervision ensure access to medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.

NEGLECT

Parents who neglect their children basically just don’t know any better because of their own poor upbringings. If we send them to a family centre for Parental Skills training, all will be well.

NEGLECT

Parents who neglect their children basically just don’t know any better because of their own poor upbringings. If we send them to a family centre for Parental Skills training, all will be well.

IF ONLY!!....

NEGLECT

So neglected children who come into care may be a bit thin, a bit dirty, badly in need of seeing a doctor or dentist, maybe a bit wild.

But we can place them with foster carers for a bit of looking after, a bit of TLC, a bit of structure and everything will be fine. The children will absolutely love it and will immediately start to thrive. Simple really!

NEGLECT

So neglected children who come into care may be a bit thin, a bit dirty, badly in need of seeing a doctor or dentist, maybe a bit wild.

But we can place them with foster carers for a bit of looking after, a bit of TLC, a bit of structure and everything will be fine. The children will absolutely love it and will immediately start to thrive. Simple really!

IF ONLY!!....

Brain development

At birth our brains are only 25% developed By age 3, a child’s brain has reached almost 90%

of its adult size and has accomplished 80% of its total development.

The growth in each region of the brain largely depends on receiving stimulation.

This stimulation provides the foundation for learning.

Experience Affects the Structure of the Brain

Brain development is “activity-dependent” Every experience excites some neural

circuits and leaves others alone Neural circuits used over and over

strengthen, those that are not used are dropped resulting in “pruning”

Poor integration of hemispheres and underdevelopment of the orbitofrontal cortex

Difficulty regulating emotion, Lack of cause-effect thinking, Inability to recognize emotions in others, Inability to articulate own emotions, Incoherent sense of self and

autobiographical history Lack of conscience.

Other physiological issues

Serotonin: emotional stability and feeling good

Malnutrition: cognitive and motor delays, anxiety, depression, social problems, and attention problems

MyelinationSensitive periods (infancy & attachment)

Emotional development

Sensitive period for emotional development: up to 18 months

Shaped primarily by the way in which the prime carer interacts with the child

Emotional deficits harder to overcome once the sensitive window has passed.

How often do we intervene assertively at this point?

Building a child

Building a child is like building a house, each new level built on the one below. If the lower levels are unsound, no amount of tinkering with the upper floors will make it stable.

Checkpoint 1: timing intervention

If we wait until we can see the evidence of neglect in a child’s behaviour, it may be too late to put it right completely.

Neglect

Behavioural

Constant hunger

Constant tiredness

Frequent lateness or non-attendance at school

Destructive tendencies

Neglect

Low self-esteem

Neurotic behaviour

No social relationships

Running away

Compulsive stealing or scavenging

Neglect

Physical

Poor personal hygiene

Poor state of clothing

Emaciation, pot belly, short stature

Poor skin and hair tone

Untreated medical problems

Significant harm

Harm is defined by Children Act 1989:

ill-treatment (including sexual abuse and, by implication, physical abuse)

impairment of health (physical or mental) or development (physical, intellectual, emotional, social or behavioural)

The child's basic needs

basic physical care

affection

security

stimulation of innate potential

guidance and control

responsibility

independence

Why do parents neglect?

We need to understand the interaction between:

3 Ns: Nurture, Nature, Now

Circumstantial factors and fundamental factors

Why do parents neglect?

Circumstantial Poverty

Particular relationships

Lack of skill/knowledge

Temporary illness

Lack of support

Environmental factors

Fundamental

Lack of parenting capacity

Deep seated attitudinal/behavioural/ psychological problems

Long term health issues

Entrenched problematical drug /alcohol use

Forms of neglectHowe identifies 4 types of neglect

Emotional neglect

Disorganised neglect

Depressed or passive neglect

Severe deprivation

Each is associated with different effects and implications for intervention

(Howe, D (2005) Child Abuse and Neglect, Basingstoke: Palgrave Macmillan)

Emotional neglect Sins of commission and omission

‘Closure’ and ‘flight’: avoid contact, ignore advice, miss appointments, deride professionals, children unavailable

However, may seek help with a child who needs to be ‘cured’

Intervention often delayed

Associated with avoidant/defended patterns of attachment

Emotional neglect: parents Can’t cope with children’s demands:

avoid/disengage from child in need; dismissive or punitive response

Children provided for materially but there is a failure to connect emotionally

More rules; everyone has a role and knows what to do.

Parents may feel awkward & tense when alone with their children.

Emotional neglect: children

When attachment behaviour rejected: Learns that caregiver’s physical and emotional

availability is reduced when emotional demands are made;

Caregiver most available when child is showing positive affect, being self-sufficient, undemanding and compliant;

Reverse roles, “false brightness” to care for/ reassure parent.


Frightened, unhappy, anxious, low self-esteem

Withdrawn, isolated, fear intimacy and dependence

Precocious, ‘streetwise’, self-reliant


May show compliance to dominant caregivers but anger and aggression in situations where they feel more dominant.

May learn that power and aggression are how relationships work and you get your needs met

Behaviour increasingly anti-social and oppositional

Brain development affected: difficulties in processing and regulating emotional arousal

Disorganised neglect Classic ‘problem families’

Thick case files

Can annoy and frustrate but endear and amuse

Chaos and disruption

Reasoning minimised, affect is dominant

Feelings drive behaviour and social interaction

Worker may feel agenda co-opted by family’s immediate needs

Disorganised neglect: carers Feelings of being undervalued or emotionally

deprived in childhood so need to be centre of attention/affection

Demanding and dependant with respect to professionals

May be regarded as overwhelmed but amenable to services

Crisis is a necessary not a contingent state

Associated with ambivalent/coercive patterns of attachment

Disorganised neglect: carers

Cope with babies (babies need them) but then…

Parental responses to children

– unpredictable and insensitive (though not necessarily hostile or rejecting).

– driven by how the parent is feeling, not the needs of the child

Lack of ‘attunement’ and ‘synchronicity’

Disorganised neglect: children Anxious and demanding

Infants: fractious, fretful, clinging, hard to soothe

Young children: attention seeking; exaggerated affect; poor confidence and concentration; jealous; show off; go to far

Teens: immature, impulsive; need to be noticed leads to trouble at school and in community

Neglectful parents feel angry and helpless: reject the child; to grandparents, care or gangs

Depressed neglect

Classic neglect

Material and emotional poverty

Homes and children dirty and smelly

Urine soaked matresses, dog faeces, filthy plates, rags at the windows

A sense of hopelessness and despair (can be reflected in workers)

Depressed neglect: carers Often severely abused/neglected: own parents

depressed or sexually or physically abusive

May seem unmotivated, mild learning disability

Learned helplessness in response to demands of family life;

Stubborn negativism; passive-aggressive Have given up both thinking and feeling

Depressed neglect: carers Listless and unresponsive to children’s needs

and demands, limited interaction

Lack of pleasure or anger in dealings with children and professionals

No smacks, no shouting, no deliberate harm but no hugs, no warmth, no emotional involvement

No structure; poor supervision, care and food

Depressed neglect: children

Younger the child, more debilitating the effects

Lack interaction with parents required for mental and emotional development

Infant: Incurious and unresponsive; moan and whimper but don’t cry or laugh

At school: isolated, aimless, lacking in concentration, drive, confidence and self-esteem but do not show anti-social behaviour

Depressed neglect: case management

These families need: Long term involvement Supportive approach Responsiveness to family’s signals and needs BUT these need to be balanced with a

recognition of the children’s needs. (How long is too long? How much is too much?)

Depressed neglect: infants and children

Must experience responsive and stimulating environments that also provide human comfort for a few hours each day.

The longer the child is exposed to helplessness, the more intense and longer the intervention needed to remedy the situation.

Depressed neglect: parents

Must learn appropriate ways to show their feelings– Practice smiling, laughing, soothing– May be mechanical at first– Genuine feelings will emerge with repetition

As parents learn to show their feelings, the child’s responsiveness will increase; virtuous spiral

Severe deprivation

Eastern European orphanages, parents with serious issues of depression, learning disabilities, drug addiction, care system at its worst

Children left in cot or ‘serial caregiving’

Combination of severe neglect and absence of selective attachment: child is essentially alone

Severe deprivation: children Infants: lack pre-attachment behaviours of smiling,

crying, eye contact

Children: impulsivity, hyperactivity, attention deficits, cognitive impairment and developmental delay, aggressive and coercive behaviour, eating problems, poor relationships

Inhibited: withdrawn passive, rarely smile, autistic-type behaviour and self-soothing

Disinhibited: attention-seeking, clingy, over-friendly; relationships shallow, lack reciprocity

Checkpoint 2: case management

How should we manage cases of:

Emotional Neglect

Disorganised neglect

Depressed neglect

Severe deprivation

Emotional neglect: case management

Help parents to learn to use others for support.

Teach parents to engage emotionally with their children.

Must be highly structured as neither parent or child know how to interact normally & spontaneously.

Fear of affect – need clear rules & roles

Disorganised neglect: case management

Logic would argue for warding off crises for a while so that families can be taught to organise their lives, but…

Family may want to have needs met, but cannot delay gratification or trust logic and planning;

Without intense demands associated with crises, have no way of being important to others;

Will CREATE new crises.

Disorganised neglect: case management

Feelings must be addressed

Need a structured, predictable environment with no surprises where:

– There are rewards for clear, direct, and undistorted communication of feelings and accurate cognitive information about future outcomes

– Family can learn the value of compromise

Teach parents how to use cognitive information to regulate feelings (without denying them)

Depressed neglect: case management

Involves much more than teaching appropriate parenting

All family members must learn that their behaviour has predictable and meaningful consequences

Teach that it helps to share feelings with empathetic others.

Depressed neglect: case management Our standard approaches don’t work Threats / punitive approaches particularly

ineffective:– Parents don’t believe they can change so don’t

even try.– Even most reasonable pressure results in “shutting

down” / blocking out all info. Parent education – may be ineffective because

judgment impaired and gains not transferable.

Severe deprivation: case management

Highly unlikely to be in the child’s best interests to remain in the environment which caused the harm;

It is probable that the child and new carers will require substantial therapeutic and emotional support;

Significant challenges often persist despite a move to a caring and predictable environment.

Capturing chronic abuse

Judging the quality of care is an essential component of any assessment but how well do we do it?

Judgements subjective and prone to bias

Intangible: Difficult to capture and compare

High threshold for recognition

Neglect is a pattern not an event

The pattern of neglect: atypical

The pattern of neglect

Intervention Intervention


'G ood enough' level




'G ood enough' level

Intervention ceases

Cumulativeness

T h r es h o ld f o rin te r v en tio n

SEXUAL

ABUSE

PHYSICAL

ABUSE N

EGLECT

NEGLECT

NEGLECT

Failure of cumulativeness

T h r es h o ld f o rin te r v en tio n

SEXUAL

ABUSE

PHYSICAL

ABUSE

NEGLECT

NEGLECT

NEGLECT

NEGLECT

What’s the problem?

Chronic abuse and the principle of cumulativenessFiles very long and badly structured

Patterns missed and ‘chronic abuse’ overlooked

The problem of proportionality

Acclimatisation (case, agency and geographical)

Assessment Pitfalls

Parents’ behaviour, whether co-operative or uncooperative, often misinterpreted

Information from family friends and neighbours undervalued

Coping with aggressive or frightening families

Failure to give sufficient weight to relevant case history; ‘Start again syndrome’

Not enough attention is paid to what children say, how they look and how they behave; maintenance of a wholly child-centred approach

A child centred approach

The purpose of assessment is to understand what it is like to be that child (and what it will be like in the future if nothing changes)

Information handling pitfalls Picking out the important from a mass of data

Facts recorded faithfully but not always critically appraised

Too trusting/insufficiently critical;

Decoyed by another problem False certainty; undue faith in a ‘known fact’ Discarding information which does not fit the

model we have formed

Department of Health (1991) Child abuse: A study of inquiry reports, 1980-1989, HMSO, London

Assessment pitfalls

Rule of optimism

Natural love

Cultural relativism

Too much

not enough

Adult services and children’s services (hand-in-hand or hand-to-hand?)

Children’s services and adult services

Working on the same case but not working jointly

Mutual incomprehension and misunderstanding

False expectations and assumptions

Abdicating responsibility

Need for ‘interpreters’

Information handling pitfalls

Keeping your head down

Hesitancy to challenge other professionals or the conventional wisdom

Tendency to move from facts to actions without ‘showing your working’

Challenge your dodgy thinking

I am only a… and he is a…, so I had better keep my opinion to myself.

I am obviously in a minority, so I had better keep my opinion to myself.

We need to maintain harmonious relations, so I had better keep my opinion to myself.

The chain of reasoning

Facts

Analysis/summary

Conclusions/recommendations/action

The chain of recording

What happened/what you saw

What this means

What you did/what should be done (and why,

if this is not clear from the above)

The chain of recording

But how do you know which facts?

Must be informed by a basic risk assessment (would not always be spelled out on paper)

Risk assessment The dangers involved (that is the feared outcomes);

The hazards and strengths of the situation (that is the factors making it more or less likely that the dangers will realised);

The probability of a dangerous outcome in this case (bearing in mind the strengths and hazards);

The further information required to enable this to be judged accurately; and

The methods by which the likelihood of the feared outcomes could be diminished or removed.

But what is analysis?

You have gathered lots of information but now what?

All you need to do is ask yourself my favourite question:

“So what?”

You have collected all this data, but what does this mean, for the service user, for the family and for my setting?

Checkpoint 3: So what?

We have spent some time considering how to recognise and respond to neglect.

What does this mean for us? What are the implications for local services? What, if anything, will be different?

Why do some sink and some swim?

Why do some children thrive in situations of grave adversity, whilst others are severely damaged?

What can we to promote the first outcome and avoid the second?

Part of the answer lies in the concept of RESILIENCE

‘Normal development under difficult conditions’ (Fonagy et al 1994)

Seven characteristics Personal anchors Cognitive competence Success Active coping Positive temperament Social climate open and supportive, in home

and out Additional support

http://content.iriss.org.uk/fosteringresilience/

http://content.iriss.org.uk/fosteringresilience/

Individual level

Benard, 1996

Environmental level

Benard, 1996

Blending demand and support

Demanding Undemanding

Responsive Authoritative Indulgent

Unresponsive Authoritarian Neglectful

Neglectful parenting


Responsive Unresponsive Neglectful

Authoritarian parenting


Responsive Unresponsive Authoritarian

Indulgent parenting


Responsive Indulgent

Unresponsive

Good parenting


Responsive Optimal

Unresponsive

Three building blocks

A secure base

Good self esteem

Self-efficacy or a sense of mastery and control

Daniel, B. and Wassell, S. (2002) Assessing and Promoting Resilience in Vulnerable Children, London, Jessica Kingsley Publishers.

Secure base

Individual: Does the child appear to feel secure?

Family: Do the child’s carers provide a secure base?

Community: What wider resources contribute to child’s attachment networks?

Education

Individual: Does the child show curiosity and interest in learning, school or college?

Family: Do carers facilitate learning?

Community: What wider support is there for learning?

Friendships

Individual: What characteristics does the child have that help to facilitate making and keeping friends?

Family: Do carers support the development of friendships?

Community: What are the child’s friendships currently like?

Talents and interests

Individual: What talents or interests?

Family: Do carers encourage?

Community: What resources are there for nurturing talents and interests?

Positive values

Individual: Level of moral reasoning; understanding of own feelings and empathy with others?

Family: What level of helpful behaviour does the child show?

Community: What level of pro-social behaviour does the child show?

Social competencies

Individual: Do the child’s personal characteristics contribute to social competence?

Family: Do carers encourage social competence?

Community: What opportunities are there for developing social competence?

Resilience matrix in assessment

Checkpoint 4: Resilience

Three things I will do to improve the way I and colleagues work with resilience at the child, family or community level.

Working with resistance“In many cases parents were hostile to helping agencies and workers were often frightened to visit family homes. These circumstances could have a paralyzing effect on practitioners, hampering their ability to reflect, make judgments, act clearly, and to follow through with referrals, assessments or plans. Apparent or disguised cooperation from parents often prevented or delayed understanding of the severity of harm to the child and cases drifted. Where parents made it difficult for professionals to see children or engineered the focus away from allegations of harm, children went unseen and unheard”.

“Families tended to be ambivalent or hostile towards helping agencies, and staff were often fearful of violent and hostile men. Although parents tended to avoid agencies, agencies also avoided or rebuffed parents by offering a succession of workers, closing the case, losing files or key information, by re-assessing , referring on, or through initiating and then dropping court proceedings”.

Brandon, M, and others (2008) Analysing child deaths and serious injury through abuse and neglect: what can we learn? London: Department for Children, Schools and Families

Engagement

Engagement is the basic task of a child and families worker but can never be taken for

granted and must always be worked for

Context

‘Involuntary’ work may be characterised by

Guardedness or reluctance to share information

Avoidance and a desire to leave the relationship

Strong negative feelings such as anxiety, anger, suspicion, guilt or despair.

Context

We need to accept that: The best we may be able to achieve is

honesty rather than positive feelings and a high degree of mutuality

Conflict and disagreement are not something to be avoided, but are realities that must be explored and understood.

How might resistance show itself?

By only being prepared to consider 'safe' or low priority areas for discussion.

By not turning up for appointments By being overly co-operative with

professionals. By being verbally/and or physically

aggressive. By minimising the issues.

(Egan, 1994)

Potential parental responses

Genuine commitment

Compliance / approval seeking

Tokenism

Dissent / avoidance

(Howarth and Morrison, 2000)

Identifying resistance: 4 categories

Hostile resistance: anger threats, intimidation, shouting

Passive aggressive: surface compliance covers partly concealed antagonism and anger

Passive hopeless: Tearfulness and despair about change

Challenging: Cure me if you can!

Strategies for enhancing engagement

Before you start, check your mindset (your own biases and assumptions)

Have realistic expectations:– It is reasonable that involuntary clients resent being

forced to participate– Because they are forced to participate, hostility,

silence and non-compliance are common responses that do not reflect my skills as a worker

– Due to the barriers created by the practice situation, clients may have little opportunity to discover if they like me

– Lack of client co-operation is due to the practice situation, not to my specific actions and activities

(Ivanoff et al, 1994 )

During initial contacts

Adopt a non-defensive stance Be clear, honest and direct and

acknowledge the involuntary nature of the relationship

Clarify roles and expectations, including what is required of the client

Explain consequences of non-compliance and the advantages of compliance


Try to

Invite participation

Understand how the client sees the problem as well as how we see it

Understand what the client wants, as well as what we want


What might we be doing to make it worse?

Becoming impatient and hostile Doing nothing, hoping the resistance will

go away Lowering expectations Blaming the family member Allowing the family member to control the

assessment inappropriately Failing to acknowledge our fear

What might we be doing to make it worse?

Becoming unrealistic Believing that family members must like

and trust us before assessment can proceed.

Ignoring the enforcing role of some aspects of child protection work and hence refusing to place any demands on family members.

(Egan, 1994)

Avoid

Expressions of over-concern

Moralising

Criticising the client

Making false promises

Displaying impatience

Productive approaches

Give practical, emotional support - especially by being available, predictable and consistent

See some resistance and reluctance as normal

Explore our own resistance to change and by examining the quality of our own interventions and communication style

(Egan, 1994)

Productive approaches

Helping family members to identify incentives for moving beyond resistance

Tapping the potential of other people who are respected as partners by the family member

Understanding that reluctance and resistance may be avoidance or a signal that we are not doing our job very well

(Egan, 1994)

Confrontation

In child welfare services, the Children’s Service Worker must be a skilled confronter. Confrontation is, basically, facing the client with the facts in the situation and with the probable consequences of behaviours

(Texas Department of Human Resources)

Checkpoint 5: Resistance

I am good at working with resistance because…

I could be better at working with resistance because…

A final thought

“We are guilty of many errors and many faults but the worst of our crimes is abandoning our children, neglecting the fountain of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him we cannot answer 'Tomorrow.' His name is 'Today.'”

Gabriela Mistral (Chilean poet, 1889-1957)

Bonus material

A scale for assessing motivation

1. Shows concern and has realistic confidence.

2. Shows concern, but lacks confidence.

3. Seems concerned, but impulsive or careless

4. Indifferent or apathetic about problems

5. Rejection of parental role.

Shows concern and has realistic confidence.

Parent is concerned about children’s welfare; wants to meet their physical, social, and emotional needs to the extent he/she understands them.

Parent is determined to act in best interests of children

Has realistic confidence that he/she can overcome problems and is willing to ask for help when needed

Is prepared to make sacrifices for children.

Shows concern, but lacks confidence Parent is concerned about children’s

welfare and wants to meet their needs, but lacks confidence that problems can be overcome

May be unwilling for some reason to ask for help when needed. Feels unsure of own abilities or is embarrassed

But uses good judgement whenever he/she takes some action to solve problems.

Seems concerned, but impulsive or careless Parent seems concerned about children’s

welfare and claims he/she wants to meet their needs, but has problems with carelessness, mistakes and accidents. Professed concern is often not translated into effective action.

May be disorganised, not take enough time, or pays insufficient attention; may misread ‘signals’ from children; may exercise poor judgement.

Does not seem to intentionally violate proper parental role; shows remorse.

Indifferent or apathetic about problems

Parent is not concerned enough about children’s needs to resist ‘temptations’, eg competing demands on time and money. This leads to one or more of the children’s needs not being met.

Parent does not have the right ‘priorities’ when it comes to child care; may take a ‘cavalier’ or indifferent attitude. There may be a lack of interest in the children and in their welfare and development.

Parent does not actively reject the parental role.

Rejection of parental role Parent actively rejects parental role,

taking a hostile attitude toward child care responsibilities.

Believes that child care is an ‘imposition’, and may ask to be relieved of that responsibility. May take the attitude that it isn’t his or her ‘job’.

May seek to give up the responsibility for children

(Magura et al,1987)

neglect, resilience and resistance patrick ayre department of applied social studies university of...

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