Introduction

Child maltreatment is defined as all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity; in the context of a relationship of responsibility, trust or power.

There are four types of recognized child maltreatment:

• Physical abuse;

• Sexual abuse;

• Emotional and psychological abuse;

• Neglect;

• Exposure to family violence. 1

Neglect

Neglect is the persistent failure to meet the child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. It may involve a parent or carer failing to provide adequate food, shelter and clothing, failing to protect from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs. ^{2, 3.}

The victims’ age, the setting in which the neglect occurs and the relationship between victim and perpetrator emphasize the complexity of this social, human rights, legal and social issue.

Susceptibility And Risk Factors

Child neglect must be approached as a result of an interaction between several risk factors. These factors are contributory and not direct causes of child maltreatment. Fig.1

Figure 1

Fig.1. A model outlining the interplay of these different factors (www.WHO.org).

A number of factors contribute to a higher occurrence in child maltreatment. As far as the parents or caregivers are concerned, the risk factors concerning them are plenty and refer to the persons who generally have difficulties in establishing emotional and therefore physical bonds with their babies. This result is a lack of understanding of their child’s needs band there is a subsequent deficiency of communication, which itself leads to lack of self-control and use in violence. Also poor care for the child is caused by use of alcohol or drugs, by occurrence of illness such as depression, or simply low self-esteem and young age. ^{4, 5, 6.}

In many cases an unwanted baby, who may cry persistently or may have various physical abnormalities and may demonstrate hyperactivity or impulsivity or a chronic illness, can be the cause for the maltreatment of this specific baby. ^{6, 7.}

In contemporary societies family bonds vary and often the “unclear” family has collapsed, with the result of failure of connecting between members of family and lack of sentimental attachment, as well as no existence of emotional safety nets between child and parents. There is a feeling of isolation among children which can lead them to criminal activities in a community that actually tolerates violence and suffers from inequality, poverty, drug and alcohol abuse, unemployment and environmental pollution.

Generally, children live in a society, which has no programmes to shelter them from maltreatment and offers them no alternative way of living. Instead violence is legalized through the media, child labor blossoms and child pornography and prostitution thrives. ^{8, 9}.

Protective Factors

Researchers, practitioners, and policy makers are now increasingly thinking about protective factors within children and families that can reduce risks, build family capacity, and foster resilience. In 1987, case studies of three victims of child maltreatment began to shed light on the dynamics of survival in high-risk settings. Resilience in maltreated children was found to be related to personal characteristics that included a child’s ability to: recognize danger and adapt, distance one from intense feelings, create relationships that are crucial for support, and project oneself into a time and place in the future in which the perpetrator is no longer present. ¹⁰

Parent and family, protective factors that may protect children include secure attachment with children, parental reconciliation with their own childhood history or abuse, supportive family environment including those with two-parent households, household rules and monitoring of the child, extended family support, stable relationship with parents, family expectations of pro-social behavior, and high parental education. Social and environmental risk factors that may protect children include middle to high socioeconomic status, access to health care and social services, consistent parental employment, adequate housing, family participation in religious faith, good schools, and supportive adults outside the family who serve as role models or mentors.--- Some recent studies have found that families with two married parents encounter more stable home environments, fewer years in poverty, and diminished material hardship. ¹¹ Common protective factors are cited below in Table 1.

Figure 2

Table 1: Common Protective Factors for Child Neglect (www.familysupport.org/Abuse.cfm)

Child neglect is a phenomenon that is not very well known due to limited research on child neglect and the meshing of child neglect with child abuse. There are disagreements among neglect researchers about several important issues; such as whether to frame child neglect as a child’s unmet needs or as omissions in parental behavior. It has therefore been difficult to develop a standard conceptual definition of child neglect. ¹² .

A new measure of perceptions of child neglect, for use in community samples, has been developed and it is named Community Norms of Child Neglect Scale (CNCNS).

The CNCNS differentiates among four subtypes of neglect (failure to provide for basic needs, lack of supervision, emotional neglect, and educational neglect).Scenarios ranging in seriousness for each subtype were presented to large community sample. Confirmatory factor analyses indicated that a four-factor model provided a better fit to the data than did a a model specifying only one overall neglect factor, suggesting this sample distinguished among the four subtypes of neglect. Scientists tested measurement equivalence across individuals who work with children and lay community respondents and across rural and urban respondents, with results indicating a very similar structure across these groups. These initial reliability and validity data suggest that the CNCNS may be of use in comparing perceptions of child neglect among individuals and across communities. ¹³

Developmental pathways between childhood emotional maltreatment and adaptational outcomes in early adolescence were examined. A variety of correlations revealed that both emotional neglect and emotional abuse were associated with increased aggression and social withdrawal in middle childhood, and lower ratings of socio-emotional competence in early adolescence. Analyses revealed that this association was only significant for boys. While social withdrawal in middle childhood significantly explained the observed relation between emotional abuse and decreased competence in adolescence, this process did not emerge as salient in understanding the relation between emotional neglect and adolescent adaptation. Furthermore, these developmental processes appeared to vary by gender. The results are in need of replication and extension to other outcome domains, but represent an important contribution to the empirical study of specific forms of emotional maltreatment. ¹⁴

Emotional abuse, while frequent, was seldom the focus of the child protection services investigation. The nature of this abuse was not minor, but rather likely to be dangerous to the mental health and well being of these children. Furthermore, emotional abuse in samples of young adolescents, at least, was likely to be accompanied by other forms of maltreatment, especially physical abuse and/or neglect. ¹⁵

Dental Neglect

Dental neglect (Fig. 2), as defined by the American Academy of Pediatric Dentistry, is the “willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.” Dental caries, periodontal diseases, and other oral conditions, if left untreated, can lead to pain, infection, and loss of function. These undesirable outcomes can adversely affect learning, communication, nutrition, and other activities necessary for normal growth and development. Some children who first present for dental care have severe early childhood caries (formerly termed “baby bottle” or “nursing” caries); caregivers with adequate knowledge and willful failure to seek care must be differentiated from caregivers without knowledge or awareness of their child's need for dental care in determining the need to report such cases to child protective services. ^16,17.

Figure 3

Fig. 2. Neglect is the failure to provide for a child’s basic needs. This can include the failure to provide medical or dental care

Failure to seek or obtain proper dental care may result from factors such as family isolation, lack of finances, parental ignorance, or lack of perceived value of oral health. The point at which to consider a parent negligent and to begin intervention occurs after the parent has been properly alerted by a health care professional about the nature and extent of the child's condition, the specific treatment needed, and the mechanism of accessing that treatment. Because many families face challenges in their attempts to access dental care or insurance for their children, the clinician should determine whether dental services are readily available and accessible to the child when considering whether negligence has occurred. ^16,17.

The physician or dentist should be certain that the caregivers understand the explanation of the disease and its implications and, when barriers to the needed care exist, attempt to assist the families in finding financial aid, transportation, or public facilities for needed services. Parents should be reassured that appropriate analgesic and anesthetic procedures will be used to ensure the child's comfort during dental procedures. If, despite these efforts, the parents fail to obtain therapy, the case should be reported to the appropriate child protective services agency. ^16,17.

Consequences Of Child Neglect

The negative impact of abuse and neglect on children and adolescents should not be underestimated, especially in relation to its burden on physical and mental health. Often, children suffer more than one form of maltreatment. A combination of emotional abuse and neglect, together with physical and/or sexual abuse over time, has a greater impact than being victimized by severe physical punishment or a single sexual assault. Furthermore, children who are maltreated by more than one person consequently have more problems than those maltreated by one person. ¹

Child maltreatment remains a major public health and social-welfare problem in high-income countries. It substantially contributes to child mortality and morbidity and has long lasting effects on mental health, drug and alcohol misuse (especially in girls), risky sexual behavior, obesity, and criminal behavior, which persist into adulthood. Neglect is at least as damaging as physical or sexual abuse in the long term but has received the least scientific and public attention. Generally maltreated/neglected children show less confidence, joie de vivre and hope for the future. ^{18, 19.}

Prevention

Researchers used prevention strategies, in early childhood, to fight against child maltreatment and neglect. These methods include home visits, parent education classes, and provision of health services. The conclusion is that the evidence base for programmes in early childhood to prevent child maltreatment remains relatively weak. ²⁰.

Conclusions

Child neglect is a health and social issue, that is not very well studied. Determining which child is in need and clarifying what those needs are, requires professional judgment to be made by staff in all agencies. If there is an indicator that a child may be a child in need and that there are moderate concerns about a child, a referral to social services may be necessary, in order that more comprehensive assessment can be undertaken.