Responding to Neglect in the ED ECHO Presentation, March 2018 Nina Livingston, MD

Clinical Services of SCAN Program (Suspected Child Abuse and Neglect) at Connecticut Children’s Inpatient consults Outpatient consults Phone consults Record Reviews Assessment for all types of suspected maltreatment, including physical abuse, sexual abuse, neglect, psychological abuse, and medical child abuse

Overview of presentation Definitions Epidemiology Neglect of neglect Approach to evaluation/response Reporting Case examples

“Yeah, I was drunk, but the X was keeping me focused” (ecstasy as parenting aid)

Defining Neglect: Two Paradigms Child focused definition: includes all circumstances where a child’s basic needs are not met; contributing factors guide response Caregiver-focused definitions: Most state laws and CPS agency definitions focus on caregiver behaviors/omissions that result in actual or potential harm e.g. Being homeless or without health insurance may not be the sole fault of a caretaker; adolescents bear some responsibility for themselves, etc CT DCF definitions: http://portal.ct.gov/DCF/Policy-Homepage/Chapter-34/34-2-7

What are basic needs? Food Clothing Protection Supervision Stable home Nurturance Health care Education

A heterogenous problem Neglect exists on a spectrum, and there is a threshold that is concerning grossly inadequate care---------- needs optimally met The specifics of the child and situation must be considered in order to assess Asthma with smoker at home Latchkey kid Craniofacial delay

A multifactorial problem Is this neglect? Dental and mental health care often neglected due to inadequate resources/coverage 8 million uninsured kids Half of mentally ill children do not receive appropriate care How would you define neglect?

How common is neglect? NIS-4 estimates (2005-2006) Sentinel professionals across the US recording maltreated children set definitions harm and endangerment standard not all reported to CPS 10.5/1,000 kids in general population Physical neglect 4/1,000 Emotional Neglect 2.6/1000 Educational neglect 4.9/1000 Community professionals, 0ver 10,000, including pediatricians, recruited as sentinels to record abuse or neglect, whetehr or not reported to CPSNote: Neglect of health care was a subset of physical neglect http://www.acf.hhs.gov/programs/opre/abuse_neglect/natl_incid/index.html

https://www.acf.hhs.gov/sites/default/files/cb/cm2016.pdf

Why do we neglect neglect? It’s common, and it is serious. So why do we neglect neglect? Show of hands…How many have reported physical abuse or sexual abuse How many have reported neglect?

Why do we neglect neglect? Hard to quantify We don’t do the assessments that would allow us to make the diagnosis We don’t want to fracture tenuous therapeutic relationships We don’t want to spend the time to report Often not a “crisis” situation

When evaluating for neglect, consider: Actual or potential harm If potential, must judge likelihood of harm Severity Frequency/chronicity A heterogeneous phenomenon, varying in type, severity, and chronicity In practive, often measuring only actual harm e.g. infant learning to walk e.G single lapse of not supervising toddler by a pool or a road can be devastating—must consider all factors

Responding to Neglect Ensure safety Get social work consultation Assess caretaker understanding of the situation Assess contributing factors Make plan (with PCP) to address unmet needs of child Tailored to child and family Least intrusive interventions first—may include home based services such as VNA, school RN or other community resources, family support network (needs not adequately met) (assess likelihood and seveity of potential future harm) (child, parent, family, community, society)

Keys to a successful plan Parents should be involved in setting goals Goals should be reasonable and measurable Plan should be documented in writing and signed by those responsible; copy to caregivers and copy to chart Plan should include follow-up reassessment to monitor progress (PCP)

Medical Neglect Takes two forms: Failure to heed obvious signs of illness Failure to follow physician instructions (Either can be fatal or disabling)

Medical Neglect: Necessary Factors for Diagnosis Child harmed or at risk of harm due to lack of health care Recommended care offers significant net benefit Anticipated benefit of treatment is significantly greater than its morbidity, so a reasonable caregiver would choose treatment Health care is available and not used Caregiver understands medical advice given

Reporting to DCF Report reasonable suspicion of neglect Provide objective information about harm, severity, frequency Articulate ongoing risks to child Describe interventions that have been tried and failed Always call DCF Careline with new concerns (NOT ongoing DCF worker)

Conclusion: Don’t neglect neglect Don’t DO NOTHING until there is a crisis Proactively identify children at risk and take steps to address unmet needs Get social work consultation Communicate clearly to families, assess their understanding, and document well Involve CPS (DCF) when indicated Consult with your child protection team

Your Cases/Discussion