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

2. 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

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

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

5. 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:

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

7. 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

8. 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?

9. 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

11. 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?

12. 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

13. 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

14. 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)

15. 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)

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

17. 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

18. 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)

19. 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

20. Your Cases/Discussion