A Review of Child Neglect in Scotland

HOW GOOD ARE WE AT RECOGNISING CHILDREN WHO ARE AT RISK OF, OR EXPERIENCING, NEGLECT?

Definitions and recognition

It was generally seen as helpful to have a national definition which could be used across services and act as a starting point when considering whether a child was experiencing neglect. However, for some respondents this posed a question about the adequacy of such over-arching definitions.

Does the formal definition matter? Is it not more about the impact on the individual child and the need to intervene early before there is too much impact on them?
Survey respondent

This comment may be a reflection of a broader shift towards a language of unmet needs and a focus on the potential for later neglect rather than current neglect. In practice, though, it should be possible to refer to an overarching definition whilst still responding at early signs of problems. For example, some respondents were also thinking through how the terminology used within a GIRFEC approach might necessitate a change in emphasis from blanket terms such as 'neglect' and 'abuse' to encompass new ways of framing children's needs:

We're not really using the word 'neglect' in a practice context. We are framing children's risks and needs through the five Integrated Assessment Framework (IAF)/GIRFEC questions (e.g. What does the child need? Can I provide it? If I can't provide it, who needs to?) We use the My World Triangle to identify areas of risk rather than using the term neglect. We would look at what needs to be put in place to identify gaps in care - for example, is parenting work needed? Or is housing the issue?
Survey respondent

While a small number of areas are still at the point of ensuring that all services have a shared understanding of the national definition, some areas have developed it in order to help practitioners consider in more detail what constitutes child neglect in relation to individual children and what is acceptable in terms of levels of care in particular circumstances:

We have not developed the definition as such but have padded it out locally in other respects through the 'Keeping Children Safe' tool, similar to a type of threshold matrix which breaks concerns down into factors. It helps agreement about at what stage to refer and help people understand what to do with their concerns. A locally developed tool, it helps define neglect at a practical level.
Survey respondent

There was some discussion about the use of the term 'neglect' in itself, both in relation to what it encompasses and how it relates to 'lack of parental care'.

Sometimes I think neglect is used as a category even if it is really emotional abuse. Neglect may better be called 'lack of parental care'.
For example, in this area we have great variation in social and economic backgrounds, with child protection issues in the most middle-class families but this would be more lack of parental care/exposing young people to danger, for example letting them drink and party at home. This is neglect - but in a different way.
Survey respondent

The majority of respondents reported that, to their knowledge, the national definition was generally known, helpful, and used by most agencies in their area and that the use of the GIRFEC Well-being Indicators and My World Triangle categories^[2], when assessing children, had contributed to a shared understanding of children's needs. In some cases multi-agency training and the on-going discussions about individual children and their families which staff across services have daily, had been instrumental in this. Some areas were less certain about the extent to which working definitions were really shared by some agencies in practice and that there are still inconsistencies in interpretation about the stage at which children and families require intervention:

The definition is shared but I'm not sure if it is interpreted and used consistently. It appears in documents inspected as part of case file audits and we've not found any differences there but there are likely to be differences in individual interpretation. It's something we discuss at Practitioners' Forums, the thresholds issue, and people say they do their best to come to a shared understanding of what they mean with people they are co-working with. I don't think it's a particular concern.
Survey respondent

In general there was a prevailing view that common ground was increasingly being negotiated, although determining thresholds of risk and what constituted acceptable care were still influenced by availability of resources and what was described as the 'cultural acceptance' of barely good-enough levels of care in some neighbourhoods. Further research would be required to explore the extent to which apparent differences in culture are associated with differential responses and referral rates.

Identification by the general public

The YouGov poll of the public across the UK did not expressly ask about the particular signs of possible neglect, however, the public were asked if they had been worried about a child experiencing neglect (Burgess et al., 2012). Thirty percent of the Scottish public, who were asked, replied that they had been worried or very worried about a child therefore obviously making a judgement about the possible signs of neglect (in Wales it was 29% and in England around 26%).

Focus group participants queried the extent to which the public were getting the message about what were acceptable levels of care and whether there needed to be more awareness raising with the public to put this message across more effectively. Having said this, respondents asserted that referrals from neighbours and family, who were concerned about a child, were always followed up but commented that there was sometimes a problem if referrals were anonymous or there was insufficient evidence to act. It was felt that the public were as yet unaware of the GIRFEC approach to safeguarding children and that more information about this needed to be conveyed.

Identification by professionals

The participants in the focus groups identified professionals who are well-placed to recognise when a child is not being cared for adequately. There is evidence that a range of practitioners are now part of the 'identification' network.

Health service staff

Participants in one focus group area described the way in which a Public Health approach was being adopted locally:

We also have the Joint Health and Well-being Unit led by the Health Board. It's a public health approach within early intervention. The Comprehensive Health Assessment offers a holistic view of health which could pick up some aspects of neglect.
Focus group participant

Midwives report that, where possible, they are doing home visits as early as possible to identify potential neglect risk factors for unborn children. Many areas have specialist practitioners or dedicated services to support particular groups of parents, for example those who are identified as misusing substances.

Health visitors are seen as ideally placed to assess and identify the risks for children in the home, but the majority we met in focus groups have been frustrated by the constraints of high caseloads limiting the amount of contact they have had with many of the families. There are now moves to address this, for example by reinstating the 24 month health check for all children, which should help target those in most need of additional support alongside the provision of a universal service to all. The reintroduction of the 24-30 month assessment should provide an opportunity to undertake a comprehensive assessment (yet to be finalised at the time of publication). Some areas have early years staff attached to health visitor services who are able to work more intensively with families and can have a monitoring role if there are concerns about the care of children.

School nurses have a role in identifying potential neglect although some areas have seen a reduction in this service:

In part of our area, two posts were funded with a School Nurse role and although only one is actually in post, the difference is that she spends much time in the school undertaking one to one work with children with additional support needs whether physical, educational or behavioural. She also does a lot of health promotion work and gets to know the wider population of children.
Focus group participant

Accident and Emergency Department staff, GPs, paediatricians, psychologists and dentists alert colleagues when children come to their attention who are showing signs of possible neglect or who are not attending scheduled appointments.

School and nursery staff

Nursery and primary school staff were considered key in recognising signs of neglect in children as daily contact with parents, as well as children, enable them to see changes in behaviour and whether, for example, the child is being collected by numerous people or other children. Some schools have Home School Link staff who go out to homes and can, in some cases, obtain a holistic picture of the child's living circumstances. Educational Welfare Officers or school-attached social workers can provide a useful bridge between school and home in assessing what is happening in a child's life:

Transition times, say in the move from nursery to primary to high school, can flag up problems for children. We have Multi-agency Transition Groups to try to identify children who are struggling and find ways of helping them.
Focus group participant

We were given examples of guidance and pupil support staff and school counsellors in secondary schools raising money for 'hardship funds' for toiletries and essential items for young people, which also gave an opportunity for young people to talk about any difficulties at home.

Targeted services staff

Social workers and voluntary sector staff who are already involved with families or who become involved through out-of-hours and duty systems may uncover signs of neglect while discussing other presenting issues. Voluntary sector agencies working in communities and housing schemes were sometimes approached by local families for help. However, as resources became more stretched it had been noted by the voluntary sector survey respondent that such services were increasingly seen as being targeted and referred to them as being 'gate-kept' by social work services who had commissioned them, with self-referral considered to be on the decrease.

Youth justice social workers are often able to identify young people who have experienced or are experiencing neglect, in relation to 'absent' parenting, lack of boundaries and supervision.

Police, housing and community/youth workers

Police in all areas have processes in place for identifying and referring children who come to their attention during domestic violence incidents or other call outs. 'Child Concern' or 'Vulnerable Persons' forms are passed on to social work services and can result in what is viewed by the recipients as an 'overload' of potential referrals. In some areas there is a 'marker' system in place so that police will actively look for signs of neglect in homes which have this type of alert recorded.

In some areas there are developments in the ways in which council and housing association staff, including tradespeople who are entering homes, are looking out for signs of child neglect, which can go hand-in-hand with poor housing conditions. Staff were also becoming involved in projects to work with people to improve their physical and social circumstances.

Practice example:
Glasgow Housing Association is taking a more pro-active response to families who are identified as needing help, with a view to encouraging better care of their homes, themselves and their children. Housing Association staff are having more discussions with social work services staff about how best this can be done for individual families. The approach is to try to intervene early on with children, in part because they are the future generation of housing tenants. Housing has some resources to spend on services and is looking at a befriending service which offers support in these areas.

This chimes with the idea of 'neglected neighbourhoods' which was raised in several primarily urban focus groups. Participants commented on the importance of the living environment for families and the benefits of improvements in these and how this can have an impact on housing conditions and on family life. For some focus group participants, there was frustration that good work and progress with families was often seriously tested or undermined by not being able to address issues of poverty and unemployment in the wider communities; communities that many participants described as 'neglected'.

Youth and community workers, mentoring and befriending service staff, were seen as having a role in identifying neglect in older children and young people. The less formal and often trusting relationships they are able to develop with young people and their role, which often encompasses visiting the family home, can give them opportunities to check out what is happening with the family and either offer help or advise about available supports.

Rural and urban differences

The focus groups took place in both urban and rural areas and while many aspects of the ways in which professionals were able to identify and respond to children who needed help were common to both settings, there were some additional factors for those working in rural areas. In relation to children being identified it was felt that families who were experiencing difficulties were often more visible in a rural environment and that families who moved to very remote areas in order to disappear from the notice of services found that the opposite occurred. In some very small communities there could be difficulties for professional staff who were approached informally with concerns about children which were difficult to substantiate.

Multi-agency screening groups

Most areas were able to describe multi-agency groups aimed at the early identification of children who it appeared were not being cared for adequately. In some areas these were well-established groups, for example those based in schools but with representation from other agencies. Others were issue-specific groups, for example when domestic violence or parental substance misuse was raising concerns for children. Some groups described were locality-based; some discussed several children at a time and others considered individual children on a case-by-case basis:

We have put a lot of effort into early identification, by way of multi-agency groups which enables the safety net to be quite wide. We've taken a systems approach in that a wide range of children are considered and that can escalate issues, which we are conscious of, but it's getting the balance so that we catch children with potential difficulties early.
Focus group participant

It was clear that some areas had designed multi-agency groups specifically to meet the requirements of the GIRFEC approach, whereas other areas had continued to use previously existing groups and saw them as being congruent with the GIRFEC approach.

Many groups have a dual role in both identifying and responding to children. The GIRFEC framework has been a driver in some areas for rethinking the role and purpose of such groups and whether the Named Person role will preclude the need for such screening groups and lead on directly to a multi-agency forum which agrees on support packages:

The Named Person system is being introduced so currently there are transition arrangements. That is a Pre-referral Screening Group to try to reduce referrals down the statutory or Children Hearing route, unless really needed. A twice weekly multi-agency forum is held for concerns to be raised and a lead worker to be allocated to stop the child and family being bounced around before contact occurs. All the agencies research what is known about the family. When the Named Person is in place this should be a health visitor or teacher. So only referrals from the public would come to the group.
Survey respondent

The stage at which the child's parents become involved in groups, where the identification of need and response planning takes place, is also under discussion in some areas given the focus on working with parents as partners. One survey respondent outlined how their area had moved away from the practice of holding multi-agency discussions between professionals about several families in one meeting because of confidentiality issues.

Practice example:
Dundee Multi-Agency Screening Hub (MASH) is made up of a group of multi-agency representatives who are co-located and whose role is to gather and share information about children who are referred to the MASH. There will be some filtering of referrals before MASH staff are contacted. The MASH is where the jigsaw pieces of information are fitted together and the parent informed of the referral. As a result of the discussion, there might be a single or multi-agency response or a joint visit to the family, for example from health and social work staff or education and social work staff.

Although not long established, it is generally thought that the MASH process has helped the sharing of information about children experiencing neglect and helped to ensure responses are more timely and appropriate to the identified need or concern.

All areas within Scotland have localised structures aimed at maximising the ways in which all those working with children in universal and targeted services can identify those whose behaviour and/or physical and emotional problems signal possible neglect. In some areas this is extending, perhaps more incrementally than it should be, to professionals working primarily with adults whose circumstances indicate that children in their care may be at risk of neglect.

The GIRFEC approach

The structures, processes and paperwork within the GIRFEC Practice Model have been designed to identify and respond to children at as early a stage as possible when problems are recognised and by offering supports at a universal service level if this is adequate and feasible. The evidence from the evaluation of the early impact of the roll-out of GIRFEC in a 'pathfinder' local authority suggests that it has the potential to reduce the numbers of children experiencing neglect (Stradling et al., 2009). It will be some while before the effectiveness of the system for doing so can be evaluated more widely. Feedback from survey responses and the focus groups indicated that some staff thought that the current lack of information-sharing protocols and incompatible IT data systems act as a barrier and that more work could be undertaken to improve local and national systems in order to help the GIRFEC framework to operate most effectively. There is a national project to develop the Inter-Agency Communication Tool (IACT), which may help with this issue.

Partnership working

Analysing the findings from the survey responses and the focus groups there was an overall message that the ways in which agencies work together was an improving picture. In small areas, in particular, generally good relationships were reported both at practitioner level and also developing strategic ones, which was felt to be partly due to the implementation of the GIRFEC framework. It was reported that some adult services in some areas were seen as reluctant or unable to adopt the multi-agency approach and share information about families but it was hoped that multi-agency training and a 'culture of learning together', which had helped child-focused services collaborate more effectively, could be rolled out to adult services in time.

The focus on GIRFEC has helped the buy-in to partnership working and we have to keep reiterating this. The Getting Our Priorities Right^[3] agenda does help the link with adult services - we are linking in with Housing and other adult-focussed agencies like that more now too.
Survey respondent

Practice example:
Stirling Community Safety Partnership and the Local Authorities and Research Councils Initiative (LARCI) jointly funded a partnership project that included Stirling Council, Forth Valley N.H.S., Central Scotland Police and the Voluntary sector and drew on the knowledge of practitioners and from research to raise awareness of issues about early intervention by services working with expectant mothers who use drugs and alcohol and to improve parenting and reduce the potential for abuse and neglect of this vulnerable group of children (McIlquham et al., 2011).

Are more children being identified?

The feedback from survey responses and focus groups reflected the general consensus that an increasing number of children who are experiencing or are suspected of being neglected are being identified by staff from across all agencies. This cannot currently be evidenced by quantitative data as some local data collection systems are limited. The general view is that there is a better understanding of the signs and effects of neglect and a widening range of formal processes in place by which professionals can share knowledge about children about whom there are worries. Some participants reported that, while on the whole this was clearly a positive development, there were sometimes difficulties in targeting help at those most in need, because of the 'big haystack' of referrals. The implication of targeting help, though, is that those who are not targeted do not receive help, even though there must have been sufficient concerns about them to lead to the initial referral.

Respondents reported as struggling with the enduring issue of making decisions about identifying when precisely the level of care being provided could be considered unacceptable:

There is agreement on the serious cases but it's those in the big grey area of uncertainty for whom we need a framework for identification and clarity about triggers into appropriate supports. We are getting towards a shared understanding but thresholds can be different across services. When social workers are out visiting homes they need to take notice of health visitor colleagues who have ordinary households as the benchmark. Social workers' norms have shifted about what's acceptable. Is it good enough? Even within agencies, personal standards have a bearing too.
Survey respondent

There was a view that many parents would make just enough improvements to prevent removal from care, but that this was not always sustained without close monitoring. There was also concern about tracking children living in families who move between areas. Emotional neglect was described as often much harder to evidence. This is congruent with UK-wide concerns about the difficulty of identifying and evidencing emotional neglect, even following training (Glaser et al., 2012).

Focus group participants, in particular, also noted that greater recognition has led, in turn, to more children becoming accommodated. This is backed up by official statistics which show that at 31 July 2010 there were 15,892 children looked after by local authorities, an increase of four per cent since March 31, 2009. The number of children looked after has increased every year since 2001, and is at its highest since 1982 (Scottish Government Statistical Services, 2011). This in itself means that social work staff in the statutory sector are spending more time resourcing the processes required when this occurs. It was thought by some participants that as the demand for foster care placements becomes higher and placement choice less available then the care experience for some of these children can be damaging in itself. This view would need to be explored further as the current evidence suggests that being looked after away from home can also be associated with better outcomes for some neglected children (Farmer and Lutman, 2010).

Assessment

The majority of CPC areas make use of the Integrated Assessment Framework forms and most cited the GIRFEC tools (My World Triangle, SHANARRI well-being indicators and Resilience Matrix) as a way of assessing the extent to which children's needs are assessed or met. In some areas these are used widely by all agencies working with children now; in others they are being introduced more incrementally. On the whole, they were seen as very helpful and provided a common language for all services.

In addition, the most common assessment tools used by health service agencies are the Profile of Significant Factors (NHS Greater Glasgow Perinatal Care Pathway), the Health Needs Assessment (Hooper and Longworth, 2002) and the Schedule of Growing Skills (Bellman et al., 2009). Pre-birth assessments were also cited. Social workers mentioned use of the Graded Care Profile (Polnay and Shrivastiva, 1996), Signs of Safety (Turnell and Edwards, 1999), Real Time evaluation assessment tools (aka Realist Evaluation, Kazi, 2003) and the Keeping Children Safe toolkit (NSPCC and others). Ways of assessing the impact of neglect on the individual child were mentioned by some as important and some outlined that this is the analysis which led on from the assessment. The NSPCC Ten Pitfalls practice paper was used in at least one area to look at the impact of neglect on children (Broadhurst et al., 2010). In another area the Action for Children Neglect Assessment Tool was in use and being evaluated as part of a wider Neglect Project operating in four areas across the UK (Long et al., 2010).

The view of some was that risk assessment tools were required to give an added perspective to GIRFEC assessment forms. Some CPC consortia have developed their own tools. Calder's Risk Assessment Framework (Calder, 2002) and other forms of assessment of need and risk were also mentioned. A National Risk Assessment Toolkit is under development and currently being piloted (Scottish Government, 2010b). The tool is located within the GIRFEC framework and augments the National Child Protection Guidance (Scottish Government, 2010a).

Parenting capacity was also assessed using various formats, such as the Parenting Assessment Manual (McGaw et al., 2002) used by Action for Children and others, primarily for assessing parents with learning difficulties:

The My World Triangle is not really enough in itself for assessing emotional neglect - it comes back to how people record and interpret what they find out. We need to do more on the analysis of the actual impact on the child. The Department of Health materials were good for this as they offered a range of tools although they were time-consuming if they were all used.
Focus group participant

Discussion in the focus groups indicated that there was still an important role for professional judgement and 'instinct' about how family life is for children, with the tools offering a structured list of areas for consideration and a format for reporting on these. Structured tools go some way towards a shared understanding between services of a child's needs and also their protective factors. However, respondents reported that there is still inconsistency in views about the point at which intervention in some form is required, for example the offer of family support or referral to the Reporter to the Children's Hearing System (commonly referred to as the 'thresholds issue').

Is there a shared understanding of when neglect requires a response?

We asked survey respondents whether they felt that there was a common understanding across all agencies about the level of concern that warrants referral to a statutory service rather than direct provision of help by informal or universal services. This question had been formulated for the UK wide review. In Scotland, as GIRFEC becomes embedded, this would be reframed as 'the level of concern at which a multi-agency response, probably involving targeted help, would be required' (see figure 1).

Other = this is an on-going issue so unable to complete options (1)

Figure 1: The survey response to the question: 'there is a common understanding across all agencies about the level of concern that warrants referral to a statutory service rather than direct provision of help by informal or universal services'

Comments suggested that multi-agency training helped develop a shared understanding and that continuously stressing the need for shared responsibility at every opportunity when undertaking joint case work with families also led to common levels of understanding between services. As joint work increasingly takes place staff report that they are more able, if necessary, to challenge those from other agencies about what is an acceptable level of care.

What is getting in the way of children being identified?

Obtaining evidence of a child being neglected is still seen as problematic, certainly in comparison to other forms of abuse. The importance of chronologies and not starting again as families move out and then back into services is recognised, but when there are multiple case files it can be hard to find the most relevant information. It can be overwhelming for staff trying to make sense of previous events and to then present this in a way that can be seen as evidence. Although identification of neglected children was seen as improving, there were clear gaps reported, particularly by focus group respondents.

In some urban areas there was felt to be what was described as 'a cultural acceptance of neglect', particularly where inter-generational low standards of care were prevalent. There was a danger that professionals working in these areas had become desensitised by what had become a local norm:

There is a role for education about how we teach our young children about what is normal and acceptable in terms of living without domestic abuse, neglect and unacceptable parenting. In some areas we have to address where neglect sits within societal norms.
Focus group participant

In some areas the numbers of children who were living in these circumstances were almost overwhelming and poverty was clearly part of the issue for some of these families, coupled with low aspirations and little or no hope of future change and improvement in their lives and those of their children.

There was thought to be a need for greater acceptance by professionals of the fact that some parents did not have the capacity to parent, despite the provision of services to support change, and that children should then be removed from the home:

It's difficult to help some children whose parents seem compliant but aren't doing what is necessary to care for their children - there is sometimes perhaps an element of us being over-optimistic. We need a shared understanding of when neglect can no longer be tolerated.
Focus group participant

Social workers and health visitors told us that they need to be able to spend more time with families in their homes to be able to assess what daily life is like for children:

It is better once the child is surrounded by other professionals - but one gap could be before the child gets to nursery. Few professionals see them and it can be very difficult to make some sense of the child's situation. The health visitor service is extremely stretched. Also health visitors have no right of access and families can refuse, but this can be discussed with social work services. Although even if a health visitor manages to visit the family they may not see them enough to make sense of the family environment and see what is going on with the child and the impact of possible neglect.
Focus group participant

Some children were described as being good at masking what is really going on, perhaps showing signs of 'false resilience' which may disguise the impact on them of lack of care unless someone sees the situation at close hand. Teenagers who are unsafe due to lack of guidance and boundaries sometimes go unnoticed unless they are coming to the attention of youth justice agencies. There were also comments about extended family trying to cover up and manage situations where children are living in neglectful situations when it would be better if services became involved.

It was thought that some professionals, in some cases from both adult-focused but also child-focused services, saw the adult as the primary client and children's needs could be lost. It was important to bring adult-focused services into the GIRFEC process and this was not yet happening in a widespread way:

Getting referrals from adult drug services can be difficult - there is a will and some understanding of child protection, but drug workers are sometimes out of their depth when it comes to children who may not hit the high tariff - and they may not be sure what to do about protecting them. Some teams are more confident - there is inconsistency across the region. Adults' workers are starting to see things in a broader, whole-family way but maybe this is not as much as it should be - it's perhaps lack of confidence or experience.
Focus group participant

Emotional neglect, often resulting from parental depression was seen as particularly difficult to identify. In some areas the situation of fathers working off-shore for extended periods and the impact on family life both when they are there and absent was also raised. Alcohol misuse was often used as a coping mechanism, in some cases by both parents.

Other children seen as at risk of neglect but hard to identify were:

• those in transient families who often moved on when problems were being identified
• home educated children who were not in contact with any professionals
• children of parents with learning difficulties, particularly those who had been inadequately parented themselves
• children and young people in 'middle-class' families suffering neglect that is difficult for agencies to recognise.

Summary

There is some on-going consideration about the use of the definition of neglect in the context of the GIRFEC framework and its focus on the language of children's unmet needs. The definition is generally thought to be shared across agencies although there are still considered to be some inconsistencies in interpretation about the stage at which children and families require intervention. The multi-agency collaboration through the GIRFEC system is considered to be helpful in working towards overcoming this.

We identified a wide range of professional staff in a position to identify children at risk of or experiencing neglect. All areas have multi-agency groups which meet to discuss and identify children at risk. Some of these groups are undergoing a change of emphasis as a result of GIRFEC and rather than screening for referral on to services aim to focus on putting in place appropriate support packages for children and families.

The GIRFEC Assessment tools are viewed positively by staff across most agencies and are now in use by some. It is thought that additional tools are valuable, for example in assessing risks for children and to assess information about levels of parental care and parenting capacity in relation to potential neglect of children.

The perception is that there is a better understanding of the signs and effects of neglect and a widening range of formal processes in place by which professionals can share knowledge about children about whom there are worries.

There are still a number of factors which get in the way of children being identified. These include professionals becoming 'desensitized' to inter-generational neglect, staff being over-optimistic about some parents' capacity for change, extended family covering up the extent of neglect for some children and difficulties in evidencing emotional neglect.