Version May 2024
INTRODUCTION — The evaluation of child neglect will be reviewed here. The evaluation and management of physical abuse and sexual abuse are discussed separately. (See "Physical child abuse: Diagnostic evaluation and management" and "Evaluation of sexual abuse in children and adolescents".)
DEFINITIONS — Child neglect is the most prevalent form of child abuse, accounting for more than one-half of cases reported to child protection services [1,2]. For the purposes of this topic, we adopt the definition provided in the United States Federal Child Abuse Prevention and Treatment Act (CAPTA) in which child neglect refers to any action or failure to act which causes serious physical or emotional harm or death or puts the child at imminent risk for such harm [3].
Furthermore, specific types of neglect are defined as follows:
●Physical neglect – Physical neglect refers to the caregiver's failure to provide adequate food, clothing, shelter, or hygiene.
●Supervisory neglect – Supervisory neglect means that inadequate supervision puts the child at major risk for physical, emotional, or psychological harm [4,5].
●Emotional neglect – Emotional neglect describes the caregiver's failure to do any one of the following [6]:
•Provide love, affection, security, and emotional support
•Obtain psychological care when needed
•Protect the child from exposure to domestic violence or substance use
●Educational neglect – Educational neglect consists of failure to do any one of the following [6]:
•Enroll the child in school or homeschool
•Ensure regular and prompt attendance at school
•Address special education needs
●Nutritional neglect – Nutritional neglect can either mean failure to provide adequate nutrition to maintain physical growth and development [7] or failure to prevent overnutrition leading to serious medical complications [8].
●Medical neglect – Medical neglect refers to either failure to provide prescribed medical care or treatment or failure to seek appropriate medical care in a timely manner [5,9].
●Dental neglect – Dental neglect describes failure to provide adequate dental care or treatment despite adequate access to care [10].
Neglect definitions are impacted by the accepted standards of care for children and the role of the community in families' lives. Issues to take into account include harm to child, primary caregiver's/parent's ability or intent, family's concrete resources, community norms, and availability of community resources [6].
EPIDEMIOLOGY — According to national surveillance studies in high-income countries such as the United States or Canada, child neglect is the most pervasive and prevalent form of maltreatment [2,11,12]. It accounts for more than one-half of reported cases analyzed yearly by the National Child Abuse and Neglect Data System (NCANDS). Each year in the United States, child maltreatment results in more than 1800 child fatalities [1]. The majority of fatalities involve vulnerable children under three years of age and are strongly associated with poverty [13]. Multiple forms of child maltreatment often coexist, and more than 70 percent of reported cases involve neglect [1].
The following risk factors place children at a greater risk of being harmed or experiencing neglect [6]:
●Poverty
●Domestic violence
●Family stress
●Mental health or substance use problems
●Young maternal age
●Lack of social support
●A caregiver's lack of understanding of child development or behavior
By contrast, protective factors include [6]:
●Healthy nurturing by the caregiver with normal child attachment
●Caregiver who is knowledgeable about parenting and child development
●Parental resilience (ie, cognitively, emotionally, and physically able to manage hardship)
●Social connections (family and friends) for caregiver and child
●Concrete supports (eg, adequate shelter, food, transportation, and finances)
●Social/emotional competence of the child
EVALUATION — Child neglect can be attributed to the complex interaction of cultural and socioeconomic factors related to the child, caregiver(s), environment, and resources [14]. The comprehensive evaluation of child neglect must consider these factors in an assessment of the barriers to and resources available for meeting a child's needs.
The evaluation should seek to answer the following essential questions [5,15]:
●Are the child's needs being adequately met?
•What type of neglect has occurred? (See 'Definitions' above.)
•Is there a pattern of repeated events?
•Has there been actual harm to the child or is there potential harm?
•Is there a high or low risk of imminent harm to the child?
●Have there been other types of child maltreatment such as physical, sexual, or psychological abuse?
●What factors are contributing to the neglect?
•What are the child's or caregiver's barriers and/or environmental or other barriers?
•What is the role of poverty?
•What are the family's strengths or protective factors, or resources?
•What interventions have been tried previously? What were the results?
●Are there other contact children (siblings or children that share the same environment) that need evaluation [16]?
●Is there a safe discharge plan as determined by positive answers to the following questions?
•Is the family motivated to make the necessary changes?
•Are the necessary resources available?
•Is the family willing to accept assistance on behalf of their child?
•How vulnerable is the child if change does not occur?
●Based on the answers to the questions above, is a report to Child Protective Services (CPS) indicated?
Clinical presentations — The presentation of child neglect will vary depending upon the neglect type(s) as well as any comorbid child maltreatment such as physical, sexual, or psychological abuse.
Neglect occurs on a continuum requiring an assessment of the likelihood of harm:
●Physical neglect may present with poor hygiene, lack of adequate clothing or diapers, or injuries from exposure due to lack of shelter (eg, frostbite, hyperthermia, or heat illness).
●Supervisory neglect or inadequate caregiver supervision can result in serious injury (eg, ingestion, injury from a firearm, dog bite, near drowning, or burns) or fatality [17] and may be caused by a combination of barriers including caregiver knowledge, supervision, and/or resources. Additional history, for example, may include screening for access to firearms or medications, use of car seats or bicycle helmets, supervision during bathing, safety plans used when the child is left home alone, and childcare arrangements when the caregiver is away from home or working.
●Emotional neglect may manifest as a lack of a nurturing positive relationship between a child and a caregiver providing that sense of emotional security as well as in a caregiver's inability to follow through with recommendations for psychological care or services.
●Educational neglect may arise due to chronic truancy, poor attendance, or reported homeschooling without an educational plan or activities.
●Nutritional neglect encompasses all malnutrition, including undernutrition (starvation, failure to thrive) and overnutrition, such as obesity with significant medical complications [8].
●Dental neglect results in untreated dental caries or oral infections and pain [10].
●Medical neglect has multiple presentations but may include:
•A seriously ill child where signs of illness were not recognized, or care not sought.
•Serious or life-threatening exacerbation of chronic health conditions in children with a lack of adherence to treatment plans and/or recommended follow-up.
•Lack of primary care visits for vulnerable children, such as premature infants or children with complex medical needs. (See "Poor weight gain in children younger than two years in resource-abundant settings: Etiology and evaluation", section on 'Causes'.)
Medical history — The comprehensive medical history includes history from the caregiver(s) and, if the child is verbal, a separate history from the child obtained without the caregiver present. In addition to the typical medical history, evaluation for neglect should include an assessment of barriers and strengths impacting the child’s proper nurturing (psychosocial risk factor screening). Most caregivers do not intend to harm their children, so the focus should be on the circumstances surrounding the child's presentation and care rather than on intent. Practitioners should give families an opportunity to provide information about possible neglect by asking them open-ended questions. The questions should be phrased in a way that allows the health care provider to maintain a good relationship with the patient and family.
The goal of the caregiver history includes learning:
●How healthy is the child?
●How is the child's behavior and development?
●How does the caregiver view the relationship with the child?
●How are the child's needs being met?
●Are the caregiver's needs being met?
Although obtaining useful information from a child may be challenging, even children as young as three years of age can answer "how did you get this bruise?" or "what happened here?" when the medical provider points to an injury of concern. It may be more difficult for a child to answer questions on how well their needs are met. The goal of the history from the child may include learning:
●How is the relationship between the caregiver and child?
●Does the child see a doctor?
●Does the child have enough to eat or drink?
●Does the child feel safe?
Examples of questions for caregivers, children, and families are provided in the table (table 1).
Additional elements of the medical history may be related to the presentation and concerns noted on comprehensive physical examination for the type of neglect:
●Physical neglect may arise from a lack of financial resources, caregiver knowledge, or other risk factors. Additional history may include screening for food insecurity, safe housing, and the source of financial supports.
●Supervisory neglect or inadequate caregiver supervision can result in serious injury (eg, ingestion, injury from a firearm, dog bite, near drowning, or burns) and may be caused by a combination of barriers including caregiver knowledge, supervision, and/or resources. Additional history, for example, may include screening for access to firearms or medications, use of car seats or bicycle helmets, supervision during bathing, safety plans used when the child is left home alone, and childcare arrangements when the caregiver is away from home or working.
●Emotional neglect may occur in the setting of caregiver depression or other mental health diagnoses, substance use, or domestic violence. As noted in caregiver history, the provider should ask about caregiver-child interactions and observe whether there is a nurturing or negative relationship between caregiver and child during the examination.
●Educational neglect involves determining whether the child is enrolled in school, regularly attending school, and receiving needed services. This information may require conversations with additional professionals such as teachers, principals, school nurses, or guidance counselors.
●Nutritional neglect, like physical neglect, may be due to combination of factors and requires assessment of financial resources, food insecurity, and access to supplemental nutrition programs. Both undernutrition (failure to thrive) and overnutrition (severe obesity) require a detailed history of dietary intake and feeding behavior and a psychosocial assessment (table 2) [8]. (See "Poor weight gain in children younger than two years in resource-abundant settings: Etiology and evaluation", section on 'Evaluation'.)
●Medical neglect is perhaps the most complex form of neglect to identify. Medical neglect is not as simple as whether a caregiver fails to take a child for medical care or to administer a recommended treatment. Medical neglect occurs on a continuum based on both (1) risk of harm and (2) role of the caregiver in the neglect. This determination requires assessment of whether the child has been harmed or is at risk of harm, whether the neglect occurred repeatedly or is at risk to recur, and whether there are risk factors that increase the risk of harm or if there are protective factors that decrease the risk of harm [5]. When considering medical neglect, the following questions are important [15]:
•Is the child harmed or at risk of harm because of a lack of health care?
•Is the recommended health care likely to have a significant benefit?
•What are the barriers to care?
•Are there cultural or religious factors that would contribute to an understanding of health care or adherence to the treatment plan?
•Was the treatment plan clear and education provided to the caregiver? How was the caregiver's knowledge and/or literacy assessed? How was the treatment plan provided and agreed upon?
•If medical treatment was delayed or not given, would a reasonable layperson have recognized the need for medical treatment?
●Dental neglect can result in caries, infections, and loss of function [10]. Dental neglect, like medical neglect, includes an assessment of the benefit of treatment as well as access to dental care.
Psychosocial risk factor screening — Screening by the health care provider for psychosocial risk factors can be brief but should focus on factors that are associated with serious physical abuse and neglect [18]:
●Prior child social services involvement
●Criminal history of any adult in close contact with the child
●Domestic violence
●Caregiver substance abuse history
●Caregiver mental health issues and/or negative caregiver-child interactions
●Negative attributions about the child (eg, caregiver has unrealistic expectations of child behavior or describes child using negative words) [19]
Psychological assessment — As the health care provider becomes more facile with the psychosocial assessment, this screening may easily expand to a psychosocial assessment, which can identify barriers and strengths (protective factors) for normal parenting:
Barriers may include:
●Child – The child has a physical or cognitive disability, chronic illness, mental health, and/or behavioral issues.
●Caregiver – The caregiver has an intellectual disability or lack of literacy, mental health issues, physical limitations, and/or substance use.
●Attachment – Issues of attachment are present in the caregiver-child relationship such that the child does not look to caregiver to meet emotional or physical needs.
●Environment – There is a lack of social support for the caregiver(s) (household composition, relative and community support) and child, and/or presence of violence in the home and/or community.
●Resources – These resource barriers include financial insecurity, lack of transportation, access to insurance, as well as food and housing insecurity.
Strengths may include:
●Child – The child demonstrates attachment to the caregiver as well as regulation of behaviors, age-appropriate development and thinking, and social connections to peers.
●Caregiver – The caregiver demonstrates pride in parenting, views the child with positive attributions, coping skills, and has social supports at home and in the community.
If a provider has concerns about child neglect after completing their medical examination and psychosocial risk factor screening, it is important that they ensure that a complete psychosocial assessment is conducted. This assessment may be completed by a social worker or other designated expert. A thorough psychosocial assessment will include information surrounding:
●The family's living situation
●Caregiver level of education
●Caregiver work history and employment status
●Caregiver coping skills
●Mental health and substance use history
●Family finances
●Family support system
●History of child protective services and law enforcement involvement
●Child's safety at home
Although similar to risk factor screening, the assessment goes into much greater detail regarding the specifics in each of these areas. The role of a psychosocial assessment is crucial for addressing concerns of neglect [6] because children without social capital (caregiver support systems within the household as well as within the extended family and community) are at higher risk for neglect [20]. This assessment can identify deficits in protective factors and/or resources which a social worker or other designee may mitigate by providing information or connection to key services (eg, food, clothing, or shelter). In this way, child neglect can be averted or mitigated, and the family supported.
In summary, it is important during an evaluation for neglect to complete a psychosocial assessment of both the family’s protective factors and risk factors, as well as an observation of the caregiver, the child, and the caregiver-child interaction.
There is published guidance on the complex assessment of neglect [5,8] available to the primary provider as well as effective tools for screening and prevention in the health care setting including the following:
●Safe environment for every kid (SEEK) (online training) [21]
●Neglect identification measurement tool (NIMT)
●Social needs screening toolkit (screening for social needs including housing and food insecurity)
●Adverse childhood experiences questionnaire (ACEs)
Children seeking urgent or emergency care — A comprehensive medical history is ideal but may not be feasible in the urgent or emergency setting. For patients in these settings, evaluation may need to be tailored to the injury or medical disease as well as the concern for abuse or neglect using a risk factor screening approach. (See 'Psychosocial risk factor screening' above.)
If the provider continues to have concerns about child neglect after the assessment is completed or if other forms of abuse such as physical or sexual abuse are evident, then consultation with a child abuse team, if available, is warranted. Furthermore, the provider should report their suspicion for child abuse or neglect to the appropriate governmental agency. In many parts of the world, this reporting is mandatory. (See 'Notification of child protective services' below and "Child abuse: Social and medicolegal issues", section on 'Mandatory reporting'.)
Physical examination — Any concern for child neglect warrants a thorough physical examination with specific attention to the following:
●Hygiene and clothing – Neglected children may be dirty. Clothing is often in poor condition and may be inadequate (eg, the wrong size or lack of warm clothing in the winter).
●Nutritional status – Is the child hungry? This may or may not be associated with neglect depending on the time of day and the last time the child has eaten, but an important part of the examination is asking the child about hunger and their last meal. Next, an assessment of overall nutritional status is important. Ideally, nutritional status includes review of prior growth charts, but at a minimum it includes height, weight, weight-for-height or body mass index (BMI), and, in children younger than two years of age, head circumference. A child who is under- or overnourished may have concerns for nutritional neglect and need further medical evaluation for associated complications such as refeeding syndrome with starvation or inadequate nutrition, or for diabetes and obstructive sleep apnea with overnutrition or obesity [8]. (See "Laboratory and radiologic evaluation of nutritional status in children".)
In extreme cases, malnutrition may present with the manifestations of marasmus (eg, emaciated and weak with thin, dry skin, poorly healing wounds, and thin, sparse hair) or kwashiorkor (eg, edema, loss of muscle mass, enlarged abdomen); listless affect, hepatomegaly, distended abdomen, and peripheral pitting edema. (See "Malnutrition in children in resource-limited settings: Clinical assessment", section on 'Marasmus' and "Malnutrition in children in resource-limited settings: Clinical assessment", section on 'Kwashiorkor (edematous malnutrition)'.)
●Hair – Hair loss can result from inadequate nutrition, inadequate attention to infection (eg, tinea capitis), or intentional hair pulling (physical abuse) and can lead to significant alopecia. Lice infestation may represent lack of appropriate medical care (eg, secondary infection from prolonged scratching) but may reflect a lack of access to resources (eg, inability to purchase needed medical treatment).
●Mouth – Multiple caries or dental abscesses suggest inadequate dental health care (irregular or absent tooth brushing, no regular dental visits and/or inadequate follow-up of identified early childhood caries, also known as bottle caries) [22].
●Skin and nails – In addition to signs of malnutrition mentioned above, skin manifestations of neglect include:
•Multiple scars from past injuries (lacerations, abrasions, or burns) due to inadequate supervision
•Unmanaged infections including scabies, impetigo, abscess, or cellulitis
•Skin ulcers in children with limited mobility who are confined for long periods of time.
•An absence of normally expected bruising (eg, shins, bony prominences) in ambulatory children may also be due to confinement
•Marked diaper dermatitis
•Cracked, thin, or ridged nails from malnutrition
•Missing finger or toenails from past injuries due to inadequate supervision
Neglected children may also have findings of physical abuse such as suspicious bruising, burns, or oral injuries (table 3). (See "Physical child abuse: Recognition", section on 'Red flag physical findings'.)
Ancillary studies — Additional laboratory studies and diagnostic imaging will be based upon the child's presentation, physical examination findings, nutritional status, and type of neglect concern.
For nutritional neglect, additional testing is determined by the specific concern; undernutrition (failure to thrive) or overnutrition (obesity) and the severity of the presentation. In children with failure to thrive or malnutrition, additional testing should be based upon history and physical examination findings as well as the risk for refeeding syndrome and medical complications. (See "Poor weight gain in children younger than two years in resource-abundant settings: Etiology and evaluation", section on 'Diagnostic evaluation' and "Laboratory and radiologic evaluation of nutritional status in children".)
Children with overnutrition (obesity) may also need testing for medical complications such as hyperlipidemia, diabetes, and fatty liver disease. In both obesity and failure to thrive from inadequate nutrition, children may benefit from testing for nutrient deficiencies such as iron and vitamin D. (See "Laboratory and radiologic evaluation of nutritional status in children" and "Clinical evaluation of the child or adolescent with obesity", section on 'Routine blood tests'.)
Child neglect and physical abuse often coexist. The laboratory and radiographic evaluation of abusive head trauma and physical child abuse is provided separately. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Evaluation' and "Physical child abuse: Diagnostic evaluation and management".)
DIAGNOSIS — Child neglect is a clinical diagnosis based upon the medical history, including a detailed psychosocial assessment, and physical findings supplemented, as needed, by targeted ancillary studies. (See 'Evaluation' above.)
When making the diagnosis, key factors include [5]:
●Evidence of harm or concern for imminent harm to the child caused by a caregiver's action or failure to act.
●Type, severity, and frequency of the neglect (eg, minor injury or no harm while the caregiver was briefly distracted versus significant or repetitive injury [fractures, burns, lacerations, or drowning] only explained by prolonged or repeated episodes of caregiver inattentiveness).
●Suspicion for associated physical, sexual, or emotional abuse.
●In cases of medical neglect, continued deterioration in the child's condition despite attempts to educate and fully engage the family regarding necessary care and the importance of adherence to scheduled visits, testing, and recommended therapy.
●The balance of risk factors for continued neglect versus the ability to provide protective factors or resources that can mitigate these risk factors and prevent neglect. (See 'Psychological assessment' above.)
Identifying child neglect can be challenging because it often results from caregiver inaction rather than caregiver infliction of physical or sexual abuse. Consultation with a multidisciplinary child abuse team and child abuse specialist can be helpful when the clinician is uncertain about the diagnosis.
DIFFERENTIAL DIAGNOSIS — The comprehensive medical history and physical examination supplemented by a psychosocial assessment or risk factor screening, appropriate ancillary studies, and the input of a multidisciplinary team can build an appropriate differential diagnosis and effective treatment plan with the caregiver.
●Social determinants of health – Social determinants of health, including poverty, food insecurity, housing insecurity [23], and lack of affordable child care, are major elements to be differentiated from physical or supervisory neglect when determining the proper management. The psychosocial assessment is an important tool to help the health care provider determine the next steps.
The following scenarios provide examples of how key factors in the history help to identify social determinants of health and child neglect:
•A child consistently presents to clinic looking unkempt and wearing clothes that appear to be dirty. The child often states that he is hungry and asks for a snack.
-Social determinants – After further evaluation and assessment, you learn that the primary caregiver has lost their job, has been unable to pay rent, and has been "couch hopping." For this family, the clinician can talk with the primary caregiver about community resources such as homeless shelters, food pantries, and clothing distribution centers. Whenever possible, connecting the family to a social worker would be a key step in addressing these ongoing needs.
-Child neglect – After further evaluation and assessment, you learn that parent is struggling with substance abuse issues and that they recently lost their job and apartment due to drug use. The parent informs you that they had been in recovery for six months, but that they recently relapsed. They state that they have spent all money on drugs. While this is also a good time to talk with parent about resources, particularly for substance use treatment, it would also be warranted to make a report to child protective services.
•When a child presents to clinic, you notice that they have missed three appointments with a specialist.
-Social determinants – After further evaluation and assessment, you learn that the parents' car recently broke down and that they have no transportation. They tell you that they have tried to find rides but not been successful. This visit would be a good opportunity to talk with the parents about community resources to assist with transportation.
-Child neglect – You learn that they missed the appointments because they were scheduled too early in the morning and parents/primary caregivers do not like to wake up early. This visit would be a good time to talk with the family about the importance of the medical appointments and the potential consequences if their child does not get medical care from the specialist. If this behavior continues, a report to CPS would be warranted.
•A parent comes to clinic with their eight-year-old child for a well-child visit. The child, when asked if she feels safe, states "no."
-Social determinants – You learn that the child is often home alone for several hours in the evening when the parent works due to lack of access to childcare after hours. This situation may represent a struggling single parent's/primary caregiver's limited resources and job requirements without a safer alternative for childcare while they work. In some jurisdictions, this situation will require a report to child protective services. However, this is a good opportunity to talk with the parent/primary caregiver about family and community resources to assist with childcare.
-Child neglect – The child reports not feeling safe has been caring for herself and three younger siblings while the caregiver stays out all night with friends at parties. The child reports worrying about strangers coming to the door and also says she hides with her siblings while the caregiver is out. This is demonstrating supervisory neglect and would require a report to child protective services.
●Failure to thrive – In children with failure to thrive, the presence of findings for possible child neglect can create a cognitive bias that prevents the identification of underlying medical illnesses. By definition, failure to thrive always involves inadequate nutritional intake, which negatively impacts normal growth. However, in addition to psychosocial assessment of the family, the cause of failure to thrive requires careful evaluation and may require supportive studies or specialty consultation to evaluate for medical illness including inflammatory bowel disease, metabolic disease, or other medical conditions. (See "Poor weight gain in children younger than two years in resource-abundant settings: Etiology and evaluation", section on 'Evaluation'.)
●Other medical disease – Just as child abuse and neglect can be underrecognized and identified, the presence of findings of possible child neglect and even the identification of risk factors on the psychosocial assessment can create additional anchoring bias such that medical diseases that may mimic neglect are not considered. Perhaps the child does not have extensive skin infection from untreated scabies but instead has severe eczema, an undiagnosed generalized skin condition such as guttate psoriasis, or an immune disorder. At the same time, it is important that medical providers entertain a broad differential diagnosis when evaluating children and also remember that neglect and medical disease may coexist.
INDICATIONS FOR CHILD ABUSE TEAM CONSULTATION — Consultation with a child abuse team, whenever available, is warranted if the medical care provider is not sure about assessment or diagnosis of child neglect or if, after full evaluation, the provider suspects that child neglect has occurred.
MANAGEMENT — Partnership with caregiver(s) is crucial to the development of a multidisciplinary approach. Caregivers rarely intend to harm the child. The provider should convey concern to the caregiver about the child's overall health and development, wellbeing, and safety. After assessment of barriers (risk factors) and strengths (protective factors), a treatment plan should be developed that engages the caregiver and includes measurable outcomes. This should be written in conjunction with the caregiver after assessing the caregiver's literacy level and signed by the provider and caregiver [5].
Health care professionals should always take into account their duty to report suspected maltreatment to child welfare services, especially when harm is involved, interventions have been attempted and have failed, and there is concern for other types of abuse [5]. Typically, a report must be made when the reporter, in his or her official capacity, suspects or has reason to believe that a child has been abused or neglected [6]. In many parts of the world, this reporting is mandatory. (See "Child abuse: Social and medicolegal issues", section on 'Mandatory reporting'.)
Ensure child safety — The health care team must first make a determination as to whether the child is being adequately supported by the caregiver such that voluntary interventions are appropriate or, because of harm that has already occurred or is very likely to occur, a report to child protection services is needed. (See 'Notification of child protective services' below.)
Indications for hospitalization — The need for hospitalization in the neglected child is dependent upon presentation, history, physical examination findings, and the presence of concomitant injuries. Hospitalization may be warranted for the treatment of certain medical conditions (eg, failure to thrive, starvation/malnutrition, poisoning, burns, near-drowning, or exacerbation of chronic medical disease).
Hospitalization may also be indicated for the safety and discharge planning of the child in the following situations:
●The caregiver is unable to assume responsibility for the child and safe, temporary placements are otherwise unavailable (child protective services may also need to be involved, depending upon the circumstances) (see 'Notification of child protective services' below):
•Caregiver injured or hospitalized
•Caregiver needs inpatient hospitalization for mental health needs (eg, depression)
•Caregiver presents with altered mental status, intoxication, or overdose
●The response of child protective services or other community agency will be delayed, and the child cannot be safely discharged to the caregiver.
●Neglect appears chronic with imminent risk of harm.
●For further evaluation in a protective environment by knowledgeable consultants (if such specialized services are not available in the community).
●For detailed observations of caregiver-child interaction by medical, nursing, social services, and behavioral staff.
Education and documentation — When medical neglect is a concern, the health care provider should make sure that, the treatment plan is simplified, practical, and clearly communicated to the caregiver verbally and documented in written instructions. The caregiver should be able to express an accurate understanding of the medical disease, potential complications, and the purpose and outcomes of therapy.
Follow-up appointments should be scheduled and the caregiver provided with verbal and written indications to seek medical attention before the follow-up appointment [15]. Discharge planning, whether from a hospitalization or from an emergency department setting, should also include arrangement of appropriate resources or referrals to minimize barriers to caregiver adherence to the treatment plan. Key resources may include health insurance, supplemental nutrition programs, and transportation assistance for travel to medical appointments. However, they may also more broadly encompass access to housing, community services, and early childhood education.
The health care provider should provide support and arrange for follow-up (by telephone, office visit, or visiting nurse) to review progress and adjust the treatment plan, if necessary.
Assemble a multidisciplinary team — The management of child neglect is enhanced through the use of multidisciplinary teams, which at minimum should include the medical provider and a social worker. Due to the complexity of managing care for children with special health care needs, this approach may expand to include multiple subspecialists, therapists, and case managers. The team should be led by the child’s medical home or primary medical provider to facilitate optimal communication and use of subspecialty referrals and to minimize redundancy in medical services and appointments as well as missed appointments. The team approach provides multiple perspectives to better identify the presence or risk of harm to the child and to determine if the threshold for reporting has been reached. (See 'Notification of child protective services' below.)
In addition, a multidisciplinary team can better identify ways to prevent harm through proactive provision of resources and reduction of barriers that impede the caregiver's efforts to provide a nurturing environment for their child.
Engage the caregiver — The treatment plan and education should be provided to the caregiver at the caregiver's knowledge and literacy level. Access to age-appropriate community services and resources should be provided such as referral to a social worker, early childhood intervention programs, nutritionist, mental health services, or visiting nurse. Caregivers may need assistance in accessing financial resources such as supplemental nutritional programs, health care insurance programs, or Supplemental Security Income (SSI). In some situations, a referral to child protective services may be the only way to assess the safety of the home and to address substance use and mental health needs of caregivers.
NOTIFICATION OF CHILD PROTECTIVE SERVICES — If the medical care provider continues to have concerns about child neglect after the assessment is completed or if other forms of abuse such as physical or sexual abuse are evident, then consultation with a child abuse team, if available, is warranted. Furthermore, the provider should report their suspicion for child abuse or neglect to the appropriate governmental agency. In many parts of the world, this reporting is mandatory. (See "Child abuse: Social and medicolegal issues", section on 'Mandatory reporting'.)
Because child neglect encompasses both actual and potential harm and can be attributed to factors related to the child, caregiver, community, or resources, it is sometimes difficult to know when to involve Child Protective Services (CPS). The author's guidelines for reporting child neglect include, but are not limited to, the following:
●Child at risk of imminent harm
●Significant trauma or serious medical illness caused by the caretaker's failure to provide appropriate supervision or treatment
●Continuing neglect despite removing barriers, offering resources and support, and providing necessary education
●Gross failure to provide adequate food, shelter, clothing, protection, or education
When reporting suspected child neglect or abuse, photo-documentation is warranted to substantiate physical injuries (eg, bruises, abrasions, patterned injuries, burns), the child's appearance and hygiene, nutritional status, skin condition (including wounds, infections, ulcers), and the condition of the child's indwelling medical equipment. A general rule of thumb is to take an image of the child's name, date of birth, and medical record number (eg, medical label), followed by (1) images of the child's face and body (to document appearance and age at the time of the medical visit) and (2) images of the areas of concern with a ruler. (See "Child abuse: Social and medicolegal issues", section on 'Photographs'.)
Religious objections to medical care — The American Academy of Pediatrics (AAP) recommends that clinicians respect parental religious beliefs and the role of parents in rearing their children, and seek to make collaborative decisions with families whenever possible [24]. However, in circumstances in which the clinician believes that parental religious convictions interfere with appropriate medical care that is likely to prevent substantial harm, suffering, or death, the medical professional should consult with hospital legal services or risk management and request court authorization to override parental authority, or, under circumstances of imminent threat to a child's life intervene over parental objections [24]. In many jurisdictions, legal statutes support this approach but typically require that the medical professional provide sufficient evidence that, in the judgement of the professional, there is a risk to the minor's life or health and that the requirements of consent would result in a delay or denial of treatment. When faced with this situation, the medical professional should also consult with their hospital risk management for additional guidance. A report to child protective services (CPS) is also indicated.
If the need for treatment is not as immediate, the medical professional should contact hospital risk management, ensure a psychosocial assessment occurs, and consider a referral to child protective services (CPS) as temporary custody and/or court orders may also be needed for treatment.
Most states have exemptions to the child neglect laws for religious objection to medical care [24,25]. However, the AAP views such exemptions as potentially harmful to children and advocates that all children, regardless of parental religious beliefs, deserve effective medical treatment when such treatment is likely to prevent substantial harm, suffering, or death [24]. In one review of 172 childhood fatalities associated with religion-motivated medical neglect, all but three of the cases would likely have had some benefit from clinical help [25]. In 140 cases (81 percent), the deaths were due to conditions for which survival rates with medical care would have exceeded 90 percent; in another 18 cases (10 percent), the expected survival rates would have been >50 percent.
SEQUELAE — Although the impact of child neglect may not seem as obvious as physical or sexual abuse, the consequences of child neglect are just as serious [6]. Child neglect has a negative impact on all domains of child development: physical, cognitive, emotional, and social. Observational evidence also indicates that, similar to victims of physical and sexual abuse, neglected children demonstrate signs and symptoms of posttraumatic stress disorder [26]. During childhood, child neglect is associated with serious effects on emotional learning, behavior, caregiver-child interaction, and academic performance [27,28], as well as high-risk behavior and criminal activity in adolescence [29-31].
Neglect appears to predict negative outcomes in adulthood as well. For example, longitudinal studies of adults with adverse childhood experiences, including child abuse and neglect or being exposed to violence, mental illness, suicide, or substance abuse by members of the household have found that such adverse experiences are associated with serious health conditions (eg, heart disease, chronic lung disease, obesity, cancer, and depression) and, on average, a shorter life expectancy [32-34].
Child neglect can lead to childhood traumatic stress, the intense fear and stress response occurring when children are exposed to potentially traumatic experiences that overwhelm their ability to cope with what they have experienced [35]. Symptoms of childhood traumatic stress include difficulty with sleep, hypervigilance, intrusive thoughts, and changes in mood and cognition. Some may also experience suicidal ideation and/or suicide attempts. When working with children who have experienced neglect, consider screening them for symptoms of trauma and suicidal ideation by using tools such as the PTSD Reaction Index Brief Form [36] or the recently developed Pediatric Traumatic Stress Screening Tool in the Intermountain Care Process Model [37]. Identifying childhood traumatic stress allows us to recommend trauma-focused therapeutic services to children and adolescents [38].
ADDITIONAL RESOURCES — The National Clearinghouse on Child Abuse and Neglect provides additional information and resources regarding prevention, management, and statutes regarding the reporting of child abuse and neglect (table 4).
The following tools may be useful for psychosocial risk factor screening:
●Adverse childhood experiences questionnaire
●Safe environment for every kid (online training) [21]
●Social needs screening toolkit (screening for social needs including housing and food insecurity)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Child abuse and neglect".)
SUMMARY AND RECOMMENDATIONS
●Definitions – Child neglect refers to any action or failure to act which causes serious physical or emotional harm or death or puts the child at imminent risk for such harm. Specific types of neglect include physical, supervisory, emotional, educational, nutritional, dental, and medical neglect. (See 'Definitions' above.)
●Clinical presentation – The manifestations of child neglect include any or all of the following (see 'Clinical presentations' above):
•Undernutrition or overnutrition
•Poor hygiene of child's body, clothes, or diapers
•Severe, untreated dental caries
•Injuries due to exposure (eg, frostbite, hypothermia, or heat illness)
•School truancy
•Injuries caused by lack of supervision (eg, ingestions, burns, near-drownings, or other "accidental" injuries)
•Lack of adherence to medical treatment plans with serious or life-threatening exacerbation of chronic health conditions in the child
•Inappropriate delay in seeking medical care for a seriously ill or injured child
●Evaluation – Proper evaluation for child neglect in the primary care setting requires a careful medical history, including psychosocial screening and assessment for risk factors for neglect (table 1), and a physical examination focused on findings that suggest neglect or abuse. (See 'Medical history' above and 'Psychological assessment' above and 'Physical examination' above.)
For patients in emergency or urgent care settings, evaluation for neglect may need to be tailored to the presenting injury or medical disease as well as the concern for abuse or neglect. This concise approach includes:
•History of current presentation and review of systems
•Past medical history of chronic health conditions
•Medications (dose and knowledge of administration)
•Nutrition
•Development (important for assessment of injury and supervision)
•Family medical and social history.
Whenever possible, social work assessment and discussion with the primary care provider can be invaluable to identify psychosocial risk factors and, based upon caregiver resources and barriers to care, to clarify further the level of concern for neglect. (See 'Children seeking urgent or emergency care' above.)
●Diagnosis – Child neglect is a clinical diagnosis based upon a careful history, psychosocial assessment, physical examination, and, when appropriate, ancillary studies. Identifying child neglect can be challenging because it often results from caregiver inaction rather than caregiver infliction of physical or sexual abuse. Consultation with a multidisciplinary child abuse team and child abuse specialist can be helpful when the clinician is uncertain about the diagnosis and is warranted, whenever available, for all cases where child neglect is identified. (See 'Diagnosis' above and 'Indications for child abuse team consultation' above.)
●Differential diagnosis – Child neglect must be differentiated from social determinants of health including poverty, food insecurity, housing insecurity, and lack of affordable childcare. In addition, the clinician must differentiate neglect from medical illnesses that may impact growth and development. (See 'Differential diagnosis' above.)
●Management – Once neglect is diagnosed, the health care team must first make a determination as to whether the child is being adequately supported by the caregiver such that voluntary interventions are appropriate or, because of harm that has already occurred or is very likely to occur, a report to child protective services (CPS) is needed. In addition, the team should determine if hospitalization is needed for medical treatment or to prevent further harm to the child. (See 'Ensure child safety' above and 'Indications for hospitalization' above.)
Because child neglect encompasses both actual and potential harm and can be attributed to factors related to the child, caregiver, environment, or resources, it is sometimes difficult to know when to involve CPS and other appropriate government agencies. The author's guidelines for reporting include, but are not limited to, the following (see 'Notification of child protective services' above):
•Child at risk of imminent harm
•Significant trauma or serious medical illness caused by the caretaker's failure to provide appropriate supervision or treatment
•Continuing neglect despite removing barriers, offering resources and support, and providing necessary education
•Gross failure to provide adequate food, shelter, clothing, protection, or education
The management of child neglect is enhanced through the use of multidisciplinary teams, which at minimum should include the medical provider and a social worker with a medical home provided for children with special healthcare needs. (See 'Assemble a multidisciplinary team' above.)
Partnership with caregiver(s) is crucial to the development of a multidisciplinary approach. Caregivers rarely intend to harm the child. The provider should convey concern to the caregiver about the child's overall health and development, well-being, and safety.
A treatment plan should be developed that engages the caregiver and includes measurable outcomes. This plan should be written in conjunction with the caregiver at the caregiver's literacy level and signed by the provider and caregiver. (See 'Assemble a multidisciplinary team' above and 'Engage the caregiver' above.)
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