PREVENT CHILD ABUSE AMERICA
www.preventchildabuse.org
By Anne Reiniger, M.S.W., J.D.*
Summer/Fall 2004 Articles Section Editor

Editor's Note: The mission of Prevent Child Abuse America (PCAAmerica) to prevent the abuse and neglect of our nation's children. This issue of Perspectives on Youth is designed to provide information to professionals and the general public about various issues we are addressing and the reason why preventing child abuse is so important. Each year an estimated three million cases of suspected child abuse and neglect are reported to Child Protective Services agencies. More than three children die each day in America from child abuse and neglect. There is no disease or natural disaster or trauma that is killing more children under the age of four than abuse and neglect.

The authors of these articles are professionals who staff PCAAmerica and who have devoted their careers to this worthy cause.

The first article Overview of Child Neglect: Theory, Research & Practice by Drs. John Holton and Domarina Oshana describes the scope of the problem, including the definition of neglect, the types of neglect, contributing factors to neglect, characteristics of neglected children and families, consequences of neglect, and the implications for research in our goal to eliminate child neglect in our society.

The article Total Estimated Cost of Child Abuse and Neglect in the United States by Suzette Fromm, presents the first attempt to document the nationwide costs resulting from abuse and neglect: both direct-costs associated with the immediate needs of abuse or neglected children and indirect-costs associated with the long term or secondary effects of child abuse and neglect.

The article Reframing Child Abuse and Neglect Prevention by Kevin Kirkpatrick addresses the concern that although child abuse and neglect kills nearly 1,000 children every day, the issue has never become a public policy priority. This article describes strategic reframing of child abuse prevention to identify a more effective strategy for communicating about and advocating on behalf of child abuse and neglects prevention, including various hypotheses to engage the general public and raise the public policy makers interest in preventing child abuse.

The article The Role of Pediatricians in Child Abuse Prevention by Julie Rowe describes the important role pediatricians play in preventing child abuse and the training, the barriers they face and how these challenges can be overcome.

The article Dynamite Dads for Dynamic Children, Families and Communities by Lori Friedman, describes the Healthy Families America home based child abuse prevention program and the effort to include fathers in this service. She highlights a site in Florida that has incorporated a fatherhood program in its service and the benefits it provides to the entire family.

The article Partners for Kids Creating a Continuum of Parent Support in Your Community by Laura Galbraith and Michelle Freeman describes two research based programs that increase parent participation: Circle of Parents and Healthy Families America and the importance of collaboration as a means of assuring successful programs.

We hope that this issue will provide you with a understanding of the various aspects of child abuse prevention and the work of PCAAmerica and will encourage you to learn more about this important and complex issue and join forces with us ensure that every child can grow up in a safe and secure home without suffering from the torment of child abuse and neglect.

*Anne Reiniger is the chairwoman of the Board of Prevent Child Abuse America and former Executive Director of The New York Society for the Prevention of Cruelty to Children.

For site visitors who wish to click on a specific article, you can click on the article's title. If you prefer, you may scroll down to read all articles at once.

Total Estimated Cost of Child Abuse and Neglect In the United States
By Suzette Fromm, Ph.D., Vice President of Planning,
Program Evaluation and Quality Improvement, ChildServ

Reframing Child Abuse & Neglect for Increased Understanding & Engagement: Defining the Need for Strategic Reframing
By Kevin T. Kirkpatrick, MS, Vice President, Marketing,
Communications and Advancement, Prevent Child Abuse America

The Role of Pediatricians in Child Abuse Prevention
By Julie Rowe, MA, Manager of Communications, Prevent Child Abuse America

Dynamite Dads For Dynamic Children, Families and Communities
By Lori Friedman, MPH, Healthy Families America Research Liaison,
Prevent Child Abuse America

Partners for Kids...Create a Continuum of Parent Support in Your Community
By Laura Galbraith, MA, State Systems Coordinator, Healthy Families America
and Michelle Freeman, Intern, Healthy Families America

	If you prefer to read this article separately from the other articles listed in this section, please

Overview of Child Neglect:
Theory, Research, and Practice
By John K. Holton*, Ph.D., Acting President and CEO, Prevent Child Abuse America
and Domarina Oshana**, Ph.D., Acting Vice President, Research Prevent Child Abuse America

SCOPE OF THE PROBLEM
Child Neglect-Standing alone or written by itself, the word neglect carries a bland, if not, innocuous insinuation of need or forgetfulness. Seemingly in need of an adjective to dramatize its meaning, as in "benign" or "willful," the neglect of children is a serious social problem in the United States. Unlike the word "abuse," which portrays negative images of physical interactions between an adult caregiver and child that feature maliciousness, anger, hostility, and pain, neglect connotes a less serious, perhaps non-intentional form of maltreatment. Nothing could be further from the truth. Neglect is an "act of omission" or the failure of the responsible adult to care for children. Neglect is just as detrimental for children and can be more harmful than physical or sexual abuse. It can be intentional and calculated or chronic and unintentional. Its power to harm children is its mechanism of delivery, that is, neglect, like water slowly eroding the foundation of a building, often goes unnoticed and unrecognized by other adults. When identified, its impact is difficult to overcome and a neglected child continues to suffer well into adulthood. When fatal child maltreatment occurs, neglect is a substantial contributing factor (Trocme (4) & Lindsey, 1996).

Combining the different types of neglect (physical, medical, educational, and emotional) into one aggregated figure, neglected children make up the majority of both child maltreatment reports and substantiations to child protective services (CPS) in the United States (U.S. Department of Health and Human Services [DHHS], 2000). According to national data collected from each state, the estimated total for neglected children reported in 1999 was 1,654, 000 or approximately 51% of all child maltreatment reports and 45% of all substantiated reports or 482,000 children (Peddle & Wang, 2001). Further, from 1995 to the present, neglected children have produced the majority of reports and substantiations of child maltreatment in the United States (U.S. Department of Health and Human Services [DHHS], 2001). As compelling as these data are, they only capture cases of child maltreatment that have been identified to states.

In an effort to better measure the incidence of child maltreatment, a national survey, periodically conducted on behalf of the U.S. Congress by the Office of Child Abuse and Neglect (OCAN), not only gathers information from child protective services (CPS) staff who work with "harmed" children but also "sentinels" or individuals whose work involves children who may be harmed or endangered. Sentinels are staff in "law enforcement, public health, juvenile probation, hospitals, schools, day-care, mental health, and voluntary social service" (Sedlak & Broadhurst, 1996, p. 1-5). When examining the latest survey results (three national incidence studies were completed between 1979 and 1995), the rate of neglected children increased faster and harmed more children than any other category of child maltreatment (Sedlak & Broadhurst). If both categories of harm and endangerment are combined for neglect, children today are more than two times as likely to be neglected than they were ten years ago, a surprising finding given the 1990 decade of unprecedented prosperity in the United States.

Definition of Neglect
Child neglect is a paradox. It claims the most victims but is the least understood form of child maltreatment in the United States. One explanation for this is that neglect is difficult to define and consequently, identify. Unlike physical abuse where the scars are clearly visible, neglect is a form of maltreatment that sometimes is invisible. As an act of omission, neglect is the absence of a parenting action.

Neglect can be defined in two parts-the harm received and the person(s) responsible (Gough, 1996). More specifically, neglect is the failure of a child's primary caregiver to provide adequate food, clothing, shelter, supervision, education, emotional support, and medical care. However, one pitfall of this definition is delineating adequacy. Both legal and research professionals question not only the meaning of "adequacy" but its context as well. Consequently, in addressing the problem it is important to understand what it is, who is affected, what the consequences are, and what can be done about it.

Major Issues in Defining Neglect
In a review of recent definitions of child neglect, Zuravin (1999) found that the most common method of measuring neglect was by use of the label applied by official agency personnel (i.e., substantiated for neglect). This method requires that the definition of neglect meets certain operational criteria (i.e., clearly defined measures) or uses some instrument that describes neglect in great detail.

Another major issue in defining neglect is context. Garbarino and Collins (1999) imply that child neglect is the failure to meet social judgment about minimal standards of care. They assert that these standards are a reflection of culture and community values or contexts that evolve and change. The standards assume that children have basic needs that must be met. These needs involve that a child is being physically cared for (i.e., making sure the child is properly fed and clothed), that a child is allowed to learn and thrive, and that a child is treated well emotionally. The difficulty in coming to a universal standard is how we define these basic needs to take into account not only community and professional standards, but also standards that are relevant across cultures while keeping in mind the centrality of the child's basic needs.

Legislative Definitions
While there are a number of legal and practice definitions of child neglect, it is important to note that there is no one universal legal or practice definition. According to the Federal Child Abuse Prevention and Treatment Act (CAPTA),

"The term 'child abuse and neglect' means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm" (42 U.S. C.A. §5106g (2) (West Supp. 1998) (as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001).

This legal definition is considered to be the minimum standard by which each State provides its own definitions of child abuse and neglect. Three places in State statutes that define child abuse and neglect include: 1) reporting laws for child maltreatment; 2) criminal codes; and 3) juvenile court statutes (U.S. Department of Health and Human Services [DHHS], n.d. [a]).

In State reporting laws, neglect is often defined as deprivation of adequate food, clothing, shelter, or medical care (DHHS, n.d. [a]). What contributes to the difficulty of identifying neglect, however, is great variation among the States in the explicit specification of their definitions. Approximately one-fifth of the States do not define neglect separately from abuse. Among States that define neglect separately, some also define specific types of neglect, such as abandonment or medical neglect. Additionally, a number of States address related issues in their statutes such as parental incapacity (i.e., parent is hospitalized or incarcerated) or injurious environments (i.e., child is exposed to criminal activity in the home). In most States, exemptions or issues to be taken into consideration, including religious exemptions for medical neglect and financial considerations for physical neglect are specified (DHHS, n.d. [a]). The National Clearinghouse on Child Abuse and Neglect Information provides a complete list of all States' reporting laws and definitions of child abuse and neglect (Available online: http://www.calib.com/nccanch/pubs/stats01/define/index.cfm).

Research Definitions
Among researchers, there is no consensus on a conceptual or operational definition of neglect. This lack of agreement not only makes it difficult to compare findings across studies, it also complicates the application of findings to practice (Black & Dubowitz, 1999). Another major issue that lacks consensus among researchers is the measurement of neglect. Researchers have used a variety of methods to measure neglect including observations of the home, behavioral criteria, medical history, self-report measures, interviews, case record abstractions, CPS case findings, and structured experiments (Black & Dubowitz; Zuravin, 1999).

For researchers, identification of behaviors or conditions that are considered "neglectful" is crucial to defining and measuring neglect. Some behaviors that appear universally classified as neglect include: inadequate nutrition, clothing, or hygiene; inadequate medical, dental, or mental health care; unsafe environments; inadequate supervision, including use of inadequate caregivers; and abandonment or expulsion from the home (Barnett, Manly, & Cicchetti, as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001; Sedlak, Hantman, & Schultz, 1997). However, it is important to note that there are a number of classification systems and each may categorize behaviors differently from the other. Two widely known classification systems are the Third National Incidence Study of Child Abuse and Neglect (NIS-3) (Sedlak & Broadhurst, 1996) and the Maltreatment Classification System (MCS) developed by Barnett, Manly, and Cicchetti (1993) (as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001). In the NIS-3, exposure to drugs in utero is categorized as "other maltreatment" while in the MCS it is categorized as "physical neglect-failure to provide." Exposure to or allowing a child to engage in illegal activities is another example of how differently behavior is categorized in these two systems. Specifically, in the NIS-3 this behavior is classified as "emotional neglect" while in the MCS it is considered "moral-legal/educational maltreatment."

Other considerations in the definition of neglect include questions regarding evidence of harm and intent to harm. Is evidence of harm required or does neglect include endangerment of a child's health or welfare? Stated differently, should definitions of child neglect be broad or narrow? Should definitions be general or precise? For example, should definitions be restricted to clear instances of serious physical harm? Should they encompass neglect incidents of emotional harm, or should they include all acts that jeopardize the development of children? And, should the caregiver's intent to harm be considered? Such questions are but a mere taste of the definitional debates around a number of issues impeding the development of a well-operationalized (i.e., well measured), standard definition of neglect.

Types of Neglect
As defined in this entry, neglect is an act of omission by the caregiver to meet a child's basic needs resulting in harm or a threat of harm to the child. The primary goal is to focus on the basic needs of the child and to protect the child from harm (actual and potential), not to blame caregivers. Given this definition, it is understood that neglectful conditions are not always due to omissions by caregivers alone but may be due to other factors, such as lack of community resources to support parents in their efforts to provide children with adequate care and guidance. In determining adequacy of care, it is important to consider that a child's basic needs may not be met in many different ways including circumstances such as the following: inadequate supervision, inappropriate substitute child care, abandonment, instability of living arrangements, failure to receive needed health care, abandonment, inattention to personal hygiene, inattention to household sanitary conditions, inattention to household safety, presence of hazardous physical conditions in the home, inattention to nutritional needs, inadequacy of clothing, witnessing violence, permitting drug or alcohol use (or both), permitting other maladaptive behavior, inadequate nurturance or affection, isolation, inattention to mental health care needs, and inattention to educational needs (DePanfilis, 1999).

Conceptually, it is important to note that defining neglect depends in part on the purpose for which the definition is used. For example, legal advocates require clear evidence of serious harm to a child before proceeding to court intervention to remove a child from parents. In contrast, for caseworkers intervening with a family to protect the child from further harm, the definition of neglect is defined as parental acts of omission in care that are likely to increase the risk of harm to the child. And, in studying the long- and short-term consequences of neglect, researchers define neglect as parental behaviors that result in harm to the child. Recognizing this variability of definitions is critical to understanding that there is no universal definition of neglect. Moreover, these differences in defining neglect highlight the challenges posed in research, practice, and policymaking.

To overcome the problem of non-uniform definitions of child neglect, the U.S. Department of Health and Human Services' study on the National Incidence on Child Abuse and Neglect (Sedlak & Broadhurst, 1996) used a standard definition of neglect. The definition included physical neglect, child abandonment and expulsion, medical neglect, inadequate supervision, emotional neglect and educational neglect by parents, parent substitutes, and other adult caretakers of children.

Important Areas for Professional Attention
Chronic neglect is an important issue in defining neglect because as opposed to "incidents" of neglect, chronic neglect refers to a pattern of behavior. It is suggested that rather than focusing on individual incidents that may or may not be classified as "neglectful," an accumulation of incidents that may together constitute neglect must be considered. For example, a pattern of behavior that might constitute neglect might include frequent reports of not having enough food in the home or keeping older children home from school to watch their younger siblings. Complicating this matter is that in most CPS systems, the criteria for identifying neglect focuses on recent, discrete, verifiable incidents rather than a repeated pattern of neglectful behavior.

Although there is no standard definition of death due to neglect, it is usually defined as death due to caregiver failure to provide for a child's needs adequately, supervise a child, or intervene to protect a child from harm. With increased recognition of the role that neglect plays in child fatalities, the lack of a clear definition obstructs estimation of incidence and prevention efforts. Complicating the matter is incomplete information on the circumstances of deaths, a death classification system that inaccurately categorizes neglect-related deaths, and a lack of expertise on the part of those investigating child deaths. To mitigate this problem, investigation and evaluation of child deaths should be approached comprehensively through assessment of all factors involved in the death, not just caregiver responsibility. Based on this information, appropriate prevention efforts may be identified and implemented (Bonner, Crow, & Logue, 1999).

CONTRIBUTING FACTORS TO NEGLECT
Factors that contribute to neglect are multiple, cumulative, and complex (National Research Council, 1993). In the majority of circumstances, neglect is caused by a combination of personal deficits in parents, non-supportive family systems, highly stressful life circumstances and absence of environmental supports for parenting (Gaudin, 1993). Below is a summary of three key contributors to child neglect.

Substance Abuse and Child Neglect
The relationship between parental substance abuse and child neglect is becoming increasingly evident. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in the U.S., there are more than 6.6 million children under the age of 18 living in alcoholic households and an additional number of children living in households where parents have problems with illicit drugs. Among some CPS agencies, it is estimated that substance abuse is a factor in as much as 70 percent of all cases they serve (Gaudin, 1993). Further, research suggests that neglect is a major factor in the removal of a child from a home in which parents have alcohol or other drug problems (Prevent Child Abuse America, n.d. [a]).

The extent of the relationship between parental substance abuse and child neglect has been well documented. Magura and Laudet's study found that for substance abusing parents their ability to maintain employment is affected (as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001). Moreover, substance-abusing parents may redirect money needed for basic necessities to buy drugs and alcohol (Munkel, as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001). Parents who abuse drugs heavily are shown to have inadequate nurturing and caregiving skills (Zuckerman, as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001). Munkel also found that exposure to criminal behaviors and dangerous people is likely among children who live with parents who abuse substances. The likelihood that they will become intoxicated is also greater, regardless of whether their drinking was deliberate, passive or accidental.

The relationship between parental substance abuse and neglect has also been documented in studies on newborns. Recent statistics from the National Institute of Drug Abuse Statistics indicate that 5.5 percent of pregnant women used some illicit drug during pregnancy (as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001). That percentage translates to approximately 221,000 babies who had the potential to be born drug exposed.

While some studies have found that prenatal drug exposure results in physical and neurological deficits; growth retardation; cardiovascular abnormalities; and long-term developmental abnormalities including learning and behavior problems (Zuckerman, as cited in National Clearinghouse on Child Abuse and Neglect Information, 2001); and language delays, others have found few enduring effects (Sagatun-Edwards & Saylor, 2000). Compounding the problem of drug-affected babies are issues around women's rights. Policymakers use preliminary findings from research studies on drug-affected newborns to encourage judges and legislators to implement criminal and civil sanctions that deter or punish women who have used illicit drugs and alcohol during pregnancy (Chasnoff & Lowder, 1999). Actually, at least five states include drug-affected newborns in their State statutes under the definition of neglect (DHHS, 2000) and the NIS-3 includes drug-affected babies in its research definition of neglect (Sedlak & Broadhurst, 1996).

Poverty and Child Neglect
While poverty is associated with reports of all types of maltreatment, it is most powerfully related to neglect. There are a number of factors that may explain the connection, particularly low socioeconomic status. Associated with low socioeconomic status are factors such as unemployment, limited education, social isolation, large numbers of children, and childbirth to unmarried adolescents (Crittenden, 1999).

Characteristically, neglectful families tend to live in poor neighborhoods that they view as less helpful and supportive. In fact, there is little involvement in church or other formal organizations that might be sources of support. Further, supportive interactions with relatives, friends, and spouses are often lacking and limited. Because neglectful families are often not capable of maintaining relationships, they become lonely and isolated (Gaudin, 1993).

Another critical characteristic of neighborhoods, either impoverished or well-to-do, is the absence of a civility structure among residents. Often referred to as "social capital" (Coleman, 1988) or more recently as "collective efficacy" (Sampson, Raudenbush, & Earls, 1997), neighborhoods may promote a bunker mentality among residents and stifle their ability to get to know each other, support each other's families by being community caretakers for children, or advocate together for social action.

Approximately one-third of the States consider a family's financial means in their definitions of neglect (DHHS, n.d. [a]). These typically assess the family's access to available sources of support services.

Domestic Violence and Child Neglect
Parents who are victims of domestic violence are likely to neglect their children for a number of reasons. For example, they may be unresponsive to their children as a result of their own fears or they may give full attention to their abusive partner in an attempt to placate and control the level of violence. In any case, according to Sykes and Symons-Moulton there are serious physical effects on the children in the form of developmental delay, listlessness, and failure-to-thrive. "Behavioral effects may include begging for or stealing food and eating inappropriate objects; erratic school attendance; poor social relationships with peers; and delinquent acts such as vandalism, drug use, and drinking" (National Clearinghouse on Child Abuse and Neglect Information, n.d.).

CHARACTERISTICS OF NEGLECTED CHILDREN & FAMILIES
Initially, research on causal variables and their sequencing leading to neglectful behavior focused on parents, usually represented by mothers. Since most parents do not neglect their children, the behavior of those who did, became the entry point to understand and describe the neglectful process (Schakel, 1987). The early research explanations emphasized psychiatric disorders that apparently conspired to make parents (i.e., mothers) less effective, organized, attentive, or responsible to the caring of their child (ren). Polansky, Chalmers, Buttenwieser, & Williams (1981) for example, summarized their findings of neglectful parents as "...less able to love, less capable of working productively, less open about feelings, more prone to living planlessly and impulsively, but also susceptible to psychological symptoms to phases of passive inactivity and numb fatalism" (p. 109). Although the conclusiveness of Polansky et al.'s findings have been debated by later researchers, the emphasis on parenting psychological and behavioral aberrations as primary precipitating agents of neglect remain pervasive in the literature.

For example, Crittenden (1985) found differences in what neglecting mothers thought of their relationships with their children. Neglecting mothers felt incompetent as parents and were likely to view their roles as "one of emptiness and depression." Coohey's (1996) delineation of isolating behaviors frequently exhibited by neglectful mothers concluded that relationships with other adults were seen as less helpful, positive, instructive, or supportive. Consequently the number of relationships were fewer and less frequent between neglectful mothers and members of their social networks.

Garbarino (1977) however, was an early proponent of an ecological model that stressed the importance of studying behavior in context, that is to appreciate the embedded or nested relationships surrounding not only the child, but also the parent(s), i.e., the quality of institutions and neighborhoods (see also Bronfenbrenner, 1977, 1979). Garbarino's work emphasized random stressful events such as unemployment or the entrapment of economic isolation as important research variables to understand the neglect process. Current research status on individual factors has moved away from documenting the presence and influence of specific psychiatric disorders (e.g., schizophrenia, depression, panic disorders, etc.) to determining what symptomatic behaviors of psychological imbalance, such as substance abuse, are most prevalent. In two studies to discern when child maltreatment begins, Kelleher, Chaffin, Hollenberg and Fischer (1994) and Chaffin, Kelleher, and Hollenberg (1996) concluded that the presence of an emotional imbalance coupled with substance abuse significantly raises the risk for neglect and other forms of child maltreatment.

As a recent overview of child neglect ("psychological unavailability") reveals, research perspectives have broadened beyond individual parenting behaviors to the family's setting within communities and society (Erickson and Egeland, in press). Three perspectives are emerging from the current research: understanding the origins of parental inabilities and incompetence, child characteristics, and community characteristics.

Understanding how parents are unable to provide adequate care for their children also includes understanding their inability to maintain supportive household and community relationships. Some research suggests that prior parental exposures to violence or a past maltreatment are the significant precursors for neglectful parenting (Belsky, 1993). This finding is not an endorsement of the intergenerational process of child maltreatment however. The occurrence of abuse/neglect in one generation does not guarantee that the cycle is to be repeated in the next generation, but it can be a considerable factor (Belsky, 1993). Parenting incompetence can be extended to peer incompetence as well. Neglecting parents move their families frequently, seldom becoming members of a community Zuravin, 1989) and are not involved in community activities, including those sponsored or supported by churches (Polansky, Gaudin, Ammons, & Davis, 1985). For one reason or another, spousal support and other significant adult supports are seldom constructed (Egeland, Jacobvitz, & Papatola, 1987; Belsky, 1993; Crockenberg, 1987) resulting in neglectful parents possessing smaller peer networks, unable to obtain help from their family of origin and other relatives, and ultimately achieving social isolation. Research has not been able to pinpoint the primary cause of such parenting behavior, given that the more compelling conclusion may be that the presence of a confluence of deficits and orientations develops disorganized and haphazard behavior.

Neglecting parents may also be unaware of a child's developmental trajectory. Particularly susceptible of unreasonable expectations from their children would be teenaged parents and parents living within numbing and unremitting impoverishment. In this vein, it has been suggested that child characteristics encourage avoidance for care. Some children may have birth abnormalities, may be perceived as passive or less demanding, burdensome, or unwanted. But placing the culpability on child characteristics has not found conclusive evidence, "researchers have not found neglected children to emit aversive behaviors at rates much different than comparison children" (Wolfe, 1985).

The third theme, community factors, specifically examines the contributions from neighbors and community institutions to assist, support, and ultimately protect children and their families. It represents a social view of child neglect in contrast to a solitary personal/parental responsibility. "Community effects" research would argue that the conduct of neighbors and neighborhood institutions contribute to the existence, maintenance, and desistence of child maltreatment. One research example found that neighborhoods rated as having greater "communal cohesion" reported fewer abuse and neglect incidences to the state child protective system than those similar (i.e., ethnic, income, racial compositions) neighborhoods having lower rated systems of cohesion (Garbarino & Kostelny, 1992).

CONSEQUENCES OF NEGLECT

Neglected children, given their oft-camouflaged maltreatment, may endure long lasting consequences as a result. The impact of neglect can arrest a child's normative cognitive, physical, emotional development and create cumulative outcomes that may span their lifetime or encroach on the next. Depending upon several factors every neglected child will not be impacted similarly. The impact of neglect may depend upon the type and severity and its frequency, the characteristics of parent and child as well as the neighborhood context that ultimately shape the future for neglected children. The most compelling conclusions on neglect consequences have been derived from longitudinal studies, which follow children from birth to early adulthood. For example, at each stage of childhood to adolescent to early adulthood, neglected children display distinguishable effects of a developmental delay. In the period of infancy to pre-school, Egeland (1997) found neglected 18 month olds to be "insecurely attached" [to their parent/caregiver]. The same children 6 months later (24 months), "displayed considerable negative affect in a tool use situation and they exhibited more anger, noncompliance, frustration, and whining…. In a teaching task situation at 42 months they were observed to be negative, oppositional, avoidant of their mothers and expressed little affection toward their mothers." By age three, neglected children have "less ability to engage in age-appropriate play"(Gaudin,1999). In summary, before many neglected children reach the doors of elementary schools, they possess a temperament and disposition that will impose itself on the mastery of language, math, and the nuances of effective relationships. The prospect for academic and social failure builds.

In elementary school years researchers find "neglected children did …fare more poorly in school than did their nonmaltreated counterparts, and that performance markedly decreased in the transition from elementary school to junior high" (Kendall-Tackett & Eckenrode, 1996). Similar findings had been reported earlier (Egeland, Sroufe, & Erickson, 1983). Once neglected children reach puberty, most often during the junior high school period (approximately grades 7 - 9 and ages 11 - 13), the transition and adjustment to new developmental challenges exacerbates their academic performance. Performance, as measured by teacher grades, drops (Sroufe, Cooper, & DeHart, 1992; Leiter & Johnsen,1994; Kendall-Tackett & Eckenrode, 1996). And to compound their schooling difficulties, neglected children are more likely to be absent from school, which contributes to their poorer performances on academic tests.

Once in high school and afterwards, researchers noted that neglected students possess the identified traits of emotional distancing from parents, peers and teachers. Academically, they tended to have "poorer language comprehension skills," to be more dependent students lacking confidence, assertiveness, and creativity (Egeland & Erickson, 1987). Neglecting parents tend to avoid teacher-parent meetings, allow for truancy, are not able to structure the home environment to be conducive to learning, and often lack the social skills needed to model help-seeking behaviors in their children. Neglected adolescents develop antisocial behavior during their high school years that include alcohol and drug usage, delinquency, and the onset of serious psychiatric disorders. Their pathways to adulthood, ill-nurtured by the absence of consistent caregiving, are layered with obstacles, particularly the problem of comorbidity, or the occurrence of more than one behavior coexisting with another.

Protection, Intervention & Prevention

Protection
When neglect is suspected, Child Protective Services (CPS) is the first to respond. Part of the process of responding to suspected neglect involves verifying if it constitutes neglect in the jurisdiction in which it was reported. Then, the report is referred to investigation by CPS staff who speak with relevant parties to find out the facts of the allegation and determine if the child is still at risk of harm. A family is referred to services if reported neglect is found and if CPS staff conclude that the child is at risk for harm. A child may be removed from the caregiver's home, by order of a court of law, if the case is severe. In this circumstance, the child is then placed with a foster family while services are provided. Services including parenting skills classes for the parent and counseling for the child may be provided by CPS programs or community-based programs, regardless of whether or not the child was removed from the caregiver. A child can be returned to the family only if a court determines that the family can provide a safe and stable environment. If services are provided while the child remains at home, the family's participation may be voluntary. This is an important point because a number of factors including the family's wishes, the programs guidelines or the availability of insurance for payment of services may play a role in retaining "voluntary" families in services (National Clearinghouse on Child Abuse and Neglect Information, 2001).

Compared to physical or sexual abuse, reports of neglect are less likely to be investigated or meet the guidelines for provision of intervention services. This is one reason why many practitioners and researchers believe that in its current state, the CPS system is inadequate for meeting the needs of neglected children and their families. One method for addressing this problem is a "multi-track" response system implemented by CPS in which reports determined to be low-risk (including many neglect reports) are referred for an "assessment" rather than an investigation (National Clearinghouse on Child Abuse and Neglect Information, 2001). Generally this response is voluntary, uses a holistic approach, and services are more likely to be community-based. Efficacy of this type of system is yet to be determined.

Intervention
Given that neglect is a complex problem with multiple causes, an approach to intervention must respond to a range of needs. In a review of intervention programs designed to treat neglecting families, Gaudin (1993) found that these programs had difficulty achieving desirable outcomes. Characteristically, interventions that showed some success addressed problems individually, were long-term, and delivered a broad range of services. Gaudin found that severity of families' problems was a strong predictor of targeted treatment outcomes. That is, families with the severest problems were less likely to reach treatment outcomes. Gaudin suggests that an approach to intervention must be comprehensive, including assessment of individual personality of parents, family systems issues, and community stressors and resources. Moreover, the design of interventions should consider the type of neglect as well as information collected from assessment (see Child Neglect: A Guide for Intervention).

Briefly, interventions generally include home visitation on some level, can range from short-term crisis intervention to long-term support and stabilization to removal of children from their families for their protection (Gaudin, 1993). Interventions can be family-focused including all family members, not just the alleged victim and parent perpetrator or they can target societal conditions (e.g., unemployment, inadequate housing, etc.). Research also suggests that intervention programs should actively engage fathers or father figures (Dubowitz, Black, Kerr, Starr & Harrington, 2000).

Prevention
Recognizing that child neglect is a complicated problem, a number of prevention efforts respond to a range of needs. For example, Prevent Child Abuse America (formerly the National Committee to Prevent Child Abuse) implements a comprehensive approach to preventing child maltreatment that includes support programs for new parents; education programs for parents, regardless of specified risk; early and regular child and family screening and treatment; child care opportunities; programs for abused children; life skills training for children and young adults; family support services; and public information and education. While a community may not choose to offer services in all program areas, as a group they respond to the needs of all family members (Prevent Child Abuse America, n.d. [b]).

Healthy Families America (HFA) is one nationally implemented program of Prevent Child Abuse America that employs home visitation by paraprofessionals to provide support and assist parents with skill development and referrals to community resources. Initially, the program began with a demonstration project called the Healthy Start program (National Center on Child Abuse Prevention Research, 1996). High-risk families were targeted for preventive services to enhance family functioning and child development. The program included screening, nurse home visitation, coordination with other community services, and long-term follow-up until the child reached age 5. Outcome evaluations of Healthy Start found significantly lower rates of child abuse and neglect in approximately 99% of the families that participated in the program (Wallach & Lister, as cited in Holden & Nabors, 1999).

Another model prevention program is that of Olds, Henderson, Chamberlin, and Tatelbaum's (1986) nurse home visitation. The program was initially conducted in Elmira, New York, as a randomized clinical trial of intensive nurse home visitation during pregnancy and the first 2 years of a child's life. Early reports revealed lower rates of child maltreatment and positive effects on child development in a high-risk group of parents (i.e., teenage, single, low socio-economic status). It is important to note that although this trial did not target child neglect, the implications of its results are promising for prevention. Theoretically, generalizing nurse home visitation makes sense for the prevention of child neglect, as the project documented that provision of support to high-risk families is an effective strategy for developing parent and child strengths and preventing negative outcomes. Another important implication for programs designed to target neglect is that ideally they should follow families for long periods of time to measure varying outcomes (Holden & Nabors, 1999). Other implications include allocating resources to intensive selected interventions for at-risk populations rather than allocating to less intensive universal interventions aimed at whole populations; and recognizing that effective prevention will be labor-and time-intensive.

SUMMARY
Though not exhaustive, the aim of this chapter was to overview the theory, research, and practice issues in the field of child neglect. Although child neglect is a social problem that has been well-documented over a century and despite being the most prevalent type of maltreatment, it has historically received little attention. In recent years, however, much has been learned about its impact on children's development, the characteristics of neglectful families, its antecedents, as well as growing knowledge of models of family support and early intervention as strategies for prevention. In fact, the latter is a key area that merits further inquiry from both research and practice.

Neglect is a complex problem that takes many forms and is related to a number of social problems such as poverty, substance abuse, and domestic violence. This complexity contributes to continuing difficulty in identifying, defining, and treating neglected children and families. The problem of neglect is one that requires collaborative efforts by researchers and practitioners as well as communities and families to protect children from the risk of harm. Since neglect is a social problem, policy must also address the causes and correlates of child neglect at the individual, family, community, and societal levels. Given that neglect encompasses intentional or unintentional acts of omission by a caregiver, interventions to treat children and families affected by neglect must implement thorough assessments and customized treatment. What is essential to prevention efforts is the amelioration of contributing factors (such as poverty, substance abuse, and domestic violence) and provision of basic health care, education, childcare, and mental health services. An approach to prevention must respond to a range of needs.

Based on the research summarized here, it is clear that home visitation programs are one promising key to the prevention of neglect. If progress is to be made in eradicating the problem of neglect, then research must assess not only what prevention programs are effective, but it also must identify for whom prevention programs are effective, and to what extent and under what conditions. Further, any societal solution to neglect requires collaborative efforts among policymakers, researchers, and practitioners that encompass and involve families and communities united to protect children.

One researcher summarized succinctly the causes of neglect in this manner, "That that which is not valued is not well treated should come as no surprise" (Belsky, 1993). Children and their well-being in the United States face an uneven ambiance of attention, care and value from their parents and their communities. As pervasive as neglect has been as a form of maltreatment, it remains misunderstood and secondary in perceived importance to physical and sexual child abuse. Perhaps the outcome of the initial exercise readers of this entry were asked to perform indicates how much knowledge we possess and how much more will be needed to prevent and limit the effects of this devastating form of child maltreatment.

*John Kingsley Holton, Ph.D.
Dr. Holton is the acting President and CEO of Prevent Child Abuse America. He is a social psychologist who has specialized in urban education, juvenile delinquency, infant mortality, and child abuse. A native of Philadelphia, Dr. Holton attended Howard University where he received a bachelor's degree in political science and the University of Hartford where he received a master's degree in education. He completed his doctorate in the College of Human Development at the Pennsylvania State University. He has served on the faculty of DePaul University and the Illinois School of Professional Psychology. Dr. Holton is a member of the American Professional Society on the Abuse of Children, American Public Health Association, the National Black Child Development Institute, and the Society for the Study of Social Problems. He presently serves on the editorial board for Family Violence & Sexual Assault Bulletin, as a board member for the Citizens Committee of the Juvenile Court (Cook County), Jane Addams Juvenile Court Foundation, McCormick Theological Seminary, and the Target Group, Inc.

**Domarina Oshana, Ph.D.
FMs. Oshana is acting Vice President for Research at Prevent Child Abuse America. She received her Bachelor of Arts in Psychology from Northeastern Illinois University and graduated Magna Cum Laude. She received her Master of Arts in the Social Sciences from the University of Chicago, her Ph.D. in Research Methodology from Loyola University Chicago. Ms. Oshana's research interests lie at the intersection of human development and public policy, being mainly concerned with how government and non-government policies shape the development and socialization of children and adolescents.

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Total Estimated Cost of Child Abuse and Neglect In the United States
By Suzette Fromm, Ph.D., Vice President of Planning,
Program Evaluation and Quality Improvement, ChildServ*

Introduction
For years, we have recognized the tragic effects of abuse and neglect on the children against which it is perpetrated. Innumerable scientific studies have documented the link between the abuse and neglect of children and a wide range of medical, emotional, psychological and behavioral disorders. For example, abused and neglected children are more likely to suffer from depression, alcoholism, drug abuse and severe obesity. They are also more likely to require special education in school and to become juvenile delinquents and adult criminals.

This data represents the first attempt to document the nationwide costs resulting from abuse and neglect. These costs can be placed in one of two categories: direct (those costs associated with the immediate needs of abused or neglected children) and indirect (those costs associated with the long-term and/or secondary effects of child abuse and neglect).

The data cited in the following pages has been drawn from a variety of sources, including the Department of Health and Human Services, the Department of Justice, the U.S. Census and others. Appropriate data citations are included throughout the report.

In all instances, we have opted to use conservative estimates. For instance, only children who could be classified as being abused or neglected according to the harm standard were included in the analysis. The harm standard is the U.S. Department of Health and Human Services' more stringent classification category. In addition, we have not attempted to quantify all of the indirect costs of abuse and neglect including, for example, the provision of Welfare benefits to adults whose economic condition is a direct result of the abuse and neglect they suffered as children. For this reason, we believe the estimate of $92 billion per year is conservative.

Regardless of the economic costs associated with child abuse and neglect, it is impossible to overstate the tragic consequences endured by the children themselves. Each year, more than three million children are reported as abused or neglected in the United States. And three children die each day from abuse and neglect in this country. The costs of such human suffering are incalculable.

Total Annual Cost of Child Abuse and Neglect in the United States
DIRECT COSTS
Statistical Justification Data

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Reframing Child Abuse & Neglect for Increased Understanding & Engagement:
Defining the Need for Strategic Reframing
By Kevin T. Kirkpatrick, MS, Vice President, Marketing,
Communications and Advancement, Prevent Child Abuse America*

Abusive behavior is considered to be a very individual and private act against society, and therefore difficult to detect. Nearly everyone agreed that the existence of, and accessibility to, extensive educational programs is the one most significant factor in the reduction of the problem. In accordance with the above, it was felt that society has a responsibility to train those parents who have had no, little or improper training to become more cognizant of their children's needs. And it was also recognized, that although society can offer educational services, there will always be a portion of society that still fails to recognize any need for behavioral modification (1).

Introduction
The observation above, included in a 1983 research study commissioned