Mandatory Reporting and the Difficulties Identifying and Responding to Risk of Severe Neglect: A Response Requiring a Rethink
© Springer Science+Business Media Dordrecht 2015Ben Mathews and Donald C. Bross (eds.)Mandatory Reporting Laws and the Identification of Severe Child Abuse and NeglectChild MaltreatmentContemporary Issues in Research and Policy410.1007/978-94-017-9685-9_12
12. Mandatory Reporting and the Difficulties Identifying and Responding to Risk of Severe Neglect: A Response Requiring a Rethink
Faculty of Health, School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
KeywordsChild neglectDiverse natureConsequencesCausesMerits of mandatory reporting of neglectCritical analysisProblems with child neglect reporting
Neglect of children is a significant social issue worldwide and is typically the most frequently reported form of maltreatment in Western nations, with its severe forms sometimes resulting in significant illness and disablement or death. Yet, paradoxically, it remains ‘neglected’ and largely in the shadow of physical and sexual abuse, often being viewed as less serious despite the real-life consequences of its insidious and compounding nature and the lasting damage it causes to intergenerational familial relationships and the life outcomes of those affected. This chapter explores the many complex forms of child neglect, its causes and impacts and the strategies to prevent it.
In particular, a critical standpoint is taken in analysing the rationale and merits of mandatory reporting of neglect and their effects, systemically and for children. It is argued that with respect to neglect, and severe neglect in particular, that mandatory reporting is counterproductive to our efforts to prevent maltreatment because it has too many unintended consequences that hinder system and family responses to access necessary preventative programs and supports, particularly concerning the social structural factors at play. Examples are used to highlight the characteristics of system failures regarding severe neglect and to understand why our reporting system responses can fail. Finally, key practice and policy issues regarding mandatory reporting of severe neglect are unpacked and examined, exploring the ways in which we can enhance our efforts to prevent child neglect, render support in timely and effective ways and thereby protect children from its more profound impacts.
What Is Neglect?
Differing Social Constructions
Despite long-standing attention there is not yet available a universally accepted definition of ‘neglect’, although Dubowitz (2007) rightly notes that there is ‘a surprising level of agreement about what constitutes neglect’ (p. 604). Essentially, definitions of neglect are socially constructed and are, therefore, dependent upon localised individual, collective and normative processes that take account of a diverse array of considerations (Dubowitz 2012; Horwath 2007; Moran 2009; Tanner and Turney 2003). These include cultural, religious, community and societal beliefs, values and ethics, not to mention a myriad of interpretations applied to specific behaviours and events and their situational and circumstantial contexts.
Many personal, professional and organisational influences are at play when practitioners make determinations about neglect, with one study identifying that the assessment task is as much a practice – moral activity as a technical – rational one, that is, both their head and heart are used in the process (Horwath 2007). Moreover, many of those with an interest in determining whether or not social interventions should be undertaken come from different organisational and disciplinary backgrounds with their own distinct discourses and perspectives (Horwath 2007). Hence, what is defined as neglect in one community may not be defined as such in another, even though they are in the same country or region, perhaps with a shared language and other cultural characteristics.
Neglect is a global term for quite different phenomena. Stein et al. (2009) identified important differences in the way neglect might be defined at the various stages of childhood, positing that more age-sensitive definitions were required. Scott (2014) in an Australian Institute of Family Studies (AIFS) review identified neglect types including physical, supervision, medical, educational, abandonment and emotional which have distinct aetiologies.
Further, the characteristics and causes of neglect are dissimilar to physical abuse and sexual abuse in particular ways including its sometimes chronic nature; definitional difficulties that mean its occurrence is less binary compared to abuse; different intentions of parents/carers; and that neglect increases the risk of exposure to other forms of harm (Mennen et al. 2010; Scott et al. 2012). Neglect is also harder to prove than abuse incidents because it requires establishing that something is missing and that its absence will cause an observable harm or risk of harm in the future, a feature that makes reporting potentially speculative. These differences require differentiated responses, whereas most child protection systems treat them as the same.
Viewpoints about child abuse and neglect are evolving and highly contested within social policy, not the least because of the variety of understandings about children and their needs, the role of the state in ensuring their safety and well-being and families’ rights to privacy (Ferguson 2004). Nigel Parton (2006) has explored various social constructions of children and childhood in England and how these have changed over time, along with understandings of child abuse and neglect and governance of the family. He noted heightened social surveillance and wider regulation and intervention into families under the rubric of protecting children from risk of harm within ‘the preventive state’.
Many organisational and legislative definitions of neglect are actually contained within broad definitions of ‘child abuse and neglect’ with no attempt to distinguish these different concepts. Despite these differing social constructions and definitional issues, there is a dominant theme within most definitions of neglect, and this is the assigning of responsibility and fault with the parent/carer. This blaming aspect is problematic (Dubowitz 2013; Harries and Clare 2002) because it individualises the events and places responsibility for social structural factors with parents/carers and, arguably, hinders them taking up voluntary support services. Whilst it is evident that finding fault with parents is more likely to occur in situations where their own actions are central to the maltreatment, what is at issue here is the extent to which this happens within forensic approaches to child protection. The emphasis placed on blaming here stems from the deficit-oriented features of such investigatory systems (Lonne et al. 2009) and leads to many service users feeling stigmatised and fearful (Shemmings et al. 2012), which is quite different to their typical responses when voluntary services are provided through differential response approaches (Kyte et al. 2013; QUT and Social Research Centre 2013; Winkworth et al. 2010).
Nonetheless, fault is present in criminal legislation in many jurisdictions, particularly with severe neglect being a criminal offence (Mathews and Bross 2014). Fault, or at least a ‘failure’ to provide the child with a basic necessity, is also implied in definitions used in professional circles. For example, the US National Child Abuse and Neglect Data System defines neglect as ‘a type of maltreatment that refers to the failure by the caregiver to provide needed, age-appropriate care although financially able to do so or offered financial or other means to do so’ (see American Humane Society 2014). The Australian Institute of Family Studies (AIFS 2014) refers to neglect as ‘the failure by a parent or caregiver to provide a child (where they are in a position to do so) with the conditions that are culturally accepted as being essential for their physical and emotional development and wellbeing’. Finally, the Department of Children and Families Connecticut (2014) defines neglect as ‘the failure, whether intentional or not, of the person responsible for the child’s care to provide and maintain adequate food, clothing, medical care, supervision, and/or education’.
Uncertainty and Complexity in Determinations of Neglect
In many ways, dealing with neglect captures many of the tensions, challenges and complexities of working in child protection. Neglect is a very complex phenomenon to definitively determine (Dubowitz 2007; Gaudin 1999; Mennen et al. 2010; Stoltenborgh et al. 2013) and personal beliefs play a role (Horwath 2007). A recent meta-analysis of prevalence rates in 13 studies of physical neglect and 16 of emotional neglect found ‘a disturbingly high prevalence of physical neglect (163/1,000 cases) and emotional neglect (184/1,000 cases)’ (Stoltenborgh et al. 2013, p. 354).
There are, however, a multitude of definitional, methodological and data system issues present, and comparing different studies is not a precise science as assumptions do need to be made in reaching conclusions (Gilbert et al. 2009a; Scott 2014; Stoltenborgh et al. 2013). Nonetheless, this meta-analysis puts neglect in the vanguard to protect children and reflects its dominance as a maltreatment type within formal child protection data around the globe (AIHW 2013; Child Trends 2012; Gilbert et al. 2009b, 2011; Mennen et al. 2010; Stein et al. 2009; US Department of Health and Human Services 2010).
When operationally defining neglect we must take into account a messy and uncertain interplay of risk indicators at the child, family, community and societal levels, knowing that these are understood within a normative framework of what is ‘reasonable’ in light of the circumstances and the general expectations of relevant social roles, such as being a father and mother. Dubowitz (2013) has depicted neglect as being on a continuum, with ‘optimal’ and ‘grossly inadequate’ being polar ends, and determinations of adequate care being variable dependent upon a range of contextual factors. Where exactly the threshold point is for severe neglect is unclear, and the available literature tends to focus on those matters that entail children’s deaths or significant illness and disablement, but does not provide much guidance on the many other examples of neglect that entail a potential risk for dire consequences but no actual current presentation of serious harm.
The development of poor care events into neglect and the emergence of signs of demonstrable harm is an insidious process. The challenge of identifying the early signs of neglect, and particularly severe neglect, in advance of tangible signs and outcomes of harm is very difficult indeed and may be impossible. There is a huge difference between the prospective and the retrospective as we shall see later in some tragic examples.
The consequences of neglect are sometimes profound and are often experienced well after the neglectful event or behaviour occurs (Gaudin 1999; Gilbert et al. 2009a, b). Tanner and Turney (2003) identify that neglect can be occasional and reactive or entail a sustained and chronic breakdown in the relationship of care. Scott et al. (2012) highlight that when making determinations about neglect, we need to take into account both the level of severity and chronicity along a continuum and to also assess the cumulative effects of multiple relatively low-level events that may compound over time. For example, a lack of emotional response from a parent may not be significant if it is a one-off event, but continuing emotional absence can have significant impacts on children.
Moreover, neglect does not just concern what someone, typically a parent or carer, has done to a child in a particular situation or over time, such as recklessly placing them in harm’s way, but what they also might not have done but should have. Hence, acts of commission as well as omission are relevant, but always within a normative understanding as to what was the ‘proper thing to do’ – what ought to have been done in the particular circumstances but was missing.
The parents’/carers’ failure to provide an appropriate aspect or level of care for a child of a particular developmental level also entails the assignment of responsibility upon the parent/carer to do so in order to prevent unwanted and potentially dangerous events occurring. Here the concept of risk plays a central part. That is, the neglect must involve either a demonstrable and significant negative consequence upon the child’s health and well-being or an unacceptable risk of this eventuating. Determining prospective risk is replete with suppositions about future events or impacts that might, or might not, be able to be reliably and accurately measured, but are nonetheless perceived as real.
These usually entail moral judgments about the level of adult behaviour and responsibility displayed by the carer, a key feature of many definitions. Assigning responsibility can also spill over into blaming parents, which can hinder the opportunities for working collaboratively with health and welfare professionals (Shemmings et al. 2012). In light of this, Dubowitz (2013) has argued for definitions of neglect to focus on when a child’s basic needs are not being met rather than parental omissions. Yet, there are limits to moral expectations of parents because neglect also entails definitions and assessments about ‘good enough care’ rather than a good or high standard of care.
In its more severe examples, though, neglect may entail a legal and criminal response such as when there has been a ‘failure to provide the necessities of life’, or the neglectful act is deemed to have entailed a degree of behaviour, or the consequences are so serious as to constitute criminal negligence. The task of setting these standards is one shared by many within particular cultures, communities and societies. This includes extended family, elders, community leaders and people of eminence such as the judiciary and health and welfare professionals. Gender is often at the heart of these frameworks for child-rearing behaviours and caring, with women usually carrying primary caregiving roles. On the broader front there is the United Nations Convention on the Rights of the Child that sets particular standards and which most nations have ratified (Reading et al. 2009).
There is ‘strong evidence linking neglect to poverty’ (Dubowitz 2007, p. 605; Carter and Myers 2007; Jonson-Reid et al. 2013). This factor makes for real complexity when trying to determine whether children are being neglected because of their parents’/carers’ actions or primarily because of social and economic deprivations. For example, McSherry (2007) and Dubowitz (2007) explored the issues surrounding a 10-year-old caring for younger siblings due to their parents being at work and identified many grey areas in determining whether or not neglect was occurring and even whether this may in some circumstances be the ‘lesser of two evils’ and a positive learning experience for the child in the caring role.
Cultural relativism is also at play when matters of child abuse and neglect are at issue (Gilbert et al. 2011; Reading et al. 2009). There is any amount of evidence from around the globe that illustrates the critically important part that culture plays in the determination of what does, and does not, constitute a situation of child abuse and neglect (Dubowitz 2012; Jonson-Reid et al. 2013; Saunders et al. 1993), although some US studies have identified general agreement about what constitutes neglect across different racial/ethnic and socio-economic groups (Dubowitz et al. 1998).
Of particular note are the issues that arise for immigrants, people of colour and indigenous peoples as well as other groups who are socially excluded, such as people with intellectual and mental health disabilities, and single parents, particularly those households headed up by women (Bilson et al. 2013; Daniel et al. 2010; Child Trends 2012; Gilbert et al. 2011; Gillespie et al. 2010; Kaplan 2013; Jonson-Reid et al. 2013; LaLiberte and Lightfoot 2013; MacLaurin et al. 2005; McConnell 2013; Saunders et al. 1993; Scott 2014). These groups experience overrepresentation in most child protection and welfare systems and in the case of indigenous peoples profound overrepresentation. Whilst the reasons for indigenous overrepresentation are complex and interrelated, the Australian Institute of Health and Welfare (AIHW) has identified one of the factors as ‘perceptions arising from cultural differences in child-rearing practices’ (2012, p. 14). There are major social, economic and health disparities evident for indigenous peoples that both contribute to this overrepresentation and are also made worse by it (see Steering Committee for the Review of Government Service Delivery 2013).
Neglect is the most frequently reported type of harm for indigenous Australian children (AIHW 2013, p. 54). The largest groups of notifiers are primarily those who are subject to mandatory reporting requirements: police, school authorities and health and welfare personnel (AIHW 2013, p. 55). Recent Australian inquiries into state child protection systems have identified the increasing overrepresentation of Aboriginal and Torres Strait Islanders, despite a raft of policies aimed at reducing it (Cummins et al. 2012; Queensland Child Protection Commission of Inquiry 2013; Wood Inquiry 2008). Further, aggregated child protection data identifies increasing overrepresentation of Australia’s indigenous children who are subject to reports of alleged maltreatment, substantiated harm and children under orders and in alternative care – their overrepresentation increases the further they progress into the care system (AIHW 2013). The situation is similar in Canada for First Nations children (Blackstock et al. 2004; Gillespie et al. 2010; Sinha et al. 2010, 2011) and elsewhere (Child Trends 2012; Gilbert et al. 2011).
This overrepresentation by reporting and intervention systems should not be viewed as arbitrary. Rather, these are patterns associated with poverty, marginalisation and race, and we find that groups with these characteristics find themselves targeted within our reporting systems – that is, they are significantly overrepresented and, as we shall see later, increasingly so as they go further into the care system. Mandatory reporting within such systems cannot be properly seen as a benign policy affecting all equally, but should be seen as part of an overall system that accentuates overrepresentation for groups that already experience substantial inequality and disadvantage (Bywaters 2013). One could perhaps conclude differently if mandatory reporting and investigation led to effective helping that specifically addressed the influential social structural factors, but they do not and are instead fashioned around individualising the matter and emphasising interventions that reinforce parental responsibility within a blaming and stigmatising orientation.
Moreover, not only are these social structural dimensions not taken account of and corrected within our mandatory reporting systems, they are reinforced by it, with a preponderance of reporters being those who are required either legislatively or organizationally to report suspected harm (AIHW 2013). The evidence overall is strong that the overrepresentation results from more than just social disadvantage (Doolan et al. 2013; Sinha et al. 2011; Steering Committee for the Review of Government Service Delivery 2013), although some evidence is mixed (Sinha et al. 2010). These situations are very difficult for people and groups feeling alienated and distrustful of societal support structures, even to the point of being unwilling to access needed assistance, particularly if they fear being reported to child protection authorities and losing their children (Bilson et al. 2013). This is an important point and highlights the inadvertent consequences of mandatory reporting, namely, that such approaches promote investigation but are far less successful in providing helpful assistance and guidance to struggling families, particularly when they fall just short of the reporting thresholds or just short of being a substantiated outcome and therefore remain ineligible for ongoing support.
In this author’s view, when determining whether neglect of children is occurring and its level, a range of contextual factors are pertinent, such as the:
Child’s characteristics, including their age, developmental level, vulnerability and the presence of any special needs, particularly disability
Levels of capacity of the parent/carer, including their maturity, mental health, resourcefulness and commitment to their children’s well-being
Severity and chronicity of neglectful events and the risk of cumulative harm
Approaches taken to child-rearing practices within the family, cultural group and community, including influences such as ethnicity, religion and gendered responsibility
Family environment, including relationship quality and the levels of conflict and interpersonal violence present
Community context, including the relative levels of poverty and social exclusion experienced by particular groups; the access to resources, supports, and services; and the perceptions of safety and well-being within the neighbourhood
Actual harm experienced and the risk of potential harms evident, neglect often involving an insidious process of harm accumulation over time
Before examining the merits of mandatory reporting for neglect, including its severe manifestations, it is important to understand the diversity found across the various types, forms and continuum of neglect, which is often conflated within the literature into a global maltreatment category. It is argued that this can result in a loss of the different aetiologies present and a push for generalised interventions that take no account of these important differences. Moreover, the complexities inherent when making prospective assessments of risk of future harm and outcomes are often ignored within assessments where the thresholds for intervention are blurry at best and assumptions about the supposed predictability of relatively low-level neglect escalating to become severe. Further, as described earlier, those needy families that fall just short of the mandatory reporting and investigation thresholds often find themselves ineligible for supportive services, or more often, health and welfare staff are focused on reporting the matter rather than offering direct universal support (Daniel et al. 2010). In this chapter the argument is made that in light of the difficulties and unreliability of such professional assessments, that mandatory reporting of neglect and severe neglect are counterproductive.
Types of Neglect and Impacts
The literature suggests many different types of neglect and specific forms within each of these; however, there are various findings regarding the ability to accurately assign particular impacts to specific acts, types and forms of neglect (Jonson-Reid et al. 2013). Indeed, most professional literature on neglect depicts it as a global category of maltreatment, with the sequelae undifferentiated as to their origins and specific types of neglect or abuse (Gaudin 1999; Gilbert et al. 2009b; Stoltenborgh et al. 2013). This reflects and compounds the ‘neglect of neglect’ within the literature and hinders recognition of its impacts (Dubowitz 2007; McSherry 2007; Stoltenborgh et al. 2013). Further, there are numerous definitional and methodological variations that make it hard to compare research findings (Dubowitz 2012; Gilbert et al. 2009b; Stein et al. 2009; Stoltenborgh et al. 2013; Tanner and Turney 2003).
Scott’s review (2014) highlighted the frequently identified types as:
This pertains to the child’s needs for adequate food, nutrition, clothing and shelter. Each of the forms within this type of neglect is distinguishable and has different impacts, but is nonetheless viewed as the ‘necessities of life’, and parents/carers are deemed responsible to provide them. Yet, the linkage here to poverty is clearly apparent, and parents may be unable rather than unwilling to do so. Severe neglect will often be associated with physical neglect and entail serious consequences for children’s health and well-being, including death or significant illness and disablement.
According to Scott et al. (2012, p. 6), supervisory neglect occurs when ‘inadequate supervision leads to or has the potential to lead to harm to the child. The difficulty in adequately defining supervisory neglect is compounded by a lack of clarity of what constitutes adequate supervision in a given situation, combined with the lack of clarity in defining neglect’. It entails inadequate supervision for a relatively short period where there are unacceptable risks of harm for the child, such as young children being unsupervised around water or a dependent child being left alone at home whilst the parent is elsewhere. For example, recent studies of fatal maltreatment identified supervisory neglect as critical in determining child drowning as neglect rather than ‘accidents’ (Damashek et al. 2013; Welch and Bonner 2013). Determination of supervisory neglect is dependent upon a range of factors including the child and parent/carer’s abilities, capacity (including impairment) and relationship; accessibility of help and resources; the danger present and potential consequences; and the nature of the circumstances in which the supervision was inadequate.
This entails a failure to provide appropriate and necessary health care in a timely manner, which has a material impact on the child’s health, and where a reasonable parent would have sought such care. It can involve medical recommendations being ignored and treatment not being accessed, but, again, it is not straightforward as not all recommendations for treatment are essential, not all parental behaviour will have a significant impact on the child, and poverty may be a factor in making medical care unaffordable. Religious beliefs may also be present, and many states in the USA, for example, allow religious exemptions in their civil codes for child abuse and neglect (Dubowitz 2013), although most other jurisdictions around the world do not.
Scott (2014) has identified this as a failure to provide a child with ‘an education and the necessary tools to participate in an education system’ (p. 4), where parents/carers take decisions to either prevent the child accessing education or support the child’s decision to refuse to attend school. Educational neglect can result in significant detriment to a child’s life chances of securing sustainable employment and may trap them into ongoing poverty, which is also an important factor for consideration because low-income households may not have the resources available to adequately support children’s education. We will later examine high-profile Australian cases where educational neglect was at issue.
This involves a parent/carer leaving a child alone or in the care of another person for a lengthy period and either a prolonged separation or severing of the relationship with the child. In essence, the child is left to their own devices to care for themselves, or is left with an inappropriate person who has an uncaring relationship with them, or who does not have the capacity or commitment to undertake a caring role.
This occurs when there is significant inconsistency in, or the absence of, nurturance and affection within the caring relationship to the point where the parent/carer is unable to meet the child’s needs. Research indicates that its impacts can be very severe upon the child’s emotional and psychological health and well-being and their social development (Dubowitz 1999; 2013; Gaudin 1999; Gilbert et al. 2009a, b; Stoltenborgh et al. 2013), as well as the ongoing familial relationships and children’s behaviour and identify formation, particularly with attachment disorders (Crittenden 1999; Howe et al. 2000). Longer-term effects include adolescents demonstrating a higher likelihood of substance abuse, risky and aggressive behaviours and poorer physical and mental health (Gaudin 1999; Scott 2014; Stoltenborgh et al. 2013). However, there are considerable methodological limitations in the research undertaken of emotional neglect, and further detailed studies are required to fully understand the short-term and long-term impacts (Gaudin 1999).
The literature identifies that effects can be compounding and cumulative, with a multifarious array of harm sometimes evident and featuring physical, emotional, psychological and relational aspects. Damage to a child’s emotional and psychological well-being can occur, leading to difficulties developing wholesome relationships with others (Crittenden 1999; Howe et al. 2000; Tanner and Turney 2003), with failure in parent–child attachment being replicated across generations (Reder and Duncan 2001). There is evidence that children who were neglected are more likely than others to experience poor economic circumstances as adults and to need higher levels of social support (Gilbert et al. 2009a; Scott 2014; Stoltenborgh et al. 2013). However, these consequences are often insidious and only become clearly evident over the long term, making earlier predictions difficult.
What can also occur is an intergenerational transmission of powerful life narratives that children build to explain and understand themselves, their situations and relationships. These can entail an overt sense of hopelessness and despair, becoming a pervasive influence through life because the messages they contain are used to guide their interactions with others, their feelings about themselves and their emotional investments into relationships. The sorts of narratives can include messages such as:
‘I am unloved and unlovable’.
‘I am damaged goods, needy, vulnerable and downtrodden’.
‘Family members will always hurt you, and they only like you when they want something’.
‘People cannot be trusted as they will always let you down and use you’.
‘There is no use trying as you can never get ahead’.
‘My life will never get any better because people like me are destined to be losers’.
‘For people like me, life is full of tragedies and disappointments. That’s just the way it is and will always be’.
Carrying these sorts of negative narratives can have the effect of sapping their energy for living a full and rewarding existence – their life force is reduced by powerful self-messages that make it difficult to aspire or to see a better future. Hence, mental health issues are observable, including PTSD and substance abuse, along with relationship difficulties and other adverse outcomes (Gilbert et al. 2009b; Jonson-Reid et al. 2013). It is unsurprising that their lack of trust in others and reduced life expectations should spill over into their relationships with health and welfare personnel who intervene in relation to their care of their own children (Crittenden 1999; Howe et al. 2000; Tanner and Turney 2003).
Why Does Child Neglect Happen?
The early work of Crittenden (1999) and Dubowitz (1999) was important in developing conceptual understandings about why people neglect children and shaping intervention approaches, such as working in the longer-term rather than brief interventions (Jonson-Reid et al. 2013; Tanner and Turney 2003). Putting aside the already identified issues around definitions and the types of neglect, and the influence of poverty, there are a number of reasons postulated for neglect occurring.
Tanner and Turney (2003, pp. 27–29) identified the causes as being within the intrapersonal, interpersonal, social and ecological domains. These are too complex and interrelated to go into detail within this chapter, but generally involve the following factors, and typically there are multiple combinations at play:
Personalistic – e.g. immaturity, sense of powerlessness
Psychiatric/psychological – e.g. information processing, mental health and substance abuse, learned helplessness
Psychological/psychosocial – family functioning, communication, conflict resolution, leadership, role and characteristics of extended family
Attachment – e.g. disordered parent–child relationships
Child development – e.g. impacts of developmental history and disability
Sociological – e.g. poverty, social exclusion, community impoverishment
Ecological – interplay between the intra- and interpersonal and social/societal factors
Parental environment – links between parental skills, social support, resource management
The literature indicates that a range of typical factors, whilst not necessarily causal, can affect how chronic and severe neglect manifestations may present, including parent/carer illness and mental health disability, alcohol and drug abuse, child illness and disability, low income, ethnicity, domestic violence, prior history of maltreatment and being in care and poor access to social supports (Daniel et al. 2010; Dubowitz 1999, 2007; Fallon et al. 2013