Child neglect: what does it have to do with general practice?

Child protection and the wellbeing of children are inextricably linked in the provision of an adequate child health service. GPs, with access to extensive privileged information about families, have a central, though often misunderstood, role. Child health generally, and child maltreatment in particular, have nevertheless rarely featured in recent UK general practice policy development. Child maltreatment may be dichotomised into acts of abuse or neglect. Abuse is less problematic conceptually and practically because of its focus on physical evidence. GPs can follow clearly defined referral pathways into the child protection system, confident that they are supported by comprehensive services and a robust legal and administrative framework. However, child neglect is more challenging. It is essentially an act of omission and its detection requires an interpretation of parental behaviours, parent–child interactions and observation of children themselves. There is no accepted standard definition of child neglect, so a shared understanding between professions is difficult to achieve. Furthermore, collecting reliable data on an ill-defined phenomenon is a great challenge. Depending on the method of data collection and the definitions used, prevalence estimates have ranged from 3% 1 to a lifetime rate as high as 37%. 2 From the perspective of children and society, neglect is more important than abuse. We know that neglect is more prevalent than abuse 3 and least likely to be dealt with by child protection services. 4 Harsh or abusive parenting is also generally less damaging than severe neglect in terms of cognitive 5 and behavioural 6 outcomes. The negative and pervasive long-term effects of neglect, such as poor educational achievement, addictions, mental health problems, and criminal behaviour, ultimately affect children's life chances and contribute to early mortality 7 and the impact of neglectful parenting persists into second and subsequent generations. 8 In a study linking child protection and behavioural data among 1308 at-risk US children, Kotch et al 6 found that neglect accounted for two-thirds of all reported cases of maltreatment. Neglect was defined as failing to provide for basic needs or emotional support, or leaving a child unsupervised or with an inappropriate carer. Only early neglect (before 2 years of age) significantly predicted aggression. Abuse at any age and neglect after age 2 years were not significantly predictive of aggressive behaviour, in a controlled model. Child neglect is not simply a social construct. Neglected children display persistent abnormalities of brain function 9,10 and the hypothalamic-pituitary-adrenal axis, 11 …