Reflective Portfolio on Neglect

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I am now in the second semester of my health visitor training and studies as a Specialist Community Public Health Nurse. Throughout the process I have had the opportunity to enhance and develop my skills and knowledge through a wide variety of experiences. I have also been able to, and accepted more unsupervised/independent responsibility to consolidate my learning. Working in an area with a large proportion of clientele subject to high intervention plans and requiring intensive support, I have had the invaluable opportunity to observe and be part of numerous safeguarding cases/issues.

To assist in structuring the reflective element of my portfolio I have used John’s Model of Structured Reflection (2000). By using the series of questions I have been able to break down experiences and work through my feelings and learning outcomes. Throughout my portfolio any reflections will not include names or locations to protect client confidentiality in line with NMC guidelines (NMC 2008). For this portfolio I have decided to focus on neglect with a particular interest in the emotional neglect.

This will enable me to gain an understanding of neglect, the impact it has upon children and the importance of collaborative working and early interventions. I feel that health visitors have a unique role in identifying maltreatment or neglected children and ensure that appropriate actions are taken to help and improve outcomes. Neglect is widely recognised as the most common form of maltreatment in children in the United Kingdom and Worldwide (Hmurovich, 2008, Legano et al, 2009, Action for Children, 2009, Gilmore, 2010, DofE, 2011, and NSPCC, 2011).

Neglect has been defined in Working Together to Safeguard Children (HM Government, 2010: 39) as: “the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development……. neglect may involve a parent or carer failing to: * provide adequate food or clothing and shelter * protect a child from physical and emotional harm or danger * ensure adequate supervision * ensure access to appropriate medical care or treatment it may also include neglect of, or unresponsiveness to a child’s basic emotional needs” It is evident from this description that equal value is placed on both the physical and emotional needs of a child.

A recent NSPCC study (2011) found that almost 10% of children surveyed had experienced emotional neglect or lack of physical care. Neglect has also been the leading reason for children being made subject to a child protection plan (DofE, 2011). It is however highly likely that the numbers of children experiencing neglect are substantially higher as neglect may not be obviously manifested or reported.

Throughout my health visitor training I have been fascinated, surprised, overawed and at times dismayed at the effects emotional neglect can have on the development of a child’s brain and the subsequent impact that this has on them in later life. I am aware that when a child is born, their brain is not fully developed and it is within the first two years of life that rapid development occurs. This is tempered by the emotional and physical stimuli and influences the child receives.

It is the early interactions and relationships experienced by the child within this timeframe that will determine their ability and responses throughout life (DH, 2009). This is also supported by the Child Development Center at Harvard University (2012) which demonstrates that the circuits and connections within the brain are developed through experiences and environments. The more that an area within the brain is used, the stronger and more permanent the circuits and connections within the brain become. Consequently when there is less use of these circuits and connections, pruning occurs and they simply fade away.

These circuits within the brain formulate the centres for emotion, behavioural control, motor skills, language and memory. If the circuitry in any one of these areas is incomplete or absent it will inevitably leave deficits in the child’s/adults capabilities. Neglecting a child will not only have an impact on that child during that period of time. The potential for long-lasting, negative impact on a child’s health and well-being is immeasurable. The cummulative effects of neglect result in harm to the child’s physical and mental health and their ability to function socially throughout their life (Gilmore, 2010).

There is also a strong correlation between neglect and debilitating/chronic illness, delinquency, criminal behaviour, mental health issues, drug dependency and low academic performance (Hmurovich, 2008). Bearing these potential problems in mind it is clear to see that the impact of neglect not only has a high cost for society but also for the neglected individual (DH, 2010). I find it both shocking and saddening that simple things like talking to your child, smiling at them, encouraging them and providing a safe environment are not a common part of every parents artillery.

For me as a mother they feel like the most natural and the least difficult elements of raising a child. However I acknowledge that many babies are born into family circumstances or situations that are less than ideal for many different reasons. At times these reasons may take precedence for the mother and the child may not receive as much time or attention. In some cases this remedies within a given timeframe, yet sadly for others, the environment remains ‘toxic’ and continues to impact on the child’s well-being. I was absolutely horrified to realise the lasting damage that the absence of these simple things can cause.

In the back of my mind I have always been aware of and had a basic understanding of neglect, however I had not comprehended quite how life limiting and destructive it can be for a child. I distinctly remember the NSPCC advertisements on the television and feeling my heartbreak at the child who doesn’t cry because they know no-one will come and the boy rummaging for food in the dustbin. I remember feeling sickened, horrified and outraged at the suffering and treatment endured by Victoria Climbie (Laming, 2003) and Baby P (DfE, 2010) and questioning how anyone could treat a child in this way.

I was aware that these things are happening. However the enormity and reality of neglect didn’t fully penetrate until I started working as a health visitor. Because I had never actually encountered neglect directly, I had no idea of the vein it takes, how prevalent and pervasive, (although I fully acknowledge that the area in which I work may account for the number of cases) or quite how debilitating it is. It is for these reasons this portfolio will focus predominantly on emotional neglect According to the Nursing Midwifery Council (2008) the health visitor role is to promote and protect the population’s health and wellbeing.

To prevent, identify and minimise risk of interpersonal abuse, violence, safeguarding children and other vulnerable groups. The Acheson report (1998) reinforces this by saying that the best way to reduce inequalities in mental and physical health is to improve interventions to parents, which is a vital element of the health visiting role. Consequently it is important that vulnerable groups are identified and strategies are put in place to support them (DH, 2009). It is difficult to describe vulnerability as a concept as the meaning can differ depending on the context in which it is being used.

The term vulnerability is used to identify individuals and groups at risk of harm (Spiers, 2000). Conversely it could be argued that everybody is vulnerable at some point in their lives, however age and circumstance have the greatest influence on who will be vulnerable and the reasons why (Penhale & Parker, 2008). This can be demonstrated as the DH (2000) regards adults as vulnerable when they are unable to take care of themselves, however Aday (2001) suggests that vulnerable groups can be defined as those who are likely to have additional needs and experience poorer outcomes if these needs are not met.

The area in which I practice as a health visitor has a greater number than the national average of households living in poverty (End Child Poverty, 2012). Poverty alone has the potential to increase the vulnerability of this and any population. It is only when one starts to factor in the startling prevalence of additional risk factors that one can fully comprehend quite how significant the potential extent for vulnerability, and consequently the increased probability of some form of neglect occurring within this locale actually is.

There are large numbers of young parents, families with one or both partners with a history of abuse, single parent families, substance misuse, domestic violence and unemployment. Nikulina, Widom and Czaja (2011) categorically state that child neglect is positively related to poverty. I do not agree entirely with this statement. During my weeks in practice I have observed numerous cases of abject poverty and the deprivation in which families are striving to live.

Many of these fall far below what I would consider the minimum requirements to survive, and yet, on a daily basis I observe the resiliency and struggles that many parents undertake to try ensure better for their children. In support of this, Gilmore (2010) states that being unable to meet a child’s basic needs due to family poverty is distinctly different to neglect. One family that I visit is predominantly led by a single mother as her partner does not live within the family dwelling and the relationship could be described as ‘on and off’.

For the purpose of ease and to protect the mother’s identity I will call her Louise. Louise was adopted and at the time had a strained relationship with her adopted family. She currently has four children and is expecting her fifth. They live in social housing and their income is from benefits. As previously identified, this family has many of the risk factors associated with neglect. My first impression before even entering the house and meeting the mother were not good.

The front and side garden were strewn with detritus, the curtains were drawn despite it being midday and the front door broken. This gave me the initial impression of a haphazard, chaotic household. When Louise invited us into her home I was physically affected by the smell and the dirt throughout the living area. Through my limited experience I felt alarm bells ringing because I felt that neglect of the home would be synonymous with neglect of the children. This visit taught me a valuable lesson about being judgemental and the necessity of forming opinions based on facts.

On meeting Louise and her children, it was immediately apparent that all of her time and energy went into ensuring that her children are well cared for, nurtured and loved. Every child is clean and well presented. They are polite, friendly and well behaved. Each child is in good health, regular and consistent attendees at school, where they are achieving well. The youngest child is also meeting all the expected developmental levels for her age. There is no hiding that the environment in which they are being brought up is not, from my personal perspective, ideal.

It does however support that in spite of poverty and many of the risk factors that may preclude neglect, neglect is not necessarily endemic. Having said this, I have to admit that this family, within this locale, would appear to be in the minority. When considering some of the attendees at the weekly health clinic and observations I have made of the interactions between the majority of the mothers and babies that regular attend the session. I see mothers who regular self-harm and are alcohol dependent their children/babies entertaining themselves and always smiling profusely at anyone who offers them attention.

Mothers who are so low in mood/depressed that their children don’t look at them, don’t cry, aren’t able to speak and demonstrate this frustration through tantrums and aggression. Older siblings offering the support and care giving role expected of a mother, offering solace when their younger sibling cries, giving them bottles and rocking them to sleep whilst whispering sweet words. Mothers, who complain that their babies give them no peace, cry whenever they leave the room, yet ignore the child and offer no comfort when they are crying in the clinic. Most of these babies are ‘smiley’, self-soothe and practice self-containment.

This small demographic demonstrates many of the parental attributes associated with emotional neglect. They have poor parenting skills, low self esteem, poor social skills, have substance misuse issues, depression, lack of empathy and are experiencing domestic violence and/or other family dysfunction. This is evidently having an adverse effect on their children’s emotional health, which includes low self-esteem, anxiety symptoms and depression (Legano et al, 2009). During the last six months I have, as a consequence, become suspicious of very smiley babies.

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