Role of intent

The International Classification of Diseases (ICD) (World Health Organization, 1992) is used to apply a statistical classification to injury causes. The role of intent in the causal chain of injury is classed as intentional, unintentional or undetermined. Undetermined intent is used to capture those injuries that cannot be clearly assigned a category of unintentional or intentional injury, such as the teen who dies after taking a large number of sleeping tablets after a fight with a parent, but has not expressed any suicidal intent and has not left a note. It may be unclear whether the intention is to simply be able to sleep, to express - or draw attention to - their distress, or indeed to die. Unintentional injury has, in the past been classed as "accidental", however injury prevention practitioners tend not to use such terminology as it imparts a fatalistic or non-preventable perspective (Langley, 1986). An example of unintentional injury is a child breaking an arm due to a fall while skateboarding, or a young rugby player who sprains an ankle while tackling another player. Intentional injuries are those injuries where the intent is to cause harm. These include assaults such as a father who punches a teen with the intent of teaching him a lesson and at the most serious includes homicide. Intentional injury can also be self-directed, as in the adolescent who causes disfigurement by cutting her arms and legs; or at the most severe, suicide where the victim has clearly expressed an intent to die.

Researchers are now acknowledging that the division between unintentional and maltreatment-related injuries is perhaps an artificial one from a prevention perspective. Peterson and Brown (1994) compared the likelihood of injuries being either unintentional or maltreatment-related, and found that the following characteristics were not reliable predictors of an injury classified as "unintentional" or "maltreatment-related": low socio-economic status backgrounds; chaotic, noisy or unintentional families; crowded home environments; families that were highly mobile or had limited access to support services; or parents with histories of substance abuse or mental health issues. In a recent study exploring maltreated children identified in health data sets, Schnitzer, Slusher, Kruse, and Tarleton (2011) found that burns, poisonings and drowning-related injury in children under 4 years of age were frequently associated with maltreatment. If not in terms of inflicted injury then as injuries that were, for the most part, preventable and so occurred in absence of appropriate protective factors, particularly supervision.

Neglect

In Australia in 2010-11 neglect formed 29% of all substantiated reports of harm to children nationally, accounting for anywhere from 8% in Victoria to 49% in the Northern Territory (Australian Institute of Health and Welfare [AIHW], 2012). Despite forming a large proportion of substantiated maltreatment, Dubowitz (1994) suggested that neglect is the least well-researched form of maltreatment and that this lack of research was due to the lack of a clear definition of the phenomenon.

The focus on neglect in statutory child protection systems is "new" in one sense. The modern statutory child protection systems were set up in the 1970s and 80s to respond to severe cases of harm - typically, these were seen as events such as physical abuse or sexual abuse. There was an increased focus on neglect in the 1990s, based on social science research showing the potential for neglect to have severe impacts on children's development. Now the category of neglect typically forms the largest proportion of all substantiations of harm to children across each state and territory (with the exception of Victoria, where the largest category of harm is "emotional"). The Northern Territory stands out in particular, with neglect making up approximately half of all substantiations (AIHW, 2012).

However, neglect has a long history in the antecedents to the formal statutory child protection system in Australia. The early child rescue movement of the late 19th and early 20th century was primarily focused on "rescuing" children from neglect by "morally corrupt and lazy" parents (Bromfield & Holzer, 2008; Lamont & Bromfield, 2010). One of the reasons why the focus on neglect has re-emerged on the child welfare agenda is the understanding of the chronic nature of many forms of maltreatment - particularly neglect and emotional abuse. Many families in the statutory child protection systems across Australia have been subject to multiple notifications (chronic maltreatment), sometimes for several different types of child maltreatment (multi-type maltreatment). Child protection authorities now recognise the cumulative harm from ongoing exposure to lower levels of abuse or neglect, even if a single event does not satisfy the criteria for statutory intervention (Bromfield, Gillingham, & Higgins, 2007; Higgins & Katz, 2008). Research has also shown that exposure to one type of harm (such as neglect) increases the risk of exposure to other forms of harm (such as physical or sexual abuse), and the experience of multi-type maltreatment is common and associated with poorer outcomes for children experiencing one type of harm alone (Higgins, 2004).

There are a number of definitions of neglect, but generally speaking neglect is understood to be a failure, on the part of a caregiver, to provide for the physical, psychological, developmental and medical wellbeing of a child. However, unlike other forms of child maltreatment, there is no universally accepted, all-encompassing definition of the concept of neglect. Sexual abuse and physical abuse are clearly understood to be abuse regardless of the context, or the characteristics of the perpetrator or child. Physical and sexual abuse are acts of commission, a behaviour or incident can be clearly identified and described, neglect, on the other hand is the result of an omission of behaviour, a much more difficult concept to quantify and more likely to be influenced by risk factors that a parent or caregiver may or may not have direct influence over. Poverty is one such risk factor. Impoverished families may be unable to provide adequate nutrition, medical care or education for their children not because of a lack of recognition of the child's needs or a want to do so; but because of a lack of access to resources to enable that. Poor families also may face additional challenges in supervising children due to their lack of access to resources and safe products and the distraction of stresses and anxiety due to the concerns of everyday living.

Table 1 summarises some of the critical differences between different types of maltreatment in terms of how they are measured or identified, and the role of the child protection and criminal or justice system in each. Sexual abuse is the most easily classified type of abuse once it has been established that a particular behaviour has taken place: the child was either sexually abused or not and the child protection focus is whether or not a parent or caregiver will protect, supervise and respond appropriately to ensure the safety of the child. If a child is sexually abused a criminological focus results in charges and convictions, there is no regard for extenuating circumstances or the severity of the impact of the abuse on the child. Moving down the table there is an increasing complexity both in terms of identifying when a situation constitutes abuse and whether it warrants a child protection response. Physical abuse depends on whether or not an injury is inflicted but the severity (serious harm) and chronicity of that abuse may also be taken into consideration. For many types of maltreatment, charges and convictions of perpetrators are uncommon. In addition to the complexity of measurement definition, with a continuum of severity considered in the definition and the child protection response for exposure to domestic violence, emotional abuse and neglect, the child protection response must also consideration of whether the harm is likely to occur in the future.

Strauss and Kantor (2005) provided a definition of neglect for research purposes as:

Behaviour by a caregiver that constitutes a failure to act in ways that are presumed by the culture of a society to be necessary to meet the developmental needs of a child and which are the responsibility of the caregiver to provide. (p. 20)

This definition assumes cultural, behavioural, and responsibility factors play a role in the definition. The Queensland Child Safety Services described the occurrence of neglect as "when a child's basic necessities of life are not met, and their health and development are affected" (Queensland Department of Communities, 2011, para 11). Dubowitz, Black, Starr, and Zuravin (1993) pointed out that there can be no clear definition of neglect without a societal understanding of what constitutes adequate care and advocates for a shift from considering neglect to be a construct of parental culpability to that of a shared responsibility between parents, families, communities, and society. They suggested that any assessment for neglect must consider the frequency and chronicity of the behaviour and the likelihood and severity of potential and actual harm, the maturity of the child. Further, this must all be considered in the ecological context of poverty and parental or caregiving capability.

As can be seen in the conceptualisation of neglect in these definitions, understanding and evaluating what comprises "good enough parenting" remains subjective and difficult to evaluate (Budd, 2001), particularly if the evaluation is complicated by socio-economic and/or cultural factors. Ultimately, identification remains a subjective decision with parental competence, cultural context, child personality, and environmental risk all playing a role in its identification - despite arguments that identification of maltreatment must remain an objective decision (Higgins, 1998).

To further complicate the definitional issue, child protection authorities use the concept of harm, and some, serious harm, as a threshold for substantiating the actual or likely consequences of neglect, despite a lack of a concrete, universal definition of what serious harm looks like. It is possible for one incident of neglectful behaviour to result in the death of a child. Conversely, a child who is frequently left unattended may not come to any harm. As described by Straus and Kantor (2005), harm is not considered in definitions of other forms of maltreatment, sex with a child is sexual abuse by definition, the amount of harm or the ability to measure the harm caused by the act is considered in isolation (Strauss & Kantor, 2005).

Public health approach

Consideration of supervisory neglect suggests that there is no "one size fits all" definition. The National Framework for Protecting Australia's Children (COAG, 2009) calls for a public health approach to child protection. In such an approach responses to child protection issues are delivered across three "tiers". In the primary intervention level, the general population is targeted. Legislation prescribing an age limit under which no child can be left unsupervised would be such an intervention. At the secondary level of intervention, families identified as at risk of neglect are targeted and receive specific support to minimise the likelihood of maltreatment. Child care subsidies to families unable to afford after-school care are an example of secondary support. Tertiary interventions rely on the statutory child protection units in each state and territory to intervene in cases where significant harm is suspected and focus primarily on substantiation of maltreatment and then appropriate intervention. These families receive very targeted specific support to enable them to change their behaviours or remove children until they can be considered as safe as possible in their home environment.

The adoption of this framework means that supporting parents and caregivers to adopt behaviours that ensure adequate supervision at all times becomes "everyone's business". Researchers are compelled to identify risk factors associated with injury and at risk populations and disseminate information to injury prevention practitioners and policy-makers so that program can be designed and policies implemented that apply new research knowledge. Government agencies must provide support for high-risk families to enable them to make responsible decisions and keep their children safe. This may be in the form of financial support or providing facilities for occasional out of hours care, for example. Doctors and the health care sector should proactively take responsibility for educating parents and caregivers about developmental stages for children and changing patterns of risk, alerting parents to likely new risks as children grow. Teachers and child care settings should adopt best-practice principles for injury prevention and share knowledge with parents and children that, while modelled at school or in the child care setting, can also be implemented at home. Ideally, community members are involved and ensure their behaviours do not increase risk to children through adopting proven preventive methods like adhering to speed limits and installing pool fences for instance.

Resources and references

Kidsafe - The Child Accident Prevention Foundation of Australia
Kidsafe is a non-government organisation dedicated to preventing unintentional childhood injuries and reducing the resulting deaths and disabilities associated with injuries in children under the age of 15 years.

References

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