Contents

• Abstract
• Introduction
• Definitions of child neglect
• Fatal child neglect
• Conclusion
• Appendix
• Notes
• References

ABSTRACT

This paper outlines a developmental theoretical framework to underpin the definitions of fatal child neglect and provides an ecological perspective on prevention of fatal neglect, which takes into account broad social and contextual factors associated with neglect. In order to reduce the risk of fatal child neglect, the authors recommend a shift towards shared responsibility for child safety and wellbeing at the level of the family, community and society.

INTRODUCTION

Only rarely is fatal child neglect brought to the attention of the public in media headlines, such as the international examples quoted on this page. Instead, there has been a much greater emphasis on violent child deaths, and child protection failures that are regularly highlighted by the media (Goddard and Saunders 2001). Child neglect, in its non-fatal form, suffers from inattention in research, policy and human service practice. This has led to the now well-known term: the 'neglect of neglect' (coined by Wolock and Horowitz 1984).

Even less attention has been given to fatal child neglect. With little professional and community consensus on the phenomenon, there has not been an accepted theoretical framework underpinning the definition and explanation of fatal child neglect. This has meant that fatal child neglect is not well-recognised and definitions of fatal neglect are not aligned with definitions of neglect. As deaths of children from neglect are not well detected or classified as such this results in a lack of information and research in the area.

Mother gets 10 years for fatal neglect. She was charged with the death of her 13-year-old son Ismael, who suffered from cerebral palsy.... Ismael...depended on a ventilator and feeding tube for survival.... (Machado 2003)

Grandmother pleads guilty to neglect in fatal house fire.... The 66-year-old grandmother who was legal guardian of three of the six children who died ... in the fire.... Prosecutors allege cocaine use...contributed to the neglect of the children (Breckenridge 1999)

A babysitter has been jailed for neglecting his flatmate's three-year old daughter who drowned in a bath as he watched television.... (BBC 2003)

Parents of dead boy to be tried for bad care. The parents of a four-year-old boy who died last week appeared in court. They're accused of starving their son..... (WGAL 2002)

There has also been a continuing trend to view fatal child neglect within an individualistic perspective. Explanations of inadequate care of the child have focused on the child's mother and her personality or psychological characteristics (Tanner and Turner 2003). However, the role of social and economic factors, in contributing to fatal child neglect has received less recognition. In this paper it is argued that fatal child neglect must be recognised within a new framework. A developmental-ecological perspective is presented that gives recognition to the child's developmental stages, and recognises multiple layers of responsibility beyond the family for child safety and wellbeing.

This paper has two sections. In order to place fatal neglect in context, in the first part of the paper different definitions of child neglect are considered, including historical, legal, research and worker definitions. The size of the problem of neglect is also outlined. With this background in mind, in the second section, a new conceptualisation of fatal child neglect, is presented. The developmental-ecological perspective is applied to deaths of children from neglect. Although the framework may be considered to be commonsense, it makes explicit the importance of a child's developmental phase, and the contexts within which a child develops. The framework is presented with case examples of fatal neglect drawn from the state of New South Wales (NSW), Australia. In the concluding comments, questions of responsibility, risk and prevention in the policy context are raised.

DEFINITIONS OF CHILD NEGLECT

The lack of consensus on a definition of child neglect has been well documented (Minty and Pattinson 1994; Sullivan 2000; Tomison 1995). It is arguable that more than other types of child maltreatment, the concept of 'child neglect' embodies specific sociocultural values regarding adequate standards of childrearing. There has also been a historical shift in the use of the term. Different definitions of neglect reflect different historical and cultural perspectives. In addition, as with other social problems, each profession also has a perspective on the problem. This includes an explanation as to what the problem is - whether neglect is seen as a crime, or a health, psychological, social or legal problem (see, for example, Lawrence 2004). Assumptions are made, not only regarding the definition and scope of the problem, but also about its cause. Definitions are, therefore, inexorably linked to explanations of the set of events. Hence neglect is seen as a problem of the individual (child or parent), of social interactions, of the environment, or of family or social/structural institutions.

In this section of the paper, different definitions of neglect are presented. The definition of neglect adopted is important, as it will determine the size of the problem and how the problem is measured, and will determine what avenues will be the focus for prevention. Historical background is given before turning to legal and research definitions of neglect. Having presented an overview of the diverse usage of the term, consideration is then given as to whether there are common elements of neglect.

Historic definitions of child neglect

The word neglect comes from classical Latin neglectus, the 'fact of taking no notice' and is recorded as early as the 1500s (Oxford University Press 2003). However, it was 300 years later that the concept of 'child neglect' emerged. In colonial Australia, a child was 'boarded out' if his or her parents were seen to be inadequate or if the child was lapsing into crime (State Children Relief Act 1881, Tomison 2001 ¹ ). In the late 1890s the link between parental inadequacy and juvenile crime was emphasised in the establishment of separate Children's Courts. In the 1905 NSW Neglected Children and Juvenile Offenders Act, for example, a neglected child included a child:

who is in a brothel, or lodges, lives, resides ... with reputed thieves or with persons who have no visible lawful means of support ... who has no visible lawful means of support or has no fixed place of abode; ... or who sleeps in the open air in any public place; who without reasonable excuse is not provided with sufficient and proper food, nursing, clothing, medical aid or lodging; ... who is living under such conditions as to indicate that the child is lapsing into a career of vice and crime (NSW Neglected Children and Juvenile Offenders Act 1905, s.5).

A similar concern with neglect and juvenile crime can also be seen in Canadian legislation of the time. In the late 1800s in Canada, in the context of industrialisation, urbanisation, poor housing, overcrowding and poverty, child neglect referred to abandoned, destitute and unkempt children (Swift 1995). Many children were orphaned, abandoned, or destitute, often absconding and ending up in the streets of large cities loitering, begging, and committing petty crime.

Child neglect in Australia also had another historical path. Neglect was used in legislation drawn along racial lines that resulted in the forced removal of Aboriginal children from their parents - the 'stolen generation' (Human Rights and Equal Opportunity Commission [HREOC] 1997). In 1909, the Aborigines Protection Act gave the Aborigines' Protection Board power to remove Aboriginal children if the court found the child to be 'neglected'. In 1915 these powers were expanded so that Aboriginal children could be removed without the Board having to prove that the child was neglected. In the 1930s, a new Board, the Aborigine's Welfare Board, again had to prove that the Aboriginal child was neglected. However, this included destitution and poverty, which cast a broad net in the Aboriginal community (HREOC 1997). It was not until 1969 that the Aborigine's Welfare Board was abolished.

In the 1960s, public interest in child rescue was renewed - not because of concern about juvenile crime or inadequate parents, but by publication of medical research on physically abused children. In 1962, Dr Henry Kempe and his colleagues in their paper on the battered child syndrome described the clinical condition of 'young children who had received severe physical abuse, generally by a parent or foster parent' (Kempe et al. 1962: 17). The condition included unrecognised trauma by radiologists, orthopaedists, paediatricians and social service workers. This discovery shifted the focus of the child welfare system to physical child abuse, a much more politically palatable option as the emphasis deflected away from poverty and family support (Nelson 1986). Although neglect has been retained in the child welfare system, current definitions and explanations of neglect tend to focus on the individual level. In the Australian context, individual parental responsibility is emphasised, while factors such as poverty and inadequate housing and family support are not given weight. This emphasis can be seen in legal definitions of child neglect.

Legal definitions of child neglect

There is no uniform legal definition of child neglect in Australia. The word 'neglect' is not always specified in legislation that covers grounds for removal of children who are deemed to be in need of care and protection, criminal offences, and reporting of child maltreatment.

In NSW, for example, neglect is mentioned as a criminal offence. The types of neglect included are physical and medical neglect and the definition does not restrict the offence to parents:

A person, whether or not the parent of the child or young person, who, without reasonable excuse, neglects to provide adequate and proper food, nursing, clothing, medical aid or lodging for the child or young person in his or her care is guilty of an offence (NSW Children and Young Persons (Care and Protection) Act 1998, s.228).

In contrast, the grounds for making a report about child maltreatment focus on the risk of harm to the child, rather than the obligations of the parents or caregivers. According to the Children and Young Persons (Care and Protection) Act 1998, s.23, the child or young person is seen to be at risk of harm in a range of circumstances including when: '(a) The child's or young person's basic physical or psychological needs are not being met, or are at risk of not being met; and (b) The parents or other caregivers have not arranged and are unable or unwilling to arrange for the child or young person to receive necessary medical care.' Reportable conditions in NSW therefore include medical, physical and psychological neglect.

In Australian states and territories, parental responsibilities are clearly defined in laws that specify under what conditions a child is in need of care and protection (Australian Institute of Health and Welfare [AIHW] 2003). What is included in these conditions varies between each state/territory. Overall there are eight aspects of neglect that are covered (see Appendix A for examples of types of neglect covered by state/territory legislation). Each of these domains is not recognised in every state or territory, but all are recognised in the neglect research literature (Sullivan 2000).

An inclusive definition of neglect that appears in the literature, and can be seen when legislation from states and territories is combined (as in Appendix A), identifies children as neglected in a range of circumstances,² as follows.

• Abandonment: circumstances where the parents or guardians are dead, incapacitated, unable to be found, or are unwilling to care for the child.
• Physical neglect: basic physical needs are not met as the child is not provided with necessary food, shelter, and clothing.
• Medical neglect: the child is not provided with medical care.
• Psychological neglect: the child is likely to suffer psychological harm detrimental to the child's wellbeing.
• Developmental neglect: the child or young person's safety, wellbeing, or development is threatened due to the caregiver not taking into account the child's developmental capabilities.
• Supervisory neglect: the guardians of the child are unable or unwilling to exercise adequate supervision and control of the child or young person.
• Failure to provide guidance (fostering delinquency): permitting criminal behaviour.
• Educational neglect: the school-aged child is not regularly attending school.

Research definitions of child neglect

Researchers have measured child neglect in a variety of ways. Measures have included: reported or substantiated cases of neglect to child protection agencies, numbers of prosecutions of neglect, child welfare workers' perceptions of scenarios presented to them (Feldman, Monastersky and Feldman 1993), young people's perceptions of parental behaviour, parents' perceptions of their own behaviour (Salmelainen 1996), specific neglect scales (for example, Childhood Level of Living Scale and Trocme's child neglect index, Sullivan 2000), as well as neglect subscales in broader measures of child maltreatment such as the Comprehensive Childhood Maltreatment Scale (CCMS; Higgins and McCabe 2001). Neglect scales may be based on children's self-reports of their current situation, parents' reports on the child's current situation (for example, CCMS for Parents), or adults' retrospective self-reports (for example, Childhood Trauma Questionnaire, Bernstein et al. 1994).

Depending on which definition is used and how the problem is measured, estimates of the size of the problem of neglect vary considerably. As with other types of maltreatment (Lawrence- Karski 1997; National Center on Child Abuse and Neglect [NCCAN] 1988), estimates of incidence reflect a pyramid shape with the pinnacle representing a small number of criminal prosecutions, and the base, a large number of estimated cases in the community (as shown in Figure 1). The middle of the pyramid includes neglect that is reported to the child welfare system, including numbers of unsubstantiated and substantiated reports, and children removed from their homes due to neglect.

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There are gaps in knowledge regarding the extent of the problem of neglect. Taking NSW as an example, as shown in Figure 1, in 2002 there were 15 charges of criminal neglect laid (under s228 of the Children and Young Persons (Care and Protection) Act 1998) with ten proven (NSW Bureau of Crime Statistics and Research, unpublished data). In 2001-2002, there were also 1,511 substantiated reports of harm or risk of harm due to neglect in NSW, involving 1,241 children, giving a rate of 7.9 per 10,000 children aged 0 to 17 years (AIHW 2003). However, this figure underestimates the number of children for whom neglect was substantiated in NSW because if a child was the subject of neglect as well as another type of maltreatment then the report is generally labelled under the other category of maltreatment, rather than as neglect³. Further research in NSW would need to be undertaken to determine the number of children placed on Care and Protection orders due to neglect and the total numbers of reports of neglect.

In addition to the problem of data not being available, it is difficult to compare neglect estimates across jurisdictions due to the differences in how neglect is classified in official reports in each jurisdiction. As noted earlier, the states and territories in Australia vary in the definition of neglect specified in legislation and the type of matters that are reported (AIHW 2004).

Similar difficulties arise in comparing estimates of neglect internationally. For example, in Australia, the United Kingdom and Canada, reports of abandonment are included in the category 'neglect', whereas some states within the United States report on abandonment in the category 'other forms of maltreatment' in official reports (AIHW 2003; Trocme, MacLaurin, Fallon et al. 2001; UK Department of Health 2001; US Department of Health and Human Services 2003). Changes in child protection policies and practices also make it difficult to interpret trends over time when examining official reporting rates of neglect (AIHW 2004).

Differences in definitions and reporting procedures also contribute to different patterns that emerge from the data. In Australia, the United Kingdom and the United States, the rate of neglect appears to be highest for children under the age of five years (James 1994; UK Department of Health 2001; US Department of Health and Human Services 2003). With increasing age, substantiated reports of neglect decrease. In contrast, data from Canada indicate that children aged between 12 and 15 years, along with those aged up to three years, make up the largest groups (Trocme et al. 2001). This different developmental distribution may reflect differences in neglect reporting: the most frequent issues in investigated cases in Canada included general behaviour problems, irregular school attendance and negative peer involvement (Trocme et al. 2001). Differences in definitions thus also make it difficult to obtain a clear picture of the most common forms of neglect.

Measuring neglect

Neglect scales were an attempt to come to more objective measures of neglect, rather than relying on administrative categories in the child welfare and legal system. The work of Polansky and colleagues in the 1970s and 1980s resulted in the creation of the Childhood Level of Living Scale (CLL), which was designed to be a reliable measure of child neglect. In one study for example, Polansky and colleagues investigated the congruence of worker and parental views as to what constituted neglect. Using the CLL scale, they found there was close congruence between social workers and parents of different social classes as to what constituted neglect (Polansky and Williams 1978).

Both Canada and the United States have conducted National Incidence Studies (NIS) of child abuse and neglect. In these studies a global definition of child neglect has been adopted for research purposes (despite different legislative definitions operating in different jurisdictions). Information is collected from community professionals in order to estimate the actual number of children abused and neglected. This is not an accurate population-based estimate of incidence. The approach uses cases reported and estimates the number of cases known to professionals. The United States and Canadian definitions overlap, with the United States study having four domains with many subcategories, and the Canadian study having eight major areas (see Table 1).

These national incidence studies show that official rates of neglect from child protection systems grossly underestimate the actual incidence of neglect in society. In the most recent United States National Incidence Study, for example, it was estimated that almost 2 million children had experienced neglect - equating to a rate of 292 neglected children per 10,000. This was more than twice the size of the estimate based on United States child protection data, and far exceeds the rate suggested in NSW data (Sedlack and Broadhurst 1996).

Measuring the consequences of neglect

There has been increasing amount of international research on the short- and long-term consequences of child neglect (see Sullivan 2000 for a critique of this literature). Associations between neglect and poor social outcomes have been found at both the community and individual level. For example, Weatherburn and Lind (2001) found that the level of juvenile delinquency in communities in NSW could in part be explained by the level of child neglect in the community. At the individual level, the consequences of neglect for the child include attachment and selfesteem problems, impaired cognitive development and impaired academic achievement (US Department of Health and Human Services 2003). In addition, several large-scale longitudinal studies have shown that parental rejection of children, lack of a close emotional bond, lack of monitoring and inconsistent erratic discipline greatly increase the risk of later juvenile and adult involvement in crime (Henry et al. 1993; Loeber and Southhamer-Loever 1986).

Child neglect: One or many phenomena?

Considering the various definitions of child neglect used in research, legal and child protection contexts, it is evident that diverse situations are labelled as child neglect. But is child neglect one concept with subtypes or domains, or have several diverse phenomena been grouped together? Scholars in this field have proposed the following items as central elements of the concept of child neglect.

Omission

More than a decade ago, Zuravin (1991) noted that most definitions see child neglect as an act of omission (or a failure to act) that is judged to be inappropriate and damaging to the child or young person. The omission/commission distinction is, however, quite tenuous. A child may not experience an adequate standard of care through 'extraordinary inattentiveness' of the parent or through deliberate actions on the parent's part (Cantwell 1997). Examples of deliberate actions resulting in child neglect include: encouraging a child to commit a criminal offence; knowingly exposing the child to a person the caregiver knows may sexually abuse or exploit the child; or keeping the child home from school (Trocme et al. 2001). Moreover, a specific type of neglect can be caused by acts of omission or commission. For example, medical neglect can result from failing to seek medical care or refusing medical care when offered (for example, blood transfusions). Deliberate parental actions resulting in child neglect do not align well with the concept of neglect as an act of 'omission'. Deliberate parental actions are recognised as neglect in some jurisdictions such as California, where severe neglect includes wilfully putting a child in danger (Center for Disease Control and Prevention [CDC] 2002). More recent definitions and analysis focus on the consequences of the situation for the child, rather than on parental behaviour, motivation or intention (CDC 2002).

Standard of care

In contrast, standard of care is a central tenant in defining child neglect. Definitions of child neglect implicitly include a moral judgement on what are adequate standards of care, safety and protection of the child. Neglect is a negative term involving a judgement on the adequacy of child rearing and an assessment of what are acceptable risks. When definitions are translated into child welfare practice, a decision has to be made as to what constitutes adequate care of the child. If quality of care of the child is considered as a continuum, there is agreement at the extreme end of the spectrum as to what is considered harmful, but there is debate as to what is an adequate standard of care in less extreme situations, that is, a definition of 'good enough' parenting (CDC 2002).

Severity of consequences

Although neglect involves negative consequences for the child or young person, definitions vary in the level of severity of consequences for the child. Some definitions focus on the risk of serious danger to the health or safety of the child, while others focus on actual harm, impairment, or injury. 'Risk' is a poorly defined concept.

Chronic versus one-off

A distinction has been made between chronic persistent neglect and single episodes (Tanner and Turner 2003). This distinction draws attention to the frequency and duration of the child's situation. For example, a child may not be adequately supervised for one hour in a one-off incident in an overall pattern of adequate care and supervision of the child. In contrast, another child may not ever be adequately supervised, and may live without any parental monitoring. Such chronic conditions may not be able to be resolved without ongoing support (Tomison 1995). In the United Kingdom, neglect is defined as 'the persistent failure to meet a child's . . . needs' (Tanner and Turner 2003: 25).

Individual or community focus

In the majority of definitions of child neglect, it is presented as an individual problem, focusing on either the individual child or parent. Child-focused definitions concentrate on a child's physical, emotional, medical and social needs not being met (Dubowitz, Klockner, Starr and Black 1998). These definitions do not contain an explanation of neglect nor specify who is responsible for the child and the respective roles of the parents, community and the state. By concentrating on the child's wellbeing, no determination is made as to whether the caregiver/parent was aware of the consequences of their actions and thus whether the neglect was willful/intentional or not.

In contrast, other definitions, also at the individual level, focus on parental or caregiver failures in responsibilities and duties. Neglect is 'explained' as a failure by parents to provide supervision, or attend to the physical needs of the child. As the vast majority of child-rearing still falls to mothers (Kolar and Soriano 2000), more often than not, neglect has been connected with a critique of mothering (Swift 1995). The role of fathers and other family members in child rearing has not been well recognised (Tanner and Turney 2003).

Neglect has rarely been defined as a community or structural problem. Emphasis has remained on individual children and families, rather than placing community at the centre of the analysis. In the same way that neglect is often seen as failure of caregivers to provide for children's needs, the phrase 'community child neglect' would refer to how a community fails to provide for the social, psychological and emotional needs of children. This reconceptualisation would draw attention to the structural causes of neglect that include unemployment, racism and poverty (Kasinsky 1994).

There has been little recognition of the possible roles for the community and social structures in child rearing, despite increasing recognition of the ecological framework. Although individual parents are seen to have the primary responsibility to raise children, an ecological framework (proposed by Bronfronbrenner 1979) suggests several layers of responsibility exist. Not only are parents and the family responsible for a child's development and safety, but also the community and neighbourhood in which the child lives, since research findings have shown that this also directly influences the child (Homel and Burns 1985). The child is also situated within the broader social structural context and neglect has been found to be consistently associated with poverty, deprivation, social isolation, and neighbourhood poverty (Coohey 1996; Gaudin, Polansky, Kilpatrick, and Shilton 1993; Klebanov, Brooks-Gunn, and Duncan 1994; Polansky, Ammons, and Gaudin 1985; Sedlack and Broadhurst 1996; Weatherburn and Lind 2001). Nowhere is this clearer than for Indigenous communities (Stanley, Tomison, and Pocock 2003).

Considering the different forms of neglect, it appears that there are several domains of neglect which, although diverse, share central themes. The underlying concept across these domains is that the child experiences inadequate care and protection either in a chronic or episodic form and the inadequate care has consequences for the child (which may be severe). Although most definitions focus on neglect as a failure of maternal (or parental) care, research on the role of neighbourhoods and structural factors such as poverty in explaining neglect broadens these conceptions.

FATAL CHILD NEGLECT

There is not a well developed body of literature on fatal child neglect. This is due to the fact that fatal abuse (rather than neglect) and the battered-child syndrome have been the central focus in the modern child welfare tradition (Nelson 1986; Swift 1995). Also, while child neglect has been included as part of the child welfare tradition in legislation, child welfare practice and research, fatal child neglect remains firmly tied to legal and medical processes. Fatal child neglect has not, to date, been integrated well into research, practice and legislation on child neglect.

Defining fatal neglect

In this paper fatal neglect is defined as the death of a child due to inadequate care. In contrast to child neglect, there are definite points of reference in the definition of fatal child neglect. Fatal neglect is a retrospective concept: a death has already occurred. Thus, unlike child neglect, there is no argument regarding the level of consequences for the child. For the death to be attributed to neglect, it must be determined that the minimum standard of care required for the child to stay alive in the situation was not met either in a one-off situation or as part of an ongoing pattern, and that the cause of death must be able to be attributed to that inadequate standard of care. This distinguishes fatal child neglect from cases where the child may not have had an optimum standard of care, but the cause of death was not directly related to the neglect.

This definition, based on consequences to the child, does not restrict the concept of fatal neglect to parents or caregivers. Without specifying attribution of responsibility, the definition allows a broad perspective to be taken on who is responsible for a child's safety and wellbeing. Responsibility can be attributed to parents and caregivers, groups charged with care of the child (for example, school, child care centre), or whole societies (Gough 1996).

Recognising and classifying fatal neglect

There are difficulties recognising and classifying child neglect deaths. In NSW, as in many other jurisdictions, diagnosis of cause of death routinely involves medical and legal procedures. The cause of death entered on a medical certificate include all those diseases, morbid conditions or injuries that either resulted in or contributed to the death and the circumstances of the accident or violence that produced any such injuries.

Neglect and abandonment are recognised as causes of death in the latest version of the International Classification of Diseases (ICD-10) system of coding (ICD-10 code Y06). Although ICD-10 coding allows for classification of neglect, this determination is dependent on the definition of neglect and the information available regarding the social context of the child's death. Currently in coronial and forensic processes in NSW, the broader circumstances of the child's death may not be known. Information is not routinely collected regarding the standard of care the child received, including factors such as the mother's mental health status, or drug and alcohol dependency. With a lack of comprehensive information on these factors being routinely available, it may not be known what part these factors played in the death. In this paper it is suggested that social information regarding the context of the child's death should be routinely and systematically collected. It is also suggested that this much-needed information is called a 'social autopsy' (which parallels the use of 'psychological autopsies' in suicide research; see Beautrais 2000).

Child death review teams - multi-disciplinary teams that review the circumstances and patterns in child deaths - represent a point of departure from the traditional and narrowly focused diagnoses of cause of death. Most teams come to their own determination of cause of death using extensive records from human service agencies (Durfee, Durfee and West 2002). In NSW, the NSW Child Death Review Team was mandated, under the Children (Care and Protection) Act 1987, to identify and review all child deaths due to neglect or which occur in suspicious circumstances from 1996 to 2002^4. . The team consists of independent experts in areas of paediatrics and child health, forensic pathology, mental health, and child protection, as well as representatives from NSW government departments concerned with the safety and wellbeing of children (NSW Child Death Review Team 2002). The role of the team is to review child deaths with a view to prevention and formulate recommendations to be implemented by government and non-government agencies and the community for the prevention of, or reduction in, child deaths.

Research definitions of fatal neglect

Early reports on fatal child neglect examined cases where children died from 'passive neglect' because they were 'unwanted'; or when children died as an extreme consequence of deprivation, such as malnutrition and when parents failed to provide adequate health care (Margolin 1990). The definition of fatal neglect has now broadened to include common injury deaths. The role of parental supervision in these preventable injury deaths is now recognised.

For example, in research undertaken by Margolin in Iowa in the United States, the most common causes of neglect fatalities were drowning, house fires, failure of caregivers to seek or follow medical advice, and scalding. The role of inadequate supervision in childhood fatalities due to injury has also been demonstrated in Alaska and Louisiana. Landen, Bauer and Kohn (2003) found supervision was inadequate in 39 per cent of injury deaths in Alaska and 44 per cent of injury deaths in Louisiana. This was the most frequently violated safety standard. Caregivers were absent in 38 per cent of fatalities, and in 17 per cent of incidents, a caregiver actually increased the danger to the child. Most common causes of deaths involving inadequate supervision were drowning, pedestrian and fire deaths.

As with non-fatal neglect, recorded rates of fatal neglect certainly underestimate true rates. As shown in Figure 2, in NSW, the NSW Child Death Review Team attributed the deaths of 31 children to fatal neglect over the three-year period (Sankey 2003). This represents 1.4 per cent of all deaths of children and young people. These 31 children were aged between three months and 11 years, with most aged between one to four years. Criminal charges were laid in relation to six deaths (Sankey 2003).

The most common cause of death was drowning, accounting for 16 of the 31 deaths, followed by motor transport incidents (nine deaths). Other methods of death included fires, suffocation/strangulation, bronchopneumonia, starvation and firearm incidents. The circumstances of the 31 deaths were grouped into three categories: inadequate supervision by a caregiver, caregiver's negligent driving, and failure of a caregiver to obtain medical care. Inadequate supervision was by far the largest category accounting for 26 of 31 deaths. Toddlers aged from one to four years made up almost three-quarters of this group. Four children died as a result of their parents negligent driving, and one child died as a result of her parents' failure to obtain medical care.

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The circumstances of the carers of these 31 children were also examined. Of the 30 families (two children died in one family), 24 had experienced problems associated with health, violence, crime, social or economic difficulties. Thirteen families had experienced at least three or more family stress factors. Among the children whose deaths were due to inadequate supervision, 12 died in the context of family stress factors. An additional five children died while being supervised by drug- or alcohol-affected parents. Although inadequate supervision may result from a number of factors, the presence of enduring health, social and economic difficulties and parental substance use at the time of these children's deaths suggest that at least in some cases, these factors may have contributed to the fatal neglect deaths (Sankey 2003).

Broadened conception of fatal neglect

Before presenting an ecological-developmental perspective of fatal neglect, the possible broadening of the current definition of neglect is considered. Fatal neglect has not to date been aligned with recognised domains of non-fatal neglect. Yet a broader conception of fatal neglect can be logically developed from aligning fatal neglect with non-fatal neglect. There are several reasons why this alignment may prove to be valuable.

The ultimate aim of any discourse, research or theory regarding fatal child neglect is to prevent child deaths. The broadened conception may lead practitioners to take a second look at some types of child deaths, leading to improved assessment. Also, each different domain of neglect recognises different parental and societal responsibilities; this recognition may lead to the development of new prevention strategies. The alignment also breaks down the artificial barriers which separate children's wellbeing into the business of child welfare agencies (for non-fatal neglect), and legal and forensic agencies (for fatal neglect). A broadened conception of fatal neglect is presented for consideration.

The starting point for broadening the definition of fatal neglect is the domains of neglect that were developed from research literature and reflected in Australian state or territory legislation (as outlined in the first section). With the exception of educational neglect, in extreme circumstances each of these domains has a fatal form. Table 2 gives examples of causes of death drawn from analysis of child deaths in NSW, which correspond to these identified domains (NSW Child Death Review Team 2001 2002; Sankey 2003).⁵

Although abandonment, physical neglect (Trube-Becker 1977) and medical neglect (including for religious reasons, Asser and Swan 1998) are the most commonly recognised forms of fatal neglect, supervisory neglect has also recently been recognised (Bonner, Crow and Logue 1999; Sankey 2003). Developmental neglect, psychological neglect and failure to provide guidance are also recognised in the neglect literature (Cantwell 1997), but as yet these types of neglect are not recognised as forms of fatal neglect. There are different reasons for this. Fatal psychological neglect - that is, parental rejection of the child and emotional deprivation - has been recognised in the early work of Bowlby (1969) on bonding and attachment, and is seen in 'failure to thrive' syndrome and research concerning very young children in institutions. Rejection of the child can also lead to dehydration and starvation of the child, or failure to supervise the child.

Fatal developmental neglect has not been recognised, as it is only recently that the importance of children's developmental stages has received prominence. This perspective has not as yet been incorporated into analysis of death data. Developmental neglect draws attention to the caregiver's understanding of developmental stages of the child. It is relevant, for example, when a caregiver overestimates the capacity of children to ensure their own safety.

Source: Lawrence and Fattore (2002); Sankey and Lawrence (2003).

In contrast to developmental and psychological neglect, failure to provide guidance has a less direct relationship with cause of death. For young people who die from suicide or risk-taking behaviour, it may be a distal factor that played a part in the death.

Key parental responsibilities are recognised in these forms of fatal neglect. Rosenberg (1994) has recognised three overarching categories of parental responsibilities: to provide, to supervise and to intervene. The categories of fatal neglect can be classified into these three overarching categories: fatal neglect can occur if there is a failure to provide for the child's needs (including physical, medical, psychological, and developmental needs), a failure to provide supervision and guidance, or a failure to protect from harm. Whether or not the broadened definition of fatal neglect that is presented here is adopted, a developmental - ecological perspective is relevant.

A developmental framework for fatal neglect

Although there are well-documented patterns in violent child deaths according to the developmental stage of the child (Crittenden and Craig 1990; Finkelhor 1997; Lawrence and Fattore 2002), the developmental patterns in fatal child neglect have been less well recognised in the literature. Examination of deaths from neglect in NSW shows that children's vulnerability changes during the life course and at each developmental stage children are at risk of different causes of death⁶. Table 3 shows key developmental stages and causes of death in each age group with examples drawn from child deaths in NSW between 1996-2002.

Recognition of a developmental framework is important for practitioners, researchers and policymakers. To increase understanding of the relationship between developmental stages and fatal neglect, in the following section each developmental stage is presented with an illustrative case example. The developmental framework is important as it gives emphasis to children's evolving capacities and abilities and the changing social world of the child. It also draws attention to changes in parental responsibilities parallel to the child's development. As there is very little literature on fatal neglect, the following section presents a detailed account of each developmental stage and its relation to fatal neglect.

Source: NSW Child Death Review Team (1999, 2000a, 2000b, 2001, 2002); Sankey (2003).

Infants (birth to one year)

Infants are the most physically and socially vulnerable group, and are at risk of multiple forms of fatal neglect including abandonment, physical, medical and developmental neglect. Many different causes of death are associated with fatal neglect in infancy such as drowning, overheating, pneumonia, malnutrition, dehydration, choking, poisoning, overlaying and treatable medical conditions or diseases (for example, bronchopneumonia). These patterns have been found in NSW and international research (Asser and Swan 1998; Fieguth, Gunther, Kleeman, and Troger 2002; Margolin 1990; NSW Child Death Review Team 1999, 2000a, 2000b, 2001, 2002).

Fatal neglect in infancy is best understood within the context of the physical and developmental limitations of this developmental period. Because of these limitations, infants are entirely dependent on their caregiver for adequate physical care, nutrition, sensory stimulation and emotional support. The physical capabilities and limitations of infants can be seen in their stages of development (Owens 2002). During the first year of life, infants undergo rapid growth and development with their movement and balance being restricted by uneven growth and a lack of strength. With time, infants develop the ability to control their head, to roll over, to sit upright without support, and by ten months, most are crawling.

An example of fatal neglect in infancy is the case of Sean⁷, who died from excessive exposure to natural heat (NSW Child Death Review Team 2002).

Sean's case highlights the physical fragility of infants and their complete dependency on carers (being restricted to the sleeping environment in which they are placed and unable to push off blankets or remove layers of clothing).

Some infant deaths can occur from inadequate supervision at a critical moment when an infant is in an unsafe situation due to their physical limitations (Bonner et al. 1999). For example, with drownings in bathtubs, a typical scenario involves a caregiver bathing the child, and stepping out briefly to perform a chore such as answering the phone or getting some toys or clothes for the infant. When the parent returns, the baby is lying face down in the water, lacking the ability to stay in an upright position and not having the strength to right oneself once fallen over.

Other types of fatal neglect in infancy, such as death from malnutrition, result from slowly encroaching problems (Bonner at al. 1999). In addition to physical vulnerabilities, the social sphere of infants is usually severely limited, often being restricted to individual parents or carers in the home environment. This means that the infant may not come to the attention of others outside the family if they are neglected.

There are multiple policy options for prevention of fatal neglect in infancy. Parenting not only requires skills and motivation but knowledge of children's developmental stages and evidencebased safe practices for infants. In NSW, for example, material on safe sleeping environments is provided for parents within hospitals at the child's birth (the safe sleeping booklet produced by SIDS and KIDS). Parental knowledge and education is one area to consider and appears to be particularly relevant to inadequate supervision deaths (such as drownings), chokings, recognition of infant illnesses, and some unexpected sleep deaths.

However, other infant neglect deaths are not amenable to an educational approach. Infanticide, abandonment and malnutrition deaths raise questions regarding the adequacy of social support for parents of infants. Is there sufficient community, economic and social service support (such as child care and respite services) for parents of infants? Also, it must be considered whether social service interventions, designed to protect children, are adequate for infants. Reviews of infant deaths in some jurisdictions have led to the establishment of specific child welfare policies and services for infants. In Victoria, for example, a High Risk Infants Service Quality Initiatives Project, established in 1997, provides for specialist child protection workers for infants (Medson 1999; Naylor, Breen and Myers 1999).

Toddlers (one to four years old)

The following example, the death of Nick who drowned, is typical of fatal neglect of a toddler (NSW Child Death Review Team 2002; Sankey 2003).

Nick's case is a typical example of a fatal neglect drowning in this age group. As a curious and mobile 17-month-old, Nick was capable of wandering to a nearby dam when left with no adult supervision. Similar to some other fatal neglect deaths, the capacity of an older child to supervise a younger sibling was overestimated. As a toddler, the child himself was unable to recognise a dangerous situation, and was not capable of staying afloat or getting out of the dam once in the water.

For toddlers, most deaths from neglect occur in and around the home, where children of this age spend most of their time (Margolin 1990; Sankey 2003). The home is also a setting where carers may be isolated from other adults, and if a carer is distracted, falls asleep or is focussed on other activities, children are essentially left on their own. Although physically more robust than infants, toddlers are at risk of similar forms of neglect to infants including abandonment, medical, physical and developmental neglect. In addition, toddlers are exposed to new hazards due to their increasing mobility and curiosity.

Australian and international research shows that deaths of toddlers due to neglect are caused by drowning (in baths, swimming pools, and dams); pedestrian fatalities in driveways and local roadways; and scalding, burns and smoke inhalation from fires (Margolin 1990; NSW Child Death Review Team 1999, 2000a, 2000b, 2001, 2002; Sankey 2003). Inadequate supervision is a common theme in these deaths. Less common causes of neglect deaths in toddlers include passenger fatalities due to parents' negligent driving, deaths from treatable diseases and medical conditions, and malnutrition.

Fatal neglect of toddlers is best understood within the context of their developmental capabilities. At this age, children continue to grow rapidly and further develop both fine and gross motor skills. Most toddlers have learnt to walk and climb and are curious to explore the world around them through touching, feeling and tasting. Toddlers imitate parents and follow older children, and their newfound mobility and curiosity means they are able to disappear quickly and quietly. Toddlers are, however, just learning to control their body movement; they are still top heavy and having balance problems and are prone to falling over.

Toddlers are attracted to moving objects, noise and water (Geddis 1984). Living in the present moment, they focus on only one thing at a time, and will attempt to overcome obstacles to get what they want. Due to their small size they will climb or step out to see things. They cannot, however, judge speed or distance properly. As a result, they may run out into the path of vehicles, and go into water in pursuit of objects or toys. Toddlers have limited awareness of common hazards and become easily confused if a situation changes. Toddlers gain increasing confidence in familiar situations and typically overestimate their skills (Owens 2002).

Information regarding the relationship between fatal neglect of toddlers and children's developmental stages could be used for prevention work. The research on fatal neglect highlights unsafe situations for toddlers and the need for constant supervision of this age group (Sankey 2003). Attention has also recently been drawn to the responsibilities of local councils and sporting organisations in ensuring children's safety. Following reports identifying pool fencing as an issue in drownings of young children in swimming pools, an article entitled 'Neglect putting lives at risk' drew attention to the role of local councils in NSW in enforcing legislation on swimming pool fencing (Southern Courier 2004). Attention has also been drawn to the role of local councils and sporting organisations in adhering to safety guidelines after a young child was fatally injured at her local sports ground when a portable soccer post fell on her (Sydney Morning Herald 2004).

Educational campaigns to date have focused on a number of safety measures including supervision of children when swimming, fencing of private swimming pools, road safety, overheating in cars and more recently the supervision of young children around driveways. A greater understanding of children's developmental abilities across the community could potentially increase the potency of messages that are already promoted by groups such as Kidsafe and SafeWaters (Kidsafe 2004; SafeWaters 2004). Educational campaigns also need to be evaluated to gauge whether they are in fact an effective way to increase awareness, change behaviour and actually reduce the incidence of childhood injury and death.

The needs of children at this developmental stage also need to be examined more broadly. Both within and outside the home, environments need to be designed or modified to take into account the need for toddlers to explore the environment, develop skills, and play safely. For example, safe playspaces, which physically separate young children from hazardous areas such as dams and driveways, and construction of common playspaces, without traffic between houses, are design options (Tranter and Doyle 1996). Some of these strategies are considered in Farmsafe - Australia's National Strategy for Child Safety on Farms and promoted in the Safe Play Areas on Farms Resource Package (Farmsafe 1999, 2004).

Middle childhood and adolescence (five to twelve years of age)

Compared to infants and toddlers, fatal neglect is rare at this later developmental stage. Unlike infants and toddlers, the majority of neglect fatalities in middle childhood involve developmental and supervisory neglect and include transport fatalities, drownings and fire-related deaths.

The following example of fatal neglect in middle childhood is the case of Ben who died at nine years of age (Sankey 2003).

Ben's situation illustrates the increasing independence of children in middle childhood who play outside of the home environment. In this example, the nine-year-old who was caught up in a game, unaware of danger and not likely to have judged speed or distance accurately even if he had seen the car approaching.

The causes of fatal neglect for this age group can be understood within the developmental characteristics of this stage. During middle childhood, gross motor skills further develop and are mastered, and children become competent in activities such as bike riding, rollerblading, swimming and ball games. Children in middle childhood continue to learn through play, and tend to get caught up in play when with playmates. Although they are generally aware of common hazards, they do have difficulty in judging speed and distance, and have slow reaction times to changing hazards.

The case example of Ben raises questions about the availability and design of safe urban playspaces for children in middle childhood. Fatal neglect in middle childhood also raises questions about supervision for this age group, and the role of parents and the community. Once at school, the social sphere of children expands, as does the range of environments they inhabit.

The broader social sphere of these children suggests that others may be more aware when children are not being adequately cared for. If parents are not available or are unable to supervise their children, what other community arrangements are available to ensure a child's safety? Although child safety is typically conceived as the responsibility of individual parents, the child's context in the community has been forgotten. Child safety can be considered within the social capital literature, with communities providing supervision of children who are increasingly independent in middle childhood.

Teenagers (13 to 17 years of age)

Teenage deaths due to neglect are rare, and generally occur in the context of chronic neglect combined with other problems. An example of teenage fatal neglect is the case of Greg (NSW Child Death Review Team 2000a).

In Greg's case, his family's failure to seek medical care directly contributed to his death. However, the reasons for a teenager's drug use are also relevant, although more difficult to determine. Thus the seventh category of neglect 'failure to provide guidance' (identified earlier in Table 2) may be relevant to some teenage deaths. Although recognised in legislation as a form of neglect, failure to provide guidance is not currently recognised as a form of fatal neglect. The distal relationship between the neglect (as a lack of guidance) and the death makes it difficult to establish a causal link between them. Such distal relationships have also been noted in the deaths of teenagers associated with violent crime, and those from suicide and risktaking (Lawrence and Fattore 2002; Sankey and Lawrence 2003).

In research to date there have been very few reports of fatal neglect among teenagers. Teenagers have reached physical independence and the dangers potentially confronted by small children are generally not as hazardous to teenagers. With developed capacities, teenagers are able to anticipate changing situations and danger and take action to avoid it. With increasing social competence, young people are able to look after themselves, access health and medical care, and meet their own physical needs for food, clothing and shelter. The teenage years however, also include experimentation and some young people engage in risk-taking behaviour.

Other neglect deaths in this age group, which are also rare, include deaths from anorexia and suicide where psychological help may not have been sought for young people clearly in need of assistance.

CONCLUSION

It has been argued in this paper a broadened definition of fatal neglect will result in recognition of a range of child deaths in diverse circumstances as fatal neglect. It has also been argued that it is critical to analyse child deaths from neglect within a developmental framework, where children's developmental stages are recognised, as are the corresponding responsibilities of parents at each age. The profile of fatal neglect at each developmental stage, and the case examples lead to questions regarding prevention.

Fatal child neglect raises difficult policy questions: Who is responsible for prevention of fatal neglect deaths? What level of risk is acceptable within the society for children to be exposed to? What incidence rate of fatal neglect is acceptable to us as a society?

Within an ecological framework, prevention of fatal neglect can be undertaken at different levels: the family, community, neighbourhood and social structural levels.

• Families can be resourced to be able to undertake their parenting role, and parental education can alert parents to the needs of children at different developmental stages.
• Communities can be resourced with community workers to build social support. Communities can also build social trust and offer community supervision of children growing towards independence.
• Neighbourhoods can be designed with children's safety, wellbeing and development in mind - for example, urban design can enhance the availability of playspaces for children with designs that separate playspaces from roads and traffic, or provide safe playspaces away from bodies of water or driveways.

Finally, social policy can address the structural dimensions of fatal neglect and the association between neglect and poverty and deprivation. A shift towards shared responsibility for child safety and wellbeing at each of these levels - individual, family, community, and structural - could lead to advancements in reducing the incidence of fatal neglect.

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