The Nature of Neglect and Its Consequences
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Neglect is the most common form of child maltreatment. Repeated calls have implored the scientific community to remedy the “neglect of neglect,” the paucity of research on neglect relative to abuse. Barriers to the advancement of scientific knowledge and to tackling this intractable public health problem include the difficulties defining neglect and less concern regarding its relative harm. Despite these challenges, numerous studies on the nature and consequences of child neglect have been conducted. Many of these have been published since major reviews last evaluated research on neglect. This review focuses on recent advances in research regarding child neglect’s nature, measurement, prevalence, and consequences. It is guided by the question: What is new about neglect? Although much work remains to be done, noteworthy advances have been made.
KeywordsChild neglect Definitions Prevalence Effects Measurement Assessment
Introduction: The Historical “Neglect of Neglect” and Past Reviews
Approximately 35 years have passed since the first alert to the scientific community regarding the “neglect of neglect,” the inattention to child neglect research despite its prevalence (Wolock and Horowitz 1984). Researchers have continued to note the relative dearth of knowledge on child neglect, and multiple calls to action have been made to remedy this gap (Widom 2013; US Department of Health and Human Services [USDHHS] 1997). A comprehensive review by Proctor and Dubowitz (2014) examined nearly 30 years of literature on neglect through 2012. The purpose of the present review is to assess the current state of knowledge on neglect focused on research published between 2012 and 2019. In this chapter, we review recent literature on the definitions and nature of child neglect, its measurement/assessment, and its consequences. A second chapter in this volume focuses on the etiology of neglect and preventive and other interventions. We fully recognize that knowledge is also derived from clinical experience, a different kind of evidence helping guide good practice. These chapters, however, are limited to a consideration of research on child neglect.
Definitions of Child Neglect
Neglect is often defined as omissions in care by parents or surrogates that constitute a failure to meet children’s basic needs, in contrast to abuse, acts of commission. A scientific consensus on one definition of child neglect however has proven elusive and may not be realistic. Different disciplines have inherently different approaches to neglect. A pediatrician may be concerned about a baby growing poorly due to inadequate food, whereas a prosecutor may be focused on criminal behavior. Another barrier is the relatively nebulous nature of neglect as the inadequacy of care versus discrete abusive acts. There is also a tension between focusing on parental behavior (and responsibility) or on children’s unmet basic needs or rights. In addition, neglect exists on a continuum from grossly inadequate to optimal care; the likelihood and severity of harm associated with various levels along this continuum are often difficult to gauge (Proctor and Dubowitz 2014). The lack of a clear definition to anchor neglect research impedes scientific progress, often precluding comparisons across studies.
Variation in law . Definitions of neglect by states in the USA are guided by the federal Child Abuse Prevention and Treatment Act (CAPTA).These definitions thus apply especially to research based on child welfare policy and practice. The 2014 Institute of Medicine (IOM) and National Research Council (NRC) report provided this definition: “The failure of a parent, guardian, or other caregiver to provide for a child’s basic needs” (p. 21). However, US states vary widely in their legal definitions of neglect. Most include abandonment and failure to provide health care and adequate nutrition, supervision, and shelter, but they vary considerably regarding educational and emotional neglect and prenatal exposure to illicit substances (Rebbe 2018). Furthermore, states vary in whether they include religious exemptions (i.e., excusing omissions in health care based on religious beliefs), neglect caused by poverty, and actual as well as potential harm (Rebbe 2018). While actual harm standards offer relatively concrete, objective guidance, there is concern that such restrictive interpretations of CAPTA preclude child protection in many potentially harmful situations.
Parent versus child focus. In contrast to the above, researchers have advocated for child-centered definitions of neglect, defined as circumstances when a child’s basic needs (or rights) are not adequately met, thus harming or jeopardizing a child’s health, development, or safety. This alternative definition prioritizes what is important for children and their experiences over parental responsibility or culpability (Proctor and Dubowitz 2014). Child-centered definitions of neglect draw from ecological perspectives, which recognize the often multiple, interrelated multilevel contributors to child well-being, many of which may be beyond parents’ control (e.g., poverty; Belsky 1993). Child-centered definitions allow for consideration of a greater spectrum of potentially harmful circumstances, not limited to those primarily due to parents’ omissions in care. Focusing on children’s needs offers a more constructive less blaming frame, one that may better resonate with parents, facilitating their engagement in services. This does not imply that the parental role should be ignored (Proctor and Dubowitz 2014).
A child-centered definition of neglect is supported by evidence of contributors beyond parents’ control, including structural and environmental factors (e.g., the availability of drugs in a community) to neglect (Freisthler et al. 2017). In addition, there has been recognition of bureaucratic neglect (e.g., the failure of the child welfare system to meet children’s needs) as well as societal neglect (e.g., a wealthy society that fails to ensure access to health care for all children; Yang and Ortega 2016). It is also important to consider neglect in indigenous communities in the context of historical trauma, including the legacy of colonization and forced removals of children from their families, another view supporting a child-centered definition (Newton 2018).
A phenomenon that exists on a continuum. Care naturally occurs on a continuum, and the gray zone is large. It is difficult to establish specific cut points at which inadequate care becomes neglect or likely to cause harm. For many problems such as not having enough food, it is tricky to pinpoint when a threshold is crossed (e.g., inadequate food on a regular basis, lack of specific nutrients, or experiencing hunger). Currently, varying thresholds are used to indicate child neglect in research, contributing to inconsistent findings.
Child’s development level . There is a long-standing consensus on the need for developmentally sensitive definitions of neglect. Children’s needs for care vary greatly over the course of their development, and there are naturally individual-level differences among children. Recent studies have begun to consider what constitutes neglect during adolescence (Kobulsky et al. 2019b). More than younger children, adolescents’ dual, competing needs for independence and parental nurturing, monitoring, emotional support, and protection require consideration in conceptualizing neglect. The blurred responsibilities of adolescents and their parents may allow for the normalization of potentially persistent, damaging situations (e.g., routinely not intervening if the adolescent rather than the parent is held responsible for the inadequate care; Hicks and Stein 2015). Moreover, potentially neglectful situations that are unique to adolescents, such as having significant caregiving responsibilities for younger siblings or parents, should be considered in terms of their development and needs (Hicks and Stein 2015), as well as the cultural context.
Beyond the poles of early childhood and adolescence, what constitutes neglect during different developmental periods may be unclear. A recent study of experts aptly illustrates this point, demonstrating the difficulty in defining a specific age at which children can be left home alone (Jennissen et al. 2018). Nearly all experts considered leaving a 4-year-old home alone neglectful but not a 14-year-old; 88%, 48%, and 4%, respectively, considered leaving a child 8, 10, and 12 years old home alone neglectful, respectfully (Jennissen et al. 2018). In addition to development, there are multiple other considerations regarding children left home alone: child’s physical and mental health, duration of time left alone, time of day or night, presence of nearby support, and the nature of the neighborhood. This raises the importance of context.
Social context and culture . Neglect becomes even more difficult to define when taking a multicultural or international perspective (Lansford et al. 2015). Some scholars contend that the very concept of child neglect is biased by Western ideas, prioritizing nuclear family structures and parental versus community responsibility for the child (Laird 2016). Their contentions are mainly with parent-centered versus child-centered definitions of neglect. The difficult circumstances of many families (e.g., inadequate access to health care) do need to be considered, rather than simply and solely blaming parents for conditions that may be beyond their control. In sub-Saharan Africa, the lack of education and economic resources for ensuring child safety contributes to injuries from burns and falls (Laird 2016). In another example, having an adolescent (or child) take care of younger siblings may be a necessity for low-income families but irresponsible in other contexts. Missed educational opportunities due to such arrangements may also vary by society, particularly for girls. In response to these myriad circumstances, researchers in one international study defined neglect based on children’s perceptions that their parents did not pay attention to them and the things that were important to them (Lansford et al. 2015).
Children’s needs partly depend on the demands of adulthood, which vary by society and culture. For example, the education and skills needed for a living wage job in the USA are considerably higher than in rural parts of a low-income country. In another example, the risks and benefits of “free-range” parenting, which emphasizes fostering children’s autonomy and sense of responsibility, need to be viewed in the context of the family and community culture. In contrast, “helicopter” parenting emphasizes vigilance and protection; this may unintentionally foster dependency and fearfulness (Pimentel 2012). These parenting approaches vary within and across cultures. Ultimately, children’s needs are largely individually determined, although a remarkable degree of common ground exists. This is demonstrated by the international consensus regarding the needs of children in the United Nations Convention on the Rights of the Child (United Nations General Assembly 1989) and in a study of indigenous communities (Newton 2017).
Bias and perceptions. Biases may shape perceptions of neglect. Racial bias in perceptions of neglect has been documented, with caseworkers more likely to perceive a scenario featuring a Black baby (96%) as neglected than a White baby (94%, Ards et al. 2012). Gender may also affect perceptions of neglect. For example, in one study, laypersons were more likely to perceive a situation as neglectful if the gender of the parent and child in vignettes matched (Dickerson et al. 2017). Another study found that neglect was less often attributed to fathers than mothers (Kobulsky and Wildfeuer 2019). This likely reflects higher caregiving expectations of mothers. On the other hand, when neglect was attributed to fathers, it more often resulted in a criminal investigation (Kobulsky and Wildfeuer 2019). This may indicate a less forgiving attitude (i.e., more criminalization) when neglect is attributed to fathers. These biases underscore the fallibility of considering neglect through a parent-blaming lens and the importance of a child-centered approach.
Youth may have different views from parents and professionals in what constitutes neglect, with youth perceiving a wider spectrum of neglectful scenarios. For example, youth considered parental failure to provide emotional sensitivity as potentially neglectful (Hicks and Stein 2015). Youth similarly considered favoring siblings or prioritizing partners over children as potentially neglectful (Hicks and Stein 2015). The meaning and cognitive appraisal of the experience influence the potential effect on the youth. And, this would be influenced by the relationship of the responsible party to the child and other sociocultural and contextual factors.
The Heterogeneity and Dimensions of Neglect
Neglect varies by subtype, chronicity, frequency, developmental timing, severity, co-occurrence, the relationship of the responsible party to the child, and context. Some of these have already been addressed. Most definitions recognize neglect to be a multidimensional phenomenon, but there are a variety of typologies.
Subtypes . The IOM and NRC report (2014) specified that neglect may be physical (failure to provide food, shelter, or supervision), medical (failure to provide medical or mental health treatment), educational (failure to educate a child or attend to educational needs), or emotional (inattention to emotional needs, failure to provide mental health care, or permitting child to use alcohol or drugs). Other typologies combine medical and physical neglect or emotional neglect and emotional abuse (Barnett et al. 1993; Sedlak et al. 2010). Some separate physical and supervisory neglect or moral-legal neglect (e.g., exposing a child to illegal activity or other activities that promote delinquency) and emotional neglect (Barnett et al. 1993). Neglect subtypes are largely based on tradition and are not necessarily supported by empirical research. For example, a confirmatory factor analysis found evidence for physical, supervisory, and emotional neglect but not for educational neglect as a distinct subtype among 12- and 14-year-olds (Dubowitz et al. 2011). An exploratory and confirmatory factor analysis suggested five subtypes for adolescent neglect: inadequate monitoring, inattention to basic needs, permitting misbehavior, exposure to risky situations, and inadequate support (Kobulsky et al. 2019b). Clearly, subtypes of neglect can often co-occur.
Chronicity and frequency . Chronicity is an important aspect of neglect. Neglect is usually considered to be a problem only when there is a chronic pattern; sporadic lapses in care are less likely to be viewed as neglect (Logan-Greene and Semanchin Jones 2015). Likewise, chronic abuse can be construed as neglect (e.g., sexual abuse that is long ignored). Many situations only become harmful when there is a pattern of omissions in care. Some single lapses, however, can be fatal, such as an infant left unattended in a bathtub and missed medical care for children with certain medical conditions (Okun 2017). The frequency or recurrence of neglect experiences, such as measured by CPS referrals, is sometimes used as a proxy for chronicity (Jonson-Reid et al. 2019). However, while chronicity implies persistence over an extended period, frequency simply refers to the number of known instances.
Timing of neglect. Experiences of neglect may have varying salience depending on when they occur in relation to a child’s development. For example, a father’s absence may be far more difficult for a 10-year-old boy compared to a 4-year-old. Similarly, a mother’s unresponsiveness to an infant’s cues due to postpartum depression likely has different impact compared to an older child. One recent study found that of three classes of neglect, chronic, late (i.e., middle or late adolescent onset), and limited, the late neglect group had the highest risk for young adult substance use and related problems, suggesting the importance of developmental timing (Dubowitz et al. 2019a).
Severity . The severity of neglect varies considerably from circumstances that are questionably harmful to others that are fatal. Severity concerns potential or actual harm and the seriousness of the consequences. For example, neglect resulting in occasional hunger due to missed meals is clearly less severe than neglect resulting in stunting or wasting due to severe malnutrition. Potential harm is important given an interest in preventing harm. A challenge regarding potential harm is estimating the likelihood and seriousness of outcomes, in the short and long term. For example, leaving a toddler in the care of an older, preadolescent child for a short period may be perceived to be less severe than leaving this child in the care of a known abuser. Moreover risk varies depending on the child and circumstances. For example, a mature 8-year-old may manage adequately being home alone after school. A child this age who is involved in setting fires presents a different risk. Child welfare policies in the USA tend to capture only the more severe circumstances for substantiating neglect (Proctor and Dubowitz 2014). An advantage of a child-focused definition is that less severe circumstances (e.g., an unimmunized child) may still be addressed, without necessarily involving CPS.
Co-occurrence. Clearly, neglect frequently co-occurs with other forms of maltreatment and other adversities, such as exposure to community violence and poverty. In addition, children may experience more than one subtype of neglect. Patterns of co-occurrence vary by study samples, measures, and the adversities studied (Debowska et al. 2017). Research may focus on cumulative adversity or the similar construct, poly-victimization. One study found that physical and supervisory neglect was strongly linked to other forms of victimization (Turner et al. 2019). Physical neglect was strongly associated with physical and sexual abuse, as well as economic stressors; supervisory neglect was associated with victimization by non-relatives.
Measurement and Assessment
The challenges in defining neglect have implications for its measurement and assessment. For research purposes, neglect may be measured by CPS reports, parent or child self-reports, reviews of medical records, and direct observation. Each method has advantages and shortcomings. CPS reports are limited to instances that have been identified, reported, screened, and investigated, with bias a concern, and these reports are also susceptible to varying assessment, laws, and policies. Self-report of neglect may be particularly prone to recall error and social desirability (Compier-de Block et al. 2017). Medical records generally capture very limited aspects of children’s experiences. Videotaping and coding behavior and home observations, such as adequacy of food and presence of hazards, are labor intensive. Both may also be hampered by the Hawthorne effect (i.e., behaving differently when watched). To partly circumvent the limitations of any one measure, information from different measures and sources may be integrated.
Among the most prominent self-report measures of neglect have been Straus’ Multidimensional Neglectful Behavior Scale and its derivations (Dubowitz et al. 2011; Kobulsky et al. 2019b; Straus et al. 1995). These measures capture multiple dimensions and key characteristics of neglect and its subtypes and have known psychometric properties (Dubowitz et al. 2011; Kobulsky et al. 2019b). Another is the Child Neglect Questionnaire, a 46-item measure that incorporates both parents’ and children’s perspectives (Stewart et al. 2015). Results supported physical, emotional, educational, and supervisory neglect dimensions, with discriminant, concurrent, and predictive validity (Stewart et al. 2015). Other measures include neglect together with other forms of maltreatment. For example, the Maltreatment and Abuse Chronology of Exposure Scale includes retrospective self-report of the timing of physical and emotional neglect; these subscales had adequate test-rest reliability and convergent validity (Teicher and Parigger 2015).
Although practice guidelines exist for the clinical assessment of neglect (DePanfilis 2006), little research has been done in this area. Unclear definitions, time constraints, and lack of training complicate the screening for and assessment of neglect in practice settings (Delong-Hamilton et al. 2015). The Graded Care Profile 2 (GCP2) is a practical assessment tool of neglect in four domains: physical care, care and safety, emotional care, and developmental care (e.g., stimulation; Johnson and Fisher 2018). It is designed to help social workers, home visitors, and other professionals know when to provide referral, prevention services, or more intensive intervention. The tool was recently found to be reliable and valid in centers serving neglected children in England (Johnson and Fisher 2018). The Rapid Assessment of Supervision Scale (RASS) is a clinical decision-making tool for the assessment of supervision of young children; it has been shown to predict injury (Anderst et al. 2015). Similar efforts are underway, such as the initial Signs of Neglect in Infants Assessment Scale (SIGN; Arimoto and Tadaka 2019).
Incidence and Prevalence of Neglect
Estimations of the incidence or prevalence of neglect clearly depends on definitions and assessment methods. Neglect is by far the most common form of maltreatment reported to CPS in the USA, typically comprising 75% of reports investigated and involving 7 per 1,000 children in 2017 (US DHHS 2019). Reports of neglect were four times more common than of physical abuse and nearly nine times more common than of sexual abuse (US DHHS 2019). By age 17, 25% of youth in the USA have had a CPS neglect report, with substantially higher rates among Black youth (Kim et al. 2017). Studies outside of the USA have similarly shown neglect to make up more than half of CPS reports (Braham et al. 2018).
Prevalence studies based on self-report are important because neglect is often not reported to CPS (Sedlak et al. 2010). A meta-analysis of studies based on survey and interview methods found a prevalence of 16% for physical neglect and 18% for emotional neglect (Stoltenborgh et al. 2013). More recently, the National Survey of Children’s Exposure to Violence found 15% of children 0–17 years had experienced lifetime neglect and 6% in the past year (Vanderminden et al. 2019). A Canadian study found a somewhat higher annual incidence of neglect: 26% for children aged 6 months to 4 years, 29% for those aged 5–9 years, and 21% for the 10- to 15-year-olds (Clément et al. 2016).
The paucity of studies on the prevalence of neglect outside of North America has been noted (Stoltenborgh et al. 2013). Recent analyses have begun to remedy this situation, often using the International Society for the Prevention of Child Abuse and Neglect’s (ISPCAN) Child Abuse Screening Tool (ICAST; for review see Kobulsky et al. 2019a). However, studies of low- and lower-middle income countries remain rare. A large study (n = 41,194) of Balkan countries identified rates of neglect ranging from 23% (lifetime) and 17% (past year) in Romania to 48% (lifetime) and 20% (past year) in Bosnia (Nikolaidis et al. 2018). Rates as high as 94% of children exposed to emotional neglect and 89% to physical neglect were found in Burundi, a country severely affected by civil war and political violence (Charak and Koot 2014). These rates were three to four times higher than in Canadian, German, and South Korean samples (Charak and Koot 2014).
Of note, rates of physical and sexual abuse have declined dramatically in the USA since 1990, by 53% and 65%, respectively (Finkelhor et al. 2018). In contrast, the rate of neglect has declined by only 12%. The reasons for this only modest decline are likely complex. They may include lack of attention to neglect and the related difficult circumstances faced by many families (Finkelhor et al. 2018).
Summary of consequences of neglect identified by research 2012–2019
Lower cognitive functioning
Less involvement with tasks and less creativity
Lower overall intelligence
Deficits in interpreting emotions
Lower general intelligence and IQ, intellectual performance, numeracy, language, and literacy skills; impaired language development and cognition
Impaired executive decision-making
Disciplinary problems, suspensions, grade retention, and more special educational needs
Depressive, anxiety, eating and behavioral/conduct disorders
Suicidal behavior and attempts
Risky sexual behavior, sexually transmitted infections (STIs)
Psychological maladjustment, hostility or aggression, emotional dysregulation, lower emotional responsiveness, negative worldview
Dependence or defensive independence
Poor self-esteem and low self-efficacy
Insecure-avoidant and insecure-disorganized attachment; withdrawn and avoidant behavior
Negativity in play
Disruptive behavior, aggression, conduct problems
Internalizing behavior problems, attention deficit hyperactivity disorder, coping problems, emotional dysregulation
Injury and fatality
Ischemic heart disease, migraine headaches, and arthritis
Reduced cortical thickness in prefrontal, parietal, and temporal lobes
Lower hippocampal volume (males)
Altered white matter connectivity
Heightened amygdala activity and differences in functional coupling of amygdala and medial prefrontal region when viewing emotional facial expressions
Differences in activities of the brain associated with executive control
Lower emotional knowledge
Better problem solving, abstraction, and planning
Less cognitive flexibility
Deficits in interpreting emotions
School dropouts, school adjustment problems, less academic competence
deficits in interpreting emotions
Less educational attainment, employment
Externalizing behavioral problems
Less prosocial behavior
Depression, posttraumatic stress, anxiety, sexual concerns, anger, dissociation, sleep disturbances
Aggression and delinquency
Sexual risk taking
Major depressive disorder, dysthymia, posttraumatic stress disorder, psychopathy, non-suicidal self-injury, psychopathology
Substance use and severe withdrawal symptoms
Risky sexual behavior
Violence perpetration and victimization
Epigenetic modulations in genes
Research has continued to show neglect’s detrimental effects on cognitive outcomes, including IQ, achievement test scores, reading ability, perceptual reasoning, and academic performance – from early childhood through adulthood. We focus on systematic reviews in our summary of recent literature.
Preschool. Studies have identified cognitive effects of neglect or emotional abuse in preschoolers (Naughton et al. 2013). Specifically, infants with neglect and failure to thrive had lower cognitive performance; neglected infants with depressed mothers had language delays. There were, however, no differences in play complexity and cognitive play among those 0–20 months. Memory delays have been found in toddlers aged 20–30 months and language delays in children aged 3–5 years. In children aged 4–5 years, neglect was associated with lower cognitive functioning, less involvement in tasks, less creativity, and difficulty discriminating emotional expressions of peers. Lower overall intelligence in neglected children aged 5–6 years was also identified (Naughton et al. 2013).
School-aged children. Another systematic review of neglect or emotional abuse in school-aged children (5–14 years old) suggested that neglect led to inferior general intelligence, executive decision-making, intellectual performance, and numeracy, language, and literacy skills (Maguire et al. 2015). More disciplinary problems, suspensions, grade retention, and special educational needs have been observed among neglected children, as well as deficits in emotional knowledge (ability to identify and understand emotions; Maguire et al. 2015). In children age 3–10 years, neglect was associated with impaired cognitive and language development (Spratt et al. 2012). However, in one study, neglected children were found to have better problem-solving, abstraction (identification of a common relationship or feature in a series), and planning abilities than non-maltreated children; although unexpected, this is consistent with children being left alone to deal with their environment (Maguire et al. 2015).
Adolescence and adulthood. In adolescence, physical neglect has been associated with decreased cognitive flexibility, an executive function that involves the ability to shift thinking from one concept to another (Spann et al. 2012). Deficits in interpreting emotions have been demonstrated among neglected adolescents and adults (Doretto and Scivoletto 2018). Other studies found emotional neglect to be associated with difficulty identifying feelings and recognizing emotional cues, with low IQ mediating this relation (Cahall Young and Widom 2014). Importantly, neglected children who lived in a stable environment for longer periods of time had higher IQ scores compared to those with less stability (Spratt et al. 2012).
One challenge in synthesizing research is that studies vary in whether they compare neglected children to non-maltreated or abused children. Some studies have pointed to its detrimental influence on school dropouts, but not on academic performance and school engagement, relative to maltreated youth (Naughton et al. 2017). Other studies have associated neglect with school adjustment problems in South Korean adolescents, with direct and mediated effects via emotional/behavioral problems and impaired academic competence, peer attachment, and self-esteem; these relationships tended to be stronger and more consistent than those related to physical and emotional abuse (Lim and Lee 2017; Oh and Song 2018). Another study identified associations of neglect and lower rates of high school graduation and employment stability (Font and Maguire-Jack 2020). The latter finding was more significant for neglect than for abuse.
In sum, neglect appears clearly related to impaired cognitive and academic functioning, although many studies do not account for other adversities often associated with neglect. Certain mediators, such as peer attachment and emotional and behavioral problems, offer useful pointers for interventions to help ameliorate the harms associated with neglect. Likewise findings that stability in the environment may buffer effects of neglect offer important direction for developing interventions.
Research has demonstrated the relation between neglect and attachment and an array of mental health problems throughout the life course. Across studies, neglected youth are at two to three times higher risk for depressive, anxiety, eating, and behavioral/conduct disorders, with a dose-response relationship for depressive disorders (Norman et al. 2012). Broad relations between neglect and suicide attempts, risky sexual behavior, sexually transmitted infections (STIs), drug use (but not substance abuse), and “non-problem” alcohol use are evident (Norman et al. 2012).
Research has also attempted to disentangle the relative effects of abuse and neglect on mental and behavioral health. Some studies have suggested stronger effects of abuse (physical, sexual, or emotional) relative to neglect alone on aggression, anxiety, and posttraumatic stress disorder (Augusti et al. 2018). However, other research has found that neglect had equivalent or stronger effects on such outcomes (Vachon et al. 2015). In addition, research has demonstrated the effects of neglect to extend beyond those attributable to poverty (Font and Maguire-Jack 2020).
Studies on neglect and mental health have also been conducted in countries other than in North America (Khaleque 2015). Overall, these have similarly shown harmful effects of neglect on children’s psychological adjustment, hostility/aggression, dependence or defensive independence (e.g., not accepting help when needed), self-esteem, self-efficacy, emotional stability, emotional unresponsiveness, and worldview. These studies suggest robust effects of neglect across cultures (Khaleque 2015).
Preschool. Research has shown the effects of neglect on age-specific groups throughout the lifespan. One systematic review of neglect combined with possible emotional abuse described associations with insecure-avoidant attachment, insecure-disorganized attachment, and passive and withdrawn behavior in infants aged 0–20 months (Naughton et al. 2013). Toddlers aged 20–30 months exhibited more negativity in play as well as avoidant behaviors. Children aged 3–4 years had more negative affect in their play. Those aged 4–5 years had social difficulties, withdrawn behavior, disruptive behavior, aggression, emotional dysregulation, and conduct problems. Five- to 6-year-olds manifested problems with self-esteem, peer relations, insecure-avoidant attachment, dissociation, and rule-breaking behavior. Throughout the preschool years, longitudinal studies have found transitions from ambivalent-insecure attachment to avoidant attachment, from passivity to anger and avoidance, from behavior problems to difficulties in peer relations, and lower self-esteem (Naughton et al. 2013).
School-aged children. Another systematic review of school-aged children that included emotional abuse found multiple problems associated with neglect, including internalizing behavior, attention deficit hyperactivity disorder, coping and social skills, self-esteem, and emotion regulation (Maguire et al. 2015). With less consistency, effects of neglect in this age group appear to also involve externalizing problems and less prosocial behavior (Maguire et al. 2015). These relations may be influenced by other contextual factors such as community violence (Manly et al. 2012). Indeed, many of the effects associated with neglect may interact with other co-occurring adversities. Protective factors may also influence the effects of neglect; in a Chinese sample, sibling relationships were found to buffer effects on children’s internalizing problems (Wong et al. 2019). More research is needed on protective factors buffering the effects of neglect (e.g., positive father involvement; Dubowitz et al. 2019b).
Adolescence. School-neglected children in Tanzania were found to have internalizing and externalizing problems in 6–9-year-olds, but not in the 10–15-year-olds (Hecker et al. 2018). However, another study found more consistent relations between neglect subtypes and trauma symptoms in 10–17-year-olds than in 2–9-year-olds (Vanderminden et al. 2019). A review of research on adolescents who had self-reported neglect or emotional abuse identified multiple problems, such as depression, posttraumatic stress, anxiety, sexual concerns, anger, dissociation, and sleep disturbances, but not low self-esteem (Naughton et al. 2017). Other research has suggested moderated effects, for example, neglect together with few peer relationships was associated with depression (Christ et al. 2017). Associations between neglect and suicidal ideation have been identified (Vanderminden et al. 2019).
There have been mixed results regarding the association between substantiated neglect and externalizing problems in adolescents (Naughton et al. 2017). Self-reported neglect has been associated with aggression (Logan-Greene and Semanchin Jones 2015) and delinquency (Ryan et al. 2013). Neglect together with other forms of victimization, such as sibling violence, may aggravate the effect on delinquency (Van Berkel et al. 2018).
Findings regarding the effect of neglect on adolescent substance use have also been varied (Naughton et al. 2017; Vanderminden et al. 2019). For example, overall lifetime neglect was associated with alcohol and illicit drug use, but some specific neglect subtypes (not being provided food, medical care, or shelter, hygiene neglect, parental incapacitation) did not predict illicit drug use, nor did past-year overall neglect predict alcohol and illicit drug use (Vanderminden et al. 2019). This relation may pertain to more severe substance use, such as early onset use or dependence. In one study, direct effects between neglect and earlier age of marijuana use were found (Proctor et al. 2017). This relation may also be indirect, mediated by internalizing problems, externalizing problems, and/or peer use (Dubowitz et al. 2016; Duprey et al. 2017; Proctor et al. 2017). The relation may also depend on contextual factors, such as neighborhood violence or the extent of maltreatment (Dubowitz et al. 2016; Duprey et al. 2017).
Naughton et al.’s (2017) systematic review found evidence for sexual risk taking among neglected adolescents. However, in general, effects varied and depended on whether neglected youth were compared with non-maltreated or abused youth. One study identified anxious attachment as mediating the relation between neglect and number of sexual partners and avoidant attachment as mediating the relations between neglect and number of sexual partners, casual sexual behavior, and, in boys only, age of first intercourse (Thibodeau et al. 2017). Neglect has been associated with adolescent smartphone addiction, mediated by poor relationships with teachers (Kwak et al. 2018). Finally, neglected youth are at risk for other forms of victimization, including later peer victimization (Vaughan-Jensen et al. 2018).
Few studies have examined exposure to neglect specifically during adolescence. Chronic physical neglect persisting into adolescence appeared to increase aggression and delinquency, particularly in boys, with social problems mediating these relations (Logan-Greene and Semanchin Jones 2015). Likewise, ongoing neglect in teens involved in the juvenile justice system has been associated with continued offending (Ryan et al. 2013). However, in another study adolescent onset neglect had stronger associations with subsequent substance use than chronic and low level of neglect (Dubowitz et al. 2019a).
Adulthood. Neglect has been associated with major depressive disorder, dysthymia, posttraumatic stress disorder, psychopathy, and non-suicidal self-injury in adults (Cahall Young and Widom 2014). Moreover, a study in Kenya, Zambia, and the Netherlands suggested that associations between neglect and psychopathology hold across cultures (Mbagaya et al. 2013). A systematic review, however, found inconclusive evidence of a relation between emotional neglect and adult eating disorders (Kimber et al. 2017).
Neglect has been found to affect young adult substance use; in one study, drug use and abuse via compromised adolescent self-esteem (Dubowitz et al. 2019a; Oshri et al. 2017). In one study, supervisory neglect predicted those with high-risk drinking patterns in early adulthood (Snyder and Merritt 2016). Childhood neglect may also complicate substance use treatment in adulthood, leading to stronger withdrawal symptoms (Francke et al. 2013). In addition, neglect has been associated with risky sexual behavior among young adults (Abajobir et al. 2018). Child neglect has also been associated with increased risk for the perpetration of child maltreatment and intimate partner violence (IPV) in adulthood as well as for victimization from IPV (Bartlett et al. 2017; Widom et al. 2014). Finally, neglect predicted incarceration in young adulthood, although this relation appears to be stronger for abuse (Font and Maguire-Jack 2020).
The short-term physical health effects of neglect include dental caries, injury, and sometimes death (Brandon et al. 2014; Fisher-Owens et al. 2017). Indeed, about three-quarters of deaths attributed to child maltreatment involve neglect, most commonly due to inadequate supervision involving primarily drownings and home fires (US DHHS 2019). Death may also result from deprivation (withholding food or water), medical neglect (failure or delay in obtaining necessary medical care), unsafe infant sleeping arrangements, and suicide (where the risk is not identified or addressed; Brandon et al. 2014).
There is evidence that neglect can affect long-term physical health (Norman et al. 2012). For example, a systematic review identified effects of neglect on ischemic heart disease, migraine headaches, and arthritis, but not for hypertension, type 2 diabetes, obesity, asthma, ulcers, stroke, and neurological disorders (Norman et al. 2012). A more recent meta-analysis however linked physical but not emotional neglect and obesity (Danese and Tan 2014).
Studies have suggested biological mechanisms through which neglect may exert a deleterious and lasting influence on children’s cognition and health. These include neurological, neuroendocrine, genetic, and cellular mechanisms. Although much of this work remains preliminary, evidence of biological effects of neglect is quickly accumulating.
Neurology. Functional magnetic resonance imaging (fMRI) research continues to suggest effects of neglect on brain size and function. However, most studies have not focused on neglect specifically, and several (e.g., the Bucharest Early Intervention Project; McLaughlin et al. 2014) focused on severely neglected institutionalized children such as those from Romanian orphanages. Attributing neurocognitive changes to neglect has been difficult because of frequently co-occurring adversities (McCrory et al. 2017).
Widespread reductions in cortical thickness across the prefrontal, parietal, and temporal areas of the brain have been associated with neglect, which may help explain symptoms such as inattention and impulsivity (McLaughlin et al. 2014). Gender differences have also been suggested; one study showed that neglect was associated with less hippocampal volume in males but not females (Teicher et al. 2018). In boys, physical neglect alone was associated with altered white matter connectivity in areas of the brain involved in emotional expression and regulation and reward seeking (Tendolkar et al. 2017). These changes mediated the relation between physical neglect and trait anxiety, a personality dimension thought to underlie affect disorder. Other findings associated early neglect with more diffuse organization of prefrontal white matter, which in turn was linked to neurocognitive deficits (Hanson et al. 2013).
Brain differences suggest effects of neglect on fear and reward processing systems. Studies using fMRI have consistently identified heightened amygdala activity in neglected individuals exposed to facial expressions (Doretto and Scivoletto 2018). In one study, emotionally neglected adolescents had higher amygdala reactivity, but only if they carried specific genetic polymorphisms (White et al. 2012). Hanson et al. (2013) found that emotional neglect was related to less reward-related striatal activity, which in turn was associated with depressive symptoms in adolescents. One study found differences in children and adolescents exposed to early institutional neglect in the functional coupling of the amygdala and the medial prefrontal region when viewing emotional faces (Gee et al. 2013). Specifically, patterns of more negative connectivity were seen in the younger children but not in the adolescents (Gee et al. 2013). Finally, fMRI studies have suggested differences in brain activities associated with executive control in institutionally neglected children (Mueller et al. 2010).
Neuro-endocrine. The hypothalamic-pituitary-adrenal (HPA) axis is important for the stress response, with cortisol an end product of this system. Studies have found that neglected youth have elevated cortisol levels (Sullivan et al. 2013). This may signal disruptions in the neuro-endocrine and immune systems predisposing to health problems.
Epigenetics (DNA methylation). Recent research has examined DNA methylation, an epigenetic process regulating gene expression, as a potential mechanism linking childhood neglect to health. In general, studies have associated child maltreatment with methylation of genes involved in the stress response or have shown such methylation to be associated with child and adolescent psychopathology (Barker et al. 2018). An investigation focused on neglect found that patterns of epigenetic modulations in genes of high-risk inner city 16–24-year-olds varied by type of maltreatment exposure, with some common patterns across maltreatment types and others differing for neglect (Cecil et al. 2016). Although the cross-sectional nature of this research and high rates of poly-victimization complicate the interpretation, it suggests that molecular mechanisms play a role in linking child neglect to later psychopathology. Importantly, in another study, emotional support attenuated effects of severe childhood physical and sexual abuse on methylation, suggesting that meeting children’s emotional needs buffers epigenetic effects (Shields et al. 2016). This last study is an example of research showing the possible reversibility of adverse outcomes, with intervention.
Cellular aging (telomeres). Advanced aging at the cellular level as indicated by telomere length has also been associated with maltreatment, as well as various health outcomes, suggesting another mechanism through which neglect influences health. A rare case-controlled study that attempted to isolate neglect showed that a history of physical neglect predicted telomere length in adulthood, with greater differences associated with more severe physical neglect and among older individuals. No effects on telomere length were associated with other forms of maltreatment (Vincent et al. 2017).
Key Points Related to Child Neglect
Neglect definitions, particularly as they pertain to specific developmental periods, continue to be unclear. Child-centered definitions based on unmet needs or rights have advantages compared to assigning blame for child neglect.
Research has advanced significantly. It has demonstrated effects of neglect throughout the lifespan on cognitive, mental health, and physical health outcomes. Biological effects likely play a role in these outcomes.
Research has included many studies outside of the USA, although more information is needed about neglect in low- and middle-income countries.
Recent research has examined mediators and moderators of the effects of neglect and has included useful systematic reviews and meta-analyses.
Evidence has accumulated that the effects of neglect often differ from other forms of maltreatment, are distinct from poverty, and are often as pernicious as abuse.
There is a need for increased research attention to neglect dimensions (i.e., subtypes, chronicity, timing, and severity), including building empirical support for the dimensions and examination of their predictors and effects.
There is a need to build evidence of neglect as it pertains to distal outcomes (i.e., long-term physical health). Biological studies need to be replicated.
There is also a need to better elucidate the moderating and mediating influences to understand the pathways to different outcomes, to guide interventions. In particular, there is a need to further identify protective factors that may buffer the effects of neglect and contribute to resilience.
Summary and Conclusion
In conclusion, the short answer to the central question guiding this article “What is new about neglect?” is “a lot!” Unqualified statements regarding “the neglect of neglect” are no longer warranted as they were three decades ago (Wolock and Horowitz 1984). Notable scientific advances have been made regarding neglect’s nature, prevalence, and consequences. These advances include a growth of international studies and systematic reviews examining aspects of neglect throughout the lifespan. Cutting-edge research has probed effects of neglect on neurobiology, epigenetics, and cellular aging and has examined mediated and moderated pathways to and from neglect to elucidate underlying processes. In sum, studies convincingly portray neglect as a highly prevalent, menacing problem. They document neglects’ consequences on multiple domains throughout the lifespan, including biological, cognitive, mental health, and physical health.
More research is still needed, of course, as well as in areas such as specific dimensions of neglect, the effects of neglect during different developmental stages, and the effects of neglect beyond childhood into adolescence and adulthood. Improved tools for measuring and assessing neglect throughout the developmental continuum are much needed to guide future research and clinical practice. Finally, much progress has been made, and much remains to be learned.
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