Mandatory reporting on child abuse and neglect: the consultation

I’ve just responded to the government consultation Reporting and acting on child abuse and neglect which closes on 13 October. It’s prompted some thoughts;

The challenge

Preventing children being harmed. Obviously.   But that’s a pretty broad remit. Local authorities and the agencies they work with have a statutory duty to ‘make arrangements for ensuring that their functions are discharged having regard to the need to safeguard and promote the welfare of children’ (s. 11 Children Act 2004). Basically they should have appropriate procedures in place. That prompted this comment from Eileen Munro in her Review of Child Protection;

‘…instead of “doing things right” (i.e. following procedures) the system needed to be focused on doing the right thing (i.e. checking whether children and young people are being helped)’ (Consultation document para 5)

Since the 2004 Children Act, safeguarding children seems to have had an increasingly high profile; promoting the welfare of children appears to have taken a back seat. Here’s how the current government sees it;

“…Safeguarding children – the action we take to promote the welfare of children and protect them from harm…”(para 2)

In other words the broad duty to promote the welfare of children – with all that that entails – now boils down to protecting children from abuse and neglect.  And the child protection system doesn’t always work. Numerous people have pointed out that no system can guarantee the protection of all children; we don’t have, and never will have, the resources to do that.

The nation has been, understandably, shocked to the core by accounts of the appalling abuse some children have suffered. The news that one child each week is killed on our roads and over 2000 a year are seriously injured in contrast barely makes the headlines; child protection isn’t just about abuse and neglect.  But children are abused and neglected and recent high profile cases have been shocking partly because they’ve highlighted clear failings in the child protection system. The reporting and acting consultation is part of the government’s response.

What the consultation proposes is that reporting and acting on suspected child abuse and neglect is made mandatory for people working in certain organisations. If they don’t report and take appropriate action, they could face serious sanctions. The people include not only those working directly with children but support staff and senior officers. As the consultation document points out, the possibility of sanctions introduces a significant risk of unintended and unwanted outcomes, such as unwarranted intrusion into family life and even more problems with recruitment and retention of social workers.

The evidence

On the face of it, mandatory reporting and acting looks as if it makes sense; if everyone reported and acted on their concerns, surely children would be much safer. But the evidence doesn’t support that reasoning. The evidence shows that when mandatory reporting is introduced the number of referrals increases dramatically (in Australia it doubled), but the proportion of substantiated cases is low (around 20% in several jurisdictions).   As the consultation document itself says:

‘Overall, the literature seems to show that “there remains some question about the efficacy of reporting laws in achieving their ultimate goal: protecting children from harm”’(Annex D p.22).

The causes

Not only does the evidence demonstrate that mandatory reporting doesn’t help, but reporting and acting per se don’t play a major role in the failures of the child protection system to protect children, either. Serious case review after serious case review identifies complex decisions to which there is no obvious right answer, and not following existing procedures properly, as key factors in the failure to protect children from harm. SCRs are littered with accounts of novice social workers being assigned to difficult cases, agency staff unfamiliar with cases, inadequate supervision, lack of understanding of the law and poor communication between agencies – all signs of services that don’t have the capacity to meet demand. In the vast majority of cases, the problem wasn’t that no one had reported their suspicions or failed to act on them.

Given the lack of evidence for the effectiveness of mandatory reporting and acting, and the fact that reporting and acting weren’t the main causal factors of failure, why is the consultation happening at all?

Why consult?

The consultation appears to be have been prompted by some recent high profile cases where abuse and neglect was known about but ignored; the consultation document cites Jimmy Savile’s activities and the sexual exploitation cases in Rotherham, Rochdale and Oxfordshire. Mandatory reporting and acting has been suggested by “MPs, MPs, Peers, campaign groups and members of the public” (consultation document Foreword). But MPs, Peers, campaign groups and members of the public might not be familiar with the evidence for the efficacy of their suggestion.   The way the child protection system is designed isn’t a matter of opinion, it’s a matter of the evidence for what’s effective.

The only reason for consulting that I can think of that is that it’s politically advantageous; the government is seen to be doing something. As the consultation document says “… it is crucial that we do all that we can to strengthen our arrangements to minimise the risks as far as possible” (para 14). Yes, it is, but there’s no evidence to suggest this is the way to do it.

If there are problems with a system, the only way to address them effectively is to identify the root causes of those problems.   SCRs provide a wealth of evidence for those root causes. We need to be looking at them, not quick fixes that we know won’t work and could make things worse.

Advertisements

The ‘Baby P effect’ and home education

In August 2007, a toddler living in the London Borough of Haringey died. 18 months later on 11 November 2008 his mother, her boyfriend and her boyfriend’s brother were convicted of causing or allowing the child’s death. The toddler was Baby P, eventually named as Peter Connelly.

Media interest was intense. On the day of the conviction, Sharon Shoesmith, director of Haringey’s children’s services, and Jane Collins, CEO of Great Ormond Street Hospital (GOSH) held a press briefing that mentioned the disciplinary proceedings against individual social workers finding no evidence of gross misconduct. On the following day, November 12, the Department for Children, Schools and Families (DCSF) issued a press statement condemning the behaviour of those convicted.

Later that day, at Prime Minister’s Questions, Gordon Brown (then PM) appeared to be taken by surprise by David Cameron’s (then Leader of the Opposition) criticism of the way Haringey Council had responded to Peter Connelly’s death. Cameron asked who was taking responsibility and why no one had resigned. He followed up his attack later with an emotive article in the Evening Standard, and the next day with a letter to the Sun. The Sun launched a petition calling for Sharon Shoesmith, the social workers involved, and a paediatrician at GOSH to be sacked, and by the weekend could claim the petition had 1.4 million signatures. The Government’s reaction triggered a chain of events culminating in a ‘perfect storm’ that had significant, far-reaching repercussions for national and local government, the news media, social work as a profession, children’s services, individual social workers and vulnerable children.

The Government response

The Government’s response to the criticisms was swift and robust. A press officer was sent to Haringey Council and on 1 December the Council leader George Meehan and the cabinet member for children and young people Liz Santry, resigned. Ed Balls, Secretary of State for Children, Schools and Families announced in a press conference that he was replacing Sharon Shoesmith with John Coughlan, then director of children’s services in Hampshire, and appointed Graham Badman, previously director of children’s services in Kent, as chair of Haringey’s Local Safeguarding Children Board. A week later, Shoesmith was formally dismissed by Haringey Council.

Shoesmith didn’t take her sacking lying down. She appealed and in 2011 the High Court ruled that Ed Balls and Haringey Council acted unlawfully in dismissing her. In 2015, she completed a PhD through which she had tried to understand the psychosocial factors involved in the aftermath of Peter Connelly’s death. A couple of weeks ago, she published Learning from Baby P, which draws on her research. In the book, she notes some of the factors that prompted the government to act as it did. Shoesmith’s analysis is well worth reading; it’s incisive and insightful. My only quibble is that she appears to accept some conceptual frameworks uncritically, such as the feminist, psychoanalytic and medical models.

Shoesmith points out that by late 2008, the ‘New Labour project was running into trouble’ (pp.123-127). Gordon Brown had taken over from Tony Blair as PM the previous summer, but in May 2008 Labour had had its worst local government election results for 35 years and Labour’s attempts to reduce child poverty were faltering. In October 2008 the Healthcare Commission’s investigation into the Mid-Staffs scandal was completed revealing significant failings, and the global financial crisis prompted a £500bn rescue package for UK banks.

Cameron’s framing of Peter Connelly’s death in political terms had significant implications for the Labour government. Their flagship strategy Every Child Matters couldn’t be seen to fail, nor could Ed Balls, who had been Brown’s chief economic adviser until Brown became PM. Then there was Haringey. Haringey had high levels of deprivation and a history of what Shoesmith calls ‘defining events’. It had witnessed the Broadwater Farm riots in 1985 during which PC Keith Blakelock had been murdered, and the death of Victoria Climbié in 2000 that had led to the Laming Inquiry and significant changes in child protection policy. In addition, Haringey Council had long been perceived as hailing from the ‘loony left’; understandably a centre-left government might want to distance itself. Lastly, the government felt compelled to align its narrative with that adopted by large sections of the public and press – that public sector services should to be seen to take responsibility for Peter Connelly’s death.

All three key political figures – Cameron, Brown and Balls – used the press directly to manage the political narrative.  It could be argued that the press used politicians to the same end. In July 2007, six months after he’d resigned as editor of the News of the World following the conviction of two reporters in the phone hacking scandal, the Conservative Party had appointed Andy Coulson as its director of communications. The Sun, another News International paper, had a history of campaigning for changes in the law as a result of high profile child abuse cases; for longer sentences following the death of James Bulger in 1993, and for disclosure of previous sex offences following the death of Sarah Payne in 2000. During the Leveson Inquiry into phone hacking, it was suggested that after the Baby P trial the Sun put pressure on Ed Balls to order resignations (p.183).  The press narrative in the Baby P case centred around calls for the resignation of professionals involved with Peter Connelly. Shoesmith explains her reasons for not offering to resign, but I think the issue of resignation warrants further comment.

It’s a resigning matter

Traditionally, tendering your resignation if something goes wrong is seen as an honourable thing do to – even if no one believes you’re responsible for what went wrong and your resignation isn’t accepted. A resignation symbolises acceptance of responsibility and would have been one factor in the calls for resignations over the Baby P case. But Shoesmith makes it clear in Learning from Baby P that she saw voluntary resignation as an admission of responsibility for Peter’s death, an impression she wanted to avoid – understandably given the introduction of the offence of ‘causing or allowing the death of a child or vulnerable adult’ in 2004 to close a legal loophole. Although the offence can be committed only by people living in the same household as the victim, its title begs the question of who else might be responsible for causing or allowing a death of a child by, for example, neglecting their professional duty. Police officers, social workers or paediatricians might be brought into the frame, something that could be inferred from David Cameron’s Evening Standard article (p.144).

But there’s another factor involved in the calls for sackings; it’s the assumption that if a public sector worker failed to prevent the death of child, they would have been able to prevent it if they’d acted differently. That’s nonsense of course. Even if a child were taken into care or a social worker were to live with the family, no child can be totally protected from harm. But the idea that children can be fully protected persists. Cameron, Brown and Balls all vowed to ensure that nothing like Peter Connelly’s death happened again (p.178) – even though, in reality, such promises are meaningless.

Child protection had become a political football and government, opposition and the media were vying for control of the ball. Ironically, the outcomes had significant negative repercussions for vulnerable children. Directors of social services became very nervous about their jobs, and social worker recruitment and retention, already under strain, became even more challenging, further increasing the vulnerability of the children social workers were dealing with. Local authorities made sure they erred on the side of caution; between October 2008 and March 2012 the number of applications for care proceedings increased by 79% (p.19).

Elective home education and the Badman review

The ‘Baby P effect’ rippled out to another group of children Shoesmith doesn’t mention – those educated at home. English law gives parents a duty to cause their child to receive an education suitable to their age, ability, aptitude and any special educational needs they may have (s.7 Education Act 1996). Local authorities can intervene if it appears a child is not receiving a suitable education (s.437(1) Education Act 1996). The law, rightly, puts the individual child at the heart of the education, and sensibly, gives final responsibility for the child’s education to parents. Some parents make a complete hash of bringing up their children, but historically they’ve done a much better job than the state. Home education has been a contentious issue however, and in 2007 Alan Johnson, Ed Balls’ predecessor at the then Department of Education and Skills, published a set of guidelines for local authorities about elective home education.

In January 2009, Ed Balls announced a review of elective home education. Home educating parents were perplexed, not least because the guidelines had been issued only a year or so earlier. Also, the review was framed in terms of home educated children being ‘hidden’ and home education being used as a cover for child abuse, even though there appeared to be no robust evidence of this actually happening.   In addition, the review conflated education and welfare, which are treated as distinct issues by the law.

The review was led by Graham Badman, introduced as the former director of children’s services at Kent County Council. A month earlier, Balls had appointed Badman as chair of Haringey LCSB, but unless they’d been following the news closely, most home educating parents wouldn’t have made a connection with the Baby P case. They would also have been unaware that in May 2008, seven year-old Khyra Ishaq had starved to death at her home in Birmingham. She had been educated at home for the previous six months. Khyra’s death came to public attention only in June 2009, when the trial of her mother and her mother’s partner began. Her death was presented as reinforcing the government’s call for reforming the law relating to home education, rather than as a trigger for the review happening in the first place.

In 2009 Graham Badman was busy. In November 2008 he’d set up an education consultancy, Nektus, that carried out two local authority progress reviews in its first year.  In December he’d been appointed Chair of Haringey LCSB, to oversee the aftermath of a very high profile child protection case.   In January 2009 had become a visiting professor at the Institute of Education, and Acting Chair of BECTA – being appointed Chair on 1 May. He became a Trustee and Board member of UNICEF in July. His elective home education report was published on 11 June, and his recommendations accepted in full the same day by Ed Balls. Given all these commitments, it’s not surprising that more than one organisation complained that Badman’s account of what they said to him wasn’t quite what they recalled saying, and that Graham Stuart MP, a member of the Children, Schools and Families Select Committee felt obliged to point out that Badman had made a significant sampling error in his assessment of the risk to home educated children.

Badman made 28 recommendations, including giving local authority officers the right to enter the homes of home educated children, to interview them alone and to assess their educational progress.  A public consultation on Badman’s proposals followed, with a record number of responses. The full government response to the Badman report wasn’t published until October 2009, towards the end of the consultation period, so many people who responded to the consultation wouldn’t have seen it. Throughout the review, I got the strong impression that the Government didn’t see those who disagreed with the proposals as citizens expressing their opinions, but as political opponents. The Government planned to include the Badman proposals in the Children, Schools and Families Act 2010, but many were abandoned in the ‘wash up’ prior to the 2010 General Election, due to opposition from other parties. Conservative MPs had, not surprisingly given the political overtones of the review, been quite supportive of home educating parents. In December 2009, a record number of petitions protesting against the proposed changes to the law were presented to Parliament, a strategy initiated by Graham Stuart.

Learning from the Baby P effect

The primary task of government, national and local, is to protect the population to allow us – all of us – to go about our lawful business without let or hindrance. Obviously, there are going to be instances where legislation that protects one group of people inconveniences another – the law has to weigh up the interests of different parties. On the face of it, it looked as if that the actions of government, opposition and press in the wake of Peter Connolly’s death could result only in beneficial outcomes for vulnerable children. But their focus was on only one aspect of child protection and other aspects got completely overlooked, including local authority priorities (disabled children are also children in need but LA thresholds for support are set so high many disabled children get no social care support), social worker recruitment and retention and the consequent impact on vulnerable children, and children being taken into care unnecessarily. The proposals for home educated children, such as social workers being entitled to enter the family home and to interview children alone had significant implications for a number of important legislative principles.

Government, opposition and the press framed child protection solely in terms of the behaviour of individuals, whether they were adults who might harm children directly, social workers who might fail to prevent harm, or elected members of local government responsible for implementing national policies. Little attention was paid to the effectiveness of legislation, key legislative principles, local authority resources, the impact of the government’s action on social workers and on children deemed to be at risk when they weren’t. Good legislation requires careful thought and wide consultation, not a knee-jerk response to a party political attack. If government is seen as a party political project, rather than an institution that exists to serve the population, it puts everyone’s welfare in jeopardy, not least that of vulnerable children.

Reference

Shoesmith, S (2016).  Learning from Baby P.  Jessica Kingsley Publishers

Updated 4 September 2016 with minor corrections.

Invisible disability: Building Great Britons

A report was published on Wednesday by the All Party Parliamentary Group (APPG) for Conception to Age 2 – the First 1001 days. It’s called Building Great Britons.
The thrust of the report is similar to Early Intervention: Good Parents, Great Kids, Better Citizens (2008) and Early Intervention: The Next Steps (2011) from MPs Graham Allen and Iain Duncan Smith. Building Great Britons sets out a policy framework aimed at preventing the social problems believed to originate in adverse experiences between conception and a child’s second birthday.

Breaking the cycle

The conceptual model underpinning the report is a familiar one. Neglect, maltreatment and insecure relationships in early childhood are assumed to be a primary cause of mental health problems and antisocial and criminal behaviour. Parents who had such experiences during childhood tend to adopt the same child-rearing strategies as their parents, setting up a damaging (and costly) self-perpetuating intergenerational cycle.

Like the Early Intervention reports, Building Great Britons argues that preventing child neglect, maltreatment and insecure attachment will save money and result in a flourishing society due to the emergence of well-rounded citizens who are “physically and mentally healthy, well educated, empathic, prosocial, hardworking and contributing to the costs of society” (p.3). As Tim Loughton, Co-Chair of the APPG says “the economic value of breaking these cycles will be enormous” (p.4).

“This” it’s claimed, “is not ‘rocket science.’ Technically it is ‘neuro-science’” (p.3).
The basis for that claim seems to reside in repeated references to brain development, although there’s no detail about how brain development is involved. The association between early adverse experiences and long-term unwanted outcomes is well established, but there are some problems with the model.

what causes what?
The first is that just because two things are correlated, it’s not safe to assume that one causes the other. They might both be caused by something else, or be totally unrelated. So parents might neglect, maltreat or form poor attachments with their children because their parents did, or because the family has a genetic predisposition towards severe post-natal depression, or because they are grappling with challenging life circumstances.

multiple causes
The second problem is that even if we could predict with certainty that all neglected, maltreated, chaotically attached children will develop mental health problems or anti-social behaviour in later life, the causal chain doesn’t always hold in the opposite direction because mental health problems and anti-social behaviour have other causes such as poor physical health, adverse life events or peer pressure.

looking back vs looking forward
A third problem is that retrospective surveys linking adverse childhood experience with later health and social problems, such as the ACE study referred to in Building Great Britons (p.14), tend to rely on self-reports – not always the most reliable sources of information, especially about early life. Prospective assessments that track children through their life course such as the Dunedin and Cambridge studies tend to be more reliable. They have also found correlations between adverse childhood experiences and problems in later life but that the emerging patterns are quite complex.

When reading through the research findings, I was struck by how often researchers expressed surprise at the frequency of adverse childhood experiences. The ACE study was prompted by the unexpectedly high incidence of sexual abuse in childhood reported by people dropping out of a weight loss programme. The Dunedin study began as a small-scale follow-up assessment of perinatal risk. Its scope was broadened after researchers found a higher incidence than they expected of accidental injury and impairments to sensory function, development and behaviour in 4/5 year olds. The implication wasn’t that the children had been neglected or maltreated (although some might have been), but that developmental impairments in the general population were more frequent than had been previously thought.

children with disabilities: noticeable by their absence

This brings me to a glaring omission in Building Great Britons. One group of children is especially susceptible to social, emotional and behavioural problems and is at increased risk of poor physical and mental health in later life. They are children with disabilities. But the only mention of disability that I could find in Building Great Britons was of children with Foetal Alcohol Syndrome, caused by a mother’s excessive alcohol intake during pregnancy.

Childhood disabilities can be caused by neglect or maltreatment but they can also be caused by factors such as;

• inherited genetic conditions
• spontaneous genetic variations at or before conception
• mother’s illness during pregnancy
• environmental damage during gestation (e.g. exposure to toxins)
• childhood infections
• accidental injury.

Whether you think disability is caused by a ‘functional impairment’ or by the way society responds to that functional impairment, for administrative and legal purposes a clear-cut distinction is usually made between someone who’s deemed disabled and someone who isn’t. But from a biological perspective the boundary is rather blurred. As the Dunedin study found, a significant proportion of children has some sort of developmental impairment; currently in the USA it’s 15%. In the UK, only 6% of children are classified as disabled, but that figure rises with age. Around 16% of the working-age population has a disability.

Not all disabilities are obvious, and some are difficult to detect. The average age at which autism is diagnosed, for example, is 5.5 years, and diagnosis is often much later than that. Autistic children have unusual attachment patterns and autism is so frequently confused with attachment disorder that Heather Moran, a consultant clinical psychologist, devised the Coventry Grid to help professionals distinguish between them.

There’s little doubt that neglect, maltreatment or poor attachment in childhood can, and does, lead to social, emotional and behavioural problems and to impaired physical and mental health. But what Building Great Britons does is to frame the causes of those problems solely in terms of neglect, maltreatment or poor attachment, and more specifically in terms of the ‘troubled families’ who are deemed to be the source of these societal ills (pp.3-4).

When I was delving into the thinking behind the Early Intervention reports, I asked a few researchers who’d been actively involved how some obviously erroneous claims about brain function had crept in. None had had a say in the final content of the reports, but one told me that it was sometimes necessary to present data in a way that was most likely to persuade government to come up with funding. I take his point; but I couldn’t see how that justified presenting the data in a way that was misleading.

What the data on social, emotional, behavioural, physical and mental health problems tell us is that children by definition are vulnerable, and parenting by definition is challenging. They also tell us that we are all, at all times, at risk from unforseen life events that could trigger social, emotional, behavioural, physical or mental health problems that result in us needing help from the community. That’s why in the developed world we have education, health and social care services.

It’s true that a minority of families cause a disproportionate number of problems, for themselves and others. There are good reasons why early intervention is appropriate for them. But because all children are vulnerable and all parenting is challenging, there are good reasons why early intervention should be available to all families. We shouldn’t have to justify it in terms of ‘good citizenship’ or the financial costs for ‘society’ – which at one time we were told didn’t exist.

Nor should reports produced by Members of Parliament about vulnerable children and challenged parents look right past one of the most vulnerable groups of children and one of the most challenged groups of parents. In the total of 351 pages that make up the two Early Intervention reports and Building Great Britons, childhood disability is mentioned, in passing, only five times – and three of those references are to Foetal Alcohol Syndrome.

When I contacted @first1001days, the Twitter account for http://www.1001criticaldays.co.uk/ to point out the omission, I got a prompt response inviting me to write some supplementary material. Within an hour, another parent and I had responded with a paragraph summarising the main issues, and notified @first1001days. I wasn’t surprised not to get an immediate reply, as the report was being launched that morning. But we’re still waiting…

Disabled people are still invisible, it seems.

the claims: NSPCC briefing on home education

logicalincrementalism

The NSPCC briefing Home education: learning from case reviews claims to consist of ‘learning about child protection pulled from the published versions’ of seven Serious Case Reviews (SCRs) published between 2008-2013. In this and subsequent posts, I want to focus on the patterns of events that emerge from the case reviews, but I’ll also refer to examples of what happened to specific families or specific children. I’ve numbered the cases to anonymise the children as much as possible, but have linked to the published versions of the SCRs. I’ve listed brief details of each case below for reference.

Family 1 2007 serious maltreatment of adopted children
Child 2 2008 non-accidental poisoning with prescription drug
Child 3 2009 unexplained death
Child 4 2010 death due to severe malnutrition
Child 5 2011 suicide
Child 6 2012 death due to natural causes
Family 7 2013 neglect, and sexual abuse of adopted child

In…

View original post 1,821 more words

NSPCC briefing on home education: the law

logicalincrementalism

In March this year the NSPCC published a briefing entitled Home education: learning from case reviews. It’s based on seven Serious Case Reviews (SCRs) published since 2008 ‘where elective home education was highlighted as a key factor’ and ‘consists of learning about child protection pulled from the published versions of the reports’.

I got the impression from the briefing that the seven cases involved tragic situations in which parents had neglected or abused children and that home education had played a significant role in that neglect and abuse. The picture painted by the SCRs themselves is somewhat different. In only three cases was there unambiguous evidence that parents and carers were directly responsible for the harm the child suffered. In only one case were local authorities unaware of the challenges faced by the families or of the risk to children. There were several examples of healthcare actually contributing to…

View original post 1,820 more words

fabricated or induced illness

In November 1999, a solicitor named Sally Clark was found guilty of the murder of her two infant sons and sentenced to life imprisonment. Three years later, her conviction was overturned on her second appeal, but it was too late for Mrs Clark. She died of alcoholic poisoning in 2007, four years after her release. In response to this miscarriage of justice, the Attorney General ordered a review of similar cases, including those of Donna Anthony, Angela Cannings and Trupti Patel.

Two key factors in overturning Sally Clark’s conviction were that evidence of a bacterial infection had been known to the prosecution’s pathologist, but not disclosed to the defence, and the nature of the statistical evidence presented by an expert witness, Professor Sir Roy Meadow, a paediatrician and former Professor of Paediatrics. Meadow claimed that the chances of two children in a family like Clark’s dying of Sudden Infant Death Syndrome (SIDS) were 1 in 73 million. Meadow had calculated these odds by squaring the chances of one child dying (1 in 8,500). Statisticians have pointed out that since SIDS deaths are likely to have genetic and/or environmental factors in common, the probability of a second child in the same family dying of SIDS is increased, not decreased. They have also pointed out double murder is even less prevalent than double SIDS. After the case, the prosecution pathologist was found guilty of serious professional misconduct and Roy Meadow was struck off the medical register, only to be reinstated on appeal a year later.

Statistical anomalies aren’t Roy Meadow’s only claim to fame. He’s also responsible for describing Munchausen’s Syndrome by Proxy (MBP or MSbP). Munchausen’s Syndrome (that is, without the proxy) had first been described in 1951 by Richard Asher, an endocrinologist and haematologist (and the father of Peter, Jane and Clare Asher). It’s a supposed psychiatric disorder in which the patient fabricates the symptoms of an illness in order to get attention and/or sympathy. In MSbP (that is, with the proxy) a parent or carer exaggerates or fabricates symptoms in someone else – MsbP usually involving mothers fabricating symptoms in their children.

Those who have read my blog on autism will be familiar with the some of the theoretical problems involved in defining syndromes and psychiatric disorders. Syndromes often vary considerably between individuals and frequently it’s not clear whether or not a psychiatric disorder actually exists as a distinct disorder – in other words, patients might be experiencing similar symptoms, but it doesn’t follow that the same thing causes those symptoms in every case. Not surprisingly, the term Munchausen’s Syndrome by Proxy has largely been replaced in the UK by the concept of Fabricated or Induced Illness by carers (FII). In the USA, the term ‘factitious disorder by proxy’ is often used.

In order to explore the idea of FII I’ve focused on an NSPCC Research Briefing by Anne Lazenbatt, NSPCC Reader in Childhood Studies at Queen’s University, Belfast and Julie Taylor, Professor of Family Health at the University of Dundee, and also Head of Strategy and Development with the NSPCC. [The briefing no longer appears to be available on the NSPCC website but can be downloaded here.]§

What is FII?

The briefing describes FII like this;

FII occurs when a caregiver…misrepresents the child as ill either by fabricating, or much more rarely, producing symptoms and then presenting the child for medical care, disclaiming knowledge of the cause of the problem. (p.1)

The authors make it clear that there’s been a good deal of debate about the nature of FII, and they point out that it isn’t a clear-cut construct. FII is seen as a ‘spectrum’ (p.4) and The Royal College of Paediatrics and Child Health (RCPCH) introduced the term FII in 2001, and according to the briefing ‘helpfully offer five examples of behaviour across the FII spectrum’. They are (p.5);

1. Simple anxiety or over-interpretation of trivial symptoms.
2. Child’s symptoms are misperceived, perpetuated or reinforced.
3. Carer actively promotes sick role by exaggeration, fabrication or falsification.
4. Carer suffers from psychiatric illness.
5. Child has a genuine and unrecognised medical problem.

Note that according to the briefing, the RCPCH includes ‘simple anxiety or over-interpretation of trivial symptoms’ and ‘a genuine and unrecognised medical problem’ as part of the spectrum of FII. In fact the RCPCH Guide describes the spectrum as a ‘spectrum of cases where FII concerns may arise’ (p.8), which puts a rather different slant on things. The authors of the briefing do at least comment that ‘the extremes are useful to note and should be borne in mind throughout’. Indeed.

Prevalence of FII

The briefing then goes on to look at the prevalence of FII. Estimating the prevalence is challenging, given the width of the FII spectrum and the heated debate about its definition, or even whether it exists at all. In these circumstances, the authors’ comment that ‘epidemiological studies used to demonstrate prevalence rates are fraught with methodological difficulties’ is something of an understatement, but they have a go. Here are some of the estimates reported (pp.4-5):

• 0.5 per 100,000 children

• 2.8 cases per 100,000 children per year

• 89 per 100,000 children over two years

• 97 new cases of FII in two years

• 451 cases from many different countries

The definition of what constituted a ‘case’ varied widely.

Despite the huge variations in estimates, the briefing emphasizes the view of some professionals that FII is more common than might first appear. I thought it might be instructive to compare the prevalence of FII with that of disorders that might fall into the category of ‘genuine and unrecognised medical problem’.

• Ehlers-Danlos syndrome: (all types) 20 per 100,000*
• Fragile X: 25 per 100,000
• Coeliac disease: 1,000 per 100,000
• Autism: 1,000 per 100,000
• Lactose intolerance: (N. Europe) 5,000 per 100,000

In other words, even the highest estimates for FII are lower than for several medical conditions practitioners would have heard of, but which frequently go undiagnosed for years. But my search of the NHS Choices website could find no results for ‘under-diagnosed’ or terms similar to it, despite each of the conditions listed above being reported by researchers as likely to be under-diagnosed. The NSPCC briefing doesn’t expand on this issue, although it does warn that:

It is important to recognise that children may have genuine significant illnesses or medical conditions in addition to ones that are fabricated and/or induced. (p.10)

How is FII diagnosed?

So how is a clinician supposed to distinguish between a genuine and fabricated or induced illness? With difficulty, it seems. Here are examples of warning signs of FII (p.9):

• The child has repeated and unexplained illnesses or symptoms.

• The child has unexplained multiple illnesses or symptoms.

• The child’s supposed symptoms only occur when the mother is present.

• The mother appears to know a lot about medicine.

• Although the mother stays with the child all the time while he/she is in hospital and attends to him/her well, she may not appear as concerned about the child’s well being as the health care professionals who are providing treatment; in contrast she may appear overly concerned.

• The father is not involved in the care of the child, or his involvement is minimal. Note however that fathers are sometimes involved in FII.

One can understand why the NSPCC wants clinicians to be alert to the possibility that symptoms might be being fabricated or induced, and to protect children from further harm from unnecessary medical tests and procedures. On the other hand, it’s difficult to see how mothers who are single parents or whose partners are working, and whose children have genuine multiple, repeated, unexplained, intermittent symptoms are expected to approach health professionals without exhibiting the ‘warning signs’ of FII listed above.

And here are some words of advice for social workers:

It is not only health professionals who have a role in the detection of FII. Social workers play an important part and may struggle because they have little knowledge about FII, or when they suspect FII, they may not be able to convince the GP (Griffiths, 2010).

Of course that could also be because the GP has medical knowledge, which the social worker might also lack. Griffiths suggests specific points for social workers to bear in mind:

• Being honest about suspicions from the start may scare off the parent (making it difficult to gain evidence), attract undue media attention, or worse, can lead to an increase in harmful behaviour in an attempt to be more convincing.

• Consider motivation. For example, the family might be having financial trouble and fabricating or inducing an illness may entitle them to extra welfare benefits.

• Verify the personal histories of family members, as lies may have been told (for example, that one of the parents has a medical background).

• Remember that some parents may be extremely manipulative and convincing. They may be middle class and they will know how to invoke complaints procedures. (pp.10-11)

The last sentence is especially ironic. Interestingly, the Griffiths reference isn’t, as you might expect, to a research paper but to an article in Community Care magazine. I couldn’t find out who Julie Griffiths is, but she’s written a number of articles on the Community Care website. Her advice is summed up by the authors of the briefing as follows;

Although Griffiths offers cautionary advice, the point for social workers is ultimately the same as for health professionals: it is crucial to do the detective work. (p.11)

Yes it is, absolutely, but the detective work is required to find out the underlying cause of the child’s presenting symptoms, not to prove suspicions of FII correct.

Tragically, there’s no doubt that some parents do harm their children and present the consequences of that harm as a medical condition. Controversial covert video surveillance at the Royal Brompton Hospital, carried out by another doctor with expertise in FII, Professor David Southall (also struck off the medical register and then reinstated) and numerous cases have made that clear. However, the content of the NSPCC research briefing implies that some serious questions need to be asked about how FII is being approached.

How valid is FII?

1. The Royal College of Paediatrics and Child Health’s definition of FII is so broad that accurate determination of the prevalence of FII is impossible.

2. Having said that, even the highest estimates for the prevalence of FII are much lower than the prevalence of genuine medical disorders that are frequently under-diagnosed. It might have been helpful for the research briefing to have provided a checklist of commonly under-diagnosed disorders for medical practitioners to rule out, prior to making a default assumption that FII is involved.

3. I don’t have figures for the prevalence of under-diagnosis of genuine medical conditions, although one study of coeliac disease showed an under-diagnosis rate in four European countries between 76% and 94%. Given the range of disorders involved and their estimated prevalence, it’s possible that children might be at significantly greater risk from undiagnosed medical conditions than from abuse or neglect from parents and carers. For obvious reasons the NSPCC sees its task as drawing attention to active abuse or neglect, but if our focus of concern is the health and wellbeing of children, systems neglect is an important issue that shouldn’t be overlooked.

4. The FII coin has two sides; one is the ability of carers to fabricate and induce illness in children without this being detected, and the other is the under-diagnosis of medical conditions. Both sides of the coin call into question the diagnostic capacity of health services. Clearly, it’s impossible for GPs to know about all illnesses, but rather than raise the profile of FII, it might make more sense to improve access to specialist medical knowledge, in order to rule out genuine medical conditions and increase detection of fabricated symptoms.

What’s FII got to do with child development theory?

FII is assumed to be both a medical disorder and a form of child abuse. However, the NSPCC briefing presents FII within a theoretical framework that will be familiar to readers of previous posts. Firstly, although there’s some discussion about its definitions and prevalence and the briefing does allude to FII being manifest at the systems level (p.1) the FII construct is framed in terms of individual carers’ behaviour towards individual children, even though children can come to harm in a variety of ways that don’t involve carers. Also, carers’ behaviour can be influenced by many factors, including economic policies and flaws in the design of the health, education and social care systems. In other words the FII model itself is framed in terms of the behaviour of individuals, rather than being set in the broader ecological context described, for example, by Uri Bronfenbrenner.

Secondly, even in cases where carers are guilty of abusing children, attempts to explain FII appear to have focused on psychoanalytic, attachment and ‘cycle of abuse’ models – an implicit assumption that the carers themselves might have been abused (p.7). What receives less attention is the possibility that the carers might have a neurological problem that results in delusions, lack of impulse control or fabrication that itself might require medical investigation. Alternatively, some carers might have a vested interest in harming their children – qualification for additional benefit payments is mentioned in the briefing. Although this motivation might be perverse, it isn’t necessarily the result of a delusional illness or of childhood abuse.

The briefing cites, uncritically, a definition of FII that includes over-anxiety and undiagnosed medical conditions, a list of warning signs for FII that include responses that would be common in non-abusive parents and carers, and frames FII predominantly in terms of a ‘cycle of abuse’ model involving only the behaviour of individuals. It overlooks systems factors such as the training of health professionals and the demise of the family doctor who would be familiar with a patients’ family history.

I contacted one of the authors of the briefing for her comments. It was clear from her response that the remit of the briefing and the limit on length made a complete analysis of FII impossible. In addition her area of expertise didn’t qualify her to comment on medical conditions that might be mistaken for FII and that the primary purpose of the briefing was to raise awareness of FII amongst health professionals. An analysis like the NSPCC one doesn’t provide an exhaustive overview of the FII research literature, obviously. However, this briefing is written for professionals and, because it’s endorsed by the NSPCC it is, worryingly, likely to be taken as authoritative despite its shortcomings.

Reference

Lazenbatt, A. & Taylor, J. (2011). Fabricated or induced illness in children: A rare form of child abuse?, NSPCC.
Royal College of Paediatrics and Child Health (2009). Fabricated or Induced Illness
by Carers (FII): A Practical Guide for Paediatricians.

Notes
*corrected 19.03.14
§ A set of slides on FII by the authors of the briefing is available online at http://www.baspcan.org.uk/files/Lazenbatt%20Ann%20F2.1%20Mon%2010.30.pdf
It highlights many of the problems with the FII concept.

Bruce Perry on nature, nurture and neglect

Bruce Perry is an internationally recognised authority on child trauma, and, like Allan Schore, is frequently cited in the child development and child protection literature. In this post, I look at Perry’s paper “Childhood Experience and the Expression of Genetic Potential: What Childhood Neglect Tells Us About Nature and Nurture”. I’ve chosen this paper because it tackles the nature/nurture issue head-on and also because it’s the source of the cover illustration for Graham Allen’s Early Intervention: The Next Steps. (The illustration also appears in a recent article in The Telegraph.)

On first reading, I found Perry’s paper slightly disconcerting due to its variable style. The opening section gets quite lyrical;

Are we born evil – natural born killers or the most creative and compassionate of all animals? Are we both? Does our best and our worst come from our genes or from our learning? Nature or nurture?” (p.80)

and

Humankind’s transient but magnificent rebellion against nature is allowed by the brain” (p.81).

That’s followed by a densely factual account of brain development and function, a brief review of historical studies of infant neglect, a detailed account of a study co-authored by Perry involving brain scans and finally a highly speculative section on socio-emotional growth derived from the concept of attachment. Stylistic issues aside, my first problem with this paper was that Perry frames human survival primarily in terms of social relationships.

Survival and instinctive behaviours

Although, oddly, Perry doesn’t actually mention Bowlby in this paper, he begins with what’s essentially an expansion on Bowlby’s environment of adaptedness ;

Three key brain-mediated capabilities must be present for our species to survive: individual survival, procreation and the protection and nurturing of dependents. Failure in any of these three areas would lead to extinction of our species. The brain, therefore, has crucial neural systems dedicated to (1) the stress response and responding to threats – from internal and external sources; (2) the process of mate selection and reproduction and (3) protecting and nurturing dependents, primarily the young.” (p.81)

My reservation about this claim is that although Perry is right about the three capabilities, the first – individual survival – doesn’t map directly onto (1), a neural system dedicated to a stress response, because survival requires more than just a response to threat. It also requires the ability to find food and shelter, for example. I suppose the reflexes that underlie rooting, suckling, foraging, hunting and nest-building (used by many species for their sleeping arrangements) could at a stretch be classified as responses to threat (of starvation, predation or hypothermia), but these behaviours come into play in order to avert threat, rather than as a response to it. Not only are they not responses to stresses or direct threats, but stresses or threats usually disrupt them. In addition of course, the brain has ‘crucial neural systems’ dedicated to many functions other than the three listed.

Perry then goes on;

The primary strategy we use to meet these objectives is to create relationships. Relationships which allow us to attach, affiliate, communicate and interact to promote survival, procreation and the protection of dependents. It is the brain that allows humans to form the relationships which connect us – one to another – creating the myriad groups – that have been the key to our success on this planet.” (p.81)

Creating relationships has certainly been an important factor in our ecological ‘success’ but whether it is the primary strategy is debatable. Our problem-solving capability and language have been also been crucial, demonstrated by the fact that human beings have been more successful, than say, chimpanzees, who are social primates par excellence.

So although I wouldn’t dispute Perry’s conclusion that

“… some of the most powerful and complex neural systems in the human are dedicated to social affiliation and communication.” (p.81),

I get the impression that he sees human ecological success in terms of social affiliation and communication, rather than social affiliation and communication being two factors that contribute to human ecological success. The nature of Perry’s model might explain the absence of a detailed discussion of the role of genetic factors in development.


Normal and abnormal: genetic variation

The next section of the paper consists of an excellent summary of brain development and function, listing eight key processes. My one reservation is about Perry’s conclusion. He says:

The eight key neurodevelopmental processes described above are dependent
upon the genome and environmentally-determined microenvironmental cues …. Disruption of the pattern, timing or intensity of these cues can lead to abnormal neurodevelopment and profound dysfunction.
” (p.85)

What bothered me was the implicit assumption that there is such a thing as ‘normal’ neurodevelopment. In a large population, the measures of many characteristics, such as height or weight, fall into a ‘normal’ distribution – when represented as a graph, they form a bell-shaped curve. The majority of individuals cluster around the middle of the curve – the 50th percentile. In the case of head circumference (the measure Perry uses in cases of neglect), as head size increases above or decreases below the 50th percentile, fewer and fewer individuals have those larger or smaller head sizes. With regard to measures used in medicine, approximately 95% of the population is generally considered to form the ‘normal range’. So around 2.5% of the population with the smallest head sizes and around 2.5% with the largest head sizes are considered to have ‘abnormal’ head sizes, but in a statistical sense only – it doesn’t mean there’s necessarily anything wrong with the individuals concerned.

normal distribution


The bell-shaped curve reflects the range of genetic and environmental factors that contribute to differences between individuals. I think Perry’s (and Bowlby’s and Schore’s) omission of a discussion about genetic variation between individuals is significant. It’s especially significant in Perry’s case, since his paper claims to be about genetic potential. Each of these authors appears to employ a model of genetic development similar to the one popular during the early days of genetic research – of an unfolding species-specific genetic blueprint. For example, Perry says;

Sensitive periods are different for each brain area and neural system, and therefore, for different functions. The sequential development of the brain and the
sequential unfolding of the genetic map for development mean that the sensitive periods for neural system
[sic] (and the functions they mediate) will be when that system is in the developmental ‘hot zone’ – when that area is most actively organizing.” (p.88, my emphasis)

which means that;

The simple and unavoidable conclusion of these neurodevelopmental principles
is that the organizing, sensitive brain of an infant or young child is more malleable to experience than a mature brain. While experience may alter the behavior of an adult, experience literally provides the organizing framework for an infant and child. Because the brain is most plastic (receptive to environmental input) in early childhood, the child is most vulnerable to variance of experience during this time.
” (p.88)

Although at one level Perry’s conclusion is correct, he doesn’t mention that individual variations in genetic endowment are also involved in neural development; I get the impression that he sees human genetic endowment as standard issue (any exceptions being immediately obvious), so that as a general rule experience alone provides the organizing framework for brain development. This isn’t the case, of course. Deletions, insertions and duplications of genetic material, both inherited and occurring spontaneously between generations, combined with epigenetic changes (the environment acting on genetic expression) that can also be inherited, result in each individual being genetically as well as environmentally unique. This means that the only way one can safely use the term ‘abnormal’ in relation to development is in a statistical sense – in terms of the normal range for any particular characteristic. But Perry’s paper isn’t about genetic endowment, it’s about genetic potential.

Genetic potential

Perry explains genetic potential like this;

Genes are designed to work in an environment. Genes are expressed by microenvironmental cues, which, in turn, are influenced by the experiences of the individual. How an individual functions within an environment, then, is dependent upon the expression of a unique combination of genes available to the human species. We don’t have the genes to make wings. And what we become depends upon how experiences shape the expression – or not – of specific genes we do have. For thousands of years, the genetic potential to use “joysticks” was not expressed – nor that for written language or reading. Yet when experiences are provided in a structured, patterned and appropriately timed way, that potential can be expressed and neural systems which mediate all of those functions will develop.”(p.86; Perry’s emphasis)

There are several ambiguities in this paragraph; notably about genetic design and genetic expression and potential.

Firstly, as far as I’m aware, there’s no evidence that genes are designed to do anything. Genes are molecular units that behave in certain ways in the presence of other molecular units or in certain chemical and physical microenvironments. How an individual functions in response to those microenvironments is dependent not upon the expression of a unique combination of genes available to the human species, but to the individual human being. Genetic endowment alone, regardless of environment, can, for example, result in a failed conception, a miscarriage or an individual born with ‘profound dysfunction’.

Secondly, the term genetic expression usually refers to the chemical (in most cases a protein) that’s produced using information from a gene; using the term ‘genetic expression’ in relation to broader human potential is, I feel, a bit confusing. Being able to read, write or use joysticks aren’t abilities encoded in our genes, they are affordances– a range of things we have the potential to do as a consequence of genetic expression.

Normal and abnormal: environmental variation

Perry points out that animals raised in enriched environments have been found to have larger, more complex and functionally more flexible brains than those raised in more deprived environments, and that animals raised in the wild tend to have larger brains than their domesticated offspring. He concludes;

It is plausible, however, that abnormal microenvironmental cues and atypical patterns of neural activity during sensitive periods in humans could result in malorganization and compromised function in a host of brain-mediated functions. Indeed, altered emotional, behavioral, cognitive, social and physical functioning has been demonstrated in humans following specific types of neglect.” (p.90)

I’m not convinced that Perry has fully thought through the implications of what he considers to be ‘normal’ and ‘abnormal’ microenvironmental cues. Perry clearly approves of the hunter-gatherer lifestyle – or at least the social aspects of it;

The genetic potential for healthy socio-emotional functioning – to be empathic, to share, to invest in the welfare of the community – is better expressed in children living in hunter-gatherer bands or extended families or close-knit communities in comparison with our compartmentalized modern world.” (p.96)

And he disapproves of aspects of the modern developed world, questioning the size of households, the amount of television we watch and the way our children are segregated from adults in schools (p.96). What Perry fails to recognize, I feel, is that lifestyle isn’t necessarily based on free choice. Nor does he recognize that something that’s beneficial in some respects might be damaging in others.

Children raised in hunter-gatherer communities are essentially brought up in ‘the wild’. Animals and humans raised in the wild are at high risk of death from starvation, injury or disease, so we would expect their brains to reflect such an ‘enriched’ environment because of the constant need to be on the alert for risk factors. Domesticated animals (and humans) clearly don’t face the same challenges, so we’d expect their brains to reflect that difference. It doesn’t follow, of course, that an animal kept confined in a concrete pen, or a neglected child, is better off than a member of its species engaged in hunting and foraging. But hunter-gatherer communities have no choice about living in large groups, because nuclear family units wouldn’t have the resources to ensure a constant food supply or protection from attack. That doesn’t mean a high risk of starvation, injury or disease is a good thing, nor does it mean that people are necessarily happier when living in close proximity to large numbers of other people. One has only to read the Old Testament to learn some salutary lessons about how extended families can malfunction; I don’t think it’s any coincidence that when they’ve had the option, many families have chosen to live as nuclear units.

Perry clearly doesn’t think that a high risk of starvation, injury or disease is beneficial to children’s development, and despite his doubts about ‘electronic activities’ (p.97) believes that some modern technologies (reading, writing and joysticks) are benign. In short, he picks and chooses which aspects of modern life he considers to be damaging, but doesn’t provide a coherent explanation as to why. Suggesting that it’s because we’ve departed from a hunter-gatherer lifestyle doesn’t hold water, because there are aspects of hunter-gatherer lifestyles that Perry would object to. I think he needs to clarify what he means by ‘abnormal microenvironmental cues’, ‘atypical patterns of neural activity’ and ‘altered emotional, behavioral, cognitive, social and physical functioning’ – altered from what, exactly? What does he consider to be the norm and why?

Neglect

Following his discussion of neurodevelopment, Perry introduces the topic of neglect, which he defines as ‘the absence of critical organizing experiences at key times during development’(p.88). He then considers two forms of neglect, one involving sensory deprivation and the other affecting the development of socio-emotional potential.

Two forms of “neglect” will be considered below: extreme multi-sensory
neglect in childhood and a more subtle, insidious decrease in our opportunities to
elaborate our socio-emotional potential caused by the sociocultural changes in how
we choose to live. The sensory deprivation neglect results in obvious alterations in
neurobiology and function while the second form has an almost invisible toxic
impact on the developing child – and ultimately, society.
” (p.88)

Perry claims that neglect has – ironically – been neglected by researchers mainly because it’s difficult to “see”, citing specifically emotional neglect (p.88) and the importance of touch in early development and referring to Rene Spitz’ work with institutionalized infants (p.89). I wouldn’t dispute that emotional neglect is harmful, nor that tactile experience is important for the development of proprioceptive and motor function, but, as far as I recall, Spitz (and Harlow with his baby monkeys) made some assumptions about what was missing from the environment of the deprived infants. In addition to emotional engagement and tactile deprivation, there were clearly questions over the adequacy of nutrition – vitamin D levels, for example – and precisely what sensory stimuli were absent. Spitz’ children would have been very susceptible to viral infections, also difficult to “see”. For example, Spitz (1957) describes deprived children rotating their heads around the sagittal axis (i.e. from side to side) and interprets this movement as the children using a universal human signifier for ‘no’ – despite the fact that head-shaking isn’t a universal human signifier for ‘no’ and that it can result from middle ear infections (common in infants, especially if they are supine for long periods) or from impaired development of the cerebellum.

The outcomes of neglect

Perry then moves on to clinical findings in relation to neglect and presents the results from a study he co-authored comparing children subjected to different types of neglect. To summarise, institutionalized and neglected children tend to show low IQs, developmental delays and small head size. This developmental trend is reversed when children are placed in good foster homes or adopted, younger children making better progress than older ones. Perry’s investigation of head size leads him to conclude that neglect results in impaired brain development and he supports this conclusion by referring to evidence from brain scans.

Perry and Pollard (1997) investigated four groups of children;

Global Neglect (GN; n = 40); Global Neglect with Prenatal Drug Exposure (GN+PND; n = 18); Chaotic Neglect (CN; n = 36); Chaotic Neglect with Prenatal Drug Exposure (CN+PND; n = 28). Measures of growth were compared across group [sic] and compared to standard norms developed and used in all major pediatric settings”. (p.92)

Global neglect is defined by “a history of relative sensory deprivation in more than one domain (e.g., minimal exposure to language, touch and social interactions)” and chaotic neglect as “far more common and was considered present if history was obtained that was consistent with physical, emotional, social or cognitive neglect.” (p.92)

Perry and Pollard found that for the global neglect group, the mean head circumference was below the 5th percentile, but such a dramatic variation from the norm wasn’t seen in the chaotic neglect group. For the global neglect group, 17 MRI or CT scans were available – 11 of them were judged ‘abnormal’ by neuroradiologists. 26 scans were available for the chaotic neglect group, but only 3 were judged ‘abnormal’.

Unanswered questions

The material on clinical and neurobiological findings raises many unanswered questions. Why were the children in institutions? Were their parents dead, ill or did they lack the resources or ability to care for their children? Were genetic or physiological causes for the children’s poor development ruled out? Why were children neglected at home? What specific factors necessary for healthy development were absent? Why were CT and MRI scans available? Had brain damage or a medical condition been previously suspected?

Until these questions are answered, all that Perry’s data can tell us is that specific groups of children, raised in specific conditions (characterized by unspecified inadequacies), showed delayed or abnormal development. All we have is a correlation between neglect and poor development. We don’t know if the neglect caused the poor development, or if it did, which elements of the neglect caused what developmental deficits.

But Perry doesn’t identify precisely which sensory domains were neglected or how, or what aspects of physical, emotional, social or cognitive input were missing. Specifying the components of neglect isn’t important if you’re interested only in the degree of neglect, but it becomes very important if you’re mapping neglect onto brain abnormalities or want to compensate for specific factors that might have been absent in early development.

Brain abnormalities

What Perry does tell us is that two particular brain anomalies were identified from the CT and MRI scans; enlarged ventricles or cortical atrophy. (You can see abnormalities of the ventricles and cortex in the right-hand image of Perry’s Figure 1, below.)

Perry’s Figure 1

The ventricles are spaces in the brain that join up with the central canal of the spinal cord and are filled with cerebro-spinal fluid. The lateral ventricles are visible in the centre of the CT scan images. Cortical atrophy means that the cortex of the brain has shrunk, usually due to the degeneration of cells.

It’s possible that the neglect experienced by the children resulted in these two brain anomalies; but there are other possible causes. Enlarged ventricles occur in around 1% of pregnancies for a variety of reasons, unlikely to be due to global or chaotic neglect as defined by Perry, but he doesn’t mention the possibility of enlarged ventricles occurring prenatally. Perry and Pollard’s data indicate that the globally neglected children also showed low height and weight, and the authors do mention that nutrition might be involved. Cortical atrophy can also have a variety of medical causes. In short, although neglect is a possible cause, it’s only one of several possibilities.

Support for the hypothesis that neglect rather than genetic make up or medical conditions caused the brain abnormalities comes from the finding that a year after neglected children were placed in foster care, head size had increased, the increase being inversely correlated with the child’s age (younger children showed greater increases). Even so, in the Perry and Pollard study the youngest children’s head size was still below the 30th percentile – we aren’t told whether the youngest children eventually ‘caught up’ with their non-neglected peers and we don’t know whether the children would have had small heads regardless of whether or not they were neglected. In addition, the head circumference data are presented as means – we aren’t told the range of measurements involved for each age range. It could be that the group mean is artificially high because one child’s head size increased significantly, or artificially low because one child’s head size remained small.

Although some parts of Perry’s paper are very useful – the sections on brain development and the summary of the history of child neglect research, for example – in general I found it frustrating, for three reasons. These are that Perry conflates correlation with causality, fails to take adequately take into account individual variations and doesn’t define neglect with sufficient accuracy.

Correlation and causality
Running through this paper is an implicit assumption that if that neglect is associated with developmental and brain abnormalities, those abnormalities must be caused by neglect. This is a basic error of data analysis. Although it’s likely that neglect causes developmental problems – otherwise it wouldn’t be called ‘neglect’ – it’s impossible to tell from Perry’s data whether;

• neglect caused the brain abnormalities
• the brain abnormalities caused the neglect (if the brain abnormalities were also present in parents or neglect was a response to the children’s behaviour)
• there were other causes for the abnormalities, or
• which components of neglect were responsible for which brain abnormalities.

Individual variation Perry doesn’t seem to take individual variation into account; in his Figure 1 he compares a neglected brain on the 3rd percentile with a non-neglected one on the 50th percentile, when a comparison with a 3rd percentile non-neglected brain would probably have been more informative. And his graph of the increase in head-size when children of different ages are fostered, presents mean values for each age group rather than the range of head sizes for each group.

Defining neglect There’s no question that children need certain conditions for healthy development. A nutritious balanced diet, fresh air, exercise and sunlight, a stimulating environment and consistent, caring stable relationships suggest themselves. The absence of any of these factors can cause deficits in development – the child might not reach their genetic potential as Perry suggests. But apart from making a distinction between extreme (global) neglect and more common (chaotic) neglect, Perry doesn’t discriminate between the different components of neglect and their possible effects. It’s important that we know what components of neglect have what outcomes because if we don’t, whether or not a child has been ‘neglected’ ends up being a matter of personal judgement. In his closing section, for example, Perry suggests that living in small social units and watching several hours of television a day is detrimental. He’s entitled to his view of course, but provides no evidence to support his claim, apart from pointing out the decline in the number of people who vote in Presidential elections (p.97).

Why Perry’s paper worries me

What worries me about Perry’s paper is that, despite its weaknesses, because it’s relevant to a highly specialised domain, it’s unlikely to be read by the geneticists and the evolutionary, developmental and molecular biologists who are in a position to critique it. Perry’s work has been cited, uncritically, in a number of policy documents. His argument in this paper is superficially plausible because, like Bowlby, he constructs it by juxtaposing several indisputable ideas (e.g. human lifestyles have changed, children are developing, neglect can be harmful) but the definitions of underlying concepts and the causal links between them, by contrast, are rather tenuous. But a busy social worker, school nurse, health visitor or even doctor, is quite likely not to notice the weaknesses in the definitions or causal links. Perry’s paper is likely to be seen as providing evidence that neglect (sometimes seen by professionals as synonymous with parenting strategies of which they personally disapprove) causes abnormal brain development. Or worse, that abnormal brain development will be assumed to be caused by neglect, rather than by one or more of many possible causes.


References

Perry, B.D. and Pollard, D. (1997). “Altered brain development following global neglect in early childhood”. Society For Neuroscience: Proceedings from Annual Meeting, New Orleans.

Spitz, R.A. (1957). No and yes : on the genesis of human communication. New York : International Universities Press.

Normal distribution curve from: http://en.wikipedia.org/wiki/Percentile_rank