The Case

EMS brings a 2-year-old female to the emergency department with concern for hypothermia and malnutrition (see Figure 1). During a police welfare check, the patient’s deceased mother was found surrounded by drug paraphernalia in the bedroom of a small apartment. The child was on the floor next to her mother. No other people were present. EMS noted there was no heat in the apartment and that the floor was covered with animal feces.

The child did well during her emergency department stay. A children and youth caseworker was contacted and took custody of the child because no adult relatives could be located.

Discussion

Neglect is the most common form of child abuse, accounting for 75 percent of child abuse cases in the United States in 2015. In the United States, roughly 1,700 children die from child abuse and neglect each year. Most of these fatalities are thought to occur due to neglect.¹

Definitions of neglect vary from state to state, but the common thread is failure of a caretaker to provide for a child’s basic needs, including food and water, clothing, shelter, medical care, and supervision appropriate for the child’s age, resulting in actual or potential harm.²

Neglect can be classified as follows:

• Physical neglect: Failure to provide adequate food, clothing, or shelter, and inadequate supervision
• Emotional neglect: Failure to provide love, attention, and security
• Educational neglect: Failure to enroll the child in school, and truancy without a medical cause
• Medical neglect: Failure to seek medical care or nonadherence with health care recommendations, resulting in actual or potential harm to the child
• Inadequate supervision: Failure to provide adequate supervision for the child’s level of maturity, failure to provide adequate caretakers, or failure to protect the child from safety hazards

Risk Factors

Risk factors for neglect can be divided into environmental and family factors. Examples of environmental factors include poverty and lack of social support. Family factors can include a single-parent home or a history of domestic violence.

Children are more likely to suffer neglect if a parent is a substance abuser, is unemployed, or has mental illness. Substance abuse is a factor in one-third to two-thirds of child abuse cases. Most children affected are very young or have medical problems, such as developmental delay and/or behavioral issues.

Consequences of Neglect

Emergency physicians may readily recognize the acute manifestations of child neglect, such as failure to thrive, untreated medical and dental conditions, and environmental exposures. In the long-term, neglected children experience more severe cognitive deficits than children who suffer other types of abuse.³ The psychological effects of neglect may result in high-risk behaviors, such as alcohol or drug abuse. Neglected children are at increased risk for adverse health effects and certain chronic diseases as adults, including coronary artery disease, cancer, pulmonary disease, hepatic disease, obesity, hypertension, and hyperlipidemia.⁴

Recognition and Screening

Because there are different types of child neglect, there is no single correct approach for screening. If you suspect neglect, interview the child alone if possible. Specific questions may include:

• Where do you live? Is it warm enough in the winter?
• Do you have enough food?
• Do you get medicine when you are sick?
• Do you go to school every day?
• When your parents are not home, who takes care of you?

Mandated Reporting

All U.S. states and territories have statutes regarding mandated reporting of child abuse and neglect to an appropriate agency. In most jurisdictions, individuals who have frequent contact with children as a result of employment or volunteer work are mandated reporters. Typically, only reasonable grounds for suspicion of abuse or neglect are required—the burden of proof falls upon the investigating agency. Most states and territories have statutes that protect the identity of the reporter from disclosure.⁵ Important: Emergency physicians must know the reporting requirements and procedures in the state in which they practice.

References

1. Child maltreatment 2015. US Department of Health and Human Services Children’s Bureau website. Available at: acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment. Accessed April 16, 2018.
2. Acts of omission: an overview of child neglect. Child Welfare Information Gateway website. Available at: childwelfare.gov/pubPDFs/acts.pdf. Accessed April 16, 2018.
3. Hildyard, KL, Wolfe, DA. Child neglect: developmental issues and outcomes. Child Abuse Negl. 2002;26(6-7):679-695.
4. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) study. Am J Prev Med. 1998;14(4):245-258.
5. Mandatory reporters of child abuse and neglect. Child Welfare Information Gateway website. Available at: childwelfare.gov/topics/systemwide/laws-policies/statutes/manda/. Accessed April 16, 2018.

Dr. Rozzi is an emergency physician; director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania; and chair of the Forensic Medicine Section of ACEP.

Dr. Riviello is professor of emergency medicine at Drexel Emergency Medicine in Philadelphia.