Breaking the Cycle of Neglect

Teresa Huizar: Hi, I’m Teresa Huizar, your host of One in Ten. On today’s episode, Breaking the Cycle of Neglect, I speak with Dr. Robin Ortiz, assistant professor in the Department of Pediatrics at NYU Grossman School of Medicine. Now talk with any child abuse professional long enough and they’ll tell you a story about neglect recurrence: the family involved in CPS across four generations, the same parents cycling through over and over, the treatment that never quite takes, the generational harm and the personal despair. But what do we actually know about why neglect recurs? Why is it for some families a relapsing remitting condition rather than a one-time event?

And most importantly, what can we do to more effectively prevent neglect in the first instance and address any recurrence in a way that breaks the cycle? I know you’ll be as interested in this conversation as I was. Please take a listen.

Robin, welcome to One in Ten.

Robin Ortiz: Thank you so much for the invitation. I’m really honored and excited to be here.

TH: So how did you become first interested in the topic of neglect and especially neglect recurrence?

RO: Yeah. Thank you. Well, it does involve a little bit of introducing myself as I’m actually not a child abuse pediatrician or really, you know, compared to others in this space, maybe a specialist.

Where I came to this work, and it’s relevant to what we’re gonna talk about today, is I’m a researcher and internist and pediatrician, a clinician scientist by training who became interested in the space of adverse childhood experiences or ACEs, I’m sure familiar to much of the audience many years ago and began exploring how ACEs are experiences in childhood that are challenging, right?

And related, they can be abuse, they can be other things we’ll probably get into today. But what was interesting to me as a clinician was that these are associated with poorer health outcomes or various disease outcomes later in life. And so I went down the explorative pathway of what factors contribute to these ACEs to try to offset them and offset their consequences.

But the key thing to know about ACEs that ties back to your question is their dose-dependent relationship. The more ACEs exposure, the greater the risk. Well neglect actually is not only an ace, but it carries a similar paradigm that I learned about through the work of this paper where neglect itself is associated with many other adversities and challenges and some of the risk factors for it and for its recurrence, like we’ll speak about today, exacerbate the risks of not only neglect, but probably some of those factors downstream that I am interested as a clinician. So that’s how I came to this work and partnered with Dr. Vince Palusci, who is a child abuse pediatrician to explore that. And so the way we’ve approached the work of adverse childhood experiences, looking at the Socioecological model, was a great fit for exploring neglect and neglect recurrence and trying to get to the root causes to be able to affect not only neglect, not only ACEs, but many of the contributing factors on other levels.

TH: So in your lit review, you talked a little bit about what the literature already said about the topic of child maltreatment recurrence. And so just for the listeners who may not be very familiar with that literature, and they may not have yet read your study, which I hope they will. Is it super uncommon, super common?

Like how would you describe child maltreatment recurrence overall?

RO: Yeah. Overall, very common that once an individual may have experienced an adversity or an actual case of maltreatment, it may be common to, again, have another experience or be re-referred within the system. What’s most relevant, I think in the background of this paper and to the topic today, is the fact that neglect is so common specifically, and in fact, it’s one of the substantiated type of abuse.

So of those that are reported to CPS, when it’s neglect, 75% of the time is found to be that neglect is substantiated, and then the recurrence question is known pretty well. As you alluded to in our lit review, we cite studies in the world of physical abuse and sexual abuse, but less is known about neglect recurrence.

So I couldn’t answer that question until we did the study and that’s where we found kind of a gap in the literature and said, we don’t know how often neglect occurs, or the few studies that have shown that it does recur, it’s less known what contributes to it. And so those are the gaps where we tried to answer those questions somewhat.

And I think what we tried to get at is the idea that when you read the literature in the background and other types of abuse that present commonly or recur commonly. The hypothesis there is that they have signs or symptoms that are a little bit more overt, something that somebody could recognize a little bit more straightforward, especially those who are trained, maybe even not necessarily those who don’t know so much, but physical abuse or sexual abuse, there may be signs or symptoms, unfortunately, of course, I don’t mean to say there are many cases, there’s not, but neglect less so can be often less obvious until very severe. And so that was one thing that popped out to me about the literature was that some of the recurrence in other spaces of abuse spoke to those signs and symptoms and neglect had a gap, likely because it’s somewhat harder to classify.

TH: Well, I think that one of the issues, because we’ve talked about it on this podcast quite a bit actually over the years, part of it is that definitionally, it can be a little muddy across states. So you talked about that in your paper as well, in terms of trying to get people to recognize signs of neglect.

The definitions in some states are just very vague, and you know, there’s been this effort also to make sure that it’s not conflated with poverty alone. And so I think, can you talk about this just, I was thinking about the very hard job you set yourself. Not only looking at this gap in the literature around neglect recurrence, but just that because neglect is a little bit fuzzy in terms of its legal definition, it makes it harder to go, well, how often is it recurring?

RO: Exactly, and actually I’m really glad you brought this up because I myself often have to go back to the definition of neglect, which we cite in our own paper. And so what I will is quickly read it for the viewers who are listeners who haven’t necessarily read the paper yet, because it’s relevant to answer your question, I feel like, so we define it using the Federal Child Abuse Prevention Treatment Act, defining neglect as quote, any recent act or failure to act on the part of a parent or caretaker that presents an imminent risk of serious harm to the child. And so there’s a lot to unpack there. I’m sure every word in there is mulled over with all the best intentions, but even the phrases I’ll Parse out imminent risks. So somebody in immediate danger or someone in immediate harm.

But how do we define immediate when neglect is often a chronic situation, an environment, you know, physical abuse and sexual abuse and other forms of adversity are often chronic in that they’re often repeat exposure is happening to an individual, even under one point of investigation. But neglect is often environmental, ongoing, maybe smaller insults that amount to a deficit rather than an immediate threat being presented.

And so how to capture that is hard, the imminent risk, and then the harm to the child. So neglect’s harm may also be a bit more subtle, where some the harm is not in the immediate injury or psychological injury, it certainly can be, and it’s a very powerful adversity to face, but it often is like a cumulative effect that’s seen when it presents and presents more severely or has those downstream consequences.

So yeah, how do you define that? And then that’s just the definition. So to your point about the policies overlap with definitions, and the way we speak to it in our paper for the listeners to hear is that every state may have a different definition. So of, not just taking the federal definition, but adapting it and may actually broaden it to have certain caveats or qualifiers is what may count as those risks or harms to children that fall under the category of neglect.

And I really appreciate that you brought up the point about poverty because the listeners may think, you know, I understand how poverty may overlap. Right? But why, specifically in the context, talking about definitions and policies? Well, because, poverty in some states is a part of the definition that it may be permissible for the definition or a case of neglect to be substantiated as neglect if poverty is contributing.

But there are a handful of states, I believe, 25 if I’m remembering off hand or so that actually specify whether poverty or not can be included. And we even in our paper, tried to get at some of those classifications. We even have an exposure where we say, we test, like, what about neglect? You know, not contributing, not in the case of poverty, which we, it’s just much more complicated to disentangle those two topics, but I raise it in reference to your question because certain, in short, certain states allow the inclusion of poverty and others don’t and disentangling that is really, really complicated. And so you’re right to quantify neglect and then quantify its recurrence on top of money or vague definitions is challenging, but also why we were excited about the work.

’cause we hope that we could start to disentangle even just a little bit or get other researchers excited so that we can start to have these conversations with policymakers to say what should. Shouldn’t in the definition or what should be classified as a risk factor rather than maybe a substantiating factor for a case.

TH: That’s interesting, making that distinction between the two, and I think that I wanna get into that in a minute. Let’s talk a little bit about the hypotheses you had going into the study. What were you trying to find out? Just fundamentally.

RO: Thank you. Yeah, so number one, just how often neglect occurs, at least in this data set.

There’s, of course, researchers listening will say, you know, may or may not be completely generalizable. There’s some limitations, but this is quite a large national data that we were using. And so that that number, the representation across states, with the exception of some limitations of course, but gives us at least some idea of how often does neglect occur? And our hypothesis to your point is probably quite often, but we didn’t have the numbers to go by. And secondarily, what were the contributing factors to that recurrence be very broadly speaking, and we know, as I alluded to that neglect is an environmental manifestation.

It may be as we also alluded to, in part because of poverty, limited resources that may contribute to the inability to sufficiently support a child as needed. It may also be because of other factors in the child’s life, or the family or caregiver’s experience. And so we wanted to look at those contributing factors in addition to those at a more societal level, like the policies or definitions of neglect. So that was objective to what contributes to neglect recurrence. But then this interesting piece of that, I would say as a third question or a sub question was, what about after, because of recurrence, you’re actually definitionally saying, well, it’s already recurred and there’s already been a case, and there may have been services provided to that individual in the report or in the case that was substantiated in the first place.

So we also wanted to look at, you know, were there types of services that might have decreased risk or increased risk for that recurrence?  Yeah, in brief it was just how frequently does neglect recur? And secondarily, what factors contribute at all levels to potential recurrence?

TH: Well, each one of those could probably be a whole podcast episode, but we’re just going to tease ’em out one by one.

So I wanna start with what you found for neglect recurrence. So, in your dataset, how often did it recur?

RO: Yes. Neglect, recurred, so we have, I have here about 21% of childhood maltreatment first and foremost recurred, meaning any type of abuse case. And that’s important because where we are talking about neglect recurrence, and it’s default to think, oh, a recurring is neglect.

It was recurrence in general, meaning it could be any other type of abuse. That’s pretty high, pretty significant, right. Between one and four, one and five individuals having another case of maltreatment. But what did substantiate our hypothesis was that the most common type of recurrence was often neglect.

There’s also this other category which is complicated because there, as we say, there are limitations to the data. There are some types of abuse that are not cleanly categorized as physical abuse. So I don’t wanna ignore that chunk because there was a large chunk that were also other types of abuse much more broadly.

But we hypothesized that some overlay probably with neglect and different definitions of neglect, but nonetheless, more frequently than we saw recurrence in the forms of physical abuse or other types of abuse cases. So that substantiated hypothesis that neglect recurs, what we would call frequently.

Some may hear 20% and say, not frequent, but that is affecting one in four to one in five children. And then number two is that in fact neglect commonly recurs as neglect, but not always it recurs as other types of abuse as well.

TH: I don’t wanna go yet too far down the policy rabbit hole, but I do think it has some important implications.

Well, first of all, you don’t want any child to experience recurrence and the fact that if a family has a confirmed case of neglect that about one in five of those cases are going to come back and there’s going to be another confirmed case. I mean, that’s more pain and suffering on the part of the children and family than you would want to see.

But also I think we’re not at a level of effectiveness around intervention and neglect where we’d like to be.  And we’ll talk about this more when you looked at services. ’cause I thought that was fascinating, that chart, but I was just thinking, you know, this is what it feels like to me when I was a practitioner and in all this time, it’s like for physical abuse, we have evidence-based interventions that we feel very confident about and that if they’re applied, people respond.

We can really successfully intervene so that there is less recurrence. If you look at child sexual abuse, the same thing, you know, we believe that there are good interventions that can occur and child sexual abuse, even in your own data, the recurrence rates were low, lower. Then you get to neglect.

And I think actually if you talk to any CPS worker, MDT member, they would have sort of the same thing, that there’s some subset of families, which they seem to see for neglect all the time. And they know sooner than finished one case, then they feel like they’re cycling back through six months after the last one closed.

And I think that this is both a point of frustration for people, but also points to something potentially missing in the way in which we’re intervening in these. And I just, I guess I’m just, you know, what are your thoughts about it? Because, you know, we’ve all been kind of talking about this without the data, but now you are presenting us with data that says, you know, you weren’t crazy to have this feeling that there are some subset of families who don’t seem to be benefiting as much as we would like them to from our interventions and keep cycling through.

RO: Yes, I agree with everything you just stated. So my thought is speaking to the study, that’s what I’m trying to speak through, is we looked at so many risk factors for neglect occurrence, right? And even if you don’t disentangle one from the other, which I’m happy to do, but just to say it speaks to the heterogeneity of both the risk factors for neglect, the risk for its recurrence, and therefore the likely multifactorial environment that we’re trying to treat when we need to try to support an individual who’s experienced neglect. And so it’s not that easy by any means to treat any other type of abuse, but it may be that it’s much more personalized of an experience that it’s hard to say that one individual experiencing neglect needs the same intervention that another individual experiencing neglect needs.

There may be different types of neglect in terms of the contributing factors, and that’s what motivated us was to say, are there factors that are more risk factors than others? So that we can start to look at the sort of antecedents to neglect and be able to allow clinicians and maybe even service providers to say, oh, these are factors that may be contributing, of course, to hopefully prevent neglect, but also to say, how can we then target an individualized to the, not necessarily the individual at hand, but at least the family or that community’s environment, interventions that will help them, and then we will be faced, the researchers, with the challenge of figuring out how to figure out what is the most evidence-based approach when something, when the solution, the intervention itself is very different for each person. So that poses a separate challenge, but I think that’s part of it. And I know we’re gonna speak about the services.

I think that’s part of what we see and why we see differential effects based on different service types.

TH: It’s a good point that you’re making, which is that we use the term neglect, but it’s actually covering a whole host of things. Not one thing, first of all. And so naturally, because it covers not only many different things, but many different constellations of particular risk factors that there’s probably not just one solution to it. Now let’s talk about those risk factors, because that was the other thing. You know, speaking of the complexity of this, because they exist at the child level, at the family level, at the community level, at the sort of policymaking and systems level, but what were the most common picking, wherever you want to start in that. What were the most common contributing risk factors for neglect recurrence?

RO: Yeah, so the more common are also probably those that are a bit more intuitive perhaps. So challenges faced at the level of the child, for example, behavioral problems or having what was classified in this dataset as a disability.

Which also may be something a little bit more challenging to treat if it’s ongoing and chronic, and also requires multidisciplinary clinical efforts. Right? Then there were factors at the family level, so contributing things like having a parent or caregiver who had substance use, for example, also financial challenges is a big contributing factor as well. And then the service level, which I think we’ll talk about separately, but depending on, there were actually a handful of services that surprised me, actually led to increased risk of recurrence. But I think we can talk about this, it might be an indicator of the complexity of those contributing factors. So things like disability or things that are hard to address. And then there’s the societal level. So another thing that contributed, which is probably intuitive, but important for those listeners, we were talking about policies, was when the case was in a location where there were more definitions of neglect, it was also more likely to recur.

And that makes sense because there is more ways to be able to indicate that neglect had happened, but it also may because it’s capturing more of the risk factors, whether it’s financial strain or stressors in the environment.

TH: One of the things that I was struck by when I was looking at the charts and especially around the kids and families, and I think it sort of helps explain both the chronicity of neglect in some cases, but also its recurrence is that many of the risk factors for it are things that are chronic themselves. You know, a type of disability that a child has or that a parent has, or that someone in the family has.

Or some kind of emotional or behavioral problem that’s ongoing, or a mental health condition that’s ongoing, or domestic violence, which is ongoing. And so in some ways.  You know, the thing that I was thinking about was that these are really families under tremendous stress, is what it struck me as.

RO: I would corroborate that and my background is really in that space of stress and adversity as a whole, and I think that’s what neglect speaks to. So, to your point, I think.  One thing we should probably disentangle about neglect, big picture, I think we lend some results to support is the important distinction between neglect and other forms of abuse in that it is in definitionally a deficit.

It meaning that a lack of, you know, meeting substantial need for the child or something that then poses harm. But it’s not the same as a threat introduced like a physical threat or a sexual assault threat. And that’s important because I think it comes from things that are more chronic, more environmental, and then lead to inability to meet need.

And so it could be chronic stress, it could be chronic lack of financial resources or supports. It could be an ongoing mental illness, yes, that’s untreated, and then all of those things, yes, enhance stress and lead to this deficit space. Now that’s super important as well, because of the consequences of neglect have differentiating, you know, influences on families as well. So you’re looking more at that children end up having sort of cognitive challenges or learning difficulties in school settings and those sorts of effects because we’re looking at a differential neurologic pathway rather than those who have been acutely immediately stressed by the presentation of physical or sexual injury or insult, which may affect stress response and a fight or flight mechanism in the long run. So it is about stress, but it’s important to think about the different type of stress that neglect is. It’s an environmental circumstantial with multiple contributing factors that then lead to these downstream more chronic consequences.

TH: I think also it’s unsurprising that where it was most likely to recur seemed to be around younger children too. Because they’re more vulnerable to any form of maltreatment. Right. And I think people are quicker to make a report about something that seems dangerous or problematic when it involves very young children than perhaps older.

And maybe there are other reasons too, but it’s just, to me, that was one of the, those that I thought it may be,  I mean it is true and it’s what makes the long-term effects of neglect, so especially pernicious because it’s impacting these very young children with potentially, if it’s uninterrupted, lifelong impact.

RO: Absolutely. And we know the zero to three or zero to five brain is quite vulnerable and susceptible to stress, but also especially to lack of support, stimulation, all the things that are needed to help promote health and positive outcomes later in life. And also that that age range is, as you mentioned, more susceptible to having a recurrence, being that they’re so dependent on their resources and environment, and it’s a shorter timeframe in that vulnerable period that likely could succumb to multiple insults. So very critical that we address that early childhood period that sets us up for lifetime outcomes, and especially in the deficit framework where those children really would benefit the most from the stimulating environment of healthy relationships with their caregivers and all of their resources that they deserve for the opportunity to learn and thrive.

And lastly, I’ll say of course, because like we said, the outcomes associated with neglect are cognitive and learning related. That furthers the cycle that if a young child is not only experiencing neglect where their brain is susceptible to the impacts, but also are, you know, seeing the outcomes associated with neglect in that early period where learning and cognitive stimulation is so important to setting up their nervous system and all the downstream effects of that for life.

TH: Now I wanna turn for a moment to the list of services and I have to say it was a pretty exhaustive list. You all listed every conceivable service a family could receive, and I’m curious what you found about them. You pointed out earlier that there were a couple that were a little bit head scratching and why, but just in general, what looked, you know, maybe more promising in terms of not as associated with recurrence and what was sort of like, well that doesn’t seem to really be impacting recurrence at all.

RO: Yeah, that’s helpful. So overall, you mentioned this exhaustive list and it’s important to highlight the list even includes foster care, which it’s important to point out. It’s not even necessarily an intervention at the family level, but even to go as far as to that child be placed in foster care. So very comprehensive, which may have its own limitations, but we try to piece them apart.

Any service, any one of those things. So taken together that at least some service had been provided was actually only done in under 60%. Like 58% of initial neglect cases. So that’s point one. It’s just to say, even forget the hypothesis we were trying to attest in terms of recurrence. Not every initial case is even getting a service despite how exhaustive our list was, at least in this data set.

And so that, that speaks to something. What about those other 40%? That’s probably a risk factor in and of itself for recurrence, but also speaks to the level of reflection we probably need to do in society to try to think about what can we do for everyone. Then there are of the people who did receive a service, any service, any one of them did have some benefit. So at least having one service was about a 5% decreased risk of the neglect recurrence. So that is a positive thing to give us all before we get into the nuances of some services, maybe not as effective. Just to say it is a good thing that we are providing any service.

Let’s do something even if we’re caught in the strengths of not knowing what to do in neglect cases as we may feel it is better to do something than nothing hopefully is what we can say, even if it just offsets the risks slightly. But then it’s when we get into the nuances of which services provide what and what we found that actually kind of perplexed me, I had to think through and process a bit, was there are some services like providing broad education to families or support that were actually associated with either no or increased risk of recurrence, which is counterintuitive thinking, well, we’re providing something. What’s going on there? I think that probably is more of an indicator that we’re missing something in that equation.

It may be that circumstance of neglect. So that child’s family level, those factors may be more complicated than that service was able to provide. Rather than saying necessarily it’s possible the service was just insufficient and a failure. But I don’t necessarily feel that’s the case. I think likely it was yes, insufficient, something else was needed to support that individual or family.

TH: One of the things I was thinking of when I was looking at the list of how they fell out, you know, some of them in, in some ways. It’s not surprising. So for example, I looked at substance abuse that might have slightly reduced the risk, but not dramatically for recurrence. On the other hand, like substance abuse treatment, I mean.

I was thinking that’s such a chronic condition for many people and often takes repeated attempts at treatment before it’s successful. And when you are looking at a relatively small band in time, you can see why the level of substance abuse treatment that might be available while someone has an open case, because in the US that’s really how you get access to these things and cases aren’t kept open forever.  That might not be sufficient to the task at hand if that’s the critical issue. Right. So I think you had some in the list that, I mean, I know it’s one piece of research, it doesn’t answer every question, but that was kind of my reaction to some of them wasn’t to say, well, they don’t work, but what do we need to know or understand better about how much of something and for how long they need it in order for it to be more effective.

RO: I would agree with that. So maybe a dose sort of question. But also the other one there was like physical disability was both a risk factor and then the services provided to it were seemingly not sufficient enough to at least to see the effect we were looking for in decreasing neglect recurrence.

But similarly, because it probably requires a larger dose, a lot more multifactorial, contributing, you know, supports. And there’s this nuance of we are using a dataset which has multiple different states in our analysis. We did try to adjust for the effects that happen at different levels, random effects at different states, but it’s not perfect.

And it’s possible that also there are just a variety of types of disability services and we don’t know exactly which ones are more efficacious than others, at least when we’re speaking about neglect recurrence as the outcome, you know, may the same as substance abuse, where we do know what’s evidence-based for helping in substance use, but maybe less so knowing specifically what’s evidence-based in substance abuse to helping with neglect recurrence, and maybe an extra piece of the puzzle we need to address.

TH: Well, and what’s available.

And what’s the waiting list like? This is what I was thinking about as I was reading it, right? Like just from a practical level. You know.  You can only look at this at a point in time, but someone might have had to wait three months to get into the queue, you know? And then once they’re in the queue, maybe they only get six or eight weeks of treatment.

And so I think there’s just a lot to unpack about all of that. And the other thing, and this is gonna be a little bit of a hot take, and it’s not in your paper, but I do think from working on these cases that one of the issues is that courts tend to kind of have a set menu of things that they approve, including in a treatment plan.

And it’s not to say that they’re not customized to some degree, but I think in most jurisdictions, if you took a set of treatment plans for neglect and you laid them all out on a desk, it would have a lot of commonality. And so to your point about the need for tailored treatment based on which of the factors are actually contributing in a specific family, I think that’s a level of sophistication that I think has been hard to achieve and not because anybody’s, you know,  trying to neglect neglect, but because I think it is often hard to have the resources and everything else to buy the perfect array, to train your staff to, you know, assess accurately what people need, like all of the things.

But I think it does kind of contribute less of the kind of highly tailored treatment that may be indicated by your results.

RO: I would agree with that. And I will say, if I’m allowed to have a little hot take outside of the paper myself, would be to speak to that. There’s a huge need of work to compliment this type of work in the area of social needs or what has prior been referred to as social determinants of health. Because it’s a similar question of there are circumstantial, environmental, structural, societal, if you will, contributing factors to people’s health. Just the same as there are two neglect or recurrence, and one can argue those are this the same thing. Neglect, recurrences are directly related to health, and so. We are still trying in the world of health equity research to figure out how do we survey inaccuracy for social needs and then how do we address them because it is a heterogeneous experience and similarly not a one size fits all intervention.

So we’re experiencing the same thing in health systems or other places as courts may be experiencing when they’re trying to address neglect and we can, the fields could learn from each other. If we can start with the work here, like we tried to do, just piecing apart some of those risk factors, then potentially building some tools and systems to assess for those risk factors.

And then tailoring interventions to people to address those would be ideal for both health equity and for neglect recurrence interchangeably. Now, can’t answer the question about making sure we have trained staff and all resources available, but part of that would speak to well if we know those that are most effective or the needs that are most needed, we can know how to allocate resources accordingly. Okay. Let’s at least try to really strengthen those particular types of interventions or addressing, or even more upstream, trying to prevent those needs from being as prevalent as they are to begin with.

TH: Well, exactly. I mean, to your point, probably a lot of good could be done by focusing and making greater societal investments around mental health, addressing domestic violence and providing adequate access to substance abuse evidence-based treatment, I mean.

If we did those three things, probably it would make some significant impact on this. Even knowing that that doesn’t address everything every family needs, and certainly not those that are dealing with disabilities within kids or of a caregiver of a different type. But you know that those three popped up so frequently and it’s like, you know, are we over investing in, here’s your parenting class and under-investing in something else that might be more salient as one of the things that I wondered about.

RO: Yeah, and I would like to add the emphasis on interventions, policies, or programs that could support financial health and equity in everyone. We talked about the complex overlay. It’s not linear that poverty equals neglect, but it is a contributing fact. And it certainly contributes to social need inequities.

I think that if we could really figure out how to impact distribution of wealth and resources in that way, that might make a huge impact across the board as well.

TH: I was really touched by something that was on the paper, which was you also looked at housing instability. And it looked and basically indicated that when there was housing instability, caregivers were making sure there wasn’t food instability along with it.

And I thought it was a really interesting thing and speaks to the fact that we need to keep in mind that these are parents that really love their children.  You know, they may have experienced neglect, but at the same time, often with very limited resources, they’re trying to do what they can to create a stable environment as they can.

RO: Yes, thank you for bringing that up. I think you’re hitting on two points. One is the housing stability piece, which I’m gonna briefly speak about, and the other is the distribution of resources, even when resources are insufficient. The first, the housing stability piece, what I thought was really impactful in our results was housing intervention actually did help. It does help prevent or reduce neglect occurrence. And I think that speaks to something that is a concrete need and if it is concretely met can have downstream consequences beyond just housing. Right. Many things that affect our healthcare system. We can get more meta, probably spending probably our, you know, collective tax dollars.

By intervening on housing security. Secondly, to your point though about the distribution of resources, parents are doing their best and we have to think about that importantly, that often neglect and I don’t wanna say often ’cause I don’t know we didn’t look at the differential types of neglect, but from my own clinical experience, I can say it’s quite frequent that it’s not necessarily always an intentional act. It’s more we’re working best with what we have, or mom and dad are dealing with their own things, their own challenges, substance use or working so frequently and not having childcare or whatever it may be that may contribute.

We see in separate work that I have a quick plug to, you know, I’m trying to investigate how we can support better parents and caregivers, to your point, without simply, here’s a parenting class, you know, do better. And what we’re finding is that when there’s food insecurity in a household, it’s common for a caregiver to say, I will eat even less than I already do to give you what food we have. And so we know parents are doing the best, and if there’s lack of resources all around, they’re trying their best to make almost their own economic decisions about what can I try to fulfill the gap of that’s gonna most help my child now if I can’t do it all.

And so housing stability may be the best thing at that time. And then the food insecurity piece struggles or suffers, and that ends up resulting in a picture that may look like or is neglect, whether it’s intended or not important. Definitional to neglect is not, you know, this intentional harm or not. It may be that there is just such an insufficient support that it results in that harm. So I think parents are doing what the best they can, and we deserve maybe as a society to think more critically about how can we support them to do better and not have to make those choices that result in harm to their child, in this case neglect or to themselves where they’re sacrificing resources.

TH: As you were talking, what I was really thinking about is that our current paradigm is that when there’s an instance of neglect, a neglect recurrence, we look at the parent first, right? And we’re sort of like, what did you do and why? Or what did you not do and why? When often we should look at sort of society and policy first, right?

And say, what did we do or not do that set up a scenario that made this possible, and then let’s hold parents accountable. But there’s not this accountability to make sure that there’s even a basic, even the most basic safety net for these kids and families who have disabilities, who have the other things that we’ve talked about.

Maybe mental health challenges, other kinds of things. And in the absence of those things, it’s kind of unsurprising, honestly, that we would have neglect and neglect recurrence the way that we do.

RO: I will put a plug for the idea that even if there’s individuals listening, although we hope we all care about children, I know often some things come down to policy and dollars.

And while we didn’t explore this fully in our paper, but I will say lots of evidence if we think about the immediate term, we might have more luck in getting some buy-in and partnership in. What I can say is that if we could help offset some of these social needs and end up also being associated with risk for neglect recurrence, we may actually see immediate effects in the current generation.

’cause we are talking about parents and caregivers, we may see that their health improves and their contributions to society improve. And what we found in this paper is that, likely that will also offset our current neglect recurrence in which will help future generations and become healthier and be able to contribute more to society.

So it is not only on us as society’s responsibility to help these families and their children and the caregivers, but it also will benefit us all to kind of give those resources and we’ll see the consequences. Now, we don’t have to wait for that future generation to say, oh, well, what will happen when those kids hopefully are not neglected and do better?

No, no. We’ll see the effects at the current generation, the parents and caregivers themselves. So yeah, I would corroborate that need to reflect in society and what we can do. In our paper, we see that policies make a difference. Yes. Maybe it’s just broadening definitions, but if that means that we’re capturing more children to provide more services to, that’s helpful as well.

So there’s lots of areas here for further exploration of how different levels of society can help and not put it all on parents, but then yes, hold them accountable, of course, and basically partner in the prevention of neglect recurrence.

TH: Well, Robin, I could talk to you about the topic of neglect much longer, but I know that you have other commitments. So is there anything else that I should have asked you and didn’t or anything else that you wanted to make sure we talked about today as we close out this episode?

RO: Thank you. I would say, I would love to just give some take home messages. So we highlighted how heterogeneous neglect is, and so I think the biggest take home from our paper is that there’s so many contributing factors, and even some of them are the differences that exist in types of services provided in these cases.

And so when you’re a clinician, whether you’re a clinician or a researcher, just to think about how neglect is different than some other adversities individuals experience. But then how neglect itself can present differently and requires different approaches because there’s a lot of work to be done.

So just to empower. And then lastly, I’ll say to support our parents and caregivers now, like we talked about, one thing that we’ve done some other work with Dr. Palusci, who is on this paper with me and some other colleagues and collaborators nationally, is to look at what support services can we provide?

And how does that help families? One of those being like the National Child Abuse Helpline. So for those who are caregivers who are out there listening, you know, there is evidence that we’re working to find platforms that provide intervention that addresses multiple potential needs. And it may be something as simple as a helpline as a start, because then we as researchers also get more data to be able to help those downstream interventions become more strong to support individuals and families.

So. I would just say if you’re a clinician, researcher, think about neglect a little harder ’cause it’s not quite so simple. And then as a collective society, let’s work to combat financial insecurity in our children and families.

TH: Well Robin, thank you so much for coming to talk about this and do feel free to come back at any time.

RO: It was an honor, it was all mine and I really would love to join you for more conversation and thank you for those listening and tuning in. Reach out to me anytime as well. I’m happy to share more insights on this paper or other things.

TH: Thanks for listening to One in Ten. If you like this episode, please share it with a friend or colleague. And for more information about this episode or any of our other ones, please visit our podcast website, oneintenpodcast.org.