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1.4.5 Neglect and Parents with Learning Disability

This chapter is currently under review.


Contents

  1. Background
  2. Legislative Context
  3. Recognition and Assessment of Neglect
  4. Parental Learning Disability
  5. Assessment Process
  6. Post Assessment, Support and Intervention

    Appendices


1. Background

1.1 This guidance has been issued as a response to a recommendation of a formal Serious Case Review in late 2004.
1.2 The case review concerned a family of 7 children in respect of whom Care Proceedings had been initiated in June 2003 and were completed when Care Orders were made on the youngest 6.
1.3 Hillingdon’s Children & Families Services (C&F) had been involved with the family, periodically and at times intensively, since its first apparent referral on 10.03.93 (reports to Court suggested that in the 10 years from March 1993, C&F recorded 82 referrals + 174 separate concerns, of which 104 related to the children).
1.4 The primary purpose is to offer practical and evidenced advice to practitioners, managers and advisers about neglect of children with particular emphasis on the context of parental learning disability.
1.5 Many studies have shown that neglect can have far more damaging consequences for children than physical, emotional or sexual abuse, particularly when it occurs over a long period of time.
1.6 The number of parents with learning difficulties or disabilities is unknown, though the numbers known to health and welfare services are acknowledged to be rising steadily.
1.7 Many parents with mild learning impairment cope well in society, often with help and support from family, friends and/or professionals. Those with a higher level of impairment may need additional support.
1.8 Where a parent has a learning disability it should not be equated with abusive parenting or wilful neglect. However, parents may lack understanding, resources, skills and experience to meet the needs of their child/ren and require considerable support to be able to do so.
1.9 In some cases, even with support, the parents are still unable to meet their child/ren’s needs over time.


2. Legislative Context

2.1

Article 8 of the European Convention on Human Rights (the Right to Respect for Private and Family Life) applies to all UK citizens (adults and children alike). At first glance, it might seem to inhibit or constrain non voluntary involvement with neglectful parents (whether or not they have a learning disability). However, the Article 8 right is not absolute and interference with it is permissible if it is to:

  • Safeguard a child;
  • Protect her/his health or morals;
  • Protect the rights and freedoms of others or;
  • Prevent disorder or crime.
2.2 Article 3(1) of the UN Convention on the Rights of the Child (to which the UK is a party) is also relevant and states that ‘in all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the ‘best interests’ of the child shall be the primary consideration’
2.3 In any contemplation of legal proceedings, it should be borne in mind that a Section 47 Enquiry or Care Proceedings must relate to the child in question. S/he may, because of disability or other characteristic, be more vulnerable and/or less resilient than others.
2.4

Staff should also bear in mind the case law where the European court found that failure by the local authority over 5 years to respond appropriately to concerns about children who were being neglected and abused by their parents disclosed breaches of their human rights under:

  • Article 3 (Freedom from Inhuman or Degrading Treatment); and
  • Article 13 (Right of Access to the Courts and the Right to an Effective Remedy).


3. Recognition and Assessment of Neglect

3.1 Social workers must be able to recognise neglect of an individual. In order to assist in this task some tables have been produced in the Appendices to this guidance.
3.2

The assessment checklist and minimum standards provided in the appendices provide:

  • A means of considering the immediate level of concern about the care of any child; and
  • Tools that contribute to the evaluation of parenting capacity as part of an Assessment.
3.3

There is value in defining some key ‘minimum standards’ for the care of all children which are: 

  • Very simple and transparent;
  • Modest in the demands placed upon parents and staff;
  • Capable of being shared with parents/carers.
3.4 Whilst each child has a different level of resilience and the contents of the tables should not be regarded as absolute, the standards within it reflect a consensus developed in consultation with Hillingdon managers.
3.5

Application of these standards will require an informed and sensitive appreciation of development needs that vary according to a child’s:

  • Ethnic and cultural context;
  • Age;
  • Any disability s/he may have.
3.6 Minimum standards are what the name indicates i.e. the minimum acceptable and cannot be compromised because a child’s parent has a lifelong difficulty or disability. 
3.7 These tools give an indication about current and recent standards of care provided to the child. To make decisions on individual cases, practitioners must integrate this information into an holistic assessment. This will involve evaluation of the child’s individual developmental needs, family and environmental issues and other factors which may impact on the parenting capacity e.g. mental health, substance misuse and parental learning disability.
3.8 Where the care of the child fails to meet the minimum standards detailed below or there are long standing issues about neglect, a critical consideration is the ability of the parent/s to learn and be able to meet their child/ren’s needs. In some cases it will be necessary to engage specialist opinion to provide information on this.


4. Parental Learning Disability

4.2 Given the evidence that adults with IQs below 60 may be unlikely to parent adequately unless they receive effective support, it follows that there should always be consideration of the circumstances of these parents to ensure they are comprehensively supported by relatives, friends and/or professionals.
4.2 The remainder of this guidance offers some ideas on the additional measures that may be required when staff in Local Safeguarding Children Board agencies suspect or know that that one or both parents may have a learning disability.

Need for pre-birth multi-agency involvement

4.3 It is important to assess the needs and provide support for learning disabled parents as early as possible.
4.4 Those professionals who are aware of the pregnancy e.g. GP and midwife should make referrals to the community team for people with learning disabilities (CTPLD) for a common assessment under the Early Help Assessment of the pregnant woman’s needs, her capacity for self care and ability to provide adequate care for the baby. This assessment should consider the nature of any support available from her family and partner.
4.5 If any professional or agency has any concerns about the capacity of the pregnant woman and her partner to self-care and/or to care for the baby, a referral should be made to Children’s Services (Social Care) in line with pre-birth procedures in the London Child Protection Procedures.
4.6

The involvement of CTPLD is essential in subsequent assessments.

Post birth

4.7 Where evidence of a learning disability is present in one or both parents, each service will provide assessment and support directed at the family members identified as the primary focus of that service’s provision, but the paramount consideration of all agencies must be safeguarding and promoting the welfare of the child/ren.
4.8 If any professional or agency has any concerns about the capacity of the parent/s to self-care and/or to care for the child, a referral must be made to Children’s Services (Social Care) in line with normal procedures for either family support or under the London Child Protection Procedures.
4.9 Children’s Services’ assessment should be the same as for any other child, using the Assessment Framework to consider the extent of vulnerability and needs of the child/ren.
4.10 Assessments of learning disabled parents will need to integrate specialist assessment functions provided by the CTPLD, Adult Services (Social Care) and Health. The paramount consideration remains the welfare of the child/ren.
4.11 Additional support to child protection professionals in the way of consultation and/or supervision may also be available from specialist adult services both within Children’s Services (Social Care), CTPLD and elsewhere in health in particularly complex cases.
4.12 The parents’ ability to learn to respond to the needs of their child and the time-scale involved will be critical in any assessment.
4.13 A full scale intellectual assessment (e.g. Wechsler Adult Intelligence Scale or WAIS) is helpful in building up a picture of relative strengths and weaknesses in particular areas of cognitive functioning.
4.14 The results of this should be considered along with a functional assessment e.g. Activities of Daily Living assessment, to understand the impact of the learning disability. This assessment, typically carried out by occupational therapists (OTs) within the CTPLD, provides vital information on the parents’ ability to manage daily living tasks.
4.15 Learning disabled parents are likely to derive most benefit from being taught parenting skills if this input is intensive, consistent and concrete. Verbal explanation should be supported by practical demonstration and the opportunity to apply skills in the actual setting where they will be used.
4.16

Assessments should include extent to which parent/s are able to:

  • Evaluate the impact of experiences on their own behaviour;
  • Where appropriate, engage in therapeutic work;
  • Meet the child’s emotional needs (as opposed to wanting the child to fulfil the parents’ own emotional needs);
  • Prioritise the child’s needs above their own.
4.17 Whilst it may be possible to teach parents practical and concrete parenting skills, deficits in anticipating and meeting a child’s emotional needs will be harder to address effectively.
4.18

The ability of the parent/s to consistently ensure the safety of their child within the context of their relationships with partner/s will need assessing and consideration should be given to the need for:

  • Clear and specific information about the possible risks posed to children by present or potential partners;
  • Explanations to be provided in a way the parent can understand, given the learning disability;
  • Help to the parent to develop and implement concrete strategies to keep themselves and their child safe.
4.19

Consideration needs to be given to the ability of the parents to respond to their child’s needs over time including:

  • Different developmental stages;
  • Any special needs the child may have;
  • The child’s own intellectual ability and need for stimulation.


5. Assessment Process

5.1 Multi-agency assessments will be necessary to address both the needs of the child/ren and the learning disabled parent/s. This should involve both children’s and adult services and the involvement of a number of professionals, e.g. social workers from Children’s Social Care, adult learning disability workers in health and social care (OTs, psychologists, social workers), child health services and possibly independent / voluntary agencies.
5.2 It is vital that all relevant professionals and agencies are involved at the beginning, with a meeting held to plan the assessment, setting child focused goals and objectives and providing clarity about the role of each agency and professional.
5.3 It is important that the family is not overloaded with confused, duplicated and potentially contradictory professional input.
5.4 Consideration should be given to parent/s’ need for advocacy support.
5.5 The Assessment Framework should be applied to take account of relevant issues; with relevant specialist assessments undertaken of parent and child e.g. parenting cognitive and functional factors should be assessed by a psychologist and an OT respectively.
5.6

The purpose of the assessment will usually include consideration of the:

  • Level of support that will be necessary to maintain the child appropriately within the family;
  • Parent/s’ ability to accept and tolerate this level of support over a prolonged period of time;
  • Parent/s’ ability to learn new skills to keep pace with her/his child’s potential developmental progress.
5.7 Practitioners should modify their communication styles: check for understanding, use simpler language, avoid abstract questions and keep to one point at a time
5.8 Practitioners should be aware of the potential difficulties of the parent/s generalising their learning across different settings and the potential advantages of some home based assessment, as opposed to e.g. a family centre.
5.9 Parent/s’ needs may be different (and possibly greater) if assessment occurs in an unfamiliar environment.
5.10 Parent may lack a clear concept of time (so that lack of punctuality should not be misconstrued as lack of motivation).
5.11

Practitioners should be aware of possible illiteracy of parent/s (even if not admitted) and the need for:

  • Careful use or avoidance of written material, use of visual images, constant checking of comprehension;
  • Provision of information in small amounts;
  • Need for repetition.
5.12 Where there is the possibility that help and support may be provided from the extended family, a Family Group Conference may be a helpful method of exploring and planning, and subsequently reviewing, this resource. Where family members and/or friends do offer support, further individual assessments should be undertaken so as to ensure the task is fully understood and that the child’s or children’s needs will be met over time.


6. Post Assessment, Support and Intervention

6.1 Support and reassessment is likely to be required over a lengthy period to take account of the learning disabled parent/s’ ability to adjust and learn how to meet changing needs of their children over time.
6.2 Some parents may find it difficult to accept and tolerate this level of support over the long term and there may be resource implications for professionals, family and friends.
6.3 Further Family Group Conferences may usefully be held to review the support being provided.
6.4 Following assessment, some learning disabled parents may have to face the loss of their child/ren. Parents will need support through and after such assessment processes, even where they have consented to such a decision.
6.5 Where the conclusion of discussions and assessments suggest a possibility of Care Proceedings, legal advice must be sought, the Public Law Outline Pre-Proceedings Checklist followed and a Legal Planning Meeting set up without delay.


Appendices

Table 1: Physical and behavioural indicators of child neglect

usually sometimes almost never

Physical indicators

1. Dressed inappropriately for the season or weather; exposure symptoms may include recurrent colds, pneumonia, sunburn or frostbite etc.


2. Extremely dirty and un-bathed i.e. dirty face, hair, persistent body odour, severe nappy rash or persistent skin disorders or rashes as a result of poor hygiene


3. Inadequately supervised or left unattended more frequently or for longer than acceptable; may be left in the care of an inappropriate carer e.g. another child


4. Not receiving adequate medical or dental care and has unattended health problems e.g. squint or tooth ache


5. Not receiving adequate nutrition or sufficient quantity / quality of food - may result in child being constantly hungry


6. Being given inappropriate food or drinks


7. Malnutrition, manifested by being undersized, underweight or chronic lethargy


8. Unsafe, inadequately heated or unsanitary house


Behavioural indicators

9. Child ignored or pushed aside when trying to tell parent something


10. Afraid to tell parents of minor accidents e.g. breaking a toy


11. Role reversal where child assumes a parental role of providing or emotional support


12. Severe speech, motor or sensory developmental lags without obvious physical cause


13. Child displays of extreme and often unpredictable behaviour ranging from being unusually aggressive and destructive to being extremely passive and withdrawn


14. Demonstrates a lack of attachment to parent/s


15. Excessively clingy to, or in absence of parents, may be inappropriately affectionate with strangers


16. Exhibiting sudden behavioural changes e.g. regression, wetting pants, thumb sucking, frequent crying or becoming disruptive or uncommonly shy and passive


Adapted from Garden of Missing Children Society (1998) 

Table 2 Physical care of child

Question usually sometimes almost never
1. Is the child regularly fed


2. Is the child given enough (age appropriate) food


3. Are the signals of hunger or being full-up properly interpreted


4. Is the manner of feeding comfortable and anxiety free


5. Is food available


6. Is the child too thin, small or unwell


7. Is the child’s medical care being seen to e.g. medical examinations, vaccinations, eye and ear tests etc.


8. Is medical advice sought when the child is unwell


9. Are medical or other welfare related appointments being kept


10. Do the parents administer required medication


11. Is there recognition and concern about the child’s well-being


12. Is the child appropriately dressed for the weather


13. Is the child changed and clean


14. Are the sleeping arrangements adequate


15. Is the safety of the child ensured


16. Is the child supervised when playing outside


17. Is the child provided with fresh air and outdoor activities


18. Is the child protected from the use of alcohol, smoky atmosphere and other unhealthy and damaging substances


 From Iwaniec(1996) 

Table 3: Social & educational care of child

Does parent / carer : usually sometimes almost never
1. Encourage the child’s ideas


2. Listen carefully so as to understand


3. Communicate clearly to the child


4. Respect child’s privacy


5. Set an example for the child


6. Provide guidance at appropriate times


7. Share – family news appropriate decisions


8. Respect child’s views


9. Acknowledge the child’s efforts


10. Offer emotional support (comfort etc.)


11. Keep confidences


12. Make eye contact during conversation


13. Address child by name


14. Remember child’s birthday


15. Talk to child about family matters


16. Discuss (when age appropriate) death, education, religion, sex or religion


17. Teach child appropriate social skills


18. Accept child’s appropriate friendships


19. Resolve (fairly) any conflict between children


20. Set reasonable limits e.g. bed and meal times and stick to them


21. Ensure that child receives compulsory education


Adapted from Herbert with permission by Iwaniec

Notes for completion of tables 2 and 3:

‘Usually’ indicates good quality of care; ‘sometimes’ suggests there are problems to be investigated and ‘almost never’ indicates Neglect and a lack of interest in the child. A majority of ‘almost nevers’ indicates the child is at serious risk. For table 1 the opposite applies with ‘usually’ indicating that a child is at risk.

Table 4: Psychological care of child

Adequate (good) Inadequate (poor)

Affection

Frequent physical contact, admiration, touching, holding, comforting, making allowance, being tender and loving, saying nice things about the child, showing concern, talking softly and warmly to the child

Limited physical contact, child seldom picked up and given attention, signals of distress ignored or dealt with harshly, seldom talked to in a warm and reassuring way, chill talked about in a negative way, lack of satisfaction and emotional commitment persistently shown to child

Security

Continuity of care, predictable environment, consistent control, settled patterns of care and daily routine, fair and understandable rules, harmonious family relationships, stability and security of home and family

Tense and changeable environment, child cared for by different and unsuitable people, confusing and inappropriate rules and routines, hostile relationships between family members, frequent threats of being abandoned, sent away, disruptions in family functioning and unity

Guidance / control

Discipline appropriate to child’s stage of development, provision of models to emulate, indication of boundaries, insistence on concerns for others

Unrealistic expectations of child’s ability to behave in a manner parents want, physical and emotional punishment applied in an inappropriate way, parental behaviour not a good model from which to learn, poor teaching of right and wrong, failure to establish fair and clear rules of behaviour, disregard of the feelings and needs of others

Independence

Creation of opportunities for child to do more self, make decisions initially about small issues and building up, all requiring a balance between being laissez-faire and over protective

Failing to teach a child to acquire skills to function independently and appropriately, prevention of child being able to make her/his own decisions – parent being dictatorial or over-protective or neglectful and paying no attention to developmental needs

Stimulation

Encouragement of curiosity and exploratory behaviour, responses to questions, engagement in play, promotion of training / educational opportunities

Restriction of a child in exploration of environment, failure to engage a child in new activities and seeing new things, lack of response to a child’s questions, failing to provide play materials, low interest in child’s school performance, poor help and encouragement with homework, no help in development of interests, hobbies or talents

End