The objective was to answer the following question:
1. What features, (excluding serological markers), are identifiable in school-aged children who are experiencing physical / emotional / supervisory / medical / educational / nutritional neglect and / or emotional abuse?
We performed an all-language literature search of original articles, their references and conference abstracts published since 1946. The initial search strategy was developed across OVID Medline databases using keywords and Medical Subject Headings (MeSH headings) and was modified appropriately to search the remaining bibliographic databases. The search sensitivity was augmented by the use of a range of supplementary ‘snowballing’ techniques including consultation with subject experts and relevant organisations, and hand searching selected websites, non-indexed journals and the references of all full-text articles.
We limited our search strategy to Organisation for Economic Co-operation and Development populations due to similarities in culture and patterns of health status. Identified articles, once scanned for duplicates and relevancy, were transferred to a purpose-built Microsoft Access database to coordinate the review and collate critical appraisal data. Where applicable, authors were contacted for primary data and confirmation of information, such as data duplication across publications, age range of subjects or the confirmation of neglect / EA as appropriate. Relevant studies with an English-language version available were scanned for eligibility by the lead researcher and selected for review.
Standardised data extraction and critical appraisal forms were based on criteria defined by the National Health Service’s Centre for Reviews and Dissemination1. We also used a selection of systematic review advisory articles to develop our critical appraisal forms 2-6. Articles were independently reviewed by two reviewers. A third review was undertaken to resolve disagreement between the initial reviewers when determining either the evidence type of the article or whether the study met the inclusion criteria. Decisions related to inclusion and exclusion criteria were guided by Cardiff Child Protection Systematic Reviews, who laid out the basic parameters for selecting the studies.
Our panel of reviewers included pediatricians, psychologists, psychiatrists, teachers and child protection researchers, information specialists and social workers. All reviewers underwent standardised critical appraisal training, based on the CRD critical appraisal standards 3.
We included all primary studies addressing neglect and/or emotional abuse in children aged 5-14 years (where the majority of children were aged 6-12 years), for which the authors explicitly recorded emotional, behavioural, or cognitive features in the child. We combined emotional neglect and emotional abuse since, in practice, these descriptions appear concurrently, and this acknowledges the broader term of ‘psychological maltreatment’ as defined by the American Professional Society on the Abuse of Children (1995)7. Among international definitions of neglect and emotional abuse, we opted for those of the World Health Organization, as follows:
- Neglect is defined as:
“Neglect refers to the failure of a parent to provide for the development of the child – where the parent is in a position to do so – in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions. Neglect is thus distinguished from circumstances of poverty in that neglect can occur only in cases where reasonable resources are available to the family or caregiver.” 8
- Emotional abuse is defined as:
“Emotional abuse includes the failure of a caregiver to provide an appropriate and supportive environment, and includes acts that have an adverse effect on the emotional health and development of a child. Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other non-physical forms of hostile treatment.” 8
- In the absence of an identifiable UK / World definition of educational neglect, we developed our own for the purposes of the review:
Educational neglect involves one or more of the following: The parent or caregiver’s –
- Failure to enrol a child of mandatory school age in school
- Failure to comply with state requirements regarding school attendance
- Failure to access / provide appropriate home schooling
- Failure to avail of recommended special educational provision
- Failure to cooperate with treatment if the child is experiencing mental, emotional or developmental problems associated with school, and treatment is offered
- Failure to show an interest in the child’s education at school and support their learning
- Failure to provide a stimulating environment
- Repeatedly keeping the child at home, thus failing to comply with state requirements
- Allowing the child or youth to engage in chronic truancy
Adapted from: American Humane Association9, Public Health Agency of Canada10, Horwath11
- Centre for Reviews and Dissemination. Systematic Reviews: CRD's Guidance for Undertaking Reviews in Health Care, 2009 Centre for Reviews and Dissemination, University of York. [PDF from York University]
- Weaver N, Williams JL, Weightman AL, Kitcher HN, Temple JM, Jones P, Palmer S. Taking STOX: developing a cross disciplinary methodology for systematic reviews of research on the built environment and the health of the public. Journal of Epidemiology and Community Health. 2002;56(1):48-55. [Pubmed]
Critical Appraisal Skills Programme (CASP) [Website]
- Polgar A, Thomas SA. Chapter 22. Critical evaluation of published research in Introduction to research in the health sciences. 3rd edition. Melbourne: Churchill Livingstone, 1995.
- Weightman AL, Mann MK, Sander L, Turley RL. Health Evidence Bulletins Wales: A systematic approach to identifying the evidence. Project Methodology 5. Cardiff: Information Services UWCM, January 2004. [PDF from Health Evidence Bulletins Wales]
- Rychetnik L, Frommer M. A schema for evaluating evidence on public health interventions (version 4). National Public Health Partnership, Melbourne 2002. [PDF from The National Public Health Partnership]
- [American Professional Society on the Abuse of Children website]
- World report on violence and health (2002) page 60. Edited by Etienne G. Krug, Linda L. Dahlberg, James A. Mercy, Anthony B. Zwi and Rafael Lozano. [World Health Organization website]
American Humane Association. Child Neglect. [American Humane Association Website]
Public Health Agency of Canada. Canadian Incidence Study of Reported Child Abuse and Neglect. CIS-2008 Guidebook. 2010 [PDF from Public Health Agency of Canada]
Horwath J. Child Neglect: Identification and Assessment. Palgrave Macmillan, Basingstoke. 2007