Children who face neglect have a high risk of negative outcomes in adulthood, including engaging in neglectful behaviours towards their own children (Bartlett et al, 2017; Avdibegović and Brkić, 2020). The responsibility for identifying and safeguarding children lies with education, social care and health professionals. Reporting concerns to relevant services for assistance can help to address this (Hood et al, 2016), with prevention a more effective approach than intervention (Rooke, 2015; Glasgow Child Protection, 2022).
Health visitors support interventions from birth to pre-school, and play a crucial role in identifying children at risk of neglect (Scottish Government, 2012; Coles et al, 2016; Peckover and Appleton, 2019). Nonetheless, there are many barriers to identifying and safeguarding these children, both in the workplace and households in which they live (Jarrett and Barlow, 2014).
This article explores the barriers health visitors and other professional practitioners face when identifying children at risk of neglect. Identifying such barriers, and how to address these, can provide valuable insights into the professional role health visitors have in contributing to the prevention of child neglect in Scotland.
Searching the literature
A search of literature published between 2015 and 2023 focused on westernised healthcare provision, excluding hospital or care home settings. The inquiry used the terms ‘health visitor’, ‘specialist public health nurse’, ‘family nurse’, ‘child abuse’, ‘maltreatment’, ‘neglect’, ‘infant ill treatment’, ‘home setting’, ‘household’, ‘residence’ and ‘living environment’, with Boolean operators ‘OR’ and ‘AND’. The databases CINAHL, MEDLINE, Education Source, and Health Source: Nursing/Academic Edition were searched. Grey literature, including government policy documents, was also explored. Articles identified in the search and referenced in this paper are relevant to the themes discussed below.
Defining child neglect
An estimated one in 10 children in the UK experience neglect, making it a significant issue (NSPCC, 2021). The exact number is difficult to determine due to under-reporting and lack of recognition (Herendeen et al, 2014; Azizi and Shahhosseini, 2017). Child neglect can be considered a form of child abuse (Hills, 2019; Riley and AlQahtani, 2020; Child Protection Scotland, 2022) with National Guidance for Children in Scotland (2023: 12) defining child neglect and abuse as ‘inflicting harm or failing to act to prevent harm’, resulting in impairment of the child's health and/or development.
It has been proposed that this definition should be broadened from addressing current neglect to the probability of future neglect (Scottish Government, 2012), while recognising that the impact of neglect on individual children must be identified early and interventions prioritised to prevent further harm.
To meet this, both public and professional practitioners need to be vigilant and report any suspected cases of neglect (Donelan-McCall, 2009; Ammerman et al, 2014). As such, it is crucial for health professionals, specifically health visitors, to understand the complexity of child neglect and its implications for a child's development and their health and wellbeing.
GIRFEC and the health visitor role
In the UK, a health visitor is a postgraduate registered nurse or midwife, who leads an assessment and intervenes, if necessary, in the wellbeing of children aged 0–5 years (Institute of Health Visiting [iHV], 2017). Health visitors have a broad and significant role in promoting children's health and wellbeing. Their role in identifying and safeguarding children at risk of neglect is crucial (Rooke, 2015; iHV, 2024); nevertheless, there are challenges that health visitors face in fulfilling this role. In many areas of Scotland, there is evidence of deprivation and persistent health inequalities. To address this, the Scottish Government (2015) implemented strategies to make Scotland a place where children can thrive. Health visitors play a significant role in implementing these strategies, with a key focus on the health and wellbeing of pre-school (0–5 years) children.
In 2015, the Scottish Government introduced Get It Right For Every Child (GIRFEC). The GIRFEC framework plays a vital role in ensuring the wellbeing of pre-school children in Scotland. Health visitors advocate for children by gathering information from their families and sharing a robust understanding of the child's needs with relevant statutory and non-statutory services. The GIRFEC model has eight indicators that can show how a child is thriving in the present and for them to thrive in the future. If the indicators identify unmet needs and/or concerns for the child, the health visitor can use the National Practice Model and its associated tools, ‘My World Triangle’ and ‘Resilience Matrix’ (Scottish Government, 2015) to further assess the child's needs and identify potential risk of harm occurring.
Despite this, some suggest that health visitors have gaps in their understanding of the GIRFEC framework (Coles et al, 2016) and that different health visitors interpret the ‘frameworks’ they use differently to support their assessment (Raman et al, 2012), resulting in children's needs not being identified early enough to prevent harm. Different interpretations made by health visitors can be influenced by their professional experiences, anxieties and their beliefs and attitudes to the GIRFEC framework (Coles et al, 2016; Welsh, 2019). This can lead to health visitors experiencing uncertainty over the sharing of information and managing confidentiality, as well as challenges in balancing children's wellbeing with maintaining their safety.
Organisational barriers, clinical supervision, leadership and support
Home visiting services are a universal service employed to identify vulnerable children and those at risk of harm (Rooke, 2015; Kim, 2019). One of the biggest challenges experienced by health visitors when attempting to identify child abuse are organisational barriers (Azizi and Shahhosseini, 2017). Barriers can start in the workplace and not necessarily in a child's family home. Barriers that originate from the health visitor's workplace, such as the absence of professional or peer support and/or unsupportive leadership, can have an impact on a professional's work while engaging with families in the community (Herendeen, 2014; Jarrett and Barlow, 2014). Additionally, due to ‘lone working’ practices or having to make what can often be rapid safeguarding judgements, health visitors are exposed to high levels of stress and anxiety (Devereux, 2023). Little (2017) asserts that good support from leaders and work colleagues can control and mitigate this.
Peer and emotional support from colleagues and managers, as well as improved role recognition from wider professionals in the multidisciplinary team, are necessary for health visitors to provide a quality service that addresses the needs of children and their families. Health visitor leaders and colleagues play a significant role in supporting one another in their safeguarding capacity to protect children and families (Rooke, 2015; Riley and AlQahtani, 2020).
It is crucial that leaders of healthcare teams have the ability to support the emotional wellbeing of their practitioner colleagues should they encounter professional challenges when engaging with the families of children in their clinical care (Busch et al, 2021). Recognising, acknowledging and addressing emotions allows practitioners to ask peers for support, which can lead to increased self-confidence when experiencing challenging or difficult home visits (Naughton et al, 2018). However, Appleton (2011) and Naughton et al (2018) also suggest that, as well as the health visitor role becoming increasingly complex, it is often misunderstood. Misconceptions are held by many, including other professional disciplines linked to childcare and welfare. Some health visitors believe their role and professional responsibility is perceived by others as limited to weighing babies, chatting with parents, and drinking tea. Moreover, managers who have no health visiting caseload experience can fail to appreciate the workload demands health visitors experience and the day-to-day challenges they encounter (Jarrett and Barlow, 2014).
These misunderstandings and/or inactions by leaders can cause health visitors to feel emotionally unsupported and have a negative impact on their health and wellbeing or, conversely, cause them to suppress how they feel at work for fear that their colleagues and peers will think they are unable to cope (Naughton et al, 2018; Rooke, 2015). As Taylor et al (2019) point out, the role is emotionally complex. Leaders need to ensure emotional support is available in the workplace. Without this, professional practice and personal wellbeing can be affected. The provision of clinical supervision can assist with mitigating against this.
Clinical supervision is confidential, protected time for practitioners to reflect on their practice, gain professional support and discuss any professional concerns they have about families they engage with (Corey et al, 2020). While clinical supervision is recognised as a valuable aspect of health visiting, its effectiveness can be undermined if not carried out at planned times or interrupted by other tasks (Burton, 2009; Jarrett and Barlow, 2014; Appleton, 2015). Reflective and critical thinking by supervisor and supervisee are essential for clinical supervision to be effective (Taylor et al, 2019). Health visitors who receive effective clinical supervision, even from a different professional discipline, provide a significantly better quality of service to families when the supervisor has had training in relevant supervision tools (Snowdon et al, 2017).
Disguised compliance
The number of children in Scotland being placed on the child protection register for abuse or neglect continues to rise (Child Protection Committee, 2020). When a child is suspected or known to be suffering from abuse or neglect and subsequently dies or experiences significant harm, a multi-agency review is conducted to identify potential weaknesses in the statutory agencies' collaborative practices. In Scotland, these reviews are carried out by the Child Protection Committees (NSPCC, 2021). A recurring theme across several previous case reviews is the presence of ‘disguised compliance’ (Scottish Government, 2015). Despite disguised compliance being frequently identified when investigating child abuse or neglect, in the recent past across the UK, little has been done to implement the findings and recommendations from such reviews in professional practice (NSPCC, 2019). It is essential, then, for practitioners to have a thorough understanding of disguised compliance and to consider and assess for this when working with families.
Disguised compliance involves the primary caregiver appearing to comply or engage with professional agencies to downplay or dismiss safeguarding concerns and avoid further engagement (Reder et al, 1993; NSPCC, 2019). Therapeutic relationships between professionals and families are critical when supporting families and their children; yet, as Vincent (2013) notes parents may say and appear to do the ‘right things’, or engage ‘just enough’ to satisfy professionals, or offer justifiable excuses for when not fully engaging.
Evidence from case reviews elsewhere in the UK (NSPCC, 2019) suggests that professional practitioners can be accepting of information provided or presented by a child's family rather than explore further for corroboratory information. Brandon et al (2014) suggest that it can be difficult for professionals to know whom to trust and whose explanation is truthful. Such actions (by families and professionals) can result in disguised compliance.
Thresholds
Effective safeguarding work requires expert professionals who work collaboratively with other agencies (Hood et al, 2016; Azizi and Shahhosseini, 2017). Despite this, professional decision-making can be influenced by a person's education, opinions and experiences, which shape the individual's ‘thresholds’ (Taylor et al, 2019) to such a degree that similar ‘cases’, with similar characteristics, can result in different outcomes depending on the ‘thresholds’ of the professionals involved (Ben Natan et al, 2012).
Thresholds are the point at which decisions should be made to prevent exacerbation of risk or harm, or to protect the child's welfare. Thresholds can change outcomes for children depending on the professional ‘leading the case’. As individual thresholds can differ, in Scotland, the Children (Scotland) Act 2020 (section 11) provides threshold criteria for the professional to identify the stage at which (legal) interventions can be taken to protect children from harm. This can, however, be hindered when different professional agencies set local or personal threshold points. For example, a small study by Hood in 2017 explored the ’threshold’ decision-making in nursing, education and social work professionals when safeguarding children and found differences in approach. Nursing practitioners demonstrated a reluctance to refer on for further assessment citing past negative experiences where they have done so or that not enough ‘red flags’ were evident justifying an onward referral. Similarly, Hood noted that education practitioners refrained from making onward referrals on safeguarding grounds for fear of damaging relationships with the families of children they educated. Social work practitioners, on the other hand, did make onward safeguarding referrals, although there was a difference between more and less experienced practitioners.
More experienced social work practitioners reflected on past professional experiences to assist with decision-making, while less experienced practitioners tended to gather more inter-agency information and then sought guidance from more experienced colleagues before reaching a decision. Health visitors in Scotland can use the ‘My World Triangle’ to help subjectively assess the level of risk of a child (Scottish Government, 2015), but perhaps health visitors should also routinely seek out second opinions from colleagues and supervisors to check thresholds are not crossed and safeguarding actions takes place at the correct time.
Respectful uncertainty
In Scotland's health visiting services, it is not mandatory for parents to accept the health visiting programme (Scottish Government, 2015). It is therefore crucial for the health visitor to adopt an approach of ‘respectful uncertainty’ (Laming, 2003; Heron and Black, 2023) and not be too trusting with families (McNicoll, 2017). If there is evidence of non-engagement, health visitors should seek further information to assess whether there are other issues indicating disguised compliance (Akehurst, 2015). For instance, not attending health appointments, nursery attendance, how the nursery reports on the children's health and wellbeing, and whether the family is known to, and how they engage with, other statutory and non-statutory services.
When such information or evidence is limited, or the complexities and myriad of issues experienced by families can appear overwhelming, health visitors should trust their instincts and act when something does not feel right (Desai et al, 2017). As mentioned, regular case reviews and supervision can assist with this, offering a fresh perspective from a professional peer (Jarrett and Barlow, 2014) and an opportunity to talk through the concerns and the evidence that support this. It is essential that information gathered from significant case reviews need wide dissemination to ensure that professional practitioners involved in safeguarding children are aware of patterns of disguise compliance and other factors that impact on child protection and welfare.
Conclusion
Child neglect is a pressing issue in the UK, with long-lasting consequences for the wellbeing of children and their futures. Health visitors, as crucial figures in safeguarding and promoting child welfare, play a pivotal role in identifying and addressing neglect. Nonetheless, numerous barriers hinder their efforts in this regard. Organisational challenges, such as unsupportive leadership, place undue stress on health visitors. Additionally, disguised compliance by caregivers when engaging with health visitors further complicates the identification of neglect cases. Moreover, differing professional thresholds for intervention can lead to inconsistent responses to similar cases, potentially putting children at risk.
To improve the effectiveness of health visitors and other practitioners in safeguarding children from neglect, there is a need for clear and consistent support from health visitor leaders, enhanced training on disguised compliance, and the alignment of professional thresholds. Moreover, maintaining respectful uncertainty when engaging with families – even in the face of limited information – can help identify and address child neglect more effectively.
It is essential for leaders to provide emotional support to their team, recognise the complexity of the health visitor role, and encourage practitioners to express their emotions freely, without fear of judgment, to improve their wellbeing and provide better care to children and families. This will allow professionals to be more confident in the workplace, and approach their team leader for any education they may need to help with their quality of care delivered to families.