Types of Child Neglect, Part 2

by Child Welfare Information Gateway

(Page 4 of 15)

Withholding of Medically Indicated Treatment From Newborn Infants

The withholding of medically indicated treatment from newborn infants with serious birth defects that are life-threatening is a category of neglect that was defined in the amended Child Abuse Prevention and Treatment Act of 1984 (P.L. 98-4576). These situations have been referred to as "Baby-Doe" cases, after a 1982 Indiana court case contesting the parents' rights to withhold medical treatment, food, and water from an infant who was born with a life-threatening but surgically correctable condition that prevented oral feeding.

The 1984 amendments to the Child Abuse Prevention and Treatment Act defined as neglectful: "The failure to provide treatment (including appropriate nutrition, hydration or medication) which, in the judgment of the physician would be most likely to be effective in ameliorating or correcting the life-threatening condition." The law and the regulations issued by the Department of Health and Human Services require that States receiving Federal funds for CPS programs regard the withholding of medically indicated treatment from these disabled infants with life-threatening conditions as a form of neglect and to actively investigate reported cases. Hospitals are likewise obligated to observe the provisions of the law and to post notices in newborn wards that failure to feed and provide care for disabled infants is a violation of Federal law.

The law does make exception for withholding treatment (other than nutrition, hydration, or medication) to an infant when, in the physician's reasonable medical judgment:

• The infant is chronically and irreversibly comatose.
• The provision of such treatment would merely prolong dying, be ineffective in correcting the life-threatening condition, or be futile in terms of the survival of the infant.
• The treatment would be virtually futile in terms of the survival of the infant and the treatment itself would in such a situation be inhumane. Food and water must always be provided regardless of the extent of disabilities, and "quality of life" cannot be used as a criterion for deciding upon appropriate medical treatment.

Decisions about minimally adequate care for these infants present difficult moral and ethical dilemmas for physicians, hospital personnel, and parents of infants born with severely disabling mental and physical handicaps.

Prenatal Exposure to Drugs

Considerable controversy surrounds the issue of prenatal exposure of infants to drugs and alcohol. Courts are still debating whether such exposure is neglectful behavior on the part of a pregnant woman. Pregnant women who abuse alcohol, however, have exposed their fetuses to the serious mental and physical disabilities known as fetal alcohol syndrome. An estimated 73 percent of pregnant 12-34-year-old women have used alcohol sometime during their pregnancy. The incidence of fetal alcohol syndrome is 1.9 births per 1,000. Prenatal exposure to cocaine and other drugs also results in negative developmental consequences for 30-40 percent of the estimated 500,000-740,000 drug-exposed infants in the United States.

Failure to Thrive/Malnutrition

Children whose physical development falls below the third percentile in height and or weight for no known medical reason have been designated "nonorganic failure to thrive." Recent thinking calls for categorizing all children whose development is thus significantly impeded by inadequate nutritional intake as "acutely malnourished." The parents' failure to provide necessary nutritional and/or emotional nurturing, often in spite of efforts to do so, presents a challenging problem which has proven difficult to remedy beyond immediate improvements with hospitalization. Failure to thrive children respond with improved weight gain and developmental progress to inpatient hospital treatment, which includes intensive enhancement of nutritional and emotional nurturing. Normal developmental progress frequently does not continue when the children are returned home to the care of parents, and followup studies indicate continuing developmental delays in about half of the children. Outcomes of intervention appear to be related to the cause of failure to thrive and the parents' degree of awareness and cooperation with the treatment. The less chronic the developmental failure and the greater awareness and cooperation of parents, the more positive the outcomes.

Deficits in the critical bonding and attachment process between parent and child are thought to be at least partially responsible for the significant developmental delays among children. Depression and other personality problems in the parents, lack of knowledge about child care, poverty, and other sources of social stress have been identified as contributing causes of nonorganic failure to thrive.

Chronic vs. "New" Neglect

Recent studies have revealed significant differences in the characteristics and problems of chronically neglectful families and "new" neglectful families. Chronically neglecting families had more and older children, were poorer, had more problems, and less parenting knowledge than the newly neglecting families. Newly neglecting families had higher levels of stress, especially from recent serious illness or injury, and drugs were more likely to be a problem in their communities than for the chronically neglecting families.

The distinction between chronic and "new" cases of neglect may not hold up over time, however. "New" cases may actually represent the initial phase (stage) of chronic neglect. Whether this is so requires further research on the outcomes of "new" neglectful families.

To summarize, the definition of child neglect is problematic because of the lack of consensus on what is considered "minimally adequate" care of children. Although there is general agreement among professionals and the general public on what is clearly inadequate care, there are differences among professionals and ethnic groups on minimally acceptable levels of physical, psychological, and educational care and nurturing for children of different ages. Conceptual definitions of neglect differ depending upon the purpose for which they are used. Clear evidence of specific harm to a child is needed in legal proceedings for removal of a child from a parent's custody. Protective services intervention to remedy parental omissions and prevent placements may use definitions of neglect that focus on parental skills deficits and the risk of harm to a child. There are newly debated areas of neglect that present difficult moral-ethical dilemmas, for example, prenatal exposure to drugs in utero. Research studies on neglect suggest that it is important for the child protection practitioner, policy maker, and the researcher to clearly differentiate among the specific types of neglect being considered.

About the Author

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