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A Systematic Review of Measures of Child Neglect

A Systematic Review of Measures of Child Neglect Purpose: Child neglect is prevalent in children’s social work and assessing neglect is complex because it is multifaceted and opaque. This systematic review identifies and evaluates evidence of tools or measures to better assess child neglect. Methods: Informed by Cochrane methodology and adapted to the needs of social work practice, a systematic search and review of measures of child neglect was undertaken. Ten databases were searched, augmented by grey literature, and are in contact with relevant experts. Results: Only two measures, the Child Neglect Index (CNI) and modifications of the Maltreatment Classification System (MCS), met the inclusion criteria. Neither tool was completely comprehensive for child neglect. Discussion: Our findings indicate (a) a dearth of suitable tools to measure neglect and (b) the need for robust testing of neglect measures in the social work setting. The current evidence based on measuring child neglect is too limited to effectively inform policy and practice. Keywords systematic review, child neglect, measurement, evidence-based practice, assessment Child neglect is prevalent across all societies and can cause measurement tools are important for measuring abuse and long-lasting and significant harm for children and young neglect, there are currently no gold standards for the measure- people (Daniel, 2015; Daniel et al., 2010; English et al., ment of child neglect or abuse (Bailhache et al., 2013). 2005; Horwath, 2013; Moran, 2009; Stevenson, 2007). In this article, which has been co-produced with an advi- Neglect is often defined as unmet need (Daniel, 2015). sory group of relevant stakeholders, we present a systematic However, a variety of more sophisticated definitions have review of neglect measurement tools for children’s social been developed within professional practice and academia. work. Although we focused on measures of neglect, we rec- Without clarity on the definition of a concept like neglect, ognize that risk assessments of potential neglect are also com- precise and accurate measurement is difficult to achieve monly undertaken in practice (De Bortoli et al., 2017; Mulder (Perron & Gillespie, 2015). et al., 2018). Neglect incorporates a variety of experiences for children and young people ranging from lack of supervision to Background and Significance extreme deprivation. It is widely recognized that experiencing neglect during childhood can increase the risk of negative Research into maltreatment has been criticized for lacking health and of negative emotional and social outcomes later methodological rigor, imprecise definitions, and inadequate in life (Corby et al., 2012; Horwath, 2007; Howe, 2005; measurement strategies (Manly, 2005), issues that have Radford, 2011). Neglect raises issues for the helping profes- been linked to its complexity and definitional challenges sions in terms of identification, assessment, and support (Gershater-Molko et al., 2003). There has been a notable (Brandon et al., 2009; Daniel et al., 2010; Horwath, 2007). Despite this, there has been limited research into neglect com- Department of Social Work and Social Care, University of Birmingham, pared to other forms of child abuse (Daniel et al., 2011; Birmingham, UK Dubowitz, 2007; McSherry, 2007; Mulder et al., 2018). Department of Social Policy, University of Birmingham, Birmingham, UK A number of authors have raised concerns related to the School of Social Policy, University of Birmingham, Birmingham, UK significant limitations and imprecision of the evidence base Corresponding Author: around neglect (Barlow & Schrader-Macmillan, 2010; Simon Haworth, Department of Social Work and Social Care, University of Horwath, 2013; Moran, 2009; Morrongiello & Cox, 2020; Birmingham, Edgbaston, Birmingham B15 2TT, UK. Mulder et al., 2018). Although evidence-based high-quality Email: [email protected] 2 Research on Social Work Practice 0(0) lack of research into assessing neglectful parenting, likely prevalence is the harm category given to cases deemed to influencing the tendency of practitioners to rely on subjective meet the threshold of significant harm. These harm categories judgements as opposed to evidence-based measures (Hines are neglect and physical, sexual, and emotional abuse (DfE, et al., 2006; Morrongiello & Cox, 2020; Stewart et al., 2018b). As of March 31, 2021, there were 50,010 children 2015). The extent, impacts, and costs of neglect merit subject to a child protection plan in England and Wales, greater attention and scientifically rigorous research and neglect accounted for 52% of initial child protection (Dubowitz et al., 2005; Horwath, 2013). plans (DfE, 2021). While international comparisons of neglect data are difficult (May-Chahal & Cawson, 2005), similarly high Definitions and Complexity of Child Neglect levels can be found in countries such as the United States, There are clear issues in defining neglect in both scholarship Canada, and the Netherlands (Euser et al., 2010; and professional practice. While abuse is typically identified Stoltenborgh et al., 2015; Trocme et al., 2003). In the as an act, neglect is often correlated with omission (English United States, neglect accounts for 75% of initial et al., 2005; Moran, 2009), and as such is frequently dichoto- referrals to child protective services (CPS) and for the major- mized (Sullivan, 2000). Neglect is now understood as a het- ity of recurrent maltreatment reports (Bae et al., 2010; erogeneous concept and phenomenon, inclusive of a variety Jonson-Reid et al., 2019; U.S. Department of Health & of (in)experiences for children and young people (Dubowitz Human Services, 2021). It is important to note that the UK et al., 2005; Horwath, 2013). It has been described as the and US figures quoted should be compared with caution, as most subjective of all legally recognized concepts in child like-for-like data is not available. welfare (Dubowitz et al., 2005; Zuravin, 1999), which occurs on a continuum with varying frequency and types Existing Social Work Assessments of Child Neglect (Helm, 2010; Higgins & McCabe, 2001; Mennen et al., 2010; Slack et al., 2003). As discussed, there is currently no gold standard for the mea- The scope of neglect, whether it should incorporate both surement of child neglect (Bailhache et al., 2013). A global potential and actual harm or just the latter, is debated systematic review for the National Institute for Health and (Horwath, 2007; Zuravin, 1999). Debates continue around Care Excellence (NICE) guidelines for child abuse and whether definitions should rely on children’s basic needs neglect failed to find any high-quality evidence for the pre- not being met from their perspectives or parental omissions dictive validity of any tools for identifying neglect (NICE, in care (Dubowitz et al., 2005). The concept of neglect is con- 2017). tested and open to significant interpretation in academia and In the absence of clear standards and effective tools, practice (Dubowitz et al., 2004). It is an expansive concept assessments can be subjective, with practitioners setting where additional dimensions could be included until it their own criteria for what is neglectful (Daniel et al., 2010; becomes too complex to effectively measure. These issues Stokes & Taylor, 2014; Sullivan, 2000). Neglectful care can are important in light of the long-standing issues of accuracy be difficult to capture as a static picture within assessments in assessments of neglect (Daniel et al., 2011; Horwath, 2013; due to a variety of interlocking issues, which include break- Taylor, 2017). downs in social relationships, inconsistent levels of care, var- For this review, we have used the operational definition of iable impacts of neglect on children, and social workers acting neglect adopted by the UK government in their Working on partial information (Horwath, 2007; Jones et al., 2006; Together to Safeguard Children (2018) guidance which is Lacharite, 2014). “the persistent failure to meet a child’s basic physical and/ Assessment of neglect is complicated by the role of wider or psychological needs, likely to result in the serious impair- social and political contexts. The roles of social harms, such ment of the child’s health or development” (Department for as poverty and insecure housing, should arguably influence Education [DfE], 2018a, p. 105). Although operational defini- what we define as neglect and where responsibility lies. tions of neglect vary due to factors such as social and cultural Chronic neglect often involves families facing a wide range influences, definitions in Western countries such as the United of social harms, including socioeconomic disadvantage States, Australia, and Canada have distinct similarities, for (Chambers & Potter, 2009; Dufour, 2008). For assessments example, all refer to parental failure to meet a child’s needs of neglect to be thorough, an evidence-based approach to sys- (Horwath, 2013). The US federal legislation provides guid- tematically construct a layered social reality attentive to these ance on child neglect, but definitions are state specific interlocking issues is required (Helm, 2010; McNaughton, (Horwath, 2013; Child Welfare Information Gateway, 2019). 2009; Sayer, 2000), while maintaining a focus on the child (Department of Health [DoH], 2000; Dyke, 2019). Further, the presence, absence, and levels of all neglect categories Prevalence of Child Neglect need to be given full consideration. As with broader social It is often difficult to accurately determine the prevalence of work, effective assessments should be collaborative with fam- neglect (Daniel et al., 2014; Moran, 2009). One proxy for ilies (O’Brien, 2004). Haworth et al. 3 The evidence from research and serious case reviews et al., 2014; Lacharite, 2014; Mulder et al., 2018; NICE, shows that social work assessments can range from good to 2017). flawed (Barlow et al., 2010; Dorsey et al., 2008; Macdonald et al., 2017). Assessments are only as good as the workers Existing Reviews of Neglect Measures completing them and as the support they receive in terms of Extant reviews of neglect measures have not considered evidence, research, and training (Milner et al., 2015). Even neglect in isolation or have only considered parent/caregiver with these challenges, a thorough social work assessment reports (Daniel et al., 2010; Saini et al., 2019; Yoon et al., remains the best tool available in the field (Holland, 2010; 2021a, 2021b). Research into child maltreatment measures Milner et al., 2015; Taylor, 2017), and high-quality assess- has raised concerns about validity, reliability, and usability ments are the cornerstone of good practice (Munro, 2020). of tools and the quality of the research undertaken. Yoon They are completed by qualified professionals in accordance et al. (2021a) raised concerns about the validity of child mal- with government laws and policies (Holland, 2010; Munro, treatment measures, stating that the current evidence base is 2020). This study’s advisory group and existing guidelines not sufficient. Vial et al. (2020) found that further research indicated that these continue to be the best and most com- is required on the validity, reliability, and usability of child monly used tools in practice (Boyd Webb, 2019; DfE, safety assessment instruments, and that an evidence-based 2018a; DoH, 2000; National Association of Social Workers approach to measure development is required. Saini et al. [NASW]; 2013). Good social work assessments can capture (2019) found significant variation in approaches to measure the child within their environment, the feasibility of change, child abuse and in methodologies employed. and the support required to effect such change (Milner et al., 2015). The Present Study This systematic review’s evaluation of the evidence of tools Measuring Neglect or measures for social work assessments of child neglect, The lack of clarity in defining neglect leads to challenges in therefore, helps fill a key gap. We compared and evaluated how to measure or quantify it (Dubowitz et al., 2005). these tools against the gold standard of an assessment by a However, well-developed tools and frameworks can support qualified children’s social worker or by an assessor working more accurate and holistic assessments, and counter signifi- within children’s social work (DoH, 2000; Leveille & cant sources of bias within assessments and decision Chamberland, 2010). The choice of this gold standard is dis- making (Barlow et al., 2010; Parker, 2020). Such tools can cussed in the section entitled “The Gold Standard for this be intelligently utilized to inform sound professional judge- Review”. ments (Barlow et al., 2010), enabling a balance between intu- A revised version of Horwath’s (2007) neglect typology itive and analytical reasoning (Munro, 2020). has been used for this review in line with our advisory For neglect, there are four main fundamental assessment group’s advice: elements (Daniel et al., 2011; Horwath, 2013; Jones et al., 2006): � emotional, � medical, � assessment of actual neglect, including types, fre- � physical, quency, severity, and chronicity, � educational, � assessment of family circumstances, including risk and � lack of supervision and guidance, and protective factors, � social. � assessment of risk of further neglect, including pros- pects for change, and It was developed from a review of other relevant definitions, � how best to meet the child’s needs. has a logical delineation into comprehensible neglect catego- ries, and offers a comprehensive understanding of neglect. It This systematic review focuses on tools to assess actual has been adopted in the United Kingdom by organizations neglect. Predictive tools have clear limitations for neglect. such as Action for Children. Social neglect has been added They are not considered good predictors of neglect in a to the typology, which involves parents/carers failing to range of both US and UK studies (Logan-Greene & meet a child’s social needs for close bonds and relationships, Semanchin Jones, 2018; Semanchin Jones & Logan– friendships, and social adaptation. It can be understood to Greene, 2016; Taylor et al., 2008). There are multiple and play a role in all types of neglect (Horwath, 2013). fluctuating individual, familial, community, and societal risk The adopted typology is visually represented in our theory factors for neglect that are nigh on impossible to capture of change diagram (Figure 1), which depicts an outline of effectively in a predictive tool, while some risk factors can children’s basic needs, categories of neglect, risk, and protec- also be consequences of abuse, leading to a further level of tive factors. Developed from the review’s neglect typology, complexity and confusion for accurate prediction (Brandon consultation with the advisory group, and a review of 4 Research on Social Work Practice 0(0) Figure 1. Theory of change. literature on children’s needs and neglect, it provides the service and practitioner collaboration to mobilize social work framework to guide this review. Its simplicity, clarity, and values throughout the review (Uttley & Montgomery, 2017). focus on the range of factors influencing neglect fit well A review protocol was registered with PROSPERO by with our project’s ethos and purpose, and are key features Haworth et al. (2020). of theories of change (Taplin & Clark, 2012). Munro (2020) has proposed that in order to practice effec- Search Strategies and Procedure tively, social workers need a formal knowledge base, value base, set of reasoning skills, emotional wisdom, and practice A systematic search of the national and international, clinical wisdom. Instead of these complicated knowledges and and academic, single index, and multidimensional measures skills, social workers tend to rely on practice wisdom of child neglect was undertaken. Measures were defined as (a combination of everyday skills and wisdom enriched those concerned with the extent, frequency, chronicity, or through experience and training) in their assessments severity of neglect as well as those with a focus on its (Crisp et al., 2007; Munro, 2020). This study addresses impact on, harm to, and significance for the child. this gap between knowledge and practice actuality by We searched relevant multidisciplinary and science/social adding to the formal knowledge base for neglect to science electronic databases, search engines, and grey litera- support practitioners to undertake more focused, evidence- ture. This strategy decreased publication bias (Burdett et al., based, and informed assessments. 2003; McFadden et al., 2015). Searches were tailored accord- ing to the scope of each database. The following databases and platforms were searched orig- Method inally between June and August 2020, with an updating search completed between March and June 2021: This review has broadly followed guidance from the Cochrane Collaboration (Higgins et al., 2020). Compared to many medical conditions, however, neglect is a complex phenome- Bibliographic Databases non (Horwath, 2013). Therefore, our approach has been adapted to the field of social work by a deeper exploration of � ProQuest ASSIA (1987-); the “target condition” and acceptance of a greater range of � Ovid MEDLINE (1946-); study types, in light of the evidence base. In line with recent � Ovid PsycINFO (1806-); methods’ developments, this study includes an emphasis on � SCIE Social Care Online; Haworth et al. 5 � ProQuest Sociological Abstracts (1952-); constraints). Studies in other languages that may be relevant � ProQuest Social Services Abstracts (1979-); have been listed. � Web of Science: Social Science Citation Index (SSCI) Tools or measures: Tools must have been designed for (1900-); children aged 0–18, with suspected neglect who have been � EBSCOhost ERIC (Educational Information Resources referred to children’s social work services, or for the child- Centre) (all available years); ren’s parents or carers. The tool had to ascertain at least one � EBSCOhost CINAHL (Cumulative Index Nursing and form of child neglect. Screening tests were not assessed, Allied Health) (1981-); and because the evidence, although weak, suggests unacceptably � Prospero https://www.crd.york.ac.uk/prospero/ high false positives (McTavish et al., 2020). For further #searchadvance. details on this criterion, please refer to the study protocol. Evidence included: No restriction was set on the type of Grey Literature study; published and unpublished material was reviewed. For evidence of diagnostic accuracy, only cross-sectional � OpenGrey. studies, and index or test measures involving the target pop- ulation with a contemporaneous (± 3 weeks) comparison of Theses and Dissertation Databases a (gold standard) social work assessment was included. All included studies were quality-assessed against this criterion. � ProQuest Dissertations and Theses Global; Studies that did not meet the inclusion criteria were � DART—Europe E-Theses Portal; excluded. They fell into one of the following categories: � EThOS—the British Libraries e-theses online service; � Networked Digital Library of Theses and Dissertations � no comparison with the gold standard of a social work (NDLTD); and assessment, � Open-Access Theses and Dissertations. � no child neglect, � not a tool or measure for child neglect, Other Resources � wrong setting (e.g., a medical setting), � wrong population (e.g., tool used retrospectively with � Key websites were searched directly (DoE, Children’s adults), Society, and NSPCC). � assessment of future risk not current measurement of neglect, and Handsearching was undertaken to identify additional liter- � small sample size (less than 10 subjects). ature. Relevant email alert services were used to identify newly published literature. New and unpublished trials were Because of a paucity of studies, we modified our protocol to searched in ClinicalTrials.gov and through contact with key include measures with retrospective comparisons with a authors in the fields of measurement tools in social work social work assessment. and neglect. The original search terms can be found in our registered The Gold Standard for This Review protocol. Additional relevant keywords identified during the searches were incorporated within a modified search strategy. We compared and evaluated tools against the gold standard of A list of named instruments identified through a preliminary an assessment by a qualified children’s social worker or asses- scoping search was included, and instruments identified sor working within children’s social work. through the review process were appended to the search. Social work assessments can be of variable quality. Information on these modifications and the number of However, as discussed, a thorough social work assessment studies identified in each search can be obtained from remains the best tool available in the field, and these assess- Simon Haworth ([email protected]). ments are completed by trained professionals, in line with government laws and policies, and subject to quality control mechanisms (Dubowitz et al., 2005; Holland, 2010; Munro, Criteria for Considering Studies for This Review 2020). The advisory group to this study and existing guide- Prior to starting the search, inclusion, and exclusion criteria lines indicated that these remain the best and most commonly were determined as follows: used tools currently in practice; offering comprehensive and Population: Children aged 0–18 years referred to child- holistic assessments of people within their environments ren’s social work services, and parents or caregivers of (Boyd Webb, 2019; DfE, 2018a; DoH, 2000; NASW, 2013). these children. Social workers are the lead professionals that identify and Dates of studies: No limits set. intervene in child neglect, both in the UK and North America Language of the studies: No restrictions applied. We only (where the included studies were conducted) (Horwath, 2013; reviewed studies in English (due to resource/time Stevenson, 2007). Social work is a key profession that 6 Research on Social Work Practice 0(0) engages with neglect in many countries globally (UNICEF, One review author extracted the key information on the 2021; World Health Organization [WHO], 2020). In the template, which was then verified by a second reviewer. United Kingdom and United States, undertaking high-quality Any disagreements were addressed through discussion and informed and holistic assessment focused on people in their consensus. environments is a key competency for practice (British Association of Social Workers [BASW], 2022; NASW, Assessment of Risk of Bias/Study Quality. We adopted a multi- 2013). step approach to assess study quality. First, we assessed A range of established and validated measurement tools which tools measured which domains of child neglect. Any have been tested against the gold standard of clinical and pro- measures with no face validity were screened out. Next, we fessional assessments completed in the field in a range of critically appraised the evidence for measures with some countries and settings. This includes the Beck Depression relevance. Inventory (I and II) (Gomes-Oliveira et al., 2012; Wang & Evidence was classified into the study method employed Gorenstein, 2013; Williams et al., 2021); the Child and the relevant CASPs (Critical Appraisal Skills Behavior Checklist (Ebesutani et al., 2010; Nakamura et al., Programme) checklist was used to assess the risk of bias 2009; Skarphedinsson et al., 2021); and the Children’s (CASP, 2018). One review author assessed and a second Depression Inventory (de la Vega et al., 2016; Sorensen then validated the assessment. Any disagreements were et al., 2005; Wu et al., 2010). resolved through discussion and reaching a consensus. Social work assessments have been used as a comparator We distinguished between levels of evidence (type and for validation in other studies. This includes King et al. quality of evidence available based on how well tests have (2013), who compared a structured assessment tool with been performed, on whom, in which settings, and against social work assessments, Smith et al. (2015), who used which other tests or assessments) and reported properties of social work assessments as comparators in the development tests including reliability, validity, accuracy, and precision; of a screening tool, and Flood et al. (2005), who used assess- then included measures were inspected for further properties ments by social workers as a comparison when assessing the of content validity, reliability, accuracy, interpretability, and Community Dependency Index. Further, arguments have sensitivity to change. We placed importance on the concur- been made that social work research underuses practice or rent validity of tools, as “concurrent validity is the most clinical information such as assessments, closely linked as it appropriate form of criterion validity to examine when the is to practice realities and key concepts used in real-world aim is to make inferences on the psychometric quality of an practice (Epstein, 2001). instrument” (Vial et al., 2020, p. 108). We used the definitions used in the COSMIN framework Review Procedure for key characteristics of good measures (Mokkink et al., 2010). They are as follows: Identified records were stored and screened on the Rayyan QCI database for systematic reviews (Ouzzani et al., 2016). � validity, The primary review author reviewed the title and abstract of � reliability, each record, based on the inclusion criteria. A random � responsiveness or sensitivity to change, and sample of 25% of these records was independently reviewed � interpretability. by a second review author. Second review authors reviewed 100% of the first reviewers’ decisions. Full texts of all poten- Following these quality assessment steps, we sought the tially relevant articles were obtained and reviewed. Duplicate views of the advisory group on the following criteria: records were removed through each subsequent database search and on further checking. Figure 2 presents the � simple and easy to use, PRISMA (Preferred Reporting Items for Systematic � child-focused, Reviews and Meta-Analyses) flowchart of the evidence selec- � able to be used throughout the organization (from the tion process. front door to long-term work with children and their families), and functional for different service areas, Data Collection and Analysis � identifies the type of support needed, and � designed for the needs of families and of the profes- Data Extraction. We extracted data from retrieved articles and sional/organizational system. studies using a piloted data extraction template designed for this review. The template consisted of (a) face validity, (b) key properties and risk of bias, (c) diagnostic accuracy Missing Data. The effect of missing data was assessed under testing, and (d) desired properties (developed from the recom- risk of bias. There were two missing results in Trocme’s mendations of the advisory group, to ensure practice study, and these were judged unlikely to have significantly relevance). altered the study’s findings. Haworth et al. 7 Figure 2. PRISMA flowchart. 8 Research on Social Work Practice 0(0) codes to two types of alternative classification systems—the Collaborative Approach MMCS and the National Incidence Study 2 (NIS-2) (the This review adopted a collaborative approach with practice NIS-2 is a further research tool, not meeting our inclusion cri- partners, Birmingham Children’s Trust. User involvement teria). The outcomes measured were those reported by has been in the form of advisory and stakeholder groups. Dubowitz et al. (2005). Mennen et al. (2010) used the same For this review, “user” has been defined as a social worker, approach to reclassify neglect and maltreatment, and to the individual using the neglect measurement tools. The advi- measure co-occurrence in 9- to 12-year olds in the care sory group consisted of nominated social work staff from system. Birmingham Children’s Trust and gained the views of Trocme’s (1996) study was the smallest, focusing on 127 service users recruited through the Trust. This was achieved consecutive “intake” investigations. The sample population through social workers seeking their views and subsequently for the Dubowitz et al. (2005) and Runyan et al. (2005) sharing these with the group. The stakeholder group also studies were children and their primary carers from four includes key academics in the field, services users, and research sites in eastern, southern, midwestern, and north- social workers from other organizations. The additional western parts of the United States. These sites differed in element of user involvement has been used previously by terms of sample populations, with some children at risk for, other systematic reviews (Hyde et al., 2017; Oliver et al., and some having suffered maltreatment. Cases were 2014; Pollock et al., 2015). described as routine CPS cases; these were collected and The review has been conducted at the participation level on reclassified by research staff, not social workers. Mennen Arnstein’s (1969) Ladder of Citizen Participation. There were et al.’s (2010) study focused on 303 cases of children identi- four advisory group meetings, where responsibilities, including fied as maltreated by a public child welfare agency. idea generation on the quality and relevance of measures, were shared. Their involvement helped orient the review and promote the relevance of findings (Esmail et al., 2015). Study Designs. The four studies that met our inclusion criteria all used variations of cohort study designs. Dubowitz et al.’s (2005) and Runyan et al.’s (2005) studies included follow-up Results data, whereas Mennen et al.’s (2010) and Trocme’s (1996) In total, 5,109 records were reviewed. Just four studies met stand-alone studies did not. our inclusion criteria (Figure 2). We were unable to access Trocme’s (1996) study incorporated a two-stage process. 12 studies, which are described in Table 1. For one of these Stage one involved gaining expert views on index construc- references, we were able to find the data in an alternative tion from practitioners in the child welfare field. Stage two article. We made requests through our institution and the involved field testing within a social work setting. British Library for all articles written in English. Classification of neglect using the CNI was compared to mal- treatment classifications of the NIS child protection worker survey form. Concurrent validity was assessed against 14 Description of Included Studies neglect-related scales from the Child Well-Being Scales Study Characteristics. There were four cohort studies reviewed (CWBS) (n= 125 for each scale). Test–retest reliability was and analyzed, all based in high-income countries (Canada and assessed by workers completing the tool twice within a the United States): a study by Trocme (1996) on the Child 2-week period. Neglect Index (CNI) and studies by Dubowitz et al. (2005), Dubowitz et al. (2005) examined 481 CPS records to Runyan et al. (2005), and Mennen et al. (2010) on modifica- determine how the MMCS, capturing six subtypes of tions of the Modified Maltreatment Classification System “failure to provide,” three of “lack of supervision,” and fre- (MCS or MMCS). The studies were completed between quency of reports of each, compared to two CPS classifica- 1996 and 2010 and in total included 1,715 cases. The children tions of neglect defined as “general neglect” and “caregiver in these studies were all considered at risk or having suffered absence.’ They also examined how well the categories and harm. Table 2 sets out the key characteristics of these studies. subcategories of each predicted a range of child outcomes Whereas Trocme’s (1996) study aimed to develop a short, ascertained at the age of 8 years from a set of standardized valid, and reliable measurement instrument for the type and measures for all 740 children. Runyan et al. (2005) attempted severity of neglect in Canada, Dubowitz et al.’s (2005) and to answer two questions. First, how did MMCS classifications Runyan et al.’s (2005) studies formed part of a larger longitu- compare with CPS and NIS-2 classifications of the main child dinal study in the United States examining antecedents and maltreatment categories of physical abuse, sexual abuse, outcomes of child abuse and neglect. Dubowitz et al. neglect, or emotional maltreatment and second, how well (2005) used the MMCS to retrospectively rescore and reclas- did the various categories of abuse predict child problems at sify neglect from CPS records. Runyan et al.’s (2005) com- the age 8 years. Mennen et al. (2010) extended the MMCS panion paper compared the concordance of the main types tool to also include caretaker incapacity and child “at risk” of child maltreatment classifications defined by CPS’ official from neglect and/or abuse. Haworth et al. 9 Table 1. References not Reviewed. Author Reference Reason Comment Berube et al. Berube, A., Lafantaisie, V., Coutu, S., Dubeau, D., Caron, J., Unable to Title and abstract suggest absence of (2015) Couvillon, L., & Giroux, M. (2015). Elaboration d’un outil access comparison with social work ecosystemique et participatif pour l’analyse des besoins des assessment enfants en contexte de negligence: L’outil Place aux parents [Development of an ecosystemlc and participatory tool for the analysis of children’s needs in the context of child neglect: The experience of Place aux parents]. Revue de Psychoéducation, 44(1), 105–120. Gaudin et al. Gaudin, J. M., Polansky, N. A., & Kilpatrick, A. C. (1992). The Unable to Title and abstract suggest absence of (1992) Child Well-Being Scales - A Field Trial. Child Welfare, 71(4), access comparison with social work 319–328. assessment Polansky et al. Polansky, N. A., Cabral, R. J., Magura, S., & Phillips, M. H. (1983). Unable to Title and abstract suggest absence of (1983) Comparative norms for the Childhood Level of Living Scale. access comparison with social work Journal of Social Service Research, 6(3), 45–55. assessment Polansky et al. Polansky, N. A., Chalmers, M., Buttenweiser, E., & Williams, Unable to Title and abstract suggest absence of (1978) D. (1978). Assessing Adequacy of Child Caring: An Urban access comparison with social work Scale. Child Welfare, 57(7), 439–449. assessment Polansky and Polansky, N. A., & Pollane, L. (1975). Measuring Child Adequacy Unable to Title and abstract suggest absence of Pollane (1975) of Child Caring: Further Developments. Child Welfare, 54(5), access comparison with social work 354–359. assessment Polansky et al. Polansky, N. A., Gaudin, J.M., & Kilpatrick, A. C. (1992). The Unable to Title and abstract suggest absence of (1992) Maternal Characteristics Scale: A cross validation. Child access comparison with social work Welfare: Journal of Policy, Practice, and Program, 71(3), 271–280. assessment Trocme (1993) Trocme, N. M. (1993). Development of an expert-based Child Unable to Data extracted from Trocme (1996). Neglect Index: Making social work practice knowledge access explicit. Dissertation Abstracts International Section A: Humanities and Social Sciences, 53(12), 4478. Pasian et al. (2015) Pasian, M. S., Bazon, M., Pasian, S., & Lacharite, C. (2015). Foreign Title and abstract suggest absence of Negligencia infantil a partir do Child Neglect Index aplicado no language comparison with social work Brasil [Child neglect based on the use of the Child Neglect assessment Index Applied in Brazil]. Psiclogia. Reflexeao e Critica, 28(1), 106–115. Picornell (2004) Picornell, L. A. (2004). Model of definitions for situations of Foreign Title and abstract suggest absence of child-juvenile neglect. An instrument for strategic planning. language comparison with social work Portularia: Revista de Trabajo Social, 4, 277–285. assessment Vandevoorde Vandevoorde, J. (2013). Checklist for the assessment of children Foreign Title and abstract suggest absence of (2013) and adolescents at risk of abuse. Neuropsychiatrie de l’Enfance language comparison with social work et de l’Adolescence, 61(6), 371–378. assessment Valencia (2010) Valencia, E., & Gómez, E. (2010). An eco-systemic family Foreign Title and abstract suggest absence of assessment scale for social programs: Reliability and validity of language comparison with social work NCFAS in a high psychosocial risk population. Psykhe, 19(1), assessment 89–103. Vezina (1992) Vezina, A., & Bradet, R. (1992). Validation quebecoise d’un Foreign Title and abstract suggest absence of inventaire mesurant le bien-etre de l’enfant [Validation of the language comparison with social work Child Well-Being Scales (CWBSs) in Quebec]. Science et assessment Comportement, 22(3), 233–251. All four studies met our gold standard comparison with a MMCS tool and NIS-2 data, with the MMCS viewed as their social work assessment through different routes: Trocme’s gold standard. For these three studies, comparisons were (1996) study through the social workers completing the CNI made between CPS classifications decided by CPS workers when they completed their standard assessment reports; and reclassifications of narrative data by trained research assis- Dubowitz et al.’s(2005) and Mennen et al.’s(2010) studies tants, not social workers. through comparing a modified MMCS with CPS records of assessments by child protection workers; and Runyan et al.’s Types/Subtypes, Severity, and Chronicity of Neglect. Our review (2005) study through CPS data being compared to the focuses on six subtypes of neglect: emotional, medical, 10 Research on Social Work Practice 0(0) Table 2. Characteristics of Included Studies. Population description Social Work Author and Population Children’s Referral Reasons/Risk Parental Risk Date Measure (Index Test) Brief Description Type of Neglect Assessed Comparator/Control Country Setting (Type, n) Subject (n) Children’s Age Circumstance Factor Protective Factor Factor Other Risk Factor Trocme Ontario Child Neglect Short tool for assessing Supervision 1. Maltreatment Canada 1 large Ontario urban 5 "intake" 127 consecutive "intake" Mean age of 7 56% single parent Referred for variety Not reported 45% cases Not (1996) Index (CNI) type and severity Food/nutrition classifications of the child welfare workers, so investigations. years old family. concerns: Physical abuse referred for reported neglect Clothing/hygiene National Incidence agency duty and Average of 1.8 35% Canadian, 22% (19%), Sexual abuse "parent Medical care Study (NIS) child assessment children per family Asian, and 27% (14%), Neglect (11%), behaviour" Mental health care protection worker workers West Indian Parent behavior (45%), under Development/educational survey form and Child behavior (7%) Ontario’s care 2. Neglect-related scales 31% cases previously system (no from the CWBS for opened, 39% open more more details concurrent validity. than 6 months provided) n = 125 for each scale Dubowitz Modified 1.To compare neglect Failure to provide: CPS classifications of USA Part of the Longscan Routine 740 children aged 8 Children were Children taking part in 1. Taken into early foster Not reported Parental risk Risks differed et al. Maltreatment Classification defined by CPS official Food neglect defined as longitudinal narrative CPS years, as part of the interviewed Longscan care (around half factors between the (2005) System (MMCS) codes with neglect Medical “general neglect” and cohort (Longscan) data, Longscan longitudinal between longitudinal cohort returned to family varied four sites and defined by a review of Clothing “caregiver absence.” n study of “children collected by cohort (Longscan) the ages of before the age of 4 between the within the sites CPS narrative data Shelter = 481 for valid CPS at risk” research staff, study 4 and 8 years) four included Regression using MMCS Hygiene records reclassified by MMCS was compared years 2. Children reported to sites analyses were 2. To compare the neglect Sanitation research staff to CPS classifications CPS before the age of 5 controlled for categories at predicting Lack of supervision: only in the 481 years, with substantiated age, gender, a range of child Supervision children with CPS or unsubstantiated race, income, outcomes ascertained Environment records cases, and judged at site, and at age 8 from a set of Substitute care “moderate risk” for subtypes of standardized measures future maltreatment neglect 3. Children born in hospitals involved in a programme for babies of families with high risk medical or social factors 4. Low-income family children recruited from paediatric clinics with either nonorganic failure to thrive, mothers at risk of HIV infection, or neither (i.e., a comparison group) (continued) Haworth et al. 11 Table 2. (continued) Population description Social Work Author and Population Children’s Referral Reasons/Risk Parental Risk Date Measure (Index Test) Brief Description Type of Neglect Assessed Comparator/Control Country Setting (Type, n) Subject (n) Children’s Age Circumstance Factor Protective Factor Factor Other Risk Factor Runyan MMCS; Companion paper to Reclassification of CPS CPS records with only USA Comparisons Routine CPS 545 children and their Children were Children taking part in As shown in Dubowitz et al. Not reported As above As above et al. National Incidence Study 2 Dubowitz et al. (2005) records by researchers one single between data by SWs, primary caregivers interviewed Longscan (2005) above (2005) (NIS-2) To compare into predominant maltreatment classifications by collected by who were assessed at at ages 4 longitudinal cohort concordance of MMCS maltreatment type— classification of CPS workers and research staff, ages 4 and 8 and had and 8 reclassification of the physical abuse, sexual physical abuse, sexual reclassifications of reclassified by lifetime CPS reviews predominant type of abuse, neglect, or abuse, neglect, or narrative data by research staff up to age 8, child maltreatment emotional maltreatment. emotional abuse trained research maltreatment reports defined by CPS to Using an algorithm for assistants before the age 8 official codes and NIS-2 cases with multiple types Interview and CPS reclassification of maltreatment searched and reviewed before age 8 interview Mennen Maltreatment case records To compare neglect Reclassification of records by 303 child welfare USA Large public welfare Routine 303 cases Children aged 3 ethnic groups (Latino, 136 sibling cases and 167 “Substantiated Not Not et al. abstraction system defined by CPS official researchers into type of records of new agency; narrative CPS 9–12 years African-American, non-sibling cases referrals (i.e., reported reported (2010) (MCRAI) codes with neglect and abuse or into the 11 reports of longitudinal data, or Caucasian), report of Longitudinal cohort study abuse defined by a categories of neglect—the maltreatment cohort study of collected by resident in selected maltreatment)” review of CPS nine MMCS definitions of effects of retired CPS postcodes in Los narrative data using neglect used by Dubowitz maltreatment on supervisors, Angeles MCRAI, (a further et al. (2005) (above) plus adolescent reclassified by modification of MMCS) two extra categories of development research staff caretaker incapacity or “substantial risk” of abuse and/or neglect Note. CWBS= Child Well-Being Scales CPS= child protection services; NIS-2 =National Incidence Study 2. 12 Research on Social Work Practice 0(0) physical, educational, social, and lack of supervision or guid- maltreatment were included, resulting in 35% of records ance. No tool assessed all of these, but the CNI assessed being excluded. This left the study open to selection bias. medical, physical, and educational neglects, as well as lack The number of CPS negative/MMCS positive, or CPS nega- of supervision and guidance. Emotional neglect was partially tive/NIS-2 positive, could not be ascertained. The exclusion measured under “mental health care,” but social neglect was of multiple maltreatment cases and manner of reclassifica- not captured. Neglect severity was measured, but chronicity tions into one subtype left the study open to measurement was not. The tool would be easily repeatable for measuring bias. Within the study, being placed lower down their hierar- the change in cases, but the age-weighted component would chy of abuse (as follows: sexual abuse, physical abuse, have to be disregarded. neglect, and emotional abuse) translated into being less The MMCS measured medical and physical neglect, and likely to be classed as the predominant type of abuse. lack of supervision or guidance. Facets of neglect severity Trocme (1996) recognized that the assessment of neglect is and chronicity were captured, but only partially, in complex, but provided a limited discussion of potential con- Dubowitz et al.’s (2005) study. No data on severity or chro- founding factors. The child’s age was considered in the nicity was provided in Runyan et al.’s (2005) study. CNI, with higher scores added to the index for younger chil- Additionally, the MMCS would not be easily repeatable for dren but confounding factors such as worker issues, family measuring the change in cases, as it takes considerable time issues, difficulty disaggregating neglect from poverty, or and effort to complete. issues in the NIS and CWBS tools against which the CNI was validated were not discussed. Dubowitz et al. (2005) also recognized the complexity of Quality of Evidence and Risk of Bias of Included assessing neglect, but no data were provided on other types Studies of potentially co-existing maltreatment. For example, there There was no selection bias identified in the Trocme (1996) was no assessment of differences in outcomes between chil- study: it contained 127 consecutive intake cases. Two dren remaining in foster care and those who returned home, missing results were judged unlikely to have significantly which may be a confounder for children’s problems. altered the findings. The tool is simply designed and there Table 3 sets out the overall quality of the evidence of the is no reason to suspect any other measurement bias. included studies. However, validity assessment against the NIS classifications was not blinded: repeat CNI and CWBS assessments were Validity and Reliability of Included Studies completed by the same worker up to 2 weeks later, raising the possibility of these being influenced by social work case The results in Trocme’s (1996) study indicated that the CNI decisions. Trocme (1996) provided no information as to has face validity. It is specific for neglect and measures whether the CNI score influenced workers’ decisions. It is neglect type and severity. The MMCS tool also appeared to possible that Trocme’s results were influenced by the have face validity. It measures neglect and Runyan et al.’s results of the reference tools. (2005) results indicated specificity for neglect. There was variation in the sample population within The CNI was developed with the input of an expert panel Dubowitz et al.’s (2005) study, some with CPS records (n= and tested in practice. However, Trocme (1996) relied on 481) and some not (n= 259). However, all children used for practitioners’ substantiation and intervention criteria for comparison had CPS records. Sixty-five children were neglect and Ontario’s legal definition of neglect (Ontario excluded from the sample mostly because of omissions in Child and Family Services Act, 1984), meaning the under- data, but the number of children lost to follow-up was standing of neglect was context-specific. Academic and unstated. Records were retrospectively re-coded using the service user perspectives were not included. The MMCS or MMCS by trained research assistants, but separate simultane- a further variation was applied retrospectively by Dubowitz ous coding by social workers using the MMCS independently et al. (2005), Runyan et al. (2005), and Mennen et al. and blind of CPS findings was not carried out. It is possible (2010), and its development was not discussed. that more cases may have been classified as neglect using Cross-cultural factors were not discussed by any authors. MMCS than through the CPS definitions. There was therefore The CNI was tested against the NIS and CWBS which potential for selection bias. Mennen et al. (2010) counted the have not been evaluated as part of this review, but as with number of children classified and not classified as subject to other abuse/neglect measurement tools, both have their own neglect by experimental and control methods, meaning that weaknesses and limitations. Concurrent validity scores were selection bias was limited only by willingness to take part generally good for the CNI. The CNI correlated with the in the study. CWBS overall (inverse correlation 65%), with only the To compare CPS classifications with MMCS and NIS-2 CWBS parent stimulation scale not correlating. Trocme codes, Runyan et al. (2005) re-coded CPS data for each mal- (1996) compared the predictive validity of CNI and CWBS treatment report into MMCS and NIS-2 codes. Only those scores with the decision to provide ongoing child welfare ser- CPS records with a single, valid CPS classification of vices. Table 4 sets out the properties of the included measures Haworth et al. 13 Table 3. Overall Quality of Evidence. Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment Trocme Concurrent Comparison: 78 cases of neglect None found (two Results of Liable to CNI results could Only age was None beyond 2 No data NIS is not a High (1996) comparison of 1. NIS* Child using NIS had a missing results neglect score measurement bias have influenced discussed or weeks after provided standardized likelihood methods in the Protection CNI score M= unlikely to using the CNI The same social other taken into intake on range of measure for of bias same cohort of survey form 48, 27 cases of no substantially were workers all test outcomes, for account The test was scores or neglect, and has (low level consecutive completed by neglect had a CNI affect overall compared with the same example., intended to variation— undergone later of intake cases, the social score M= 21 findings) with results of children, so no overall substantiate no data to revisions certainty) with no workers (p < .0001). scores using blinding was caseworker neglect not enable Applicability of follow-up 2. Standard Indicating CNI is the NIS possible decisions on to predict assessment this as a control undertaken assessment of specific for child Inter-reliability was whether to risk of is uncertain beyond 2 whether to neglect. No assessed by keep the case precision weeks keep the case cut-off scores Trocme and SW open (used as open were suggested supervisor an assessment 3. elected items “Good” correlation checking SWs’ of CNI from the with CWB Scales case notes—so performance) CWBS (0.65), higher with not completely and scoring of most individual independent of subsections of scales original the CWBS Mean scores assessment used to assess significantly higher validity of the for cases kept tool open than for Mean values for closed cases (45 addition of two vs. 31, p < .001) separate Test–retest ordinal values reliability from the Statistical text was 86% methods overall (weighted unclear kappa 0.86, with individual scores 0.83–0.91) Inter-reliability ranged from 88% to 91% (based on reassessment of case worker notes) Dubowitz Part of a Used CPS 1. Correlations Main problems: Effect of other maltreatment No data Unable to et al. longitudinal records with between the two 1. Retrospective, types of child not taken provided quantify. (2005) cohort study, assessments coding methods non-blinded into account on p-values were with CPS by child ranged coding for MMCS attrition (continued) 14 Research on Social Work Practice 0(0) Table 3. (continued) Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment records protection small-large, but scores rates for provided, but (narrative workers as were generally 2. No data on follow-up no SDs or CIs documenting comparison moderate confounding by assessment of allegation) 2. Correlation of other types of at the age reclassified MMCS with child co-existing of 8 years retrospectively behavior maltreatment by study problems at the 3. Variation in personnel age of 8 years, as population (all assessed by included children "standardized had CPS records) measures" or checklists for children and parents (not appraised in our systematic review) (n= 740 children) Retrospective High level of re-coding— bias, low level not applicable of certainty to routine assessment Population characteristics not necessarily comparable to other populations Runyan Part of a Used CPS After reclassification Very high level of As above Exclusion of CPS Very high et al. longitudinal records with of type of selection bias: But also: records with likelihood (2005) cohort study, assessments maltreatment by only those CPS Reclassifications multiple of bias with CPS by child original CPS records with a into just one maltreatment Very low records protection designation and single, valid CPS predominant type classifications certainty (narrative workers as MMCS classification of of maltreatment: excludes of documenting comparison, re-designation, maltreatment high risk of accurate evidence of allegation) but data were MMCS were included measurement bias estimation reclassified manipulated classification Out of 1,980 Hierarchy of retrospectively to only agreed with CPS reports, 717 maltreatment account for for 82% of (36%) were type, although in (continued) Haworth et al. 15 Table 3. (continued) Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment by study the physical abuse, excluded. 387 use at the time, is personnel “predominant 90% of the SA were excluded also questionable type” of child cases, 82% of for having no valid maltreatment neglect and only CPS allegation 37% of emotional type codes, 167 abuse for having Results suggested multiple types of that large number maltreatment. of cases recorded 163 were as neglect by CPS excluded because were “false no valid MMCS positives” could be coded. Using this This leaves the methodology CPS study open to was 82% sensitive selection bias. for neglect and Numbers of cases 76% specific, that may have compared to been CPS MMCS with an negative but 83% positive MMCS positives predictive value of for neglect cannot MMCS be ascertained Emotional abuse was reported poorly classified by CPS —with a sensitivity of 16%, specificity of 99% and PPV of 87% compared to MMCS Mennen Part of a Used CPS MCRAI method Participants were Data provided CPS retired 136 of the 303 No follow-up No data High et al. longitudinal records with classified 215 children and their indicate that supervisors cases were reported provided likelihood (2010) cohort study, assessments cases (71%) as carers who had CPS practice abstracted CPS in sibling on range of of bias with CPS by child neglect compared already been may have data and research groups scores or Low level of records protection to CPS records of reported and who been to workers carried variation— certainty (narrative workers as 124 (41%) accepted an record the out re-coding no data to documenting comparison p < .001 invitation to take main form of Researchers may enable of allegation) MCRAI additionally part in the study abuse or have been keener assessment reclassified captured multiple No comparison data neglect as to report neglect (continued) 16 Research on Social Work Practice 0(0) and, as highlighted in Table 43, mean scores were higher for open than for closed cases. By comparison, the differences in the CWBS scores were very small. Structural validity is reported in Table 4. The MMCS was tested against the NIS-2. There was a kappa score of 0.743 for agreement between the MMCS and NIS-2 codes for neglect and a predictive value of 94% for the NIS-2, suggesting that the MMCS classification would also be neglect. Each MMCS neglect subtype was moderately correlated with CPS “general neglect.” There was limited or no correlation between MMCS subtypes and CPS “caregiver absence.” The findings were that the MMCS had an 83% positive predictive value for neglect. MMCS classification agreed with CPS for 82% of physical abuse, 90% of sexual abuse, 82% of neglect, and only 37% of emotional abuse cases. Structural validity of the MMCS is highlighted in Table 4. Trocme (1996) provided partial data on reliability, as shown in Table 4. No data for the reliability of the MMCS over time were provided in either Dubowitz et al.‘s (2005) or Runyan et al.‘s (2005) studies. Dubowitz et al. (2005) and Runyan et al. (2005) found a 90% inter-rater reliability between assessors, with Runyan et al.’s score measured after training had been provided. Mennen et al.’s (2010) study provided limited data to add to our review. No data were provided on the range of, or variation between, scores using the CNI, resulting in no data to enable assessment of precision. It was not possible to assess the precision of the MMCS from Dubowitz et al.‘s (2005) study. They provided p-values for study outcomes, but no SDs or confidence intervals. Runyan et al.’s (2005) study pro- vided data for sensitivity, specificity, and positive predictive values. These suggested that a large number of cases recorded as neglect by CPS records were “false positives.” CPS scores were slightly more sensitive than MMCS scores in predicting child outcomes. The Runyan et al. (2005) study completed a regression analysis for outcomes measured in the Dubowitz et al. (2005) study and each of the classification systems. However, due to the methodology used, we have not rated the prospective validity of the study high enough to warrant detailed analysis. How the Tools Perform Against our Desired Characteristics We tested for the desired characteristics in a neglect measure- ment tool, based on the views of the advisory group as stated previously. Table 5 sets out the applicability of each tool for social work. The CNI is a short tool that appears simple to administer and comprehensible, whereas the MMCS does not meet these criteria (Table 5). Dubowitz et al. (2005) state regarding use of the MMCS that “findings in the present study do not support the considerable time and effort involved in Table 3. (continued) Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment retrospectively types of neglect as provided on very few than social of by study well as those who instances of workers precision personnel co-occurrence of declined to take co-abuse Unit of analysis was physical, sexual, or part were each report not emotional abuse, recorded each child caretaker incapacity and substantial future risk Note. CNI = Child Neglect Index; CPS = child protection services; CWBS = Child Well-Being Scales; MMCS = Modified Maltreatment Classification System; NIS=National Incidence Study. Haworth et al. 17 abstracting and coding CPS records, at least for studying the the best evidence of the effectiveness of tools or measures frequency of reported types and subtypes of neglect” (p. 508). for the assessment of child neglect. Comprehensibility for social workers was not tested in any This review revealed the limitations of the evidence base of the included studies. Trocme (1996) recognized that due to for social workers to assess child neglect. The overall evi- the CNI’s brevity, accuracy and comprehensiveness could be dence base for measures of child neglect can be considered questioned, but also stated with some justification that “… weak. The most significant finding of the review is the lack brevity of the CNI may simply reflect our limited knowledge of rigorous testing of potential measures for assessing child of the characteristics of neglect and the lack of consensus neglect. There is a paucity of high-quality evidence and about underlying constructs” (p. 150). The CNI performed robustly tested tools, with studies of “popular” tools lacking well against the lengthier CWBS tool. The MMCS is a methodological rigor and robustness. This raises significant more detailed tool than the CNI, but covers fewer subtypes issues for social work assessments of neglect and the in this review’s neglect typology, which raises questions impact of child neglect means that the lack of valid, usable, about its comprehensiveness. and reliable measurement tools is a significant concern. In The CNI focuses on substantiating neglect rather than sum, only four studies met the inclusion criteria, with only future risk. Neglect is assessed as categories ranging from one tool, Trocme’s CNI, considered simple enough to feasi- adequate to seriously inadequate, with scorings applied, bly be used in practice. whereas the MMCS simply assesses neglect as present or The findings suggest the need for robust testing of neglect absent. As shown in Table 5, the CNI appears to have more measures in social work settings. Robust testing is important potential to be used across the stages of children and families for the development of tools that can satisfy the criteria of social work than the MMCS. validity, reliability, and practice/clinical utility. Child protec- The MMCS questions primary carers and children, while tion social workers’ time with children and families has been Trocme (1996) does not state who the CNI questions. None reduced through the COVID-19 pandemic, with in-person of the studies reported acceptability of the tools to children home visits becoming less frequent and shorter (Ferguson and families. Potential benefits, harms, and false positives et al., 2020). This change in practice accentuates the need and negatives were not reported by Dubowitz et al. (2005) for assessments to be focused and feasible in terms of time or Trocme, but the CNI and MMCS are neglect-specific. and resources. Because of these changes and issues, it is Runyan et al. (2005) did report false positives, but the timely to develop a new evidence-based, short, and results were vulnerable to measurement and selection easy-to-administer child neglect measurement tool. biases. Runyan et al.’s (2005) results would not be reliable Analysis revealed the gaps between the two included tools, for neglect if other types of maltreatment were also present. the CNI and MMCS. The tools conceptualize and measure child neglect very differently, reflecting wider issues and imprecision around how neglect is defined and understood, Excluded Studies but both present clear omissions and weaknesses. The CNI was designed for simplicity and brevity, while the MMCS Due to the small number of studies that met the inclusion cri- was more complicated and cumbersome. The CNI captured teria for this review, and to promote the review’s rigor and a greater range of neglect subtypes identified in this review, transparency, we thought it important to discuss studies one but certainly not all of them. Notably, neither tool covered might plausibly expect to find among the included studies, social neglect. Assessments that do not examine social such as well-known neglect measurement tools, and studies neglect are not as holistic as would be preferred. The CNI cap- that on the surface met the eligibility criteria, but on further tures neglect severity and recognizes that neglect should not inspection did not (Page, Cumpston, et al., 2020; Page, be assessed dichotomously as present or absent, but neither McKenzie, et al., 2020). Three studies were of significant tool effectively captures chronicity. Severity and chronicity interest but did not meet the inclusion criteria. They are are both key features of neglect for children’s social work, shown in Table 6. given that children’s services often become involved in situ- ations of chronic and severe neglect (English, 1997). The CNI could at best be considered partially effective in measuring Discussion and Applications to Practice neglect. Trocme’s (1996) study did not discuss cross-cultural The aim of this systematic review was to examine neglect factors and transferability to the UK context would need to be measurement tools that may be useful for children’s social tested. The MMCS would not merit testing, due to the time work. We examined the published and unpublished reports and effort needed to complete it being unfeasible in practice. against strictly defined criteria of population, tool focus As reported in the results section, there are significant con- (neglect), evidence type, and comparison to a defined gold cerns about the quality, validity, and reliability of the included standard. We further examined the validity, reliability, and studies. The findings of this review resonate with previous quality of the evidence base and key features of reviewed research by Yoon et al. (2021a), Vial et al. (2020), and tool’s usability and feasibility in practice. We synthesized Saini et al. (2019) into child maltreatment. As discussed 18 Research on Social Work Practice 0(0) Table 4. Properties of Included Measures. Sensitivity to Neglect Validity Reliability Severity Chronicity Change Structural Validity Does it Record Is it Easily Relevance/ Across Items in Does it Measure How Long the Repeatable in Type of Actual Face Test (Scale Between Degrees of Neglect Has Been Order to Measure Measure Neglect Measured Validity Comprehensibility Comprehensiveness Overlap) Cross-Cultural Concurrent Prospective Assessors Across Time Severity? Taking Place? Change? Ontario Child Supervision, Cited as 6 subscales, each scored Good Psychological and Not reported 46 cases classified as Cases kept open Inter-rater Not known. The scale ranges No Scores for a Neglect Physical care good 0–60 for severity. The Developmental neglect but not by social reliability CNI was from theoretically Index (CNI) (Food/nutrition overall score combines Care Scales abuse had a CNI workers had a (87 cases completed Adequate to constant level of (Trocme, and clothing and the score from the correlated score M= 49; 26 CNI score M rated by twice by Seriously neglect would 1996) hygiene), scale with the highest above 0.50, classified as abuse = 45; cases supervisor intake Inadequate decrease as the Provision of severity rating and an rest below 0.35 but not neglect had a closed had a and author) workers for each type child ages health care age score ranging from CNI score M= 21 CNI score M was 88% to within a of neglect To measure (Physical, Menta,l 20 points for the ages 78 cases with neglect = of 31 91% (but 2-week measured change, the and of 0–2 years down to 0 (with or without (p < .001) based on period. age-weighted Developmental, points (aged 13–16) other maltreatment) CWBS scores supervisor Average component and Educational Maximum CNI score had a CNI score M = were M= 82 and author 86% would have to care) would be 80 of 48, 47 classified as for those kept using reliability be disregarded (Anticipation and Appears simple and easy having no neglect had open, M= 88 workers’ (0.86 response to to understand a CNI score M= 21 for cases case notes) weighted child’s emotional (p < .0001) closed kappa) needs classified Overall correlation (p < .03) with health care) between CNI and CWBS was good (inverse correlation of 65%) Correlation for individual subscales: 49% for developmental/ educational care and CWB scale parental teaching/stimulation, > 70% for remainder MMCS "Failure to provide": Has face Carried out by trained Emotional, social, or Data suggest that Not reported Each of the individual After controlling Not reported Not reported Frequency of Counts frequency No (Dubowitz Food, medical, validity research assistants educational while individual MMCS subtypes was for child age, recorded of reports Coding was et al., clothing, shelter, No data on neglect not items are moderately gender, maltreatment carried out 2005) hygiene, comprehensibility for covered correlated with correlated with CPS ethnicity, type was used retrospectively sanitation and social workers in the each other, "general neglect" income, and as a Said to be very time "Lack of field they are (each between 24% site, MMCS substitute for consuming supervision": distinct and 54%, each with overall scores severity supervision, phenomena p < .001) had low environment, and No clear support Low/no correlation correlation substitute care for "lack of between individual with child supervision" MMCS subtypes and functioning* and "failure to CPS "Caregiver and were less absence" (clothing = predictive (continued) Haworth et al. 19 Table 4. (continued) Sensitivity to Neglect Validity Reliability Severity Chronicity Change Structural Validity Does it Record Is it Easily Relevance/ Across Items in Does it Measure How Long the Repeatable in Type of Actual Face Test (Scale Between Degrees of Neglect Has Been Order to Measure Measure Neglect Measured Validity Comprehensibility Comprehensiveness Overlap) Cross-Cultural Concurrent Prospective Assessors Across Time Severity? Taking Place? Change? provide" 22%, food= 19%, than the CPS typology supervision = 18%, designation each p < .001; sanitation= 9% and supervision = 10%, both p < .05. No correlation with medical/ environmental neglect) Mennen “Failure to Has face Carried out by trained Emotional, social, or Not reported Not reported No data No data Kappa scores Not reported Measures Duration and No. Coding was et al. provide": Food, validity research assistants educational for neglect frequency specifics can be carried out (2010) medical, clothing, No data on neglect not 0.75 not severity entered retrospectively shelter, hygiene, comprehensibility for covered For 13 neglect sanitation social workers in the items, "Lack of field kappa was supervision": 0.84, supervision, ranging environment, and from 0.55 substitute care to 1.0 “Caretaker incapacity” (absence/inability to care for child) “Substantial risk” of neglect and/or abuse (e.g., sibling is abused and/or neglected) Note. MMCS = Modified Maltreatment Classification System; CPS = child protection services; CWBS= Child Well-Being Scales. 20 Research on Social Work Practice 0(0) Table 5. Applicability for Social Work. Of Whom is Possibly be The Tailored to Does the Assessment Different Are Benefits and Measure Tool Service Areas, Harms Indicate the How Many Questioned? With Perhaps Reported? What Type of Hours of (e.g., Parents, Has Can it be Used Different is its Sensitivity Interpretability: Support that Training Carers, and Has Acceptability Comprehensibility Across All Stages Versions for and Specificity Categorical Outcomes? is Needed for What is Average Time are Children, Been Tested? If So, Been Tested? If So, of Child Different (False Positives Measure Cut-off Points? the Family? of Administration? Needed? Teachers) How? How? Protection? Teams? and Negatives)? No Not reported Not Not reported Authors cited a 1994 Not reported but Not reported, but Not reported Not reported CNI Each type of neglect (Trocme, receives its own reported survey of 285 appears simple and its simplicity but as 1996) severity rating randomly selected self-explanatory would suggest it previous Overall score child welfare could be used to column combines the workers using CNI assess changes in would seem highest reported modified to include individual types simple severity rating with other forms of of neglect enough to an age rating, to a maltreatment Care would need tailor and maximum score of High face validity in to be taken to adapt 80 training sessions, compare scores Originally a cut-off 89% response rate, before age score of 50 was and over 95% adjustment suggested (with completion rate limited clinical reported significance) but best used as severity rating without cut-offs MMCS Reported as presence/ No Not reported but Not Parents carers No data No Unlikely, due to Unlikely Not reported (Dubowitz absence for each findings "do not reported and children Incentives were time and effort et al., 2005) subtype of neglect support the provided to needed * considerable time compensate for and effort involved time spent in abstracting and answering the coding CPS records" questions Note. MCRAI (Mennen et al., 2010) is essentially the same tool as the MMCS, with two added categories. CNI= Child Neglect Index; MMCS = Modified Maltreatment Classification System. Haworth et al. 21 Table 6. Excluded Studies of Interest. Reason for Authors Tool Details Exclusion National/International Johnson & Graded Care Profile 2 Measures levels of care, used by Not assessed United Kingdom only Fisher social work and multi-agency against gold (2018) teams standard Glad et al. Home Observation for Focuses on assessment of home Not assessed Used in a variety of countries, (2012) Measurement of the environment and stimulation against gold including the United States, Environment (HOME) Predominantly used in health standard United Kingdom, and Sweden Inventory care, but can be applied to social work Kantor et al. Multidimensional Neglectful Comprehensive, focusing on Not assessed Used in a variety of countries, (2004) Behavior Scale Child Report cognitive, emotional, physical, against gold including the United States, and supervisory neglects standard Turkey, and France Tests revealed good reliability scores for use with older children earlier, their studies also found issues around validity, reli- Only 25% of identified records were independently reviewed ability, and usability, and suggested that the current evidence by a second review author; however, inter-rater agreement at base is not sufficient. this stage was greater than 90% and thus we do not see this as This review has a number of strengths. It has followed a significant limitation. Cochrane Collaboration recommendations (Higgins et al., It is reasonable that the findings from this review will be 2020) (adapted to the field of social work), providing a rigorous broadly generalizable to high-income countries. Although and systematic approach. We systematically searched a range of there is significant variation across time and between cultures multidisciplinary and science/social science electronic databases as to what is considered abusive (Munro, 2020), there are and search engines, as well as grey literature. Social work values international and cross-cultural aspects to the basic founda- and practice relevance have been promoted through the collabo- tions of neglect as an unmet need. However, caution should ration of an advisory group of practitioners. Development of a be adopted in generalizing the findings to countries with sig- template specifically for this review has enabled clear and nificantly different economic, social, and legal contexts. focused data extraction to answer the research questions. A mul- Variations in definitions of neglect between countries tistep approach to assessing study quality has promoted rigorous further complicate the practice landscape and create issues analysis. Finally, the review has set out clearly what measure- for a consistent approach to neglect measurement. ment issues are important and how to assess them. Given the current evidence base for neglect measures, Whiting et al. (2016) state that “bias occurs if systematic social workers should continue to undertake assessments flaws or limitations in the design, conduct or analysis of a based on established frameworks, such as the Framework review distort the results” (p. 226). We undertook steps to for the Assessment of Children in Need and their Families minimize bias throughout this review, including following (DoH, 2000). Current neglect measures are largely untested the protocol in full. This set clear eligibility criteria and laid and should be used cautiously. Until reliable, valid, and out robust methods for the review, including the risk of bias usable measures are available, social workers should of included studies being assessed by one review author conduct full detailed assessments and not rely on measures and checked by a second. The adoption of a team-based whose validity, reliability, and neglect specificity are not approach with Birmingham Children’s Trust was important robustly investigated. for lowering bias (Uttley & Montgomery, 2017). Assessment of need as opposed to a singular focus on As with any study, this review has limitations. Setting a assessing risks should be adopted in practice, as neglect can contemporaneous comparison to a social work assessment be understood as an unmet need (Daniel, 2015). A risk- as a gold standard and limiting the review to studies published focused approach fails to fathom the relationship between in English reduced the number of included studies. Further, it the wider economic, social, and community contexts influen- restricted the type of measurement instrument and excluded tial in neglect and practice, and can exclude effective assess- measures from linked professional fields such as health. ment of needs and support for these to be met (Bilson & Social work assessments can be of variable standards, Hunter-Munro, 2019; Warner, 2015). although the advisory group and existing guidelines indicated The current evidence based on measuring child neglect is that these remain the best tools currently available—thus we too limited to effectively inform practice. The significant cost contend that our review gives greater rigor in its approach. of neglect at personal, professional, community, and societal 22 Research on Social Work Practice 0(0) levels justifies the need for a thorough and robust research the diagnostic accuracy of the identification of abused children. BMC Pediatrics, 13, 202. https://doi.org/10.1186/1471-2431-13-202 project to develop a new child neglect measurement tool. Barlow, J., Fisher, J., & Jones, D. (2010). Systematic review of The study should be practice-informed and focussed on the models of analysing significant harm. Department for development of a tool that is accessible and useable in prac- Education. https://assets.publishing.service.gov.uk/government/ tice Therefore, the tool should be designed with, as well as uploads/system/uploads/attachment_data/file/183949/DFE-RR199. for, professionals and families. The development of an pdf evidence-based, valid, and reliable child neglect measurement Barlow, J., & Schrader-Macmillan, A. (2010). Safeguarding chil- tool, rigorously tested in practice, is likely to improve the dren from emotional maltreatment: What works. Jessica standards of social work assessments. Kingsley. Any future neglect measurement tool will need to pay par- Bilson, A., & Hunter-Munro, E. H. (2019). Adoption and child pro- ticular attention to validity, reliability, and relevance of the tection trends for children aged under five in England: Increasing investigations and hidden separation of children aspects measured. Further, it will need to capture neglect sub- from their parents. Children and Youth Services Review, 96, types, severity, and chronicity. We suggest the clear neglect 204–211. https://doi.org/10.1016/j.childyouth.2018.11.052 typology used in this review would be applicable. Trocme’s Boyd Webb, N. (2019). Social work practice with children. Guilford (1996) study starts to demonstrate that measurement tools Press. can be concise, but a fuller evidence base requires one to Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., have full confidence in this. Dodsworth, J., Warren, C., & Black, J. (2009). 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A Systematic Review of Measures of Child Neglect

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10.1177/10497315221138066
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Abstract

Purpose: Child neglect is prevalent in children’s social work and assessing neglect is complex because it is multifaceted and opaque. This systematic review identifies and evaluates evidence of tools or measures to better assess child neglect. Methods: Informed by Cochrane methodology and adapted to the needs of social work practice, a systematic search and review of measures of child neglect was undertaken. Ten databases were searched, augmented by grey literature, and are in contact with relevant experts. Results: Only two measures, the Child Neglect Index (CNI) and modifications of the Maltreatment Classification System (MCS), met the inclusion criteria. Neither tool was completely comprehensive for child neglect. Discussion: Our findings indicate (a) a dearth of suitable tools to measure neglect and (b) the need for robust testing of neglect measures in the social work setting. The current evidence based on measuring child neglect is too limited to effectively inform policy and practice. Keywords systematic review, child neglect, measurement, evidence-based practice, assessment Child neglect is prevalent across all societies and can cause measurement tools are important for measuring abuse and long-lasting and significant harm for children and young neglect, there are currently no gold standards for the measure- people (Daniel, 2015; Daniel et al., 2010; English et al., ment of child neglect or abuse (Bailhache et al., 2013). 2005; Horwath, 2013; Moran, 2009; Stevenson, 2007). In this article, which has been co-produced with an advi- Neglect is often defined as unmet need (Daniel, 2015). sory group of relevant stakeholders, we present a systematic However, a variety of more sophisticated definitions have review of neglect measurement tools for children’s social been developed within professional practice and academia. work. Although we focused on measures of neglect, we rec- Without clarity on the definition of a concept like neglect, ognize that risk assessments of potential neglect are also com- precise and accurate measurement is difficult to achieve monly undertaken in practice (De Bortoli et al., 2017; Mulder (Perron & Gillespie, 2015). et al., 2018). Neglect incorporates a variety of experiences for children and young people ranging from lack of supervision to Background and Significance extreme deprivation. It is widely recognized that experiencing neglect during childhood can increase the risk of negative Research into maltreatment has been criticized for lacking health and of negative emotional and social outcomes later methodological rigor, imprecise definitions, and inadequate in life (Corby et al., 2012; Horwath, 2007; Howe, 2005; measurement strategies (Manly, 2005), issues that have Radford, 2011). Neglect raises issues for the helping profes- been linked to its complexity and definitional challenges sions in terms of identification, assessment, and support (Gershater-Molko et al., 2003). There has been a notable (Brandon et al., 2009; Daniel et al., 2010; Horwath, 2007). Despite this, there has been limited research into neglect com- Department of Social Work and Social Care, University of Birmingham, pared to other forms of child abuse (Daniel et al., 2011; Birmingham, UK Dubowitz, 2007; McSherry, 2007; Mulder et al., 2018). Department of Social Policy, University of Birmingham, Birmingham, UK A number of authors have raised concerns related to the School of Social Policy, University of Birmingham, Birmingham, UK significant limitations and imprecision of the evidence base Corresponding Author: around neglect (Barlow & Schrader-Macmillan, 2010; Simon Haworth, Department of Social Work and Social Care, University of Horwath, 2013; Moran, 2009; Morrongiello & Cox, 2020; Birmingham, Edgbaston, Birmingham B15 2TT, UK. Mulder et al., 2018). Although evidence-based high-quality Email: [email protected] 2 Research on Social Work Practice 0(0) lack of research into assessing neglectful parenting, likely prevalence is the harm category given to cases deemed to influencing the tendency of practitioners to rely on subjective meet the threshold of significant harm. These harm categories judgements as opposed to evidence-based measures (Hines are neglect and physical, sexual, and emotional abuse (DfE, et al., 2006; Morrongiello & Cox, 2020; Stewart et al., 2018b). As of March 31, 2021, there were 50,010 children 2015). The extent, impacts, and costs of neglect merit subject to a child protection plan in England and Wales, greater attention and scientifically rigorous research and neglect accounted for 52% of initial child protection (Dubowitz et al., 2005; Horwath, 2013). plans (DfE, 2021). While international comparisons of neglect data are difficult (May-Chahal & Cawson, 2005), similarly high Definitions and Complexity of Child Neglect levels can be found in countries such as the United States, There are clear issues in defining neglect in both scholarship Canada, and the Netherlands (Euser et al., 2010; and professional practice. While abuse is typically identified Stoltenborgh et al., 2015; Trocme et al., 2003). In the as an act, neglect is often correlated with omission (English United States, neglect accounts for 75% of initial et al., 2005; Moran, 2009), and as such is frequently dichoto- referrals to child protective services (CPS) and for the major- mized (Sullivan, 2000). Neglect is now understood as a het- ity of recurrent maltreatment reports (Bae et al., 2010; erogeneous concept and phenomenon, inclusive of a variety Jonson-Reid et al., 2019; U.S. Department of Health & of (in)experiences for children and young people (Dubowitz Human Services, 2021). It is important to note that the UK et al., 2005; Horwath, 2013). It has been described as the and US figures quoted should be compared with caution, as most subjective of all legally recognized concepts in child like-for-like data is not available. welfare (Dubowitz et al., 2005; Zuravin, 1999), which occurs on a continuum with varying frequency and types Existing Social Work Assessments of Child Neglect (Helm, 2010; Higgins & McCabe, 2001; Mennen et al., 2010; Slack et al., 2003). As discussed, there is currently no gold standard for the mea- The scope of neglect, whether it should incorporate both surement of child neglect (Bailhache et al., 2013). A global potential and actual harm or just the latter, is debated systematic review for the National Institute for Health and (Horwath, 2007; Zuravin, 1999). Debates continue around Care Excellence (NICE) guidelines for child abuse and whether definitions should rely on children’s basic needs neglect failed to find any high-quality evidence for the pre- not being met from their perspectives or parental omissions dictive validity of any tools for identifying neglect (NICE, in care (Dubowitz et al., 2005). The concept of neglect is con- 2017). tested and open to significant interpretation in academia and In the absence of clear standards and effective tools, practice (Dubowitz et al., 2004). It is an expansive concept assessments can be subjective, with practitioners setting where additional dimensions could be included until it their own criteria for what is neglectful (Daniel et al., 2010; becomes too complex to effectively measure. These issues Stokes & Taylor, 2014; Sullivan, 2000). Neglectful care can are important in light of the long-standing issues of accuracy be difficult to capture as a static picture within assessments in assessments of neglect (Daniel et al., 2011; Horwath, 2013; due to a variety of interlocking issues, which include break- Taylor, 2017). downs in social relationships, inconsistent levels of care, var- For this review, we have used the operational definition of iable impacts of neglect on children, and social workers acting neglect adopted by the UK government in their Working on partial information (Horwath, 2007; Jones et al., 2006; Together to Safeguard Children (2018) guidance which is Lacharite, 2014). “the persistent failure to meet a child’s basic physical and/ Assessment of neglect is complicated by the role of wider or psychological needs, likely to result in the serious impair- social and political contexts. The roles of social harms, such ment of the child’s health or development” (Department for as poverty and insecure housing, should arguably influence Education [DfE], 2018a, p. 105). Although operational defini- what we define as neglect and where responsibility lies. tions of neglect vary due to factors such as social and cultural Chronic neglect often involves families facing a wide range influences, definitions in Western countries such as the United of social harms, including socioeconomic disadvantage States, Australia, and Canada have distinct similarities, for (Chambers & Potter, 2009; Dufour, 2008). For assessments example, all refer to parental failure to meet a child’s needs of neglect to be thorough, an evidence-based approach to sys- (Horwath, 2013). The US federal legislation provides guid- tematically construct a layered social reality attentive to these ance on child neglect, but definitions are state specific interlocking issues is required (Helm, 2010; McNaughton, (Horwath, 2013; Child Welfare Information Gateway, 2019). 2009; Sayer, 2000), while maintaining a focus on the child (Department of Health [DoH], 2000; Dyke, 2019). Further, the presence, absence, and levels of all neglect categories Prevalence of Child Neglect need to be given full consideration. As with broader social It is often difficult to accurately determine the prevalence of work, effective assessments should be collaborative with fam- neglect (Daniel et al., 2014; Moran, 2009). One proxy for ilies (O’Brien, 2004). Haworth et al. 3 The evidence from research and serious case reviews et al., 2014; Lacharite, 2014; Mulder et al., 2018; NICE, shows that social work assessments can range from good to 2017). flawed (Barlow et al., 2010; Dorsey et al., 2008; Macdonald et al., 2017). Assessments are only as good as the workers Existing Reviews of Neglect Measures completing them and as the support they receive in terms of Extant reviews of neglect measures have not considered evidence, research, and training (Milner et al., 2015). Even neglect in isolation or have only considered parent/caregiver with these challenges, a thorough social work assessment reports (Daniel et al., 2010; Saini et al., 2019; Yoon et al., remains the best tool available in the field (Holland, 2010; 2021a, 2021b). Research into child maltreatment measures Milner et al., 2015; Taylor, 2017), and high-quality assess- has raised concerns about validity, reliability, and usability ments are the cornerstone of good practice (Munro, 2020). of tools and the quality of the research undertaken. Yoon They are completed by qualified professionals in accordance et al. (2021a) raised concerns about the validity of child mal- with government laws and policies (Holland, 2010; Munro, treatment measures, stating that the current evidence base is 2020). This study’s advisory group and existing guidelines not sufficient. Vial et al. (2020) found that further research indicated that these continue to be the best and most com- is required on the validity, reliability, and usability of child monly used tools in practice (Boyd Webb, 2019; DfE, safety assessment instruments, and that an evidence-based 2018a; DoH, 2000; National Association of Social Workers approach to measure development is required. Saini et al. [NASW]; 2013). Good social work assessments can capture (2019) found significant variation in approaches to measure the child within their environment, the feasibility of change, child abuse and in methodologies employed. and the support required to effect such change (Milner et al., 2015). The Present Study This systematic review’s evaluation of the evidence of tools Measuring Neglect or measures for social work assessments of child neglect, The lack of clarity in defining neglect leads to challenges in therefore, helps fill a key gap. We compared and evaluated how to measure or quantify it (Dubowitz et al., 2005). these tools against the gold standard of an assessment by a However, well-developed tools and frameworks can support qualified children’s social worker or by an assessor working more accurate and holistic assessments, and counter signifi- within children’s social work (DoH, 2000; Leveille & cant sources of bias within assessments and decision Chamberland, 2010). The choice of this gold standard is dis- making (Barlow et al., 2010; Parker, 2020). Such tools can cussed in the section entitled “The Gold Standard for this be intelligently utilized to inform sound professional judge- Review”. ments (Barlow et al., 2010), enabling a balance between intu- A revised version of Horwath’s (2007) neglect typology itive and analytical reasoning (Munro, 2020). has been used for this review in line with our advisory For neglect, there are four main fundamental assessment group’s advice: elements (Daniel et al., 2011; Horwath, 2013; Jones et al., 2006): � emotional, � medical, � assessment of actual neglect, including types, fre- � physical, quency, severity, and chronicity, � educational, � assessment of family circumstances, including risk and � lack of supervision and guidance, and protective factors, � social. � assessment of risk of further neglect, including pros- pects for change, and It was developed from a review of other relevant definitions, � how best to meet the child’s needs. has a logical delineation into comprehensible neglect catego- ries, and offers a comprehensive understanding of neglect. It This systematic review focuses on tools to assess actual has been adopted in the United Kingdom by organizations neglect. Predictive tools have clear limitations for neglect. such as Action for Children. Social neglect has been added They are not considered good predictors of neglect in a to the typology, which involves parents/carers failing to range of both US and UK studies (Logan-Greene & meet a child’s social needs for close bonds and relationships, Semanchin Jones, 2018; Semanchin Jones & Logan– friendships, and social adaptation. It can be understood to Greene, 2016; Taylor et al., 2008). There are multiple and play a role in all types of neglect (Horwath, 2013). fluctuating individual, familial, community, and societal risk The adopted typology is visually represented in our theory factors for neglect that are nigh on impossible to capture of change diagram (Figure 1), which depicts an outline of effectively in a predictive tool, while some risk factors can children’s basic needs, categories of neglect, risk, and protec- also be consequences of abuse, leading to a further level of tive factors. Developed from the review’s neglect typology, complexity and confusion for accurate prediction (Brandon consultation with the advisory group, and a review of 4 Research on Social Work Practice 0(0) Figure 1. Theory of change. literature on children’s needs and neglect, it provides the service and practitioner collaboration to mobilize social work framework to guide this review. Its simplicity, clarity, and values throughout the review (Uttley & Montgomery, 2017). focus on the range of factors influencing neglect fit well A review protocol was registered with PROSPERO by with our project’s ethos and purpose, and are key features Haworth et al. (2020). of theories of change (Taplin & Clark, 2012). Munro (2020) has proposed that in order to practice effec- Search Strategies and Procedure tively, social workers need a formal knowledge base, value base, set of reasoning skills, emotional wisdom, and practice A systematic search of the national and international, clinical wisdom. Instead of these complicated knowledges and and academic, single index, and multidimensional measures skills, social workers tend to rely on practice wisdom of child neglect was undertaken. Measures were defined as (a combination of everyday skills and wisdom enriched those concerned with the extent, frequency, chronicity, or through experience and training) in their assessments severity of neglect as well as those with a focus on its (Crisp et al., 2007; Munro, 2020). This study addresses impact on, harm to, and significance for the child. this gap between knowledge and practice actuality by We searched relevant multidisciplinary and science/social adding to the formal knowledge base for neglect to science electronic databases, search engines, and grey litera- support practitioners to undertake more focused, evidence- ture. This strategy decreased publication bias (Burdett et al., based, and informed assessments. 2003; McFadden et al., 2015). Searches were tailored accord- ing to the scope of each database. The following databases and platforms were searched orig- Method inally between June and August 2020, with an updating search completed between March and June 2021: This review has broadly followed guidance from the Cochrane Collaboration (Higgins et al., 2020). Compared to many medical conditions, however, neglect is a complex phenome- Bibliographic Databases non (Horwath, 2013). Therefore, our approach has been adapted to the field of social work by a deeper exploration of � ProQuest ASSIA (1987-); the “target condition” and acceptance of a greater range of � Ovid MEDLINE (1946-); study types, in light of the evidence base. In line with recent � Ovid PsycINFO (1806-); methods’ developments, this study includes an emphasis on � SCIE Social Care Online; Haworth et al. 5 � ProQuest Sociological Abstracts (1952-); constraints). Studies in other languages that may be relevant � ProQuest Social Services Abstracts (1979-); have been listed. � Web of Science: Social Science Citation Index (SSCI) Tools or measures: Tools must have been designed for (1900-); children aged 0–18, with suspected neglect who have been � EBSCOhost ERIC (Educational Information Resources referred to children’s social work services, or for the child- Centre) (all available years); ren’s parents or carers. The tool had to ascertain at least one � EBSCOhost CINAHL (Cumulative Index Nursing and form of child neglect. Screening tests were not assessed, Allied Health) (1981-); and because the evidence, although weak, suggests unacceptably � Prospero https://www.crd.york.ac.uk/prospero/ high false positives (McTavish et al., 2020). For further #searchadvance. details on this criterion, please refer to the study protocol. Evidence included: No restriction was set on the type of Grey Literature study; published and unpublished material was reviewed. For evidence of diagnostic accuracy, only cross-sectional � OpenGrey. studies, and index or test measures involving the target pop- ulation with a contemporaneous (± 3 weeks) comparison of Theses and Dissertation Databases a (gold standard) social work assessment was included. All included studies were quality-assessed against this criterion. � ProQuest Dissertations and Theses Global; Studies that did not meet the inclusion criteria were � DART—Europe E-Theses Portal; excluded. They fell into one of the following categories: � EThOS—the British Libraries e-theses online service; � Networked Digital Library of Theses and Dissertations � no comparison with the gold standard of a social work (NDLTD); and assessment, � Open-Access Theses and Dissertations. � no child neglect, � not a tool or measure for child neglect, Other Resources � wrong setting (e.g., a medical setting), � wrong population (e.g., tool used retrospectively with � Key websites were searched directly (DoE, Children’s adults), Society, and NSPCC). � assessment of future risk not current measurement of neglect, and Handsearching was undertaken to identify additional liter- � small sample size (less than 10 subjects). ature. Relevant email alert services were used to identify newly published literature. New and unpublished trials were Because of a paucity of studies, we modified our protocol to searched in ClinicalTrials.gov and through contact with key include measures with retrospective comparisons with a authors in the fields of measurement tools in social work social work assessment. and neglect. The original search terms can be found in our registered The Gold Standard for This Review protocol. Additional relevant keywords identified during the searches were incorporated within a modified search strategy. We compared and evaluated tools against the gold standard of A list of named instruments identified through a preliminary an assessment by a qualified children’s social worker or asses- scoping search was included, and instruments identified sor working within children’s social work. through the review process were appended to the search. Social work assessments can be of variable quality. Information on these modifications and the number of However, as discussed, a thorough social work assessment studies identified in each search can be obtained from remains the best tool available in the field, and these assess- Simon Haworth ([email protected]). ments are completed by trained professionals, in line with government laws and policies, and subject to quality control mechanisms (Dubowitz et al., 2005; Holland, 2010; Munro, Criteria for Considering Studies for This Review 2020). The advisory group to this study and existing guide- Prior to starting the search, inclusion, and exclusion criteria lines indicated that these remain the best and most commonly were determined as follows: used tools currently in practice; offering comprehensive and Population: Children aged 0–18 years referred to child- holistic assessments of people within their environments ren’s social work services, and parents or caregivers of (Boyd Webb, 2019; DfE, 2018a; DoH, 2000; NASW, 2013). these children. Social workers are the lead professionals that identify and Dates of studies: No limits set. intervene in child neglect, both in the UK and North America Language of the studies: No restrictions applied. We only (where the included studies were conducted) (Horwath, 2013; reviewed studies in English (due to resource/time Stevenson, 2007). Social work is a key profession that 6 Research on Social Work Practice 0(0) engages with neglect in many countries globally (UNICEF, One review author extracted the key information on the 2021; World Health Organization [WHO], 2020). In the template, which was then verified by a second reviewer. United Kingdom and United States, undertaking high-quality Any disagreements were addressed through discussion and informed and holistic assessment focused on people in their consensus. environments is a key competency for practice (British Association of Social Workers [BASW], 2022; NASW, Assessment of Risk of Bias/Study Quality. We adopted a multi- 2013). step approach to assess study quality. First, we assessed A range of established and validated measurement tools which tools measured which domains of child neglect. Any have been tested against the gold standard of clinical and pro- measures with no face validity were screened out. Next, we fessional assessments completed in the field in a range of critically appraised the evidence for measures with some countries and settings. This includes the Beck Depression relevance. Inventory (I and II) (Gomes-Oliveira et al., 2012; Wang & Evidence was classified into the study method employed Gorenstein, 2013; Williams et al., 2021); the Child and the relevant CASPs (Critical Appraisal Skills Behavior Checklist (Ebesutani et al., 2010; Nakamura et al., Programme) checklist was used to assess the risk of bias 2009; Skarphedinsson et al., 2021); and the Children’s (CASP, 2018). One review author assessed and a second Depression Inventory (de la Vega et al., 2016; Sorensen then validated the assessment. Any disagreements were et al., 2005; Wu et al., 2010). resolved through discussion and reaching a consensus. Social work assessments have been used as a comparator We distinguished between levels of evidence (type and for validation in other studies. This includes King et al. quality of evidence available based on how well tests have (2013), who compared a structured assessment tool with been performed, on whom, in which settings, and against social work assessments, Smith et al. (2015), who used which other tests or assessments) and reported properties of social work assessments as comparators in the development tests including reliability, validity, accuracy, and precision; of a screening tool, and Flood et al. (2005), who used assess- then included measures were inspected for further properties ments by social workers as a comparison when assessing the of content validity, reliability, accuracy, interpretability, and Community Dependency Index. Further, arguments have sensitivity to change. We placed importance on the concur- been made that social work research underuses practice or rent validity of tools, as “concurrent validity is the most clinical information such as assessments, closely linked as it appropriate form of criterion validity to examine when the is to practice realities and key concepts used in real-world aim is to make inferences on the psychometric quality of an practice (Epstein, 2001). instrument” (Vial et al., 2020, p. 108). We used the definitions used in the COSMIN framework Review Procedure for key characteristics of good measures (Mokkink et al., 2010). They are as follows: Identified records were stored and screened on the Rayyan QCI database for systematic reviews (Ouzzani et al., 2016). � validity, The primary review author reviewed the title and abstract of � reliability, each record, based on the inclusion criteria. A random � responsiveness or sensitivity to change, and sample of 25% of these records was independently reviewed � interpretability. by a second review author. Second review authors reviewed 100% of the first reviewers’ decisions. Full texts of all poten- Following these quality assessment steps, we sought the tially relevant articles were obtained and reviewed. Duplicate views of the advisory group on the following criteria: records were removed through each subsequent database search and on further checking. Figure 2 presents the � simple and easy to use, PRISMA (Preferred Reporting Items for Systematic � child-focused, Reviews and Meta-Analyses) flowchart of the evidence selec- � able to be used throughout the organization (from the tion process. front door to long-term work with children and their families), and functional for different service areas, Data Collection and Analysis � identifies the type of support needed, and � designed for the needs of families and of the profes- Data Extraction. We extracted data from retrieved articles and sional/organizational system. studies using a piloted data extraction template designed for this review. The template consisted of (a) face validity, (b) key properties and risk of bias, (c) diagnostic accuracy Missing Data. The effect of missing data was assessed under testing, and (d) desired properties (developed from the recom- risk of bias. There were two missing results in Trocme’s mendations of the advisory group, to ensure practice study, and these were judged unlikely to have significantly relevance). altered the study’s findings. Haworth et al. 7 Figure 2. PRISMA flowchart. 8 Research on Social Work Practice 0(0) codes to two types of alternative classification systems—the Collaborative Approach MMCS and the National Incidence Study 2 (NIS-2) (the This review adopted a collaborative approach with practice NIS-2 is a further research tool, not meeting our inclusion cri- partners, Birmingham Children’s Trust. User involvement teria). The outcomes measured were those reported by has been in the form of advisory and stakeholder groups. Dubowitz et al. (2005). Mennen et al. (2010) used the same For this review, “user” has been defined as a social worker, approach to reclassify neglect and maltreatment, and to the individual using the neglect measurement tools. The advi- measure co-occurrence in 9- to 12-year olds in the care sory group consisted of nominated social work staff from system. Birmingham Children’s Trust and gained the views of Trocme’s (1996) study was the smallest, focusing on 127 service users recruited through the Trust. This was achieved consecutive “intake” investigations. The sample population through social workers seeking their views and subsequently for the Dubowitz et al. (2005) and Runyan et al. (2005) sharing these with the group. The stakeholder group also studies were children and their primary carers from four includes key academics in the field, services users, and research sites in eastern, southern, midwestern, and north- social workers from other organizations. The additional western parts of the United States. These sites differed in element of user involvement has been used previously by terms of sample populations, with some children at risk for, other systematic reviews (Hyde et al., 2017; Oliver et al., and some having suffered maltreatment. Cases were 2014; Pollock et al., 2015). described as routine CPS cases; these were collected and The review has been conducted at the participation level on reclassified by research staff, not social workers. Mennen Arnstein’s (1969) Ladder of Citizen Participation. There were et al.’s (2010) study focused on 303 cases of children identi- four advisory group meetings, where responsibilities, including fied as maltreated by a public child welfare agency. idea generation on the quality and relevance of measures, were shared. Their involvement helped orient the review and promote the relevance of findings (Esmail et al., 2015). Study Designs. The four studies that met our inclusion criteria all used variations of cohort study designs. Dubowitz et al.’s (2005) and Runyan et al.’s (2005) studies included follow-up Results data, whereas Mennen et al.’s (2010) and Trocme’s (1996) In total, 5,109 records were reviewed. Just four studies met stand-alone studies did not. our inclusion criteria (Figure 2). We were unable to access Trocme’s (1996) study incorporated a two-stage process. 12 studies, which are described in Table 1. For one of these Stage one involved gaining expert views on index construc- references, we were able to find the data in an alternative tion from practitioners in the child welfare field. Stage two article. We made requests through our institution and the involved field testing within a social work setting. British Library for all articles written in English. Classification of neglect using the CNI was compared to mal- treatment classifications of the NIS child protection worker survey form. Concurrent validity was assessed against 14 Description of Included Studies neglect-related scales from the Child Well-Being Scales Study Characteristics. There were four cohort studies reviewed (CWBS) (n= 125 for each scale). Test–retest reliability was and analyzed, all based in high-income countries (Canada and assessed by workers completing the tool twice within a the United States): a study by Trocme (1996) on the Child 2-week period. Neglect Index (CNI) and studies by Dubowitz et al. (2005), Dubowitz et al. (2005) examined 481 CPS records to Runyan et al. (2005), and Mennen et al. (2010) on modifica- determine how the MMCS, capturing six subtypes of tions of the Modified Maltreatment Classification System “failure to provide,” three of “lack of supervision,” and fre- (MCS or MMCS). The studies were completed between quency of reports of each, compared to two CPS classifica- 1996 and 2010 and in total included 1,715 cases. The children tions of neglect defined as “general neglect” and “caregiver in these studies were all considered at risk or having suffered absence.’ They also examined how well the categories and harm. Table 2 sets out the key characteristics of these studies. subcategories of each predicted a range of child outcomes Whereas Trocme’s (1996) study aimed to develop a short, ascertained at the age of 8 years from a set of standardized valid, and reliable measurement instrument for the type and measures for all 740 children. Runyan et al. (2005) attempted severity of neglect in Canada, Dubowitz et al.’s (2005) and to answer two questions. First, how did MMCS classifications Runyan et al.’s (2005) studies formed part of a larger longitu- compare with CPS and NIS-2 classifications of the main child dinal study in the United States examining antecedents and maltreatment categories of physical abuse, sexual abuse, outcomes of child abuse and neglect. Dubowitz et al. neglect, or emotional maltreatment and second, how well (2005) used the MMCS to retrospectively rescore and reclas- did the various categories of abuse predict child problems at sify neglect from CPS records. Runyan et al.’s (2005) com- the age 8 years. Mennen et al. (2010) extended the MMCS panion paper compared the concordance of the main types tool to also include caretaker incapacity and child “at risk” of child maltreatment classifications defined by CPS’ official from neglect and/or abuse. Haworth et al. 9 Table 1. References not Reviewed. Author Reference Reason Comment Berube et al. Berube, A., Lafantaisie, V., Coutu, S., Dubeau, D., Caron, J., Unable to Title and abstract suggest absence of (2015) Couvillon, L., & Giroux, M. (2015). Elaboration d’un outil access comparison with social work ecosystemique et participatif pour l’analyse des besoins des assessment enfants en contexte de negligence: L’outil Place aux parents [Development of an ecosystemlc and participatory tool for the analysis of children’s needs in the context of child neglect: The experience of Place aux parents]. Revue de Psychoéducation, 44(1), 105–120. Gaudin et al. Gaudin, J. M., Polansky, N. A., & Kilpatrick, A. C. (1992). The Unable to Title and abstract suggest absence of (1992) Child Well-Being Scales - A Field Trial. Child Welfare, 71(4), access comparison with social work 319–328. assessment Polansky et al. Polansky, N. A., Cabral, R. J., Magura, S., & Phillips, M. H. (1983). Unable to Title and abstract suggest absence of (1983) Comparative norms for the Childhood Level of Living Scale. access comparison with social work Journal of Social Service Research, 6(3), 45–55. assessment Polansky et al. Polansky, N. A., Chalmers, M., Buttenweiser, E., & Williams, Unable to Title and abstract suggest absence of (1978) D. (1978). Assessing Adequacy of Child Caring: An Urban access comparison with social work Scale. Child Welfare, 57(7), 439–449. assessment Polansky and Polansky, N. A., & Pollane, L. (1975). Measuring Child Adequacy Unable to Title and abstract suggest absence of Pollane (1975) of Child Caring: Further Developments. Child Welfare, 54(5), access comparison with social work 354–359. assessment Polansky et al. Polansky, N. A., Gaudin, J.M., & Kilpatrick, A. C. (1992). The Unable to Title and abstract suggest absence of (1992) Maternal Characteristics Scale: A cross validation. Child access comparison with social work Welfare: Journal of Policy, Practice, and Program, 71(3), 271–280. assessment Trocme (1993) Trocme, N. M. (1993). Development of an expert-based Child Unable to Data extracted from Trocme (1996). Neglect Index: Making social work practice knowledge access explicit. Dissertation Abstracts International Section A: Humanities and Social Sciences, 53(12), 4478. Pasian et al. (2015) Pasian, M. S., Bazon, M., Pasian, S., & Lacharite, C. (2015). Foreign Title and abstract suggest absence of Negligencia infantil a partir do Child Neglect Index aplicado no language comparison with social work Brasil [Child neglect based on the use of the Child Neglect assessment Index Applied in Brazil]. Psiclogia. Reflexeao e Critica, 28(1), 106–115. Picornell (2004) Picornell, L. A. (2004). Model of definitions for situations of Foreign Title and abstract suggest absence of child-juvenile neglect. An instrument for strategic planning. language comparison with social work Portularia: Revista de Trabajo Social, 4, 277–285. assessment Vandevoorde Vandevoorde, J. (2013). Checklist for the assessment of children Foreign Title and abstract suggest absence of (2013) and adolescents at risk of abuse. Neuropsychiatrie de l’Enfance language comparison with social work et de l’Adolescence, 61(6), 371–378. assessment Valencia (2010) Valencia, E., & Gómez, E. (2010). An eco-systemic family Foreign Title and abstract suggest absence of assessment scale for social programs: Reliability and validity of language comparison with social work NCFAS in a high psychosocial risk population. Psykhe, 19(1), assessment 89–103. Vezina (1992) Vezina, A., & Bradet, R. (1992). Validation quebecoise d’un Foreign Title and abstract suggest absence of inventaire mesurant le bien-etre de l’enfant [Validation of the language comparison with social work Child Well-Being Scales (CWBSs) in Quebec]. Science et assessment Comportement, 22(3), 233–251. All four studies met our gold standard comparison with a MMCS tool and NIS-2 data, with the MMCS viewed as their social work assessment through different routes: Trocme’s gold standard. For these three studies, comparisons were (1996) study through the social workers completing the CNI made between CPS classifications decided by CPS workers when they completed their standard assessment reports; and reclassifications of narrative data by trained research assis- Dubowitz et al.’s(2005) and Mennen et al.’s(2010) studies tants, not social workers. through comparing a modified MMCS with CPS records of assessments by child protection workers; and Runyan et al.’s Types/Subtypes, Severity, and Chronicity of Neglect. Our review (2005) study through CPS data being compared to the focuses on six subtypes of neglect: emotional, medical, 10 Research on Social Work Practice 0(0) Table 2. Characteristics of Included Studies. Population description Social Work Author and Population Children’s Referral Reasons/Risk Parental Risk Date Measure (Index Test) Brief Description Type of Neglect Assessed Comparator/Control Country Setting (Type, n) Subject (n) Children’s Age Circumstance Factor Protective Factor Factor Other Risk Factor Trocme Ontario Child Neglect Short tool for assessing Supervision 1. Maltreatment Canada 1 large Ontario urban 5 "intake" 127 consecutive "intake" Mean age of 7 56% single parent Referred for variety Not reported 45% cases Not (1996) Index (CNI) type and severity Food/nutrition classifications of the child welfare workers, so investigations. years old family. concerns: Physical abuse referred for reported neglect Clothing/hygiene National Incidence agency duty and Average of 1.8 35% Canadian, 22% (19%), Sexual abuse "parent Medical care Study (NIS) child assessment children per family Asian, and 27% (14%), Neglect (11%), behaviour" Mental health care protection worker workers West Indian Parent behavior (45%), under Development/educational survey form and Child behavior (7%) Ontario’s care 2. Neglect-related scales 31% cases previously system (no from the CWBS for opened, 39% open more more details concurrent validity. than 6 months provided) n = 125 for each scale Dubowitz Modified 1.To compare neglect Failure to provide: CPS classifications of USA Part of the Longscan Routine 740 children aged 8 Children were Children taking part in 1. Taken into early foster Not reported Parental risk Risks differed et al. Maltreatment Classification defined by CPS official Food neglect defined as longitudinal narrative CPS years, as part of the interviewed Longscan care (around half factors between the (2005) System (MMCS) codes with neglect Medical “general neglect” and cohort (Longscan) data, Longscan longitudinal between longitudinal cohort returned to family varied four sites and defined by a review of Clothing “caregiver absence.” n study of “children collected by cohort (Longscan) the ages of before the age of 4 between the within the sites CPS narrative data Shelter = 481 for valid CPS at risk” research staff, study 4 and 8 years) four included Regression using MMCS Hygiene records reclassified by MMCS was compared years 2. Children reported to sites analyses were 2. To compare the neglect Sanitation research staff to CPS classifications CPS before the age of 5 controlled for categories at predicting Lack of supervision: only in the 481 years, with substantiated age, gender, a range of child Supervision children with CPS or unsubstantiated race, income, outcomes ascertained Environment records cases, and judged at site, and at age 8 from a set of Substitute care “moderate risk” for subtypes of standardized measures future maltreatment neglect 3. Children born in hospitals involved in a programme for babies of families with high risk medical or social factors 4. Low-income family children recruited from paediatric clinics with either nonorganic failure to thrive, mothers at risk of HIV infection, or neither (i.e., a comparison group) (continued) Haworth et al. 11 Table 2. (continued) Population description Social Work Author and Population Children’s Referral Reasons/Risk Parental Risk Date Measure (Index Test) Brief Description Type of Neglect Assessed Comparator/Control Country Setting (Type, n) Subject (n) Children’s Age Circumstance Factor Protective Factor Factor Other Risk Factor Runyan MMCS; Companion paper to Reclassification of CPS CPS records with only USA Comparisons Routine CPS 545 children and their Children were Children taking part in As shown in Dubowitz et al. Not reported As above As above et al. National Incidence Study 2 Dubowitz et al. (2005) records by researchers one single between data by SWs, primary caregivers interviewed Longscan (2005) above (2005) (NIS-2) To compare into predominant maltreatment classifications by collected by who were assessed at at ages 4 longitudinal cohort concordance of MMCS maltreatment type— classification of CPS workers and research staff, ages 4 and 8 and had and 8 reclassification of the physical abuse, sexual physical abuse, sexual reclassifications of reclassified by lifetime CPS reviews predominant type of abuse, neglect, or abuse, neglect, or narrative data by research staff up to age 8, child maltreatment emotional maltreatment. emotional abuse trained research maltreatment reports defined by CPS to Using an algorithm for assistants before the age 8 official codes and NIS-2 cases with multiple types Interview and CPS reclassification of maltreatment searched and reviewed before age 8 interview Mennen Maltreatment case records To compare neglect Reclassification of records by 303 child welfare USA Large public welfare Routine 303 cases Children aged 3 ethnic groups (Latino, 136 sibling cases and 167 “Substantiated Not Not et al. abstraction system defined by CPS official researchers into type of records of new agency; narrative CPS 9–12 years African-American, non-sibling cases referrals (i.e., reported reported (2010) (MCRAI) codes with neglect and abuse or into the 11 reports of longitudinal data, or Caucasian), report of Longitudinal cohort study abuse defined by a categories of neglect—the maltreatment cohort study of collected by resident in selected maltreatment)” review of CPS nine MMCS definitions of effects of retired CPS postcodes in Los narrative data using neglect used by Dubowitz maltreatment on supervisors, Angeles MCRAI, (a further et al. (2005) (above) plus adolescent reclassified by modification of MMCS) two extra categories of development research staff caretaker incapacity or “substantial risk” of abuse and/or neglect Note. CWBS= Child Well-Being Scales CPS= child protection services; NIS-2 =National Incidence Study 2. 12 Research on Social Work Practice 0(0) physical, educational, social, and lack of supervision or guid- maltreatment were included, resulting in 35% of records ance. No tool assessed all of these, but the CNI assessed being excluded. This left the study open to selection bias. medical, physical, and educational neglects, as well as lack The number of CPS negative/MMCS positive, or CPS nega- of supervision and guidance. Emotional neglect was partially tive/NIS-2 positive, could not be ascertained. The exclusion measured under “mental health care,” but social neglect was of multiple maltreatment cases and manner of reclassifica- not captured. Neglect severity was measured, but chronicity tions into one subtype left the study open to measurement was not. The tool would be easily repeatable for measuring bias. Within the study, being placed lower down their hierar- the change in cases, but the age-weighted component would chy of abuse (as follows: sexual abuse, physical abuse, have to be disregarded. neglect, and emotional abuse) translated into being less The MMCS measured medical and physical neglect, and likely to be classed as the predominant type of abuse. lack of supervision or guidance. Facets of neglect severity Trocme (1996) recognized that the assessment of neglect is and chronicity were captured, but only partially, in complex, but provided a limited discussion of potential con- Dubowitz et al.’s (2005) study. No data on severity or chro- founding factors. The child’s age was considered in the nicity was provided in Runyan et al.’s (2005) study. CNI, with higher scores added to the index for younger chil- Additionally, the MMCS would not be easily repeatable for dren but confounding factors such as worker issues, family measuring the change in cases, as it takes considerable time issues, difficulty disaggregating neglect from poverty, or and effort to complete. issues in the NIS and CWBS tools against which the CNI was validated were not discussed. Dubowitz et al. (2005) also recognized the complexity of Quality of Evidence and Risk of Bias of Included assessing neglect, but no data were provided on other types Studies of potentially co-existing maltreatment. For example, there There was no selection bias identified in the Trocme (1996) was no assessment of differences in outcomes between chil- study: it contained 127 consecutive intake cases. Two dren remaining in foster care and those who returned home, missing results were judged unlikely to have significantly which may be a confounder for children’s problems. altered the findings. The tool is simply designed and there Table 3 sets out the overall quality of the evidence of the is no reason to suspect any other measurement bias. included studies. However, validity assessment against the NIS classifications was not blinded: repeat CNI and CWBS assessments were Validity and Reliability of Included Studies completed by the same worker up to 2 weeks later, raising the possibility of these being influenced by social work case The results in Trocme’s (1996) study indicated that the CNI decisions. Trocme (1996) provided no information as to has face validity. It is specific for neglect and measures whether the CNI score influenced workers’ decisions. It is neglect type and severity. The MMCS tool also appeared to possible that Trocme’s results were influenced by the have face validity. It measures neglect and Runyan et al.’s results of the reference tools. (2005) results indicated specificity for neglect. There was variation in the sample population within The CNI was developed with the input of an expert panel Dubowitz et al.’s (2005) study, some with CPS records (n= and tested in practice. However, Trocme (1996) relied on 481) and some not (n= 259). However, all children used for practitioners’ substantiation and intervention criteria for comparison had CPS records. Sixty-five children were neglect and Ontario’s legal definition of neglect (Ontario excluded from the sample mostly because of omissions in Child and Family Services Act, 1984), meaning the under- data, but the number of children lost to follow-up was standing of neglect was context-specific. Academic and unstated. Records were retrospectively re-coded using the service user perspectives were not included. The MMCS or MMCS by trained research assistants, but separate simultane- a further variation was applied retrospectively by Dubowitz ous coding by social workers using the MMCS independently et al. (2005), Runyan et al. (2005), and Mennen et al. and blind of CPS findings was not carried out. It is possible (2010), and its development was not discussed. that more cases may have been classified as neglect using Cross-cultural factors were not discussed by any authors. MMCS than through the CPS definitions. There was therefore The CNI was tested against the NIS and CWBS which potential for selection bias. Mennen et al. (2010) counted the have not been evaluated as part of this review, but as with number of children classified and not classified as subject to other abuse/neglect measurement tools, both have their own neglect by experimental and control methods, meaning that weaknesses and limitations. Concurrent validity scores were selection bias was limited only by willingness to take part generally good for the CNI. The CNI correlated with the in the study. CWBS overall (inverse correlation 65%), with only the To compare CPS classifications with MMCS and NIS-2 CWBS parent stimulation scale not correlating. Trocme codes, Runyan et al. (2005) re-coded CPS data for each mal- (1996) compared the predictive validity of CNI and CWBS treatment report into MMCS and NIS-2 codes. Only those scores with the decision to provide ongoing child welfare ser- CPS records with a single, valid CPS classification of vices. Table 4 sets out the properties of the included measures Haworth et al. 13 Table 3. Overall Quality of Evidence. Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment Trocme Concurrent Comparison: 78 cases of neglect None found (two Results of Liable to CNI results could Only age was None beyond 2 No data NIS is not a High (1996) comparison of 1. NIS* Child using NIS had a missing results neglect score measurement bias have influenced discussed or weeks after provided standardized likelihood methods in the Protection CNI score M= unlikely to using the CNI The same social other taken into intake on range of measure for of bias same cohort of survey form 48, 27 cases of no substantially were workers all test outcomes, for account The test was scores or neglect, and has (low level consecutive completed by neglect had a CNI affect overall compared with the same example., intended to variation— undergone later of intake cases, the social score M= 21 findings) with results of children, so no overall substantiate no data to revisions certainty) with no workers (p < .0001). scores using blinding was caseworker neglect not enable Applicability of follow-up 2. Standard Indicating CNI is the NIS possible decisions on to predict assessment this as a control undertaken assessment of specific for child Inter-reliability was whether to risk of is uncertain beyond 2 whether to neglect. No assessed by keep the case precision weeks keep the case cut-off scores Trocme and SW open (used as open were suggested supervisor an assessment 3. elected items “Good” correlation checking SWs’ of CNI from the with CWB Scales case notes—so performance) CWBS (0.65), higher with not completely and scoring of most individual independent of subsections of scales original the CWBS Mean scores assessment used to assess significantly higher validity of the for cases kept tool open than for Mean values for closed cases (45 addition of two vs. 31, p < .001) separate Test–retest ordinal values reliability from the Statistical text was 86% methods overall (weighted unclear kappa 0.86, with individual scores 0.83–0.91) Inter-reliability ranged from 88% to 91% (based on reassessment of case worker notes) Dubowitz Part of a Used CPS 1. Correlations Main problems: Effect of other maltreatment No data Unable to et al. longitudinal records with between the two 1. Retrospective, types of child not taken provided quantify. (2005) cohort study, assessments coding methods non-blinded into account on p-values were with CPS by child ranged coding for MMCS attrition (continued) 14 Research on Social Work Practice 0(0) Table 3. (continued) Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment records protection small-large, but scores rates for provided, but (narrative workers as were generally 2. No data on follow-up no SDs or CIs documenting comparison moderate confounding by assessment of allegation) 2. Correlation of other types of at the age reclassified MMCS with child co-existing of 8 years retrospectively behavior maltreatment by study problems at the 3. Variation in personnel age of 8 years, as population (all assessed by included children "standardized had CPS records) measures" or checklists for children and parents (not appraised in our systematic review) (n= 740 children) Retrospective High level of re-coding— bias, low level not applicable of certainty to routine assessment Population characteristics not necessarily comparable to other populations Runyan Part of a Used CPS After reclassification Very high level of As above Exclusion of CPS Very high et al. longitudinal records with of type of selection bias: But also: records with likelihood (2005) cohort study, assessments maltreatment by only those CPS Reclassifications multiple of bias with CPS by child original CPS records with a into just one maltreatment Very low records protection designation and single, valid CPS predominant type classifications certainty (narrative workers as MMCS classification of of maltreatment: excludes of documenting comparison, re-designation, maltreatment high risk of accurate evidence of allegation) but data were MMCS were included measurement bias estimation reclassified manipulated classification Out of 1,980 Hierarchy of retrospectively to only agreed with CPS reports, 717 maltreatment account for for 82% of (36%) were type, although in (continued) Haworth et al. 15 Table 3. (continued) Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment by study the physical abuse, excluded. 387 use at the time, is personnel “predominant 90% of the SA were excluded also questionable type” of child cases, 82% of for having no valid maltreatment neglect and only CPS allegation 37% of emotional type codes, 167 abuse for having Results suggested multiple types of that large number maltreatment. of cases recorded 163 were as neglect by CPS excluded because were “false no valid MMCS positives” could be coded. Using this This leaves the methodology CPS study open to was 82% sensitive selection bias. for neglect and Numbers of cases 76% specific, that may have compared to been CPS MMCS with an negative but 83% positive MMCS positives predictive value of for neglect cannot MMCS be ascertained Emotional abuse was reported poorly classified by CPS —with a sensitivity of 16%, specificity of 99% and PPV of 87% compared to MMCS Mennen Part of a Used CPS MCRAI method Participants were Data provided CPS retired 136 of the 303 No follow-up No data High et al. longitudinal records with classified 215 children and their indicate that supervisors cases were reported provided likelihood (2010) cohort study, assessments cases (71%) as carers who had CPS practice abstracted CPS in sibling on range of of bias with CPS by child neglect compared already been may have data and research groups scores or Low level of records protection to CPS records of reported and who been to workers carried variation— certainty (narrative workers as 124 (41%) accepted an record the out re-coding no data to documenting comparison p < .001 invitation to take main form of Researchers may enable of allegation) MCRAI additionally part in the study abuse or have been keener assessment reclassified captured multiple No comparison data neglect as to report neglect (continued) 16 Research on Social Work Practice 0(0) and, as highlighted in Table 43, mean scores were higher for open than for closed cases. By comparison, the differences in the CWBS scores were very small. Structural validity is reported in Table 4. The MMCS was tested against the NIS-2. There was a kappa score of 0.743 for agreement between the MMCS and NIS-2 codes for neglect and a predictive value of 94% for the NIS-2, suggesting that the MMCS classification would also be neglect. Each MMCS neglect subtype was moderately correlated with CPS “general neglect.” There was limited or no correlation between MMCS subtypes and CPS “caregiver absence.” The findings were that the MMCS had an 83% positive predictive value for neglect. MMCS classification agreed with CPS for 82% of physical abuse, 90% of sexual abuse, 82% of neglect, and only 37% of emotional abuse cases. Structural validity of the MMCS is highlighted in Table 4. Trocme (1996) provided partial data on reliability, as shown in Table 4. No data for the reliability of the MMCS over time were provided in either Dubowitz et al.‘s (2005) or Runyan et al.‘s (2005) studies. Dubowitz et al. (2005) and Runyan et al. (2005) found a 90% inter-rater reliability between assessors, with Runyan et al.’s score measured after training had been provided. Mennen et al.’s (2010) study provided limited data to add to our review. No data were provided on the range of, or variation between, scores using the CNI, resulting in no data to enable assessment of precision. It was not possible to assess the precision of the MMCS from Dubowitz et al.‘s (2005) study. They provided p-values for study outcomes, but no SDs or confidence intervals. Runyan et al.’s (2005) study pro- vided data for sensitivity, specificity, and positive predictive values. These suggested that a large number of cases recorded as neglect by CPS records were “false positives.” CPS scores were slightly more sensitive than MMCS scores in predicting child outcomes. The Runyan et al. (2005) study completed a regression analysis for outcomes measured in the Dubowitz et al. (2005) study and each of the classification systems. However, due to the methodology used, we have not rated the prospective validity of the study high enough to warrant detailed analysis. How the Tools Perform Against our Desired Characteristics We tested for the desired characteristics in a neglect measure- ment tool, based on the views of the advisory group as stated previously. Table 5 sets out the applicability of each tool for social work. The CNI is a short tool that appears simple to administer and comprehensible, whereas the MMCS does not meet these criteria (Table 5). Dubowitz et al. (2005) state regarding use of the MMCS that “findings in the present study do not support the considerable time and effort involved in Table 3. (continued) Study Study Design Measurement of Outcome Confounding Accuracy/ Overall Author Evidence Gold Standard? Results Selection Bias Neglect Measurement Bias Measures Factors Follow-up Precision Generalizability Assessment retrospectively types of neglect as provided on very few than social of by study well as those who instances of workers precision personnel co-occurrence of declined to take co-abuse Unit of analysis was physical, sexual, or part were each report not emotional abuse, recorded each child caretaker incapacity and substantial future risk Note. CNI = Child Neglect Index; CPS = child protection services; CWBS = Child Well-Being Scales; MMCS = Modified Maltreatment Classification System; NIS=National Incidence Study. Haworth et al. 17 abstracting and coding CPS records, at least for studying the the best evidence of the effectiveness of tools or measures frequency of reported types and subtypes of neglect” (p. 508). for the assessment of child neglect. Comprehensibility for social workers was not tested in any This review revealed the limitations of the evidence base of the included studies. Trocme (1996) recognized that due to for social workers to assess child neglect. The overall evi- the CNI’s brevity, accuracy and comprehensiveness could be dence base for measures of child neglect can be considered questioned, but also stated with some justification that “… weak. The most significant finding of the review is the lack brevity of the CNI may simply reflect our limited knowledge of rigorous testing of potential measures for assessing child of the characteristics of neglect and the lack of consensus neglect. There is a paucity of high-quality evidence and about underlying constructs” (p. 150). The CNI performed robustly tested tools, with studies of “popular” tools lacking well against the lengthier CWBS tool. The MMCS is a methodological rigor and robustness. This raises significant more detailed tool than the CNI, but covers fewer subtypes issues for social work assessments of neglect and the in this review’s neglect typology, which raises questions impact of child neglect means that the lack of valid, usable, about its comprehensiveness. and reliable measurement tools is a significant concern. In The CNI focuses on substantiating neglect rather than sum, only four studies met the inclusion criteria, with only future risk. Neglect is assessed as categories ranging from one tool, Trocme’s CNI, considered simple enough to feasi- adequate to seriously inadequate, with scorings applied, bly be used in practice. whereas the MMCS simply assesses neglect as present or The findings suggest the need for robust testing of neglect absent. As shown in Table 5, the CNI appears to have more measures in social work settings. Robust testing is important potential to be used across the stages of children and families for the development of tools that can satisfy the criteria of social work than the MMCS. validity, reliability, and practice/clinical utility. Child protec- The MMCS questions primary carers and children, while tion social workers’ time with children and families has been Trocme (1996) does not state who the CNI questions. None reduced through the COVID-19 pandemic, with in-person of the studies reported acceptability of the tools to children home visits becoming less frequent and shorter (Ferguson and families. Potential benefits, harms, and false positives et al., 2020). This change in practice accentuates the need and negatives were not reported by Dubowitz et al. (2005) for assessments to be focused and feasible in terms of time or Trocme, but the CNI and MMCS are neglect-specific. and resources. Because of these changes and issues, it is Runyan et al. (2005) did report false positives, but the timely to develop a new evidence-based, short, and results were vulnerable to measurement and selection easy-to-administer child neglect measurement tool. biases. Runyan et al.’s (2005) results would not be reliable Analysis revealed the gaps between the two included tools, for neglect if other types of maltreatment were also present. the CNI and MMCS. The tools conceptualize and measure child neglect very differently, reflecting wider issues and imprecision around how neglect is defined and understood, Excluded Studies but both present clear omissions and weaknesses. The CNI was designed for simplicity and brevity, while the MMCS Due to the small number of studies that met the inclusion cri- was more complicated and cumbersome. The CNI captured teria for this review, and to promote the review’s rigor and a greater range of neglect subtypes identified in this review, transparency, we thought it important to discuss studies one but certainly not all of them. Notably, neither tool covered might plausibly expect to find among the included studies, social neglect. Assessments that do not examine social such as well-known neglect measurement tools, and studies neglect are not as holistic as would be preferred. The CNI cap- that on the surface met the eligibility criteria, but on further tures neglect severity and recognizes that neglect should not inspection did not (Page, Cumpston, et al., 2020; Page, be assessed dichotomously as present or absent, but neither McKenzie, et al., 2020). Three studies were of significant tool effectively captures chronicity. Severity and chronicity interest but did not meet the inclusion criteria. They are are both key features of neglect for children’s social work, shown in Table 6. given that children’s services often become involved in situ- ations of chronic and severe neglect (English, 1997). The CNI could at best be considered partially effective in measuring Discussion and Applications to Practice neglect. Trocme’s (1996) study did not discuss cross-cultural The aim of this systematic review was to examine neglect factors and transferability to the UK context would need to be measurement tools that may be useful for children’s social tested. The MMCS would not merit testing, due to the time work. We examined the published and unpublished reports and effort needed to complete it being unfeasible in practice. against strictly defined criteria of population, tool focus As reported in the results section, there are significant con- (neglect), evidence type, and comparison to a defined gold cerns about the quality, validity, and reliability of the included standard. We further examined the validity, reliability, and studies. The findings of this review resonate with previous quality of the evidence base and key features of reviewed research by Yoon et al. (2021a), Vial et al. (2020), and tool’s usability and feasibility in practice. We synthesized Saini et al. (2019) into child maltreatment. As discussed 18 Research on Social Work Practice 0(0) Table 4. Properties of Included Measures. Sensitivity to Neglect Validity Reliability Severity Chronicity Change Structural Validity Does it Record Is it Easily Relevance/ Across Items in Does it Measure How Long the Repeatable in Type of Actual Face Test (Scale Between Degrees of Neglect Has Been Order to Measure Measure Neglect Measured Validity Comprehensibility Comprehensiveness Overlap) Cross-Cultural Concurrent Prospective Assessors Across Time Severity? Taking Place? Change? Ontario Child Supervision, Cited as 6 subscales, each scored Good Psychological and Not reported 46 cases classified as Cases kept open Inter-rater Not known. The scale ranges No Scores for a Neglect Physical care good 0–60 for severity. The Developmental neglect but not by social reliability CNI was from theoretically Index (CNI) (Food/nutrition overall score combines Care Scales abuse had a CNI workers had a (87 cases completed Adequate to constant level of (Trocme, and clothing and the score from the correlated score M= 49; 26 CNI score M rated by twice by Seriously neglect would 1996) hygiene), scale with the highest above 0.50, classified as abuse = 45; cases supervisor intake Inadequate decrease as the Provision of severity rating and an rest below 0.35 but not neglect had a closed had a and author) workers for each type child ages health care age score ranging from CNI score M= 21 CNI score M was 88% to within a of neglect To measure (Physical, Menta,l 20 points for the ages 78 cases with neglect = of 31 91% (but 2-week measured change, the and of 0–2 years down to 0 (with or without (p < .001) based on period. age-weighted Developmental, points (aged 13–16) other maltreatment) CWBS scores supervisor Average component and Educational Maximum CNI score had a CNI score M = were M= 82 and author 86% would have to care) would be 80 of 48, 47 classified as for those kept using reliability be disregarded (Anticipation and Appears simple and easy having no neglect had open, M= 88 workers’ (0.86 response to to understand a CNI score M= 21 for cases case notes) weighted child’s emotional (p < .0001) closed kappa) needs classified Overall correlation (p < .03) with health care) between CNI and CWBS was good (inverse correlation of 65%) Correlation for individual subscales: 49% for developmental/ educational care and CWB scale parental teaching/stimulation, > 70% for remainder MMCS "Failure to provide": Has face Carried out by trained Emotional, social, or Data suggest that Not reported Each of the individual After controlling Not reported Not reported Frequency of Counts frequency No (Dubowitz Food, medical, validity research assistants educational while individual MMCS subtypes was for child age, recorded of reports Coding was et al., clothing, shelter, No data on neglect not items are moderately gender, maltreatment carried out 2005) hygiene, comprehensibility for covered correlated with correlated with CPS ethnicity, type was used retrospectively sanitation and social workers in the each other, "general neglect" income, and as a Said to be very time "Lack of field they are (each between 24% site, MMCS substitute for consuming supervision": distinct and 54%, each with overall scores severity supervision, phenomena p < .001) had low environment, and No clear support Low/no correlation correlation substitute care for "lack of between individual with child supervision" MMCS subtypes and functioning* and "failure to CPS "Caregiver and were less absence" (clothing = predictive (continued) Haworth et al. 19 Table 4. (continued) Sensitivity to Neglect Validity Reliability Severity Chronicity Change Structural Validity Does it Record Is it Easily Relevance/ Across Items in Does it Measure How Long the Repeatable in Type of Actual Face Test (Scale Between Degrees of Neglect Has Been Order to Measure Measure Neglect Measured Validity Comprehensibility Comprehensiveness Overlap) Cross-Cultural Concurrent Prospective Assessors Across Time Severity? Taking Place? Change? provide" 22%, food= 19%, than the CPS typology supervision = 18%, designation each p < .001; sanitation= 9% and supervision = 10%, both p < .05. No correlation with medical/ environmental neglect) Mennen “Failure to Has face Carried out by trained Emotional, social, or Not reported Not reported No data No data Kappa scores Not reported Measures Duration and No. Coding was et al. provide": Food, validity research assistants educational for neglect frequency specifics can be carried out (2010) medical, clothing, No data on neglect not 0.75 not severity entered retrospectively shelter, hygiene, comprehensibility for covered For 13 neglect sanitation social workers in the items, "Lack of field kappa was supervision": 0.84, supervision, ranging environment, and from 0.55 substitute care to 1.0 “Caretaker incapacity” (absence/inability to care for child) “Substantial risk” of neglect and/or abuse (e.g., sibling is abused and/or neglected) Note. MMCS = Modified Maltreatment Classification System; CPS = child protection services; CWBS= Child Well-Being Scales. 20 Research on Social Work Practice 0(0) Table 5. Applicability for Social Work. Of Whom is Possibly be The Tailored to Does the Assessment Different Are Benefits and Measure Tool Service Areas, Harms Indicate the How Many Questioned? With Perhaps Reported? What Type of Hours of (e.g., Parents, Has Can it be Used Different is its Sensitivity Interpretability: Support that Training Carers, and Has Acceptability Comprehensibility Across All Stages Versions for and Specificity Categorical Outcomes? is Needed for What is Average Time are Children, Been Tested? If So, Been Tested? If So, of Child Different (False Positives Measure Cut-off Points? the Family? of Administration? Needed? Teachers) How? How? Protection? Teams? and Negatives)? No Not reported Not Not reported Authors cited a 1994 Not reported but Not reported, but Not reported Not reported CNI Each type of neglect (Trocme, receives its own reported survey of 285 appears simple and its simplicity but as 1996) severity rating randomly selected self-explanatory would suggest it previous Overall score child welfare could be used to column combines the workers using CNI assess changes in would seem highest reported modified to include individual types simple severity rating with other forms of of neglect enough to an age rating, to a maltreatment Care would need tailor and maximum score of High face validity in to be taken to adapt 80 training sessions, compare scores Originally a cut-off 89% response rate, before age score of 50 was and over 95% adjustment suggested (with completion rate limited clinical reported significance) but best used as severity rating without cut-offs MMCS Reported as presence/ No Not reported but Not Parents carers No data No Unlikely, due to Unlikely Not reported (Dubowitz absence for each findings "do not reported and children Incentives were time and effort et al., 2005) subtype of neglect support the provided to needed * considerable time compensate for and effort involved time spent in abstracting and answering the coding CPS records" questions Note. MCRAI (Mennen et al., 2010) is essentially the same tool as the MMCS, with two added categories. CNI= Child Neglect Index; MMCS = Modified Maltreatment Classification System. Haworth et al. 21 Table 6. Excluded Studies of Interest. Reason for Authors Tool Details Exclusion National/International Johnson & Graded Care Profile 2 Measures levels of care, used by Not assessed United Kingdom only Fisher social work and multi-agency against gold (2018) teams standard Glad et al. Home Observation for Focuses on assessment of home Not assessed Used in a variety of countries, (2012) Measurement of the environment and stimulation against gold including the United States, Environment (HOME) Predominantly used in health standard United Kingdom, and Sweden Inventory care, but can be applied to social work Kantor et al. Multidimensional Neglectful Comprehensive, focusing on Not assessed Used in a variety of countries, (2004) Behavior Scale Child Report cognitive, emotional, physical, against gold including the United States, and supervisory neglects standard Turkey, and France Tests revealed good reliability scores for use with older children earlier, their studies also found issues around validity, reli- Only 25% of identified records were independently reviewed ability, and usability, and suggested that the current evidence by a second review author; however, inter-rater agreement at base is not sufficient. this stage was greater than 90% and thus we do not see this as This review has a number of strengths. It has followed a significant limitation. Cochrane Collaboration recommendations (Higgins et al., It is reasonable that the findings from this review will be 2020) (adapted to the field of social work), providing a rigorous broadly generalizable to high-income countries. Although and systematic approach. We systematically searched a range of there is significant variation across time and between cultures multidisciplinary and science/social science electronic databases as to what is considered abusive (Munro, 2020), there are and search engines, as well as grey literature. Social work values international and cross-cultural aspects to the basic founda- and practice relevance have been promoted through the collabo- tions of neglect as an unmet need. However, caution should ration of an advisory group of practitioners. Development of a be adopted in generalizing the findings to countries with sig- template specifically for this review has enabled clear and nificantly different economic, social, and legal contexts. focused data extraction to answer the research questions. A mul- Variations in definitions of neglect between countries tistep approach to assessing study quality has promoted rigorous further complicate the practice landscape and create issues analysis. Finally, the review has set out clearly what measure- for a consistent approach to neglect measurement. ment issues are important and how to assess them. Given the current evidence base for neglect measures, Whiting et al. (2016) state that “bias occurs if systematic social workers should continue to undertake assessments flaws or limitations in the design, conduct or analysis of a based on established frameworks, such as the Framework review distort the results” (p. 226). We undertook steps to for the Assessment of Children in Need and their Families minimize bias throughout this review, including following (DoH, 2000). Current neglect measures are largely untested the protocol in full. This set clear eligibility criteria and laid and should be used cautiously. Until reliable, valid, and out robust methods for the review, including the risk of bias usable measures are available, social workers should of included studies being assessed by one review author conduct full detailed assessments and not rely on measures and checked by a second. The adoption of a team-based whose validity, reliability, and neglect specificity are not approach with Birmingham Children’s Trust was important robustly investigated. for lowering bias (Uttley & Montgomery, 2017). Assessment of need as opposed to a singular focus on As with any study, this review has limitations. Setting a assessing risks should be adopted in practice, as neglect can contemporaneous comparison to a social work assessment be understood as an unmet need (Daniel, 2015). A risk- as a gold standard and limiting the review to studies published focused approach fails to fathom the relationship between in English reduced the number of included studies. Further, it the wider economic, social, and community contexts influen- restricted the type of measurement instrument and excluded tial in neglect and practice, and can exclude effective assess- measures from linked professional fields such as health. ment of needs and support for these to be met (Bilson & Social work assessments can be of variable standards, Hunter-Munro, 2019; Warner, 2015). although the advisory group and existing guidelines indicated The current evidence based on measuring child neglect is that these remain the best tools currently available—thus we too limited to effectively inform practice. The significant cost contend that our review gives greater rigor in its approach. of neglect at personal, professional, community, and societal 22 Research on Social Work Practice 0(0) levels justifies the need for a thorough and robust research the diagnostic accuracy of the identification of abused children. BMC Pediatrics, 13, 202. https://doi.org/10.1186/1471-2431-13-202 project to develop a new child neglect measurement tool. Barlow, J., Fisher, J., & Jones, D. (2010). Systematic review of The study should be practice-informed and focussed on the models of analysing significant harm. Department for development of a tool that is accessible and useable in prac- Education. https://assets.publishing.service.gov.uk/government/ tice Therefore, the tool should be designed with, as well as uploads/system/uploads/attachment_data/file/183949/DFE-RR199. for, professionals and families. The development of an pdf evidence-based, valid, and reliable child neglect measurement Barlow, J., & Schrader-Macmillan, A. (2010). Safeguarding chil- tool, rigorously tested in practice, is likely to improve the dren from emotional maltreatment: What works. Jessica standards of social work assessments. Kingsley. Any future neglect measurement tool will need to pay par- Bilson, A., & Hunter-Munro, E. H. (2019). 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Journal

Research on Social Work Practice – SAGE

Published: Jan 1, 2024

Keywords: systematic review; child neglect; measurement; evidence-based practice; assessment

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