When Is Lack of Supervision Neglect?

BACKGROUND

Laws in all 50 states mandate that pediatricians report any suspicion of child abuse or neglect to the appropriate child protective services agency. Barriers to physician reporting include lack of knowledge and training, previous negative experiences with a child protective services agency, fear of damaging the relationship with the child's family, and fear of courtroom testimony.¹ There are no guidelines specifically designed to help pediatricians decide when to report suspected supervisory neglect.

In our society, parents, guardians, baby-sitters, and other designated caregivers* are expected to protect children from harmful people or situations. Nevertheless, epidemiologic studies confirm that many young children are injured in their own homes,^2,3 and inadequate supervision is cited frequently as a contributing cause.⁴ The extent to which adequate supervision protects children from injury or inadequate supervision increases injury risk remains largely undefined.^5–11 Furthermore, there are no established standards that define adequate (or inadequate) parental supervision across a wide variety of cultures and specific circumstances.^12,13

Under what circumstances should a pediatrician report a suspicion of supervisory neglect? Are parents neglectful only when an inadequately supervised child suffers harm? Or, can a parent be considered neglectful before actual harm occurs? There are no easy answers to these questions. Many pediatric injuries occur while a child is being supervised, and many poorly supervised children do not get injured. Injury risks in young children are related to their developmental capabilities.¹⁴ Certainly, the attention, proximity, and/or continuity of adult supervision necessary to protect an active toddler is vastly different from that required to safely monitor a responsible 10-year-old.⁵

The American Academy of Pediatrics believes that supervisory neglect occurs whenever a caregiver's supervisory decisions or behaviors place a child in his or her care at significant ongoing risk for physical, emotional, or psychological harm.

ADVICE FOR PEDIATRICIANS

1. In some jurisdictions, child protective services agencies promote or enforce age-specific guidelines for the supervision of children. Become aware of these guidelines (if any) in the local community and consider educating parents about them. Jurisdictional laws or guidelines may not reflect best practices for prevention of injuries.

2. Consider every allegation or suspicion of supervisory neglect individually.

3. If the information is available, carefully consider:

   1. whether the child has previously demonstrated an ongoing ability to execute appropriate judgments regarding his or her own behaviors;

   2. whether the child has any physical, developmental, genetic, behavioral, emotional, cognitive, or psychiatric disabilities;

   3. the length of time and the time of day that the child was inadequately supervised;

   4. the caregiver's reasoning and understanding of the situation;

   5. the inherent danger(s) of the child's unsupervised environment (eg, a young child left home alone, unattended in a car or bathtub, or with unrestricted access to a swimming pool);

   6. the child's level of discomfort regarding his or her unsupervised situation;

   7. the specific nature of the child's activities while he or she was left unsupervised (eg, age-appropriate play activities versus accessing pornography on the Internet, vandalism, or shoplifting);

   8. the child's knowledge of emergency telephone numbers†and procedures;

   9. the child's knowledge and use of protocols for safely answering the telephone and/or door when he or she has been left unsupervised;

   10. the child's accessibility to his or her parent or to another, specific, informed individual designated to be his or her caregiver;

   11. past allegation(s) of supervisory neglect or abuse involving the child and/or the child's caregiver;

   12. the physical, emotional, and mental capabilities of the designated caregiver (eg, a young baby-sitter or an elderly grandmother asked to care for too many children simultaneously);

   13. the number, ages, and maturity of the other children under the caregiver's supervision; and

   14. the age-appropriateness of the responsibilities given to the child.

4. Remember that some child injury risks are unpredictable or unavoidable; caregivers may underestimate the supervisory requirements for some children, and even the most careful caregiver may experience a brief lapse of supervisory attention, proximity, and/or continuity that leads to childhood injury. In these circumstances, counseling regarding child supervision may be an appropriate initial intervention.

5. Be mindful of the emotional burden a caregiver endures when a child in his or her care suffers a preventable injury.

6. When a reasonable suspicion exists that a pattern of caregiver decisions or behaviors have placed a child at significant ongoing risk for physical, emotional, or psychological harm, report the incident to the appropriate child protective services agency.

COMMITTEE ON CHILD ABUSE AND NEGLECT, 2005–2006

Robert W. Block, MD, Chairperson

Roberta Ann Hibbard, MD

Carole Jenny, MD, MBA

Nancy D. Kellogg, MD

Betty S. Spivak, MD

John Stirling, Jr, MD

LIAISONS

David L. Corwin, MD

American Academy of Child and Adolescent Psychiatry

STAFF

Tammy Piazza Hurley