Denial of Critical Care/Child Neglect
Resmiye Oral, MD, Assistant Professor of Clinical Pediatrics
Director, Child Protection Program, University of Iowa Hospitals and Clinics
Spring 2004 

What is meant by "denial of critical care"?

The denial of critical care, or DCC, occurs when a child's caregiver, who is capable of or has the means to provide care, refuses to do so, and this refusal seriously harms or threatens to harm the child. Harm is caused by the failure to meet a child's basic needs for: 

Food and nutrition Shelter Clothing Supervision A safe environment Medical, dental, and mental health care Care in life-threatening situations Love and nurturing Medical care and religious beliefs. In Iowa, refusal of needed medical care on the basis of religious belief does not constitute child neglect. In this situation, a court order must be obtained in order to provide care regardless of the parents' religious beliefs. Such a court order may be granted if:

1. The treatment refused or not provided has substantial benefits over alternatives (for example, using insulin rather than prayer to treat diabetes)
2. Not receiving the treatment results in or presents risk of serious harm (for example, severe asthma attack, diabetic coma, kidney failure)
3. When treated, the child is likely to enjoy higher quality or more normal life

Forms of neglect 

Neglect may be physical, emotional, or educational. Some examples: 

• Physical neglect
  • Inadequate nutrition, failure to thrive
  • Inadequate supervision (can lead to frequent accidents, injuries such as burns, fractures, cuts; drug and toxin ingestion)
     
• Medical neglect
  • Failure to get needed health care, non-compliance with treatment recommendations to prevent or treat serious illness
  • Dental neglect resulting in oro-facial disorders that make eating difficult or impossible; cause chronic pain; or result in untreated pain, infection, bleeding, or trauma
     
• Emotional Neglect
  • Inadequate nurturing and protection
  • Chronic spouse abuse in the presence of child
  • Permitting inappropriate child behaviors such as chronic delinquency
     
• Educational Neglect
  • Failure to enroll child in school
  • Refusal to allow or failure to obtain recommended remedial education services
  • Failure to obtain or follow through with treatment for diagnosed learning disorders
  • Permitting chronic truancy

Prevention and intervention 

In most cases when a child has been neglected or denied critical care, intervention should focus on helping, rather than punishing, the family. Family preservation is the goal; intervention should be home-based.

Using the families' natural supports-family members and friends, church and peer support groups-to reduce social isolation may be a great help. Treatment recommendations should be as practical as possible. Advice should be communicated clearly, and follow-up provided to help the family implement a plan that includes:

A social worker, who will coordinate interdisciplinary efforts and monitor progress Health care providers, who can assist and guide social workers by reviewing medical records and keeping an eye on compliance with appointments and recommendations

• A psychological evaluation of the child that includes assessment of the child's development and emotional status
• An evaluation of the parents' ability to meet the child's needs
• Use of community resources like teachers and school nurses, who can be trained to assist the family by administering the child's health care and medications at school
• Involving parents in the care of the child as much as possible, in order to develop their parenting skills so that they can take full responsibility for their child's care in the long run

Ideally, intervention should be in place for 12 to 18 months. This has the potential to improve parental trust in social services, alter maladaptive family dynamics, enhance parent skills, and address associated factors like poverty. If, after 18 months and despite all intervention efforts, little progress is achieved and the family remains at high risk, an alternative long-term plan should be made for the care of the children. 

REFERENCES   

• Religious exemptions from child abuse statutes. Pediatrics 1988;81:169. 
• A conceptual definition of child neglect. Criminal Justice Psych 1993;20:8. 
• Community and professional definitions of neglect. Child Maltreatment 1998;3:235.