CH A P TER 14

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Neglect

Kathryn L. Humphreys
Lucy S. King
Ian H. Gotlib

N eglect, the most prevalent form of child mal-

treatment, is often chronic in nature, pervasive
the infant’s experience with the world. In fact,
the attachment relationship serves as the prima-
in impact and, unfortunately, common both ry experience-dependent feature of the child’s
globally and in the United States. Of the more early life (Bowlby, 1982); the caregiver is re-
than 6 million children reported to child wel- sponsible for providing stimulation to the infant
fare agencies in the United States, over 75% of in every domain (e.g., physical, cognitive, emo-
identified victims were classified as neglected tional) necessary for the infant to learn about
(U.S. Department of Health and Human Ser- the world. Indeed, there is no period in human
vices, 2016). Yet despite its predominance development during which needs are higher
among the forms of maltreatment experienced than they are in infancy.
by children, we know the least about neglect From a neural perspective, “synaptogenesis,”
(Stoltenborgh, Bakermans-Kranenburg, & the process by which neurons connect to one
van IJzendoorn, 2013; Zuravin, 1999). In this another, occurs rapidly during the first years of
chapter, we discuss the importance of neglect life (Lexmond & Reeves, 2009). This period of
in early life and describe methodological chal- rapid change provides both opportunities and
lenges that have hampered our knowledge of vulnerabilities for the developing brain. Envi-
this form of maltreatment. We also discuss our ronmental input in early life sets the stage for
knowledge of the causes and consequences of neural connections throughout the lifespan;
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neglect, the potential for prevention and inter- conversely, a lack of appropriate environmental
vention, and promising next steps in the study stimulation reduces the number of neural con-
of neglect. nections, likely resulting in less effective learn-
Across mammalian species, a caregiver ing and development. Specifically, a low level
(often the mother) is responsible for caring for of appropriate environmental input can alter
and protecting offspring. Physical proximity to neurogenesis, cell migration, and synaptogen-
one’s caregiver is necessary for survival; human esis, and ultimately affect the neural functions
infants are completely dependent on their care- that drive learning and behavior (De Bellis et
givers for their safety and sustenance. Not only al., 1999). It is clear, therefore, that neglect in
do caregivers physically protect their offspring, infancy has profound effects (see Berens & Nel-
but they are also the primary gatekeepers for son, Chapter 3, this volume).

239
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 240 I I . R isk and P rotective F actors

Much of what we know about neglect (often results of the English and Romanian Adoptees
termed “maternal deprivation” in nonhuman Study (Rutter, Sonuga-Barke, & Castle, 2010).
animal research) and its impact comes from Supporting a sensitive period hypothesis, plac-
studies of rodents and nonhuman primates ing institutionalized children into enriched en-
(Brett, Humphreys, Fleming, Kraemer, & vironments at earlier ages is associated with the
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Drury, 2015). In the earliest work on this topic, best outcomes (Nelson et al., 2014).
researchers found that laboratory rodents placed Although findings of orphanage-based stud-
in an enriched environment performed better in ies are valuable, a significant limitation of these
terms of spatial processing and memory than investigations is that orphanage rearing does
did rodents in a standard and a comparatively not represent species-typical variation in chil-
deprived laboratory environment (Hebb, 1947). dren’s experiences. Though these studies clear-
This demonstration was followed by a great ly document that extreme neglect is harmful,
deal of experimental research in which the en- they provide little information about how varia-
vironments of the animals were carefully con- tion in environmental input in typical caregiv-
trolled. Virtually all of these studies indicated ing situations (i.e., family-based care) is associ-
that placing animals in “enriched” environ- ated with outcomes of interest. The experience
ments results in positive changes in the brain of institutional rearing differs from the experi-
and in behavior (van Praag, Kempermann, & ence of children neglected in their families, for
Gage, 2000), whereas removing infant animals whom attention from primary caregivers may
from their mothers has negative consequences be infrequent but occasionally valuable or suf-
(Marco et al., 2015). In this context, therefore, ficient in certain domains but lacking in others.
it is not surprising that studies examining chil- Thus, to advance our knowledge of neglect, we
dren who have been adopted from orphan- must include in our studies participants who
ages and placed into enriched environments experience naturalistic variations in neglect–
(i.e., with families) have documented dramatic enrichment. A second limitation of orphanage-
cognitive, linguistic, and emotional growth based studies is that nearly all investigations in
(Nelson, Fox, & Zeanah, 2014). Importantly, which children experienced institutional care
however, cross-species comparisons cannot in early life are studies of recovery from de-
provide the level of detail needed to understand privation following a profound improvement in
naturally occurring variation in environmental care (e.g., adoption or transfer to high-quality
input experienced by human infants and young foster care). These studies provide insight into
children. how and when to intervene in cases in which
In fact, studies of children who experienced dramatic changes in care are possible. Yet, in
severe psychosocial deprivation in early life most situations, children do not experience dra-
represent the majority of research on the effects matic shifts in their caregiving environments;
of neglect in humans. Typically, these studies indeed, children typically remain with the same
focus on children who experienced species- caregivers in generally the same environmental
atypical caregiving environments, often due to circumstances, for better or worse, throughout
institutional (i.e., orphanage) care. Institutional their development.
care is often characterized by high child-to- Types of child maltreatment often co-occur;
caregiver ratios, rotating staff, and highly rou- neglected children have two to three times the
tinized schedules. Consequently, children have risk of also experiencing sexual abuse in child-
little opportunity to form attachment relation- hood (Dong, Anda, & Felitti, 2004). In fact, few
ships with caregivers and lack individualized children experience only one type of maltreat-
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attention. The consequences of neglect in the ment (McGee, Wolfe, & Wilson, 1997); thus, it
form of institutional care are severe and dif- is difficult to identify prototypical reactions to
fuse, affecting children’s cognitive, socioemo- neglect (but see Rutter, Sonuga-Barke, Beckett,
tional, linguistic, motor, and physical growth. et al., 2010, for proposed deprivation-specific
For nearly all outcomes, greater time in institu- psychological patterns). In the next section, we
tional care is associated with poorer outcomes, highlight the significant methodological chal-
indicating a potential dose–response effect of lenges that arise from attempts to study neglect
neglect. Nonetheless, work from the Bucharest outside of institutionalized settings, including
Early Intervention Project (BEIP) suggests that definitions of neglect, which informants can
recovery from adverse effects of institution- provide the most valid information on child ex-
alization is possible, a finding consistent with periences, and issues concerning measurement

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  14. Neglect 241

of a construct that may be better represented on not include some forms of stimulation that are
a continuum (or on several continua). expected to be provided by caregivers. In partic-
ular, psychological neglect, which encompasses
not only emotional support (e.g., praise, nurtur-
Methodological Issues ance) but also cognitive stimulation (Erickson
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& Egeland, 2002), is critical for healthy devel-

There are numerous reasons for the “neglect of opment. Definitions of neglect that are based on
neglect” in child maltreatment research (Stol- not meeting an acceptable level of the required
tenborgh et al., 2013). These include the poten- input (e.g., food, supervision), while challeng-
tial differences in the prestige of professions ing to define, are somewhat easier to use than
that identify abuse (e.g., pediatricians) versus are definitions that involve deciding whether a
neglect (e.g., social workers), the likelihood that sufficient level of emotional care or cognitive
traumas garner more attention than do chronic stimulation has been met. Indeed, children’s
conditions, and, not independent of these ex- environments that lack sufficient stimulation
planations, that it is exceedingly difficult to in social interactions have been considered to
measure the construct of neglect (Schumacher, reflect “covert neglect” (Allen & Wasserman,
Slep, & Heyman, 2001). Dubowitz, Pitts, and 1985). Given the variety of forms that neglect
Black (2004) noted several issues in neglect may take, attempts have been made to delineate
research that require further attention, includ- the structure of neglect experiences; indeed, in
ing whether neglect is binary or dimensional, those studies in which the types of neglect are
how to combine or classify types of experi- carefully parsed, moderate to large intercor-
ences that traditionally fall into the purview of relations between domains are reported (e.g.,
neglect, and what measures should be used to Dubowitz et al., 2004).
assess neglect. The Child Abuse Prevention and Researchers have used several methods to
Treatment Act of 2010 offers the following defi- study neglect, including reviewing records
nition of neglect: “failure to act on the part of a from child welfare agencies, observing families
parent or caretaker, which results in death, seri- in a home or laboratory setting, and collecting
ous physical or emotional harm, sexual abuse self-reports of behaviors and/or experiences by
or exploitation, or an act or failure to act which parents and offspring. Each method has advan-
presents an imminent risk of serious harm” (pg. tages and disadvantages with respect to time,
6; CAPTA Reauthorization Act of 2010 [Public expense, and validity.
Law 111–320]). This binary definition indicates One option for making determinations of ne-
that neglect results in harm or risk of harm due glect is to use decisions made by child welfare
to lack of caregiver actions. What constitutes agencies. These have the benefit of being vali-
“harm,” however, is dependent on one’s per- dated cases of neglect that meet an established
spective; moreover, this harm may not be im- standard. It is important to recognize, however,
mediately visible, and it may go undetected that child welfare agencies vary in their defini-
for many years. Finally, it may be difficult to tions of neglect based on jurisdiction, limiting
identify neglect because, unlike other forms of the generalizability of study findings (Barnett,
maltreatment (e.g., physical, sexual, emotional Manly, & Cicchetti, 1993); indeed, definitions
abuse), neglect involves the absence of an ex- of neglect differ by state and can include fail-
pected input rather than the presence of harmful ure to provide children with education, medical
input (Humphreys & Zeanah, 2015). care, shelter, clothing, and nutrition. Complicat-
Many approaches to defining neglect have ing this issue is the fact that some states clas-
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divided this construct into component parts sify children as experiencing neglect when a
in order to identify specific types of neglect. parent has failed to prevent abuse or harm (e.g.,
Zuravin and Taylor (1987) defined eight types when an infant is shaken by another caregiver).
of neglect in a classification system: (1) physi- Thus, operationalizing neglect for research pur-
cal health care; (2) mental health care; (3) su- poses cannot be done consistently from broad
pervision; (4) substitute child care; (5) housing legal definitions of this construct (Slack, Holl,
hazards; (6) household sanitation; (7) personal McDaniel, Yoo, & Bolger, 2004) or from es-
hygiene; and (8) nutrition. Any child may expe- tablished practices within individual child wel-
rience neglect in only one, in two, or in several fare agencies. Furthermore, if neglect exists on
of these domains. Even such coding systems, a continuum, and only the most severe cases
however, are not exhaustive given that they do become substantiated cases of maltreatment

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 242 I I . R isk and P rotective F actors

through child welfare systems (English, 1998), that neglectful parents are less likely to respond
the majority of children experiencing less ex- to their child’s attempts to engage them or to
treme but nonetheless harmful levels of neglect initiate interactions with their child (Crittenden,
are missed. Thus, relying solely on validated 1981, 1985). Although neglect broadly signifies
reports from child welfare agencies will suf- reduced time spent in parent–child interactions,
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fer from low specificity (Sedlak & Broadhurst, when interactions do occur, all behaviors are not
1996). Despite these issues, validated cases of affected equally. Specifically, in seminal work,
child welfare-determined neglect have been Burgess and Conger (1978) found reduced rates
found to be moderately associated with self- of positive parent–child interactions in families
report and observational measures, and, further with a history of neglect compared to rates in
supporting the dimensional and incremental nonmaltreating families, but twice the rate of
nature of neglect, these self-report and observa- negative interactions. Neglected children also
tional measures predicted child behavior prob- receive fewer indirect imperatives than children
lems at a subsequent follow-up assessment after who are not neglected (Christopoulos, Bonvil-
researchers controlled for the effects of child lian, & Crittenden, 1988). In another study, dur-
welfare involvement (Dubowitz et al., 2004). ing dyadic play, mothers who had been charged
It is also possible in operationalizing neglect with neglect engaged in less frequent praise and
to ask parents about their behavior and/or the criticized their children more than did control
experiences of their child. We should note, mothers (Aragona & Eyberg, 1981). Although
however, that social desirability biases may comparing group averages on constructs such
affect the validity of interviews or self-report as praise may be enlightening, this approach
measures with parents given the sensitive na- is limited in its ability to determine how much
ture of the topic. An alternative approach to as- praise is needed so that a child does not experi-
sessing neglect in specific infant and caregiver ence the negative effects of emotional neglect.
relationships involves conducting structured The majority of studies that examine child
interactions. Interaction patterns observed in maltreatment group victims together despite
the laboratory may reflect long-standing rela- varying histories of abuse and neglect. As we
tionship patterns that occur in everyday life. noted earlier, many times these experiences co-
For example, caregivers may ignore their chil- occur in children; nevertheless, different expe-
dren during “free-play” sessions or walk out of riences are likely to have differential impacts.
the room without notice. Children’s behavior in Recently, two research groups have attempted
laboratory observations may also offer insight to create a framework for understanding differ-
into their routines and expectations of their ent forms of early experiences that may affect
caregivers. Infant mental health theorists have child development and long-term functioning
posited that children who have experienced ne- (Humphreys & Zeanah, 2015; McLaughlin &
glect learn that their caregivers do not respond Sheridan, 2016; Sheridan & McLaughlin, 2014).
to efforts to make a social connection (Powell, Specifically, one can imagine two potentially
Cooper, Hoffman, & Marvin, 2009). Neglect- orthogonal dimensions: one consisting of a di-
ful parents are unlikely to support the child’s mensional approach to assessing neglect, de-
comfort seeking by welcoming the child’s bids privation, or the absence of expected environ-
for proximity and affection. Over time, children mental (ranging from highly deprived to highly
learn that they need to try to manage difficult or enriched and nurturing environments), and the
complex emotions on their own. Observations other on another axis on which levels of harmful
consistent with these behaviors would indicate or threatening input are situated (ranging from
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a cause for clinical concern, but would be insuf- low-threat environments to extremely abusive
ficient to conclude that neglect has occurred. environments). Using this approach, research-
In-home observations of mothers with and ers may be better able to examine children’s
without a documented history of neglect re- patterns of experiences, as well as the conse-
vealed significant differences in play, affect, quences of variation along each dimension.
and verbal instruction during caregiver–child Making binary determinations, which is
interactions (Bousha & Twentyman, 1984). The often the case in determining whether child
“serve and return” model of parent–child inter- welfare agencies become involved, in custody
actions (see Briggs et al., 2014) provides a frame- decisions, and in recommending prevention or
work to understand impaired interactions in intervention initiation, can be difficult if ne-
families that are characterized by neglect, given glect is conceptualized as occurring along a

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  14. Neglect 243

continuum (or along several continua represent- Cultural and contextual factors influence
ing various types of neglect). In Figure 14.1 we our definition and understanding of behaviors
outline three (of several possible) hypothetical that may reflect neglect (National Research
models of the association between the degree Council, 2013). For example, the acceptability
of environmental input early in life and subse- of a child’s housing situation is clearly cultur-
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quent healthy development. A threshold model ally dependent; whereas a lack of electricity or
is based on existing work using grouped ap- running water may be normative in some com-
proaches (e.g., children with and without vali- munities, this may be considered hazardous in
dated reports of neglect or with and without a others. Changing social norms about whether
history of psychosocial deprivation due to or- children should be allowed to play unattended
phanage care). A second, linear model is based outside of the house (Pimentel, 2012) are seen
on a smaller subset of studies that attempt to as- by some as an overcorrection of perceived dan-
sess environmental input on a continuum (e.g., gers; moreover, there are large generational
studies that use a Likert-scale to sum items of shifts in the time children spend outdoors. In
retrospectively reported neglect) and that use a the United States, there is no national law re-
linear model to examine the impact of neglect garding the age at which a minor can be left at
on development. Third, although no models home unattended. In this context, city ordinanc-
have specifically postulated a “diminishing re- es or state-level recommendations can provide
turns” association between environmental input (albeit inconsistent) guidance, and the legality
and neglect, it is conceivable that the resulting of leaving children alone at home varies based
gains for the child diminish with further envi- on often arbitrary determinations.
ronmental input. Defining where to draw the In terms of measurement, the construct of
line to determine whether neglect has occurred neglect poses significant challenges. Each
is necessarily arbitrary for any model other than measurement technique suffers from signifi-
a threshold model. Of course, this difficulty is cant limitations, highlighting the importance
not unlike those that occur in determining other of using multimodal assessment approaches.
cutoffs, such as what absolute number consti- Furthermore, assessing the frequency, severity,
tutes “low birthweight” or how many symptoms chronicity, duration, and type of neglect may
are needed to meet criteria for a psychiatric dis- provide meaningful metrics for determining
order. when, why, and how neglect is most harmful.
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FIGURE 14.1. Proposed association between environmental stimulation and healthy development (Humphreys,
2016).

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 244 I I . R isk and P rotective F actors

These determinations are critical for informing (Sedlak & Broadhurst, 1996) reported over a
future research efforts, as well as prevention 40-fold increase in risk for neglect in families
and intervention programs for this prevalent with annual incomes below $15,000 compared
form of childhood adversity. to families with annual incomes of $30,000 or
more. Similarly, a study of neglect within the
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state of Missouri found that zip codes with the

Etiology of Neglect highest poverty rates had almost 20 times the
incidence of neglect compared to zip codes
Gaining a valid and comprehensive under- with the lowest poverty rates (Drake & Pan-
standing of the etiology of neglect, as well as dey, 1996). Although poverty is a risk factor for
its consequences, requires that researchers use abuse (Bong Joo & Goerge, 1999), it is associ-
consistent definitions across studies (Slack et ated more strongly with neglect than with other
al., 2004); however, as noted earlier, we have forms of child maltreatment (Drake & Pandey,
not yet established a widely adopted definition 1996; Sedlak & Broadhurst, 1996). Moreover,
of neglect. Consequently, documented risk fac- while poverty predicts subsequent neglect, it
tors may not be associated with all aspects of does not necessarily play a simple causal role:
neglect (e.g., emotional neglect vs. cognitive Children in middle- and high-income families
neglect). The etiology of neglect is typically also experience neglect, and the majority of
considered in terms of either broader contex- low-income children are not neglected. Indeed,
tual risks (e.g., poverty) or specific caregiver the fact that neglect occurs in a minority of
characteristics (e.g., substance use; low knowl- families who live in poverty highlights the im-
edge about child needs). Before considering in portance of factors in addition to income (Slack
detail these two lines of research examining et al., 2004).
contributors to child neglect, however, it is im- Contextual features related to poverty have
portant to recognize that in these models, chil- also been linked to neglect. In a longitudinal
dren are often conceptualized as passive recipi- study examining predictors of self-reported
ents. In contrast to this approach, significant physical abuse or neglect, Chaffin, Kelleher,
research on child development has highlighted and Hollenberg (1996) used data from an epi-
the transactional nature of parent–child interac- demiological sample of over 7,000 parents (i.e.,
tions, in which infants and children play an ac- the National Institute for Mental Health’s Epi-
tive role in eliciting responses from a caregiver demiologic Catchment Area survey). Neglect
(Kiff, Lengua, & Zalewski, 2011). Considered was longitudinally predicted by several demo-
in this context, it is possible that child disposi- graphic factors that may be confounded with
tional factors contribute to the likelihood that poverty. Specifically, risk for neglect was high-
the child will experience neglect, a formulation er in families with younger mothers, unmarried
that has not yet been meaningfully explored in primary caregivers, and membership in ethnic/
etiological models of neglect (for an exception, racial minority groups (Chaffin et al., 1996). It
see Belsky’s 1993 developmental–ecological is important to note that the association between
theory). these demographic factors and neglect is likely
As with other forms of maltreatment, there driven by multiple mechanisms, including high
appears to be an intergenerational cycle of ne- levels of parenting stress and being exposed to
glect (Zeanah & Zeanah, 1989). Mothers who societal bias and discrimination. In addition to
neglect their own children often have histories low household income, the number of mem-
of being maltreated as children themselves (Pe- bers in the household predicted neglect longi-
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tersen, Joseph, & Feit, 2014). Similarly, children tudinally. Potential features that did not predict
who were neglected are at high risk for becom- child neglect included the sex of the child, level
ing parents who maltreat their own offspring of parental education, and surprisingly, social
(Heyman & Slep, 2002). Thus, neglect is one support. The nonsignificant findings for the
of many conditions that may be “passed down” relation of social support and parental educa-
generationally, through social modeling, epi- tion with neglect are inconsistent with results of
genetics, or shared environmental contributors. other studies. Researchers have found social iso-
Among contextual or environmental factors, lation in the form of few social connections and/
the most robust predictor of neglect is poverty or little social support to be a strong predictor
(Slack et al., 2011). In fact, the Third National of child neglect (Gaudin, Polansky, Kilpatrick,
Incidence Study of Child Abuse and Neglect & Shilton, 1993). Mothers identified in neglect

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  14. Neglect 245

cases report low levels of social and tangible Wan et al., 2014), and may help to identify indi-
support (Williamson, Borduin, & Howe, 1991). vidual differences in parental response to chil-
In addition, Coohey (1998) found that parents dren, to their own child versus other children,
of inadequately supervised children had fewer or to specific emotional states.
years of formal education than did parents who Features of parents in addition to empathy
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gave adequate supervision to their children. have also been linked to increased risk for ne-
Other predictors of neglect include transience, glect. Compared to parents who were not ne-
frequent moves, and shorter times in one resi- glectful, parents of neglected children have
dence (Creighton, 1985), and may differentiate been found to be less adequately prepared for
risk for neglect and abuse (Zuravin, 1999). Fi- caretaking and to have less knowledge about
nally, time spent watching television has been child development (Burke, Chandy, Danner-
found to be a strong predictor of neglect, with beck, & Watt, 1998), to have lower acceptance
high daily television viewing (i.e., more than and approval of children, and lowered expec-
4 hours per day) associated with a fourfold in- tations for those children (Coohey, 1998). Par-
creased risk for child welfare involvement due ents may also have internal working models
to neglect (Slack et al., 2004). of the child that are defined by expectations
Parent-specific factors have been of interest that children’s primary role is to serve the par-
in identifying the etiology of neglect, especially ents’ needs. If so, monitoring and acting on the
given the role parents play as gatekeepers for child’s behalf may not be a role for which they
the child’s experience. A social information- are psychologically prepared. Caregiving envi-
processing theory of child neglect proposes that ronments are often compromised by parental
parents who neglect their children may have dif- psychopathology; thus, early theories focused
ficulty (1) determining that the child has a need; on characterological problems in neglecting
(2) interpreting the meaning of the need; (3) parents (Polansky, 1985). Depression in pri-
selecting an appropriate response to the need; mary caregivers, typically mothers, has been
or (4) implementing that response (Crittenden, linked consistently to risk for neglect (Coohey,
1993). It is important to bear in mind, however, 1998; Kotch, Browne, Dufort, Winsor, & Catel-
that many parents who are not neglectful are lier, 1999; Polansky, Chalmers, Buttenwieser,
also likely to struggle with these stages of infor- & Williams, 1983). Lower levels of parental
mation processing. Similarly, a recent model of self-efficacy that are associated with depression
child neglect proposes that deficits in parental may be relevant to inappropriate caregiving
empathy, or the ability to share and understand in these parents (Slack et al., 2011). One study
the child’s mental states, play a crucial role (De found that parental depression had different
Paul & Guibert, 2008). Indeed, neglectful par- relations to abuse and neglect (Zuravin, 1989):
ents have been found to be characterized by whereas there was a linear association between
relatively low levels of empathy (Shahar, 2001); increasing levels of depression and greater lev-
again, however, it is not clear that the associa- els of neglect, the association between parental
tion between low empathy and neglect is causal. depression and abuse was curvilinear, with low
As with the information-processing model, def- levels of child abuse in families in which there
icits in empathy may occur at different stages in was severe parental depression. Another study
the process of caregiving. For example, whereas found that parental depression was a stronger
some neglecting parents may not have emotion- predictor of abuse than neglect, and that both
al responses to children’s signals of need (i.e., abuse and neglect were significantly predicted
they do not share the child’s state), other parents by substance use disorders in the parents (Chaf-
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may neglect their child despite an emotional re- fin et al., 1996). Therefore, it is not surprising
sponse to the child’s signal because they fail to that 40–60% of children with out-of-home ser-
reason effectively about what the child needs. vices for child maltreatment have parents who
A model that conceptualizes neglect as a fail- abuse substances (Wulczyn, Ernst, & Fisher,
ure of parental empathy has been advanced by 2011). Certainly, parents who are high or intoxi-
researchers conducting neuroimaging stud- cated are not capable of meeting the physical or
ies of parents. Indeed, an interesting body of emotional needs of their infants or children.
work has examined parents’ neural responses Inherent to discussions of the etiology of ne-
to children’s photos, videos, and audio record- glect is determining responsibility for maltreat-
ings (Musser, Kaiser-Laurent, & Ablow, 2012; ment. For cases in which a child is physically or
Swain, Lorberbaum, Kose, & Strathearn, 2007; sexually abused, the perpetrator of that abuse

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 246 I I . R isk and P rotective F actors

is clearly to blame. For neglect, however, it is those who experienced neglect in early life have
less clear who is responsible for providing care increased rates of psychiatric disorder, includ-
and stimulation for the child, particularly when ing attention-deficit/hyperactivity disorder,
the neglect may be occurring without a parent’s conduct disorder, disinhibited social engage-
knowledge (e.g., at day care; with a nonresident ment disorder, major depressive disorder, and
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parent). Given parental gender and other biases reactive attachment disorder (Humphreys et al.,
in assigning blame, there are benefits to focus- 2015; Widom, DuMont, & Czaja, 2007; Zeanah
ing on neglect as an experience that the child et al., 2009; Zeanah & Gleason, 2015). Difficul-
does or does not have, rather than as the failure ties in emotion and stress regulation, as well as
of a specific caregiver to provide the child with poorer social functioning, may play an impor-
the appropriate necessities. tant explanatory role from neglect to psychopa-
thology (Cicchetti & Toth, 1995; Humphreys et
al., 2018; McLaughlin et al., 2015)
Consequences of Neglect on Child Functioning Given that the socioemotional difficulties
identified in neglected children are mediated by
Attentive, nurturing, and stimulating caregiv- changes in the brain, we focus in the following
ing is optimal for fostering healthy brain de- section on the links between neglect and neuro-
velopment. Although brain networks develop at biology. Most of this research has been conduct-
different rates and reach maturity at different ed with older children and adolescents. There
times, development of the brain occurs in a se- are several explanations for the dearth of stud-
quential, bottom-up process; thus, disruptions ies conducted in infancy and early childhood.
during the earliest years of life have foundation- As noted earlier, neglect may not be immediate-
al consequences for later maturational process- ly visible; neglected children may not be identi-
es and growth. Neglect during the critical early fied until later in life, when they are adopted
years of life disrupts the experience-dependent from institutions or are identified in the school-
environmental cues that are required for healthy age years by mandated reporters (e.g., teach-
neurodevelopment (De Bellis, 2001). ers). In addition, collection of neurobiological
A great deal of our knowledge about the ad- measures in infancy is more challenging than
verse effects of maternal deprivation comes in older children and adolescents, and only re-
from research with nonhuman animals. Indeed, cently have researchers begun to use magnetic
animal research examining maternal depriva- resonance imaging (MRI) in infants to examine
tion, in which animals are separated from their the effects of variation in the caregiving envi-
mothers and kin for a period of time in infancy, ronment on brain function and structure (e.g.,
has documented a number of negative neuro- Graham et al., 2015). Currently, it is unclear
biological consequences including hyperactiv- whether the deviations that researchers have
ity/impulsivity, problems in executive func- observed in older children and adolescents are
tion, atypical hypothalamic–pituitary–adrenal evident in infancy or only manifest later.
(HPA) axis activity, and decreased cellular plas- As we described earlier, neglect is multidi-
ticity of the brain (Brett et al., 2015). Nonhuman mensional in nature, including physical, cog-
animal research allows for the direct manipula- nitive, or socioemotional deprivation. Each of
tion of early environmental experiences, allow- these aspects of neglect may affect develop-
ing investigators to draw causal conclusions. In ing neurobiology. Physical neglect (e.g., inad-
humans, however, the most direct insight we equate provision of nutrition and hygiene) can
have into the role of the environment on child have clear and direct effects on overall physical
Copyright @ 2019. The Guilford Press.

outcomes comes from randomized controlled growth and risk for disease, such as failure to
trials of early interventions, including a nurse thrive (Block, 2005). Cognitive and emotional
home visiting program (Olds et al., 2007) and neglect likely have distinct consequences (Farah
the BEIP (Nelson et al., 2014). This type of et al., 2008), but in combination may produce
research typically demonstrates treatment ef- broadly deleterious effects on endocrinology,
fects that are broad-based, such that improv- neural structure, and brain function. Specifi-
ing children’s environments and reducing the cally, deprivation of cognitive stimulation, in-
time spent in neglect leads to positive outcomes cluding the lack of rich and varied exposure
across domains, including language, cognition, to language, may cause widespread deficits in
socioemotional functioning, and psychopathol- brain development; the absence of sensitive and
ogy (Nelson et al., 2014). Across the lifespan, responsive caregiving may have specific effects

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  14. Neglect 247

on developing stress response systems. The im- activity that resembled those of a never-institu-
pact of multiple aspects of neglect on different tionalized comparison group. Similarly, child
domains of neurobiology may explain the broad welfare-referred (neglected and/or abused) chil-
ameliorative effects of interventions aimed at dren who received the 10-week Attachment and
dramatically improving the caregiving envi- Biobehavioral Catch-Up (ABC) intervention
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ronment. Below, we highlight the association in the first 2 years of life showed more typical
between neglect and endocrine function, brain (less blunted) patterns of diurnal cortisol pro-
function, and brain structure. This is not an ex- duction 3 years later than did control maltreated
haustive list of neurobiological domains known children (Bernard, Hostinar, et al., 2015).
to be affected by neglect, as a growing body of
work has also examined whether epigenetic fac-
Brain Function
tors are affected by neglect (Drury et al., 2012;
Humphreys et al., 2016; Non et al., 2016). Paralleling research documenting atypical en-
docrine responses to stress in neglected chil-
dren, investigators have demonstrated that
Endocrine Function
deprivation of caregiving results in anoma-
The body’s response to stress involves the re- lous functioning of brain circuitry implicated
lease and regulation of stress hormones in a in responses to stress and fear. Specifically,
process that maintains biological balance in there is evidence that neglect leads to acceler-
the face of a changing environment (McEwen ated development of frontoamygdala circuitry.
& Wingfield, 2003). Specifically, the HPA axis Although, in childhood, this circuitry appears
governs the release and regulation of glucocor- to be characterized by positive coupling of
ticoids, including cortisol, through a cascade the amygdala and the medial prefrontal cortex
of interactions involving the hypothalamus, (mPFC) in response to fear, recent research
adrenal gland, amygdala, and hippocampus. In suggests that there is a normative shift to nega-
typically developing children, HPA axis func- tive coupling during adolescence, indicating
tioning is sensitive to input from caregivers. For greater top-down regulatory control (Gee, Gab-
example, research indicates that the withdrawal ard-Durnam, et al., 2013). Neglected children,
of the mother during the Still-Face Paradigm, however, may arrive early at a mature profile.
a parent–infant interaction stressor, is associ- In fact, Gee and colleagues (2013) found that
ated with increases in infant cortisol output both children and adolescents who were previ-
(Provenzi, Giusti, & Montirosso, 2016). Studies ously institutionalized exhibited negative cou-
of the impact of early neglect on the HPA axis pling of the amygdala and mPFC in response to
suggest that chronic deprivation of appropriate fear, a pattern that may originate from greater
input from caregivers ultimately results in hy- amygdala reactivity in early life (Gee, Hum-
poresponsivity of the HPA axis, as evidenced phreys, et al., 2013). Based on this and other
by blunted patterns of cortisol secretion, both research, Callaghan and Tottenham (2016) have
in response to acute stress and diurnally (Ber- advanced the “stress acceleration hypothesis,”
nard, Hostinar, & Dozier, 2015; McLaughlin et positing that accelerated development of amyg-
al., 2015). dala–mPFC circuitry truncates a period in
In the absence of the regulatory support of which children acquire critical regulatory skills
sensitive caregivers, hyporesponsivity of the from their caregivers. Thus, while accelerated
HPA axis may have short-term benefits but development may be adaptive in deprived con-
long-term costs. Indeed, blunted cortisol output texts, this trajectory likely has negative long-
Copyright @ 2019. The Guilford Press.

has been associated with internalizing (Colich, term consequences.

Kircanski, Foland-Ross, & Gotlib, 2015) and Other researchers have documented anoma-
externalizing problems (Bernard, Zwerling, lies in brain function related to maladaptive
& Dozier, 2015) in children and adolescents. social behavior and emotional processing in
There is evidence, however, that when imple- neglected children. In particular, investigators
mented early, interventions can result in recov- have focused on how neglected children process
ery of the HPA axis. For example, in research faces. Given that the preference for the mother’s
from the BEIP, McLaughlin and colleagues face and the ability to recognize different emo-
(2015) found that children who were transferred tional faces develops in infancy, children who
from institutions to family-based care before are deprived of visual input from caregivers in
age 24 months showed patterns of cortisol re- early life may experience enduring problems in

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 248 I I . R isk and P rotective F actors

attention to faces, with cascading consequences ated increases in responsiveness of the ventral
for social interactions. For example, Tottenham striatum to reward from earlier to later adoles-
and colleagues (2011) found that heightened cence. Furthermore, disrupted development of
reactivity of the amygdala in response to fear- ventral striatum reactivity partially explained
ful faces in children exposed to early neglect increased depressive symptoms in emotionally
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in orphanages partially explained decreased eye neglected children, mediating approximately

contact to emotional faces in this group. Studies 20% of this association. Given estimates that
using electroencephalography (EEG) to exam- 18% of children experience emotional neglect
ine brain activity have found that institutional- (Stoltenborgh et al., 2013) and the fact that risk
ized infants and young children show cortical for depression increases in adolescence, there is
hypoarousal when processing faces of both a need for further research examining anoma-
caregivers and strangers (Moulson, Westerlund, lous reward circuitry as a mechanism linking
Fox, Zeanah, & Nelson, 2009; Parker & Nelson deprivation of emotional input in early life to
2005), and furthermore, that a broad pattern of the onset of psychopathology.
cortical hypoactivation in previously institu-
tionalized children predicted indiscriminately
friendly behavior at age 36 months (Tarullo, Brain Structure
Garvin, & Gunnar, 2011). Researchers have also Gray-Matter Morphology
implicated the amygdala in this type of devel-
opmentally inappropriate social behavior. For As described earlier, the amygdala and hip-
example, Olsavsky and colleagues (2013) found pocampus serve central roles in the HPA–axis
reduced amygdalar discrimination of maternal response to and regulation of environmental
versus stranger images in previously institu- threats; consequently, these structures have
tionalized children ages 6–15 years, which was been the focus of studies examining the impact
associated with socially disinhibited behavior. of neglect on the developing brain. In particular,
While most research on anomalous brain the hippocampus, which is central to learning
function in neglected children has focused on and memory, has the highest density of gluco-
responses to stress and socioemotional process- corticoid receptors in the brain and is one of the
ing, there is also evidence that neglected chil- most vulnerable regions to stress (McEwen, Ei-
dren show disruptions in responses to reward. land, Hunter, & Miller, 2012). Although gluco-
In fact, altered reward learning has been most corticoids can enhance hippocampal function,
frequently found in neglected versus abused chronic exposure to atypical levels of glucocor-
children (McLaughlin & Sheridan, 2016). Two ticoids is deleterious, resulting in changes in
recent functional magnetic resonance imaging dendritic branching, neurogenesis, and apop-
(fMRI) studies have documented anomalous tosis (McEwen, 2000). In the broader literature
functioning of the ventral striatum in children on stress and trauma, researchers suggest that
exposed to neglect, which may underlie in- the effects of early adversity on hippocampal
creased rates of depression in this group. In a volume may not be detectable until adolescence
cross-sectional study of the effects of institu- (Tottenham & Sheridan, 2009). Therefore, the
tionalization, Goff and colleagues (2013) found timing of both stress exposure and brain mea-
that compared to their typically developing surements influence research findings. Further-
counterparts, previously institutionalized youth more, growth of the hippocampus is nonlinear
showed reduced responsiveness of the nucleus (Gogtay et al., 2006); thus, prospective studies
accumbens (NAcc) when viewing faces, an ef- beginning in early life are needed to clarify in-
Copyright @ 2019. The Guilford Press.

fect driven by the fact that only youth in the terpretation of cross-sectional findings.
comparison group showed higher NAcc acti- Perhaps not surprisingly given these challeng-
vation in adolescence compared to childhood. es, findings related to hippocampal morphol-
Although institutionalization is an extreme and ogy following early neglect have been mixed.
species-atypical experience, emotional neglect Several studies have found no effects of ne-
in family-reared environments similarly af- glect on hippocampal volume in childhood and
fected the ventral striatum (Hanson, Hariri, & adolescence (Hanson, Nacewicz, et al., 2015;
Williamson, 2015). Supporting the interpre- Mehta et al., 2009; Tottenham et al., 2010). In
tation that neglect disrupts normative devel- a recent study, however, Hodel and colleagues
opment of reward circuitry, greater levels of (2015) found that adolescents exposed to early
emotional neglect were associated with attenu- institutionalization had significantly smaller

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  14. Neglect 249

left hippocampal volumes than did their non- which proposes that early neglect is associated
exposed counterparts. Highlighting the conse- with early development of amygdalar circuitry.
quences of prolonged exposure to neglect, only Importantly, several studies have linked greater
children institutionalized past 12 months of age amygdala volume with increased risk for mental
had significantly smaller right hippocampal health problems that are characterized by emo-
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volumes. Furthermore, across all previously tion dysregulation (Buss et al., 2012; Lange &
institutionalized children, later age of adop- Irle, 2004; Tottenham et al., 2010). Nonetheless,
tion was associated with reduced right and left other researchers have documented reduced
volumes. Unlike studies of institutionalization, amygdala volume in later-adopted previously
Rao and colleagues (2010) used a dimensional institutionalized children (Hodel et al., 2015)
approach to assess the effects of variations in
environmental stimulation (i.e., cognitive input)
White-Matter Connectivity
and parental nurturance (i.e., emotional input)
in early life. In a cohort of predominantly low- In addition to evidence that neglect results in
income children, Rao and colleagues found anomalous functional connectivity of the brain,
that parental nurturance, but not environmental a small number of studies have documented
stimulation, inversely predicted left hippocam- deficits in white-matter microstructure among
pal volume at the mean age of 14 years. More- children and adolescents exposed to neglect. In
over, there was evidence of a sensitive period typically developing individuals, white-matter
for parental care, such that nurturance at age 4, integrity (i.e., fractional anisotropy [FA]) in-
but not at age 8, was associated with hippocam- creases throughout the brain across childhood
pal volume. The authors suggest that the lack and adolescence (Lebel, Walker, Leemans, Phil-
of appropriate caregiver responses to distress is lips, & Beaulieu, 2008). Thus, reduced white-
uniquely impactful for brain regions that gov- matter integrity may indicate a developmental
ern responses to environmental stress, and that insult that has resulted in more diffuse connec-
given the age of the participants, the association tivity, lower axonal density, or reduced myelin-
between lower parental nurturance and larger ation of axons. Evidence for the specific tracts
hippocampal volumes may indicate a develop- that are affected by neglect is preliminary and
mental delay of normative decreases in volume mixed. Some research points to broad effects of
during adolescence. Generally, however, it is deprivation on white-matter development, with
reduced hippocampal volume that has been as- deficits in the integrity of numerous tracts. For
sociated with risk for mental health problems example, in research from the BEIP, Bick and
in adolescence (e.g., Chen, Hamilton, & Gotlib, colleagues (2015) found that at approximately
2010; Hanson, Nacewicz, et al., 2015). age 8 years, previously institutionalized chil-
Synthesizing research on the neurobiologi- dren showed alterations in white-matter integ-
cal effects of child maltreatment, Teicher and rity in the body of the corpus callosum, as well
Samson (2016) noted divergent findings of the as in tracts involved in limbic circuitry, frontos-
impact of different forms of adversity on amyg- triatal circuitry, and sensory processing.
dala volume. Based on the extant literature, the Other research indicates specific effects of
authors suggest that whereas early neglect leads neglect on tracts implicated in cognitive func-
to increased amygdala volume, multiple forms tion and emotional processing, although the
of maltreatment across development ultimately extent to which different dimensions of neglect
serve to decrease amygdala volume. Indeed, (cognitive and emotional) explain these findings
in a pilot study of adolescents, Mehta and col- is not clear. For example, Hanson and colleagues
Copyright @ 2019. The Guilford Press.

leagues (2009) did not find differences in hip- (2013) found support for the hypothesis that ne-
pocampal volume between Romanian children glect disrupts white-matter organization in the
adopted from orphanages and a comparison prefrontal cortex (PFC), resulting in cognitive
group, but they did find that previously insti- deficits. Specifically, in this study, previously
tutionalized children had significantly larger institutionalized youth (mean age 14 years)
amygdala volumes. Similarly, Tottenham and showed reduced FA in the PFC and in tracts con-
colleagues (2010) also found that remaining in necting the PFC to the temporal lobe. Further-
an institution after 15 months of age was asso- more, among neglected youth, FA in several of
ciated with increased amygdala volume. These these tracts was associated with reduced neuro-
results are consistent with the stress accelera- cognitive performance. The uncinate fasciculus,
tion hypothesis (Callaghan & Tottenham, 2016), which connects the temporal and frontal corti-

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 250 I I . R isk and P rotective F actors

ces, may also be specifically affected by early in making such decisions is determining what
neglect given that it is implicated in emotion value should be prioritized (i.e., the child’s right
regulation, memory, and learning (Olson, Von to an adequate environment vs. parents’ right to
Der Heide, Alm, & Vyas, 2015). In fact, reduced retain custody of their offspring; keeping fami-
FA was found in the uncinate fasciculus in a lies intact). Often social welfare agencies and
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small study of internationally adopted children judges must make determinations of how long
at the mean age of 10 years (Eluvathingal et al., to wait for birth parents who have previously
2006), a finding that has been replicated in more neglected their children to provide an adequate
recent work (Kumar et al., 2014). environment, understanding that there are ac-
An important issue in interpreting research cumulating negative consequences for children
on the neurobiological consequences of neglect in a neglectful environment. In any case, given
concerns whether findings reflect the unique the diminishing plasticity of the developing
consequences of experiencing neglect in early brain as children age, it is critical that children
life. Because different forms of maltreatment be provided enriched, or at least adequate, envi-
likely have specific neurobiological conse- ronments as early as possible.
quences (Humphreys & Zeanah, 2015; Sheri- Children who experience neglect may be
dan & McLaughlin, 2014), we have focused on less likely to be identified as victims compared
research of institutionalized children, who suf- to those children who experience other forms
fer severe psychosocial deprivation but are un- of maltreatment. Crittenden (1981, 1985) has
likely to experience abuse. Nonetheless, given found that neglected children often behave pas-
that most of this research was conducted later sively in interactions. Thus, these children may
in development, it is possible the neurobiologi- be missed in the clinical context because it is
cal deviations observed in children who expe- often the presence of behavioral problems that
rienced neglect in early life are in part due to bring children into contact with mental health
later correlated stressors. It will be important professionals. Still, waiting until behavioral
for future research to measure experiences of problems rise to the level of affecting day care
both deprivation and threat across development or preschool providers would lead to late identi-
to determine the extent to which each of these fication of neglect. Thus, pediatricians may be
dimensions and their cumulative impact con- most capable of identifying neglect when the
tributes to neurobiological deviations. impact is greatest, although the signs are not
always obvious, and they are already screen-
ing for a great number of potential problems in
Prevention and Treatment of Neglect short office visits. Furthermore, children who
are neglected are the least likely to be taken to
The prevention and treatment of neglect occur regular physician appointments, or to attend ad-
both formally and informally. Friends, neigh- ditional services if referred by another provider.
bors, and family members often step in to pro- Assessments and interventions that take place
vide additional care for children observed to be in the caregiver’s home may increase the likeli-
vulnerable to neglect. This is not always pos- hood of treatment completion; indeed, promis-
sible, however, and child welfare agencies are ing work from the parenting-based ABC pro-
frequently asked to evaluate potential cases of gram has demonstrated notable improvements
child maltreatment. Although over 6 million for children involved in the child welfare sys-
children are reported to child welfare agen- tem (Bernard et al., 2012).
cies each year (U.S. Department of Health and Prevention may be the best option for improv-
Copyright @ 2019. The Guilford Press.

Human Services, 2016), the majority of these ing the outcomes of young children at risk for
families do not receive intervention. Alarm- neglect. As in most infant mental health work,
ingly, among families with validated cases of the caregiver is often the target for prevention.
child maltreatment, there is evidence that over Candidate programs include the Nurturing Par-
one-third of victims do not receive postinvesti- enting Program (Bavolek, 2002), which pro-
gation services following the initial validation vides a variety of levels of prevention and inter-
(Waldfogel, 2009). Families who are involved in vention, and generally focuses on group-level
child protective services are obvious targets for treatments with psychoeducation and activities
interventions aimed to reduce neglect, whether oriented toward perspective taking, spending
by placing children into families that are less time with the child, and understanding how par-
likely to be neglectful or by changing aspects ents’ own experiences may affect parenting be-
of their current home environment. Inherent haviors. Reflective approaches in which parents

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  14. Neglect 251

consider their own childhood experiences and Both one-on-one care (e.g., with a “stay-at-
make conscious decisions to change learned home” parent or child care provider) and group-
parenting patterns may help those who experi- based care (e.g., day care with multiple children
enced maltreatment break the intergenerational with one or more caregivers) are likely to differ
cycle of neglect (Wahler, Cartor, Fleischman, & significantly from the experiences of infants in
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Lambert, 1993). Reflective interventions during hunter–gatherer societies. The number of care-
pregnancy may be a particularly important time giving adults per dependent child, closeness
to “reset” expectations for parenthood, includ- with kin and non-kin caregivers, and relative
ing to prepare new parents for caring for an in- lack of privacy may have dramatic differences
fant. in the experience of young children. Today, the
Infants and young children place significant average household in the United States consists
demands on caregivers, and many new parents of three individuals. Typically, children sleep
may be inadequately prepared for these chal- in their own rooms, apart from their parents
lenges. Home visiting programs, including or other siblings. Television and other forms of
the Nurse–Family Partnership, help first-time screen-based entertainment are prevalent and
mothers through their transition to parenthood, may interfere with dyadic interactions of in-
beginning with home visits during pregnancy, fants and their caregivers. Thus, considering the
and have provided evidence of prevention of context for child care environments, including
child maltreatment (Donelan-McCall, Ecken- who the caregiver is and his or her relation to
rode, & Olds, 2009; see Zeanah & Korfmacher, the child, who else may be interacting with the
Chapter 38, this volume). The Triple P (Positive child, and what the other aspects of the child’s
Parenting Program), an evidenced-based inter- environment may be fostering or suppressing
vention that draws from social learning theory interactions with the child are likely to be im-
and cognitive-behavioral therapy, includes fac- portant for determining the range of infant and
ets that directly counter neglect (e.g., promot- child experiences. Relatedly, the broader home,
ing a positive learning environment; ensuring a neighborhood, or community context of support
safe, engaging environment); this intervention and/or stress must be considered in developing
has been found to prevent child maltreatment and evaluating models of neglect.
(Prinz, Sanders, Shapiro, Whitaker, & Lutzker, The second consideration is timing, as chil-
2009). Broader-level interventions not directly dren’s needs necessarily change across devel-
tied to parenting behaviors may be a useful tar- opment. Given that infants and young children
get, especially given the link between poverty have the least physical independence and great-
and neglect. As such, interventions to address est brain plasticity, this is a period in which care-
families’ poverty may inform efforts to pre- giving experiences are particularly important.
vent neglect (Slack et al., 2004); income infu- From the perspective of the prevalence rates of
sion may decrease worry about material needs maltreatment, including experiences of neglect,
and reduce the amount of time parents spend infants are at far greater risk for maltreatment
working outside of the home, and, as a result, than are children of any other age (U.S. Depart-
increase parental physical and psychological ment of Health and Human Services, 2016). In
presence in interactions with their children. the context of conducting research that informs
practice and policy, focusing on the early life
period is useful given that interventions target-
Conclusions and Future Directions ing transition periods may be most effective in
creating behavioral changes (i.e., programs tar-
Copyright @ 2019. The Guilford Press.

The relative inattention to neglect, compared to geting new parents during the pregnancy and
other forms of child maltreatment, is particu- postnatal period result in the best outcomes for
larly concerning given its broad and enduring children). Although there are only a few groups
impact, and the large number of children who conducting MRI in infants, this method is
experience some form of neglect in their lives. promising in its ability to document both struc-
There are many challenges to studying neglect tural (Rifkin-Graboi et al., 2015) and functional
and measuring how interventions may reduce brain patterns (Graham, Fisher, & Pfeifer, 2013)
experiences of neglect. It is important to high- associated with different patterns of early ex-
light here three considerations for future work perience, and may help to identify how neglect
on neglect. First, from a cultural perspective, in- gets “under the skin” far earlier than do mea-
fant interactions with caregivers have changed sures of behavior, language, or cognition. Al-
dramatically across our evolutionary history. though neglect at older ages clearly has adverse

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 252 I I . R isk and P rotective F actors

effects, a focus on experience in the earliest velopmental ecological analysis. Psychological Bul-
years of life merits particular consideration. letin, 114(3), 413–434.
Thus, the third consideration for future di- Bernard, K., Dozier, M., Bick, J., Lewis-Morrarty, E.,
rections involves measurement of experiences Lindhiem, O., & Carlson, E. (2012). Enhancing at-
tachment organization among maltreated children:
in early life, including the postnatal period.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Results of a randomized clinical trial. Child Devel-

With advances in technology, particularly in opment, 83(2), 623–636.
wearable devices that track our movements and Bernard, K., Hostinar, C. E., & Dozier, M. (2015). Inter-
activity level, we may be able to overcome a vention effects on diurnal cortisol rhythms of child
significant “blind spot” in our understanding protective services–referred infants in early child-
of early experience. The use of ecologically hood. JAMA Pediatrics, 169(2), 112–119.
valid measures of real-world interactions be- Bernard, K., Zwerling, J., & Dozier, M. (2015). Effects
tween caregivers and children are best suited of early adversity on young children’s diurnal cor-
to provide information that is unbiased by the tisol rhythms and externalizing behavior. Develop-
laboratory environment or by potential Haw- mental Psychobiology, 57, 935–947.
Bick, J., Zhu, T., Stamoulis, C., Fox, N. A., Zeanah, C.
thorne effects of in-person observers at home H., & Nelson, C. A. (2015). A randomized clinical
visits. Similar naturalistic approaches to study- trial of foster care as an intervention for early insti-
ing auditory stimulation have led to significant tutionalization: Long term improvements in white
advances in understanding the importance of matter microstructure. JAMA Pediatrics, 169(3),
child–caregiver conversations in language de- 211–219.
velopment (e.g., Zimmerman et al., 2009). All- Block, R. W. (2005). Failure to thrive as a manifestation
day recording devices of the home environment of child neglect. Pediatrics, 116(5), 1234–1237.
such as the LENA (Ford, Baer, Xu, Yapanel, Bong Joo, L., & Goerge, R. M. (1999). Poverty, early
& Gray, 2008), which is placed in children’s childbearing, and child maltreatment: A multino-
mial analysis. Children and Youth Services Review,
clothing, may better capture everyday interac-
21(9–10), 755–780.
tion patterns. Indeed, investigators using the Bousha, D. M., & Twentyman, C. T. (1984). Mother–
LENA have documented dramatic variance in child interactional style in abuse, neglect, and con-
at-home language exposure (Christakis et al., trol groups: Naturalistic observations in the home.
2009). Finally, as Belsky (1993) noted, research- Journal of Abnormal Psychology, 93(1), 106–114.
ers must not rely only on easy-to-study families Bowlby, J. (1982). Attachment and loss: Retrospect and
(e.g., middle class, willing to travel to the labo- prospect. American Journal of Orthopsychiatry,
ratory and disclose on parenting behaviors) to 52(4), 664–678.
better understand the causes and consequences Brett, Z. H., Humphreys, K. L., Fleming, A. S., Krae-
of neglect. If we are to increase both the gen- mer, G. W., & Drury, S. S. (2015). Using cross-spe-
cies comparisons and a neurobiological framework
eralizability of our findings and specificity of
to understand early social deprivation effects on be-
our understanding of neglect, it is critical that havioral development. Development and Psychopa-
we recruit diverse families. Neglect is a multi- thology, 27(2), 347–367.
dimensional experience that, through a range of Briggs, R. D., Silver, E. J., Krug, L. M., Mason, Z. S.,
pathways, ultimately affects all of us. Schrag, R. D. A., Chinitz, S., et al. (2014). Healthy
Steps as a moderator: The impact of maternal trau-
ma on child social–emotional development. Clinical
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