Abstract
Childhood neglect is the most ubiquitous and prevalent form of adverse childhood experiences (ACEs). Given the significance of cognitive function and its malleability in retort to environmental stimuli, there is significant relevance in understanding the impact of child neglect on cognitive domains. Furthermore, examining the cognitive domains individually enables a more nuanced understanding of the impact of childhood neglect. This article details a scoping review undertaken to explore the relationship between childhood neglect and cognitive function, with the aim to recognize the observable cognitive qualities in neglected children, in the absenteeism of other ACEs. Cognitive function was divided into five domains: executive function, academic achievement, language, memory and intelligence. The findings demonstrated that executive function (working memory and attention shifting), language and intelligence were associated with childhood neglect, and there was no association between executive function (spatial planning), academic achievement, memory and childhood neglect.
Keywords: Childhood Neglect; Cognitive Function; Child Mental Health; Scoping Review; Intelligence; Language; Memory; Executive Function; Academic Achievement
Introduction
Adverse childhood experiences or ACEs are stressful and
traumatic events that arise in a child’s early life Felitti (1998) et
al. [1]; McLaughlin (2019) et al. [2]. ACEs is an umbrella term for
different types of early adversity Peterson (2013) [3]. This includes
direct harm to children otherwise known as child maltreatment
McLaughlin (2019) et al. [2] and includes physical abuse, sexual
abuse, and/or neglect. ACEs can also be indirect through their living
environments, for example through parental conflict, mental illness
or substance abuse Hughes et (2017) et al. [4]. Differentiating
between the impact of different ACEs is difficult, as studies
historically present findings as a combined cumulative risk score
rather than distinct ACEs Evans (2013) et al. [5].
Childhood neglect is the most ubiquitous and prevalent form
of ACEs English (2005) et al. [6] Maguire (2015) et al. [7]. Although
it is associated with substantial mortality Dubowitz (2004) et al.
[8], it is the least empirically studied form of child maltreatment
De Bellis (2005) [9]. The significance of child neglect should come
as no surprise, given that a lack of parental care, a trademark of
neglect, is an extreme risk to children’s growth and well-being
Rutter (2000) et al. [10].
As schools are obliged to take accountability for promoting and
safeguarding the welfare of young children Great Britain (2002)
[11], distinguishable characteristics of school-aged children facing
neglect need to be taken from recent literature Maguire (2015)
et al. [7]. Teachers and schooling staff interact with the same
children on a virtually daily basis. Therefore, they are in the best
setting to witness the children’s behaviour Burgess 2011 et al. [12].
McGarry and Buckley, 2013 [13] International research highlights
that teachers feel uncomfortable with the idea of notifying child
protection services of suspected or known neglect Gilbert [14].
Their response was mainly due to a lack of knowledge regarding
the signs of neglect [12].
Children’s environments structure their cognitive function
Nisbett (2012) et al. [15]. A child must develop through the
cognitive development stages for future health and achievement
Noble (2015) et al. [16]. Given the significance of cognitive function
and its malleability in retort to environmental stimuli [15] there
is significant interest in understanding the impact of neglect on
cognitive outcomes Guinosso (2016) et al. [17].
Once neglected children start in education, indicators of
academic concern rapidly appear Peterson (2013) et al. [3].
Academic achievement signifies performance outcomes that signify
the degree to which a child has completed educational objectives
Woolfolk (2007) [18]. In a longitudinal study, neglected children
in kindergarten were regarded by their teachers as having more
trouble understanding school tasks, compared to children who
had not been neglected Erickson (1989) et al. [19]. By second
grade, most of the neglected children had been referred to special
education services Egeland (1991) [20]. This display of academic
difficulties increased during their school years and was seen
through into adolescence Egeland (1997) [21].
Moreover, childhood neglect and the impact on the language
domain has been previously studied Eigsti (2004) [21]. Language
is a structured system of communication and involves skills such
as listening and reading (receptive skills) and writing and speaking
(productive skills; Trask (2007) [22]). Language delay becomes
more evident as children grow older, with research finding that
neglected children demonstrated more syntactic delays and
reduced vocabulary than control groups [23]. Language delay is also
apparent when child maltreatment types are compared. Children
who had been neglected had more delays in receptive language
(auditory comprehension) and expressive language (verbal ability)
than children who had been physically abused Allen (1982) et al.
[24]; Culp (1991) [25].
While previous reviews have been published looking at ACEs
and cognitive function Maguire (2015) [11]; Guinosso (2016)
[17]; Kavanaugh (2017) et al. [26]; Carlson (2019) [27]; Yingying
(2019) [28]. Most reviews Guinosso et al. [25-28] focus on child
maltreatment as a homogenous group and do not differentiate
between child abuse and child neglect [3]. Others combine child
neglect and emotional abuse Maguire 2015 [7]. In recent years,
there has been increased attention to isolate specific ACEs for
targeted interventions and to identify the specific characteristics
such children display McLaughlin (2014) [2,29].
This article details a scoping review that was undertaken to
explore the relationship between childhood neglect and cognitive
function. To recognize the observable cognitive qualities in
neglected children, in the absenteeism of other ACEs, to gain a
better understanding of the behaviours they may exhibit.
Aim
To provide a comprehensive overview of the impact of childhood neglect on cognition in school-aged children.
Method
The process and results reporting were guided by the Preferred Reporting Items for Systematic Reviews and Meta- Analysis (PRISMA) guidelines, 2009 revision Moher (2009) [30]. Three databases – MEDLINE, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL) – were searched using the following terms: (S1) childhood: child*, early childhood, middle childhood; (S2) neglect: early neglect, neglect, emotional neglect*, physical* neglect* and (S3) cognition: cognit*, language, visuospatial, memory, attention, executive function*, intelligen*. Truncation symbols and the boolean operator ‘AND’ was used in the advanced search strategy to link the different groupings of search terms (S1 AND S2 AND S3).
The inclusion criteria were that the studies had to:
a) Be peer-reviewed research.
b) Involve school-aged children (6-12 years of age) with
confirmed cases of neglect by child protection services (CPS) or
other governed bodies.
c) Explore the outcome of cognitive domains.
d) Have been published in an academic journal in the English
language, between January 2010 and January 2020.
Neglect is defined as the inability to offer health, education,
emotional development, nutrition and secure living environments,
for the development of the child. Also, if there is a high possibility
of causing harm to the child’s mental, physical, spiritual or
social development. This involves the inability to appropriately
supervise and safeguard children from harm harm (World Health
Organisation, 1999) [31].
Studies that focused on other ACEs, such as physical, sexual,
and/or emotional abuse were excluded. Case studies, literature
reviews and grey literature were also excluded. Of the 483 articles
initially identified, 89 articles were excluded due to duplication.
394 articles were screened for relevance. On reviewing the titles
and abstracts, 340 articles were excluded, as they were found not to
meet the inclusion criteria. With the remaining 54 articles, full-text
articles were assessed and 42 were excluded, leaving 12 articles.
One additional article of interest was identified when screening
the reference lists of the 12 final articles. Therefore, a total of 13
studies were included in the review. The Consolidated Standards
of Reporting Trials (CONSORT) checklist was used to critically
appraise the quality and the reliability of the included studies, none
of which were rejected based on the appraisal Moher (2010) [32].
Figure 1 is a PRISMA flow diagram, to present the flow of
information through different stages. Table 1 provides a summary
of the studies included in the scoping review. Once the articles had
been selected, data of each study’s aim, population, method and
findings were extracted. The data extracted from each study were
entered into a table to summarize the included studies. The authors
challenged each other’s interpretations and worked collaboratively
to deepen the discussion and interpretation and enhance rigour
and quality Whiting (2017) [33].
Findings
The first stage of analysis was assessing the heterogeneity of the
included articles. A high heterogeneity among these characteristics
of included articles precluded the use of a meta-analysis. This is
because high heterogeneity violates the underlying assumption
of a normal distribution Higgins (2009) [34]. As recommended by
the Cochrane review/collaboration Higgins (2019) [35] a narrative
synthesis was used to explore the relationship between childhood
neglect and cognitive function.
To provide a comprehensive review, cognitive function was
divided into five subcategories: executive function, academic
achievement, language, memory and intelligence Yingying (2019)
[28]. Once all the articles had been grouped into subcategories, this
made it substantially easier to explore the relationships within and
between articles. Further grouping occurred for studies that used
the same neurocognitive tests.
Executive Function
Executive function was divided into working memory, attention shifting and spatial planning. Whether executive function ought to be conceptualized as a unitary concept or several separate functions has been a matter of discussion Stuss and Alexander (2000) [36]. However, further research suggests executive function is best considered as distinct functions Blair (2005) et al. [37].
Working Memory
Using the Cambridge Neuropsychological Test and Automated Battery (CANTAB), spatial working memory task, one study Hanson (2013) et al. [38] found that children who had suffered early neglect have more total errors, compared to children who had not suffered early neglect (p<.001). Similar results were found by Bick et al. (2018) [39], children in the ever-institutionalized group made more total errors than children in the never institutionalized group. Those in the ever-institutionalized group also presented significantly worse strategy scores, relative to the never institutionalized group (β=−.341, p<.001; [39]). Moreover, Pollak et al. [40] found there was a distinction amongst the groups on the spatial working memory (SWM) subtest, F(2, 128)=7.96, p=.001. Post-institutionalized (neglected) children performed more poorly than both the emotional abuse (p=.008) group and the control group (p=.001). The included studies all used the same CANTAB which ensured interstudy homogeneity and all studies found similar results. Therefore, this review will accept that childhood neglect is associated with the working memory domain.
Attention Shifting
Two studies found that neglected children showed significantly
poor performance Hanson (2013) et al. [38]; Bick (2018) et al. [39].
In one study Bick (2018) et al. [39], the institutionalized group
committed more total errors, even when amended for the number
of levels accomplished, compared to those never institutionalized
(β=−.327, p<.001). Similar results were found by Hanson (2013) et
al. [38], who found that children with early neglect had more total
errors than children who had not suffered neglect (p=.012).
Conversely, Pollak (2010) [40] discovered no substantial
differences between the three groups (institutional neglect, early
adoption, and control group), with the intra-extra dimensional
set-shifting (ID/ED) test (p>.05). Further tests on attention
demonstrated that all groups performed similarly on auditory
attention tests. However, the groups varied on the visual attention
tests, as children in the post-institutionalized (neglected) group,
F(2,116) =8.96, p=.001, performed more poorly than those in
the early adoption group (p=.001) and control group (p=.006).
Although the included studies found mixed results, they all used the
same CANTAB which ensured interstudy homogeneity. Pollak et al.
(2010) [40] originally discovered no difference in attention shifting
between the groups when using the ID/ED test. An explanation for
this is the ability to voluntarily focus or shift attention cultivates
between 7 and 9 years of age Anderson (2010) [41] and Pollak
et al. (2010) [40] recruited participants between the ages of 8
and 9 years. Their capability to shift attention may not have fully
developed by the study. Therefore, this review will accept that
childhood neglect is associated with the attention shifting domain.
Spatial Planning
One study Hanson (2013) et al. [38] found that children who suffered early neglect completed fewer problems on the subtest of the CANTAB is the Stockings of Cambridge (SOC) test, in the minimum number of moves (F=8.797, p=.005), compared to the control group. The other two studies found that childhood neglect did not have an impact on spatial planning. Bick et al. [39] found that the number of problems completed in the minimum number of moves did not significantly vary between children with or without histories of institutional/neglect rearing (β=−.224, p<.013). Similar results were found by Pollak et al. (2010) [40], post-institutionalized (neglected) children performed well on tests of executive processing involving manipulation and spatial planning (p>.05). The included studies found mixed results, but with more studies finding that neglect did not have an impact on spatial planning. Neglected children are often left alone to deal with their environment so they adjust and learn themselves. Therefore, when it comes to tasks of planning and solving, they are superior compared to other children Maguire (2015) et al. [7]. Hence, this review will accept that childhood neglect is not associated with the spatial planning domain.
Academic Achievement
Two studies used school grades to assess academic achievement.
One study Manly (2013) et al. [42] found that childhood neglect was
associated with diminished language arts, in kindergarten. Neglect
was also associated with mathematics results, in first-grade, and
poorer results in general in first-grade academic achievement.
Nevertheless, neglect severity was found to not be directly
related to first-grade academic achievement, but rather indirectly
associated with cognitive function. However, McGuire and Jackson
(2018) [43] found that emotional abuse severity and physical abuse
was a significant predictor of English grades. Neglect was found to
not be a significant predictor of grades and no variables predicted
mathematics grades. Only neglect frequency was a substantial
predictor of English grades (B=0.17, p=.06). Petrenko (2012) et
al. [44] used the Wechsler Individual Achievement Test (WIAT)
and found similar results to McGuire and Jackson (2018) [43].
Physical neglect and supervisory neglect did not predict academic
achievement when using the WIAT test. The only significant
predictor of lower academic achievements was having a previous
period of out-of-home care (B=−3.55, t =−2.24, p=.026).
Petrenko (2012) et al. [44] and McGuire and Jackson (2018)
[43] use different measurement tools, but both found that
childhood neglect was not associated with academic achievement
York (2015) [45]. Both studies focused on older children and who
had been in foster care [41] or in out-of-home care [42]. Whereas,
manly who found that childhood neglect was associated with
language arts and mathematics, focused on younger children and
those recruited through the Department of Health Services (DHS).
Given the variances in data collections techniques, for example,
how neglect was recorded, inconsistencies between studies are
common. These discrepancies partially explain differences in
association with academic functions [43]. Moreover, another
reason for the discrepancy in study’s findings could be due to the
variation of what is deemed as academic achievement. From the
included articles, given that there were mixed results and more
studies found no association, this review will accept that childhood
neglect is not associated with academic achievement.
Language
Two studies used the Clinical Evaluation of Language
Fundamentals (CELF) test and both studies found that childhood
neglect did not correlate with language. De Bellis, Woolley and
Hooper (2013) [46] Lum (2018) et al. [47]. De Bellis (2013) et al.
found that only sexual abuse significantly and negatively correlated
with language (p<.05). Similar results by Lum, Powell and Snow
(2018) [47] found on a group level (neglect, emotional abuse,
physical abuse, and sexual abuse), language skills are, on average,
below the normative mean (t(82) =5.013, p<.001). However, when
neglect was considered on its own, children’s overall language
functioning was not found to be related to neglect.
Whereas Spratt (2012) et al. [48] who used the Test of Early
Language Development (TELD) found that when adjusting for
socioeconomic status, participants in the control group displayed
higher levels of language functioning than both neglect groups.
The control group performed significantly better than the United
States children with a history of physical or emotional neglect
(USN) group on TELD receptive (p=.004), expressive (p=.006) and
oral composite (p=.002). Children in the control group performed
significantly better than children in the adopted from international
institutions (IA) group on TELD receptive (p=.002), expressive
(p<.001) and oral composite (p<.001).
The included articles in this review, found mixed results when
it came to the association between childhood neglect and language.
An explanation for the studies that found no association could be
due to the measurement tool used. Despite the CELF’s effort to
formulate a comprehensive language tool, it lacks validity due to
a misleading standardized sample and an inadequate reference
standard Paslawski (2007) [49]. There is also an absence of data
as to how items and tasks are considered appropriate. As the
CELF is mainly vocabulary based, it will tend to recognize the
socioeconomic status and second language acquisition concerns,
rather than language development concerns, due to the significant
linguistic, cultural and socioeconomic bias [49]. These concerns
with the CELF could explain why the two studies De Bellis et al.
[46,47] in this review found no association between neglect and
language. Therefore, this review will accept that childhood neglect
is associated with language.
Memory
Three studies used the Paired Associated Learning (PAL) test,
to assess memory. One study Pollak et al. (2010) [40] discovered
that post-institutionalized children significantly scored lower than
the other two groups, F (2, 131) = 12.47, p = .001. Similar results
were found by Hanson (2013) et al. [38]. Moreover, Bick et al. found
that children in the institutionalized group made significantly more
errors before completing a stage (β = −.254, p = .005). However, after controlling for Intelligence Quotient (IQ), the number of
levels completed did not differ between the ever and never
institutionalized groups. The association between institutional
rearing status and performance on any of the PAL subscales was no
longer significant Bick (2018) et al. [39].
The studies that used the California Verbal Learning Test (CVLT)
found that memory ability in children who had been neglected or
abused was no different to children in the control group Cicchetti
(2010) [50]. Cicchetti established that the experience of childhood
neglect or abuse does not necessarily unfavorably affect, nor does
it improve, basic memory (recall and recognition memory) for
nontraumatic material De Bellis et al. (2013). De Bellis also used
the CVLT test and found that only sexual abuse significantly and
negatively correlated with memory.
Finally, Chae (2011) et al. [51] used the short-term memory
subtest of the SB5. They found that there were no significant
abuse or neglect differences or age and neglect/abuse interactions
found in children’s memory functioning. The included articles in
this review, found mixed results when it came to the association
between child neglect and memory. However, after controlling
for confounder variables, most studies found that neglect had no
significant impact on memory performance. Therefore, this review
will accept that childhood neglect is not associated with memory.
Intelligence
All studies recognized a negative association between childhood neglect and IQ scores even after adjusting confounders. One study Bengwasan (2018) [52] used the Full-Scale Intelligence Quotient (FSIQ) which is comprised of non-verbal IQ (NVIQ) and verbal IQ (VIQ) and found significant differences between the groups, F(2, 297)=16.766, p<.001. The children in the physically abused group (M=76.550, SD=11.515) had the highest FSIQ mean score, compared to children in the sexually abused group, (M=72.340, SD=12.324) and the neglected group, (M=66.99, SD=11.227). (Manly (2013) et al. [42]; O’Hara (2015) et al. [53]) Two studies used the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R). One study (Manly et al., 2013) found a significant negative association between the severity of neglect to the IQ of children, after controlling for maternal IQ and demographic covariates. Severe neglect before the age of 4 was associated with diminished IQ at age 4. However, the link from IQ at age 4 and first-grade academic function at age 6 was statistically insignificant (β=−0.008, p=.216). Moreover, another study (O’Hara et al., 2015) using the WPSSI-R found that neglected children scored significantly worse than children who had been neglected and abused (p=0.03). However, the groups did not differ on the block design subtest (p=0.4). One study Petrenko et al. (2012) used the Kaufman Brief Intelligence Test (K-BIT) to measure intelligence. They found that the supervisory neglect group had better verbal IQ scores than the physical neglect group (β=−4.00, p=.026) and higher verbal IQ scores than children in the sexual abused/mixed class group (p =.009). Most studies included in this review found there was an association between child neglect and intelligence. Therefore, this review will accept that childhood neglect is associated with intelligence.
Discussion
The findings from this review provided evidence that child neglect is associated with cognitive function and does have an impact on domains such as executive function (working memory and attention shifting), language and intelligence. However, the articles included in this review also found no association between neglect and executive function (spatial planning), academic achievement and memory. Although the findings from the 13 included articles found mixed results with regards to the association between child neglect and cognitive function. It is clear from the findings and previous research the difficulties that children with neglect face, from poverty to a lack of parental care, impacting their growth and well-being Rutter and Sroufe, (2000). This demonstrates the detrimental effects of not just neglect, but ACEs in general.
Limitations
In the included studies, the definition of neglect was highly variable. This made it difficult to make comparisons and similarities between the studies. Due to high heterogeneity, this precluded the use of a meta-analysis and justified the use of narrative synthesis Higgins (2009) [33]. It could be argued if there is no single operational definition for neglect, this makes it challenging to interpret and compare the findings of the research and to establish whether children are eligible for services. Moreover, in many of the included studies, the use of a wide range of age groups meant it was impossible to make comparisons and similarities between the studies. It can be argued that different regions of the brain develop at different stages. Therefore, this may be the reason there is a difference between two studies using different age bands, instead of it being as a result of childhood neglect.
Recommendations for Practice
Several recommendations for education professionals can be made based on the findings of this scoping review. Understanding the nature and frequency of ACEs in school-aged children, particularly at a young age (6-12 years of age) can guide teachers who feel they lack the knowledge of indicating neglect. By recognizing neglect and intervening early, teachers can help children who have been neglected to attain better performance in school. Recognising the impact of neglect on children can help to understand why classrooms can be challenging and upsetting places for these children. Consistent with the findings from this review and previous research, neglected children have enhanced problem solving and spatial planning skills, so these children may sometimes be seen as more independent than other children Maguire et al. (2015) [7]. At the same time, they may also have difficulty with classroom routines and other elements. Therefore, if teachers are aware of these styles of cognitive features, then child neglect can be recognized early on. Moreover, by understanding childhood neglect in school-aged children, research can help to justify the allocation of resources at a widespread level within a multitiered framework [54].
Conclusion
It is hoped that the results of this review will offer support for a universal definition of childhood neglect. Moreover, by understanding childhood neglect in school-aged children can also help to build on teachers knowledge of neglect and justify the allocation of resources at a widespread level within a multitiered framework.
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