Neglect and supervisory neglect — OSCE · Paeds Cases

Prompt

Tane is a three-year-old boy brought to the emergency department with a bath scald to his right forearm that fits a spill mechanism on history. On examination his clothing is inadequate for the winter weather, he has untreated dental caries, and his growth has drifted from the 25th to the 5th centile over the past year. The maternal and child health record shows his immunisations are 14 months overdue, and the early-learning service reports he has attended fewer than half of his days this term. His mother, Aroha, is a single parent who lost her rental six weeks ago and is now sleeping on a friend's couch with Tane and his baby sister. During the assessment Aroha confides, tearfully, that Tane's father has recently returned to the home and has hit her in front of the children, and that she is frightened for their safety but does not know where to turn.

Candidate information (2 minutes reading, 12 minutes station)

You are the general paediatric registrar in the emergency department. Tane, aged three, is brought by his mother Aroha with a bath scald. Read the presentation, then conduct the assessment and counselling. The examiner will role-play Aroha. [1] [2]

Candidate tasks

Take a non-judgemental, multi-agency history from Aroha — establish the scald mechanism, map the six domains of unmet need, and assess severity, chronicity, and caregiver capacity without blaming the mother. [1]
Separate neglect from poverty and explain to Aroha how you will respond to both the material hardship and the child-safety concerns. [1] [7]
Counsel on the stepped plan, pairing concrete family support with a child-protection notification, and explain the threshold decision in plain language. [1] [4]
Respond to the disclosed family violence by converting the plan to the acute pathway and making a same-day safety plan. [1] [13]

Model answer in one breath

Tane's presentation spans multiple neglect domains — the scald is supervisory neglect, the inadequate clothing is physical neglect, the immunisation gap is medical neglect, and the non-attendance is educational neglect — and neglect is an act of omission rather than commission, the most common form of maltreatment. The family clearly needs material help for housing and food, and that is the first response, but the chronic multi-domain pattern, the growth drift, and the scald mean a child-protection notification is also indicated; a supportive response and a protective response run together. The disclosed family violence — Tane's father hitting Aroha in front of the children — converts the plan to the acute pathway: immediate safety, a same-day safety plan, crisis supports for Aroha, and a child-protection notification, because routine family-support work cannot run in an unsafe home.

[1][7][2]

Marking anchors

Distinction (PASS)

Frames neglect as omission rather than commission and maps the presentation across the six domains, identifying the scald as supervisory neglect. [1] [7]
Separates neglect from poverty using the adequacy of the caregiving response and chronicity rather than income alone, and commits to a response that addresses both the material hardship and the child-safety concerns. [1]
Delivers a stepped plan pairing concrete family support (housing, food, immunisation catch-up, dental care, parenting and the SEEK-style primary-care approach) with a child-protection notification, and explains the threshold in plain, non-blaming language. [1] [4]
Converts to the acute pathway the moment the family violence is disclosed: immediate safety, a same-day safety plan, crisis supports, and a notification, and closes the loop with a named lead and follow-up. [1] [13]

Borderline

Names some neglect domains but cannot articulate the omission-versus-commission frame or the neglect-versus-poverty distinction, or offers support without assessing the child-protection threshold, or conversely focuses on protection without addressing the housing and food crisis. [1]

Fail

Blames Aroha for the multi-domain pattern, attributes the growth drift to a single cause without assessment, treats support and protection as alternatives, proceeds to "refer to family services and review in clinic" despite the disclosed family violence, or fails to make a child-protection notification when the threshold is clearly met. [1] [2]

Examiner prompt sequence

Opening (the mother): "Doctor, he just pulled a cup of tea on himself, I swear — and we're living on a couch, I can't cope." — Candidate must take a non-judgemental history, map the domains, and address both the injury and the material hardship. [1] [7]
The threshold: "Are you going to take my kids off me?" — Candidate must explain the support-plus-protection plan in plain language and reassure that the goal is help and safety, not removal. [1] [4]
The disclosure: "It's his dad — he came back last week and he hit me, in front of them. I'm scared." — Candidate must convert to the acute pathway, make a same-day safety plan, and notify child protection. [1] [13]

[1] [4] [13] [1] [2]

References

[1]Dubowitz H Neglect in children. Pediatr Ann, 2013.PMID 23556521
[2]Dubowitz H, Bennett S Physical abuse and neglect of children. Lancet, 2007.PMID 17544770
[4]Dubowitz H The Safe Environment for Every Kid model: promotion of children's health, development, and safety, and prevention of child neglect. Pediatr Ann, 2014.PMID 25369580
[7]Saluja G, Brenner R, Morrongiello BA, Haynie D, Rivera M, Cheng TL The role of supervision in child injury risk: definition, conceptual and measurement issues. Inj Control Saf Promot, 2004.PMID 14977501
[13]Runyan DK, Hunter WM, Socolar RR, Amaya-Jackson L, English D, Landsverk J Children who prosper in unfavorable environments: the relationship to social capital. Pediatrics, 1998.PMID 9417144