Objective: To examine the association between father involvement and child neglect. Design: Cohort study. Setting: Participants were recruited from an inner-city pediatric primary care clinic and a clinic for children at risk for human immunodeficiency virus infection in a teaching hospital. Participants: Mothers and fathers or father figures, and 244 five-year olds participating in a longitudinal study. Main Outcome Measures: Child neglect measured via home observation, a videotaped mother-child interaction, and child protective services reports. Results: A father or father figure was identified for 72% of the children. Rates of neglect ranged between 11% and 30%. Father absence alone was not associated with neglect. However, in families with an identified and interviewed father, a longer duration of involvement (P<.01), a greater sense of parenting efficacy (P<.01), more involvement with household tasks (P<.05), and less involvement with child care (P<.05) were associated with less neglect. The overall model explained 26.5% of the variance in neglect. Conclusions: There is substantial involvement of fathers in a subset of this high-risk sample, although more than a quarter of the children lacked a father or father figure. The mere presence of a father did not significantly influence the neglect of the children; rather, the nature of his involvement did. Fathers who felt more effective as parents were less likely to have neglected their children. A greater sense of efficacy may reflect parenting skills and be important in enhancing the contribution of fathers to their children's well-being. Pediatric health care providers can play a valuable role in enhancing the involvement and skills of fathers.