Key points

Introduction

Emotional maltreatment, although often overlooked and underappreciated, may be the most complex, prevalent, and damaging form of child abuse or neglect. Difficulties in understanding and defining emotional maltreatment have resulted, in part, from varying terminology used to refer to this form of maltreatment over the last 30 years: psychological abuse, emotional abuse, psychological maltreatment, and emotional neglect are terms that have been used interchangeably but inconsistently. The purpose of this article is to focus on what is known about emotional maltreatment.

Emotional maltreatment likely affects, either directly or indirectly, a large portion of the population, and its victims often suffer from a constellation of damaging cognitive, emotional, and behavioral symptoms. If these symptoms remain untreated, childhood victims of emotional maltreatment become adults with a wide range of behavioral and emotional difficulties that often put their own children at risk of emotional maltreatment. Medical professionals are in a unique position to identify children who may be at risk of emotional maltreatment and direct the child and his or her family to community programs and social service providers that can work to improve the quality of life for the family.

Introduction

Emotional maltreatment, although often overlooked and underappreciated, may be the most complex, prevalent, and damaging form of child abuse or neglect. Difficulties in understanding and defining emotional maltreatment have resulted, in part, from varying terminology used to refer to this form of maltreatment over the last 30 years: psychological abuse, emotional abuse, psychological maltreatment, and emotional neglect are terms that have been used interchangeably but inconsistently. The purpose of this article is to focus on what is known about emotional maltreatment.

Emotional maltreatment likely affects, either directly or indirectly, a large portion of the population, and its victims often suffer from a constellation of damaging cognitive, emotional, and behavioral symptoms. If these symptoms remain untreated, childhood victims of emotional maltreatment become adults with a wide range of behavioral and emotional difficulties that often put their own children at risk of emotional maltreatment. Medical professionals are in a unique position to identify children who may be at risk of emotional maltreatment and direct the child and his or her family to community programs and social service providers that can work to improve the quality of life for the family.

What is emotional maltreatment?

Emotional maltreatment may include a single traumatic event or a repeated pattern of behavior that harms a child’s emotional, developmental, or psychological well-being. It includes acts of omission or commission and can be verbal or nonverbal, active or passive, and perpetrated with or without actual intent to harm the child. This harm can be manifested as emotional distress or maladaptive behavior in the child resulting from the impact on cognitive, social, emotional or physical development. Emotional maltreatment (encompassing both emotional abuse and emotional neglect) requires no physical contact and occurs within the interactions between the perpetrator and child. These negative interactions characterize the relationship and may leave the child feeling deficient, unimportant, or unloved.

Emotional maltreatment can take several forms, including spurning; terrorizing; exploiting/corrupting; denying emotional responsiveness; isolating; and mental health, medical, and educational neglect ( Fig. 1 )—all negative and potentially degrading interactions. Single incidents may, but do not necessarily, constitute maltreatment; repeated caregiver behaviors in these categories undermine development and socialization and are clearly harmful. Mental, medical, and educational neglect may become emotional maltreatment when the omission of such care and nurturance makes the child feel unworthy and not deserving. Differentiating suboptimal parenting from emotional maltreatment is often difficult because of a lack of societal consensus. Key in the determination of maltreatment is the harm to the child.

Forms of emotional maltreatment.

( Data from Hart SN, Brassard MR, Binggeli NJ, et al. Psychological maltreatment. In: Myers JE, Berliner L, Briere J, editors. The APSAC handbook on child maltreatment. 2nd edition. Thousand Oaks (CA): Sage Publications; 2002. p. 79–104.)

Emotional maltreatment can stand alone as the sole form of maltreatment experienced by the victim or coexist with any of the other forms of child abuse or neglect. Many of the lasting and most damaging effects of physical abuse, sexual abuse, and neglect are psychological in nature and may be a manifestation of the underlying emotional maltreatment. The broken bone can heal, the sexually transmitted infection can be treated, but the fear, uncertainty, and emotional component of not knowing when or if it may happen again often has a longer-lasting, damaging effect on the child. The overlapping nature of the various types of child maltreatment make it imperative to consider all other forms whenever any one of them is suspected, as failure to do so could lead to an inadequate intervention plan. Emotional maltreatment is often the greatest predictor of potential psychological problems later in the victim’s life.

How emotional maltreatment affects children

Emotional maltreatment comprises the most damaging and consequential components of child abuse and neglect and is often the most substantive threat to the victim’s mental health. Emotional maltreatment affects a child’s mental and physical development and may lead to deficits in academic performance, IQ, memory, learning capacity, and brain volume. Children who are victims of emotional maltreatment also suffer from a wide range of social and behavior difficulties including depression, personality disorders, anxiety, and aggression.

Emotional maltreatment can begin to negatively affect children from the earliest stages of infancy. The human brain possesses a great deal of adaptability after birth, allowing for the growth and development of the areas of the brain most used by the child during the early years of life. This important process enables the brain to adapt itself to best suit the environment of the child. With attuned, responsive parenting and healthy and appropriate stimulation, the child’s developing brain can flourish in an environment that promotes growth and stability. However, when a child does not receive this healthy stimulus, which is often the case in an abusive or neglectful home environment, development of specific areas of the brain, for example those responsible for caring behavior and cognitive abilities, are damaged in a manner that becomes increasingly irreversible with age.

The elevated levels of stress, often experienced by victims of emotional maltreatment, can also put the child’s developing brain at an increased risk of structural changes. When a child experiences stress, his or her body’s physiologic response kicks in. Designed to be simply a temporary response, these changes (eg, elevated blood pressure, increased heart rate) are regulated by cortisol, a hormone released from the adrenal cortex to contain the effects of the body’s stress response and restore equilibrium. Chronic elevations of cortisol, which result from regular exposure to high-stress situations, can cause great harm to a child’s developing brain and lead to an alteration in the body’s stress response for future events.

When children live in an abusive or neglectful environment, they begin to internalize the concept that the world is a dangerous and unstable place. The development of emotional and social skills, often dependent on the strength and quality of the child’s interactions within his or her early relationships, suffer, and the child may experience an overwhelming sense of helplessness. The child becomes more likely to overestimate danger and adversity, experience a decreased sense of self-worth, suffer from anxiety and depression, and experience emotional numbing or hyperarousal (symptoms of posttraumatic stress disorder).

Perhaps the most complete examination of the overall emotional, behavioral, and social effects of abuse and neglect on a child’s functioning is the work of Egeland and his colleagues with the Minnesota Mother-Child Interaction Project. This longitudinal study followed the development of 267 children born to first-time mothers who were identified as being at risk of parenting problems based on several factors including age, lack of education, low income, lack of support, and instability. The study examined several different forms of child maltreatment, but the children who were identified as having experienced emotional neglect or “psychologically unavailable parenting” suffered the most dramatic consequences. Many of these children experienced a wide range of negative symptoms that were present throughout their childhood and extended into their teen years ( Fig. 2 ). Participants who suffered from maltreatment in the first 2 years of life seemed to exhibit more negative outcomes than those who were victimized after they had reached the age of 2 years.

Social and behavioral effects of emotional neglect.

( Data from Erickson MF, Egeland B. Child neglect. In: Myers JE, Berliner L, Briere J, editors. The APSAC handbook on child maltreatment. 2nd edition. Thousand Oaks (CA): Sage Publications; 2002. p. 3–20.)

The lingering effects of emotional maltreatment

Children who are victims of emotional maltreatment often grow up to be adults with several psychological, social, and behavioral difficulties. Research suggests they are often at increased risk for both mental and physical illness, including eating disorders, deficits in psychological functioning, depression, and low self-esteem. They may be unable to appropriately cope with stress or anxiety, more likely to exhibit violent or aggressive behavior, and more likely to abuse alcohol or drugs —all characteristics often identified as risk factors for perpetrating emotional maltreatment.

The negative effects of emotional maltreatment are not simply limited to the victim; everyone connected to the victim may also be affected in some way. The negative behavioral and social symptoms often experienced by victims of emotional maltreatment may make forming strong and healthy relationships with those around them difficult ( Fig. 3 ). If victims of emotional maltreatment become parents, they are less likely to be able to provide the kind of stable and supportive relationships that their own children need. Without sufficient care and attention, these children are placed in an environment that puts them at an increased risk of child maltreatment, often leading to a continuation of the damaging cycle of emotional maltreatment.

Relationships affected by emotional maltreatment.

Prevalence

The lack of consensus as to a working definition of emotional maltreatment and the likelihood that it often goes unreported make it extremely difficult to accurately estimate its prevalence. Researchers are limited in their means to extract and gather data on emotional maltreatment, most often asking study participants to self-report whether they were abused as children or if they have abused their own children. Conservative estimates have put the prevalence of emotional maltreatment to be in the range of 8% to 12% in the general population.

Studies repeatedly show that emotional maltreatment is present in 75% to 90% of known cases of physical abuse or neglect, but the fact that emotional maltreatment often underlies these more visually symptomatic forms of abuse can lead to it being overlooked during a child’s initial evaluation. Trickett and colleagues reviewed 303 children who were known to have been victims of some form of maltreatment. After conducting in-person interviews and reviewing a summary of the child’s involvement with the Department of Children and Family Services, including agency records, court reports, investigation documents on reports of maltreatment, and placement history, nearly half of the children were determined to have been victims of emotional maltreatment. Only 9% of these children had been identified as such at the time of their initial Children and Family Services’ referral. Despite the fact that most of these children experienced more than one form of emotional maltreatment, most commonly terrorizing and spurning, it was often only the co-occurring physical abuse or neglect that was the focus of the Child Protective Services’ investigation.

Another difficulty in estimating the prevalence of emotional maltreatment is that most definitions and studies that examine this form of maltreatment focus primarily on the child’s relationship with his or her primary caregiver. As is the case with other forms of abuse or neglect, a child can be emotionally maltreated by anyone. Although the primary caregiver is the one who likely spends the most time with the child and, therefore, may have the greatest opportunity to inflict the abuse or neglect, often other people are in a position to emotionally maltreat the child. Studies that do not limit their definition to parent-child relationships find that children report being emotionally maltreated by a variety of perpetrators. These perpetrators are most often an older person who is important in the life of the child and can include relatives, teachers, coaches, babysitters, and other adults in a position of authority over the child.