The Psychological Maltreatment of Children—Technical Report

INTRODUCTION

Because pediatricians are concerned with the physical and emotional welfare of children, they are in a unique position to recognize and report psychological maltreatment. The pediatrician may be the only professional who has regular contact with maltreated children before they enter school. Pediatricians should be aware of risk factors in children and families that may predispose to psychological maltreatment and should recognize the types and consequences of psychological maltreatment. Early recognition and reporting of suspected psychological maltreatment to proper authorities, with the provision of therapeutic services, may prevent or ameliorate the consequences of psychological maltreatment. As with physical maltreatment, individual pediatricians’ thresholds for concern will vary. State statutes on reporting document that only suspicion of psychological maltreatment is required to initiate a report to child protective services.

DEFINITION

Psychological maltreatment is a repeated pattern of damaging interactions between parent(s) and child that becomes typical of the relationship.^1–3 In some situations, the pattern is chronic and pervasive; in others, the pattern occurs only when triggered by alcohol or other potentiating factors. Occasionally, a very painful singular incident, such as an unusually contentious divorce, can initiate psychological maltreatment.⁴

Psychological maltreatment of children occurs when a person conveys to a child that he or she is worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another’s needs.⁵ The perpetrator may spurn, terrorize, isolate, or ignore or impair the child’s socialization. If severe and/or repetitious, the following behaviors may constitute psychological maltreatment⁶:

1. Spurning (belittling, degrading, shaming, or ridiculing a child; singling out a child to criticize or punish; and humiliating a child in public).

2. Terrorizing (committing life-threatening acts; making a child feel unsafe; setting unrealistic expectations with threat of loss, harm, or danger if they are not met; and threatening or perpetrating violence against a child or child’s loved ones or objects).

3. Exploiting or corrupting that encourages a child to develop inappropriate behaviors (modeling, permitting, or encouraging antisocial or developmentally inappropriate behavior; encouraging or coercing abandonment of developmentally appropriate autonomy; restricting or interfering with cognitive development).

4. Denying emotional responsiveness (ignoring a child or failing to express affection, caring, and love for a child).

5. Rejecting (avoiding or pushing away).

6. Isolating (confining, placing unreasonable limitations on freedom of movement or social interactions).

7. Unreliable or inconsistent parenting (contradictory and ambivalent demands).

8. Neglecting mental health, medical, and educational needs (ignoring, preventing, or failing to provide treatments or services for emotional, behavioral, physical, or educational needs or problems).

9. Witnessing intimate partner violence (domestic violence).

INCIDENCE AND CAUSAL FACTORS

As with other forms of child maltreatment, the true prevalence of psychological maltreatment is unknown. When it occurs exclusively, it may have more adverse impact on the child and on later adult psychological functioning than the psychological consequences of physical abuse, especially with respect to such measures as depression and self-esteem,⁷ aggression, delinquency, or interpersonal problems.⁸

Isolated psychological maltreatment has had the lowest rate of substantiation of any type of child maltreatment. In the 1997 Child Maltreatment national report,¹ psychological maltreatment (“emotional maltreatment”) was reported in 6.1% of 817 665 reports received from 43 states. In 1996, 15% of all registrations of maltreatment in England were for psychological maltreatment.⁹ Parental attributes in cases reported for psychological maltreatment include poor parenting skills, substance abuse, depression, suicide attempts or other psychological problems, low self-esteem, poor social skills, authoritative parenting style, lack of empathy, social stress, domestic violence, and family dysfunction.¹⁰ A number of studies have demonstrated that maternal affective disorder and/or substance abuse highly correlate to parent-child interactions that are verbally aggressive.^11,12

At-risk children include children whose parents are involved in a contentious divorce; children who are unwanted or unplanned; children of parents who are unskilled or inexperienced in parenting; children whose parents engage in substance abuse, animal abuse, or domestic violence; and children who are socially isolated or intellectually or emotionally handicapped.¹³

CONSEQUENCES OF PSYCHOLOGICAL MALTREATMENT

Psychological maltreatment may result in a myriad of long-term consequences for the child victim.¹⁴ A chronic pattern of psychological maltreatment destroys a child’s sense of self and personal safety. This leads to adverse effects on the following¹⁵:

1. Intrapersonal thoughts, including feelings (and related behaviors) of low self-esteem, negative emotional or life view, anxiety symptoms, depression, and suicide or suicidal thoughts.

2. Emotional health, including emotional instability, borderline personality, emotional unresponsiveness, impulse control problems, anger, physical self-abuse, eating disorders, and substance abuse.

3. Social skills, including antisocial behaviors, attachment problems, low social competency, low sympathy and empathy for others, self-isolation, noncompliance, sexual maladjustment, dependency, aggression or violence, and delinquency or criminality.

4. Learning, including low academic achievement, learning impairments, and impaired moral reasoning.

5. Physical health, including failure to thrive, somatic complaints, poor adult health, and high mortality.

Similar patterns can be seen in children who are exposed to intimate partner violence.¹⁶ Exposure to domestic violence by terrorizing, exploiting, and corrupting children increases childhood depression, anxiety, aggression, and disobedience in children.¹⁶

ASSESSMENT

A diagnosis of psychological maltreatment is facilitated when a documented event or series of events has had a significant adverse effect on the child’s psychological functioning. Often it is a child’s characteristics or emotional difficulties that first raise concern of psychological maltreatment. A psychologically abusive child-caregiver relationship can sometimes be observed in the medical office. More often, confirmation or suspicion of psychological maltreatment requires collateral reports from schools, other professionals, child care workers, and others involved with the family.

Documentation of psychological maltreatment may be difficult. Physical findings may be limited to abnormal weight gain or loss. Ideally, the pediatrician who evaluates a child for psychological maltreatment will be able to demonstrate or opine that psychological acts or omissions of the caregiver have resulted (or may result) in significant damage to the child’s mental or physical health. Documentation of the severity of psychological maltreatment on a standardized form (see Professional Education Materials for example) can assist practices to develop an accurate treatment plan in conjunction with (or cooperation with) other child health agencies. The severity of consequences of psychological maltreatment is influenced by its intensity, extremeness, frequency, and chronicity and mollifying or enhancing factors in the caregivers, child, and environment. Documentation must be objective and factual, including as many real quotes and statements from the child, the family, and other sources as possible. Descriptions of interactions, data from multiple sources, and changes in the behavior of the child are important. Ideally, the pediatrician will be able to describe the child’s baseline emotional, developmental, educational, and physical characteristics before the onset of psychological maltreatment and document the subsequent adverse consequences of psychological maltreatment. In uncertain situations, referral to child mental health for additional evaluation is warranted.

The stage of a child’s development may influence the consequences of psychological maltreatment. Early identification and reporting of psychological maltreatment, with subsequent training and therapy for caregivers, may decrease the likelihood of untoward consequences. Because the major consequences of psychological maltreatment may take years to develop, delayed reporting of suspected psychological maltreatment (in an effort to document these adverse consequences more completely) may not be in the child’s best interests.

PREVENTION

Psychological aggression (ie, parental controlling or correcting behavior that causes the child to experience psychological pain) is more pervasive than spanking.⁸ A 1995 telephone survey suggested that by the time a child was 2 years old, 90% of families asked had used 1 or more forms of psychological aggression in the previous 12 months. This same survey revealed that 10% to 20% of toddlers and 50% of teenagers experience severe aggression (eg, cursing, threatening to send the child away, calling the child dumb or such other belittling names).¹⁷ Therefore, prevention of psychological maltreatment may be the most important work of the pediatrician.

Pediatricians can offer parents developmentally appropriate anticipatory guidance about the dangers of psychological aggression and maltreatment and model healthier parenting approaches to parents in the office at each visit. They may provide educational brochures to caregivers and inform parents very clearly that improper words and gestures or lack of supportive and loving words can greatly harm children. Most importantly, pediatricians can teach parents that their children need consistent love, acceptance, and attention.

Community approaches, such as home visitation, have been shown to be highly successful in changing the behavior of parents at risk for perpetrating maltreatment.¹⁸ Targeted programs for mothers with affective disorders and substance abuse have also been shown to be useful in preventing psychological maltreatment.^19,20

Committee on Child Abuse and Neglect, 2001–2002

Steven W. Kairys, MD, MPH, Chairperson

Randell C. Alexander, MD, PhD

Robert W. Block, MD

V. Denise Everett, MD

Kent P. Hymel, MD

Carole Jenny, MD, MBA

John Stirling, Jr, MD

Liaisons

David L. Corwin, MD

American Academy of Child and Adolescent Psychiatry

Gene Ann Shelley, PhD

Centers for Disease Control and Prevention

STAFF

Tammy Piazza Hurley