Psychological Maltreatment

Article (PDF Available)inPEDIATRICS 130(2):372-8 · July 2012with24 Reads
DOI: 10.1542/peds.2012-1552 · Source: PubMed
Abstract
Psychological or emotional maltreatment of children may be the most challenging and prevalent form of child abuse and neglect. Caregiver behaviors include acts of omission (ignoring need for social interactions) or commission (spurning, terrorizing); may be verbal or nonverbal, active or passive, and with or without intent to harm; and negatively affect the child's cognitive, social, emotional, and/or physical development. Psychological maltreatment has been linked with disorders of attachment, developmental and educational problems, socialization problems, disruptive behavior, and later psychopathology. Although no evidence-based interventions that can prevent psychological maltreatment have been identified to date, it is possible that interventions shown to be effective in reducing overall types of child maltreatment, such as the Nurse Family Partnership, may have a role to play. Furthermore, prevention before occurrence will require both the use of universal interventions aimed at promoting the type of parenting that is now recognized to be necessary for optimal child development, alongside the use of targeted interventions directed at improving parental sensitivity to a child's cues during infancy and later parent-child interactions. Intervention should, first and foremost, focus on a thorough assessment and ensuring the child's safety. Potentially effective treatments include cognitive behavioral parenting programs and other psychotherapeutic interventions. The high prevalence of psychological abuse in advanced Western societies, along with the serious consequences, point to the importance of effective management. Pediatricians should be alert to the occurrence of psychological maltreatment and identify ways to support families who have risk indicators for, or evidence of, this problem.
CLINICAL REPORT
Psychological Maltreatment
abstract
Psychological or emotional maltreatment of children may be the most
challenging and prevalent form of child abuse and neglect. Caregiver
behaviors include acts of omission (ignoring need for social interac-
tions) or commission (spurning, terrorizing); may be verbal or nonver-
bal, active or passive, and with or without intent to harm; and
negatively affect the childs cognitive, social, emotional, and/or phys-
ical development. Psychological maltreatment has been linked with
disorders of attachment, developmental and educational problems,
socialization problems, disruptive behavior, and later psychopathol-
ogy. Although no evidence-based interventions that can prevent psy-
chological maltreatment have been identied to date, it is possible
that interventions shown to be effective in reducing overall types of
child maltreatment, such as the Nurse Family Partnership, may have
a role to play. Fur thermore, prevention before occurrence will require
both the use of universal interventions aimed at promoting the type of
parenting that is now recognized to be necessary for optimal child
development, alongside the use of targeted interventions directed at
improving parental sensitivity to a childs cues during infancy and
later parent-child interactions. Intervention should, rst and foremost,
focus on a thorough assessment and ensuring the childs safety.
Potentially effective treatments include cognitive behavioral parenting
programs and other psychotherapeutic interventions. The high prev-
alence of psychological abuse in advanced Western societies, along
with the serious consequences, point to the importance of effective
management. Pediatricians should be alert to the occurrence of psy-
chological maltreatment and identify ways to support families who
have risk indicators for, or evidence of, this problem. Pediatrics
2012;130:372378
INTRODUCTION
Psychological or emotional maltreatment of children and adolescents
may be the most challenging and prevalent form of child abuse and
neglect, but until recently, it has received relatively little attention. The
American Academy of Pediatrics (AAP) reviewed the topic in a technical
report in 2002.
1
This clinical report updates the pediatrician on
current knowledge and approaches to psychological maltreatment,
with guidance on its identication and effective methods of prevention
and treatments/intervention.
Roberta Hibbard, MD, Jane Barlow, DPhil, Harriet
MacMillan, MD, and the Committee on Child Abuse and
Neglect and AMERICAN ACADEMY OF CHILD AND
ADOLESCENT PSYCHIATRY, Child Maltreatment and Violence
Committee
KEY WORDS
psychological maltreatment, child abuse, emotional
maltreatment, neglect, verbal abuse, development
ABBREVIATIONS
AAPAmerican Academy of Pediatrics
NFPnurse family partnership
This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors
have led conict of interest statements with the American
Academy of Pediatrics. Any conicts have been resolved through
a process approved by the Board of Directors. The American
Academy of Pediatrics has neither solicited nor accepted any
commercial involvement in the development of the content of
this publication.
The guidance in this report does not indicate an exclusive
course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be
appropriate.
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DEFINITION
There is no universally agreed denition
of psychological maltreatment or emo-
tional maltreatment, terms that are of-
ten used interchangeably. Psychological
maltreatment encompasses both the
cognitive and affective components of
maltreatment.
2
One of the difculties in
clearly dening what such maltreat-
ment comprises involves the absence
of a strong societal consensus on the
distinction between psychological mal-
treatment and suboptimal parenting.
3
Exposure to psychological maltreatment
is considered when acts of omission
or commission inict harm on the
childs well-being , which may then be
manifested as emotional distress or
maladaptive behavior in the child.
Psychological maltreatment is difcult
to identify, in part because such mal-
treatment involves a relationship be-
tween the parent and the child rather
than an event or a series of repeated
events occurring within the parent-
child relationship.
4
Isolated incidents
of behaviors identied in Table 1 do not
necessarily constitute psychological
abuse. Psychological maltreatment refers
to a repeated pattern of parental be-
havior that is likely to be interpreted
by a child that he or she is unloved,
unwanted, or serves only instrumental
purposes and/or that severely under-
mines the childs development and so-
cialization.
4
Recent conceptualization
5
of psychological maltreatment focuses
on the caregivers behaviors as opposed
to the disturbed behaviors in the child.
Such behaviors of the caregiver include
acts of omission (ignoring the need
for social interaction) or commission
(spurning, terrorizing); may be verbal
or nonverbal, active or passive, and with
or without intent to harm; and negatively
affect the childs cognitive, social, emo-
tional, and/or physical development.
Table 1 summarizes the different types
of psychologically abusive caregivers
behaviors across 6 main categories.
2,5
Although the psychological compo-
nents of any form of child maltreat-
ment are key to understanding its
effects, psychological maltreatment is
often not recognized when other forms
of maltreatment coexist.
3
When psy-
chological maltreatment occurs alone,
itcanbeevenhardertoidentify,and
opportunities for intervention may be
missed. This form of child maltreatment
is possibly the most underreported to
authorities.
3,6
DISTRIBUTION OF PSYCHOLOGICAL
MALTREATMENT
A recent review of the burden and
consequences of psychological abuse
concluded that, although there were
few studies reporting its prevalence,
a number of large population-based,
self-report studies in the United King-
dom and United States found that ap-
proximately 8% to 9% of women and 4%
of men reported exposure to severe
psychological abuse during childhood.
7
This review found even higher rates
reported in Eastern Europe. A number
of US surveys found that psychological
and emotional maltreatment were the
most frequently self-reported forms of
victimization.
8
DETERMINANT S OF PSYCH OLOGICAL
MALTREATMENT
Although it is recognized that psy-
chological maltreatment occurs in
a wide range of families, it is more
often associated with multiple family
stresses
9
and, in particular, with
factorssuchasfamilyconict, adult
mental health problems, and paren-
tal s ubstance abuse
10
that may be
co-occurring.
11
For example, some pa-
rental mental health problems are
associated with unpredictable and
frightening behaviors, and others
(par ticularly depression) are linked
with parental withdrawal and ne-
glect.
12,13
Similarly, in terms of family
conict, attacks on a parent almost
always frighten a child, even if t he
child is not the direct target. Threats
or actual violence as part of a pat-
tern of agg ression against one par-
ent will sometimes exploit the other
parent s or childsfears.
14,15
Children
exposed to violence in the home are
at dispropor tionate risk of injury,
TABLE 1 Types of Psychologically Abusive Behaviors