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Victorian Forensic Paediatric Medical Service

General considerations - emotional abuse

  • Emotional abuse

    VFPMS Guideline: Forensic evaluation of the emotionally maltreated child

    Emotional maltreatment involves a ‘relationship’ between the child and parent or carer that includes a repeated pattern of damaging interactions or carer behaviours that become typical of the relationship and result in the child feeling unloved, worthless, flawed, unwanted, endangered or serving an instrumental purpose in meeting carer needs. Emotional maltreatment undermines development and socialization and is almost always harmful to children.

    Emotional maltreatment (abuse and neglect) can be defined as “persistent non-physical, harmful interactions with the child by the caregiver, which include both commission and omission”. The intention to harm the child is not required to fulfil the definition of emotional maltreatment.  

    Emotional maltreatment underpins the abuse of children in all domains and is the common destructive theme across all forms of child abuse and neglect.  Its negative effects are common and the resultant damage frequently extends across the life-course. Arguably the most pervasive consequences of all forms of abuse are its negative psychological effects. This information provides a strong motivation for us to increase our understanding of emotional maltreatment and the ways that it harms children in order to take action to prevent it and to remediate its harmful effects.

    The role of the paediatrician:

    Almost all clinically active paediatricians will have observed negative interactions between carers and children that potentially harm children’s emotional wellbeing. Few paediatricians will have considered whether this carer behavior meets the threshold for a diagnosis of emotional maltreatment. 

    This guideline has been developed to assist paediatricians to recognise emotional maltreatment when they see it or hear about it and to plan for effective interventions.

    Emotionally maltreated children may present to the paediatrician with a range of behavioural, social, physical or developmental problems. As paediatricians we need to be able to recognise, define and categorise emotional maltreatment, acknowledge the harm associated with it, respond appropriately when emotional maltreatment is suspected and recommend action to protect and ameliorate maladaptive outcomes.

    Fig 1 The paediatricians’ role when emotional maltreatment is suspected 

    Emot_abuse_fig_1

    How does a paediatrician assess emotional maltreatment?

    Assessing the child and family in whom emotional maltreatment is suspected involves a process of observation (development, behaviour, carer-child interactions) and information gathering (asking questions of the child, carer and others directly involved in the child’s life).  Information gathered should include social and environmental risk factors, carer risk factors, harmful carer-child interactions and information about the child’s functioning (“tiers of concern”). For a child’s functional difficulties to be attributed to emotional maltreatment, harmful carer-child interactions must be identified.

    Fig 2 Tiers of concern

    Emot_abuse_fig_2

    Once this process is complete, the range of carer behaviours, omissions or failures that may constitute emotional maltreatment (tier 2) can be categorised (see Table 1).

    Table 1 Categories of Emotional Maltreatment

     Emotionally abusive behaviour type Examples of this type of emotional maltreatment Assessment – information gathering (child, carer, others)
     Spurning, rejecting, isolating, humiliating, blaming Critical, harsh or negative comments, scapegoating, preventing normal social contact Ask child about feelings of worth, safety, being loved, feeling happy, opportunities for socialisation.
     Terrorising  

    Perpetrating or threatening violence against a loved one (exposure to intimate partner violence), fear of physical or sexual abuse.  

    		 Ask about family violence, discipline in the family, who gets angry and why, what happens when carers get angry, feelings of fear.
     Corrupting or exploiting  Modelling or encouraging socially unacceptable behaviours such as substance abuse, criminality or inappropriate sexual exposure/behaviours. Missocializing the child into self-destructive and antisocial patterns of behaviour Child victims of sexual exploitation, ask about drug use at home, inappropriate knowledge of drugs of abuse and effects of alcohol intoxication
     Unreliable or inconsistent parenting Inability to prioritise child’s needs and provide consistent physical or emotional care, for example as a result of drug or alcohol abuse or mental illness, harsh or punitive parenting. 

    Ask child where they feel safe, who makes them feel safe, where they like to be, who cares for them, is child’s wellbeing a priority?

     Parentification or overprotection, unrealistic developmental expectations (too high or too low)Using the child to undertake a parents’ role, not allowing/encouraging normal social development, expectations that the child perform roles that he/she is not developmentally capable of, relying on child for emotional or physical needs Ask child about daily tasks, who performs them, how they are done, who prepares food, who cares for younger children, role at home. 
     Denying of emotional responsiveness - emotional neglect (also one of the categories of Child Neglect) Being emotionally unavailable as a result of drug or alcohol intoxication or mental illness, lack of nurturing and responsive parenting 

    Security of attachment (warmth and love)

    Relationship with carers (reliably responsive)

    Is child left alone/abandoned?

    Changes of primary caregiver? Stable placement?
     Failure to recognise boundaries  Fabricated illness, involving the child in parental conflict 


    How does emotional maltreatment harm children?

    Emotional maltreatment can be associated with a range of maladaptive behaviours and adverse sociodevelopmental outcomes.  The relationship between child maltreatment and harmful outcomes is not linear and involves a complex interplay of biopsychosocial factors including genetic makeup, family dynamics and brain development processes.  

    Not all adverse outcomes are the result of maltreatment and significant individual variation exists in the development of resilience to adverse outcomes. However, even resilient maltreated children may feel great sadness and experience self-imposed barriers to a positive life.  

    Table 2 depicts the outcomes for the child that may be associated with emotional maltreatment.

    Table 2 Outcomes associated with emotional maltreatment

     Domain Domain
     Behaviour  

    Oppositional, defiant, hypervigilant, angry, antisocial, sexualised, conduct disorder/antisocial personality disorder, difficulties with affect regulation. May respond universally with aggression – “if the only tool you have is a hammer, you will define every problem as a nail”

    Often diagnosed early in childhood with ADHD, ODD, ASD

    Increased drug misuse, eating disorders, juvenile delinquency, criminality, poor mental health 
     Emotional state 

    Low self-esteem, fear, subjective feelings of unhappiness, withdrawal, anxiety, depression,  major mental illness,  attachment disorders

     Development/educational attainment Low IQ, developmental delay, educational underachievement, poor problem-solving skills and poor self-regulation
     Peer relationships Insecure or disorganised attachment, low empathy, social isolation, often disliked, bullying behaviours, “prickly personality”
     Physical state Poor growth, non-organic pain, toileting problems, sleep disturbance

     

    The likelihood of future harm is also important to acknowledge. Functionally resilient children experiencing emotionally abusive carer behaviour may exhibit adverse outcomes in the future. It is therefore important to recognise and respond to emotional maltreatment even when children are not currently displaying maladaptive behaviour or signs of emotional distress.

    Fig 3 The forensic assessment of Emotional Maltreatment – the pathway

    Emot_abuse_fig_3

    References:

    1. Physical and psychological maltreatment: relations among types of maltreatment. Claussen AH, Crittenden PM. Child Abuse Negl. 1991;15(1-2):5-18
    2. Psychological child maltreatment. A developmental view. Garbarino J Prim Care. 1993 Jun;20(2):307-15.
    3. Not all bad treatment is psychological maltreatment. Garbarino J Child Abuse Negl. 2011; 35: 797-801
    4. Emotional abuse and emotional neglect: antecedents, operational definitions and consequences; Glaser D unpublished report.
    5. Emotional abuse and neglect (psychological maltreatment): a conceptual framework. Glaser D Child Abuse Negl. 2002 Jun;26 (6-7):697-714.
    6. How to deal with emotional abuse and neglect: further development of a conceptual framework (FRAMEA). Glaser DChild Abuse Negl. 2011 Oct;35(10):866-75.