Emotional Maltreatment: An Overview

Introduction

Emotional or psychological maltreatment is a highly prevalent and damaging form of child abuse. It reflects a caregiver’s failure to provide a developmentally-appropriate and supportive environment, including persistent, pervasive or patterned dehumanizing acts such as frequent name-calling (emotional abuse; acts of commission) and failures in providing nurturance, affection, and approval (i.e., emotional neglect; acts of omission). Six types are recognized: (1) rejecting (e.g., constant criticism, belittling); (2) isolating (e.g., keeping family and friends from child); (3) ignoring (e.g., non-responding to child attentional bids, achievements etc.); (4) terrorizing (e.g., threatening abandonment or harm); (5) corrupting (e.g., child involvement in or exposure to criminal activities); and (6) exploiting (e.g., assigning caregiver role to child for parental care or childcare).¹ Some jurisdictions also categorize exposure to adult intimate partner violence (IPV) as a form of child emotional abuse. In this series, children’s exposure to IPV is considered as a separate category of child maltreatment.  Experiencing emotional maltreatment is strongly associated with the experience of other forms of childhood maltreatment and household dysfunction.² Unlike other forms of maltreatment, which may have physical indicators, emotional maltreatment has none. In sum, emotional maltreatment may be a stand-alone form of abuse or neglect, as well as a frequently co-occurring form.¹

Prevalence and Under-Reporting

Different estimates of emotional maltreatment prevalence arise from research with different populations. A review of meta-analyses estimates the global prevalence of emotional abuse as 36.3% of people affected, and emotional neglect as 18.4% of people affected.³ Studies of youth involved with Child Protective Services (CPS) have found that emotional maltreatment tends to occur much more frequently than what is recorded by CPS workers. In one study of CPS-involved cases that involved coding maltreatment experiences with a standard framework, over 50% of youth had experienced emotional abuse (chiefly terrorizing); the majority had also experienced physical abuse and neglect.⁴ The Ontario Incidence Study of Reported Child Abuse and Neglect placed the 2013 CPS substantiation rate for emotional maltreatment rate at 13%, and the exposure to IPV at 48%.⁵ Researchers found that 30% of cases where emotional maltreatment was the primary form had more than three prior case openings for some form of maltreatment.⁶ The U.S. CPS-involved youth longitudinal study (LONGSCAN) found that 98% of youth who reported emotional maltreatment, reported re-experiencing it.⁷ Exposure to early emotional maltreatment, number of CPS reports, and having a caregiver with depression were factors shown to predict entry into the foster care system.⁸ 

Subject

Recent longitudinal research found that maternal negative expressiveness mediated the relationship between mother’s own emotional maltreatment experiences and their infant’s emotional dysregulation and behavioral problems, in children as young as 14 months.⁹ Parents who direct intense negative emotions towards the child (disgust, anger) or create highly negatively charged environments (yelling, being over-controlling) risk overwhelming their child’s cognitive capacities and creating disorganized behavioural responses. This dynamic of parental ignore/attack and child destabilization creates a trajectory of impairment in managing emotions related to self and others. Research has shown that parents who perceive themselves as powerless, have both higher emotional reactivity and hostility towards their child’s behaviour. In response to perceived child personal attack or personalization of disobedience, the parent responds with power assertive actions (rejection, attack).¹⁰ Not surprisingly then, emotional maltreatment has been linked to significant impairment in emotion regulation, including difficulties with both emotional clarity (i.e., being able to identify one’s emotions) and emotional expressiveness.^11-14 Emotional maltreatment-related impairment spans a wide range of mental health areas, including personality problems, mood disorders, substance abuse problems, and relationship violence.^2,15,16 A systematic review showed increased risks impacting school achievement (impulsivity, inability to pay attention, reduced literacy, and numerical skills difficulties).¹⁶  Emotional maltreatment is associated with social anxiety and anxiety disorders^17-20 and depression.^21-24 Emotional neglect has been associated with drug-use and smoking,23 as well as binge drinking, alcohol abuse, and other alcohol-related problems.²⁵ There is some evidence of greater mental health impact of emotional maltreatment in adolescence on male victims.²⁶ Experiencing emotional abuse is predictive of aggression symptoms, however, there may be gender differences in the pathway from maltreatment to aggression. For example, one study found that this relationship was mediated by psychoticism in males, and neuroticism in females.²⁷ In a study of male youth offenders, maternal warmth mediated the relationship between emotional neglect and youth presenting with callous unemotional traits.²⁸

Longitudinal research has identified the experience of emotional maltreatment over the course of a three-year period as a significant predictor of youth suicide ideation.²⁹ A nationally representative U.S. study found that adolescents who reported child emotional abuse were 2.6 times more likely to report suicidal ideation, and 2.4 times more likely to report a suicide attempt in the past year than those who had not experienced emotional abuse.³⁰ A core insult may be to the victim’s sense of mattering (i.e., to one’s self, to others, and to the environment), with emotional maltreatment linked with low levels of mattering.³¹ 

Another potential area of impairment for victims of emotional maltreatment is in building and maintaining positive relationships. A systematic review of the literature on adolescent victims of emotional maltreatment identified associations to both perpetration and victimization of IPV in males.³² For CPS-involved youth, emotional maltreatment predicted dating violence perpetration in adolescent males and victimization in females, both of which were explained in part by the level of trauma symptomatology.¹⁵ Similarly, emotional maltreatment predicted risky sexual behaviour at age 18, mediated in part by trauma symptoms.³³ The link between childhood emotional maltreatment and later decreased life satisfaction was mediated by rejection sensitivity in romantic partnerships in males.³⁴ For females, emotional maltreatment has been shown to significantly predict low relationship satisfaction.³⁵ Similarly, results from the U.S. Longitudinal Study of Adolescent to Adult Health found that experiencing emotional abuse was significantly related to adult perpetration and victimization of IPV in males, and perpetration and mutually-perpetrated violence in females.³⁶ Emotional maltreatment in childhood appears to be a robust disruptor of functioning in close relationships. 

Finally, there is some evidence that children who have been victims of emotional maltreatment may be at risk of disordered eating behaviour and relationships in adolescence and adulthood. Kimber and colleagues conducted a systematic review finding the prevalence of emotional maltreatment, including IPV exposure, as it relates to eating disorders ranging from 21% to 66%.³⁷ A study of obese adults found that those with binge eating disorder reported significantly higher levels of emotional abuse and neglect.³⁸ In a large non-clinical study, emotional abuse was a significant positive predictor for hoarding of material possessions.³⁹

Problems

1. Prevalence of emotional maltreatment is high.
2. While there is emerging consensus on (a) patterned caregiver behaviour defining emotional maltreatment, and (b) parental risk factors (depression, substance abuse, psychiatric illness in general, and a history of maltreatment), there is no agreement as to how to operationalize emotional maltreatment for practical use in terms of community standards for reasonable parenting.^40,41
3. Existing parenting programs have some content relevant to emotionally maltreating caregiving (e.g., planned attention, positive time or time-in); prevention of emotional maltreatment has not yet been a focus in child welfare or public health, although IPV has in both systems.^42,43
4. Sex may be a factor in understanding the emotional maltreatment–impairment link. Impact across the gender spectrum remains to be considered further.
5. A 2011 review determined further research was needed to develop a reliable and valid instrument to measure childhood emotional maltreatment.⁴⁴ Clinicians are encouraged to ask children about their family relationships, feelings of self-worth, being loved and safety.

Research Context

Most information on emotional maltreatment, as it relates to youths receiving CPS services comes from countries with formal child protection systems. When a case of emotional maltreatment is substantiated, it means the child welfare authorities investigated the allegation and deemed it to be of sufficient seriousness. The services provided could range from investigation only to child counseling to out-of-home placement for alternate caregiving.

Key Research Questions

1. How does emotional maltreatment reflect a cycle of violence?
2. Are there emotional maltreatment indicators that signal greater risk for impairment or factors promoting resilience? 
3. How does emotional maltreatment relate to gender diverse youth experiences?

Recent Research Results

A recent meta-analysis of studies involving parents committing emotional abuse found that emotionally abusive parents typically reported negative affect, depression, verbal aggression, emotion dysregulation and anger, as well as low levels of emotional control and positive coping strategies.⁴⁵ These results draw attention to the issue of intergenerational transmission of risk, as well as the need to emphasize intervention to bolster positive coping or parenting resilience.

A recent focus of attention has been the cognitive functioning and development of maltreated children.⁴⁶ For example, among foster children (in out-of-home care), a history of emotional abuse was negatively correlated with height-for-age, visual-spatial processing, memory, language and executive function.⁴⁷ Early intervention that targets environmental enrichment shows promise in yielding better child cognitive outcomes (e.g., memory) that seem to be mediated by the child’s stress response hormones.⁴⁸ The ultimate goal is to consider the contexts for resilient functioning, integrating streams of biological, clinical and epidemiological research, with prevention.⁴⁹

To date, it appears that there have been no studies looking at how concepts of heteronormative discrimination and social stigma may relate to emotional maltreatment among LGBTQ2SI+ youth. One recent study found that gay, lesbian, and bi-sexual adults who had experienced childhood emotional maltreatment had significantly higher levels of depression and anxiety symptoms as compared to those not experiencing familial emotional maltreatment.⁵⁰

Research Gaps

Legal and medical definitions to guide CPS thresholds for intervention vary across regions, despite the clear need for CPS to accord more attention to emotional maltreatment impacts.⁴⁹ Presently, there is no “gold standard” approach to determine exposure to emotional maltreatment. In 2012, the American Academy of Pediatrics published a clinical report emphasizing the need for clinicians to be alert for this form of maltreatment, and consider interventions that promote positive parenting and child development, emphasizing the priority of child safety includes both physical and psychological safety.⁵¹ A gap area relates to the rise of e-communications and the issue that emotional maltreatment may be perpetrated over the internet or via social media by family and others.

It is also important to examine how the effects of emotional maltreatment occur beyond caregiver/family dynamics. Recent research has examined the effects of emotional maltreatment on students by their teachers.⁵² One study of Korean youth reporting that 18.2% had experienced emotional maltreatment committed by their teacher,⁵³ and another study from the Republic of Cyprus reporting that 33.1% of students surveyed had been emotionally abused by a teacher in primary school.⁵⁴ As complex as it may be to define and identify familial emotional maltreatment, it becomes increasingly complicated to detect emotional maltreatment occurring outside of the home. 

Conclusions and Implications for Parents, Practice and Policy

Emotional maltreatment is a prevalent, but less visible form of childhood maltreatment. The implications for parents, practice and policy is: (1) a consideration of the home emotional climate, emotional literacy and the provision of experiences where there is a dominance of positive over negative emotions; (2) to prevent the occurrence of child maltreatment including exposure to adult IPV; (3) to adequately promote the safety, well-being and rights of children and youth to live free of all forms of violence; and (4) to prevent or dampen maltreatment-related impairment via an increased focus on resilience. Evidence-based parenting programs exist and, given the broad range of impairment, it is severely costly to not implement these from a public health perspective.^55-58 

A chaotic, violent, antagonistic home life is maltreating in a persistent way for children and represents a toxicity to child and adolescent development. Transition from the home, such as quality preschool experiences, formal school entry, and increasing autonomy in adolescence provide opportunities to realign emotion-focused learning and orient towards positivity and healthy coping. Resilience-oriented programming may be an innovation approach to dampening the impact of emotional maltreatment. Emotional maltreatment has been linked to lower optimism; however, the experience of positive life events may buffer this effect and increase dispositional optimism.⁵⁹ Research has demonstrated the effectiveness of positive schemas (i.e., the ability to focus on positive stimuli and ignore negative, or emotionally taxing stimuli) in promoting resilience and interrupting the trajectory from childhood emotional maltreatment to poor mental health (e.g., depression).^60,61 These findings underscore an opportunity to emphasize safe, social relationship-building and to embrace service systems as partners in promoting wellbeing and resilience. Better life outcomes occur when violence in the personal and home environment ceases and positive experiences and opportunities increase. Emotional maltreatment is a preventable form of child maltreatment, and may yield sizeable dividends, given its prevalence.

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