Names Hurt as Much as Sticks and Stones

Psychological child abuse just as harmful as physical or sexual abuse

/ Author:  / Reviewed by: Chris Galloway, M.D.

The importance of recognizing, reporting and intervening when it comes to child abuse took years to gain wide acceptance in the US, helped by advocates such as Christina Crawford.

Crawford's memoir about the abuse she suffered from her mother, the Academy Award-winning Hollywood star Joan Crawford, eased the way for more people to come forward and for child welfare organizations to take a more active role in addressing child abuse.

In a recent position statement published by the American Academy of Pediatricians (AAP), the organization has pushed for further progress in ensuring the safety and security of American children.

The AAP has taken the significant step of recognizing psychological abuse as not only under-recognized and under-treated compared to other forms of abuse, but also as equally harmful as physical and sexual abuse.

"The high prevalence of psychological abuse in advanced Western societies, along with the serious consequences, point to the importance of effective management," wrote the authors of the Child Maltreatment and Violence Committee led by Roberta Hibbard, MD. "Psychological maltreatment is just as harmful as other types of maltreatment."

The authors cite studies that estimate the prevalence of psychological abuse during childhood at approximately 8 to 9 percent of women and 4 percent of men in the US and United Kingdom. Even these estimates may be low depending on the reporting methods used in the studies. In fact, several US surveys, the authors said, found psychological and emotional abuse to be "the most frequently self-reported forms of victimization."

Social worker LuAnn Pierce told dailyRx that the organization's statement is a tremendous step in the right direction despite the challenges that recognizing and treating psychological child abuse involve.

"This could be a major breakthrough for children and teens," Pierce said. "The long-term consequences of psychological abuse, which often entails witnessing abuse behavior between adults, has historically been hard to define and even harder to recognize for those who inflict the abusive behaviors on their children, either direction with verbal or emotional, or indirectly in cases where negligence or secondary trauma exists."

Defining Psychological Abuse

The organization's statement begins by discussing the difficulties in defining psychological maltreatment, pointing out that it has more to do with the relationship between a parent and a child than it does specific incidents that can be easily documented, such as occurs with physical or sexual abuse. With psychological abuse, it's the recurrence of often subtle incidents that may be incurring the damage.

"Psychological maltreatment refers to a repeated pattern of parental behavior 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 undermines the child's development and socialization," the authors wrote.

They then describe types of behaviors that fall into six different categories of psychological abuse.

"Spurning" involves any type of belittling or other rejection that affects a child's self-worth. It could include ridiculing a child for showing normal responses or emotions, such as for crying when crying is a reasonable response to a situation. It could also include singling a child out for certain behaviors or humiliating them in front of others.

"Terrorizing" includes placing children in frightening or dangerous situations, whether real or perceived. Putting a child into an unpredictable or chaotic situation, putting them in harm's way, threatening a child if they do not meet unrealistic and strict expectations or acting violently toward people or objects loved by the child all fall under the label of "terrorizing."

"Isolating" can include physically isolating a child within a small, enclosed area, such as a closet or a basement or even the child's bedroom, or it can be mean restricting the child's access to social situations and the community in general on an on-going basis.

"Exploiting" or "corrupting" has more to do with encouraging a child to take part in inappropriate behaviors or even modeling inappropriate behaviors for a child to follow. It can also involve undermining the child's ability to think for themselves, such as with emotional manipulation, or preventing a child from developing normally.

"Denying emotional responsiveness" is one of the more difficult types of psychological abuse to recognize because it relates to a parent's lack of involvement with a child. It can include detachment - when a parent only interacts with a child when absolutely necessary - or simply remaining cold to a child during interactions and conversations. Withholding warmth, praise and a nurturing attitude all fall into this category.

"Mental health/medical/educational neglect" includes restricting a child from accessing the health care he or she may need even if the parent has the means and resources to do so. Not taking a child to a mental health professional or not taking advantage of community resources for mental, physical, emotional, behavioral or educational needs are a form of neglect if the child requires professional attention.

In addition to these categories, psychological damage can occur to children simply from exposure to frightening or disturbing situations, such as homes that include partner violence, mental illness or drug or alcohol abuse.

Effects of Psychological Abuse

While the consequences of being emotionally abused do not leave the same physical scars as physical abuse, the long-term impact is just as harmful to a person's development and self-image, and psychological abuse has been linked to a higher likelihood of mental illness diagnoses later in life.

"Children exposed to violence in the home are at disproportionate risk of injury, eating disorders and self-harm, even when they are not themselves victims of physical violence" the AAP authors wrote.

The statement discusses the findings of several studies conducted with Romanian orphans which found that the earliest years of a child's life are especially vulnerable to long-term developmental damage if the child's emotional needs are neglected. Because of the rapid growth and development of a child's brain during the first three years of life, the child's environment and early parenting or early experiences with a caregiver can play a significant role in how the brain forms and whether the child develops an appropriate attachment to a caregiver.

Not developing a secure attachment, as well as having negative beliefs about themselves, has been shown in the research to have long-term consequences for an individual. A child's relationships with their peers or future friendships and romantic partners, their ability to be intimate, their ability to be a caregiver or receive care, their sexual functioning, their conflict-resolution and decision-making skills and problems with aggression can all result from childhood psychological maltreatment.

Further, adults who experience emotional neglect or psychological abuse as children are more likely to be diagnosed with a mental illness. In fact, three quarters of children who were emotionally abused end up with at least two mental health diagnoses, according to the AAP authors. The earlier the abuse occurs, the more likely the later mental health problems are.

One study found that boys who experienced physical abuse before age 12 had more serious problems later on (such as arrests and delinquency) than boys who were physically abused after age 12. Similar studies dealing with psychological abuse are harder to come by, but the research that is available points to a likelihood of similar scenarios for emotional abuse.

Another long-term effect of psychological abuse is the perpetuation of abuse. "Without intervention, the cycle of abuse is often repeated in the next generation," the authors wrote.

Challenges of Addressing Psychological Abuse in Children

Stating that society as a whole must pay more attention to the phenomenon of psychological abuse in childhood is easier said than done. Among the challenges described by the AAP paper is the lack of research about the prevention of psychological abuse and interventions for it.

The organization recommends that multiple people who are responsible for a child's care - such as pediatricians, school or daycare officials and family members - must also take responsibility for recognizing when psychological abuse may be occurring. Then, those same people must follow up with a family after referring them for help or to child welfare agencies.

"Careful follow-up is very important because parents who are psychologically abusive may not be reliable in providing information about their child's functioning or their own response to intervention," the authors wrote. They especially point to early identification: looking for signs of emotional abuse in families with infant or toddlers increases the likelihood of successful intervention.

Another challenge, however, is knowing how to appropriately treat the children and the parents. Education and home visit interventions have some evidence showing they work, but more research is needed. The AAP authors wrote that the most successful programs they have found in the research involved multiple sessions with parents that had a "clear behavioral focus."

One thing family members, friends, church officials, pediatricians, school officials and other persons can do is point out to parents that problems they have might affect their children as well. Parents who are dealing with mental health problems, domestic violence or substance abuse should consider how those situations can affect their children and then seek the appropriate professional help to address these conditions.

In the most drastic situations, the AAP does endorse removing a child from a home. "Consideration of out-of-home care interventions should not be restricted to cases of physical or sexual abuse," they wrote. "Children exposed to psychological maltreatment may also require a level of protection that necessitates removal from the parental home."

Yet this recommendation again brings up challenges, LuAnn Pierce points out.

"The child welfare and criminal justice systems do not have the money, staff or resources currently to take care of children who are in physical danger," Pierce said. "Acting on behalf of those who are psychologically abused will add millions to that deficit."

She said that healthcare reform might address some of these concerns, but local, county and state agencies will still need more funding to investigate abuse and neglect. They may face further difficulties when issues of liability - concerns about false accusations - are taken into account. Fully implementing this statement's recommendations could take years before child welfare organizations are equipped enough to seriously give this issue the attention it needs, she said.

"Because this type of abuse is harder to prove, it is often not pursued unless the actions of the abusive adults are observed directly by someone bold enough to speak up in court," Pierce said. "Even then, the damage to the child is harder to document than broken bones and bruised bodies, which prevents most abuse cases from ever going forward."

Finally, Pierce pointed out that following through on identifying and addressing psychological abuse in children will require more mental and behavioral health professionals integrated into social institutions, from schools to law enforcement to medical services to state agencies.

"As doctors and other medical providers have been trained to screen for the signs of physical abuse, mental health professionals with the proper training need to screen for signs of psychological abuse," she said. "This will lead to a society that is more aware that mental and physical health are connected and inseparable."

Pierce hopes that the challenges of this issue do not stop other organizations from taking similar policy statements as the one the AAP has taken.

"This is a necessary step in changing the cultural and societal normals that have historically viewed our physical and psychological selves as separate," she said. "To stop family violence, both for children and adults, we must begin to see the effects the abuse has on the whole person."

Pierce draws a connection between abuse in the home and violence in society at large.

"It is psychological abuse that affects the behavior and thought processes that perpetuate violence and abuse," she said. "Until we are willing to address psychological abuse, the crime and violence that plagues the US will continue - and it begins in childhood."

The AAP's statement appeared in the journal Pediatrics on July 30. The authors acknowledged support from the Family Violence Prevention Unit and the Public Health Agency of Canada in developing the paper.

Reviewed by: 
Review Date: 
July 31, 2012