HAMARMAN, STEPHANIE M.D.; BERNET, WILLIAM M.D.
Section Editor(s): Jellinek, Michael S. M.D.
Although physical and sexual abuses are well recognized by the medical and legal systems, there has been difficulty and reluctance in addressing the issue of emotional abuse in children. This is unfortunate because all cases of physical abuse contain a coexisting emotional component whose impact may persist long after physical injuries have healed (Claussen and Crittenden, 1991; Hamarman and Ludwig, 2000). Furthermore, children may suffer emotional injuries in the absence of physical or sexual attacks. Emotional abuse distorts the processes of attachment and affective development (Pearl, 1994). Emotional abuse also may impair the child's capacity to develop appropriate emotional responses and may lead to lifelong emotional difficulties (Brothers, 1989; Ferguson and Dacey, 1997; Hart et al., 1998; Kent and Waller, 1998; McGee et al., 1997).
Some of the difficulties in evaluating and reporting emotional abuse in children have derived from a lack of consensus definitions and guidelines delineating severities (American Professional Society on the Abuse of Children, 1995; Kaplan et al., 1999; Kavanagh, 1982; O'Hagan, 1995; Sedlak and Broadhurst, 1996; Thompson and Kaplan, 1996). For example, although the DSM-IV provides diagnostic criteria for parent-child relational problems (V61.20), physical abuse of child (V61.21), sexual abuse of child (V61.21), and neglect of child (V61.21), there is no diagnosis for the emotional component of abuse (American Psychiatric Association, 1994). Similarly, neither the American Psychiatric Association nor the American Academy of Child and Adolescent Psychiatry has published practice parameters on the subject of emotional abuse of children.
The intangible nature of emotional trauma makes medical and legal interventions troublesome, especially when similar provoking actions may be classified as "bad parenting" by some and "abuse" by others. Neither the federal government nor individual states have been able to give clear direction to child protective service agencies. The federal Child Abuse Prevention and Treatment Act 42 provides a vague definition of psychological maltreatment as a repeated pattern of caregiver behavior or extreme incidents that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another's needs. A survey of state laws in 1997 revealed that only 20 states have specific statutes defining emotional abuse. This lack of definition precludes protective service agencies from intervening in most cases. However several states have adopted a policy of family-centered assessments, thereby transferring cases of emotional abuse from the legal system to social programs (Christian, 1997). For example, Missouri has recently pilot-studied a 2-tiered approach in which suspected cases of child abuse are screened and referred for either family assessment or a more formal legal investigation. According to the statute (SB 595), cases of mild or moderate emotional abuse would generally be referred to the family assessment arm.
Given these difficulties, we favor an "action-based" focus. The following categories of emotional abuse proposed by Garbarino et al. (1986) and amended by Pearl (1994) serve as a useful starting tool:
Rejecting. The adult refuses to acknowledge the child's worth and the legitimacy of the child's needs. Rejecting behaviors include defining the child as a failure, refusing to show affection to the child, and refusing to acknowledge the child's accomplishments.
Isolating. The adult cuts the child off from normal social experiences, prevents the child from forming friendships, and makes the child believe that he or she is alone in the world. Isolating behaviors include not allowing the child normal contact with peers, not allowing the child to participate in the normal family routine, and locking the child in a room, basement, or attic.
Terrorizing. The adult verbally assaults the child, creates a climate of fear, bullies and frightens the child, and makes the child believe that the world is capricious and hostile. Terrorizing behaviors include threatening and frightening the child with guns, knives, or whips. Partner abuse presents a difficult problem. In our scheme it would not be a form of terrorizing. Witnessing abuse between parents may have a strong impact on a child's emotional development. However, under our format emotional abuse is an act directed against a child. In cases of partner abuse the child may not be a victim of abuse unless the partner abuse also contains elements directed at the child. We realize that witnessing this activity may influence emotional development, but witnessing a crime, a natural disaster, or some other traumatic event may also affect emotional development. None of these examples would be considered abusive. This concept also is echoed by the legal system in which partner abuse is generally not considered a factor in child custody.
Ignoring. The adult deprives the child of essential stimulation and responsiveness, stifling emotional growth and intellectual development. Ignoring behaviors include failing to stimulate child in an appropriate manner, not calling the child by name, and showing no affection.
Corrupting. The adult "mis-socializes" the child, stimulates engagement in destructive antisocial behavior, reinforces deviance, and makes the child unfit for normal social experience. Corrupting behaviors include encouraging and instructing the child in antisocial/delinquent activity, teaching the child sexually exploitative behavior, and teaching the child that "bad is good and good is bad."
Verbally Assaulting. The adult abuses the child with constant name-calling, harsh threats, and sarcastic comments that continually "beat down" the child's self-esteem with humiliation. Verbally assaulting behaviors include openly telling the child that he or she is worthless and calling the child derogatory/demeaning names.
Overpressuring. The adult imposes consistent pressure to grow up fast and to achieve too early in the areas of academics, physical/motor skills, and social interaction, which leaves the child feeling that he or she is never quite good enough. Overpressuring behaviors include excessively advanced expectations of the child, criticism and punishment of age-appropriate behaviors as inadequate, and making comparisons to those who are very advanced, consistently leaving the child "poor by comparison."
The next step is a determination of severity. We believe these determinations may be "borrowed" from legal precedent, namely that severity is a combination of (1) intent and (2) harm. A common example is the differing degrees of homicide based on intent, which range from premeditated "intent" first-degree murder to accidental "unintentional" manslaughter. An action that is both committed with intent to inflict harm and has a high probability of causing harm is considered to be severe emotional abuse. Conversely, an action that contains neither intent nor high probability of harm is considered mild. Actions falling in the middle, with either intent or harm, but not both, may be classified as moderate. Although most cases of emotional abuse are committed without intent, any abuse that contains intent to inflict harm must be considered more serious. Typically, the tangible action of abuse will be apparent and will readily allow assignment of severity. However, if additional evaluation reveals that the action was committed with malice against the child, the abuse category is advanced to more severe. The decision to label an action as intentional can be difficult in these cases, just as it is difficult in criminal cases. Determination of intent is a key responsibility of the psychiatrist, other mental health professionals, and child protective service personnel. Careful evaluations of the child, parent, and family dynamics must be reviewed to arrive at this decision. In our scheme, mild abuse leads to therapeutic counseling whereas severe abuse may require legal action.
The health care professional must first establish that a true emotional injury has occurred. The decision to label an action as emotionally abusive can be difficult because certain parental actions may upset a sensitive child, but may be appropriately administered to teach valuable lessons. "Grounding," a form of isolating behavior, is a common example. Careful review of the overall interactions between the parent and the child, observation over time, and formal evaluation may be required before a pattern emerges (Brassard et al., 1993).
Mild emotional abuse, a form of "bad parenting," is not performed with malicious intent and does not contain immediate danger of emotional harm. There is no need for legal reporting. Instead the therapist should attempt counseling. The following case of overpressuring fulfills these mild criteria.
Roger rushed home from school each day to study college preparatory texts at the constant urging of his father. Roger's father had graduated from an Ivy League school, succeeded in business, and expected his son to do the same. In trying to meet his father's demands, Roger had forsaken his friends and his assigned classroom workload. As his school grades fell, Roger's father increased the pressure on his son by forbidding him to participate in after-school sports, requiring him to spend hours alone in his room reading and refusing to allow any social interactions until his grades improved.
As this case illustrates, mild emotional abuse can be the result of a misguided, caring parent. Rather than legal reporting, we recommend family therapy, parent skills training, and supportive therapy for Roger.
Moderate emotional abuse is characterized by malicious intent or imminent probability of emotional harm, but not both. Because these actions are not benign (or are not committed with benign intent), legal notification may be warranted. In these cases, reporting to child protective services can be used to ensure enforcement of therapeutic interventions. The following case of corrupting fulfills the criteria for moderate emotional abuse.
Brian's father had been physically abused as a child. His father constantly told Brian of the poor relationship with his grandfather and warned Brian to be wary of adults. The stories of abuse were graphic. With his father's encouragement, Brian began to fear all social contacts and specifically became increasingly suspicious of his schoolteachers. Inappropriate mistrust rendered Brian unfit for normal social experiences. Brian's father forced misinterpretations of normal interactions with teachers, convincing Brian to make numerous false accusations.
Although there is potential for long-term emotional harm, the father's actions contain no malice toward his child. Family therapy that includes the father-and-son dyad and interpersonal psychotherapy may be useful.
Severe emotional abuse is characterized by actions that inflict emotional harm and are performed with malicious intent. The parent is aware that the actions may cause emotional distress and yet the parent continues. Alternatively, the parent may be unable, because of his or her own psychiatric problems, to control his or her actions and thus the malicious intent standard may be impossible to meet. However, in all of these cases the severity warrants legal reporting and removal of the child should be considered.
Sarah, aged 5, the result of an unplanned pregnancy, was the recipient of her mother's verbal outbursts. Her parents' marriage had been strained for many years, and the attention required by Sarah infuriated the mother. As the parents neared divorce, the mother's verbal assaults intensified. They included screaming at Sarah that she was the cause of the marital problems, that she should have been aborted, and that if she had not caused so much trouble her parents would be happy. Sarah stopped playing with her kindergarten classmates and was repeatedly observed enacting the death of her baby doll saying "everything would be fine if you were never born."
This case of verbal assaulting contains both elements of severe emotional abuse (malice and harm). The mother has true malice for Sarah and has purposely instilled the belief that Sarah has no worth. Symptoms of emotional harm include the depressive ones of passive suicidal ideation, decreased interest in activities, and morbid play related to the verbal assaults. Supportive therapy may empower the mother to cope with the divorce so that she can care for her daughter if she wishes to maintain a relationship with her. Play therapy and possible pharmacological management may be necessary for the child, depending on the severity of depressive symptoms. However, reporting to child protective services, with possible removal of the child from the home, is necessary.
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