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:
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
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.
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.
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.
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
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.
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
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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