Emotional Maltreatment

Gail Hornor, DNP, RNC, CPNP

Disclosures

J Pediatr Health Care. 2012;26(6):436-442. 

In This Article

Consequences of Emotional Maltreatment

Experiencing child abuse has been linked to a variety of negative consequences, including post-traumatic stress, depression, suicide, substance abuse, and obesity (Hornor, 2010). Emotional maltreatment can result from experiencing physical or sexual abuse, but children who are not physically or sexually abused can be emotionally maltreated. Children who experience emotional maltreatment undergo a unique form of abuse. The weapons used against them are not visible such as hands, belts, cords, or sexual acts, but rather ugly, hurting words or cold, uncaring silence. Although no physical pain or sexual contact is ever endured, the consequences can be just as severe and long-lasting.

One possible result of early childhood emotional maltreatment is reactive attachment disorder (RAD; Hornor, 2008b). RAD is defined as markedly disturbed and developmentally inappropriate social relatedness that usually begins before the age of 5 years. RAD can present as a persistent failure to initiate or respond in a developmentally appropriate fashion to most social situations. The child avoids or resists comforting or exhibits a frozen watchfulness; he or she appears to be unable to or has great difficulty forming relationships with anyone. Conversely, RAD also can present as excessive familiarity with strangers or a lack of selectivity in the choice of attachment figures—that is, the child may form attachments to just about anyone. These manifest behaviors are exhibited after pathogenic care, consisting of the persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection; persistent disregard of the child's basic physical needs; and/or repeated changes of primary caregivers that prevent the formation of stable attachments (American Psychiatric Association, 2000).

The long-term impact of emotional maltreatment has not been studied widely, but recent studies have begun to document its long-term consequences. Emotional maltreatment has been linked with increased depression, anxiety, somatic complaints, and difficulties in interpersonal relationships (Spertus, Wong, Halligan, & Seremetis, 2003). Further complicating research into the consequences of emotional maltreatment is the high co-occurrence rate of emotional maltreatment with other forms of maltreatment, such as physical abuse and neglect. Often it is difficult to separate the effects of various types of maltreatment (Higgins and McCabe, 2000, Arata et al., 2005).

van Harmelen and colleagues (2010) studied the relationship between experiencing child abuse and the development of depressive and/or anxiety disorders later in life; they also separated forms of abuse and examined physical abuse, sexual abuse, and emotional maltreatment and their associations with depression and anxiety. Nearly 3000 adults with a current or past diagnosis of major depressive disorder and/or an anxiety disorder were interviewed to assess a history of emotional maltreatment, physical abuse, and/or sexual abuse before the age of 16 years; a history of multiple incidents was required to meet the definition of child abuse for the study. Of all adults reporting child abuse, 93% reported experiencing emotional maltreatment. Nearly one third (31%) of adults who reported emotional maltreatment also reported physical abuse and 29% also reported sexual abuse. Emotional maltreatment, when compared with physical and/or sexual abuse, had the strongest link with enhanced automatic (and explicit) self-depression and self-anxiety associations. Emotional maltreatment, even more than physical and sexual abuse, may predispose a person to developing depression or anxiety.

Specific behaviors have been included in the definition of emotional maltreatment. Allen (2008) examined the impact of five forms of emotional maltreatment on emotional adjustment in early adulthood: spurning, terrorizing, exploiting, ignoring, and isolating. More than 230 college students between the ages of 18 and 22 years participated in the study, with their ethnicity being predominantly European American (92%); 59% were women. Allen (2008) found each form of emotional maltreatment to be significantly related to the other forms of emotional maltreatment and physical abuse. The strongest relationship was noted between isolating and ignoring, with the weakest relationship between ignoring and witnessing family violence. Each form of psychological symptomatology was significantly correlated with a number of types of emotional maltreatment. Somatic complaints, anxiety, and depression were each significantly associated with degradation, terrorizing, ignoring, and witnessing family violence. Borderline features were significantly related to degradation, terrorizing, and ignoring. None of the forms of psychological symptomatology were associated with being isolated. Experiencing acts of terrorizing at the hands of caregivers was significantly predictive of somatic complaints and anxiety in early adulthood. The frequency of being ignored by caregivers in childhood was predictive of current depression and borderline personality features. Childhood degradation predicted current features of borderline personality features. Physical abuse in the absence of the various forms of emotional maltreatment was significantly predictive for only somatic complaints. Allen's work is significant in that it is the first study that examined the impact of specific forms of childhood emotional maltreatment on different types of psychological impairment in early adulthood.

Anger and aggression are potentially destructive forms of psychological problems in adulthood. Allen (2010) examined the impact of long-term child emotional abuse on aggression using the same sample previously described. Allen specifically tested the self-capacities of interpersonal relatedness, identity, and affect regulation as mediators for the impact of emotional abuse on aggression in adulthood. Results suggested that emotional abuse is significantly predictive of participants' self-reported increased levels of various forms of aggression. Emotional abuse also was significantly correlated with all of the self-capacities (identity, interpersonal relatedness, and affect regulation) and was found to be a significant independent predictor of interpersonal problems and affect dysregulation. Detrimental alterations of self-capacities were found to predict aggression. It is possible that experiencing emotional maltreatment teaches the child ineffective ways of relating to others; the child then develops poor relationship skills that increase the likelihood of interpersonal problems as an adult. Problematic relationships result in an increased likelihood of verbal and/or physical aggression. Also, experiencing emotional abuse may result in an inability to develop adequate emotional regulation skills, which increases the risk of persons being unable to rid themselves of negative feelings of anger, predisposing them to overt forms of aggression.

Anger and aggression can manifest itself as teen dating violence. Teens as young as seventh grade report engaging in dating violence, with emotional abuse being the most common form of violence (Sears, Byers, & Price, 2007). Wekerle and colleagues (2009) examined the predictive value of child emotional maltreatment for understanding teen dating violence and adolescent post-traumatic stress disorder (PTSD) symptomatology. A random sample of 408 adolescents engaged with CPS participated in the study; 52% were girls, with a mean age of 16 years. Ethnicity was diverse. Findings indicated clearly that teens involved with CPS are at high risk for dating violence; 65% of girls and 46% of boys reported experiencing teen dating violence. Emotional abuse was found to be a significant predictor of dating violence and PTSD symptomatology among both girls and boys. Male emotional abuse perpetration and female emotional abuse victimization was found to be significantly mediated by PTSD symptomatology. Thus, when considering emotional abuse and its potential for negative impact upon relationship development, the victim of emotional abuse is made to feel worthless and the victim's thoughts, feelings, and behaviors are ignored or condemned. Emotional maltreatment, like other forms of maltreatment, teaches children that not all relationships are positively reinforcing and to expect punishment in relationships. Relationships become a source of negative affect, fear, or anger and lack positive affect and joy.

Childhood emotional maltreatment may threaten the security of attachment relationships and yield maladaptive models of self and self in relation to others. Wright, Crawford, and Del Castillo (2009) explored the extent to which experiencing emotional abuse and emotional neglect by parents uniquely contributed to young adult maladaptive long-term outcome in terms of symptoms of anxiety, depression, and dissociation. Three hundred students at a Midwestern university (53% of whom were women and 94% of whom had European American ancestry, with a mean age of 20 years) participated in a study over five semesters. Findings revealed that perceptions of childhood emotional abuse and neglect each continued to exert an influence on later symptoms of anxiety and depression even after controlling for gender, income, parental alcoholism, and other forms of child abuse. This relationship was mediated by schemas of vulnerability to harm, shame, and self-sacrifice. Only emotional neglect was related to later symptoms of dissociation and was mediated by schemas of shame and vulnerability to harm. Experiencing child sexual abuse also was a significant predictor of later anxiety, depression, and dissociation. Wright et al. (2009) suggest that how a person evaluates and internalizes experiences may be even more important than the events themselves in determining the extent to which these experiences exert a long-term impact. Emotional maltreatment may result in global, negative beliefs about the self.

The effects of emotional maltreatment can be disabling and enduring and should be carefully assessed. Shaffer, Yates, and Egeland (2009) examined if and how different forms of emotional maltreatment contributed to adolescent adjustment via aggression and social withdrawal in middle childhood. Participants for the study were drawn from the Minnesota Longitudinal Study of Parents and Children, a prospective, longitudinal study that began in 1975. Low-income women in their first trimester of pregnancy were recruited through a public health prenatal clinic. Data for the study were drawn from assessments completed when the focal children (196) ranged in age from 24 months to sixth grade. Mothers were observed interacting with their children at several points in early childhood. Data from the observations were utilized by coders to identify mothers as emotionally neglectful or abusive. Emotionally neglectful mothers were emotionally distant and unresponsive to the child's bids for comfort and help. Mothers identified as emotionally abusive were verbally hostile with their child, often making critical or sarcastic comments. Middle childhood outcomes were assessed using the Teacher Report Form of the Child Behavior Checklist, which is designed to measure children's problem behavior and adaptive functioning. Adolescent self-esteem and peer competence were derived from teacher reports using a measure designed for the study. Of the 196 child participants (43% of whom were girls), 13% were identified as emotionally neglected and 22% as emotionally abused. Only 4% were identified as both. Both emotional neglect and emotional abuse were associated with increased aggression and social withdrawal in middle childhood and lower emotional competence in early adolescence, especially for boys.

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