In its broadest sense, childhood emotional maltreatment is the breadand- butter of clinical psychiatry and general psychotherapy. Nonetheless, its weight in mainstream psychiatric research remains surprisingly light. Black and colleagues1 reported a total of only 279 articles on child psychological or emotional abuse retrieved from 3 major databases between 1974 and 1998. This small number contrasts with the thousands of publications on sexual and physical abuse. Furthermore, the literature on emotional maltreatment remains almost entirely descriptive. This is in contrast to research of other types of maltreatment, especially sexual abuse, in which researchers have begun to systematically examine neurocognitive and neurobiologic correlates.
While sexual abuse is almost always unequivocal (at least when known) and even physical abuse is usually clearcut (with the exception of appropriately timed and culturally sanctioned spanking or other low-grade physical interventions that are well controlled and consistently intended to benefit a child), emotional maltreatment is more difficult to define and more elusive in its detrimental impact. Emotional maltreatment is of 2 major types, further complicating matters; again, this is different from physical and sexual maltreatment. One type, emotional abuse, the more obvious analog to physical or sexual abuse, is easier to identify and to measure. The other type, emotional neglect, is more subtle yet pervasive and possibly more damaging than emotional abuse, and poses even more challenging barriers to definition and study. Emotional neglect is often better recognized via comparison with its oppositewarm and involved parenting.
Research studies that comprehensively assess and integrate findings across different types of childhood maltreatment remain relatively few. Studies of physical and sexual abuse have often examined these forms of abuse in a vacuum, without attending to the broader emotional and psychosocial environment in which they take place.
Briere and Runtz2 highlighted the potential pitfalls in the conclusions of studies that examined only certain types of childhood maltreatment. Such conclusions can run the risk of making false attributions of current symptoms or problems, since findings thought to be associated with one form of abuse actually could be arising from another coexisting form of abuse. As Rosenberg3 noted, this compartmentalization has extended well beyond narrow research interests to funding sources, social service agencies, and even advocacy groups that have traditionally been concerned with different types of child maltreatment.
Claussen and Crittenden4 addressed the complexity of the interaction between different types of child maltreatment. They found that in a large sample of children, psychological maltreatment was present in most cases of physical abuse and, more important, predicted poor outcomes, whereas physical abuse severity did not. This finding might not surprise many clinicians, who can readily recall patients who have confessed that they could take the beatings, whereas it was the words—spoken and unspoken—that scarred them more deeply.
According to Hamarman and colleagues, 5 there are still no consensus definitions to guide us in the identification of emotionally abused children. The DSM-IV provides V-codes for the identification of parent-child relational problems, specifying physical abuse, sexual abuse, and neglect (usually physical), but not emotional abuse.
However, there are several well–thought-out proposed classifications in the literature for emotional maltreatment. Garbarino and associates6 defined psychological maltreatment as “a concerted attack by an adult on a child's development of self and social competence” and proposed 5 forms of psychological maltreatment: rejecting, terrorizing, isolating, ignoring, and corrupting. Hart and Brassard7 delineated 5 subtypes of emotional maltreatment: spurning, terrorizing, isolating, exploiting/corrupting, and denying emotional responsiveness (Table). These 5 emerged as conceptually distinct subtypes that are largely nonoverlapping and moderately correlated with each other.
Types of maltreatment defined in the research literature
|Categories defined by Garbarino et al.6|
|Categories defined by Hart and Brassard7|
Denying emotional responsiveness
1. Black DA, Smith Slep AM, Heyman RE. Risk factors for child psychological abuse. Aggress Violent Behav. 2001;6:189-201.
2. Briere J, Runtz M. Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Negl. 1990;14:357-364.
3. Rosenberg MS. New directions for research on the psychological maltreatment of children. Am Psychol. 1987;42:166-171.
4. Claussen AH, Crittenden PM. Physical and psychological maltreatment: relations among types of maltreatment. Child Abuse Negl. 1991;15:5-18.
5. Hamarman S, Pope KH, Czaja SJ. Emotional abuse in children: variations in legal definitions and rates across the United States. Child Maltreatment. 2002;7: 303-311.
6. Garbarino J, Guttmann E, Seeley JW. The Psychologically Battered Child. San Francisco: Jossey-Bass; 1986:1-43.
7. Hart SN, Brassard MR. Psychological maltreatment: progress achieved. Dev and Psychopathol. 1991;3:61-70.
8. Jones ED, McCurdy K. The links between types of maltreatment and demographic characteristics of children. Child Abuse Negl. 1992;16:201-215.
9. Vissing YM, Strauss MA, Gelles RJ, Harrop JW. Verbal aggression by parents and psychosocial problems of children. Child Abuse Negl. 1991;15:223-238.
10. Mullen PE, Martin JL, Anderson JC, et al. The long-term impact of the physical, emotional, and sexual abuse of children: a community study. Child Abuse Negl. 1996;20:7-21.
11. Ferguson KS, Dacey CM. Anxiety, depression, and dissociation in women health care providers reporting a history of childhood psychological abuse. Child Abuse Negl. 1997;21:941-952.
12. Spertus IL, Yehuda R, Wong CM, et al. Childhood emotional abuse and neglect as predictors of psychological and physical symptoms in women presenting to a primary care practice. Child Abuse Negl. 2003;27:1247-1258
13. Carter JD, Joyce PR, Mulder RT, Luty SE. The contribution of temperament, childhood neglect, and abuse to the development of personality dysfunction: a comparison of three models. J Personal Disord. 2001;15:123-135.
14. Simeon D, Nelson D, Elias R, et al. Relationship of personality to dissociation and childhood trauma in borderline personality disorder. CNS Spectr. 2003;8:755-762.
15. Zweig-Frank H, Paris J. Parents emotional neglect and overprotection according to the recollections of patients with borderline personality disorder. Am J Psychiatry. 1991;148:648-651.
16. Grilo CM, Masheb RM. Childhood maltreatment and personality disorders in adult patients with binge eating disorder. Acta Psychiatr Scand. 2002;106:183- 188.
17. Johnson JG, Smailes EM, Cohen P, et al. Associations between four types of childhood neglect and personality disorder symptoms during adolescence and early adulthood: findings of a community- based longitudinal study. J Personal Disord. 2000;14:171-187.
18. Bernstein DP, Stein JA, Handelsman L. Predicting personality pathology among adult patients with substance use disorders: effects of childhood maltreatment. Addict Behav. 1998;23:855-868.
19. Goodman M, Weiss DS, Koenigsberg H, et al. The role of childhood trauma in differences in affective instability in those with personality disorders. CNS Spectr. 2003;8:763-770.
20. Bernet CZ, Stein MB. Relationship of childhood maltreatment to the onset and course of major depression in adulthood. Depress Anxiety. 1999;9: 169-174.
21. Walker EA, Katon WJ, Russo J, et al. Predictors of outcome in a primary care depression trial. J Gen Intern Med. 2000;15:8459-8867.
22. Kaplan MJ, Klinetob NA. Childhood emotional trauma and chronic posttraumatic stress disorder in adult outpatients with treatment-resistant depression. J Nerv Ment Dis. 2000;188:596-601.
23. Rorty M, Yager J, Rossotto E. Childhood sexual, physical, and psychological abuse in bulimia nervosa. Am J Psychiatry. 1994;151:1122-1126.
24. Grilo CM, Masheb RM. Childhood psychological, physical and sexual maltreatment in outpatients with binge eating disorder: frequency and associations with gender, obesity, and eating-related psychopathology. Obes Res. 2001;9:320-325.
25. Kent A, Waller G, Dagnan D. A greater role of emotional than physical or sexual abuse in predicting disordered eating attitudes: the role of mediating variables. Int J Eat Disord. 1999;25:159-167.
26. Simeon D, Guralnik O, Schmeidler J, et al. The role of childhood interpersonal trauma in depersonalization disorder. Am J Psychiatry. 2000;158: 1027-1033.
27. Brunner R, Parzer P, Schuld V, Resch F. Dissociative symptomatology and traumatogenic factors in adolescent psychiatric patients. J Nerv Ment Dis. 2000;188:71-77.
28. Van Houdenhove B, Neerinckx E, Lysens R, et al. Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics. Psychosomatics. 2001;42:21-28.
29. Brown RJ, Schrag A, Trimble MR. Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder. Am J Psychiatry. 2005;162:899-905.
30. Holowka DW, King S, Saheb D, et al. Childhood abuse and dissociative symptoms in adult schizophrenia. Schizophr Res. 2003;60:87-90.
31. Gearon JS, Bellack AS, Rachbeisel J, Dixon L. Drug-use behavior and correlates in people with schizophrenia. Addict Behav. 2001;26:51-61.
32. Roy A: Reported childhood trauma and suicide attempts in schizophrenic patients. Suicide Life Threat Behav. 2005;35:690-693.
33. Roy A. Self-rated childhood emotional neglect and CSF monoamine indices in abstinent cocaine-abusing adults: possible implications for suicidal behavior. Psychiatry Res. 2002;112:69-75.
34. Roy A. Urinary free cortisol and childhood trauma in cocaine dependent adults. J Psychiatr Res. 2002; 36:173-177.
35. Yehuda R, Hallig SL, Grossman R: Childhood trauma and risk for PTSD: relationship to intergenerational effects of trauma, parental PTSD, and cortisol excretion. Dev Psychopathol. 2001;13:733-753.