Daphne Simeon, MD

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 oppositewarm 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 Rosenberg

 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. 

 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. 

 there are still no consensus definitions to guide us in the identification of emotionally abused children. The 

 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 associates

 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 Brassard

 delineated 5 subtypes of emotional maltreatment: spurning, terrorizing, isolating, exploiting/corrupting, and denying emotional responsiveness (

). These 5 emerged as conceptually distinct subtypes that are largely nonoverlapping and moderately correlated with each other. 


  Preventing the child from participating in normal opportunities
  for social interactions


    Threatening severe or sinister punishment, or deliberately
    creating a climate of fear or threat      


    Being psychologically unavailable and failing to respond
    to the child’s behavior


    Behaviors that communicate or constitute abandonment
    of the child, such as a refusal to show affection


    Behaving so as to encourage the child to develop social values
    that reinforce antisocial or deviant behavior, such as aggression,
    criminal acts, or substance abuse.


  Verbal battering that includes rejection and hostile degradation


    Verbal threat to inflict major physical or psychological injury
    to a child who disobeys


    Active isolation of a child, ranging from locking in a confined
    space to limitation of appropriate social and peer interaction


    Modeling of antisocial acts and condoning of deviant standards
    and behaviors


    General unresponsiveness to child’s attempts at interaction,
    and absence of warm physical contact and empathic conversation

Prevalence estimates are available from the reported cases of emotional abuse, but such numbers are gross underestimates of its true prevalence. Hamarman and coauthors

 reviewed all the cases of emotional abuse reported by the National Center for Child Abuse and Neglect for 1998 in 43 states. They found a mean reported number of 11.7 per 10,000 children, vastly varying among states as a function of differences in caregiver culpability statutes. 

In reexamining National Incidence Study of Child Abuse and Neglect NIS- 2 data (2814 children), Jones and McCurdy

 found that emotional maltreatment, broadly defined as emotional abuse and neglect, was present in 13.7% of the sample. Similarly, Vissing and colleagues

 surveyed 3346 parents of children under the age of 17 in the Second National Family Violence Survey. Setting conservative frequency criteria, they estimated that 26.7% and 11.3% reported at least 10 and 25 verbal abuse incidents per year, respectively. 

The general psychological and psychiatric impact of emotional maltreatment has been studied in both nonclinical and clinical samples and has yielded compelling evidence that emotional abuse and neglect can have farreaching consequences, as great as or greater than thoese other types of abuse, and that these can include internalizing disorders, externalizing disorders, general psychiatric morbidity and impairment, low self-esteem, and suicidality.

 eloquently demonstrated some of the interactions between different types of abuse and the challenge of teasing them out from a large sample of 3346 American parents surveyed for verbal and physical aggression. They found that the relationship between parental physical abuse and child delinquency was minimal unless the parents were also verbally abusive. They also found that there was no significant relationship between parental physical aggression and child interpersonal problems when the overlap with verbal aggression was controlled for. In other words, the psychological damage associated with physical abuse occurs at least in part because of the verbal abuse that typically accompanies it. 

 studied a community sample of 497 women who reported an 11.5% rate of emotional abuse, similar for both maternal and paternal abuse. The association of emotional abuse to numerous negative adult outcomes (eg, adolescent pregnancy, sexual problems, low selfesteem, overall psychiatric diagnoses, eating disorders, depression, suicide attempts, and psychiatric hospitalization) was almost as strong as that for sexual abuse and stronger than that for physical abuse. 

 compared women health care providers with and without a history of psychological abuse (in the absence of physical or sexual abuse) and found that emotional abuse significantly predicted greater anxiety, depression, and dissociation. Similarly, in a sample of about 200 women presenting to a primary care practice, emotional abuse and neglect predicted psychological and physical symptoms, even when controlling for physical and sexual abuse and for lifetime trauma exposure.

Despite the relatively sparse research literature compared with that for other types of childhood maltreatment, emotional maltreatment has been shown to be associated with a wide range of Axis I and II psychiatric disorders. Some of the more relevant studies are noted here (although this is by no means intended as an exhaustive review of the literature).

In a sample of 168 outpatients who were depressed, emotional neglect predicted personality dysfunction.

 In addition, emotional abuse was found to be a risk factor for increasing personality disorder symptomatology in the outpatients. Another study compared a sample of 20 participants with borderline personality disorder (BPD) with 24 healthy controls.

 The researchers found that dissociative symptoms within the borderline group were associated only with emotional neglect and not other types of childhood trauma. Emotional neglect accounted for 23% of the total variance in dissociation scores. 

Compared with patients without BPD, those with BPD remember both parents as significantly less caring and more controlling.

 In a sample of 116 outpatients with binge-eating disorder, of all the childhood traumas, emotional abuse was the one associated with greater likelihood of personality disorders.16 In a community-based longitudinal prospective study, it was found that childhood emotional neglect was associated with more avoidant and cluster A personality disorder symptoms in adolescence and adulthood.

Similarly, in a large sample of 339 adults with alcohol or drug dependence, emotional abuse emerged as a broad risk factor for personality disorders in clusters A, B, and C, while emotional neglect was more specifically related to schizoid personality traits.

 In a sample of 174 adults with various personality disorders, emotional abuse was the only trauma variable significantly associated with affective instability.

A study of adults with major depression compared with healthy controls reported significantly greater emotional abuse and neglect, as well as physical abuse, in participants with depression.

 In a sample of 228 outpatients with major depression, greater depression severity at baseline was associated with childhood emotional abuse.

There is growing body of research providing evidence for the long-standing clinical wisdom that trauma history is associated with more treatment-refractory depressions. Kaplan and Klinetob

 reported that compared with a small sample of adult outpatients with treatment-responsive depression, those with treatment-refractory depression reported histories of greater emotional abuse. 

In one study, 80 women with bulimia nervosa were compared with a control group (there was no difference in sexual abuse history). The researchers found the most robust difference between the 2 groups was in psychological maltreatment, despite the fact that the women with bulimia nervosa had greater physical abuse histories than the controls.

In a sample of 145 outpatients with binge-eating disorder, emotional abuse was significantly associated with greater body dissatisfaction, higher depression levels, and lower self-esteem in both genders.

 Similarly, in a non clinical sample of 236 women, emotional abuse was the only form of childhood trauma that predicted unhealthy adult eating attitudes.

Although extreme childhood trauma is often encountered in the more severe dissociative disorders, such as dissociative identity disorder, emotional maltreatment appears to play a more prominent role at the less severe end of the dissociative spectrum. In a sample of about 50 patients with depersonalization disorder, severity of emotional abuse was found to predict depersonalization symptoms specifically, whereas severity of emotional combined with sexual abuse was predictive of overall dissociative symptoms.

 Similarly, in a sample of about 200 adolescent inpatients, it was found that emotional neglect was the strongest pathogenic risk factor for dissociative symptoms.

 found that patients with chronic fatigue syndrome and fibromyalgia had significantly higher emotional neglect and abuse scores than participants with medical disease and healthy controls. Similarly, in a group of patients with somatization disorder, of all childhood interpersonal traumas, chronic emotional abuse was the best predictor of unexplained medical symptoms.

In adults with schizophrenia, dissociative symptoms have been found to be associated with a history of emotional abuse as well as physical abuse.

 Similarly, emotional abuse was found to be associated with substance use in patients with schizophrenia.

 Emotional abuse and neglect, along with other childhood traumas, represent a risk factor for suicide attempts in patients with schizophrenia.

The neurobiologic correlates and sequelae of emotional maltreatment have received very little attention. Nevertheless, studies suggest that emotional maltreatment can be associated with long-standing neurobiologic perturbations in adulthood. 

In a study of individuals who were dependent on cocaine but abstaining, it was found that greater childhood emotional neglect was associated with lower cerebrospinal fluid levels of the serotonin metabolite 5-hydroxyindole acetic acid and the dopamine metabolite homovanillic acid.

 Similarly, in patients with cocaine dependence who were abstaining, emotional neglect was independently associated with decreased urinary free cortisol output.

 On the other hand, Yehuda and colleagues35 found that adult offspring of Holocaust survivors reported significantly higher emotional abuse than controls, and that this abuse was significantly associated with 24-hour mean urinary cortisol. 

In conclusion, both researchers and clinicians run an important risk of faulty or incomplete models and interpretations when focusing primarily on physical and sexual abuse as the traumas of childhood. Clinicians must always be mindful that in patients presenting with or eventually revealing physical or sexual maltreatment, the emotional milieu in which those incidents occurred and that existed outside that maltreatment is paramount for a rich and full appreciation of patients' pathology as well as resilience. 

Future psychiatric research will hopefully pay more attention to emotional abuse and neglect and their often profound impacts in their own right. It is likely that over the next decade, the growing attachment literature as well as animal models of maternal neglect will provide an important inroad to neurobiologic research on the impact of major emotional neglect on human development and psychopathologic outcomes. 

Dr Simeon is associate professor of psychiatry at Mount Sinai School of Medicine, in New York, where she is director of the Depersonalization and Dissociation Research Program and codirector of the Compulsive and Impulsive Disorders Research Program. She is the author of many journal articles and books; her latest offering, Feeling Unreal: Depersonalization and the Loss of Self, is geared for professional and general audiences and is available from Oxford University Press. She reports no conflicts of interest regarding the topic of this article.

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Articles

Emotional maltreatment is of two major types: emotional abuse and emotional neglect. While emotional abuse is easier to identify, emotional neglect is subtler, possibly more damaging, and poses even more challenging barriers to definition and study.

Author | Daphne Simeon, MD

Articles

Emotional Maltreatment of Children: Relationship to Psychopathology