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Unseen wounds
An important study finds that children who have been psychologically maltreated suffer effects that are equal or greater than children who have been physically or sexually abused.
Overview
CE credits: 1
Exam items: 10
Learning objectives:
After completing this course participants will be able to:
- Define psychological maltreatment.
- Compare and contrast the effects of psychological, sexual and physical abuse on child and adolescent clinical and behavioral outcomes.
- Reconsider conceptual models of polyvictimization (e.g., cumulative versus weighted/type-specific effects of exposure) in light of study findings.
Every year, nearly 3 million U.S. children experience some form of maltreatment, usually perpetrated by a parent, family member or other adult caregiver, according to the U.S. Children's Bureau (2010). Although more subtle to detect, psychological maltreatment is a common form of such abuse.
The American Professional Society on the Abuse of Children defines psychological maltreatment as "a repeated pattern of caregiver behavior or a serious incident that transmits to the child that s/he is worthless, flawed, unloved, unwanted, endangered or only of value in meeting another's needs."
Psychological maltreatment may also involve "spurning, terrorizing, exploiting or rejecting" the child (Kairys et al., 2002). This type of abuse represents a breach in the attachment relationship between caregiver and child through a lack of emotional nurturance, attunement, and responsiveness and/or overt acts of verbal and emotional abuse that result in harm to the child, disruptions of psychological safety, and impediments to the normative development of essential capacities such as emotion regulation, self-acceptance and self-esteem, autonomy, and self-sufficiency (English & the LONGSCAN Investigators, 1997; Wolfe & McIsaac, 2011).
It's important to note that psychological maltreatment is distinct from dysfunctional parenting in that it is characterized by a "chronic, severe and escalating pattern of emotionally abusive and neglectful parental behavior" combined with increased risk of psychological harm to the child (Wolfe & McIsaac, 2011).
While psychological maltreatment may be perpetrated by people outside the family system, such as teachers or peers, evidence suggests that when such maltreatment is inflicted by a primary caregiver in early childhood, or chronically throughout childhood and adolescence, it is more deleterious to the child's overall development (D'Andrea et al., 2012). In a series of studies on the impact of verbally abusive or psychologically unavailable behaviors of mothers, the 1983 Minnesota Mother–Child Interaction Project found that children who experience psychological maltreatment displayed a range of emotional and behavioral difficulties across development, such as negative self-esteem, impulsivity and "pathological" behaviors, including tics, tantrums, stealing, enuresis, self-punishing behaviors and clinginess (Egeland, Sroufe, & Erickson, 1983).
Although psychological maltreatment typically co-occurs with other forms of abuse and neglect, its incidence in the absence of other forms of maltreatment is more common than recognized (Hart, Brassard, & Karlson, 1996).
Emotional abuse and emotional neglect account for 36 percent and 52 percent of identified child maltreatment cases, respectively (Chamberland, et al., 2011). But the perceived prevalence of psychological maltreatment in the United States appears to depend heavily on where one looks and whom one asks. For example, official reports of psychological maltreatment to child welfare agencies portray this type of abuse as a relatively rare phenomenon: Only 7.6 percent of official reports to child welfare agencies identified the occurrence of psychological maltreatment in 2009 (Children's Bureau, 2010).
Psychological maltreatment is also less likely to be investigated: 53 percent of physical abuse and 55 percent of sexual abuse reports, but only 36 percent of psychological maltreatment reports were investigated in 2009 (Sedlak et al., 2010). Community sample studies estimate rates of psychological maltreatment of 21 percent to 80 percent — findings that indicate a more variable and pervasive problem than indicated by some governmental reports (Chamberland et al., 2005; Clement & Chamberland, 2007).
In a national clinical dataset of more than 11,000 trauma-exposed youth, Briggs and colleagues identified psychological maltreatment as the most prevalent (38 percent) form of maltreatment, and the fourth most prevalent of 20 trauma types assessed (Briggs, et al., 2013). These discrepancies between governmental and community estimates suggest that psychological maltreatment is underrecognized as a distinct and consequential form of maltreatment.
Further complicating the picture is that psychological maltreatment can be elusive and insidious, and its very nature allows it to hide in plain sight (Hart & Glaser, 2011; Trocme, et al., 2011). For example, a review of child-protective services case records for maltreated children revealed that while more than 50 percent of cases had experienced parental emotional abuse, psychological maltreatment was officially noted in only 9 percent of the cases (Trickett, Mennen, Kim, & Sang, 2009). Unlike other forms of childhood maltreatment, psychological maltreatment does not carry a strong social taboo, nor does it result by itself in physical wounds, which often make it harder to identify and substantiate as part of the child-protective service process. The inherent subtlety and lack of recognition of psychological maltreatment as a pernicious form of abuse, per se, may thus contribute to its infrequent selection by practitioners as a primary focus of child-trauma intervention, or to the fact that few interventions exist that explicitly target psychological maltreatment (NCTSN, 2011).
The impact of psychological maltreatment
Psychological maltreatment has emerged as a significant predictor of a broad range of negative youth outcomes. Youth with histories of psychological maltreatment exhibit elevated rates of inattention, aggression, noncompliance, hyperactivity, conduct problems and delinquency (Caples & Barrera, 2006; Hart, Brassard, & Karlson, 1996; Manly, Kim, Rogosch, & Cicchetti, 2001).
This type of abuse has also been linked to internalizing symptoms, including anxiety, depression, post-traumatic stress disorder, suicidality and low self-esteem (McGee, et al., 1997; Stone, 1993; Wolfe & McGee, 1994).
Differential predictive and potentiating effects
Growing evidence suggests that psychological maltreatment may exert negative predictive (and potentially causal) effects above and beyond those of other forms of maltreatment. McGee and colleagues found that psychological maltreatment accounted for the largest proportion of unique variance in externalizing symptoms and potentiated the adverse effects of other types of maltreatment, including physical and sexual abuse and neglect (McGee et al., 1997).
Similarly, compared with sexual and physical abuse, parental verbal abuse was associated with the largest predictive effects on measures of dissociation, depression and anger/hostility in young adults (Teicher, Samson, Polcari, & McGreenery, 2006). Further, Schneider and colleagues found that psychological maltreatment incrementally predicted maladjustment in adolescents above and beyond the predictive effects of other forms of maltreatment (Schneider, et al., 2005).
The present study
This study sought to build on prior research on the effects of psychological maltreatment on a wide range of child and adolescent clinical and risk indicators when compared with other forms of maltreatment. We examined baseline assessment data from maltreated youth, as archived in the National Child Traumatic Stress Network (NCTSN) Core Data Set (CDS; see Layne, et al., 2014), to test two basic hypotheses:
- Youth who report psychological maltreatment will exhibit equivalent or higher baseline levels of symptom severity, risk behavior, and functional impairment compared with physically or sexually abused youth, and
- The co-occurring presence of psychological maltreatment with physical or sexual abuse will be associated with worse clinical outcomes compared with outcomes among other categories of maltreated youth (such as those who report only physical, only sexual, or combined physical and sexual abuse).
We tested our hypotheses on the entire subpopulation of children and adolescents in the NCTSN who had lifetime histories of exposure to one or more of the three maltreatment categories targeted for consideration in this study: psychological maltreatment, sexual abuse and physical abuse. The study sample consisted of 5,616 children, 42 percent of them boys and 58 percent girls. Maltreated youth were categorized into seven mutually exclusive groups based upon their respective exposures to one or more of the three index maltreatment types.
Racial and ethnic distribution included 38 percent white, 21 percent black/African-American, 30 percent Hispanic/Latino, 7 percent other and 4 percent unknown/missing.
Results
Our study results show that the psychologically maltreated group had significantly higher scores on the widely used and well-validated Child Behavior Checklist: Internalizing (CBCL-Int), (Achenbach & Rescorla, 2004) than either the physically abused group or the sexually abused group. In addition, the psychologically maltreated group had significantly higher Child Behavior Checklist: Externalizing (CBCL-Ext.) scores (Achenbach & Rescorla, 2004) than the sexually abused group. We also found no significant differences between the psychologically maltreated versus the physically abused or sexually abused groups on Post-traumatic Stress Disorder-Reaction Index (PTSD-RI) scores. Finally, although the psychologically maltreated group had marginally lower CBCL-Ext. scores than the group with positive histories of both physical and sexual abused, the two groups had similar CBCL-Int. and PTSD-RI (Steinberg et al., 2004) scores. (See Table 1.)
Our study revealed that the psychologically maltreated group had similar or higher frequencies than both the physically abused and sexually abused groups on 21 of 27 indicators of risk behaviors, behavioral problems, functional impairments, symptoms and disorders.
Compared with the physically abused group, the psychologically maltreated group had significantly higher odds on five indicators: behavior problems at home, attachment problems, depression, acute stress disorder and generalized anxiety disorder. The psychologically maltreated group also had marginally higher odds than the physically abused group on two indicators: skipping school or day care and self-injurious behaviors.
Compared with the sexually abused group, the psychologically maltreated group had higher frequencies on the majority of outcomes (17 of 27). The psychologically maltreated group had significantly lower frequencies on only these study indicators compared with both the physically abused group (conduct disorder, general behavior problems and attention deficit hyperactivity) and the sexually abused group (sexualized behaviors, PTSD and, marginally, suicidality).
In addition, we found that the psychologically maltreated group had significantly lower odds on only two indicators compared with the combined physically and sexually abused group: sexualized behaviors and PTSD. The psychologically maltreated group had significantly higher odds on these indicators: substance abuse disorder, generalized anxiety disorder, depression and acute stress disorder.
The study also found that compared with the physically abused group, the combined psychologically maltreated and physically abused group had significantly higher CBCL-Int. scores and PTSD-RI scores. In contrast, the two groups reported similar CBCL-Ext. scores. Further, compared with the sexually abused group, the combined psychologically maltreated and sexually abused group had significantly higher scores on the CBCL-Ext., as well as marginally higher scores on the PTSD-RI.
Compared with the sexually abused group, the psychologically maltreated and sexually abused group had significantly higher odds on the majority of indicators (18 of 27).
Similarly, compared with the physically abused group, the combined psychologically maltreated and physically abused group had significantly higher odds on the majority of indicators (17 of 27).
It is important to note that our results were from the models adjusted for gender and age at baseline, and these model covariates were significantly associated with some of the measures and indicators of interest. Male status was associated with significantly higher mean scores on the CBCL-Ext. subscale, as well as a significantly higher frequency of a subset of respondent and clinician-rated indicators (8 of 27). Female status was associated with significantly higher PTSD-RI scores and with a significantly higher frequency of a different subset of clinician-rated indicators (7 of 27). (See Tables 1 and 2.)
Discussion
Our findings strongly support the hypotheses that psychological maltreatment in childhood not only augments, but also independently contributes to, statistical risk for negative youth outcomes to an extent comparable to statistical risks imparted by exposure to physical abuse, sexual abuse or their combination.
Psychological maltreatment was associated with a broad range of clinical impairment types, exerting predictive effects of comparable or greater magnitude or frequency than the predictive effects of physical abuse and sexual abuse. In addition, the co-occurrence of psychological maltreatment with physical or sexual abuse was associated with a greater magnitude or frequency of the majority of study outcomes compared with those associated with physical abuse or sexual abuse alone. Further, the occurrence of psychological maltreatment was found to be an equivalent or significantly greater predictor of 27 of 30 negative outcomes compared with the co-occurrence of physical and sexual abuse.
Adding weight to these findings is evidence that psychological maltreatment is the most prevalent form of maltreatment in the NCTSN CDS (Layne et al., 2014). A history of psychological maltreatment exposure was identified in 62 percent of more than 5,000 maltreatment cases examined in this study, with 24 percent of maltreatment cases comprised only of psychological maltreatment. These findings point to the role that psychological maltreatment may play as a formidable form of childhood trauma in its own right, and strongly suggest that psychological maltreatment should be an integral component of ongoing efforts to understand, assess and address the nature and sequelae of maltreatment in children and adolescents.
Impact of psychological maltreatment
The children in the psychological maltreatment group exhibited equivalent severity of symptoms on the PTSD-RI as the children who had been physically or sexually abused. This finding is especially noteworthy given that psychological maltreatment is not listed as a Criterion A event for PTSD in the DSM-5.
In addition, our study revealed a robust association between psychological maltreatment and most of the clinician-rated diagnostic and risk indicators assessed. Compared with the groups of children who had been sexually abused, physically abused or both, the psychological maltreatment group exhibited equivalent or higher frequency scores on the great majority of study indicators. Although the psychological maltreatment group exhibited slightly lower frequencies on a small number of outcomes compared with either the sexual abuse (e.g., sexualized behaviors) or physical abuse groups (e.g., conduct disorder) groups, the psychological maltreatment group was never associated with the lowest odds ratios on any of the 27 indicators examined.
In sum, the predictive potency of psychological maltreatment appears to be at least on par with physical or sexual abuse across a broad range of adverse outcomes. These findings lend support to the recent report by the American Academy of Pediatrics highlighting the perniciousness of this form of maltreatment (Hibbard et al., 2012).
Some evidence of the potentially unique effects of psychological maltreatment emerged in the finding that this type of abuse was the strongest and most consistent predictor of internalizing problems, such as depression, general anxiety disorders and attachment problems. Psychological maltreatment was also the strongest predictor of substance abuse, raising the question as to whether substance abuse may serve as an associated coping mechanism and "cascading" secondary outcome (see Layne et al., 2014). These findings are consistent with earlier research linking psychological maltreatment to a range of internalizing symptoms, relational insecurity and negative self-perceptions (e.g., Trickett, Kim, & Prindle, 2011).
Psychological maltreatment also exhibited a strong prediction of externalizing problems, such as behavioral problems, self-injury and criminal activity, comparable to that of physical abuse and greater than that of sexual abuse.
Exacerbating effect of psychological maltreatment upon other maltreatment groups
Consistent with prior studies suggesting that psychological maltreatment may increase the likelihood of the detrimental effects of sexual or physical abuse, the co-occurrence of psychological maltreatment with sexual or physical abuse was associated with higher PTSD symptoms, as well as CBCL-Int. and CBCL-Ext. behavior problem scores compared with sexual or physical abuse alone. These findings add to a growing body of research demonstrating that exposure to multiple forms of trauma (Cloitre et al., 2009; Higgins, 2004) is associated with an exacerbation of psychosocial impairment.
Interestingly, the co-occurrence of physical abuse with sexual abuse rarely predicted greater outcome severity. Indeed, for a number of study indicators, the predictive effect of physical abuse and sexual abuse was significantly lower than that of psychological maltreatment alone. As gauged by its incremental predictive potency, psychological maltreatment may represent a disproportionately more potent predictor to the risk for a broad array of trauma-related adverse outcomes in childhood and adolescence compared with other more extensively studied forms of maltreatment.
These findings suggest that, in evaluating risk for PTSD and other adverse behavioral and psychosocial outcomes, the accumulation of multiple maltreatment types may not follow a simple equally weighted additive pattern. Consistent with the role of a vulnerability factor (Layne et al., 2009), the co-occurrence of psychological maltreatment in this study was associated with a significant increase in the prevalence and severity of a range of internalizing and externalizing problems for children exposed to either physical or sexual abuse.
Future implications
Our findings carry important implications for public policy and the development, adaptation and implementation of child trauma interventions.
First, given its predictive potency and widespread prevalence, efforts to increase recognition of psychological maltreatment as a potentially formidable type of maltreatment in its own right should be at the forefront of mental health and social service training efforts, including incorporation of education on psychological maltreatment into graduate training curricula and continuing education of child service professionals (Courtois & Gold, 2009). This need is especially apparent in the child welfare system considering the low rates at which psychological maltreatment is detected. Enhancement of training initiatives for protective services personnel focused on screening and assessment of psychological maltreatment, as well as linking children to appropriate services, is critical. Also, mental health outreach, consumer resource development and public awareness initiatives are needed to achieve more widespread understanding of the detrimental consequences of psychological maltreatment for children and adolescents.
Second, psychometrically sound, clinically useful instruments are needed to help providers identify psychological maltreatment, categorize and appreciate various forms of emotional abuse and emotional neglect, and assess their associated effects on a range of adverse youth outcomes.
Third, effective, theoretically grounded interventions for the sizable subpopulation of traumatized youth exposed to psychological maltreatment are clearly needed. For example, few child trauma treatment models directly target psychological maltreatment, and no intervention has been developed to focus specifically on this widely prevalent form of trauma exposure. The extent to which prevailing child trauma treatment models are applicable to, and sufficiently address the needs of, psychologically maltreated youth remains an open question. Future research should explore whether existing models are sufficient or can be adapted to accommodate the needs of psychologically maltreated children and adolescents; or alternatively, whether new models or interventions are required.
Finally, greater attention should be dedicated toward understanding the complex manner in which co-occurring forms of childhood trauma may intersect to influence traumatic stress reactions, attachment and self-image problems, affective and physiological dysregulation, risk behaviors, and functional impairment across development (D'Andrea et al., 2012). Guiding theory, assessment tools, interventions and clinical training methods are needed to support accurate risk screening and case identification, effective intervention, workforce development and public policy.
If we are to heal the full spectrum of wounds inflicted by childhood trauma — both the visible and the unseen — such efforts must be guided by a clear appreciation for the variability in occurrence, intersection, etiology, developmental context, clinical course and causal consequences of all forms of maltreatment.