Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Monday, April 21, 2014

Emotional Abuse

A recent post on The Practical Psychosomaticist, ACEs Study: Guest Blog by Dr. Resmiye Oral, described the significant medical morbidity and mortality that results from childhood abuse. Clearly, if something can be done about the abuse, the general population would be much healthier.

As described in the ACEs study, abuse included Physical, Sexual, and Emotional. To my thinking, physical and sexual abuse are much easier to define and recognize than emotional abuse. (I'm not saying there aren't equivocal cases, but on the whole).

So I started wondering about the definition of emotional abuse. And the answer is, it's complicated.

First off, the terminology. There are a number of synonymous phrases that describe something like emotional abuse. These include psychological abuse, mental cruelty, psychological maltreatment, emotional neglect, mental injury, and psychological battering. These terminological differences reflect, among other things, differences in intention. For example, emotional neglect as an act of omission, rather than commission.

Some authors (O'Hagan, K. (1995), 'Emotional and psychological abuse: problems of definition', Child Abuse and Neglect, vol.19, 449 - 61; and (1993), Emotional and Psychological Abuse of Children, Open University Press, Buckingham.), differentiate between emotional and psychological abuse in terms of their effects. Emotional abuse as,

"The sustained, repetitive, inappropriate emotional response to the child's expression of emotion and its accompanying expressive behaviour. " This type of abuse impacts the child's affective development.

Whereas Psychological abuse is defined as "sustained, repetitive, inappropriate behaviour which damages, or substantially reduces, the creative and developmental potential of crucially important mental faculties and mental processes of a child: these include intelligence, memory, recognition, perception, attention, language and moral development".

However, other authors (Higgins, 2005) argue that "the degree (frequency and severity) to which young people experience abusive/neglectful behaviours is more important than the particular subtype of maltreatment in explaining subsequent psychological problems," so that distinctions between type may not be that significant.

One definition (Garbarino, J., Guttman, E. and Seeley, J.W. (1986), The Psychologically Battered Child, Jossey-Bass Publishers, California) classifies Psychological Maltreatment into 5 forms:

  • rejecting: behaviours which communicate or constitute abandonment of the child, such as a refusal to show affection;
  • isolating: preventing the child from participating in normal opportunities for social interaction;
  • terrorising: threatening the child with severe or sinister punishment, or deliberately developing a climate of fear or threat;
  • ignoring: where the caregiver is psychologically unavailable to the child and fails to respond to the child's behaviour;
  • corrupting: caregiver behaviour which encourages the child to develop false social values that reinforce antisocial or deviant behavioural patterns, such as aggression, criminal acts or substance abuse.
More recent additions include "...forcing children to live in dangerous and unstable environments (e.g. exposure to war, domestic violence or parental conflict); and the sexual exploitation of children by adults and parents who provide inadequate care while under the influence of drugs or alcohol." (Garbarino and Vondra, 1987)

There is general consensus that Emotional Abuse does not result from isolated incidents of parents losing their tempers. If it did, every child would suffer from it. The real damage lies in the chronic, sustained, and repetitive nature of the behavior.

It is also important to note that while emotional abuse can exist on its own, rarely (probably never) does physical or sexual abuse take place without an emotional component. 

Yet another complicated aspect of emotional abuse is context. In some cultures, chronic criticism is viewed as affectionate, the parent's way of demonstrating to the child that he is WORTH criticizing, that she has the potential to be even better. 

This brings up the question of goodness-of-fit. One child raised in such a culture may recognize the implicit caring, another may simply feel crushed. This is the case not just in varying cultures, but in varying parenting styles, where normative parents may not mesh well with the temperament of their normative child. Similarly, the same parental behavior may affect a child differently at different ages/developmental stages.

The effects of emotional neglect can be extensive. You may recall Rene Spitz's paper, "Hospitalism", where he writes about the infants in a Foundling, who received adequate physical and medical care, but who were emotionally neglected due to unavoidable constraints (1 nurse provided full-time care to 8 babies). There was an astronomically high rate of illness, failure to thrive, and mortality among these children. And the damage was irreparable.

In a later, heartbreaking paper (Spitz, R.A., Wolf, K.M. (1946). Anaclitic Depression—An Inquiry Into the Genesis of Psychiatric Conditions in Early Childhood, Ii. Psychoanal. St. Child, 2:313-342) Spitz describes in greater detail the anaclitic depression of these infants:

These children would lie or sit with wide-open, expressionless eyes, frozen immobile face, and a faraway expression as if in a daze, apparently not perceiving what went on in their environment. This behavior was in some cases accompanied by autoerotic activities in the oral, anal, and genital zones. Contact with children who arrived at this stage became increasingly difficult and finally impossible. At best, screaming was elicited.

A more recent paper, Emotional but not physical maltreatment is independently related to psychopathology in subjects with various degrees of social anxiety: a web-based internet survey
examined longer term effects of emotional abuse, and showed that:

...parental emotional maltreatment and emotional peer victimization were independently related to social anxiety and mediated the impact of physical and sexual maltreatment. Subjects with a history of childhood emotional maltreatment showed higher rates of psychopathology than subjects with a history of physical maltreatment.

Unfortunately, emotional abuse remains hard to identify.

Emotional abuse that exists independently of other forms of abuse is the most difficult form of child abuse to identify and stop. This is because child protective services must have demonstrable evidence that harm to a child has been done before they can intervene. And, since emotional abuse doesn’t result in physical evidence such as bruising or malnutrition, it can be very hard to diagnose.

There may be identifiable developmental delays and emotional problems, but these can exist independently of any abuse, and so are not diagnostic.

Given the scope of the ramifications of this type of abuse, as described in the ACEs study, including smoking and all its sequelae, other substance misuse, and unwanted pregnancies, this is an area that deserves extensive inquiry.

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