Although physical and sexual abuses are well recognized by the medical and legal systems, there has been difficulty and reluctance in addressing the issue of emotional abuse in children. This is unfortunate, because all cases of physical abuse contain a coexisting emotional component whose impact may persist long after physical injuries have healed. Furthermore children may suffer emotional injuries in the absence of physical or sexual attacks. Emotional abuse distorts the process of attachment and affective development. Emotional abuse also may impair the child's capacity to develop appropriate emotional responses and may lead to lifelong emotional difficulties.

Some of the difficulties in evaluating and reporting emotional abuse in children have derived from a lack of consensus definitions and guidelines delineating severities. For example, although the DSM-IV provides diagnostic criteria for parent-child relational problems (V61.20), physical abuse of child (V61.21), sexual abuse of child (V61.21), and neglect of child (V61.21), it contains no diagnosis for the emotional component of abuse (DSM IV 1994). Similarly neither the American Psychiatric Association nor the American Academy of Child and Adolescent Psychiatry have published practice parameters on the subject of emotional abuse of children.

The intangible nature of emotional trauma makes medical and legal interventions troublesome, especially when similar provoking actions may be classified as "bad parenting" by some and "abuse" by others. Neither the federal government nor individual states have been able to give clear direction to child protective service agencies. The federal Child Abuse Prevention and Treatment Act 42 provides a vague definition of psychological maltreatment as a repeated pattern of caregiver behavior or extreme incidents that convey to children that they are worthless, flawed, unloved, unwanted, endangered or only of value in meeting another's needs.

A survey of state laws in 1997 revealed that only twenty states have specific statues defining emotional abuse. This lack of definition preludes intervention from protective service agencies in most cases. However, several states have adopted a policy of family-centered assessments, thereby transferring cases of emotional abuse from he legal system to social programs.

Operational definition of emotional abuse

Given these difficulties we favor an "action-based" focus. The following categories of emotional abuse proposed by Garbarino, Guttman and Seely and amended by Pearl serve as a useful starting tool:

Rejecting- The adult refuses to acknowledge the child's worth and the legitimacy of the child's needs. Rejecting behaviors include defining the child as a failure, refusing to show affection to the child and refusing to acknowledge the child's accomplishes.

Isolating- The adult cuts the child off from normal social experiences, prevents the child from forming friendships, and makes the child believe that he/she is alone in the world. Isolating behaviors include not allowing the child normal contact with peers, not allowing the child to participate in normal family routine, and locking the child in a room, basement or attic.

Terrorizing- The adult verbally assaults the child, creates a climate of fear, bullies and frightens the child, and makes the child believe that the world is capricious and hostile. Terrorizing behaviors include threatening and frightening the child with guns, knives or whips. Partner abuse presents a difficult problem and in our scheme would not be a form of terrorizing. Witnessing abuse between parents may have a strong impact on a child's emotional development. However, in cases of partner abuse the child may not be a direct victim of abuse. We realize that witnessing this activity may influence emotional development, but witnessing a crime, a natural disaster or some other traumatic event also may affect emotional development. None of these examples would be considered abusive. This understanding is echoed by the legal system in which partner abuse is generally not considered a factor in child custody.

Ignoring- The adult deprives the child of essential stimulation and responsiveness and stifling emotional growth and intellectual development. Ignoring behaviors include failing to stimulate the child in an appropriate manner, not calling the child by name, and showing now affection.

Corrupting- The adult "mis-socializes" the child, stimulates engagement in destructive anti-social behavior, reinforces deviance and makes the child unfit for normal social experience. Corrupting behaviors include encouraging and instructing the child in antisocial/delinquent activity, teaching the child sexually exploitative behavior, teaching the child that "bad is good and good is bad".

Verbally assaulting- The adult abuses the child with constant name-calling, harsh threats and sarcastic comments that continually "beat-down" the child's self-esteem with humiliation. Verbally assaulting behaviors include openly telling the child that he/she is worthless and calling the child derogatory or demeaning names.

Over-pressuring- The adult imposes consistent pressure to grow up fast and to achieve too early in the areas of academics, physical/ motor skills and social interaction, which leaves the child feeling that he/she is never quite good enough. Over-pressuring behaviors include excessively advanced expectations of the child, criticism and punishment of age-appropriate behaviors as inadequate, and making comparisons to those who are very advanced, consistently leaving the child "poor by comparison."

Severity stratification

The next step is a determination of severity. We believe these determinations may be "borrowed" from legal precedent, namely that severity is a combination of (1) intent and (2) harm.

A common example is the differing degrees of homicide based on intent, which range from premeditated 1st degree murder (intent) to accidental manslaughter (unintentional). An action that is both committed with intent to inflict harm and has a high-probability of causing harm is considered to be severe emotional abuse. Conversely an action that contains neither intent nor high-probability of harm is considered mild. Actions falling in the middle, with either intent or harm, but not both, may be classified as moderate.

Although most cases of emotional abuse are committed without intent, any abuse that contains intent to inflict harm must be considered to be more serious. Typically the tangible action of abuse will be apparent and will readily allow assignment of severity. However, if additional evaluation reveals that the action was committed with malice against the child, the abuse category is advanced to more severe. The decision to label an action as intentional can be difficult in criminal cases.

Determination of intent is a key responsibility of the psychiatrist, other mental health professionals, and child protective service personnel. Careful evaluations of the child, parent and family dynamics must be reviewed to arrive at this decision. In our scheme, mild abuse leads to therapeutic counseling, whereas sever abuse may require legal action.

Using this parent-based, action-based focus, we believe that mental health professionals can effectively identify cases of childhood emotional abuse and begin appropriate interventions.

Stephanie Hamarman is the Medical Director of the Child and Adolescent Psychiatry Extended Outpatient Services and an Assistant Professor of Psychiatry at The New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ. William Bernet is the Director of Psychiatry at the Vanderbilt University School of Medicine, Nashville, TN.

References

Hamarman S, Bernet W. "Evaluating and Reporting Emotional Abuse in Children" Journal of the American Academy of Child and Adolescent Psychiatry. 2000; 39 (7): 928-930.