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THE JOURNAL OF SCHOOL AND UNIVERSITY MEDICINE - Volume 7 Issue 1-2, January - June 2020

Pages: 5-11
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Author: Dr. Corina Demian

Category: Medical


Child maltreatment is a widespread phenomenon, with significant consequences on physical and mental health. The most important forms are physical, emotional, sexual abuse and neglect. Emotional abuse includes humiliation, threatening, ridicule, rejection, terrorization, corruption. Neglect refers to the inability of the adult to ensure the development of the child when there are acceptable resources. Emotional neglect involves failure to provide proper care for the child, insufficient parent-child interaction, emotional unavailability, etc. To evaluate exposure to ill-treatment, various tools have been developed. The number of studies and available data varies in different regions of the globe, and in some regions there is relatively little data. In Romania, the prevalence of emotional abuse was 23.6% and emotional neglect 26.3%. Some correlations and consequences are: impaired cognitive development, higher probability of suffering from depression or anxiety at maturity, insomnia, post-traumatic stress disorder, smoking, drug use, suicide attempts, sexually transmitted diseases and risky sexual behaviors and other. Early adversities contribute to psychopathology through changes in brain structure and function, hypothalamo-pituitary-adrenal axis functioning and other neuroendocrine changes, genetic and epigenetic changes. Raising awareness of the consequences could encourage action to identify high-risk people and to implement interventions that effectively protect children from violence. Some studies estimate that reducing child maltreatment by 10-25% could prevent 31.4-80.3 million cases of depression / anxiety worldwide.

Keywords: abuse, emotional neglect, consequences, psychopathology

Full Text:

Childhood abuse or child maltreatment is unfortunately a phenomenon found around the globe, with a greater spread than one might think at first sight and not with negligible consequences. These adverse childhood experiences are important issues not only from a social and legal perspective, and therefore they are of interest not only for the child protection specialists. They are also important public health issues because the implications are multiple and important on the physical and mental health and development of the child, especially in the long term. In addition, certain consequences of adverse childhood experiences can be passed down from one generation to the next one.

According to the World Health Organization, child abuse or maltreatment comprises "all forms of physical and / or emotional abuse, sexual abuse, neglect or negligent treatment, commercial exploitation, trafficking and others, the consequences of which are actual or potential harm to the child's health, to his or her survival, development or dignity, in the context of a relationship of responsibility, trust or power.” In Romania, the forms of ill-treatment are defined in Law no. 272/2004 on the protection and promotion of children's rights. Among the various forms of abuse, the most important adverse experiences in childhood are physical abuse, emotional abuse, sexual abuse and neglect.

Types of abuse, types of neglect

Unlike physical and sexual abuse, which are better known and studied forms, emotional abuse is more difficult to detect although it is common and the long-term impact is significant. Emotional abuse is the failure of the adult to provide the child with an appropriate developmental environment, through various adult behaviors which can harm the physical, mental, spiritual, moral or social development of the child. Another form of abuse that is sometimes difficult to recognize is neglect. Neglect refers to the inability of the adult to ensure the child's development in various aspects (physical and mental health, education, nutrition, adequate and safe living conditions) if there are acceptable resources for his upbringing and care (1). In this sense, neglect can take many forms: food neglect, clothing neglect, neglect of hygiene, medical neglect, educational neglect, emotional neglect and abandonment (including the departure of parents abroad). Emotional neglect refers to the lack of attention, of physical contact, of signs of affection, of words of appreciation for the child, and it also has important consequences for the child's health.

As stated in the child protection legislation, “emotional abuse is the repeated exposure of the child to situations whose emotional impact exceeds his or her ability of psychological integration (for example, the child is threatened with being evicted from home or even expelled as form of punishment). Emotional abuse comes from an adult who is in a relationship of trust, responsibility or power with the child, and the adult fails to provide the child with an adequate developmental and supportive environment. Such abuse includes humiliation, blaming, threatening, intimidating, discriminating, restricting freedom of action, denigrating, ridiculing, terrorizing, emotional incest, corruption and other hostile or repulsive attitudes towards the child. ” With increasing interest in studying this phenomenon, there is growing evidence that emotional abuse affects the physical and / or mental health of the child and his / her development.

The neglect of the child refers to “the omission of a person who has the responsibility of raising / caring for / educating the child, to take the measures required to fulfill this responsibility, which endangers the life, the physical, mental, spiritual, moral or social development, the bodily integrity, the physical or mental health of the child ". In particular, emotional neglect refers to the adult's inability or reduced ability to engage emotionally in the care of the child and to meet the emotional needs of children. Emotional neglect includes failure to provide appropriate affection and care for the child, knowingly allowing the child's maladaptive behavior, acceptance of children as witnesses to domestic violence, failure to seek care for emotional / behavioral issues, and failure to provide a structured, age-appropriate family setting. Emotional neglect is also characterized by a lack or insufficiency of parent-child interaction, emotional unavailability, and a lack of response and validation of the child's emotions by the parent (e.g., constant ignorance of the child if he or she does not disturb the parent in the activities he or she carries out).


Various tools have been developed to assess exposure to abuse. One of the most commonly used is CTQ (Childhood Trauma Questionnaire). Other more recent tools are the CECA-Q (Childhood Experience of Care and Abuse Questionnaire) and the MACE Scale (Chronology of exposure to maltreatment and abuse - which assesses the severity of exposure throughout each year of childhood). Another important tool is the Childhood Adverse Experience Questionnaire (ACE), which tracks the number of exposures rather than the severity of the exposure. The ACE questionnaire score was used in important epidemiological studies and proved to be an important determinant of the risk of alcoholism, substance abuse, depression, suicide and overuse of psychotropic medication, and highlighted a “dose-dependent” relationship between adversity. and health consequences (2).

The situation of the phenomenon in the world and in Romania

The number of studies and data available varies in different regions of the globe, and in some areas there is relatively little data on certain forms of abuse. Prevalence rates require careful interpretation because variations may reflect methodological differences, differences in how abuse is defined, and / or differences in data collection. Prevalence rates differ depending on the category of abuse, gender and continent. Studies on child neglect are a relatively neglected field among scientific research, especially in low-income countries. In a study published in 2018, researchers investigated the prevalence of various forms of abuse in the 2000-2017 period. The most frequently investigated aspect of abuse is sexual abuse, with the most available studies. Sexual abuse had a median prevalence of 20.4% in North America and 28.8% in Australia for girls (with much lower rates for boys). For physical abuse in Europe, the prevalence is higher in boys (27%) than in girls (12.0%); the situation is similar in Africa, but the figures are much higher (60% for boys and 51% for girls). The prevalence of emotional abuse was double in girls compared to boys in North America (28% vs. 14%) and Europe (13% vs. 6%). Regarding neglect, the data were as follows: prevalence rates for neglect were highest in South America (girls: 55%, boys: 57%) and Africa (girls: 42%, boys: 39%), followed by Asia (girls: 26%, boys: 24%). In North America, neglect prevalence rates were 40.5% for girls and 16.6% for boys. In Europe the values were lower and relatively the same, meaning 15% for boys and 14% for girls (3). Other researchers have looked at more specific issues, namely a meta-analysis of studies related only to the prevalence of physical and emotional neglect. The prevalence rate for emotional neglect was 18.4% (16 samples with 59,655 participants), and for physical neglect was 16.3% (13 independent samples with a total of 59,406 participants) (4).

In Romania a study on childhood adverse experiences (ACE) was conducted on a representative sample of 2088 young adults in order to assess the prevalence of ACE in Romania and to identify the relationships between ACE exposure and health risk behaviors as well as health consequences. The results of the study show a prevalence of emotional abuse of 23.6%, and of emotional neglect of 26.3%. The prevalence for other forms of abuse was: for physical abuse 26.9%, for physical neglect 16.5% and for sexual abuse 12.7%. Participating women reported significantly more frequent exposure to sexual and emotional abuse.

Several correlations and consequences

Evidence regarding the correlation between emotional abuse and neglect on one hand and psychiatric and medical disorders is increasing as interest in studying this issue increases. In addition, more and more researchers are designing their studies so that they can show not only that there are associations between these early adverse experiences and mental and somatic health problems that occur sooner or later in life, but also that there are causal relationships that cannot be ignored.

- A history of childhood abuse contributes greatly to the development of depressive and anxiety disorders in children and adults. A 2016 meta-analysis that included five high-quality prospective studies that looked at the impact of childhood abuse on the incidence of anxiety disorders, such as anxiety and depression, provided robust evidence to support the hypothesis that childhood abuse increases the risk of depression and anxiety. In particular, children exposed to neglect were 1.75 times more likely than those not exposed to neglect to suffer from depression or anxiety in adulthood, the experience of being neglected in childhood being a significant risk factor for depressive or anxiety disorders in adulthood (6). Moreover, abuse negatively affects not only the likelihood of depression, but also the evolution of the disease and the outcome of treatment. Another meta-analysis showed that childhood abuse (including neglect) is associated with an increased risk of recurrent and persistent depressive episodes, and is sometimes associated with a lack of response to treatment or a lack of remission during treatment (7). In patients admitted to hospitals with a psychiatric profile, the evolution of depression is less good than in the general population or than in patients in primary care. A history of emotional neglect in childhood and the presence of three or more depressive episodes were independent predictors of the recurrence of depression (8).

- Among childhood abuse experiences, emotional neglect is a significant and consistent factor in predicting low resilience scores, and high scores on depressive symptoms. Emotional neglect was a significant predictor of low resilience, and elevated levels of depressive symptoms. (9)

- A three-year longitudinal study with adolescent subjects aimed to assess the long term consequences of the physical and emotional neglect they experienced in their families. High scores when measuring physical and emotional neglect corresponded to more important symptoms of depression, post-traumatic stress disorder, smoking and psychoactive substance use. Early exposure to neglect is a risk for the further development of internalization symptoms and substance use behaviors in young adults (10).

- In addition to the correlation with depression and anxiety, another meta-analysis that applied the Bradford-Hill criteria found significant associations of emotional abuse and neglect with drug use, suicide attempts, sexually transmitted diseases and risky sexual behaviors (11 ). The link between emotional neglect in childhood or adolescence and certain practices with an increased risk of HIV infection for certain categories of people is not a direct one. Emotional neglect acts through the negative impact it has on self-esteem, which in turn negatively affects attitudes about risk-taking (12).

- In a cross-sectional study of psychoactive addicts conducted to investigate the prevalence of early childhood abuse and the association with various aspects of subsequent sexual behavior among psychoactive users, it was found that experiences of emotional neglect, emotional abuse, physical neglect, physical abuse and sexual abuse were common among these people. An association has also been observed between reported adversity and the likelihood of being addicted to sex, sexual victimization in adulthood and others (13).

- A study published in 2016 explored the long-term effects of emotional neglect by mother or father, on the symptoms of post-traumatic stress following sexual assault and / or physical aggression, in participants who sought help and treatment for depression and concomitant alcohol abuse. The results suggested that parental roles have distinct protective functions. Emotional neglect by the mother can exacerbate the symptoms of post-traumatic stress and depressive symptoms, which appeared after exposure to sexual assault, and the onset of depression is earlier. Emotional neglect by the father is correlated with higher alcohol consumption and early onset of depression after exposure to physical aggression (14).

- In addition to the objective recording of adverse experiences, it seems that children's perception of their emotional neglect is a significant predictor and can be considered as a risk factor for psychopathology. A prospective longitudinal study of 1,700 children showed that among with the perception by 11-year-olds of a parenting style based on emotional neglect and excessive control, they were twice as likely to report psychopathology at the age of 15 (15).

- The way in which long-term cognitive development is affected by childhood abuse (abuse and neglect), was highlighted by a prospective study conducted on a cohort of 7223 children that was followed from birth to the age of 14 years. During the longitudinal study, notifications to child protection authorities were recorded in relation to episodes of abuse. Also, scores on two tests of cognitive ability assessment (Raven, WRAT) were recorded when children turned 14 years old. Notifications of abuse or neglect were associated with a lower score on both tests, with results suggesting that both abuse and neglect have independent and significant adverse effects on children's cognitive development (16).

- In depressed mothers who have suffered emotional abuse in childhood and who have children with psychopathology, the impact of emotional abuse on the style of raising and educating children (on parenting) is visible. These mothers are more likely to show low acceptance of the child, and to use parenting tactics based on psychological control (17).

- Even when the mother receives treatment for depression, the traumas she suffered as a child continue to affect the next generation, and there may be a delay of about 6 months from the cure of maternal depression until the appearance of the positive impact on their school-aged children with psychiatric (internalization) disorders. It seems that in addition to psychotherapeutic interventions in the case of maternal depression, interventions would be needed to improve the methods of raising and educating children, in order to observe faster improvements in children (18).

- Sleep disorders and childhood adverse experiences are more prevalent in people with a history of depression. One study looked at whether various types of childhood adverse experiences could be predictors of sleep duration and insomnia in young adults with previous episodes of depression. The results of the study showed that only emotional neglect in childhood was a significant predictor of insomnia, and sleep duration was not influenced (19).

- Adversity in childhood manifests its effect not only in the period of development or in youth, but also in late adulthood. For example, emotional neglect has been associated with stroke in people over 55 years of age. The likelihood of stroke was 2.8 times higher for subjects who reported a moderately-high level of emotional neglect in childhood compared to those with a moderate-low level (20).

Aspects of neurobiology

Early adverse experiences contribute to the development of psychopathology through changes in brain structure and function (negative change in the trajectory of brain development), changes in the functioning of the hypothalamic-pituitary-corticoadrenal axis, neurohormonal changes, certain genetic variations and epigenetic changes (6). The areas of the brain where changes in structure and function occur following exposure to childhood adversity are the hippocampus, amygdala, anterior cingulate cortex, prefrontal cortex, and other brain areas associated with stress and emotion processing (21). Subjects with a family history of major depressive disorder have low volume in the hippocampus and prefrontal cortex especially if they have experienced childhood adversity suggesting that genetic and environmental factors influence brain structure through epigenetic mechanisms, and structural abnormalities may precede the onset of the disease (22) . In addition, it seems that both the sex and the age at which adversity occurs matter. In some studies, a history of emotional abuse has been associated with reduced hippocampal volume, especially in males, and the study of subjects with disturbed attachment exposed to emotional abuse and neglect showed that the volume of the right hippocampus is especially affected between ages 7 and 14 (23).

- Intense childhood adverse experiences such as neglect have been shown to be associated with both increased reactivity of the amygdala and a change in its volume (1). In subjects with a history of emotional neglect, there was an increased activation of the left amygdala but also of the left anterior hippocampus during the processing of information perceived as threatening (24).

- Increased levels of emotional neglect have been associated with inappropriate development of ventral striatal activation (correlated with reward mechanism) in adolescence, and this development is a predictor of the emergence of depressive symptoms in adolescents. Reductions in activity were correlated with more severe depressive symptoms (25).

- Insecure / rejection attachment, which may be associated with emotional neglect, shows reduced activation of the mesolimbic (reward) dopaminergic pathway in response to infant facial stimuli, as well as decreased peripheral oxytocin discharge on mother-infant contact (26 ).

- Dysfunction of the hypothalamic-pituitary-adrenal axis is associated with a dysfunctional reaction to stress, but also with increased reactivity of the amygdala and childhood abuse. The adjustment of cortisol levels in children who have experienced intense neglect is done abnormally, in a way that can reduce the child's ability to cope with adversity (27).

- Certain genotypes of the FKBP5 gene (associated with HPA axis dysfunction or psychopathology), if present in people who suffered from emotional neglect in childhood, were predictors of increased amygdala reactivity (to stimuli perceived as threatening); these individuals may be at increased risk for stress-related psychopathology (1).

Instead of conclusions

All types of child abuse should be considered important health risks, as they have a major contribution to the burden of several diseases. Awareness of the long-term consequences should encourage measures to identify people at high risk and to implement interventions that effectively protect children from violence, wherever it might come from (11). Although progress has been made in recognizing the signs and symptoms of some forms of abuse, some forms, such as emotional abuse or neglect, may sometimes be difficult to recognize for intervention. It may be necessary to be more aware that these childhood adversities are more common than they seem and that they are not harmless. It is possible that prevention measures or early interventions by professionals who come in contact with the child (including health professionals) will change his or her life course (both from a health perspective, but not only), will reduce many sufferings in the future and, at the level of society, will save significant resources. For example, some studies estimate that a 10-25% reduction in childhood abuse could prevent 31.4-80.3 million cases of depression and anxiety worldwide (6). It may be necessary in the training and education of health professionals to emphasize the role of chronic childhood stress and the mechanisms by which it leaves its mark on the etiology of many diseases, be they somatic or mental. There may be a need for greater availability of interventions to address childhood trauma in order to reduce the negative influence of these adversities on adult health, but also to stop transgenerational transmission. With all the progress made, there is certainly much left to do.


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