case study on emotional abuse

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Can You Get PTSD From Emotional Abuse?

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Emotional abuse may lead to PTSD or another stress disorder known as C-PTSD (complex post traumatic stress disorder). The two stress disorders have several overlapping symptoms. But C-PTSD often causes more extensive issues with emotional regulation, interpersonal relationships, and negative self-thoughts.

Unlike PTSD, which is typically caused by a single traumatic event, C-PTSD usually involves chronic trauma that lasts for months or years. As a result, some people with C-PTSD may need long-term therapy to recover from emotional abuse.

This article explains how you can develop C-PTSD or PTSD from emotional abuse. Learn more about emotional abuse, its effects, and the signs you may be experiencing it.

How Is Emotional Abuse Related to PTSD?

Abusers can use many non-violent tactics to assert their power over someone. These emotionally abusive behaviors are meant to terrorize and control another person and keep them in the abusive relationship .

Living in this constant state of stress or experiencing extremely frightening events, such as being threatened, can lead to symptoms from the trauma.

The DSM-5 (Diagnostic Manual for Mental Disorders 5th revision), a handbook used by healthcare professionals to diagnose mental health disorders, does not recognize C-PTSD as a formal diagnosis, but it does recognize PTSD as one.

On the other hand, the ICD-11 (International Classification of Diseases 11th Revision), which is published by the World Health Organization, recognizes C-PTSD as a "sibling disorder" to PTSD that has three additional groups of symptoms:

• Problems in affect regulation, such as irritability or feeling emotionally numb
• Beliefs about oneself as defeated or worthless, along with feelings of shame, guilt, or failure related to the traumatic event
• Difficulties sustaining interpersonal relationships

Because the concept of C-PTSD is relatively new, healthcare providers typically make a diagnosis of PTSD instead of C-PTSD. Still, understanding C-PTSD helps providers more accurately define a person's experience and form an appropriate treatment plan.

Emotional abuse is defined as any non-physical behavior that is designed to control, subdue, punish, or isolate another person through the use of humiliation or fear.

Emotional abuse includes—but is not limited to—the following tactics:

• Erosion of self-esteem: Abusers may insult your appearance, dismiss your thoughts, feelings, or passions as silly or unimportant, attempt to humiliate you in public, belittle you, call you mean names, or accuse you of being things you are not.
• Control: Abusers may follow or spy on you, gaslight you by trying to convince you the abuse never happened, control your access to finances, force you to quit your job, or stonewall you by refusing to communicate.
• Instilling fear: Abusers may have frequent outbursts or behave unpredictably. They may destroy your property, drive recklessly with you in the vehicle, outright threaten you or your loved ones, or tell you stories of how they could physically abuse you.
• Blame-shifting: Abusers may try to convince you that the abuse wouldn't happen if you were different in some way. They may blame you for their problems, deny the abuse, or throw made-up accusations your way, such as cheating or lying, when you try to raise an issue.
• Dehumanization: Abusers may try to make you feel unimportant. They may deny you support, withhold affection, degrade you, ignore your physical or emotional boundaries, or constantly interrupt you.
• Isolation: Abusers may try to come in between you and your family and friends. They may prevent you from socializing, character assassinate you, or attempt to turn you against your family members (or your family members against you).

How Trauma Impacts the Brain

During a traumatic event, the body produces large amounts of stress hormones which affect the amygdala , hippocampus, and prefrontal cortex. These areas of the brain are responsible for feelings and actions related to fear, clear thinking, decision-making, and memory. These functions and abilities have been found to be decreased in a person who has experienced trauma.

PTSD From Emotional Abuse Symptoms

A person who is diagnosed with PTSD will experience symptoms that persist for months or even years after the traumatic event.

There are four categories of PTSD symptoms, which can vary in severity:

• Intrusive thoughts: Someone with PTSD may experience distressing dreams or flashbacks of a traumatic event over and over again. They may feel as though it is impossible for them to escape their trauma.
• Avoidance: Someone with PTSD may avoid anything that reminds them of the trauma, such as people, places, activities, or situations. They may try to avoid remembering, thinking, or talking about their feelings or what happened.
• Cognition and mood changes: Someone with PTSD may be unable to recall important aspects of the traumatic event. They may have distorted thoughts or feelings about themselves or others, or blame themselves for what happened. They may have persistent feelings of fear, horror, anger, guilt, and shame, or feel uninterested in activities they once enjoyed. They may feel detached from others, or become unable to experience positive emotions.
• Heightened reactivity: Someone with PTSD may become easily irritable, have angry outbursts, or behave recklessly. They may become easily startled, overly suspicious of their surroundings, or have problems concentrating or sleeping .

Research shows that people who experience emotional abuse often experience more severe depression, anxiety, stress, and emotional dysfunction compared to people who have experienced only physical abuse, only sexual abuse, or combined physical and sexual abuse.

Emotional abuse can have short and long-term effects on a person's mental and physical health as well as their ability to have healthy relationships down the line.

Verywell / Danie Drankwalter

Mental Health

Emotional abuse can impact your mental health. Repeatedly experiencing emotional abuse can wear down your sense of self, self-worth, and confidence. You may find yourself feeling constantly afraid, ashamed, guilty, unwanted, powerless, and hopeless. You may feel like you're unable to feel positive feelings. Emotional abuse can even lead to depression and anxiety .

Physical Health

Emotional abuse puts the body in a constant state of stress, which can lead to physical health problems, including changes to the brain. Studies have also shown that children who experience psychological abuse are at higher risk for long-term and future health problems, including diabetes , lung disease, malnutrition , vision problems, heart attack , arthritis , back problems, and high blood pressure .

Interpersonal Relationships

When you have been in an emotionally abusive relationship, the abuser has probably made you feel isolated, unwanted, and alone. These experiences affect how you see yourself and others, even when the abusive relationship ends.

Many people who have experienced abuse feel distrustful of others and cannot form stable relationships. They may end up in another abusive relationship because the dysfunctional relationship dynamic has been normalized.

The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders

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“It is not the bruises on the body that hurt. It is the wounds of the heart and the scars on the mind.” —Aisha Mirza “We can deny our experience but our body remembers.” —Jeanne McElvaney, Spirit Unbroken: Abby’s Story

Prevalence and Consequences of Childhood Maltreatment

Childhood Maltreatment Increases Risk for Illness Severity and Poor Treatment Response in Mood Disorders

Timing of childhood maltreatment: are there periods of heightened sensitivity, experiencing single subtypes of abuse and neglect versus experiencing multiple types, underlying mechanisms by which childhood maltreatment increases risk for mood disorders and contributes to disease course.

Biological Abnormalities Associated With Childhood Maltreatment

Pathways to mood disorder outcomes, childhood maltreatment and associated alterations in neural structure and function, limitations and future directions, acknowledgments, information, published in.

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Questions and dilemmas, conclusions, about the authors, data availability, author contributions, declaration of interest, emotional abuse and neglect in a clinical setting: challenges for mental health professionals.

Published online by Cambridge University Press:  21 September 2021

This article addresses some of the common uncertainties and dilemmas encountered by both adult and child mental health workers in the course of their clinical practice when dealing with cases of suspected emotional abuse or neglect (EAN) of children. We suggest ways of dealing with these according to current best practice guidelines and our own clinical experience working in the field of child maltreatment.

Within the field of child maltreatment, emotional abuse and neglect (EAN) (psychological maltreatment) refers to caregiver behaviours towards or involving a child (excluding physical/sexual abuse and physical neglect) that cause or have a strong potential to cause serious harm to all aspects of a child's well-being or development. EAN could reflect repeated caregiver acts or omissions, or a single extreme behaviour. Caregiver refers to any adult responsible for caring for the child, usually parents.

This is a form of maltreatment with a high prevalence partly because it exists both on its own and in combination with other forms of abuse or neglect. And yet it is frequently under-recognised, including by clinicians working in child and adolescent mental health services (CAMHS) and adult mental health. Part of this may be due to ambiguity and lack of consensus over the definition, and the need to distinguish between parenting difficulty and actual EAN.

Risk factors for EAN include child factors (e.g. developmental disorder), caregiver factors (e.g. psychiatric disorder and substance misuse, which will be identified by adult mental health professionals, domestic violence, parental history of childhood maltreatment) Reference Hibbard, Barlow and MacMillan 1 and wider family factors (e.g. large number of children, poverty). Reference Brassard, Hart, Baker and Chiel 2

Clinicians may observe worrying interactions between parents and children amounting to EAN, or come to recognise that a referred child's difficulties are associated with such parent–child interactions. These may be formulated as contributing to the child's mental health difficulties and be a focus of treatment.

Although identification continues to be problematic, there is evidence of the detrimental impact of harmful parent–child interactions on the child's attachments and development at the time of the maltreatment, as well as later. Reference Riggs 3 EAN is likely to cause harm through its impact on a child's thoughts, feelings and self-concept (leading, for example, to increased susceptibility to depression); the development of maladaptive behaviours, which may serve an emotion regulation function (e.g. substance misuse); interpersonal difficulties such as relationship avoidance or aggressive behaviour; reduced educational achievement; and biological changes such as altered stress response and increased damage to health due to lifestyle factors such as smoking and risky sexual behaviour.

There is a converging weight of evidence across clinical and population samples internationally suggesting the detrimental impact of EAN on mental health outcomes. The Adverse Childhood Experiences Study asked retrospectively about experiences of EAN and several other experiences (exposure to domestic violence, sexual abuse and physical abuse) that would necessarily also involve EAN. Reference Felitti, Anda, Nordenberg, Williamson, Spitz and Edwards 4 It was found that the cumulative sum of adverse childhood experiences contributed exponentially to adverse outcomes in physical and mental health. Longitudinal studies have found a significant correlation between childhood EAN and psychotic symptoms at age 21, Reference Abajobir, Kisely, Scott, Williams, Clavarino and Strathearn 5 increased rates of depression in women at age 18, Reference Gallo, De Mola, Wehrmeister, Goncalves, Kieling and Murray 6 and comorbid substance misuse, depression and anxiety into the mid-30s. Reference Skinner, Hong, Herrenkohl, Brown, Lee and Jung 7 EAN showed the strongest association, compared with other abuse subtypes, with depression and anxiety at age 21. Reference Kiseley, Abajobir, Mills, Strathearn, Clavarino and Najman 8 Few studies have been able to control for genetic risk, although one Reference Schaeffer, Moffitt, Arsenault, Danese, Fisher and Houts 9 looked at emotional abuse after age 12 in 2232 English and Welsh twins interviewed at age 18, concluding that adolescent victimisation (including internet abuse) predicted psychopathology at age 18, in a pathway that appeared to be environmentally mediated.

There are, nevertheless, some problems with existing research into the effects of EAN. The widely used Childhood Trauma Questionnaire (CTQ) enquires about only one aspect of EAN, namely spurning (targeted hostility/rejection) or the general term emotional abuse. Reference Cecil, Viding, Fearon, Glaser and McCrory 10 Much existing research Reference Schwarzer, Nolte, Fonagy and Gingelmaier 11 uses the CTQ or similar, establishing in cross-sectional studies an association between a positive score for emotional abuse, using retrospective recall, and a wide range of psychopathology in adolescence and adulthood. There are some obvious methodological problems with this approach, limiting the conclusions that can be drawn. A few longitudinal studies have attempted to correct for possible bias in reporting, for example by using cases substantiated by social services, and looking at potential environmental confounders. Differences in individual susceptibility to the effects of maltreatment need to be considered, and some studies have controlled for the presence of a neurodevelopmental disorder such as attention-deficit hyperactivity disorder (ADHD). There are limited data on age at exposure to emotional abuse, as EAN is rarely one event; rather, it is an integral part of an ongoing parent–child relationship: earlier age at onset will affect key developmental processes such as attachment formation but adolescents may be more aware of being subjected to abusive or neglectful interactions, adding to the risk of harm.

Clinicians suspecting the existence of emotional abuse or neglect in the parents and children they see are faced with a number of dilemmas. We attempt to identify these and offer current best practice solutions in the hope that this will improve awareness of and confidence in managing these cases.

Are there recognised patterns of interaction in emotional abuse?

In part as a response to difficulties in defining emotional abuse, clusters or categories of commonly observed interactions have been described both in the USA Reference Brassard, Hart, Baker and Chiel 2 , Reference Brassard, Donovan, Freerick, Knutson, Trickett and Flanzer 12 and in the UK. Reference Glaser 13 , Reference Glaser 14 Several categories may occur together. They are designed to help assessing clinicians and to provide guidance towards the focus of treatment:

(1) emotional unavailability, unresponsiveness and neglect

(2) hostility, blame, denigration, rejection or scapegoating

(3) developmentally inappropriate or inconsistent interactions with a child

(4) exposure to frightening or distressing experiences

(5) failure to recognise a child's individuality and the psychological boundary between the parent/carer and child

(6) failure to promote the child's socialisation.

Most clinicians will easily recognise categories 1 and 2. In a CAMHS setting, category 1 may take the form of a parent/carer's lack of support for recommended treatment/psychosocial interventions for their child.

Category 3 includes, as examples, harsh and inconsistent discipline, inappropriately high expectations of a child that are well beyond their developmental level (such as doing excessive housework or taking on a caring role), but equally cases of overprotective behaviour, usually stemming from a parent's own anxieties. These interactions are styles of harmful parenting, rather than interactions targeted at an individual child.

Category 4 includes inappropriate exposure to disturbing or traumatic events such as occurs in domestic violence. It will also present as a concern in adult mental health services, where some children of mentally disordered adult patients will be recognised as observing highly distressing or threatening behaviour in their parents.

Category 5 is seen, for example, in fabricated or induced illness, where a parent's own needs to have a child perceived as ill outweigh the child's needs for nurturing of their separate, individual identity. The psychological boundary between parent and child becomes blurred. It can also be seen in couple disputes, where children are used as pawns in marital conflict and breakdown, sometimes confided in inappropriately and drawn in by one parent to take sides against the other parent. At its most extreme, children can be pressured to make or collude with false allegations against a parent. Another example may be seen in parents who have experienced traumatic events or abusive relationships and wish to protect their child from similar experiences but in doing so do not accurately distinguish between their own psychological realities and those of their child.

Examples of category 6 include parents who misuse substances, who expose their children to practices such as shoplifting to fund a drug habit, or families who for a variety of reasons fail to support their child's attendance at school and isolate their children.

Helpful as these categories are, not all observed clinical cases will fit neatly, although most tend to have a predominant theme in at least one.

What to do if there are concerns about a parent–child interaction and EAN is suspected

The child is likely to have been referred with difficulties, which should be carefully noted. The next most important action is to carefully record clinical observations, including of parent–child interactions and child behaviour and reactions. Accurate record-keeping is essential in any potential child maltreatment situation, but particularly important in EAN, where it is the repetitive nature of negative interactions that is so damaging. Making a case of emotional abuse often relies on descriptions of repeated, consistent observations, in different settings and ideally by different observers. Descriptions will also be useful in most instances to raise the concern with the parent (without naming emotional abuse) to see whether they are able to acknowledge unhelpful or harmful interactions with their child.

The clinician may at this stage wish to discuss with colleagues, or simply arrange to see the family again, in order to verify the observations and gauge the parental response. If the pattern is repeatedly observed, links need to be assessed between the child's difficulties and the forms of the parent–child interactions of concern.

There are a few rare situations in which emotional abuse is associated with immediate serious risk to the child. An example might be abandonment of a child or a parent experiencing a psychotic episode whose child is caught up in the parent's delusional beliefs. If the child is aware, they may be confused and troubled, but more importantly in extremely delusional states the child's life may be at risk.

How to tell the difference between family dysfunction or parenting difficulties and abusive parenting

Clinicians will be used to working with families in which there are challenging dynamics and communications, or supporting parents whose parenting may be adversely affected by factors such as poverty, mental ill health and their own adverse history of being parented. The distinction between parenting difficulty and abuse needs to be made with reference to the definition of EAN, which is the presence of persistently harmful interactions or a single severely harmful incident with actual or likely harm to the child.

What does a good clinical assessment of emotional abuse look like? What should it include?

This again goes back to the definition of EAN, which includes evidence of harmful parent–child interactions that can be linked with some certainty to evidence of harm to the child's development or current functioning. The assessment begins with the child's mental state and development, including cognitive, emotional, behavioural, social and physical functioning (the latter is important in cases of failure to thrive, feeding/eating disorders or medically unexplained symptoms). Collateral information is especially important here and the school can usually provide invaluable information, including their observations of parent–child interaction.

It is particularly important to consider neurodevelopmental disorders and other innate child vulnerabilities that might increase a child's susceptibility to the effects of problematic parenting or might fully explain the child's difficulties. Children with neurodevelopmental disorders are at increased risk of experiencing abusive parenting; Reference McDonnell, Boan, Bradley, Seay, Charles and Carpenter 15 one likely reason for this is the more demanding nature of looking after a child with, for example, ADHD, autism spectrum disorder or an intellectual difficulty. Children with a physical disability are also at increased risk.

Detailed assessment of the specific parent–child interaction of concern follows. An overall parenting assessment must be nuanced and comprehensive, to include parenting strengths relevant to any observations.

The assessment is then extended towards the parents, including mental state and functioning, their family history and family relationships. Risk factors include parental mental ill health, substance misuse and domestic violence occurring as isolated risk factors or in combination. Reference Skinner, Hong, Herrenkohl, Brown, Lee and Jung 16 Parents’ own experiences of poor parenting, including disrupted attachments, especially intergenerational involvement of child protection agencies, are a cause for concern. However, it must be stressed that most adults with mental health difficulties do not abuse their children and many adults with disadvantaged backgrounds go on to parent successfully.

Social stressors such as unemployment, poverty, social isolation, community violence and criminality are likely to have an impact on parenting.

How can I tell whether a child's symptoms are due to EAN and not something else?

The impact of EAN on children is mostly non-specific and it can be part of the aetiology of a very wide range of psychological symptoms and impairment in the child. The assessment requires a detailed knowledge of child development and also an in-depth knowledge of the particular child being assessed. A careful process of exclusion must take place to be sure that an innate developmental disorder is not a significant factor. If a neurodevelopmental disorder is found to be present, does it fully explain the child's difficulties? It is of course possible for EAN to be an additional contributing factor in a child with ADHD or autism spectrum disorder. Aspects of the child's internal world, such as self-concept and expectations of others, are relevant to the assessment. The clinician looks out for evidence of a link between negative self-concept or unhappiness and observed negative parent–child interaction. The degree to which EAN is thought to be a significant aetiological factor in a child's difficulties is a matter of clinical judgement, but based on a careful, thorough and open-minded assessment.

EAN may have significant negative impact without a child reaching the threshold for a diagnosis. Subthreshold presentations or negative impact on general psychological functioning or development are also important and a child may engage in very risky behaviour, such as running away from home or becoming sexually vulnerable, without meeting criteria for a diagnosis. A child may seem resilient, for example being academically bright and able to make use of relationships with other adults, but still be experiencing harm in terms of gradual impact on self-concept and behaviour due to repeated negative interactions that undermine emotional development and other aspects of functioning. This is a form of hidden harm, which wears away resilience and may surface as a concern at a later date. The EAN definition includes ‘potential for harm’, which is relevant here. Based on knowledge of the child and child development it is possible to predict that if EAN continues unchecked the detrimental impact on the child will become more evident over time.

How do we allow for differing cultural practices?

Informing oneself about a culture is an important first step, sometimes requiring a consultation with someone very familiar with the particular family's culture. However, certain cultural practices relevant to emotional abuse are not condoned in the UK. An example is a belief, prevalent in a number of cultures, that an evil spirit can become lodged within a child. The child can be isolated and rejected in a way that would be described as scapegoating in an emotional abuse framework. Cultural practices therefore need to be judged within the jurisdiction's code of practice regarding child protection. The evidence of impairment of the child's development or functioning becomes particularly important in this context. Emotional abuse can occur across all cultures and socioeconomic groups.

What is the best way to feed back concerns to parents?

In most cases feedback to parents is direct and specific, giving examples of concerning interactions and observations of the child. Feedback, given orally and also in writing, should also set out the proposed treatment and the goals of treatment. The potential for further harm to the child if parental behaviour is unchanged should be clearly set out.

What is the best way of treating EAN?

In essence, treatment of EAN rests on addressing the relevant categories of EAN of concern. This is not to be equated with holding parents solely responsible for their children's difficulties. Clinicians should work on parents’ ability to acknowledge harmful interactions. Without acknowledgement, parents may well be less motivated to change. Different types of EAN, as depicted in the categories listed above, have been found to respond to different types of clinical approach. For example, emotional neglect is often associated with parental depression, drug misuse or social stressors such as poverty and social isolation. Therapeutic work to increase the parent's attentiveness to the child needs to follow the alleviation of these stressors. It may usefully include video feedback. Developmentally inappropriate interactions respond well to evidence-based psychoeducational parenting interventions. Failure to recognise a child's individuality or failure to promote the child's socialisation requires therapeutic work to improve ‘mentalisation’ – helping the parent to ‘put themselves in the child's shoes’. Clear hostility towards or rejection of the child are often based on a parent's belief about the child's innate negative qualities. Beliefs are difficult to shift and it is not helpful for a therapist to point out the child's good qualities. Rather, a sensitive exploration of the basis of these beliefs is required.

Some of this work will be with the parent(s) alone, but often work will be with the parents(s) and child together. The treatment of an adult's mental ill health by adult mental health services may be a core component of the treatment of the EAN. The child may have their own individual therapeutic needs but it should not be assumed that therapy for the child alone will suffice to reduce the EAN. The family may need social support. This multidisciplinary and multiagency work can only succeed with a coordinated, systemic approach. A modular approach may be needed, selecting goals for treatment in a stepwise fashion based on how pressing and achievable they are.

EAN patterns are often rigidly entrenched, and resist redirection by therapists who attempt to modify behaviour. For this reason, therapeutic work with EAN is best regarded as a time-limited trial, testing a parent's capacity to show some insight into the impact of their own behaviour, empathy towards their child and an indication of their capacity to change.

EAN is closely related to the formation of insecure attachments, and parent–child therapeutic work addresses this. Reference Toth, Gravener-David, Guild and Cicchetti 17

Although individual work with the child is unlikely to reduce EAN, children who have experienced EAN often require therapeutic work to deal with its effects. This requires a careful assessment of the child's psychological and interpersonal functioning and needs. For instance, it is possible that enhancing the child's capacity to mentalise may reduce subsequent aggression. Reference Schwarzer, Nolte, Fonagy and Gingelmaier 11

At what stage should a referral to social services be made? And do we always need to inform parents?

Clinicians should seek to work collaboratively with parents in ensuring that all support needs are met. This may involve referral to early help services to access resources such as parenting programmes, family workers and assistance with problems such as housing and finances that may be contributing to parenting difficulty. Such referrals should be framed positively as being made to provide support for the family.

A children's social care referral for protection should be made when it is the clinician's judgement (having discussed it with their team or supervisor) that the threshold for emotional abuse has been reached and all therapeutic efforts have reached an impasse. There is a stage where therapeutic efforts are ongoing when the clinician may be reluctant to notify in case the therapeutic alliance is jeopardised. In this scenario a careful risk–benefit analysis must be considered. Once it is clear that therapy is not progressing and there is a lack of insight or acknowledgement on the part of parents, there should be no further delay in making a referral. In some cases the risk is so evident at assessment that therapy should only be carried out within a child protection framework.

In most cases parents should be informed of the referral. There are a few exceptions where there is a concern that telling parents might heighten the risk for a child. This occasionally happens in parental psychotic disorders, or where a case of fabricated or induced illness involves physical threat to a child at the hands of a parent. 18 The risk must be discussed with the social services manager.

In the case of a referral that is declined by social services, concerns should be set out in writing to a senior manager, giving specific examples and evidence of risk to the child and escalating the concerns. A framework of EAN such as that outlined in this paper can be useful in communicating concerns.

Once a child is formally considered at risk and is on a child protection plan, can we still proceed with therapy?

A family may be willing to engage with therapy within a child protection framework. There are well-established examples of this, for example in the fabricated or induced illness field Reference Sanders and Bursch 19 or in work carried out within care proceedings, Reference DeJong and Neil 20 which we refer to as a ‘trial for change’. Therapy when there are child protection concerns is carefully constructed over a tight time frame, with clearly articulated goals reflecting those concerns. There is open liaison between the treating team and social services. It is important that the treatment goals, which should be subject to a written contract between therapist and parents, are very specific and observable in terms of the child's function or the parent's behaviour. This therapeutic work can still proceed within CAMHS, and a partnership and close liaison between health and social services teams will be the best model. In some cases the work may be carried out by clinicians employed by social services.

What can I do if the difficulties within the family are not easily addressed by the CAMHS in which I work?

Services have limited resources and the kind of extended contact that may be required for confirming the presence of EAN (or treating it) may not fit easily into the constraints of the clinical pathways being followed. For example, a clinician may be seeing the child just for a neurodevelopmental assessment, or the child's symptoms may not meet the threshold for treatment within their service. In these situations, the child's welfare must prioritised but there may be a tension between resources available, the flexibility of available pathways and the family's needs.

In the case of neurodevelopmental assessments, it may be necessary to carry out extended assessments if there are significant concerns about parent–child interaction or to advise that a child's difficulties be re-assessed once any parent–child interaction difficulties are addressed if the clinical picture is unclear. The National Institute for Health and Care Excellence (NICE) guidelines on autism spectrum disorder in under-19s include maltreatment as a possible differential diagnosis but at the same time advise against attributing signs of possible autism spectrum disorder to a disruptive home environment, indicating the need for holistic assessment that is sensitive to both neurodevelopmental and psychosocial factors. 21

A child may be discharged following an assessment when there are concerns about possible emotional abuse that were considered not to meet a safeguarding threshold. It is important to raise these concerns with whichever professionals have an ongoing relationship with the family, such as the general practitioner or teachers at the child's school, who are then in a position to monitor and act accordingly if these concerns do not subside. In a similar vein, if therapeutic work is being handed over to another service, then full communication of any concerns, accompanied by clear documentation, is vital.

What is the role of adult mental health professionals?

As part of a mental health service response to EAN, a parent may also need to access their own therapy. Referral to adult mental health services will be difficult if the parent lacks insight or denies their own role. Consent issues, lack of trust and the stigma attached to mental illness are additional challenges. Issues with service structure include high thresholds for adult services, which are generally built around diagnosis and risk to self (rather than other aspects of functioning, such as parenting), and the need for a shared approach that can be hampered by issues such as confidentiality and goals of treatment differing between services. For example, a patient-centred approach to adult psychological therapy may not adequately address abusive parent–child interactions, resulting in a parent's beliefs and behaviours being unchallenged or even reinforced. For this reason, close communication is required between services to ensure a shared understanding of the safeguarding concerns and goals in relation to protecting the children. Currently, the National Health Service is not structured in a way that facilitates this much-needed liaison. Adult mental health services should enquire about the effects of an adult patient's mental health problem on their children. There have been initiatives to encourage this, such as Think Family. 22 This would lead to improved identification of emotional abuse or neglect. Some services have benefited from innovative models such as parental mental health teams.

Emotional abuse or neglect is a very common form of child maltreatment often considered difficult to recognise or define. It appears that clinical practice has not yet caught up with the growing significance attached to EAN in relation to the mental health outcomes of our patients. We have attempted to highlight here dilemmas encountered by both adult and child mental health workers in this complex area and to suggest possible ways of resolving them.

Margaret DeJong , MDCM, FRCPsych, is an honorary consultant child and adolescent psychiatrist at Great Ormond Street Hospital, London, UK. Simon Wilkinson , MBBS, MRCPsych, is a consultant child and adolescent psychiatrist at Great Ormond Street Hospital, London, UK. Carmen Apostu , MBBS, MRCPsych, is a consultant child and adolescent psychiatrist with East London NHS Foundation Trust, London, UK. Danya Glaser , MBBS, DCH, FRCPsych, Hon FRCPCH, is an honorary consultant child and adolescent psychiatrist at Great Ormond Street Hospital, and Visiting Professor, Psychoanalysis Unit, Research Department of Clinical, Educational and Health Psychology at University College London, UK.

Data availability is not applicable to this article as no new data were created or analysed in this study.

All four authors made substantial contributions to the conception of the work and were involved in the review, drafting and final approval of the manuscript and all take responsibility for its content.

This research received no specific grant from any funding agency, commercial or not-for-profit sectors

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• Volume 46, Issue 5
• Margaret DeJong (a1) , Simon Wilkinson (a2) , Carmen Apostu (a3) and Danya Glaser (a4) (a5)
• DOI: https://doi.org/10.1192/bjb.2021.90

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Emotional Abuse

• In book: Psychology and Behavioral Health (pp.647-650)
• Edition: 4th
• Chapter: Volume 1 Essay: Emotional Abuse
• Publisher: Salem Press at Greyhouse Publishing
• Editors: Paul Moglia

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Sophie – Case Study

Sophie* put up with relentless emotional abuse from her ex-partner for almost two decades, leaving her depressed and feeling completely worthless. 

“He completel y took control of my life.  Most of my friends and family weren’t allowed to come and see me because he saw it as ‘his house’ and ‘his  rules’ and I didn’t have a say.  At one point I couldn’t even see my daughter who had just had my first gran dchild. It was horrendous.  About three months after I first met him, he started getting jealous when I went on a night  out with my friends.   

He wanted to know where I was, who I was with, what time I was coming home. He was just really, really  possessive.  At first I didn’t think it was abuse. I just thought he was keen to see me. I  didn’t really take any notice.”  

But when the pair moved in together, the abuse became overwhelming.  

“I was really ill for quite a while and needed a spell in hospital. But even when I came out and went back home, I felt like I was fat – even though I weigh ed about six stone.  I wouldn’t want to eat. I’d go to bed at about 6pm because I just didn’t want to sit up and listen to him abusing me a ll night.  He would criticise anything. If you made him food it was horrible but he’d eat it all.  

One day I did a bit of washing and there was a little bit of butter left on a knife, and he called me a lazy, fat slag and he threw the knife at me. It went on all night until I went to bed.

I think sometimes the emotional abuse can be worse than a slap. With a slap it’s over and done with, but the emotional side is continuous.”  

It wasn’t long into the relationship before her former boyfriend began taking control of her finances.  

“He took my wages off me and left me with just £50 for the week which I needed to spend on food shopping. And if I didn’t have enough money left at the end of the week he’d just say ‘tough’. 

I worked longer hours because I didn’t have any money. It got to the point where I had to tell my boss in work about  what he was doing.  So she agreed to put a little bit of money in a separate wage packe t for me so he wouldn’t see it.”    

After attempting to split up with him on several occasions without success, she finally plucked up the courage to leave their home after having a discussion with a support worker from Thrive Women’s Aid. Sophie has now been in a refuge with her young son for five months and shares the accommodation with five other women who have suffered similar forms of abuse.  

“I went the following morning while he was in work. I had an hour before they were picking me up to take me. I just grabbed the cases, threw everything together and I haven’t seen him since.”  

“From the moment I went in there I just felt total relief. I think [Thrive Women’s Aid] are absolutely wonderful. It now feels like our home. They are there if you need support, if you need taking to appointments, if you are struggling with anything the door is always open. They even help with getting on the council list for a house. They just making living easy.” 

*Names have been changed to protect the identity of the people we support

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Emotional abuse - Jane's story

My partner was very insecure about my past relationships and became jealous of anyone he thought might be ‘a threat’.

At the beginning, it seemed almost charming – like he wanted to be number in my world… but over time it became more and more frightening.

Whenever I went out, Max would want to know why, where I’d be and exactly who’d be there. If I came home later than I said, he’d accuse me of having an affair. If he’d been drinking he’d call me a ‘f**king whore’ and other stuff. He would shout, swear and square up to me – it started happening multiple times a week.

Next day he was always sorry and “felt so bad - he’d never do it again”.

Over time he stopped me from talking with friends freely, he would throw and break things afterwards if I did. He’d drive the car at high speed with me in it, knowing I hated it and was petrified.

I started to believe that Max’s behaviour was my fault, like he said. My self-esteem was wrecked and I spent most days crying.

In the end it was my GP who helped me take the first step. She also wrote a letter for me, I was able to get legal aid and advice and was able to stand up to Max’s abuse and escape him.

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Child abuse: A classic case report with literature review

Arthur m. kemoli.

Department of Paediatric Dentistry and Orthodontics, University of Nairobi, Kenya

Mildred Mavindu

Child abuse and neglect are serious global problems and can be in the form of physical, sexual, emotional or just neglect in providing for the child's needs. These factors can leave the child with serious, long-lasting psychological damage. In the present case report, a 12-year-old orphaned boy was physically abused by a close relative who caused actual bodily and emotional trauma to the boy. After satisfactorily managing the trauma and emotional effects to the patient, in addition to the counseling services provided to the caregiver, the patient made a steady recovery. He was also referred to a child support group for social support, and prepare him together with his siblings for placement in a children's home in view of the hostile environment in which they were living.

Introduction

For a long time, child protection in general has been perceived as a matter for the professionals specializing in social service, health, mental health, and justice systems. However, this problem remains a duty to all, and more so a concern for other social scientists such as anthropologists, economists, historians, planners, political scientists, sociologists, and humanists (e.g., ethicists, legal scholars, political theorists, and theologians) who contribute to the understanding of the concepts of and strategies in child protection and the responsibility for adults and institutions with roles in ensuring the safety and the humane care of children under their care. Child abuse, therefore, is when harm or threat of harm is made to a child by someone acting in the role of caretaker.[ 1 , 2 ] It is a worldwide problem with no social, ethnic, and racial bounds.[ 3 ] Child abuse can be in the form of physical abuse, when the child suffers bodily harm as a result of a deliberate attempt to hurt the child, or severe discipline or physical punishment inappropriate to the child's age. It can be sexual abuse arising from subjecting the child to inappropriate exposure to sexual acts or materials or passive use of the child as sexual stimuli and/or actual sexual contacts. Child abuse can also be in the form of emotional abuse involving coercive, constant belittling, shaming, humiliating a child, making negative comparisons to others, frequent yelling, threatening, or bullying of the child, rejecting and ignoring the child as punishment, having limited physical contact with the child (e.g., no hugs, kisses, or other signs of affection), exposing the child to violence or abuse of others or any other demeaning acts. All these factors can lead to interference with the child's normal social or psychological development leaving the child with lifelong psychological scars. Lastly, child abuse can be in the form of child neglect, when an able caregiver fails to provide basic needs, adequate food, clothing, hygiene, supervision shelter, supervision, medical care, or support to the child.[ 4 ]

It is usually difficult to detect child abuse, unless one creates an atmosphere that would encourage disclosure by the child being abused.[ 5 ] Nonetheless, a good medical and social history may help to unravel the problem. Signs and symptoms of child abuse commonly include subnormal growth of the child, unexplained head and dental injuries, soft-tissue injuries like bruises and bite marks, burns and bony injuries like broken ribs, in the absence of a history pointing to the cause or causes of the trauma. The present case report describes a child who was abuse by a very close relative, and who caused physical and psychological trauma to the young lad.

Case Report

Peter, a 12-year-old boy, accompanied by his maternal aunt, presented at the local university Dental Hospital (Pediatric Dental Clinic) in Kenya in October 2012, with a complaint of a large, painful left facial swelling related to the left upper incisors. He had been referred from a local rural hospital where he had been taken by the same aunt, for treatment of the swelling. The swelling had occurred only 2 days prior to visiting the local hospital, and 4 days before presenting himself at the University Dental Hospital. Enquiry about the causes of the swelling provided unclear answers. Family history indicated that the young boy was a first-born among three siblings (9-year-old girl, 5-year-old boy), and that their single parent (mother) had been deceased for 6 years due to HIV-related complications. The three children had moved to live with their maternal grandparents and their seven sons. The patient had no adverse past medical history and had never consulted a dentist previous to the present problem. The boy was in grade seven in a local primary school and had the aspiration of becoming a medical doctor in future. It was not possible to establish from the aunt or the boy the situation of the patient's other siblings.

An extra-oral examination showed a young boy with a normal gait, sickly, unkempt, rather withdrawn, and small for his age. He had asymmetrical face due to the swelling involving his left submandibular region and spreading upwards to the inferior orbital margin, febrile (39.1°C), a marked submandibular lymphadenopathy on the left side, the skin overlying the swelling was warm, shiny and fluctuant, and the lips were dry and incompetent (2 cm) and as shown in [Figures ​ [Figures1a 1a – c ]. However, the temporomandibular joint movements were normal. The patient was also found to have a big, healing scar on the dorsal surface of the left foot, the cause of which was also unclear [ Figure 1 ].

(a) Frontal and (b) lateral (c) profiles of the patient showing the facial asymmetry with the left submandibular to infra-orbital and the healing scar on the foot

Intra-oral examination revealed a young boy in the permanent dentition with un-erupted third permanent molars, poor oral hygiene with heavy plaque deposits on the tongue and a generalized but moderate inflammation of the gingiva. There was a grade three mobility in relation to 11, 12, 21, 22 and a grade two mobility in relation to 23, 24, 25 (Miller mobility index). There was intramucosal swelling in relation to 21-24 extending labially/buccally (measuring 4 cm × 3 cm) and palatally (measuring 3 cm × 2 cm). On elevation of the upper lip, active discharge of pus mixed with blood and some black granules could be seen emanating from the abscess. There were no alveolar/bone fractures elicited, but carious lesions were present on 46 (occlusal), 47 and 37 (buccal). Orthodontic evaluation showed Angles class I molar relation on the left and edge to edge tending to class II on the right side. The canines were in class I relationship bilaterally. There was an anterior over-jet of 3 mm (11/21), an overbite of 20%, coincidental dental/facial midline and crowding on the upper right arch with 15 palatally displaced as can be seen in Figure ​ Figure2a 2a – c .

(a) Intra-oral photographs of the patient showing the labial and (b) palatial swelling in relation to displaced 21 and 22 (c), generalized marginal gingival inflammation, palatally displaced 15, moderate dental plaque deposits and a moderate anterior dental crowding in the lower dental arch

For investigations, orthopantogram, intra-oral periapical 11, 12, upper and lower standard occlusal and bite wing radiographs were taken and examined. In addition, clinical photographs, study models, and vitality tests for the traumatized teeth were undertaken. A diet and nutrition assessment, full blood count, stool microscopic analysis for ova and cyst and bacterial culture and sensitivity were also undertaken.

The results of the radiographs showed un-erupted with potential impaction of 48 and 38, an upper midline radioluscence, widened periodontal space in relation to 11, 21 (with a mesial tilt), 22, occlusal caries on 46 and buccal caries on 47 and 37. There was the presence of root fractures involving the apical one-third of 21, 22. Vitality tests conducted on the traumatized incisors showed false positive (may be due to the presence of infection). The blood analysis showed the presence of neutrophilia (suggestive of bacterial infection), mild iron deficiency, but he was sero-negative. From the diet chart, the boy was generally on a noncariogenic diet that lacked the intake of fruits and animal proteins. Nutritional assessment revealed a boy with a height of 144 cm, a weight of 28 kg, and a body mass index (BMI) of 13.5 Kg/m 2 (below 5 th percentile (given the ideal BMI should be 17.8 Kg/m 2 in the 50 th percentile).

From the history adduced and the results of the investigations, a diagnosis of child abuse and neglect was reached, with the boy having suffered traumatic injuries resulting in facial cellulitis, Ellis class VI fracture involving 21, 22 associated dentoalveolar abscess and subluxation of 11, 12. In addition, there were dental carious lesions on 46 (occlusally), 47 and 37 (buccally) and a relatively severe malnutrition. The patient had also moderate plaque induced gingivitis, mild anemia (microcytic and iron deficiency), mild dental fluorosis, potentially impacted 48 and 38 and crowding in the upper right and lower anterior arches.

The objective of treating the boy was to eliminate the pain, infection, improve the general and oral health, restore carious teeth, improve esthetic and report the child abuse and neglect to the relevant authorities. In the initial phase of treatment, the patient was admitted for 4 days and placed on dexamethasone 8 mg stat, cefuroxime 750 mg 3 times a day, metronidazole 500 mg 3 times a day, diclofenac 50 mg tablets alternating 4 hourly with oral paracetamol 1000 mg 3 times a day, to run for 5 days. Patient was also placed on chlorhexidine mouthwash 10 ml twice daily for 7 days and ranferon (hematinics) 10 ml to be used twice a day for 1 month. The second phase of treatment included incision and drainage of the abscess, followed by the splinting of the mobile teeth in the upper dental arch using semi-rigid splint of 0.6 mm stainless steel round wire for 4 weeks while. Root canal treatment of 11, 21, 12, and 22 followed thereafter.[ 6 ] A referral of the patient was made the child support center in the main referral hospital, plus the patient was placed on future recalls to determine whether the patient would have overcome the problem and the oral health was maintained in good condition.

The third phase of treatment involved interceptive orthodontics with the extraction of 15 to relieve the crowding in the area. Oral hygiene instructions were availed to the patient and the guardian, placement of fissure sealants was done for the premolars and molars to help reduce plaque retention on these teeth, preventive resin restorations were placed on 37, 46, and 47. The root fractures involving the apical one-third of 21 and 22 meant that the two teeth were to be initially dressed using non setting calcium hydroxide, and after healing, root canals are filled in the usual manner [ Figure 3 ].

Postobturation intraoral periapial radiograph showing the restoration on 12, 11, 21, and 22

Nutrition evaluation had initially been done and when the patient was re-evaluated after 1 month, he had gained bodyweight up to 1 kg. The child support center continued to carry out psychotherapy, and during one of the sessions, the patient confessed to having undergone physical abuse and threatened not to divulge any information by one of the uncles. The center considered placing the boy into a children's home, probably together with his siblings. Radiographic examinations evaluation after 3 months indicated some external apical root resorption taking place on 21 and 22. Further follows-ups were to continue.[ 7 ] After 10 months, the oral health and general heath of the patient had remarkably improved as shown in Figure 4 .

Posttreatment photographs taken after 10 months showing improved oral health of the patient and the glimmer of confidence in the patient as shown in a-d respectively

All types of child abuse and neglect leave the affected child with long-lasting scars that may be physical or psychological, but they are the emotional scars that leave the child with life-long effects, damage to the child's sense of self, the ability to build healthy relationships and function at home, work or school. This situation can in turn result in the child turning to alcohol or drugs to numb the painful feelings. On the other hand, the exposure by the child to violence during childhood can increase vulnerability of that child to mental and physical health problems like anxiety disorder, depression, etc.,[ 8 , 9 ] and make victims more likely to become perpetrators of violence later in life.[ 10 ] The oral cavity can be a central focus for physical abuse due to its significance in communication and nutrition.[ 3 , 11 ]

A neglected and abused child like the one described here, can become helpless and passive, displaying less affect to anything whether positive or negative in his or her encounters.[ 12 ] The patient described was vulnerable to abuse as he already lacked the parental protection in his early life, and was living in a poor, but large family where competition for available resources must have been stiff. The abuser, therefore, his own uncle, probably did not like their presence gave him the assumption that the children would grow up to take away what he probably thought would be his dues from the family.

In Kenya and even in many other countries, data on the prevalence of child abuse is still scarce. A Kenyan study undertaken in 2013 showed that violence against children was very high, with 31.9% and 17.5% female and male, respectively reporting having been exposed to sexual violence, 65.8% and 72.9% female and male respectively to physical violence. In the same study, 18.2% and 24.5% female and male, respectively had been abused prior to attaining 18 years of age, and only 23.8% female and 20.6% male reported not having experienced any form of violence during childhood.[ 13 ] Child abuse in Kenya, therefore, appears to be a rampant problem within the society. In all cases of abuse reported in the literature, the perpetrators were most often well-known to the children. The motive of child abuse has not always clear, just as it was the case with the patient described here. The patient under study here hailed from a family with low socio-economic background where providing for extra needs in the family could have been a problem. Even during treatment of the patient the family found the cost of treatment to be very high and unaffordable to them, and a waiver of the cost had to be sought and obtained from the University Dental Hospital. Further, the child having been orphaned with the death of their single parent (mother) left these children unprotected and vulnerable to such abuse from uncles who may have been competing for same needs in an already crowded family. It is possible that factors as poverty, social isolation, and familial disruption could have contributed to the abuse meted by this boy.[ 1 ] The fact that the problem was established at this stage, it probably provided the patient and his siblings with the opportunity to get early support and avert serious health problems for them. The referral to the local child protection authority was done to attain this goal and also to have the children monitored consistently for their safety from further child abuse. The child protection agency was indeed considering placing them in the custody of a children's home, though sadly, according to a report by the Kenyan Government, the utilization of these support services had not been very high,[ 13 ] for reasons unknown.

The treatment of the patient was carried out in a humane manner, and assistance provided whenever possible to have the full treatment completed. The problem of nutrition was still a difficult one for this large family with a poor background. Nonetheless, the guardian was still briefed on the issue, and informed about the importance of a balanced diet for optimal growth and immunity boosting for such young child, and suggestions for alternative cost-effective foods for the child. It was hoped that the support services of giving the patient and probably his siblings a new home would help the young child to grow and develop normally without fear of abuse.

The management of child abuse can be complicated, and often require a multidisciplinary approach, encompass professionals who will identifying the cause of the abuse or neglect, treatment of the immediate problems and referral of the child to the relevant child protection authority for action. Counseling services for the child and the caregivers should form part of the management regime. In the present case, the objectives were met and the patient got full benefits of this approach.

Source of Support: Nil

Conflict of Interest: None declared.

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Important Facts and Examples of Child Abuse Cases

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People often think that child abuse cases are something that happens in other families and other neighborhoods, but not close to them. But everyone should be aware that victims of child abuse come from all socioeconomic backgrounds, living situations, and races.

Child abuse statistics showed that 1,820 children died from abuse and neglect, and 4 million child maltreatment referral reports were received in 2021. The data also show that 80.3% of child fatalities involve at least one parent, and 45.6% of children who die from child abuse are one year old.

It's not the proverbial stranger who poses the most danger to children, but the people entrusted to care for them. And it's not just men who harm children, 54 percent of reported abusers were women and 45 percent were men.

For 2021, it was reported that over 600,000 children were victims of neglect and abuse in the US.

Neglect is the most common form of child abuse , followed by physical abuse, sexual abuse , psychological abuse and, lastly, medical neglect. Do you think a child you know, or one you see on the playground may be at risk? You may be reluctant to intervene, but a child at risk may be suffering.

Yolanda Renteria, LPC, says "It's important for adults to learn to trust their gut when it comes to child abuse. People often minimize or dismiss harmful behaviors because they are afraid of being wrong, leaving children unprotected in situations in which they are completely powerless".  

If you are a victim of child abuse or know someone who might be, call or text the Childhelp National Child Abuse Hotline at 1-800-422-4453 to speak with a professional crisis counselor.

For more mental health resources, see our National Helpline Database .

Child Abuse Cases and Stories

These child abuse cases and stories straight from the headlines of newspapers can help to highlight how common child abuse is so that everyone may be more likely to report suspected child abuse and neglect:

• Neglect - A mother in Dallas, Texas, was charged with neglect after her 9-year-old died from complications of diabetes after she failed to help her manage her disease.
• Physical/Emotional Abuse - A mother in North Central Texas had her three children taken away because of a case of Munchausen syndrome by proxy .
• Physical Abuse - Two parents in Dallas, Texas, were charged with abusing their 6-month-old infant so severely that he was in intensive care and it was thought that he was not going to be able to recover.
• Physical Abuse - A mother's boyfriend was charged with the death of her six-year-old son.
• Physical Abuse - A father was charged with the death of his three-month-old infant who was found unresponsive, with bone fractures and liver lacerations.
• Physical Abuse - A father in Lodi, California, was charged with physical abuse after a school employee noticed and reported burns on a 6-year-old student, which were thought to have been inflicted by a clothes iron. She had also been beaten with a stick, and her mother was charged with child endangerment.
• Physical Abuse - A mother and her live-in boyfriend in Janesville, Wisconsin, were charged with abuse after repeatedly hitting her 3-year-old daughter to the point that she required emergency brain surgery.
• Physical Abuse - The boyfriend of a child's mother in Wilmington, Delaware, hit and killed a 16-month old girl because she wouldn't stop crying.
• Physical Abuse - A 9-year-old was beaten by his mother's boyfriend in Lawrence, Massachusetts.
• Physical Abuse - In Fall River, Massachusetts, a mother was charged with burning her four-year-old foster son with a curling iron, causing third-degree burns that required skin graft surgery.

"Severe psychological abuse and neglect can go undetected due to the absence of physical wounds," says Renteria.

The Importance of Reporting

Unfortunately, many more cases of child abuse go unreported. If you think a child is being abused or neglected, report it.

Many people are reluctant to pry or to question other people's parenting "styles," but if their behavior appears abusive or suspicious, trust your gut and contact the authorities.

Most states have a child abuse reporting number or hotline that you can use so that child welfare specialists can investigate suspected cases of child abuse or neglect.

American Society for the Positive Care of Children. Child Maltreatment Statistics . 2023.

U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth & Families, Children's Bureau. Child Maltreatment .

National Children's Alliance. National statistics on child abuse . 2023

By Vincent Iannelli, MD Vincent Iannelli, MD, is a board-certified pediatrician and fellow of the American Academy of Pediatrics. Dr. Iannelli has cared for children for more than 20 years.

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Psychological and emotional abuse of children (from case studies in family violence, p 255-270, 1991, robert t. ammerman and michel hersen, eds. -- see ncj-127384), additional details.

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