emotional abuse & psychological neglect: definition, recognition and intervention danya glaser...
TRANSCRIPT
Emotional abuse & Emotional abuse & psychological neglect:psychological neglect:
Definition, recognition and Definition, recognition and intervention intervention
Danya GlaserDanya Glaser
Great Ormond Street Hospital for Children,Great Ormond Street Hospital for Children,Institute of Child Health, Institute of Child Health,
University College,University College,LondonLondon
Social workers are used to detecting the Social workers are used to detecting the signs of physical and sexual abuse and signs of physical and sexual abuse and taking prompt action to protect a child. taking prompt action to protect a child. But how and when should they respond But how and when should they respond to indications of emotional abuse where to indications of emotional abuse where there is no "forensic" evidence and the there is no "forensic" evidence and the impact of parent-child interactions may impact of parent-child interactions may not be apparent from an initial not be apparent from an initial assessment?assessment?
Emotional abuse & neglect Emotional abuse & neglect in context of overallin context of overallchild maltreatmentchild maltreatment
1.1. Most harm of child abuse and Most harm of child abuse and neglect is psychological neglect is psychological
2.2. Several forms of child abuse & Several forms of child abuse & neglect often co-exist, neglect often co-exist, but EA can but EA can exist aloneexist alone
3.3. The child may be harmed without The child may be harmed without parental intention to harm the childparental intention to harm the child
4.4. Explanations help but do not Explanations help but do not absolve from need to interveneabsolve from need to intervene
Two definitions of Two definitions of maltreatmentmaltreatmentIll treatmentIll treatment
physical, mental or sexual physical, mental or sexual
actually or likely to cause harmactually or likely to cause harm
AND/ORAND/OR
Impairment (Harm to)Impairment (Harm to) of the child’s physical or mental of the child’s physical or mental healthhealth, , or or
physical, intellectual, emotional, physical, intellectual, emotional, social or social or
behavioural development behavioural development
attributable to the care received by the childattributable to the care received by the child
‘‘Devastating Consequences’Devastating Consequences’Egeland (2009)Egeland (2009)
1. Emotional state1. Emotional state• Unhappiness/depressionUnhappiness/depression• Low self-esteem Low self-esteem • FearFear• DistressDistress• Anxious / PTSDAnxious / PTSD2. Behaviour2. Behaviour• Attention seekingAttention seeking• Oppositional defiant - conduct Oppositional defiant - conduct
disorderdisorder• Age-inappropriately responsibleAge-inappropriately responsible
3. 3. Insecure/disorganised Insecure/disorganised attachmentsattachments 4. 4. Developmental / educational Developmental / educational
attainment (& opportunity)attainment (& opportunity) Developmental or educational Developmental or educational
underachievementunderachievement School non-attendance / latenessSchool non-attendance / lateness5. Peer relationships5. Peer relationships Withdrawn or isolatedWithdrawn or isolated AggressiveAggressive6. Physical state6. Physical state Non-organic pains & other Non-organic pains & other
symptomssymptoms Faltering growth / failure to thriveFaltering growth / failure to thrive
Threshold definition of Threshold definition of emotional abuseemotional abuse
Parent child interactions Parent child interactions which which areare•Persistent,Persistent, typical of the typical of the relationship, not single event(s)*relationship, not single event(s)*•Actually or potentially Actually or potentially harmfulharmful •Include Include commission & omissioncommission & omission•PhysicalPhysical contact contact notnot necessary necessary
•Many examples within this overall Many examples within this overall definitiondefinition
IIParental Parental
Emotional unavailability,Emotional unavailability,unresponsivenessunresponsiveness
and neglectand neglect(especially in 1(especially in 1stst 1-2 years) 1-2 years)
(APSAC - (APSAC - Denying emotional Denying emotional responsiveness)responsiveness)
Violates child’s need/right to be noticedViolates child’s need/right to be noticed
IIIIChild Child perceived as deservingperceived as deserving
hhostilityostilityblamingblaming
denigration denigration rejectionrejection
scapegoating scapegoating
(APSAC(APSAC – Spurning)– Spurning)
Violates child’s need/right to be accepted & lovedViolates child’s need/right to be accepted & loved
IIIIIIDevelopmentally inappropriate Developmentally inappropriate
interactions with the childinteractions with the child• Inconsistent & inappropriate disciplineInconsistent & inappropriate discipline• Expectations beyond or below child’s Expectations beyond or below child’s developmental capabilitiesdevelopmental capabilities• Exposure to confusing or traumatic Exposure to confusing or traumatic experiences including experiences including domestic domestic violenceviolence
(APSAC – Terrorizing, also included in (APSAC – Terrorizing, also included in Exploiting/CorruptingExploiting/Corrupting))
Violates child’s need/right to be treated Violates child’s need/right to be treated at her/his particular developmental at her/his particular developmental
stagestage
IVIV Failure to recognise/acknowledge Failure to recognise/acknowledge
child’s individuality child’s individuality • Using the child for the fulfilment of the Using the child for the fulfilment of the
parents’ psychological needsparents’ psychological needs • Inability to distinguish between the child’s Inability to distinguish between the child’s
reality and the adult’s belief & wishesreality and the adult’s belief & wishes
(APSAC – included in Exploiting/Corrupting)(APSAC – included in Exploiting/Corrupting)
Violates child’s need/right to be considered Violates child’s need/right to be considered as an individual as an individual
Kahlil Gibran – The ProphetKahlil Gibran – The ProphetYour children are not your children. They are Your children are not your children. They are the sons and daughters of Life's longing for the sons and daughters of Life's longing for itself. They came through you but not from itself. They came through you but not from you and though they are with you yet they you and though they are with you yet they belong not to you. belong not to you.
You may give them your love but not your You may give them your love but not your thoughts, thoughts, for they have their own thoughts. for they have their own thoughts. You may house their bodies but not their You may house their bodies but not their souls, souls, for their souls dwell in the house of tomorrow, for their souls dwell in the house of tomorrow, which you cannot visit, not even in your which you cannot visit, not even in your dreams. dreams. You may strive to be like them, but seek not You may strive to be like them, but seek not to make them like you. to make them like you. For life goes not backward nor tarries with For life goes not backward nor tarries with yesterday. You are the bows from which your yesterday. You are the bows from which your children as living arrows are sent forth. children as living arrows are sent forth.
VVFailure to promote child’s Failure to promote child’s
socialisation within child’s contextsocialisation within child’s context• Actively promoting mis-socialisationActively promoting mis-socialisation• Failing to promote the child’s social Failing to promote the child’s social
adaptation (including by isolating) adaptation (including by isolating) • Failure to provide adequate stimulation & Failure to provide adequate stimulation &
opportunities for learningopportunities for learning(APSAC – isolating, also included in (APSAC – isolating, also included in
Exploiting/Corrupting)Exploiting/Corrupting)
Violates child’s need/right to socialise Violates child’s need/right to socialise
Categories of emotional Categories of emotional abuseabuse
• Orthogonal Orthogonal
• Different categories can occur Different categories can occur togethertogether
• One often ‘driving’One often ‘driving’
• Severity variesSeverity varies
Cultural AspectsCultural Aspects
Is it harmful?Is it harmful? Is it cultural?Is it cultural?
‘‘Vignette’ testVignette’ test
(?) Categories applicable across (?) Categories applicable across culturescultures
Different interactions within Different interactions within categories in different culturescategories in different cultures
SeveritySeverity Severity of ill treatment: Severity of ill treatment:
Intensity, chronicityIntensity, chronicity Effects = resultant of interaction Effects = resultant of interaction
between severity of ill treatment &between severity of ill treatment &
child’s age, gender, temperament, child’s age, gender, temperament, (mal)adaptive schema(mal)adaptive schema
The respective categories The respective categories contribute unique variance in contribute unique variance in predicting various outcomespredicting various outcomes
NO validated measures of severityNO validated measures of severity
The use & power of The use & power of descriptionsdescriptions
of persistent harmful of persistent harmful parent-child parent-child
interactionsinteractions Descriptions are specific, in Descriptions are specific, in contrast to terms such as neglect contrast to terms such as neglect or emotional abuseor emotional abuse
Difficult to argue withDifficult to argue with Useful in communicating Useful in communicating
concerns to the parentsconcerns to the parents Helpful in talking with the child Helpful in talking with the child
about his/her experiencesabout his/her experiences
The meaning of the term The meaning of the term ‘abuse’‘abuse’
Imperative to interveneImperative to intervene
butbut
Need to uncouple ‘abuse’ from Need to uncouple ‘abuse’ from immediate protection immediate protection
Sexual abuse
Physical abuse
Emotional abuse/
neglect
Abuse/
interaction
Hidden Hidden or observed
Observable
Identity of abuser
Usually questioned
Sometimes known
Known
Abuser & prim. carer
Different persons
Same/ diff. persons
Same person
Need for immediate protection
Yes Usually No
4 tier model for current 4 tier model for current statestateTier 0Tier 0
Family & social risk factorsFamily & social risk factors Poverty, social isolation, displacement Poverty, social isolation, displacement
Tier 1Tier 1Parental risk factorsParental risk factors
Incl. Mental ill-health, domestic violence, substance Incl. Mental ill-health, domestic violence, substance misuse, history of maltreatmentmisuse, history of maltreatment
Tier 2Tier 2
Parent-child interactionsParent-child interactionsTier 3Tier 3
Child’s functioningChild’s functioning & explanations for difficulties& explanations for difficulties
Explanatory relationships Explanatory relationships between 4 tiersbetween 4 tiers
Tier 0 Tier 0 Family & social risk factorsFamily & social risk factors
Tier 1 Tier 1 Parental risk factorsParental risk factors
Tier 2Tier 2
Parent-child interactionsParent-child interactions
Tier 3 Tier 3 Child’s functioningChild’s functioning
Information about family Information about family historyhistory
Salient features in past history of Salient features in past history of parentsparents
Salient features in history of children Salient features in history of children
History of professional involvements History of professional involvements and family’s response and family’s response
Starting points for Starting points for recognising emotional recognising emotional
abuse and neglectabuse and neglect Tier 1 concernsTier 1 concerns
Tier 2 concernsTier 2 concerns
Tier 3 concernsTier 3 concerns
If one, look for concerns in others tierIf one, look for concerns in others tier
Assessment Assessment I. CHILDI. CHILD
Developmental profile of child - Developmental profile of child - physical, emotional, cognitive, physical, emotional, cognitive, behavioural, social.behavioural, social.
Exclude organic causesExclude organic causes
Establish baseline & severity Establish baseline & severity Observation of interactionObservation of interaction Interview with childInterview with child Parental reportParental report School reports – School reports – attendance, learning, attendance, learning,
behaviour, peer relationshipsbehaviour, peer relationships Measures – instruments - SDQMeasures – instruments - SDQ
Talking with the child Talking with the child While child in abusive situation & While child in abusive situation &
‘abuser’ = primary carer ‘abuser’ = primary carer Difficult to acknowledge being rejected, Difficult to acknowledge being rejected,
unloved, exploitedunloved, exploited Abuse denied, rationalised, reframedAbuse denied, rationalised, reframed Child may not realise being usedChild may not realise being used thereforetherefore
What it is like to be …..What it is like to be ….. What child most worried aboutWhat child most worried about What child would like to be differentWhat child would like to be different
II. PARENTS & FAMILYII. PARENTS & FAMILYInterview and observationInterview and observation
1.1. Family’s concerns about child Family’s concerns about child 2.2. Explanations for concernsExplanations for concerns3.3. What remedies have been triedWhat remedies have been tried4.4. Nature of help requested by familyNature of help requested by family5.5. Parent mental health, substance misuse & Parent mental health, substance misuse &
inter-parental violenceinter-parental violence6.6. Family’s social context Family’s social context 7.7. Strengths and protective factorsStrengths and protective factors
Testing the family’s Testing the family’s capacity to changecapacity to change
Time limited trial of interventionTime limited trial of intervention
(6 months rather than ‘stuck’ cases)(6 months rather than ‘stuck’ cases) Attending to Tier 0 & Tier 1 Attending to Tier 0 & Tier 1
concernsconcerns Specific treatment approaches for Specific treatment approaches for
different categoriesdifferent categories Remediation of child’s acute Remediation of child’s acute
difficultiesdifficulties
TrialTrial of intervention of intervention Category 1:Category 1: Emotional unavailability Emotional unavailability• Intervene 1Intervene 1stst in in parental risk parental risk
factors:factors:– DV; Drug & alcohol misuse; Adult DV; Drug & alcohol misuse; Adult
mental health issues, unresolved mental health issues, unresolved effects of childhood maltreatment effects of childhood maltreatment
• Then work on parent –child Then work on parent –child relationshiprelationship
Attachment-based parent child interaction Attachment-based parent child interaction therapy (Toth; Cicchetti; Moss)therapy (Toth; Cicchetti; Moss)
Category 2:Category 2: Negative attributions - Negative attributions - Explore with carer(s) what child’s view of Explore with carer(s) what child’s view of
him/herself might be & how to alter ithim/herself might be & how to alter it
TrialTrial of intervention of intervention
Category 3:Category 3: Inappropriate Inappropriate Developmental Expectations, Developmental Expectations, inconsistent and/or harsh parenting - inconsistent and/or harsh parenting - often young children with behaviour often young children with behaviour problems problems (not due to ADHD or autism (not due to ADHD or autism spectrum) spectrum)
Refer for Refer for trial trial of Parenting work e.g. of Parenting work e.g. Webster Stratton, Triple P, Parent-child Webster Stratton, Triple P, Parent-child interaction therapy (PCIT) e.g. Zimmer-interaction therapy (PCIT) e.g. Zimmer-Gembeck, 2011) Gembeck, 2011)
TrialTrial of intervention of intervention Category 4:Category 4: Using the child for parent’s Using the child for parent’s
needsneeds Look for maintaining factors for parentLook for maintaining factors for parent Explore child’s perceptions with parentExplore child’s perceptions with parent Look for ghosts from the Look for ghosts from the pastpast
Category 5:Category 5: Not promoting socialisation Not promoting socialisation Parent skills trainingParent skills training Discuss effects on child with educationDiscuss effects on child with education Explore with parent, the child’s Explore with parent, the child’s
experience in her/his environmentexperience in her/his environment
Working Working towards towards protectionprotectionAssessment: time limited trial of intervention towards change
Sufficient change
Insufficient change
Child remains at home as least detrimental alternative
Child looked after by alternative carers N.B. contact
Statutory involvement
PrinciplesPrinciples• Early identificationEarly identification
• Trial of best intervention to test Trial of best intervention to test parents’ capacity for sustainable parents’ capacity for sustainable change within the child’s timescalechange within the child’s timescale
• If not achievable, early alternative If not achievable, early alternative placement which can ensure placement which can ensure continuity of care (permanence)continuity of care (permanence)
Working with the childWorking with the child CopingCoping within family if EA continues within family if EA continues
Exploring child’s experiencesExploring child’s experiences Explaining parents’ difficultiesExplaining parents’ difficulties Problem solving - coping with EAProblem solving - coping with EA Working with child’s maladaptive Working with child’s maladaptive schema: guilt, vulnerability, schema: guilt, vulnerability, shameshame
Encouraging relationship with Encouraging relationship with positive adultpositive adult
Ensuring educational attainmentsEnsuring educational attainments
A pathwayA pathway1.1.Initial observations & information about Initial observations & information about
children and families of concern need to children and families of concern need to be separated into the appropriate tiers be separated into the appropriate tiers of concern:of concern: Tier 0Tier 0 -- Social & Environmental Social & Environmental
Factors Factors Tier 1Tier 1 -- Caregiver risk factorsCaregiver risk factors Tier 2Tier 2 -- Caregiver-child interactionsCaregiver-child interactions Tier 3Tier 3 -- Child’s functioning. Child’s functioning.
2. 2. If information is lacking about one or If information is lacking about one or more of the tiers, it needs to be more of the tiers, it needs to be gathered.gathered.
3. 3. Tier 2 includes the non-physical, Tier 2 includes the non-physical, harmful parent-child interactions harmful parent-child interactions which constitute emotional abuse and which constitute emotional abuse and neglect. These interactions need to neglect. These interactions need to be be describeddescribed..
4. 4. Assign different forms of persistent Assign different forms of persistent harmful parent child interactions into harmful parent child interactions into the most appropriate categoriesthe most appropriate categories
5.5. Ascertain which Tier 3 child concerns Ascertain which Tier 3 child concerns are due to emotional abuse and are due to emotional abuse and neglect neglect
6.6. Estimate severity of emotional abuse Estimate severity of emotional abuse & neglect & neglect
7.7. Initial intervention is time limited Initial intervention is time limited trial of family’s capacity to changetrial of family’s capacity to change
8.8. Intervention needs to address Tier 0 Intervention needs to address Tier 0 & Tier 1 concerns which will involve & Tier 1 concerns which will involve a number of different agencies. a number of different agencies. Therapeutic intervention is offered Therapeutic intervention is offered according to the categories of according to the categories of emotional abuse (Tier 2) which are emotional abuse (Tier 2) which are occurring for this child. occurring for this child.
9.9. Intervention may lead to Intervention may lead to improvement.improvement.
If family do not engage, then refer If family do not engage, then refer to statutory child protection services to statutory child protection services to encourage the family to to encourage the family to participate. participate.
8.8. Intervention needs to address Tier 0 Intervention needs to address Tier 0 & Tier 1 concerns which will involve & Tier 1 concerns which will involve a number of different agencies. a number of different agencies. Therapeutic intervention is offered Therapeutic intervention is offered according to the categories of according to the categories of emotional abuse (Tier 2) which are emotional abuse (Tier 2) which are occurring for this child. occurring for this child.
9.9. Intervention may lead to Intervention may lead to improvement.improvement.
If family do not engage, then refer If family do not engage, then refer to statutory child protection services to statutory child protection services to encourage the family to to encourage the family to participate. participate.
10.10. If the family still do not engage or If the family still do not engage or if there is insufficient change, if there is insufficient change, consideration needs to be given to consideration needs to be given to placing the child in an alternative placing the child in an alternative family.family.
11. 11. Some children will be too old to Some children will be too old to move, or removal may be move, or removal may be inappropriate. Direct, therapeutic inappropriate. Direct, therapeutic work is then offered to the child to work is then offered to the child to enhance coping with the ongoing enhance coping with the ongoing emotional abuse. emotional abuse.
ConclusionsConclusions Emotional abuse & neglect is Emotional abuse & neglect is
common & harmfulcommon & harmful Useful to organise information in 4 Useful to organise information in 4
tierstiers Description of Description of harmful parent-child harmful parent-child
interactionsinteractions (tier 2) is the evidence (tier 2) is the evidence Categories of harmful parent-child Categories of harmful parent-child
interactions indicate how to interactions indicate how to interveneintervene
Possible to intervene without Possible to intervene without invoking child protection proceduresinvoking child protection procedures
Trial Trial of family’s capacity to changeof family’s capacity to change
Glaser, D. (2011) How to deal Glaser, D. (2011) How to deal with emotional abuse and with emotional abuse and neglect —Further development neglect —Further development of aof aconceptual framework (FRAMEA). conceptual framework (FRAMEA). Child Abuse & Neglect, Child Abuse & Neglect, 35, 35, 866-866-875875