Emotional abuse Overcoming barriers to recognition and action Dr Margaret DeJong RCPCH Conference,...

Emotional abuseOvercoming barriers to recognition and action

Dr Margaret DeJong

RCPCH Conference, CP Committee

June 2013

Great Ormond Street Hospital for ChildrenNHS Foundation Trust

Outline of talk

• How do we understand emotional abuse?

• What are the barriers to identifying it?

• How can we improve identification?


Case example

• 5 year old girl whose mother seems excessively preoccupied by health concerns.

• History of reported early feeding difficulties

• Gastroenterology referral – reflux, mild colitis now resolved, currently no findings but some functional bowel symptoms

• Psychiatry referral for ?autism - negative


Observations

• Clingy, complaining of tummy pain in mother’s company. Baby talk and other immature behaviour

• Happy and functioning well at school but missing many days due to reported gastro problems. Home school report book is filled with mother’s anxiety about daughter’s symptoms.

• Mother emailing doctors daily, threatening to complain if daughter is discharged after investigation.


Concerns?

• Emotional development – emotional regression

• ?Learning to adopt a sick role in response to maternal anxiety

• Child being used as a vehicle for maternal anxiety

• Missing school unnecessarily


Emotional Harm

• Emotional Abuse, DoH definition (1999 and 2010): The persistent emotional ill-treatment of a child such as to cause severe and persistent effects on the child’s emotional development.

• Emotional neglect: Neglect of, or unresponsiveness to, a child’s basic emotional needs.


Emotional Harm: General Points

• Relates to the quality of the child’s relationship with their primary caretakers

• It occurs over time and not as one or more events

• Emotional abuse can exist as an isolated kind of abuse, although frequently co-exists with other forms of abuse

• It may not be caused by deliberate intent


UK Maltreatment study (Mary-Chahal et al 2005)

• 2,869 young people aged 18-24 interviewed, using postcode sampling and CAP interview

• 7% physical abuse

• 6% emotional abuse

• 11% sexual abuse involving contact (6% boys and 15% girls)


UK, USA, Australia and CanadaGilbert et al (2009)

• 4-16% Physical abuse

• 10% psychological or emotional abuse

• 1-15% Neglect

• 10-20% exposure to domestic violence


Under recognition of maltreatment

• 1.5% of UK children referred to social services in 2007 for abuse compared to 10-20% identified through research (Gilbert et al, Lancet, Dec 2009)

• Approximately half are substantiated

• Of children with Child Protection Plan, 44% were registered as neglect, 15% physical abuse, 23% psychological abuse, 7% sexual abuse and 10% multiple forms of abuse


Why under identified?

• Lack of clarity about the concept

• Uncertainty about threshold – when does it move from a concern into a referral to Social Services?

• Difficulties in compiling the evidence to substantiate the concern


Professional barriers to identifying child maltreatment (NICE 2009)

•fear of losing a positive relationship with a family

•discomfort of disbelieving, thinking ill of, suspecting or wrongly blaming a parent or carer

•divided duties to adult and child patients and breaching confidentiality

•an understanding of the reasons why the maltreatment might have occurred, and assessment that there was no intention to harm the child

•losing control over the child protection process and doubts about its benefits

•stress, concerns about safety


Barriers (cont’d)

• Fear of missing a diagnosis

• Fear of complaints, referral to GMC

For mental health professionals:

Prioritising a therapeutic alliance with a child or family


How to conceptualise emotional abuse?

• A useful conceptual framework in terms of parent-child interaction (Glaser 2002)

• Outlines broad categories of problematic interaction and indicates in what ways this results in a child’s emotional needs not being met

• Assists recognition and therapeutic intervention


1. Emotional unavailability, unresponsiveness and neglect

• Carers preoccupied by their own difficulties (mental health, substance abuse, etc)

Example: Nurses become concerned about a mother in PICU who appears extremely stressed and is unable to spend much time with her 2 year old, who has been very ill. HV records show a history of post partum depression.


2. Negative attributions – hostility, denigration or rejection

• Harsh criticism or blame

• Public humiliation

• Description of child as innately bad or defective in some way

• Child seen as source of all family tensions (scapegoating)


3. Developmentally inappropriate parent/child interactions

• Inconsistent/inappropriate discipline

• Developmentally inappropriate expectations

• Over-protectiveness

• Exposure to traumatic or confusing events such as domestic violence

• May relate to parent’s lack of knowledge or awareness


4. Failure to recognise/acknowledge a child’s individuality and psychological boundary

• Parent inappropriately confides in child

• Child used as pawn in marital conflict

• Carer uses child to fulfil their own psychological needs e.g. FII

• Child used as carer to parent


5. Failure to promote a child’s social adaptation

• Corrupting: exposure to antisocial activity or inappropriate role models

• Failure to teach or encourage appropriate social behaviour or to set appropriate limits

• Failure to promote child’s relationships with peers, including attendance at school

• Failure to promote a positive adaptation to illness


Is emotional abuse harmful?

• Evidence of neurobiological effects – disruption of the stress regulation system

• Functional changes in the brain – fear responses, executive function

• Severe and prolonged early maltreatment can lead to structural brain changes

• Established links with mental and physical illness as well as criminality

• Knowledge of impact on child development


How does emotional abuse cause harm?

• Often starts very early during a period of formative brain development

• Involves relationships with primary caregivers which are most crucial in emotional development


Experience-dependent development

• Emotional regulation

• Attachment

• Development of capacity for reflective function

• Develop within the context of a carer-infant relationship and therefore vulnerable to maltreatment effects


Impaired mother-child interaction

Abusive carers contribute to prolonged, too frequent or too extreme states of negative emotion in the infant:

•May ignore infant’s cues

•May respond harshly or inappropriately

•May misinterpret infant’s cues

•Plays less with infant, allowing less opportunity to repair the damage


Distortions in emotional development• Hyper vigilance to mother’s emotional state

• Emotional lability, poor control

• Extremes of anger and other negative affect

• Blunting of emotional responses

• Depression (in emotional neglect)

• Poor differentiation and understanding of emotional states


Assessment of emotional abuse

• Social factors – poverty, immigration, violence, social supports

• Family factors – parental relationship and mental health

• Parent child interaction

• Child’s psychological and general development


Caregiver risk factors

• Mental health problems

• Substance abuse

• Domestic violence

• Chronic parental conflict

• Parent has a childhood history of maltreatment


Psychological sequelae

• Non-specific for emotional abuse

• Affects all aspects of development: emotional, behavioural, social, cognitive and physical

• Difficult to predict at an individual level

• Outcome will depend on profile of risk/resiliency features


History: alerting features

• Presence of any of the 5 known major parental risk factors should trigger a more careful exploration of the child’s well being and development

• Erratic school attendance is an important sign

• Unusual pattern of seeking medical help


Paediatric exam

• Growth problems

• Signs of physical neglect suggesting possibility of emotional neglect/abuse

• Unusual behaviour or emotional state

• Failing to achieve developmental milestones


Health visitors

• Often pick up early concerns

• Main obstacles in referring on are scarcity of suitable therapeutic resources, reluctance of parents to seek help and HV’s perception of their role.


Developmental aspects

• Infancy: screaming inconsolably, withdrawn, disturbed feeding or growth, abnormal attachment pattern

• Young child: Rages, withdrawn, over friendly, attention-seeking, aggression, fearful, poor social skills, soiling


Psychological indicators (2)

• Late childhood: Poor attendance or underachievement at school, peer relationship problems, depression, anxiety, aggression

• Adolescence: Truancy and school failure, self harm, substance abuse, depression, failed relationships


Predicting impact of maltreatment on an individual child

• Type of maltreatment

• Age/developmental stage

• Duration and severity

• Genetic vulnerability

• Protective factors


Cultural aspects

• Some widespread cultural practices may be emotionally abusive

• Particularly difficult to assess without seeking advice from people knowledgeable of the culture

• Professional anxiety about culturally sensitivity may impair recognition of abuse


Managing concerns

1. RECORD

2. DISCUSS

3. GATHER COLLATERAL INFORMATION

4. REVIEW

5. EXCLUDE MALTREATMENT OR CONSIDER

REFERRAL TO SOCIAL CARE


Concerns

Record Observations

Get Advice:•Colleagues

•Duty Social Worker•Named Doctor

MDT ?

Team Formulation

Action as Appropriate

Referral to Social CarePossible ‘trial for

change’

Exclude Maltreatment


Referrals to CAMHS

• A suspected child protection concern will be a barrier to acceptance

• Referral can be framed as impaired parent-child interaction and a concern about the child’s emotional development.

• Use of depression and anxiety questionnaires and other specific information suggesting a possible diagnosis is helpful


Keeping under review

• Perhaps the biggest challenge!

• Helps to be very clear what needs to change in terms of concrete goals - e.g. attending school regularly

• Identification of a key professional who holds the child in mind and assumes responsibility

• Most cases drop beneath the radar, only surfacing with a significant event


Specialist assessment

• Parent factors?

• Child factors?

• Social/environmental factors?

• Identifying problematic parent-child interaction and instituting a ‘trial for change’ intervention

• Therapy may need a statutory framework (Care Order)


Assessment (2)• Is the parent aware of a child’s needs at this phase of

development?

• How do they describe the child?

• Can they distinguish between their needs and the child’s needs?

• Do they accurately read the child’s behavioural cues?

• What do you observe about the interaction?


The court arena: gathering the evidence

3 levels of psychological assessment:

1. Evidence of persistent harmful parent-child interaction (different settings, different observers)

2. Evidence of impairment to child’s health, including mental health, and development which is attributable to this interaction.

3. Evidence of parental factors which have led to the situation becoming entrenched


Significant Harm

• “harm” is defined as “ill-treatment or the impairment of health or development including, for example impairment suffered from seeing or hearing the ill-treatment of another”

• “ill-treatment” includes sexual abuse and other forms of ill-treatment which are not physical

• development is defined in its broadest sense and “health” is physical or mental


Conclusion

Emotional Abuse is a challenging form of abuse for us to recognise and manage successfully. It relies on clinical judgement rather than proof of an event occurring. It can cause profound and lasting damage.


References

• Gilbert et al, The Lancet 2009, 373, 68-81

• NICE Guideline 89: When to suspect child maltreatment, July 2009

• Glaser, D Child Abuse and Neglect 2002, 26,697-714


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