Glaser (2002)
…..
Delayed recognition and under-recognition
- Reasons
o Terms are sometimes seen as unnecessarily pejorative and therefore there is a
reluctance to use them under-recognition
o Intervention is sometimes seen as unjustifiable, because it is at the cost interrupting
an attachment bond with the caregiver (and often, maltreatment does not cause
physical harm to the child)
o Professionals are deterred by the fact that they will have to defend their professional
assessment and opinion in court
o Good parenting lies on a continuum, and a threshold is set arbitrarily – where do you
draw the line?
- Consequences
o Later recognition more exposure
o Later recognition interactional patterns more entrenched and more difficult to
change
Definitions
- Focus on evidence of ill treatment, rather than harm done to the child
- Overall definition emotional abuse and neglect – criteria:
o A relationship between parent and child (rather than event, or series of events)
o Interactions of concern characterize the relationship
o Interactions are actually OR potentially harmful by causing impairment to the child’s
psychological/emotional health and development
o Includes commission as well as omission
o Does not require physical contact
- APSAC framework (conceptual framework): ‘psychological maltreatment means a repeated
pattern of caregiver behavior or extreme incidents that convey to children that they are
worthless, flawed, unloved, unwanted, endangered or of value only in meeting another’s
needs.’ – comes in 6 forms:
o Spurning: verbal and nonverbal hostile rejecting/degrading
o Terrorizing: behavior that threatens or is likely to harm physically the child or place
the child’s loved objects in danger
o Exploiting/corrupting: encouraging the child to develop inappropriate behaviors
o Denying emotional responsiveness: ignoring the child’s needs to interact, failing to
express positive affect to the child, showing no emotion in interactions with the child
o Isolating: denying child opportunities for interacting/communicating with peers ir
adults
o Mental, health, medical and educational neglect: ignoring or failing to ensure
provision for the child’s needs
Theoretical/conceptual basis for these definitions is not evident
Alternative framework
Categorizes different forms of emotional abuse and neglect found within the overall definition
according to conceptual framework based on the elements that comprise a child’s
psychosocial being
, - Elements of a child’s being
o A person who exists
o With their own attributes
o Is vulnerable, dependent and rapidly developing
o Individual possessing and experiencing her or his own feelings, thoughts, and
perceptions
o Social being who will increasingly interact and communicate within his/her own
social context
Each of these aspects needs to be recognized, respected and valued by caregivers. Violation
or failure to respect any of these elements of the child’s psychosocial being constitute
categories of emotional abuse and neglect
5 categories of emotional abuse and neglect
o Emotional unavailability, unresponsiveness, and neglect: caregiver preoccupied with
own difficulties unable or unavailable to respond to the child’s emotional needs
Includes parental insensitivity
o Negative attributions and misattributions of the child: hostility towards, denigration
and rejection of a child who is perceived as deserving these
o Developmentally inappropriate or inconsistent interactions with the child
Expectations of the child beyond their developmental capabilities
Overprotection and limitation of exploration and learning
Exposure to confusing or traumatic events/interactions
Often thoughtless and misguided rather than intending harm
o Failure to recognize/acknowledge the child’s individuality and psychological
boundary
Using child for fulfilment of parent’s psychological needs
Inability to distinguish between the child’s reality and the adult’s beliefs and
wishes
Factitious Disorder by Proxy
o Failing to promote the child’s social adaptation
Promoting mis-socialization
Psychological neglect (not providing enough cognitive stimulation and/or
opportunities for experiential learning)
When 2 or more categories coexist, it is possible to identify the ‘driving’ category (which is
important for providing specific interventions)
Categories are important
o Because different clinical interventions are required for different categories
o Because it’s good for research
Consequences
- Often not immediately visible in the child, which makes it difficult to identify
, Kempe, C. H., Silverman, F. N., Steele, B. B., Droegemueller, W., & Silver, H. K. (1962). The
battered child syndrome. Journal of the American Medical Association, 181, 17-24
Battered child syndrome (‘unrecognized trauma’)
- Clinical condition in young children who have received serious physical abuse, is a frequent
cause of permanent injury or death
- Should be considered in any child exhibiting evidence of fracture of any bone, subdural
hematoma, failure to thrive, soft tissue swellings or skin bruising, in any child who dies
suddenly, or where the degree and type of injury is at variance with the history given
regarding the occurrence of the trauma
- Physicians have a duty and responsibility to the child to require a full evaluation of the
problem and to guarantee that no expected repetition of trauma will be permitted to occur
Clinical manifestations
- In general, < 3 years old
- Often show other evidence of neglect
- History of previous episodes
- Marked discrepancy between clinical findings & historical data
- No new lesions while in the hospital = a sign of maltreatment (and not something clinical)
Psychiatric aspects
- In cases where adult has fantasies of hurting child, they are usually responsive to treatment
- Often, parents are of low intelligence
- Child abuse not necessarily a sign of psychopathic personalities – often, there is just a defect
in character structure which allows aggressive impulses to be expressed too freely
- Could also be a sign of a history of childhood abuse (for the parent)
At this point, there is no safe remedy other than separating of battered children with their parent.
Techniques of evaluation
- There needs to be a high initial level of suspicion
- Often, the guilty parent is the one that acts the most ‘normal’
Radiologic features
- Radiologic examination has 2 main roles:
o Tool for case finding
o Guide in management
- Diagnostic signs:
o Age
o Nature of injury
o Time after injury that the X-ray examination is made (vs the time of ‘accident’ that is
indicated)
o Repetition of injury
Differential diagnosis: Scurvy, Syphilis, Osteogenesis imperfecta
Management
- Make sure there is correct diagnosis (Bias should be in favor of child’s safety) so that they
can institute proper therapy & make sure it doesn’t happen again
- Temporary placement with relatives or in supervised environment
…..
Delayed recognition and under-recognition
- Reasons
o Terms are sometimes seen as unnecessarily pejorative and therefore there is a
reluctance to use them under-recognition
o Intervention is sometimes seen as unjustifiable, because it is at the cost interrupting
an attachment bond with the caregiver (and often, maltreatment does not cause
physical harm to the child)
o Professionals are deterred by the fact that they will have to defend their professional
assessment and opinion in court
o Good parenting lies on a continuum, and a threshold is set arbitrarily – where do you
draw the line?
- Consequences
o Later recognition more exposure
o Later recognition interactional patterns more entrenched and more difficult to
change
Definitions
- Focus on evidence of ill treatment, rather than harm done to the child
- Overall definition emotional abuse and neglect – criteria:
o A relationship between parent and child (rather than event, or series of events)
o Interactions of concern characterize the relationship
o Interactions are actually OR potentially harmful by causing impairment to the child’s
psychological/emotional health and development
o Includes commission as well as omission
o Does not require physical contact
- APSAC framework (conceptual framework): ‘psychological maltreatment means a repeated
pattern of caregiver behavior or extreme incidents that convey to children that they are
worthless, flawed, unloved, unwanted, endangered or of value only in meeting another’s
needs.’ – comes in 6 forms:
o Spurning: verbal and nonverbal hostile rejecting/degrading
o Terrorizing: behavior that threatens or is likely to harm physically the child or place
the child’s loved objects in danger
o Exploiting/corrupting: encouraging the child to develop inappropriate behaviors
o Denying emotional responsiveness: ignoring the child’s needs to interact, failing to
express positive affect to the child, showing no emotion in interactions with the child
o Isolating: denying child opportunities for interacting/communicating with peers ir
adults
o Mental, health, medical and educational neglect: ignoring or failing to ensure
provision for the child’s needs
Theoretical/conceptual basis for these definitions is not evident
Alternative framework
Categorizes different forms of emotional abuse and neglect found within the overall definition
according to conceptual framework based on the elements that comprise a child’s
psychosocial being
, - Elements of a child’s being
o A person who exists
o With their own attributes
o Is vulnerable, dependent and rapidly developing
o Individual possessing and experiencing her or his own feelings, thoughts, and
perceptions
o Social being who will increasingly interact and communicate within his/her own
social context
Each of these aspects needs to be recognized, respected and valued by caregivers. Violation
or failure to respect any of these elements of the child’s psychosocial being constitute
categories of emotional abuse and neglect
5 categories of emotional abuse and neglect
o Emotional unavailability, unresponsiveness, and neglect: caregiver preoccupied with
own difficulties unable or unavailable to respond to the child’s emotional needs
Includes parental insensitivity
o Negative attributions and misattributions of the child: hostility towards, denigration
and rejection of a child who is perceived as deserving these
o Developmentally inappropriate or inconsistent interactions with the child
Expectations of the child beyond their developmental capabilities
Overprotection and limitation of exploration and learning
Exposure to confusing or traumatic events/interactions
Often thoughtless and misguided rather than intending harm
o Failure to recognize/acknowledge the child’s individuality and psychological
boundary
Using child for fulfilment of parent’s psychological needs
Inability to distinguish between the child’s reality and the adult’s beliefs and
wishes
Factitious Disorder by Proxy
o Failing to promote the child’s social adaptation
Promoting mis-socialization
Psychological neglect (not providing enough cognitive stimulation and/or
opportunities for experiential learning)
When 2 or more categories coexist, it is possible to identify the ‘driving’ category (which is
important for providing specific interventions)
Categories are important
o Because different clinical interventions are required for different categories
o Because it’s good for research
Consequences
- Often not immediately visible in the child, which makes it difficult to identify
, Kempe, C. H., Silverman, F. N., Steele, B. B., Droegemueller, W., & Silver, H. K. (1962). The
battered child syndrome. Journal of the American Medical Association, 181, 17-24
Battered child syndrome (‘unrecognized trauma’)
- Clinical condition in young children who have received serious physical abuse, is a frequent
cause of permanent injury or death
- Should be considered in any child exhibiting evidence of fracture of any bone, subdural
hematoma, failure to thrive, soft tissue swellings or skin bruising, in any child who dies
suddenly, or where the degree and type of injury is at variance with the history given
regarding the occurrence of the trauma
- Physicians have a duty and responsibility to the child to require a full evaluation of the
problem and to guarantee that no expected repetition of trauma will be permitted to occur
Clinical manifestations
- In general, < 3 years old
- Often show other evidence of neglect
- History of previous episodes
- Marked discrepancy between clinical findings & historical data
- No new lesions while in the hospital = a sign of maltreatment (and not something clinical)
Psychiatric aspects
- In cases where adult has fantasies of hurting child, they are usually responsive to treatment
- Often, parents are of low intelligence
- Child abuse not necessarily a sign of psychopathic personalities – often, there is just a defect
in character structure which allows aggressive impulses to be expressed too freely
- Could also be a sign of a history of childhood abuse (for the parent)
At this point, there is no safe remedy other than separating of battered children with their parent.
Techniques of evaluation
- There needs to be a high initial level of suspicion
- Often, the guilty parent is the one that acts the most ‘normal’
Radiologic features
- Radiologic examination has 2 main roles:
o Tool for case finding
o Guide in management
- Diagnostic signs:
o Age
o Nature of injury
o Time after injury that the X-ray examination is made (vs the time of ‘accident’ that is
indicated)
o Repetition of injury
Differential diagnosis: Scurvy, Syphilis, Osteogenesis imperfecta
Management
- Make sure there is correct diagnosis (Bias should be in favor of child’s safety) so that they
can institute proper therapy & make sure it doesn’t happen again
- Temporary placement with relatives or in supervised environment
