Which reason is the most likely explanation for why childrens psychological disorders are neglected?

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Emotional neglect

Emotional neglect involves inattentiveness to a child's emotional and development needs. This may take various forms, including allowing independence inappropriate for a child's development needs. For example, permitting a child to use drugs or alcohol could be considered neglectful of a child's emotional and physical development. Interpretations of emotional neglect must also include cultural contexts, as plural or collective caregiving in some cultures and communities may allow for greater variation in emotional responsiveness based on shared caregiving practices. More specifically, a parent's potential lack of attentiveness to a child may be balanced by caregiving and attachment systems with other caregivers, such as grandparents, who are able to respond adequately to a child's needs.

Emotional Neglect or Rejection

Emotional neglect can be defined as a relationship pattern in which an individual’s affectional needs are consistently disregarded, ignored, invalidated, or unappreciated by a significant other. People in neglectful families are emotionally disconnected from one another, behaving as if they were living on different planets. Parents may have trouble understanding their children’s needs for love, affection, closeness, and support, or they may feel too overwhelmed or powerless to meet these needs on a consistent basis. Neglectful parents usually come from families in which, as children, they were ignored or neglected by their parents. They also may lack emotionally satisfying adult relationships. Forced to rely on themselves for support, afraid of their own dependency needs, and reluctant to admit their pain, these parents are highly ambivalent about their children’s needs, particularly when their children are hurting, crying, or looking for emotional support. They may feel jealous or resentful of their children and may perceive them as excessively demanding and impossible to satisfy. They may be so preoccupied with their own needs that they never consider the children’s point of view. Alternatively, they may feel so angry and resentful about having children that they simply ignore them.

For children, affectional neglect may have devastating consequences, including failure to thrive, developmental delay, hyperactivity, aggression, depression, low self-esteem, running away from home, substance abuse, and a host of other emotional disorders. These children feel unloved and unwanted. They may strive to please others, or they may misbehave to receive the attention they crave. They may withdraw from people and appear uncaring and indifferent. They may be afraid of emotional closeness and may shun intimacy in relationships. They are at risk for emotional problems throughout the rest of their lives. The degree of neglect and the individual vulnerability apparently affect the magnitude of the consequences.

Severe cases of neglect are generally easy to spot (e.g., when the child’s development is grossly delayed or shows evidence of failure to thrive), but more subtle examples are harder to detect. Emotional neglect should be suspected if the primary care practitioner observes a relative lack of spontaneous, positive, parent-child interactions in her or his office; if the parent seems uninformed and apathetic about the child’s development and behavior; or if the child is exhibiting signs of emotional distress without an obvious cause. Questions about daily routines and sources of support to the parent should precede any direct queries into the parent-child relationship. Encouraging the parent to describe the child’s positive attributes and focusing the discussion on these strengths can serve as an opening to raising matters of concern. It is important for the parent to hear these concerns directly from the practitioner. Vague, general, or indirect comments should be avoided, and specific recommendations should be made regarding the child’s need for more sustained and positive interactions with the parent. How important the parent is to the child, and how vital it is for the parent to receive more support from his or her social network so as to be more emotionally available to the child also are important issues to emphasize. Most neglectful parents feel isolated and unsupported in their own families and feel that their own emotional needs are not being met. Encouraging the parent to talk directly with the physician about her or his view of parenting is another way of opening up the discussion.

Often it is helpful to obtain additional information from other family members, particularly other caregivers. This information enables the practitioner to assess the availability of emotional support to the parent and child from within the family system. Finally, whenever possible, a home visit and a family interview should be conducted. This interview may require the services of an experienced clinical social worker, who can help make the decision to contact CPS should emotional neglect be substantiated.

Child neglect items

Both physical and emotional neglect were measured. The Physical Neglect subscale of the CTQ (Bernstein et al., 1994) was used to define whether someone experienced childhood physical neglect. This subscale comprises five items that are rated on a 1 (“never”) to 5 (“very often”) Likert scale. The responses to items 8 and 11 (Table 1) were reverse coded to match the negative valence of the remaining items. The responses to all five items were then summed together to estimate a physical neglect score, which ranges from 5 to 25. Individuals with a score of 10 or more fall in the moderate to extreme range. Individuals retrospectively reporting the moderate to extreme level of childhood physical neglect were considered to be exposed to physical neglect.

Similarly, the Emotional Neglect subscale of the CTQ (Bernstein et al., 1994) was used to define the presence of child emotional neglect. This subscale also comprises five items that are rated on a 1 (“never”) to 5 (“very often”) Likert scale. The responses to these items were summed together to compute an emotional neglect score, which ranges from 5 to 25. Individuals with a score of 15 or more fall in the moderate to extreme range. Individuals retrospectively reporting the moderate to extreme level of child emotional neglect were considered to be exposed to emotional neglect.

Introduction

Physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, violence against a mother, parental divorce, household member having problems with substances, household member having problems with mental illness, and incarceration of a household member comprise the 10 adverse childhood experiences (ACEs) assessed in the original ACE Study (Dube et al., 2003; Felitti et al., 1998). This is not a comprehensive list of adverse experiences that can occur in childhood and, therefore, researchers, clinicians, and others working in the field have added and removed experiences while still using the term ACEs. In this chapter, an overview of the original ACEs, inconsistencies in defining ACEs in research, and ACEs from a global perspective are provided. Directions for future research, including recommendations for expanding the definition of ACEs and implications on policy and practice of an expanded ACEs list, are also discussed.

Epidemiology

Over several decades, numerous studies have led to one incontrovertible conclusion: sexual, physical, and emotional abuse, along with emotional neglect, all lead to a significant increase in the risk for depression and other mood and anxiety disorders in adulthood. Further, a history of abuse in childhood is linked to the development of other medical disorders as well. To summarize the latest data on prevalence rates of childhood maltreatment, in 2015, the U.S. Department of Health and Human Services documented 3.4 million referrals to child protective services, with 683,000 children determined to be victims of child abuse and neglect. Among these cases, 75.3% were neglected, 17.2% were physically abused, and 8.4% were sexually abused. In this context, neglect is defined as the failure to provide the child with necessary food, clothing, shelter, medical care, and supervision to the degree that the child's health, safety, and well-being are being threatened. Notably, the majority of childhood abuse goes unreported. Globally, varying rates of childhood sexual abuse are reported, with the highest overall rates being reported in Australia, Africa, and the United States. With the exceptions of Africa and South America, girls are sexually abused at a higher rate than boys. Lastly, bullying is an increasingly recognized form of ELS not previously included in many studies.

There is a vast literature on the effects of early-life trauma on risk for adult psychopathology and medical disorders, beginning with the landmark CDC-funded adverse childhood experiences (ACE) epidemiological study [2]. The study was comprised of 17,337 adult members in a health maintenance organization in San Diego, California. By assessing eight early-life trauma events including abuse, domestic violence, household substance abuse, and parental loss, investigators calculated an ACE score as a measurement of cumulative trauma in order to determine the relationship between trauma and adult pathology. The results were clear: as the number of traumatic events increased, there was a significant increase in depression as well as anxiety, panic attacks, suicide attempt, substance abuse, alcohol abuse, sleep disturbance, obesity, chronic obstructive pulmonary disease, and heart disease. Many subsequent studies have confirmed and defended these findings [3,4].

In 2007, a prospective cohort study of 676 children with documented physical abuse, sexual abuse, or neglect was compared to a matched sample of 520 non-abused and non-neglected children [5]. The study showed a significant increase in risk for the development of MDD in the ELS cohort. Further, a substantial portion of the maltreated group reported depression before what is hypothesized to be self-medicating by alcohol and others drugs. These findings have been consistent across numerous other studies [6,7].

In an attempt to demonstrate the consequences of an individual ELS on adult well-being and psychopathology, many studies have closely examined the significance of sexual abuse. A 2010 meta-analysis of 37 studies with a total of 3,162,318 participants determined the effects of sexual abuse on lifetime risk of psychiatric disorders [8]. A significant association between sexual abuse and lifetime risk of numerous psychiatric disorders, including depression, was found. A separate 2010 review found a similar association between sexual abuse and depression [9]. Other studies have expanded and confirmed the relationship between sexual abuse and depression, with a clear relationship between the two now well established [10–13].

In contrast, a 2016 meta-analysis was performed to test the hypothesis that psychological abuse was most likely to lead to the most severe course of MDD [14]. A total of 12 primary studies including 4372 participants (2918 women, 1454 men) were evaluated. The association between the composite indexes of ELS was similar to previously reported meta-analyses that psychological abuse was indeed most strongly associated with the risk of developing depression. Currently, there is no universal agreement as to which subtype of ELS is most highly associated with MDD. However, all studies have come to the same conclusion, namely ELS, as a heterogeneous domain is indeed a large risk factor for the development, severity, and course of MDD.

Although recently recognized as a significant ELS, bullying was not previously included in the majority of studies that have examined the development of depression in individuals with a history of trauma. In a study examining parental “verbal aggression” in subjects 18–25 years old, the effects of this form of ELS on risk for depression and anxiety were found to be equivalent to that of those exposed to witnessing domestic violence and nonfamilial sexual abuse [15]. A separate bullying study found that participants who were either bullied or engaged in bullying exhibited increased rates of major depression in women and suicidality in men [16]. Recently, the results of a birth cohort study revealed interesting relationships between involvement in bullying and development of psychiatric illness in adulthood. The study included only men and found a significant relationship between bullying or being bullied with the development of a number of psychiatric disorders, including depression, later in life [17].

The fact that ELS is a major risk factor for suicide is of particular importance because suicide rates have been on the rise and among the top 10 causes of death in the United States. In 2016, 44,193 suicides were reported in the United States. Further, it is estimated that, for every suicide, there are 20–25 attempts. Multiple studies have come to the conclusion that ELS is indeed an important contributor to both suicide attempt and completion risk [18–23]. In the World Mental Health Survey Initiative, sexual and physical abuse had the greatest effect on risk of suicide attempt among the different forms of ELS.

In addition to unipolar depression, there is burgeoning evidence that ELS increases the risk for bipolar disorder and appears to worsen its clinical course. Retrospectively reported childhood abuse has been associated with an adverse illness course, earlier onset of illness, more depressive episodes, more suicide attempts, higher rates of psychiatric comorbidity, and greater intensity of manic episodes [24,25]. Further, there is a higher incidence of substance abuse [26,27] and impaired performance on neuropsychological tests [28]. The 2015 National Epidemiological Survey on Alcohol and Related Conditions revealed that childhood physical and sexual abuse were associated with an increased risk for the onset and recurrence of DSM IV manic episodes [29].

While experts agree on the importance of childhood trauma in the development and course of depression, the specific course of disease depending on type of trauma is an area of current research. For example, the consequences of deprivation and neglect may differ substantially from those of threat or abuse [30]. Lastly, the negative effects of trauma on the treatment of depression and response to both antidepressant and psychotherapy are significant [31].

Environmental/Familial Correlates

A number of parental or familial correlates of ecstasy use have been identified. Ecstasy users report more childhood experiences of physical abuse, emotional neglect, and physical neglect than nonusers of MDMA. Parent drug use has been identified as a significant predictor of child initiation of ecstasy use. Living with both parents and close parental monitoring are negatively associated with ecstasy use initiation, and may be protective against it. Current ecstasy users report experiencing greater difficulties with family relationships than nonusers. Peer correlates of ecstasy use include close associations with deviant peers and drug use by close friends. Current ecstasy users report greater difficulties with peer relationships than nonusers.

Child Emotional Abuse and Later Violence

Child emotional abuse (CEA) occurs when an adult knowingly maltreats a child and includes instances of humiliation, shaming, isolation, and emotional neglect (Crawford & Wright, 2007). CEA victims often report feeling flawed, worthless, and unloved by their caregivers (Leeb, Paulozzzi, Melanson, Simon, & Arias, 2008).

CEA can have a negative impact on both interpersonal and intrapersonal skills that are necessary for effective social development. Indeed, insecure family bonds can affect the formation of healthy interpersonal boundaries within intimate relationships (Wekerle & Wolfe, 1998). Internalized symptoms of depression, suicidal ideation, and other forms of mental illness are associated with sustained emotional abuse during childhood (Vezina & Hebert, 2007). CEA distorts the development of healthy beliefs about intimacy and partnership, which can create tendency toward jealousy, obsession, and emotional blame (Wekerle & Wolfe, 1998).

Similarly, children who witness parental violence are more likely to become violent in dating relationships (Vezina & Hebert, 2007). In a study of undergraduate romantic relationships, the extent of CEA and witnessing of father-to-mother physical violence predicted males’ dating aggression and victimization (Milletich, Kelley, Doane, & Pearson, 2010). CEA victims may only value themselves in relation to their ability to fulfill someone else’s needs; they may feel undeserving of any better treatment, and often wrongfully assume responsibility for the shaming and degrading attacks of a partner. Being constantly accused and neglected by an unsympathetic romantic partner unearths hidden feelings of responsibility the child felt for his/her failure procuring love from a caregiver. The unbalanced relationship preserves the CEA victim’s maladaptive behaviors who will go to disproportionate lengths to secure the needed affection (Crawford & Wright, 2007).

Introduction

Adverse childhood experiences (ACEs) are generally conceptualized into two broad categories: child maltreatment ACEs (i.e., physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, and exposure to intimate partner violence (IPV)) and household dysfunction ACEs (e.g., household substance use, household mental illness, parental separation/divorce, and parental incarceration; Dube et al., 2003; Felitti et al., 1998). Exposure to ACEs is common (Felitti et al., 1998), and ACEs tend to co-occur (Dong et al., 2004; Dube et al., 2003; Levenson, Willis, & Prescott, 2016). ACEs increase the risk of mental health problems, substance use problems, physical health conditions, and suicidal behaviors and decrease quality of life across the lifespan (Dube et al., 2001, 2003; Dube, Anda, Felitti, Edwards, & Croft, 2002; Felitti et al., 1998). Dose-response effects have also been noted in the literature, with exposure to increasing numbers of ACEs corresponding to incremental increase in the risk of adverse outcomes (Dube et al., 2001, 2003; Felitti et al., 1998; Whitfield, Anda, Dube, & Felitti, 2003). Another potential longer-term outcome of exposure to ACEs is an increased risk of being a perpetrator or victim of violence in adulthood. Violent behavior poses a serious public health problem for society (Bland, Lambie, & Best, 2018). This chapter reviews research on the links between ACEs, including both child maltreatment ACEs and household dysfunction ACEs, and violence in adulthood. Specifically, this chapter will review links between ACEs in childhood and physical, sexual, and emotional violence in adult relationships as well other forms of interpersonal violence in adulthood. The chapter will conclude with suggested directions for future research and implications for policy and practice.

Role of Life Experience

Early-life experience also appears to contribute to the development of BPD. Histories of repeated childhood physical or sexual abuse are commonly found among borderline patients, although such abuse experiences are also associated with a variety of other psychiatric disorders as well. Severe physical or emotional neglect may also predispose to BPD. Intense levels of aggressive drive, either resulting from an inborn predisposition or exceptionally powerful anger-inducing life experiences such as abuse, painful illness, or devastating losses, are also believed to contribute to borderline pathology. Some researchers have suggested that individuals who go on to develop borderline personalities have had impairments in their ability to evoke memories of their caretakers for use in soothing themselves in the absence of the caretaker. Other researchers emphasize the interaction of the affectively unstable child with a caretaking environment in which strong feelings are disavowed and the child is made to feel that his or her feelings are invalid.

Attachment

It is a central tenet of the mentalization-based approach that a sense of self and the capacity to mentalize both develop in the context of attachment relationships (Fonagy & Luyten, 2018). In patients with BPD and ASPD there is a common history of early (in particular emotional) neglect, a disrupted early social environment, and abusive or even brutalized family relationships. These may contribute to undermining the ability of some individuals to develop full mentalizing capacities. Subsequent adversity or trauma may disrupt mentalizing further, in part as an adaptive maneuver on the part of the individual to limit exposure to a dehumanizing psychosocial environment and in part because the high level of arousal generated by attachment hyperactivation and disorganized attachment strategies serve to disrupt less well-practiced and less robustly established higher cognitive capacities. In addition, genetic influences may be expressed through the mediation of mentalizing.

In summary, the mentalizing model points to a final common developmental pathway that a range of biological, family, and broader social contextual influences may take to generate the range of difficulties that are normally considered under the term personality disorder (Fonagy et al., 2015).