Psychological cruelty to children from parents or caregivers can cause as much - or even more - emotional damage than physical and sexual abuse, according to a new US study.
The diagnosis is being overlooked and undertreated compared to physical forms of abuse, researchers say.
"When you look at symptom severity, there was no difference between the three forms of maltreatment," said Joseph Spinazzola, lead author of the study.
Psychological trauma is different from "dysfunctional parenting," where moms or dads periodically lose their tempers.
"It's sort of living in this situation where they're not receiving any kind of love or warmth and instead they're receiving either hostility, threats or impossible demands, almost as if they are an enemy or monster, a pathetic unlovable creature . . . .," said Spinazzola, executive director of The Trauma Center at Justice Resource Institute in Brookline, Massachusetts.
The study used the National Child Traumatic Stress Network Core Data set to analyse the cases of 5,616 youth with histories of psychological, physical or sexual abuse.
The children were ages 2 to 10 at the start of the data collection, which took place from 2004 to 2010. Forty-two per cent were boys and 62 per cent had a history of psychological abuse.
The children and their parents or caregivers were interviewed by clinicians and also answered questions about behavioural issues and trauma on questionnaires.
All three groups of children had scores in the same general range for so-called "internalizing problems," like social withdrawal, sadness, loneliness, difficulty concentrating or sleeping, and symptoms like headaches or stomachaches.
But children who had been psychologically abused were more likely to have negative outcomes over the long-term than victims of physical or sexual abuse.
They were 92 per cent more likely to have trouble with substance abuse, 78 per cent more likely to be depressed, 80 per cent more likely to experience separation anxiety disorder and 92 per cent more likely to be anxious, according to a paper scheduled for an upcoming issue of the journal Psychological Trauma: Theory, Research, Practice, and Policy.
Compared to children who had been sexually abused, the psychological abuse group was also 65 per cent more likely to have academic problems, 91 per cent more likely to engage in criminal activity, 47 per cent more likely to injure themselves and 147 per cent more likely to have attachment problems.
"One thing that struck me was that, of the forms of trauma measured by this core data set, psychological abuse was the most enduring form of maltreatment," Spinazzola said. "When psychological abuse co-occurred with the other two, the presence of psychological abuse heightened the negative effects to a greater magnitude than when they occurred in the absence of psychological abuse."
But psychological abuse is often overshadowed by physical and sexual abuse, the researchers note. In one previous study, only 7.6 per cent of psychological abuse was reported to child welfare agencies. Other research found psychological abuse was investigated only 36 per cent of the time (compared to 53 per cent of physical abuse cases and 55 per cent of sexual abuse).
"I think there's a hesitancy to label a parent as engaging in psychological abuse because of that fear of unfairly blaming a parent for just being human and imperfect," said Spinazzola.
Spinazzola said that while there have been improvements in educating child welfare personnel to better recognise psychosocial abuse and neglect, more work was needed.
"It's a combination of sort of education and awareness both at the training level for social workers and graduate training but also outreach to families. Educating and supporting parents in how to effectively engage with children and how to manage their own distress that can affect their ability to be effective parents," Spinazzola said.
Dr. Jill Glick, medical director of Child Protective Services at the University of Chicago Comer Children's Hospital, called the research "transformational." Glick was not directly involved in the study, though she is a colleague of study coauthor Bradley Stolbach.
"When you look at these children, you're seeing the impact of it is so significant and what's happening to them gets lost in the (mix) of child abuse and neglect," Glick told Reuters Health.
She said the study was a wake-up call to better identify and diagnose psychological abuse.
"This paper is telling us we need to have a public surveillance approach to psychological maltreatment with agreed-upon definitions," Glick said. "This is a really good thing that we're finally saying this is a terrible form of maltreatment, probably much more common than we realised."