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Review |

Emotional, Behavioral, and Developmental Features Indicative of Neglect or Emotional Abuse in Preschool Children:  A Systematic Review FREE

Aideen Mary Naughton, MB, BCh, BAO, DCH, FRCPCH1; Sabine Ann Maguire, MRCPCh, FRCPI2; Mala Kanthi Mann, MIInfSc, MCLIP3; Rebecca Caroline Lumb, BA2,5; Vanessa Tempest, BScEcon, MA, GDL/CPE, PgDChild2; Shirley Gracias, MBChB, DCH, MRCPsych4; Alison Mary Kemp, MRCP, FRCPCH2,6
[+] Author Affiliations
1Safeguarding Children Service, Public Health Wales, National Health Service Trust, Cardiff
2School of Medicine, Cardiff University, Cardiff, Wales
3Support Unit for Research Evidence, Cardiff University, Cardiff, Wales
4Families Inc CIC, Wilshire, England
5currently with Department of Mathematics, London School of Economics and Political Science, London, England
6currently with the School of Medicine, Cardiff University, Cardiff
JAMA Pediatr. 2013;167(8):769-775. doi:10.1001/jamapediatrics.2013.192.
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Published online

Importance  Early intervention for neglect or emotional abuse in preschoolers may mitigate lifelong consequences, yet practitioners lack confidence in recognizing these children.

Objective  To define the emotional, behavioral, and developmental features of neglect or emotional abuse in preschoolers.

Evidence Review  A literature search of 18 databases, 6 websites, and supplementary searching performed from January 1, 1960, to February 1, 2011, identified 22 669 abstracts. Standardized critical appraisal of 164 articles was conducted by 2 independent, trained reviewers. Inclusion criteria were children aged 0 to 6 years with confirmed neglect or emotional abuse who had emotional, behavioral, and developmental features recorded or for whom the carer-child interaction was documented.

Findings  Twenty-eight case-control (matched for socioeconomic, educational level, and ethnicity), 1 cross-sectional, and 13 cohort studies were included. Key features in the child included the following: aggression (11 studies) exhibited as angry, disruptive behavior, conduct problems, oppositional behavior, and low ego control; withdrawal or passivity (12 studies), including negative self-esteem, anxious or avoidant behavior, poor emotional knowledge, and difficulties in interpreting emotional expressions in others; developmental delay (17 studies), particularly delayed language, cognitive function, and overall development quotient; poor peer interaction (5 studies), showing poor social interactions, unlikely to act to relieve distress in others; and transition (6 studies) from ambivalent to avoidant insecure attachment pattern and from passive to increasingly aggressive behavior and negative self-representation. Emotional knowledge, cognitive function, and language deteriorate without intervention. Poor sensitivity, hostility, criticism, or disinterest characterize maternal-child interactions.

Conclusions and Relevance  Preschool children who have been neglected or emotionally abused exhibit a range of serious emotional and behavioral difficulties and adverse mother-child interactions that indicate that these children require prompt evaluation and interventions.

Neglect is the most common form of maltreatment,1,2 with devastating lifelong consequences. The neurobiology of the infant brain can be altered in response to early emotional neglect,3 and brain imaging technology has confirmed the structural effect of neglect on the developing brain.4 The link between infant neglect and later aggression5,6 is highlighted by Kotch et al,7 who identified neglect in the first 2 years of life as a predictor of later aggression. Neglect means many things to many people,8 contributing to various working definitions and numerous tools to aid assessment and recognition. Social and health care professionals have a crucial role in recognizing and responding to signs of neglect, but when faced with subjective and value-based thresholds describing parental omission of good enough care, they may lack confidence in diagnosing neglect, unless there are clear physical signs (eg, faltering growth). The severe long-term consequences of emotional neglect and emotional abuse in the first 2 years of life9,10 have been identified, alongside the difficulty in recognition at such a young age.11,12 Underrecognition has implications for physical, mental health,13 and mortality.14 Emotional neglect and emotional abuse are variously defined within child abuse categories. In the United Kingdom and the World Health Organization definition, emotional neglect is included within the category of neglect with a separate category of emotional abuse, whereas the 2 aspects are encompassed in the broader term psychological maltreatment by the American Professional Society on the Abuse of Children (eAppendix 1 in Supplement), which describes patterns of damaging interactions between the parent-carer and child through acts of omission or commission, acknowledging that emotional neglect and abuse have equally damaging effects on the child. Elements of psychological maltreatment are present in most categories of abuse, but when psychological maltreatment occurs discretely, there is often delay in both recognition and intervention.15 To optimize outcomes, early recognition is paramount. This systematic review aims to identify the scientific evidence behind the emotional, behavioral, and developmental features of the child and characteristics of primary carer-child interactions associated with neglect and/or emotional abuse of preschool children.

A literature search across 18 bibliographic databases (eAppendix 2 in Supplement) was conducted to identify original articles published from January 1, 1960, to February 1, 2011. The search strategy (eAppendix 3 in Supplement) was developed across the OVID MEDLINE databases using keywords and Medical Subject Headings and modified for the remaining bibliographic databases. Studies were included if the population resided in an Organisation for Economic Co-operation and Development country.16 These countries are likely to have a similar economy and, therefore, the studies would be of equal relevance. The search sensitivity was augmented by supplementary searching,17 including consultation with subject experts and relevant organizations, hand-searching websites, nonindexed journals, and the references of all full-text articles. Once duplicate articles were eliminated, articles were transferred to a purpose-built database to coordinate the review and collate critical appraisal data. Studies were scanned by the lead researcher (S.A.M.) for relevance. Two independent reviews of each article were completed by a panel of pediatricians, psychologists, psychiatrists, information specialists, and social workers trained in critical appraisal (eAppendix 4 in Supplement), using standardized critical appraisal forms (eAppendix 5 in Supplement) based on criteria defined by the National Health Service’s Centre for Reviews and Dissemination,18 supplemented by systematic review advisory articles.1923 A third review was undertaken to resolve disagreements (eAppendix 4 in Supplement). Inclusion criteria were all studies of children (ages 0-6 years) experiencing neglect, emotional abuse, or emotional neglect for which the authors explicitly recorded emotional, behavioral, and developmental features in the child or addressed the characteristics of the primary carer–child interactions (eAppendix 6 in Supplement). We defined neglect according to the World Health Organization definition.24

The optimal study design was deemed to be a prospective case-control study matched for socioeconomic and other demographic features, in which the assessment of the child features was conducted by independent observation and interpreted in a standardized manner. To minimize the risk of circularity, we used a quality ranking of confirmation of neglect for the studies based on a format used in our previous systematic reviews,25 including studies ranked C2 or above (eAppendix 6 in Supplement). In reporting the findings, we adhered to the explicit terms used by the authors to account for the variability of the terms used among studies. The quality standards achieved by the individual studies are detailed in eAppendix 7 in Supplement.

Forty-two studies were included (28 case-control,2653 13 cohort [12 of which were prospective],10,5465 and 1 cross-sectional study66) (eAppendix 7 and eAppendix 8 in Supplement). The case-control studies were matched for demographic features, including the child age, maternal age, child sex, parental educational level, household income, child ethnicity, and neighborhood characteristics, and represented varying populations. Neglect and emotional abuse ranking was high. Thirty-nine studies used direct observational assessment tools (eg, Bayley’s or the Strange Situation), and the remaining 3 reported assessments using standardized rating scales (eAppendix 9 in Supplement). A total of 76 assessment tools were used throughout the 42 studies (eAppendix 9 in Supplement). Almost all authors modified these tools in some way, precluding a meta-analysis. The results are presented according to the age bands (using mean age).

Child Features

Emotional, behavioral, and developmental features in the child associated with neglect or emotional abuse were described in 22 case-control studies, 1 cross-sectional study, and 12 cohort studies10,26,27,2931,3335,3744,47,4961,6366 (Table 1).

Table Graphic Jump LocationTable 1.  Emotional, Behavioral, and Developmental Features in the Neglected or Emotionally Abused Child
Children Aged 0 to 20 Months

Using the Strange Situation, 3 studies measured the attachment status (eAppendix 9 in Supplement) of 1-year-old children to their primary carer, comparing neglected or emotionally abused children with abused or control children variably.29,30,41 The neglected infants frequently demonstrate insecure-avoidant attachment, with all of the neglected and emotionally abused children in the study by Cicchetti et al29 having insecure-disorganized attachment. Neglected infants had a passive and withdrawn behavior pattern with their mothers,30,33 with early developmental delay.30 One study44 of infants with a mean age of 14.2 months noted that neglect combined with failure to thrive was associated with lower cognitive performance than either neglect or failure to thrive alone. Neglected infants (mean age, 16.7 months) of depressed mothers were more likely to demonstrate language delay.66 One study51 investigating the effect of the maltreating family environment on an infant’s social interaction noted that neglected or emotionally abused infants aged 12 months did not differ from nonmaltreated controls on complexity of play style or cognitive play abilities. The authors attributed their lack of findings to the difficulty of identifying child neglect or emotional abuse in an impoverished sample at this age.

Children Aged 20 to 30 Months

While directly observing the free play of neglected toddlers (mean age, 26 months) with their primary caregiver and family, child negativity was strongly associated with caregiver hostility.34 These children had significantly less positive social interaction compared with controls. In a separate study31 of such toddlers at home, the toddlers spent the least time with adults, avoidant even of their mothers. In a case-control study that assessed memory in a step sequence of increasingly difficult tests, Cheatham et al27 showed deficits among neglected children (mean age, 21.01 months).

Children Aged 3 to 4 Years

Specific delays in receptive and language abilities (complexity of language and auditory comprehension) became apparent from the age of 3 years.26,55 In assessing toddlers and their parents during free play and play initiated by a parent, neglected children demonstrated significantly more negative affect (anger) than either physically abused or control children,39 hypothesized as being due to a lack of attention and fulfillment of their needs by their caregivers. In children younger than 4 years, their ability to discriminate among emotions did not differ between groups of abused, emotionally neglected, and physically neglected children when IQ was entered as a covariate.37

Children Aged 4 to 5 Years

In a study of the effect of neglect on language complexity, 19 maltreated children had a 16-month delay in syntactic development of language vs a 13-month delay for controls35; the 9 girls in the study by Eigsti and Cicchetti35 had the greater delay. Three studies38,43,49 describe the increasing social difficulties exhibited by children with their peers. In the series of Hoffman-Plotkin and Twentyman,38 14 neglected children engaged in the least number of interactions with other children, had lower scores on cognitive functioning, and exhibited disruptive behavior that correlated with aggression and the need for teacher discipline. Rohrbeck and Twentyman49 found conduct problems in neglected 4-year-olds on parental report, with both parental and teacher ratings in the direction of greater dysfunction than abused cases or controls. Macfie et al43 used the MacArthur Story Stem Battery and found that the 21 neglected children perceived other children as responding less often to relieve their distress. Pollak et al47 noted that the neglected children had difficulty recognizing angry faces, had a bias for selecting sad faces, and had more difficulty in discriminating among emotional expressions compared with physically abused children. Neglected children were significantly more likely to demonstrate an undercontrolled or ambivalent emotional response to simulated interadult aggression (P < .001).45

Children Aged 5 to 6 Years

Studies have reported low self-esteem in neglected children. Children with a mean age of 5 years had the lowest scores on positive self-representation.50 Using an age-appropriate attachment measure, Venet et al52 demonstrated an insecure-avoidant pattern of attachment with more markers for disorganization (specifically, frightening markers and mother depicted as being absent or unavailable). Waldinger et al53 noted neglected 5-year-olds rated themselves as angry and oppositional and tended to rate others as sad, hurt, or anxious. Poor peer relationships were also affected by the increased rates of dissociation found in neglected children42 and their engagement in less rule-compatible behavior (P < .01) as demonstrated in one study.40

Transition Through Development

Cohorts of neglected or emotionally abused children were followed up through their early childhood in 11 studies10,54,5661,6365 (1626 cases). As these children aged from 12 to 18 months, those with ambivalent-insecure attachment changed to an exclusively avoidant pattern.59 Egeland et al60 found a marked increase in maladaptive patterns of functioning from infancy through 3 years, with emotionally neglected children becoming angry and avoidant of their mothers. Crittenden et al54 reported how neglected infants were passive initially but from 12 months onward had aggressive and resistant behavior toward their carers, particularly up to 2.25 years. Within the Longitudinal Studies of Child Abuse and Neglect, Dubowitz et al56 examined different subtypes of neglect, comparing outcomes at different ages. Neglect at 3 years did not predict behavior changes at 5 years. In a related study,57 mothers reported that neglected 5-year-olds with behavior problems had more difficult peer relationships at 6 years. Neglect predicted cognitive delay in a study following up children from 18 months to 3 years.63 A retrospective study61 of 212 neglected children found that, at 4 years, impairment in receptive and expressive language, socially aggressive behavior, withdrawn behavior, and attention problems were significantly associated with several markers for neglect. Neglected children appeared to have early deficits in emotional knowledge, which persisted over time without intervention, from 4 to 5 years.64 Toth et al65 demonstrated that from 3 to 4 years neglected children increased their negative self-representation. The Minnesota Study evaluated high-risk parents and children, using multiple methods of assessment, including extensive observation, to examine the range of caregiving, with a major focus on the antecedents of abuse and neglect and the long-term consequences of maltreatment on children’s development: the emotionally abused group had the greatest decrease in their cognitive functioning score from 9 to 12 months,58 whereas at 24 months the pure neglect group had the greatest anger when performing problem-solving tasks.58 At 54 months the neglect group was uninvolved with tasks and less creative with the curiosity box,10 whereas by 64 months they had lower scores on the Wechsler Preschool and Primary Scale of Intelligence.10

Carer-Child Interaction

Fourteen studies28,29,3236,39,43,46,48,50,61,62 addressed characteristics of the carer-child interaction (Table 2) that were marked by hostility (6 studies29,34,39,48,50,61), although more often the interaction was one of lack of interest, activity, or involvement by the mother (9 studies28,29,32,33,36,43,46,48,62).

Table Graphic Jump LocationTable 2.  Carer-Child Interactions Among Neglected and Emotionally Abused Preschoolers
Children Aged 0 to 12 Months

The mothers of 137 one-year-old infants (neglected and emotionally abused) reported that they found their infants less reinforcing and more demanding and irritating.29 On direct observation, these mothers were rated as substantially lower in maternal sensitivity compared with controls.29 Another study28 compared 10 neglected infant-mother pairs with 10 abuse and control pairs. Neglectful mothers spoke significantly less often to their children (4 neglectful mothers failed to talk to their child at all during the experiment), used restrictive patterns of speech with significantly fewer commands or questions, gave less positive feedback, and gave less praise than controls. A total of 61% of all utterances made by neglectful mothers were commands, a much higher relative incidence than the control groups.

Children Aged 1 to 3 Years

Observations of neglectful mothers found them unresponsive,33 withdrawn, uninvolved, expressing little affection,32 and showing the least positive social interaction when compared with physically abusing and adequate-care mothers.34 Among children with a mean age of 27.5 months, the mothers were less attuned and less competent in understanding their child in developmentally appropriate ways.36 Two studies39,62 linked maternal mood (depression) with an increased probability of neglect, with a lower level of maternal affect being linked to child depression. As part of the Minnesota Study, Pianta et al46 found that emotionally abusive mothers persistently found fault with their children, ignored their child’s cues for assistance in problem-solving tasks, offered no encouragement if the child failed, and even looked comfortable if the child began to look frustrated. This hostile approach was also noted by English et al,61 where verbal aggression and verbally aggressive discipline was associated with child anxiety, depression, attention problems, and aggressive behavior based on parental report.

Children Aged 3 to 6 Years

Consistent with the reduced complexity of language in neglected or emotionally abused preschoolers,35 mothers produced significantly fewer utterances than controls. Macfie et al43 used the Story Stem Vignettes and found that neglected children portrayed their parents as responding less often to relieve distress. Similarly, Toth et al50 reported that 14 neglected children with extremely low self-esteem had more negative maternal representations compared with controls, although less so than the physical abuse group. Mothers of neglected children with failure to thrive in the study by Pollitt et al48 were less likely to relate to their children and were less affectionate than the control mothers, who used more positive verbal instruction, praise, and positive contact.

This review identifies emotional, behavioral, and developmental features in preschool children who were neglected or emotionally abused and characteristics of the negative maternal-child interactions (Tables 1 and 2). These features should alert social and health care professionals to children who warrant detailed evaluation and family intervention because the effect of early neglect and emotional abuse is profound. Lifelong consequences include physical and mental health problems; impairments in language, social, and communication skills; and severe effects on brain development and hormonal functioning.13 At its worst, children develop symptoms similar to autism, such as stereotypical rocking and self-soothing,67 as seen in institutionalized Romanian orphans,68 many of whom showed serious attachment issues by the age of 6 years.

Early intervention has the potential to change children’s lives.69,70 A meta-analysis identified appropriate interventions and confirmed that behavioral programs that focused on maternal sensitivity were the most effective.71 However, effective interventions are dependent on early recognition. It is especially important to identify negative aspects of caregiver interactions in the very young infant as the earliest signs of neglect and emotional abuse. Emotional and behavioral signs in infants were ill defined in the current scientific literature because the studies that looked at child features in infancy concentrated on older infants.

Practitioners working in this field need to have an understanding of attachment theory (eAppendix 10 in Supplement). The original concept was developed by Bowlby in the 1950s, extended by Ainsworth to develop the ABC model of attachment described in terms of security in the face of fear or normal separation, based on the child having developed internal working models of his or her relationship with the primary attachment figure.72 This was expanded to include the concept of disorganized attachment (ABCD), where the parent was simultaneously the source of fear and comfort, leaving the child in a conflicted position.73 Crittenden,74 however, replaced the internal working models with the Dynamic Maturational Model of attachment, where strategies are seen in the context of processing both cognitive and emotional information received by the brain at a time of stress. There has been criticism of the explosion in the diagnosis of attachment disorder in recent years,75 without using the international classifications from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision). Many children who experience serious maltreatment may exhibit features related to transformations of the earlier disorganized attachment (oppositional or aggressive behavior toward adults) or sequels to their earlier maltreatment (lying, lack of remorse, or stealing). These behaviors are not aspects of attachment disorders.76 This complexity highlights the need for young children with suspected neglect or emotional abuse to undergo a formal specialist assessment of their social and emotional needs. Children with deficits in speech and language development may overlap with autistic spectrum disorder.77 However, unlike organic variants, the autistic traits seen in severe deprivation improved when children were adopted into caring families, particularly before age 2 years.78 The capacity to empathize can increase through interaction with sensitive and attuned minds.79 The hypervigilance, poor attention control, impulsivity, and problematic emotion regulation observed in other children may be a posttraumatic constellation; thus, neglect and family violence must be considered in the differential diagnosis of attention-deficit/hyperactivity disorder.

Although one would wish to describe the chronologic evolution of the features of neglect or emotional abuse from 0 to 6 years, studies34 addressed different age bands and time points. For certain features, only single studies27,40 could be included. Given the important role of fathers,80 it was disappointing that all the included studies examined the mother-child relationship. Flouri81 reported that children with highly involved fathers had fewer behavioral problems, higher educational achievement, and higher self-esteem and life satisfaction. We did not review the risk factors for neglect or emotional abuse (eg, domestic abuse, maternal substance misuse, and poverty); however, they featured in many included studies. A strength of this review is the number of large, high-quality case-control studies,29,39,42,44,52 which were closely matched for relevant demographic features, potentially confounding neglect (eg, maternal educational level and socioeconomic deprivation).

Definitions of neglect vary, and emotional neglect and emotional abuse can be considered as part of a spectrum from the lack of attunement to persistent harmful carer-child interactions.82 Although categories of abuse and neglect have their place and inform our understanding of the mechanisms of child maltreatment, social and health care professionals should be mindful that many children will be subjected to multiple forms of abuse and neglect simultaneously. We would caution against rigid categorization in practice and advocate that all suspected cases of maltreatment should have a developmental assessment, recording and observing behavioral and emotional difficulties, observing interactions between the child and their primary carer, exploring the parents’ views of the child, and seeking information from others about solitary play, aggression, hostility, dependency on adults, and the child’s popularity with his or her peers.

Corresponding Author: Aideen Mary Naughton, MB, BCh, BAO, DCH, FRCPCH, Safeguarding Children Service, Public Health Wales, Mamhilad House, Mamhilad Park Estate, Pontypool NP9 0YP, England (aideen.naughton2@wales.nhs.uk)

Accepted for Publication: January 17, 2013.

Published Online: June 10, 2013. doi:10.1001/jamapediatrics.2013.192.

Author Contributions:Study concept and design: Maguire, Mann, Tempest, Kemp.

Acquisition of data: Naughton, Maguire, Mann, Lumb, Tempest, Gracias.

Analysis and interpretation of data: Naughton, Maguire.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Naughton, Kemp.

Obtained funding: Lumb, Kemp.

Administrative, technical, and material support: Mann, Lumb, Tempest.

Study supervision: Naughton, Maguire, Gracias, Kemp.

Conflict of Interest Disclosure: None reported.

Funding/Support: This study was funded by the National Society for the Prevention of Cruelty to Children.

Additional Contributions: Laura Wain provided editorial assistance. The reviewers conducting these reviews for the Welsh Child Protection Systematic Review Group were Rachel Brooks, MB, BS, MD, MSc, Sue Channon, PhD, Evender Harran, CQSW, Nia John, MB, BS, MLB, Orlena Kerek, MB, BS, Zarah Newman, CQSW, Ingrid Prosser, MB, BS, MSc, Alicia Rawlinson, MB, BS, Jane Rodgers, CQSW, and Elspeth Webb, MB, BS, BSc, MSc.

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Macfie  J, Toth  SL, Rogosch  FA, Robinson  J, Emde  RN, Cicchetti  D.  Effect of maltreatment on preschoolers’ narrative representations of responses to relieve distress and of role reversal. Dev Psychol. 1999;35(2):460-465.
PubMed   |  Link to Article
Mackner  LM, Starr  RHJ  Jr, Black  MM.  The cumulative effect of neglect and failure to thrive on cognitive functioning. Child Abuse Negl. 1997;21(7):691-700.
PubMed   |  Link to Article
Maughan  A, Cicchetti  D.  Impact of child maltreatment and interadult violence on children’s emotion regulation abilities and socioemotional adjustment. Child Dev. 2002;73(5):1525-1542.
PubMed   |  Link to Article
Pianta  R, Egeland  B, Erickson  MF. The antecedents of maltreatment: Results of the Mother-Child Interaction Research Project. In: Cicchetti  D, Carlson  V, eds. Child maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. New York, NY: Cambridge University Press; 1989:203-253.
Pollak  SD, Cicchetti  D, Hornung  K, Reed  A.  Recognizing emotion in faces: developmental effects of child abuse and neglect. Dev Psychol. 2000;36(5):679-688.
PubMed   |  Link to Article
Pollitt  E, Eichler  AW, Chan  CK.  Psychosocial development and behavior of mothers of failure-to-thrive children. Am J Orthopsychiatry. 1975;45(4):525-537.
PubMed   |  Link to Article
Rohrbeck  CA, Twentyman  CT.  Multimodal assessment of impulsiveness in abusing, neglecting, and nonmaltreating mothers and their preschool children. J Consult Clin Psychol. 1986;54(2):231-236.
PubMed   |  Link to Article
Toth  SL, Cicchetti  D, Macfie  J, Emde  RN.  Representations of self and other in the narratives of neglected, physically abused, and sexually abused preschoolers. Dev Psychopathol. 1997;9(4):781-796.
PubMed   |  Link to Article
Valentino  K, Cicchetti  D, Toth  SL, Rogosch  FA.  Mother-child play and emerging social behaviors among infants from maltreating families. Dev Psychol. 2006;42(3):474-485.
PubMed   |  Link to Article
Venet  M, Bureau  J, Gosselin  C, Capuano  F.  Attachment representations in a sample of neglected preschool-age children. Sch Psychol Int. 2007;28(3):264-293.
Link to Article
Waldinger  RJ, Toth  SL, Gerber  A.  Maltreatment and internal representations of relationships: core relationship themes in the narratives of abused and neglected preschoolers. Soc Dev. 2001;10(1):41-58.
Link to Article
Crittenden  PM.  Social networks, quality of child rearing, and child development. Child Dev. 1985;56(5):1299-1313.
Link to Article
Culp  RE, Watkins  RV, Lawrence  H, Letts  D, Kelly  DJ, Rice  ML.  Maltreated children's language and speech development: abused, neglected, and abused and neglected. First Lang. 1991;11(33):377-389.
Link to Article
Dubowitz  H, Papas  MA, Black  MM, Starr  RHJ  Jr.  Child neglect: outcomes in high-risk urban preschoolers. Pediatrics. 2002;109(6):1100-1107.
PubMed   |  Link to Article
Dubowitz  H, Pitts  SC, Black  MM.  Measurement of three major subtypes of child neglect. Child Maltreat. 2004;9(4):344-356.
PubMed   |  Link to Article
Egeland  B, Sroufe  A.  Developmental sequelae of maltreatment in infancy. New Dir Child Adolesc Dev. 1981;11:77-92.
Link to Article
Egeland  B, Sroufe  LA.  Attachment and early maltreatment. Child Dev. 1981;52(1):44-52.
PubMed   |  Link to Article
Egeland  B, Sroufe  LA, Erickson  M.  The developmental consequence of different patterns of maltreatment. Child Abuse Negl. 1983;7(4):459-469.
PubMed   |  Link to Article
English  DJ, Thompson  R, Graham  JC, Briggs  EC.  Toward a definition of neglect in young children. Child Maltreat. 2005;10(2):190-206.
PubMed   |  Link to Article
Mustillo  SA, Dorsey  S, Conover  K, Burns  BJ.  Parental depression and child outcomes: the mediating effects of abuse and neglect. J Marriage Fam. 2011;73(1):164-180.
Link to Article
Scarborough  AA, Lloyd  EC, Barth  RP.  Maltreated infants and toddlers: predictors of developmental delay. J Dev Behav Pediatr. 2009;30(6):489-498.
PubMed   |  Link to Article
Sullivan  MW, Bennett  DS, Carpenter  K, Lewis  M.  Emotion knowledge in young neglected children. Child Maltreat. 2008;13(3):301-306.
PubMed   |  Link to Article
Toth  SL, Cicchetti  D, Macfie  J, Maughan  A, VanMeenen  K.  Narrative representations of caregivers and self in maltreated pre-schoolers. Attach Hum Dev. 2000;2(3):271-305.
PubMed   |  Link to Article
Sylvestre  A, Mérette  C.  Language delay in severely neglected children: a cumulative or specific effect of risk factors? Child Abuse Negl. 2010;34(6):414-428.
PubMed   |  Link to Article
MacLean  K.  The impact of institutionalization on child development. Dev Psychopathol. 2003;15(4):853-884.
PubMed   |  Link to Article
O'Connor  TG, Bredenkamp  D, Rutter  M.  Attachment disturbances and disorders in children exposed to early severe deprivation. Infant Ment Health J. 1999;20(1):10-29.
Link to Article
Egeland  B, Weinfield  NS, Bosquet  M, Cheng  VK. Remembering, repeating, and working through: lessons from attachment-based interventions. In: Osofsky  J, Fitzgerald  H, eds. WAIMH Handbook of Infant Mental Health: Infant Mental Health in Groups at High Risk.Vol 4. New York, NY: Wiley; 2000:35-89.
MacLeod  J, Nelson  G.  Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review. Child Abuse Negl. 2000;24(9):1127-1149.
PubMed   |  Link to Article
Bakermans-Kranenburg  MJ, van IJzendoorn  MH, Juffer  F.  Less is more: meta-analyses of sensitivity and attachment interventions in early childhood. Psychol Bull. 2003;129(2):195-215.
PubMed   |  Link to Article
Holmes  J. John Bowlby and Attachment Theory. London, England: Routledge; 1993.
Cassidy  J, Shaver  P. Handbook of Attachment. New York, NY: Guilford Press; 1999.
Crittenden  PM. Raising Parents: Attachment, Parenting and Child Safety. Devon, England: Willan Publishing; 2008.
Prior  V, Glaser  D. Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice. London, England: Jessica Kingsley; 2006.
Chaffin  M, Hanson  R, Saunders  BE,  et al.  Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreat. 2006;11(1):76-89.
PubMed   |  Link to Article
Strathearn  L. The elusive etiology of autism: nature and nurture? Front Behav Neurosci.2009;3:11. doi:10.3389/neuro.08.011.2009.
Link to Article
Rutter  M, Andersen-Wood  L, Beckett  C,  et al; English and Romanian Adoptees (ERA) Study Team.  Quasi-autistic patterns following severe early global privation. J Child Psychol Psychiatry. 1999;40(4):537-549.
PubMed   |  Link to Article
Fonagy  P, Gergely  G, Junst  EL, Target  M. Affect Regulation, Mentalization and the Development of the Self. New York, NY: Other Press LLC; 2002.
Pleck  JH, Masciadrelli  BP. Paternal involvement by US residential fathers: levels, sources, and consequences. In: Lamb  ME, ed. The Role of the Father in Child Development.4th ed. Hoboken, NJ: John Wiley & Sons Inc; 2004.
Flouri  E. Fathering and Child Outcomes. Chichester, England: John Wiley & Sons Ltd; 2005.
Glaser  D.  How to deal with emotional abuse and neglect: further development of a conceptual framework (FRAMEA). Child Abuse Negl. 2011;35(10):866-875.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1.  Emotional, Behavioral, and Developmental Features in the Neglected or Emotionally Abused Child
Table Graphic Jump LocationTable 2.  Carer-Child Interactions Among Neglected and Emotionally Abused Preschoolers

References

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Crittenden  PM.  Children’s strategies for coping with adverse home environments: an interpretation using attachment theory. Child Abuse Negl. 1992;16(3):329-343.
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Crittenden  PM, Bonvillian  JD.  The relationship between maternal risk status and maternal sensitivity. Am J Orthopsychiatry. 1984;54(2):250-262.
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Crittenden  PM, DiLalla  DL.  Compulsive compliance: the development of an inhibitory coping strategy in infancy. J Abnorm Child Psychol. 1988;16(5):585-599.
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DiLalla  DL, Crittenden  PM.  Dimensions of maltreated children's home behavior: a factor analytic approach. Infant Behav Dev. 1990;13(4):439-460.
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Eigsti  IM, Cicchetti  D.  The impact of child maltreatment on expressive syntax at 60 months. Dev Sci. 2004;7(1):88-102.
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Fagan  J, Dore  MM.  Mother-child play interaction in neglecting and non-neglecting mothers. Early Child Dev Care. 1993;87:59-68.
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Frodi  A, Smetana  J.  Abused, neglected, and nonmaltreated preschoolers’ ability to discriminate emotions in others: the effects of IQ. Child Abuse Negl. 1984;8(4):459-465.
PubMed   |  Link to Article
Hoffman-Plotkin  D, Twentyman  CT.  A multimodal assessment of behavioral and cognitive deficits in abused and neglected preschoolers. Child Dev. 1984;55(3):794-802.
PubMed   |  Link to Article
Koenig  AL, Cicchetti  D, Rogosch  FA.  Child compliance/noncompliance and maternal contributors to internalization in maltreating and nonmaltreating dyads. Child Dev. 2000;71(4):1018-1032.
PubMed   |  Link to Article
Koenig  AL, Cicchetti  D, Rogosch  FA.  Moral development: the association between maltreatment and young children's prosocial behaviors and moral transgressions. Soc Dev. 2004;13(1):87-106.
Link to Article
Lamb  ME, Gaensbauer  TJ, Malkin  CM, Schultz  LA.  The effects of child maltreatment on security of infant-adult attachment. Infant Behav Dev. 1985;8(1):35-45.
Link to Article
Macfie  J, Cicchetti  D, Toth  SL.  Dissociation in maltreated versus nonmaltreated preschool-aged children. Child Abuse Negl. 2001;25(9):1253-1267.
PubMed   |  Link to Article
Macfie  J, Toth  SL, Rogosch  FA, Robinson  J, Emde  RN, Cicchetti  D.  Effect of maltreatment on preschoolers’ narrative representations of responses to relieve distress and of role reversal. Dev Psychol. 1999;35(2):460-465.
PubMed   |  Link to Article
Mackner  LM, Starr  RHJ  Jr, Black  MM.  The cumulative effect of neglect and failure to thrive on cognitive functioning. Child Abuse Negl. 1997;21(7):691-700.
PubMed   |  Link to Article
Maughan  A, Cicchetti  D.  Impact of child maltreatment and interadult violence on children’s emotion regulation abilities and socioemotional adjustment. Child Dev. 2002;73(5):1525-1542.
PubMed   |  Link to Article
Pianta  R, Egeland  B, Erickson  MF. The antecedents of maltreatment: Results of the Mother-Child Interaction Research Project. In: Cicchetti  D, Carlson  V, eds. Child maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. New York, NY: Cambridge University Press; 1989:203-253.
Pollak  SD, Cicchetti  D, Hornung  K, Reed  A.  Recognizing emotion in faces: developmental effects of child abuse and neglect. Dev Psychol. 2000;36(5):679-688.
PubMed   |  Link to Article
Pollitt  E, Eichler  AW, Chan  CK.  Psychosocial development and behavior of mothers of failure-to-thrive children. Am J Orthopsychiatry. 1975;45(4):525-537.
PubMed   |  Link to Article
Rohrbeck  CA, Twentyman  CT.  Multimodal assessment of impulsiveness in abusing, neglecting, and nonmaltreating mothers and their preschool children. J Consult Clin Psychol. 1986;54(2):231-236.
PubMed   |  Link to Article
Toth  SL, Cicchetti  D, Macfie  J, Emde  RN.  Representations of self and other in the narratives of neglected, physically abused, and sexually abused preschoolers. Dev Psychopathol. 1997;9(4):781-796.
PubMed   |  Link to Article
Valentino  K, Cicchetti  D, Toth  SL, Rogosch  FA.  Mother-child play and emerging social behaviors among infants from maltreating families. Dev Psychol. 2006;42(3):474-485.
PubMed   |  Link to Article
Venet  M, Bureau  J, Gosselin  C, Capuano  F.  Attachment representations in a sample of neglected preschool-age children. Sch Psychol Int. 2007;28(3):264-293.
Link to Article
Waldinger  RJ, Toth  SL, Gerber  A.  Maltreatment and internal representations of relationships: core relationship themes in the narratives of abused and neglected preschoolers. Soc Dev. 2001;10(1):41-58.
Link to Article
Crittenden  PM.  Social networks, quality of child rearing, and child development. Child Dev. 1985;56(5):1299-1313.
Link to Article
Culp  RE, Watkins  RV, Lawrence  H, Letts  D, Kelly  DJ, Rice  ML.  Maltreated children's language and speech development: abused, neglected, and abused and neglected. First Lang. 1991;11(33):377-389.
Link to Article
Dubowitz  H, Papas  MA, Black  MM, Starr  RHJ  Jr.  Child neglect: outcomes in high-risk urban preschoolers. Pediatrics. 2002;109(6):1100-1107.
PubMed   |  Link to Article
Dubowitz  H, Pitts  SC, Black  MM.  Measurement of three major subtypes of child neglect. Child Maltreat. 2004;9(4):344-356.
PubMed   |  Link to Article
Egeland  B, Sroufe  A.  Developmental sequelae of maltreatment in infancy. New Dir Child Adolesc Dev. 1981;11:77-92.
Link to Article
Egeland  B, Sroufe  LA.  Attachment and early maltreatment. Child Dev. 1981;52(1):44-52.
PubMed   |  Link to Article
Egeland  B, Sroufe  LA, Erickson  M.  The developmental consequence of different patterns of maltreatment. Child Abuse Negl. 1983;7(4):459-469.
PubMed   |  Link to Article
English  DJ, Thompson  R, Graham  JC, Briggs  EC.  Toward a definition of neglect in young children. Child Maltreat. 2005;10(2):190-206.
PubMed   |  Link to Article
Mustillo  SA, Dorsey  S, Conover  K, Burns  BJ.  Parental depression and child outcomes: the mediating effects of abuse and neglect. J Marriage Fam. 2011;73(1):164-180.
Link to Article
Scarborough  AA, Lloyd  EC, Barth  RP.  Maltreated infants and toddlers: predictors of developmental delay. J Dev Behav Pediatr. 2009;30(6):489-498.
PubMed   |  Link to Article
Sullivan  MW, Bennett  DS, Carpenter  K, Lewis  M.  Emotion knowledge in young neglected children. Child Maltreat. 2008;13(3):301-306.
PubMed   |  Link to Article
Toth  SL, Cicchetti  D, Macfie  J, Maughan  A, VanMeenen  K.  Narrative representations of caregivers and self in maltreated pre-schoolers. Attach Hum Dev. 2000;2(3):271-305.
PubMed   |  Link to Article
Sylvestre  A, Mérette  C.  Language delay in severely neglected children: a cumulative or specific effect of risk factors? Child Abuse Negl. 2010;34(6):414-428.
PubMed   |  Link to Article
MacLean  K.  The impact of institutionalization on child development. Dev Psychopathol. 2003;15(4):853-884.
PubMed   |  Link to Article
O'Connor  TG, Bredenkamp  D, Rutter  M.  Attachment disturbances and disorders in children exposed to early severe deprivation. Infant Ment Health J. 1999;20(1):10-29.
Link to Article
Egeland  B, Weinfield  NS, Bosquet  M, Cheng  VK. Remembering, repeating, and working through: lessons from attachment-based interventions. In: Osofsky  J, Fitzgerald  H, eds. WAIMH Handbook of Infant Mental Health: Infant Mental Health in Groups at High Risk.Vol 4. New York, NY: Wiley; 2000:35-89.
MacLeod  J, Nelson  G.  Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review. Child Abuse Negl. 2000;24(9):1127-1149.
PubMed   |  Link to Article
Bakermans-Kranenburg  MJ, van IJzendoorn  MH, Juffer  F.  Less is more: meta-analyses of sensitivity and attachment interventions in early childhood. Psychol Bull. 2003;129(2):195-215.
PubMed   |  Link to Article
Holmes  J. John Bowlby and Attachment Theory. London, England: Routledge; 1993.
Cassidy  J, Shaver  P. Handbook of Attachment. New York, NY: Guilford Press; 1999.
Crittenden  PM. Raising Parents: Attachment, Parenting and Child Safety. Devon, England: Willan Publishing; 2008.
Prior  V, Glaser  D. Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice. London, England: Jessica Kingsley; 2006.
Chaffin  M, Hanson  R, Saunders  BE,  et al.  Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreat. 2006;11(1):76-89.
PubMed   |  Link to Article
Strathearn  L. The elusive etiology of autism: nature and nurture? Front Behav Neurosci.2009;3:11. doi:10.3389/neuro.08.011.2009.
Link to Article
Rutter  M, Andersen-Wood  L, Beckett  C,  et al; English and Romanian Adoptees (ERA) Study Team.  Quasi-autistic patterns following severe early global privation. J Child Psychol Psychiatry. 1999;40(4):537-549.
PubMed   |  Link to Article
Fonagy  P, Gergely  G, Junst  EL, Target  M. Affect Regulation, Mentalization and the Development of the Self. New York, NY: Other Press LLC; 2002.
Pleck  JH, Masciadrelli  BP. Paternal involvement by US residential fathers: levels, sources, and consequences. In: Lamb  ME, ed. The Role of the Father in Child Development.4th ed. Hoboken, NJ: John Wiley & Sons Inc; 2004.
Flouri  E. Fathering and Child Outcomes. Chichester, England: John Wiley & Sons Ltd; 2005.
Glaser  D.  How to deal with emotional abuse and neglect: further development of a conceptual framework (FRAMEA). Child Abuse Negl. 2011;35(10):866-875.
PubMed   |  Link to Article

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Multimedia

Supplement.

eAppendix 1. Definitions of emotional abuse and neglect.

eAppendix 2. Bibliographic databases, journals, and websites searched (with date parameters).

eAppendix 3. Search terms used for both the initial search and the update (keywords and phrases used).

eAppendix 4. Study selection process.

eAppendix 5. Critical appraisal form.

eAppendix 6. Inclusion criteria and ranking of abuse.

eAppendix 7. Quality standards reached by included studies.

eAppendix 8. Details of included studies.

eReferences

eAppendix 9. Assessment tools used by study authors.

eAppendix 10. Patterns of attachment.

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