Child Abuse & Neglect 33 (2009) 22–26

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Child Abuse & Neglect

Commentary

Taking stock: Childhood emotional maltreatment and developmental

psychopathology
Byron Egeland ∗
Institute of Child Development, University of Minnesota, 51 East River Road, Minneapolis, MN 55455, USA

Recognition of maltreatment as a social problem is relatively recent in the United States. Physical abuse came to the
attention of the American public in part through Kempe, Silverman, Steele, Droegemueller, and Silver (1962) paper on the
battered child. Mass media reports of extreme cases of physical and sexual abuse serve as continual reminders of the horrific
nature and devastating consequences of child abuse. Widespread recognition of emotional maltreatment, however, has
lagged far behind acknowledgment of childhood physical and sexual abuse as a significant social problem. Although the
prevalence of emotional maltreatment can only be estimated since good epidemiological data does not exist, emotional
abuse is quite prevalent. In their paper summarizing issues surrounding the definition and classification of maltreatment in
a large sample of maltreated youth from the Los Angeles County Department of Children and Family Services, Trickett and
colleagues report that 8.9% of the maltreated youth were labeled emotionally maltreated (EM) at the time of referral to the
agency. However, almost half were determined to be EM when their case records were coded using Broussard and Donovan’s
(2006) classification system. Not only were the rates high in the Trickett et al. study, each of the samples used to assess the
developmental sequelae of emotional maltreatment in this section found similarly striking rates.
There are many reasons why emotional maltreatment has not received the attention of physical and sexual abuse. In
addition to issues of definition and identification, one major reason for this discrepancy is that it is often assumed that the
consequences of EM are not as severe as those of more obvious forms of maltreatment. Even though EM does not leave
physical signs, it is a form of maltreatment that has devastating consequences for child development and functioning in a
variety of areas, as illustrated by the papers presented here. In many ways, these studies extend and refine prior evidence of
significant and enduring negative consequences of emotional maltreatment on child development.
Each of the three investigations of the sequelae of EM focus on two broad categories, emotional abuse (EA) and emotional
neglect (EN), both of which are more subtle and often more difficult to detect than physical abuse and neglect. Verbal hostility,
taunting, belittling, and rejection are characteristics of emotional abuse. Emotional neglect is generally characterized by
parents who are emotionally and psychologically unavailable, detached, avoidant and unresponsive to child’s needs and
desires. Perhaps the most widely recognized form of emotional neglect is nonorganic failure to thrive (FTT), which results in
failure to develop physically despite adequate nutrition. Long-term follow-up studies indicate behavioral and socioemotional
sequelae as well as educational problems FTT (Benoit, 2000; Pollitt et al., 1996). Even in cases much less profound than FTT,
the long-term consequences of emotional neglect are remarkable (Erickson & Egeland, 2002).
Drawing on data from the Minnesota Longitudinal Study of Parents and Children, Shaffer et al. examined the relation
between emotional abuse or emotional neglect in childhood and adaptation outcomes in early adolescence. Teachers in the
6th grade rated children identified as having been emotionally abused or neglected in the first six years of life as less likely to
be accepted by their peers and less emotionally healthy, yet the explanatory processes underlying these pathways differed
between emotional abuse and neglect. Social withdrawal in middle childhood significantly explained the observed relation
between emotional abuse and decreased competence in adolescence, but was not as salient in understanding the relation
between emotional neglect and adolescent adaptation.
Interestingly, Shaffer et al.’s findings also point to potentially important differences in the effects of emotional maltreat-
ment occurring at different ages. Earlier studies with this sample identified a group of 19 parents who were observed to

∗ Corresponding author.

0145-2134/$ – see front matter © 2009 Published by Elsevier Ltd.

doi:10.1016/j.chiabu.2008.12.004
 B. Egeland / Child Abuse & Neglect 33 (2009) 22–26 23

be emotionally neglecting, or what we called psychologically unavailable parenting, of their young child (3–24 months)
(Egeland, Sroufe, & Erickson, 1983). These parents tended to ignore their infants’ cues and signals, particularly the infants’
cries and pleas for warmth and comforting. Following them from infancy forward, we found 43% of emotionally neglected
children were anxiously attached at 12 months and by 18 months of age, all these children were anxiously attached with the
majority classified as Anxious-Avoidant. In videotaped assessments at 24 and 42 months, these children were observed to
be more angry, noncompliant, lacking in persistence, and displaying little positive affect compared to the high-risk children
from the same sample who were not classified as having been maltreated. One of the most dramatic findings for emotionally
neglected children was their steep decline in performance on the Bayley Scales of Infant Development from a mean score of
121 at 9 months to a mean score of 83 at the 24 month assessment. In preschool, these children continued to be noncompli-
ant and negativistic, impulsive, and highly dependent on teachers and they sometimes displayed nervous signs, self-abusive
behavior, and other problems (Egeland et al., 1983).
Although the maltreatment they experienced was the most subtle of all the groups of maltreated children, the conse-
quences were striking. Children who were emotionally neglected at an early age were more impaired in many areas of
functioning than children who were physically abused or neglected. In 1st, 2nd, and 3rd grade, the emotionally neglected
children were rated by their teachers on the Child Behavior Checklist (CBC) as more socially withdrawn, unpopular with
peers, and in general exhibiting more problems of the internalizing type compared to the control group. In the early grades,
they were also rated as more aggressive and less attentive. On the Peabody Individual Achievement Test, they earned signif-
icantly lower scores in every grade compared to the nonmaltreated children in the same sample (Erickson & Egeland, 1996).
In summary, emotional neglect identified during the first two years of life had a long lasting impact on children’s adaptation
within the family, and in school with peers and teachers.
In adolescence, children who were emotionally neglected in the first two years of life exhibited higher levels of social
problems, delinquency, and aggression on scales from the CBC-T and reported significantly more attempted suicides com-
pared to the other maltreatment groups and controls. Using the K-SADS Diagnostic Interview to assess mental illness, the
majority of maltreated children received at least one diagnosis. The highest rate was in the emotionally neglected group in
which all but one of the children received at least one diagnosis of psychiatric disorder and 73% were comorbid for two or
more disorders. Among other things, comorbidity suggests more serious impairment due to mental illness (Egeland, 1997).
Using data from the same sample, Shaffer et al. also found negative effects. However, the effects did not seem as severe
as those reported in earlier publications. One likely explanation is that the sample of EN children used in the earlier studies
were identified in infancy and toddlerhood whereas the EN sample identified for use in the current study included children
up to age 6. It appears that EN occurring in the first two years of life has a profound effect on a variety of outcomes. EN
children identified at a later age do not seem to suffer as extreme consequences compared to those identified earlier. This
suggests that intervention in infancy and toddlerhood may be critical for reducing the negative consequences of emotional
maltreatment.
In a well-designed investigation, Wekerle et al. (2001) used the Childhood Trauma Questionnaire to identify EA and EN in a
large sample of child protection involved youth. They found elevated PTSD symptomatology and high rates of dating violence
in adolescence in this child protection sample. O’Dougherty-Wright et al. used a sample of college students who reported
childhood emotional abuse and neglect and found high rates of dissociative, anxious, and depressive symptomatology. Impor-
tantly, emotional abuse and neglect contributed unique variance in predicting the outcomes controlling for other forms of
maltreatment in the papers by both Wekerle et al. and O’Dougherty-Wright et al.’s studies. In addition, O’Dougherty-Wright
et al. controlled for family income and exposure to parental alcoholism and Wekerle controlled for certain demographics,
length of time in child protection, and type of service (e.g., foster care placement). Even controlling for all these factors, both
EA and EN contributed unique variance in predicting varied outcomes.
These papers help establish that EA and EN are forms of maltreatment that make unique contributions to negative out-
comes beyond the deleterious influences of related risk factors and other forms of maltreatment. Despite using different
samples, research designs, and outcome measures, the three investigations of the sequelae of EM provide further evidence
of the significant and enduring consequences of emotional maltreatment. The negative consequences related to the two
broad forms of emotional maltreatment were highly varied, suggesting that this form of maltreatment results in serious
impairment across most domains of functioning. An important implication as pointed out by each author is the need for pro-
fessionals in child welfare and related fields to become more aware of emotional maltreatment and its potentially devastating
consequences.
Another major contribution of this set of papers is the attempt to identify the processes and mechanisms that explain
the link between EM and negative outcomes. Each of the mediational constructs examined in these studies was found to
explain part of the link between EM and negative outcomes. Shaffer et al. used teacher ratings of aggression and social
withdrawal in middle childhood as a mediator and found neither accounted for the relation between emotional neglect in
childhood and lower levels of competence in early adolescence. However, significant mediation effects for social withdrawal
did account for some of the relation between emotional abuse and decreased competence. This mediational effect was
especially salient for males. Within an organizational developmental perspective (Sroufe & Rutter, 1984), the successful
resolution of stage-salient issues increases the probability of competent functioning in the next developmental period.
Shaffer et al.’s mediational findings may be interpreted within this developmental framework. Peer competence is a salient
developmental issue in middle childhood. As expected, poor functioning in this domain was related to less competent
functioning in early adolescence. In other words, developmental maladaptation following maltreatment is likely to be related
24 B. Egeland / Child Abuse & Neglect 33 (2009) 22–26

to maladaptation in subsequent developmental periods unless there is a change in the balance of risk and protective factors
in the child’s proximal environment. The results suggest the need to study sequelae and mediational processes within a
developmental framework.
Wekerle et al. (2001) found that the number of subscales exceeding clinical cutoff on the Trauma Symptom Checklist, a
measure of post-traumatic stress disorder (PTSD) symptomatology, served as a mediator accounting for the relation between
emotional maltreatment and dating violence. Specifically, PTSD symptoms accounted for the relation between emotional
maltreatment and perpetration of dating violence in male youth and PTSD symptoms accounted for dating victimization
among female youth. To explain this relation the authors hypothesize that PTSD may interfere with social information
processing which in turn may affect behavioral decision making. Recent research on brain development provides some
support for this conclusion. Maltreated children with PTSD excrete greater concentrations of cortisol, a stress hormone that
helps an individual manage stressful experiences (DeBellis, 2001). Chronically high levels of cortisol have a variety of negative
effects on the development of the brain, contributing to smaller middle and posterior regions of the corpus collosum and
delays in neurogenesis and myelination (DeBellis, 2001; Teicher et al., 2004), all of which are likely to affect decision making
and information processing skills. More research is needed to further understand the role of PTSD as a mediator between
emotional maltreatment and dating violence and other negative outcomes. Research that includes both the psychological
processes and mechanisms associated with PTSD as well as the neuroendocrine processes is needed. No one factor, process,
or mechanism is likely to explain the link between maltreatment and negative outcomes, but PTSD symptomatology would
appear to be one promising area for future research.
The findings from the O’Dougherty-Wright et al. investigation of the mediating processes and mechanisms underlying
apparent relations between emotional maltreatment and poor outcomes have tremendous implications for both theory and
practice. Based on attachment theory, they hypothesized that the cognitive models or schemata formed of self and self
in relationship to others accounts for the association between emotional maltreatment and clinical symptoms of anxiety
and depression. These cognitive models develop based on the pattern of interaction between the young child and his/her
primary caregiver. In this view, the negative pattern of interactions that exists between the emotionally maltreating parent
and young child becomes internalized, resulting in negative cognitive models. These models provide a set of negative beliefs
and expectations about self and others that center on shame, vulnerability to harm (i.e., catastrophes may strike at any
time), and self sacrifice (i.e., focus on feelings of others at the expense of one’s own needs) and contribute to later negative
outcomes, including anxiety, depression, and dissociation.
Understanding these internalized models is important for developing more targeted intervention and prevention strate-
gies. A number of relationship-based early prevention programs exist using a home visitation approach. These programs
are designed for parents and their infants with the goal of promoting a secure attachment relationship (Egeland, Weinfield,
Bosquet, & Cheng, 2000). Unfortunately, this work has not been applied to treat or prevent emotional maltreatment or, for
that matter, any form of maltreatment, with a few notable exceptions (Lieberman, Silverman, & Pawl, 2000; Toth, Maughan,
Manly, Spagnola, & Cicchetti, 2002). Toth et al. (2002) used a modified infant-parent psychotherapy approach to promote
a positive cognitive model in preschool age maltreated children. Children in the treatment groups exhibited a significant
decrease in maladaptive maternal representations and negative self-representation, and a significant increase in positive
expectations of the mother-child relationship compared to an alternative intervention and control group. These findings
are encouraging and clearly imply a need for further development and evaluation of preventative intervention programs
designed to alter the maltreating parents’ and child victims’ negative internal representational model of self and others.
To this end, research has demonstrated success at preventing child maltreatment with the use of home visitation (Olds
et al., 1998). Olds’ Nurse Family Partner program, for example, is intensive, theoretically driven, and uses highly trained
staff. This program is not based on attachment theory but it has been shown to have long-term positive outcomes, including
continued lower rates of child maltreatment compared to randomized clinical controls. More recently, Olds has demonstrated
that the savings to society for serving high-risk families exceeded the cost of the program by a factor of four over the life of
the child. (Olds, Hill, O’Brien, Racine, & Moritz, 2003) These findings are encouraging and seem to have resulted in federal,
state, and local governments investing more in home visitation programs.
The mediating factors examined in this group of papers represent varied processes and mechanisms. Even though these
varied mediators were all significant, none of them totally accounted for the relation between emotional maltreatment
and later functioning. Partial mediation suggests the need for further research to identify other mediators, and to examine
the cumulative and interactive effects of the various mediational processes and mechanisms. Studies of the etiology and
consequences of maltreatment suggest that a main effects model is insufficient in accounting for the complex processes that
result in outcomes ranging from severe psychopathology and impairment to competence and resilience. The mediational
findings reported here and elsewhere suggest that a variety of individual family/relationship and environmental factors
contribute to our understanding of these varied outcomes. The ecological transactional model provides a framework for
identifying the many factors that influence the development of the maltreated child. Each of the broad ecological levels
(individual, family, community, and culture) contains many risk and protective factors and processes that influence the
course of development. Therefore, it is important to understand both the cumulative effects of risk and protective factors
within and across the ecological levels as well as their interactive transactional effects. As Cicchetti and Valentino (2006)
point out, the balance between risk and protective factors and processes increases or decreases the likelihood of good or
poor developmental outcomes. As the balance between risk and protective factors tips in the direction of risk factors, the
likelihood of a negative outcome increases. Once a certain number is reached, the probability of a negative outcome increases
 B. Egeland / Child Abuse & Neglect 33 (2009) 22–26 25

in an exponential fashion (Sameroff, Bartko, Baldwin, Baldwin, & Seifer, 1998). In part reflecting the trend in psychology to
move away from a main effects model or linear approach, in which one variable presumably leads directly to an outcome,
research is increasingly showing that the interaction or transaction of two (or more) variables is the major determinant of a
developmental outcome.
Determining the impact of emotional maltreatment and differentiating the effects of maltreatment from the many other
factors that influence a child’s development—including other forms of maltreatment which are likely to co-occur with
emotional maltreatment—is challenging. The sequelae studies presented here examine the contribution of other forms
of maltreatment as well as other risk factors. Each ecological level of the caregiving environment in a maltreating context
contains many risk factors. For example, we know that a disproportionate number of maltreating families live in poverty
and that poverty is associated with many additional risk factors such as social isolation (McLoyd & Wilson, 1991) and stress
(Erickson & Egeland, 2002). Higher rates of depression (Burke, 2003) substance abuse (Ondersma, 2002) and lack of impulse
control (Altemeier, O’Connor, Vietze, Sandler, & Sherrod, 1982) also occur in maltreating families compared to controls. Mal-
treating families often live in chaotic, unstable, and disorganized environments (Cicchetti & Valentino, 2006) and the family
interaction is often characterized by conflict and anger (Trickett & Sussman, 1988). Since these and many more risk factors
are often a part of the caregiving environment of maltreating families, inclusion of these risk factors in the study of the effects
of maltreatment is essential. Such risk factors are not useless statistical ‘noise,’ but rather important features of the family’s
ecology that must be considered in developing prevention and intervention programs for maltreating families.
Because of their difficult life circumstances, many maltreating families lack the resources and motivation to become
actively involved in a parenting program. The multiple problems and challenges they experience need to be addressed
before they can devote themselves to responding emotionally to their young child and improving their relationship with
their child. Psychiatric problems and substance abuse, as well as the stress and lack of support, are just a few of the problems
that must be addressed when intervening with maltreating parents and their children. The indiscriminate implementation
of the same intervention for all maltreating families is doomed to failure unless the program identifies the unique needs and
circumstances as well as the strengths of each family in the intervention program.
As Trickett et al. note, public awareness about emotional maltreatment and its consequences remains very low. In the
US, this lack of concern is reflected by the small amount of federal money allocated for research in maltreatment. Fifteen
years ago the National Research Council (1993) reported that less than one percent of social science research dollars were
spent on the entire field of child maltreatment. Since 1993 the money available for research in the area of child welfare and
child mental health has increased yet the amount budgeted for child maltreatment cases remains but a small fraction of
the total. As a consequence, child maltreatment, in particular emotional maltreatment, remains an enormous problem that
continues to exact a toll from its victims as well as society more broadly. Yet there is reason to be optimistic because not all
children who have been maltreated manifest adverse developmental outcomes, and because interventions can be effective.
However, there is a continued need for more resources directed toward the development, implementation, and evaluation
of prevention research, as well as toward more basic research on the causes and consequences of emotional maltreatment.
Future research will illuminate the circumstances and social conditions that precipitate emotional maltreatment, as well
as the developmental pathways leading to adverse outcomes. Improved knowledge about both precipitating factors and
subsequent consequences will aid in the creation of more effective preventative measures and interventions. This special
section represents an important first step in this endeavor.

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