LAUSR

Considered synonymous, child emotional and psychological abuse (hereafter referred to as psychological abuse) is a type of maltreatment that can be difficult for clinicians to detect and assess. Increasingly thought to be themost prevalent form of child maltreatment, psychological abuse involves nonphysical interactions by a caregiver toward a child, including acts of commission that place a child at risk for emotional harm. Pertinent issues for pediatricians include its prevalence, its determinants and risk factors, its negative shortand long-term outcomes, how to assess psychological abuse, and how to collaborate with child protection agencies. Psychological abuse is arguably the most poorly understood form of child maltreatment; compared with physical and sexual abuse, much less is known about its presentation, causes, consequences, prevention, and treatment. For the pediatrician, a key part of identifying psychological abuse is being attuned to interactions between children and their caregivers. Psychological abuse of a child or adolescent often manifests as a repeated pattern of behavior, but it can also involve a single incident. Examples of psychologically abusive behavior by caregivers include spurning (eg, ridiculing or humiliating), terrorizing (eg, threatening violence against a child or a child’s loved ones), isolating (eg, restricting social interactions), corrupting/exploiting (eg, involving in illegal activities), and denying emotional responsiveness (eg, providing no praise). Although single incidents of these behaviors do not necessarily constitute psychological abuse, 1 severe incident, such as terrorizing a child, could be considered psychologically abusive. A caregiver may use 1 or more of these behaviors briefly or over a longer period. Exposure to psychological abuse has occurred if a caregiver’s behavior inflicts harm or places a child at risk for harm. Examples of emotional impairment include a child or adolescent engaging in maladaptive behavior or feeling unloved, unwanted, or only of value to serve the means, desires, and purposes of the caregiver. In addition to physical and sexual abuse, psychological abuse can co-occur with neglect, including physical, medical, and psychological neglect. Notably, the term psychological maltreatment includes both psychological abuse and psychological neglect. Much less is known about the prevalence, antecedents, correlates, and outcomes of psychological abuse compared with other types of maltreatment. In addition, the studies that estimate the prevalence of psychological abuse are disproportionately focused on North American samples. Importantly, psychological abuse is likely the most underreported form of child maltreatment to child welfare authorities. Based on a recent meta-analysis of studies addressing psychological abuse, the prevalence was estimated to be only 0.3% when based on reports by professionals but was as high as 36% when determined by selfreports. Given that psychological abuse often lacks overt indicators of its occurrence, it is not surprising that prevalence rates based on reports by professionals are significantly lower than those based on self-reports of victimization. AUTHOR DISCLOSURE Dr Kimber has disclosed that she receives funding from the Public Health Agency of Canada to develop curricula on family violence, including child maltreatment. Dr MacMillan has disclosed that her institution receives funding from the Public Health Agency of Canada to develop panCanadian guidance and curricula on responding to family violence, including psychological abuse, and that she is principal investigator on the project. She receives honoraria as a speaker for continuing medical education presentations on topics that include psychological abuse and receives compensation as an expert witness on all aspects of child maltreatment. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.