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Correspondence to:
Corinne Rees, Tyndalls Park
Children’s Centre, 31 Tyndalls
Park Road, Bristol BS81PH, UK;
drcarees@doctors.org.uk
Accepted 9 October 2009
Arch Dis Child 2010;95:59–67. doi:10.1136/adc.2008.143156
Understanding emotional abuse
C A Rees
ABSTRACT
Emotional abuse lacks the public and political profile of
physical and sexual abuse, despite being at their core and
frequently their most damaging dimension. Difficulties in
recognition, definition and legal proof put children at risk
of remaining in damaging circumstances. Assessment of
the emotional environment is necessary when interpreting
possible physical or sexual abuse and balancing the risks
and benefits of intervention. This article considers factors
contributing to professional difficulty. It is suggested that
understanding emotional abuse from the first principles of
the causes and implications of the dysfunctional parent–
child relationships it represents can help prevention,
recognition and timely intervention. It may facilitate the
professional communication needed to build up a picture
of emotional abuse and of the emotional context of
physical and sexual abuse. Doing so may contribute to the
safety of child protection practice. The long-term cost of
emotional abuse for individuals and society should be a
powerful incentive for ensuring that development of
services and clinical research are priorities, and that the
false economy of short-term saving is avoided.
Emotional abuse is profoundly damaging but
readily overlooked. Whereas bruises and fractures
often heal quickly and fully, the damage of
uncorrected emotional abuse is lifelong. It com-
promises development of relationship-dependent
areas of the brain, influences programming of
neuroendocrine function,1–3 and has lifelong impli-
cations for physical and mental health, including
major causes of mortality.4 5 It is relevant to
children’s behaviour problems, substance abuse,
aggression, criminality and intergenerational par-
enting problems.6–13
Physical abuse and intrafamilial sexual abuse are
generally the tip of an iceberg of dysfunctional
relationships: their emotional context is often their
most sustaining and damaging component,14 15 yet
relatively infrequently the principle grounds for
protective intervention. There is commonly delay
in both recognition and action.16 It may be self-
limiting physical injury which leads to safety after
years of emotional abuse on which professionals
have struggled to act: such difficulties warrant
consideration amongst possible contributory fac-
tors to serious failures of child protection.
SERVICES TO PROTECT CHILDREN: WRONG
SOLUTIONS FOR EMOTIONAL ABUSE?
The child protection system has been moulded by
its history. Although physical, sexual and emo-
tional abuse have been recognised over generations
and across cultures, they were rediscovered in the
1960s, 70s and 90s, respectively. Legislation,
guidance and practice consequently evolved around
immediate, episodic, definable problems, rather
Review
than the chronic pattern characteristic of emo-
tional abuse. Legislative landmarks have been
prompted by public reaction to children’s deaths
and media analysis of professional shortcomings.17–
20
Emotional abuse has lagged behind physical and
sexual abuse in paediatric practice and training,
resource allocation and political priority. It readily
slides down priority lists shaped by media atten-
tion and political pressure.
The drift of responses to service failures has been
to tighten regulation and external control.
Although possibly helping physical protection, this
does not necessarily enhance emotional safety: by
reducing opportunity for independent thought it
may compromise it. Recognition and management
of emotional abuse depend on detailed observation,
lateral thinking, initiative and adequate freedom to
work creatively, whereas regulation tends to
narrow the focus. Measurable targets may be poor
proxies for the overall picture, yet divert resources
disproportionately: key outcomes are often diffi-
cult to measure, and manifest only years later. If
time and funding are inadequate, check-lists
determined by regulation and pulled by targets
readily become ends in themselves.
If emotional abuse is inadequately understood it
is readily overlooked, because it lacks specific
physical manifestations. Suboptimal professional
care is, likewise, readily overlooked, and comes in
many guises. These include insufficient attention
to emotional wellbeing because of inadequate time,
training or provision to learn from results of
practice, disregard of the risk of delay, and the
false economy of short-term saving. Separation of
paediatrics and child and adolescent mental health
services (CAMHS) is particularly hazardous.21 It
can affect paediatricians’ confidence in managing
emotional and behavioural difficulties, and may
influence their sense of responsibility for doing so.
Assessment of the emotional environment must be
fully integral to safeguarding children, and all
paediatricians need to feel equipped to contribute
to this.22
Pursuing a robust ‘‘evidence base’’ is not
necessarily the overriding priority. All areas of
medicine are not necessarily equally amenable to,
nor equally enhanced by doing so.23 The status of
evidence-based practice reflects its importance in
areas of medicine where the relationship between
cause, manifestation, consequence and manage-
ment is straightforward. However, emotional
abuse is multifactorial in all these respects, and
rarely entirely clear-cut. Evidence achieved by
squeezing the unmeasurable into quantifiable
moulds (eg, by artificially subdividing a conti-
nuum) may be a poor proxy for the overall picture,
and difficult to apply to practice. Research is
generally too blunt a tool to provide answers to
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complex individual decisions. It guides them, but does not safely
override detailed assessment, experience and wisdom. Services
become vulnerable if the pressure of economy encourages
evidence to determine funding.
Laming identified communication as a key problem under-
lying child protection failures.17 18 For emotional abuse, effective
communication involves exchange as much of understanding as
of fact. Unanalysed information has little value, creating a mere
illusion of comprehensive assessment.
Unless safety requires children’s immediate removal from
home, parental change must be regarded as possible and gaining
trust a priority. However, acute, reactive services readily feel
judgmental. The conflicting position in which social workers are
placed distances families from support which they may both
need and welcome. The right solution for physical protection
may be the wrong one for managing its emotional context.
DEFINING THE UNDEFINABLE?
Emotional abuse, like a well-known painting, may be described,
but not ‘‘defined’’ such that others can recognise it. Attempted
definition has produced consensus largely about the difficulty of
the task. Since untrained people across cultures recognise
emotionally abusive behaviour,24 pressure to define, not
recognition, may underlie professional difficulty in doing so.
Attribution of difficulty working with emotional abuse to
definitional problems presupposes that practically useable
definition is possible and necessary, which is not necessarily
so: conceptual understanding is the greater priority.
We are, however, signed up to a professional ethos which, in
emphasising guidelines, protocol and regulation, increasingly
creates pressure to define and label, particularly when working
with an adversarial child protection system. While important to
much of medicine, a definitional focus may constrain under-
standing when categories are arbitrarily demarcated. Artificial
distinctions help research, but can disadvantage practice by
oversimplifying, or by creating complexity, as, for example, in
differentiating between ‘‘emotional abuse’’, ‘‘emotional
neglect’’ and ‘‘psychological abuse’’. Starting from observation
rather than definition, however, allows unconstrained descrip-
tion, but observation must be made through informed lenses.
Behaviours which are deemed emotionally abusive include
overprotection, threat, terrorising, excessive punishment, deni-
gration, rejection, isolation, scapegoating, manipulation, giving
inappropriate roles or responsibilities, and allowing witnessing
of inappropriate adult activity.6 These descriptions do not,
however, generate practically definable thresholds, so remain
difficult to translate into action in an evidential system. Each
falls on a spectrum merging with what might be considered
‘‘normal’’, if not desirable, parenting. It is a matter, perhaps, of
stepping back to consider the origins and implications of these
behaviours, of understanding why they cause harm rather than
struggling to define them.
The dynamic nature of emotional abuse affects recognition.
Parents’ circumstances and their parenting change. Children are
usually at some level attached to the most dysfunctional
parents, whose care is rarely uniformly inadequate. Formulation
of parenting as abusive necessarily involves value judgement,
influenced by cultural norms.
Assessment of emotional abuse often involves several profes-
sions of disparate ethos: communicable, common understand-
ing of core principles is essential, common definition perhaps
less so.
60
BACK TO BASICS
Emotional abuse can be understood broadly as failure to provide
children with an emotional environment conducive to adequate
psychological, developmental and physical progress to achieve
safe independence. It is intimately related to the quality of
attachment, and to the assumptions, learning and physiological
responses which follow from it.
Principles of how healthy attachments are made, and their
consequences, give a framework for understanding inadequate
emotional care (table 1). Onto this core, detail can be built,
constructing a jigsaw which includes contributory factors,
manifestations and consequences, enabling recognition and
simultaneously generating therapeutic opportunities.
Although variably defined, for practical purposes attachment
can be understood as the sustaining emotional closeness which
binds families together. Its particular significance for children
relates to their immaturity, and their consequent dependence on
relationships for safety, instruction and role model to prepare
for independence. The quality of early attachment establishes
foundations for functioning both through relationships and
independently. As in a wall, the quality of foundations remains
important whatever is added: children’s early parenting estab-
lishes preconceptions of relationships which persist as a
template for those which follow, albeit ameliorated by
subsequent experience.
Healthy foundations are established by parents’ sensitive,
timely and predictable attunement to their babies’ feelings and
needs, responding through speed, tone and pitch of voice,
vocabulary, facial expression, touch and movement. In doing so,
they provide a mirror in which children see their inner world
reflected, giving meaning to emotions and body signals, and
teaching verbal and non-verbal indicators of these.25 The
timeliness, manner and consistency with which they do so
establishes children’s assumptions about the value, safety and
reliability of relationships, and their foundations for commu-
nication, trust, and ability to relinquish control. Sensitive
parenting teaches children that attention is valuable, readily
achieved and held, and restored by moderate behaviour.
Ineffective, unpredictable, confusing or frightening parenting
distorts children’s preconceptions of the desirability, reliability
and safety of attention, the extent to which they seek it and the
way they do so.
Attunement – sensitive awareness of, and response to the
feelings and needs of the other – is the core of attachment in any
relationship. It allows effective recovery after separation and
disagreement, and a sense of unconditional acceptance and
emotional safety.26 It is adversely affected by, for example,
stress, anxiety, fatigue and distractibility, and by inadequate
time together: simple measures may readily help attachment.
Because infants lack self-regulatory capacity, they depend on
attuned parents to handle their stress. The effectiveness and
promptness with which they do so influences the programming
of the stress regulation systems, ameliorating the consequences
of intrauterine stress.27
Sensitive attunement depends on parents having acquired,
through their own early parenting, the ability to respond
intuitively to their children’s needs, and the ability to regulate
their own stress and emotions effectively. The quality of their
childhood attachment is therefore a key consideration in
anticipating or assessing their capacity for good emotional care,
and the help needed to achieve it. Many whose own emotional
needs are unmet cannot put their children first, or trust
sufficiently to accept help. Effective attunement requires
physical and emotional availability: the impact on these of,
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Table 1 Core principles of attachment and attachment styles*

Core principles
Attachment is the close emotional bond which binds families, to protect children while they learn necessary skills for safe independence
The core of attachment is attunement to the feelings and needs of the other
Quality of attachment depends on the adequacy and consistency of children’s ability to elicit responses, and of parents’ ability to respond
Quality of attunement is affected by:
Foundations for intuitive attunement (ie, parents’ ability to respond instinctively to their child because of what they learnt through their own early parenting)
Stress, fatigue, anxiety, distractibility
Substance abuse, mental illness
Learning difficulties
Attunement allows stress regulation before children can self-regulate, affecting programming of stress responses
Attachment styles merge on a continuum
Quality of attachment is dynamic, and depends on both sides of the relationship, although individual tendencies persist
Quality of attachment affects the extent to which children see relationships as valuable, safe, reliable and predictable
Quality of attachment affects the extent to which children seek attention, and risk relinquishing it
Quality of attachment, and consequent assumptions about relationships, substantially affect children’s learnt behaviour, which serves a purpose determined by the anticipated
response
Emotionally abusive parenting affects perceptions of relationships and self, and programming of stress regulation; it both reflects and promotes dysfunctional attachment
Quality of attachment is always relevant to children’s wellbeing – the question is how, not whether it is significant

Attachment style* Parenting Perception of relationships Developmental implications

Secure Reliably well attuned; breaks Valuable; attention worth seeking and Competent in functioning independently and in using
effectively repaired readily achieved relationships to learn
Insecure
Anxious* Intermittently well attuned; breaks Valuable but unreliable; attention worth Attention-seeking may impair learning, or anxiety to please
unpredictably repaired seeking but unpredictably achieved. may accelerate it
Depend on attention/approval for self-worth
Ambivalent* Variably attuned and antagonistic; Confusing: valuable, frightening, May learn better at school than through close relationships.
breaks unpredictably repaired unpredictable. Crave relationships but fear Craving for attention/approval may impair or enhance aspects
closeness of learning
Avoidant Consistently non-attuned or often Unhelpful or frightening. Attention not Social learning impaired. Cognitive development affected until
aggressive worth seeking, or feels unsafe independent learning is possible. May selectively develop non-
personal abstract skills (eg, computing)
Disorganised Unpredictably but pervasively abusive Confusing, unhelpful, unusable Ineffective independently and in using relationships; unable to
integrate effectively in school
*Understanding from first principles is more important to practical application than labelling. Terminology used to describe attachment styles varies and can therefore be confusing.
Some do not differentiate between ‘‘anxious’’ and ‘‘ambivalent’’ patterns.

for example, learning difficulties, substance abuse and mental
illness is particularly great for those whose early parenting was
inadequate. Associated difficulties with self-esteem, social skills,
empathy and negotiation, and in regulating stress, emotion,
temper and impulse, contribute to emotionally abusive beha-
viour, which both results from and generates poor attachment.
WHY DOES IT MATTER?
Emotional abuse insidiously damages the developing brain. The
brain develops according to how it is used, and for infants, vital
stimulus comes through attuned parenting. During the first
18 months of life this promotes development of the right
hemisphere and its connections with the limbic system and
autonomic nervous system, affecting stress regulation, and the
right prefrontal cortex which mediates executive functions.1
Delayed brain growth is demonstrable following neglect and
becomes increasingly irreversible with age.28
Emotional abuse affects neuroendocrine function,1–3 physical
health, growth and development.5 29 It frequently underlies
behavioural difficulties. It represents dysfunction of the
relationships on which children depend for safety, guidance
and role model, to learn everything necessary for safe maturity,
including preconceptions of relationships, self and the world. It
influences the extent of self-sufficiency or dependency. Unmet
needs teach children to take control, affecting their ability to
learn from adults. Dysfunctional programming of stress regula-
tion, including the hypothalamic-pituitary-adrenal (HPA) axis
(reflected in salivary cortisol levels), dopamine and serotonin
systems, has potentially life-long implications.1–3 27 30–34 Over-
active responses produce over-reaction to threat, and adversely
affect social relationships, physical and mental health (predis-
posing, for example, to depression and post traumatic stress
disorder), concentration, and behaviour regulation.35–38 Trauma
may sometimes, conversely, cause autonomic down-regulation,
and fearlessness, a pattern linked with avoidant attachment
behaviour39–42 (table 2).
The implications of emotionally neglectful parenting depend
on its nature, variability and predictability. Its effects may be
tempered by any good relationship, and by individual resi-
lience.43 44 Any aspect of development may be affected, though
particularly those relating to use of relationships, or directly
acquired through them.45 The pattern of abuse influences its
developmental consequences. For example, avoidance of rela-
tionships, taught by aggressive parenting, may selectively
accelerate self-help, while impairing communication.
Intermittently ‘‘unavailable’’ parenting may encourage skills
which achieve attention. The way skills are used may be as
significant as whether or not they have been acquired. Quality
and content of play, imagination, and ability to risk failure
influence progress. Children’s difficulty relinquishing control
can give the false impression of delayed development when they
resist instruction.
Behaviour serves a purpose, and is determined by its
anticipated effect, learnt through experience. Perceptions of
the value, predictability and safety of attention are at its core.
For example, fear of attention because of associated violence, or

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Table 2 Why emotional abuse matters
Perceptions of relationships
Affects foundations for understanding the value, safety, reliability and
associations of relationships
Establishes assumptions concerning the use of relationships for:
Comfort, calming, friendship, intimacy, guidance, learning, cooperation
Emotional regulation
Distorts perceptions of roles and responsibilities:
Parent–child, adult–child, gender, sibling relationships
Authority, hierarchy
Sexual boundaries
Trust
Use of relationships
Establishes the extent of self-sufficiency or dependency, leading to:
Craving attention
Avoidance of attention (including autistic-like patterns)
Fluctuating use of attention because of ambivalence
Use of relationships affected by:
Inattention, affecting ‘‘reading’’ of relationships
Difficulty regulating emotion and temper
Vulnerability to rejection
Over-reading of disapproval or threat
Limited empathy
Anxiety, stress, depression
Lack of intuitive attunement
Intolerance of touch
Affects foundations for communication:
Verbal communication
Non-verbal communication
Emotional communication
Pragmatic language
Strategies learnt for using relationships:
Means of achieving and holding attention
Constant smiling, always helping
Incessant chat, intrusion, following, clinginess
Behaviour which is difficult to ignore (eg, eating and toileting problems,
endangerment, hurting others, sexualised behaviour)
Control of others
Hypervigilance
Over-reaction to threat, over-reading of disapproval
Over-adjustment to others’ expectations
Avoidance of risk of failure, over-compliance
Pre-empting rejection by negative behaviour
Acceptance of discipline affected by:
Expectations of discipline (eg, violence, isolation)
Perceptions of authority
Difficulty relinquishing control (eg, oppositional behaviour)
Exaggerated sense of rejection
Underactive stress responses (indifference to reprimand)
indifference because of consistently poor attunement can cause
aloofness. Anxiety that valued but unpredictably available
attention may be lost causes any behaviour (desirable or
otherwise) which achieves it to flourish. Emotionally neglected
children’s behaviour is often further coloured by unregulated
stress and emotion, impulsivity, craved attention, oversensitiv-
ity to disapproval, failure and rejection, lack of social skills, and
difficulty relinquishing control.
Difficulties resembling attention deficit hyperactivity disorder
(ADHD) are complexly related to emotional abuse, as cause and
effect. Overactive HPA axis programming, hypervigilance and
anxiety contribute. Familial risk of ADHD is also high, since
parents’ symptoms may underlie their substance abuse or
62
Self-perception
Affects understanding of the ‘‘inner world’’: body signals (eg, hunger, pain), emotion, sense
of self
Affects perception of personal roles and responsibilities
Affects perception of ability to influence own destiny
May distort the distinction between reality and fantasy
Damages self-esteem (eg, perceived blame, sense of deserving rejection)
Adaptability
Dysfunctional stress system programming:
Overactive (eg, excessive anxiety)
Under-active (eg, fearlessness)
Limited danger awareness
ADHD-type problems
Inadequate cognitive coping strategies
Anxiety concerning change, clinging to ‘‘sameness’’
Poor negotiation and repair strategies
Hypervigilance to threat
Underdevelopment of executive function (eg, response inhibition, concentration, planning,
problem solving)
Dysfunctional coping strategies (eg, substance abuse, self-harm)
Mood disorder, anxiety, post-traumatic stress disorder
Transition to independence
Difficulties with:
Functioning effectively independently or through relationships
Regulating stress, emotion, anger
Negotiation and conflict resolution
Self-esteem
Identity
Inadequate foundations for intuitive attunement
Vulnerability to rejection
Risk of early pregnancy
Attraction to familiar but dysfunctional patterns of relationships (eg, violence)
Parenting difficulty
Development
Affects all which should be learned through and modelled by parents (eg, communication,
safety, negotiation)
Affects ability to learn from others
Acceleration or deceleration of skills achieving attention
Self-help skills may develop disproportionately
Concentration difficulty, control issues, exclusion
Physical health
Delayed growth in height, weight and head circumference
Accidents, non-accidental injury, poor immunity, autonomic dysfunction
Early menarche
temper problems and consequent parenting difficulties. For
many children, intrauterine exposure to drugs, alcohol, smoking
and violence compound the risk.
Well-established strategies for living with dysfunctional
relationships leave children ill-equipped for healthy ones, like
negotiating London with a map of Paris. Learnt self-protective
behaviour may, perplexingly, provoke discipline and rejection.
Children’s hypervigilance and over-adjustment to others’
expectations can make a snapshot view of their behaviour
deceptive and professional continuity particularly important.
The relationship between suboptimal emotional care and
physical health is multifaceted and often imprecisely attribu-
table. It includes neglect of the practicalities of prevention,
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nutrition, hygiene, appointments and treatment. Poor attune-
ment affects parents’ recognition of illness and children’s ability
to indicate it. It compromises accident prevention. Inadequate
attachment may influence immunity and endocrine function
(eg, predisposing to early menarche).46 47 Both parents’ and
children’s need for attention influences children’s symptom
presentation and use: physical health symptoms can be a
reliable route to attention for those who crave it. Dysfunctional
stress system programming may be relevant to any illness to
which stress can contribute.
Uncorrected emotional abuse typically produces escalating
difficulty, and vicious circles with self-esteem at the core, fuelled
by peer relationship problems, elusive success, and perceived
rejection. The complexity and cost of helping recovery increases,
the longer it remains unaddressed. The likelihood of achieving
successful alternative care progressively diminishes: the cost of
failure to do so is considerable and lifelong. Decisions about
safeguarding children must take informed account of the risks
of delay.
CONSTRUCTING THE JIGSAW
Recognition of emotional abuse resembles the construction of a
jigsaw of a familiar painting, made up of pieces of varying
clarity. Interpretation depends on understanding how risk
relates to parental behaviour, how parental behaviour relates
to children’s understanding of relationships, and how children’s
understanding of relationships relates to their development,
stress regulation and behaviour (box 1 and table 3).
The task is to build a picture of the current and future
implications of the preconceptions of relationships, self and the
world which the child is acquiring from their emotional
environment. It involves considering the developmental, physi-
cal, emotional and behavioural implications of these preconcep-
tions, identifying contributory factors, sources of resilience and
therapeutic opportunities, and assessing the likelihood of
change. The priority is description, not definition.
Consideration of how children see and use relationships should
be integral to, and inform interpretation of developmental
assessment, including patterns of advanced and delayed skills.45
Fragments of the jigsaw include what is known or can be
assumed about the child’s genetic inheritance, antenatal and
postnatal experience, and experiences at home and of moves into
and within the care system. They include the behaviour of parents
and children, individually and together, described and observed.
They include factors conveying resilience – particularly any
effective relationship.43 44 Assessment of what, judging from
identified fragments, might be expected, is considered alongside
the child’s observed use of relationships and developmental
pattern in interpreting the overall picture. For example, poor
parental foundations of attachment increase the significance of
behaviour consistent with emotional abuse; parental violence is
likely to contribute to autistic-like avoidance of relationships.
The more pieces which are missing, the less reliable the image
constructed. Many fragments look individually insignificant or
ambiguous: understanding the causes, manifestations and
consequences of emotional abuse enables their relevance to be
judged. The picture is dynamic, and of complexly interrelating
parts. The greater the professional continuity and attention to
detail, the greater the opportunity to test it from alternative
perspectives, in different settings and over time, and the greater
the likelihood of accurate interpretation: photographs of
moving objects readily give an inaccurate impression.
Information gathering without analysis has little value and
contributes to delay in achieving emotional and sometimes
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physical safety. Working effectively with emotional abuse
requires attention to detail, focused on consideration of what
the child needs to achieve to be equipped for adulthood (box 2).
The central question is how, judging from the child’s
behaviour and development, they appear to see themselves,
relationships and the world, and the implications of these
perceptions, if uncorrected, for physical and emotional health,
stress regulation, and their transition to independence.
A SERVICE FOR EMOTIONAL ABUSE
The fundamental purpose of a service for emotional abuse is to
promote the effective attachment on which children depend for
sustained physical, developmental and emotional wellbeing,
while addressing consequences of its previous shortcomings.
Since children should, according to the Children Act, remain
at or return home unless it is irretrievably unsafe,19 the belief
underpinning services must be that change is possible.
Emotional abuse does not mean intent to harm: most struggle
to parent because of their own inadequately remedied dysfunc-
tional parenting. Many are consequently mistrustful, vulnerable
to rejection and failure, and lack self-worth, agency and
negotiating skills. Many cannot regulate stress, fear and
emotion effectively. Parents need to feel valued, safe, and
understood to engage with services and achieve change. Their
behaviour, like children’s, responds best to empathetically
imposed boundaries and reinforcement of positives.
Interventions which generate stress may encourage the out-
comes they aim to prevent, adversely affecting attunement,
tolerance, temper regulation and behaviour management,
encouraging substance abuse, and distancing families from
support. Services need to be encouraging, optimistic and
empowering, and to allow early non-confrontational interven-
tion.48 49 Approaches such as family group conferences, peda-
gogy, and charitable and voluntary schemes such as Action for
Children and Community Service Volunteers warrant further
development and evaluation.50–53
A smooth transition is needed from risk recognition to
support, with help integral to assessment. Factors which
ultimately lead to children’s removal and adoption usually long
predate pregnancy.16 Education about parenting, attachment,
stress regulation and temper management should be routine,
but specifically offered by adolescence to those at known risk.
Inadequate early support is a false economy, the cost, financial
and otherwise, of unaddressed emotional abuse being consider-
able. Joint funding of public services would avoid the problem of
anticipated cost falling within others’ budgets.
Because consequences of dysfunctional emotional care char-
acteristically interrelate, vicious circles and escalating problems
are typical if difficulties remain unaddressed. Support must
therefore be pragmatic and timely, addressing remediable
elements as they are identified. Parental self-care and stress
regulation are priorities. Parents need help with attunement,
and in understanding and managing behaviour reflecting its
inadequacy. Many need support with temper problems,
untreated ADHD, depression, anxiety or substance abuse.
Professional continuity helps trust and reduces the risk that a
snapshot view allows inaccurate interpretation.
Paediatricians need to feel equipped to recognise, describe and
contribute to addressing emotional abuse. Training involves
bridging gaps between disciplines of differing professional ethos.
Mental health should be integral to paediatric training from
undergraduate level onwards, and adequate supervision ensured
to allow routine practical application. All need to understand
the mechanisms through which unsatisfactory parenting
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Box 1 Jigsaw pieces for assessing emotional wellbeing: history*

Parental risks to attachment

c Poor quality early parenting (eg, in care, abuse, inappropriate sexual boundaries)
c Unregulated temper, stress, emotion; ADHD, drugs, alcohol, mental health problems, learning difficulties
Perinatal risk
c Intrauterine drugs, alcohol, smoking, stress, malnutrition
c Perinatal experience (eg, neonatal intensive care, drug withdrawal, multiple carers)
Child’s early foundations for attachment
c Pattern of care
– Consistently good
– Initially adequate (eg, substance abuse starting beyond infancy)
– Intermittently good (eg, drug or alcohol abuse)
– Consistently poor (eg, poor parental foundations of attachment, learning difficulties)
– Confusing: variably adequate and antagonistic (eg, temper control problems)
– Often aggressive
– Consistently abusive
Experiences in the family care
c Quality, consistency and appropriateness of observed parental physical affection
c Consistency, sensitivity, quality of observed parental attunement (eg, voice modulation)
c Child’s observed use of attention at home (unusually little, average, excessive)
c Child’s strategies for achieving attention (positive and negative)
c Parental approach to stress, emotion and temper regulation, negotiation and reconciliation
c Parental mental health (eg, depression affecting mirroring of emotions, psychosis affecting sense of reality)
c Parents’ ability to put children first
c Multiple carers
c Any good relationship
c Violence, child’s response (eg, ‘‘frozen’’, protecting others)
c Sexual boundaries (sexual abuse, witnessing sexual activity/abuse, exposure to inappropriate material)
c Discipline (means, consistency, effectiveness, child’s response)
c Perceptions of authority
c Physical care (eg, hygiene, toileting, feeding, day/night routines, stimulation)
c Position and role in family (eg, competing for attention, scapegoat, favourite, protector, parental role, ‘‘parented’’ by siblings)
c Siblings’ experiences and behaviour, extended family function (eg, substance abuse, violence)
Experience of moves into and within care
c Preparation and introductions, or not
c How moves happened (eg, traumatic removal, accompanied by trusted adults, accompanied by siblings)
c Behaviour on arrival (eg, seeking affection from the outset, ‘‘frozen’’, distressed, angry)
Experience of foster care
c Family structure, number of children, genders
c Quality of attunement by carers, 1:1 time
c Response to care: change over time
c Family relationships (eg, response to contact, discussion of circumstances, content of discussion about birth family)
Physical health
c Delayed growth (head circumference, height, weight)
c Injuries (accidental or non-accidental), constipation, soiling, enuresis, infections, missed immunisations
Change over time
c Attachment behaviour
c Emotional awareness/regulation, concentration, behaviour, development

*These will be of variable certainty – known, assumed, probable or possible.

influences emotional wellbeing and the natural history of
inadequate emotional care. This enables the relevance of risk
factors to be understood, and therapeutic opportunities
identified promptly. All need realistic knowledge of the efficacy
of alternative parenting, its difficulties, professional responsi-
bilities to support it, and the risks of delay. Opportunity is
needed to learn from outcomes of practice. Consultant job plans
should allow adequate time to address children’s emotional
needs, and, recognising the cost of failure to do so, be funded
accordingly,
Understanding is needed of the decision-making process,
roles, responsibilities and hierarchies: ‘‘no evidence of physical
abuse’’ may, for example, be misinterpreted as ‘‘no abuse’’ if
roles are unclear. Expert opinion readily overrides others’ views,
creating an onus to interpret it alongside the detailed knowledge
of frontline staff. The risk of separation of CAMHS and
paediatric services must be fully addressed in local organisation
and training.22
Emotional abuse needs a higher research profile, while
recognising that the relationship of research to practice differs

64 Arch Dis Child 2010;95:59–67. doi:10.1136/adc.2008.143156

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Table 3 Jigsaw pieces for assessing emotional wellbeing: current function*
Current use of relationships
Attachment
Does he seek affection? Appropriately? Of whom?
Behaviour with strangers (eg, seeking affection or excessive attention)
Behaviour in public places (eg, running off without turning)
Does he seek attention too much/too little/appropriately?
How does he react to sharing attention?
Purpose: use of relationships for:
Closeness. Does it feel appropriate?
Calming, comfort
Support, guidance, learning, play
Strategies
How does he seek attention? Does he use positive or negative behaviour?
What is the worst he will do to achieve attention?
Does he adjust to different expectations?
Response to discipline
Can he relinquish control? How does he react to confrontation?
Aggression
Sexualised behaviour
Specific relationships: quality of relationships with:
Parent figures
Other adults (eg, teachers)
Siblings (eg, roles, rivalry, jealousy, warmth)
Peers (eg, sharing attention, controlling, popularity, social confidence)
Communication
Does he understand non-verbal communication? Is this selective (eg, anger)?
Language skills (eg, receptive, expressive, pragmatic)
Does he communicate emotion? (verbally, non-verbally)
Effect on others
How does it feel to parent him?
How does he affect family relationships?
Do carers feel ‘‘needed’’?
What is the most difficult aspect of caring for him?
What are the particular positives of caring for him?
Current indicators of child’s ‘‘inner world’’
Emotional awareness
Does he show a normal range of feelings, appropriate to circumstances? Do
they seem real or acted?
Does he show excessive temper?
Does he show empathy?
Does he have words for feelings?
Body signals
Eating pattern (eg, does he recognise hunger, satiety?)
Toileting pattern (eg, does he know he needs the toilet? Wetting, soiling – Physical health
when and where?)
Response to pain/discomfort
Does he seek comfort or just attention; does he accept offered comfort?
Does he show that he feels unwell?
Self-worth
Does he accept praise? Show pride? Want to please excessively?
Does he value achievement, personal possessions, appearance?
*These will be of variable certainty – known, assumed, probable or possible.
from that applicable to many areas of medicine. Research brings
the challenge of integrating the approaches of diverse profes-
sional groups. The established body of social work and
psychology literature needs to be matched by a greater clinical
focus, including consideration of the predictive value of risk
factors, and the relevance to assessment of, for example, head
growth and manifestations of autonomic function. Clinical
application of the neurochemistry and neuropharmacology of
trauma and attachment (eg, the role of oxytocin and
Arch Dis Child 2010;95:59–67. doi:10.1136/adc.2008.143156
Review
Developmental picture
Profile of advanced and delayed skills
Does he use acquired skills consistently?
How does use of skills relate to attention use?
Does he pretend? Get in roles? What sort of content?
Control issues (eg, deliberate error, resistance to instruction)
Does he wish to please? Is he motivated by praise?
Does he show confidence? Will he risk failure?
Can he comply with quiet play, sitting still, routine?
Does he use adults to support play?
School progress (eg, milestones, social integration, opportunity for success, behaviour,
concentration, sharing attention, turn taking)
Adaptability and regulation
Temperament
ADHD-type features: inattention, impulsivity, hyperactivity
Mood (eg, affect, mood swings)
Emotional regulation, temper control, aggression
Self-calming, using others’ help for calming
Sleep pattern (eg, settling, waking, nightmares)
Response to change in routine
Sense of agency: ability to make choices
Sense of danger (eg, is he cautious in climbing? Does he startle?)
Resilience
Ability to adjust to expectations
Any good emotional relationships?
Intelligence
Observed behaviour during assessment
Attachment behaviour (seeking physical affection, response to offered comfort, eye contact,
reference back to carers during play)
Relative response to parents, foster carers, strangers
Stranger awareness (eg, does he readily leave the room with a stranger, check with carer
before approaching a stranger, seek affection of strangers?)
How much, and how does he seek/hold attention?
How does he behave if the carer’s attention is diverted from him?
How does he handle instruction?
How does he react to discipline?
Concentration, ‘‘flitting’’, impulsivity
Play pattern (eg, pretend play, affection to dolls, persistence, interest)
Parental attunement (eg, sensitivity and consistency, voice modulation, facial expression, eye
contact), physical affection, discipline
Reaction to assessment (eg, cooperative, passive, resistant)
Is his behaviour appropriate to the circumstances?
Dysmorphic features (eg, foetal alcohol syndrome)
Height, weight, head circumference proportions and trends
Eyes: brightness, dark rings under the eyes, focus, eye contact
Skin: ready bruising and blotching, peripheral temperature, eczema, excoriation, infection
Autonomic function (eg, pulse, blood pressure, skin perfusion, gastrointestinal function)
vasopressin in promoting bonding and social understanding)
warrant exploration.54 55
Circumspection and determination are needed to ensure that
systems developed primarily for physical protection are suitable
for emotional care, particularly since inadequate services readily
go unnoticed. Over-regulation is to be resisted, because it stunts
creativity and lateral thinking. Experience and wisdom should
be valued, alongside regulation which sets reasonable limits
rather than determining practice.
65
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Review
Box 2 Assessing emotional wellbeing: analysis*
What are the risk factors to attachment?
c Is it likely that the parents had satisfactory foundations for
attachment?
c What pattern of attunement would the parental risk factors be
likely to cause? (eg, initially good, consistently poor,
inconsistently good, antagonistic, consistently frightening,
unpredictable)
What would be the expected effects of the risk factors?
c What would be the child’s expected foundations of
perceptions of:
– Relationships:
Valuable, reliable, safe?
Attention worth seeking, safe, readily restored?
Close relationships different from others?
– Self:
Worthwhile, unconditionally wanted?
Aware of body signals and emotion?
– The world
Safe, predictable?
c How might early experiences be expected to have affected
stress regulation programming (exaggerated, underactive,
normal)
c How would early experiences be expected to affect behaviour?
(emotional regulation, concentration, use of attention, ability to
relinquish control)
c How would early experiences be expected to affect
development? (social skills, communication, self-help, physical
activity)
How does the current picture fit with what would be expected?
c Development
c Use of relationships
c Regulation of emotion, temper, stress
c Concentration
c Behaviour
– How does the observed behaviour pattern relate to
parenting style?
– How does the behaviour suggest that he sees
relationships?
Valuable (eg, making eye contact, using relationships)?
Safe (eg, seeking and sustaining attention)?
Reliable (eg, sharing attention, able to relinquish control)?
If there is mismatch between expected and observed develop-
ment and behaviour:
c Does he have other sustaining relationships?
c What, despite risk factors, enables the parents to parent
adequately?
What would be the probable impact of moves into and within
care, considering:
c How they happened (eg, traumatic removal, lack of
preparation)
c How he responded (eg, indifference, withdrawal, immediate
seeking of affection)
What factors may be contributing to emotional abuse?
c Parents: temper, stress, ADHD, learning difficulties, mental
health problems
c Child: ADHD, learning difficulties, autistic spectrum disorder
c Lack of support; inappropriate accommodation
Which contributory factors can be changed? How? How soon?
c How can the parents be helped to change? (Do they
acknowledge the problem? Can they accept help? Has help
66
been offered regarding parental ADHD, temper, stress
regulation, etc?)
c Can the parents prioritise the children? What might help them
to do so?
How likely is adequate change? (Likely? Possible? Unlikely?)
What other factors are likely to affect the consequences of risk
factors?
c To whom/what are the child’s key relationships?
c Have the parents been given advice concerning behaviour
management? Has ADHD been treated?
c What is the child’s probable understanding of his
circumstances?
What factors may contribute to resilience?
c High intelligence, any supportive relationship, means of
success
c How can resilience be used and developed?
What professional work is needed?
What work would be needed with birth parents, child, carers,
teachers:
c To enable the child to remain at home?
c To establish and sustain a new home?
c To develop adequate attachment?
c To remedy the consequences of previous poor attachment?
c To support education?
c To pre-empt future problems? (eg, stress regulation, ADHD-
type problems, understanding of relationships)
What are the consequences of lack of change, now and for the
future?
c Is the child likely to be able to use relationships adequately for
learning, support, friendship?
c Is he likely to make effective peer relationships? (eg, ability to
share attention, pretend, read social cues, manage temper,
relinquish control?)
What are the risks of delay in achieving change?
c Implications for learning, social integration, self-esteem; effect
on brain growth and its reversibility
c Likelihood of achieving an alternative home and effective
attachment
*From what is known, is likely or can be assumed.
CONCLUSION
Emotional abuse has lagged behind physical and sexual abuse in
paediatric training, practice and research. Recognition of the
damage it causes to the developing brain, with potentially
lifelong and intergenerational implications, should prompt a
sense of urgency in improving services, training and supervision.
Assessment of the emotional context is a necessary safeguard
for all child protection decisions and their implementation,
reducing the risk of leaving children in unsafe circumstances, of
delay in establishing alternative parenting, and of achieving
physical safety at the cost of emotional harm.
Paediatricians need to be as confident in assessing inadequate
emotional care as physical and sexual abuse. Service models must
suit its chronic, multifactorial nature, and ensure that paediatri-
cians are fully equipped to work to the edge of CAMHS services and
cooperatively alongside them. Understanding emotional abuse in
terms of the causes and the physical, developmental, emotional and
behavioural consequences of the distorted parent–child attachment
it represents can offer a practical, communicable means of working
with families, in seeking to prevent, identify and remedy it.
Arch Dis Child 2010;95:59–67. doi:10.1136/adc.2008.143156
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Acknowledgements: I am grateful to Caroline Mercier, Lynn Brown and Emma
Bradley for their helpful comments.
Competing interests: None.
Provenance and peer review: Commissioned; externally peer reviewed.
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Understanding emotional abuse

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Arch Dis Child 2010 95: 59-67

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