Consider the possibility of sexual abuse when the child: • Has difficulty walking or sitting • Suddenly refuses to change clothes for gym or to participate in physical activities • Reports nightmares or bed-wetting • Experiences a sudden change in appetite • Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior • Becomes pregnant or contracts a venereal disease, particularly if under age 14 • Runs away • Reports sexual abuse by a parent or another adult caregiver • Attaches very quickly to stranger Consider the possibility of sexual abuse when the parent or other adult caregiver: • Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex • Is secretive and isolated • Is jealous or controlling with family members Clinical Strategies for Approaching Medical Examination of Sexual Abuse Victims Sexual abuse is fundamentally an abuse of power and authority over a child in order to coerce them into inappropriate sexual activities. As a result, children often have difficulty forming trusting relationships, which can include those with health care providers. It is important, therefore, that the medical evaluation of children and teens who have been sexually abused not become an additional experience of powerful adults imposing their authority on the child’s body or removing the child’s control over events in his or her life. 19 One way to minimize this potential is to provide them with choices at every step in the medical history and examination, and by conveying a calm, gentle, and unhurried approach, explaining to the patient what to expect during the evaluation. 19 If a patient is not cooperative, the provider should not force a complete examination but, rather, should attempt to address the underlying concerns of the child. The approach of the examining clinician and other members of the health care team should be to complete the necessary medical evaluation in the least threatening and most therapeutic manner possible. 19 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2 ON THE NEXT PAGE.
Abusers constantly reject, ignore, belittle, dominate, and criticize the victims. This form of abuse may occur with or without physical abuse, but there is often an overlap. 22 Examples of emotional child abuse are verbal abuse; excessive demands on a child’s performance; penalizing a child for positive, normal behavior (smiling, mobility, exploration, vocalization, manipulation of objects); discouraging caregiver and infant attachment; penalizing a child for demonstrating signs of positive self-esteem; and penalizing a child for using interpersonal skills needed for adequate performance in school and peer groups. 22 In addition, frequently exposing children to family violence and unwillingness or inability to provide affection or stimulation for the child in the course of daily care may also result in emotional abuse. Although emotional abuse can be as damaging as physical abuse, it can be harder to identify. 22 Few well-validated measures of childhood emotional abuse exist. Clinicians can use a revised version of the Child Abuse and Trauma Scale (CATS) which targets measures for emotional abuse. 23 Caregivers can also closely observe children’s behaviors and personalities. Children suffering from emotional abuse are often extremely loyal to the parent, afraid of being punished if they report abuse, or think that this type of abuse is a normal way of life. 5 Behavioral indicators of an emotionally abused child include inappropriate behavior that is immature or more mature for the child’s age, dramatic behavioral changes (disruption of activities, clinging or compulsively seeking affection and attention), aggressiveness, uncooperativeness, bed-wetting or loss of bowel control (after a child has been trained), and destructive or antisocial behavior (being constantly withdrawn and sad). Furthermore, poor relationships with peers, lack of self-confidence, unusual fears for the child’s age (fear of going home, being left alone, specific objects), or inability to react with emotion or develop an emotional bond with others are also indicators. Realistically, any of the above behaviors may also be seen in normal children, but a change in pattern of these behaviors is a strong indicator of emotional abuse. 5 Consider the possibility of emotional maltreatment when the child: 5 • Shows extremes in behavior, such as overly compliant or demanding behavior, extreme passivity, or aggression • Is either inappropriately adult (parenting other children, for example) or inappropriately infantile (frequently rocking or head-banging, for example) • Is delayed in physical or emotional development • Has attempted suicide • Reports a lack of attachment to the parent
Consider the possibility of emotional maltreatment when the parent or other adult caregiver: 5 • Constantly blames, belittles, or berates the child • Is unconcerned about the child and refuses to consider offers of help for the child’s problems • Overly rejects the child Physical Indicators Of Emotional Abuse: • Frequent psychosomatic complaints (nausea, stomachache, headache, etc.) • Bed-wetting • Self-harm • Speech disorders What is Emotional Abuse Under Pennsylvania CPSL Child Abuse Laws? Under Pennsylvania’s CPSL definition, causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act. Serious Mental Injury is defined as a psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment, that: • Renders a child chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic or in reasonable fear that the child’s life or safety is threatened; or • Seriously interferes with a child’s ability to accomplish age-appropriate developmental and social tasks. What are the Effects of Emotional Abuse? Emotional abuse can be “more strongly predictive of subsequent impairments in the children’s development than the severity of physical abuse,” according to psychologist Danya Glaser. 24 An infant who is severely deprived of basic emotional nurturance, even though physically well cared for, can fail to thrive and can eventually die. Babies with less severe emotional deprivation can grow into anxious and insecure children who are slow to develop and who have low self-esteem. 24 Long-term effects of emotional abuse include: insecurity, poor self-esteem, destructive behavior, angry acts (such as fire setting and animal cruelty), withdrawal, poor development of basic skills, alcohol or drug abuse, suicide, difficulty forming relationships and unstable job histories. Emotionally abused children often grow up thinking that they are deficient in some way. A continuing tragedy of emotional abuse is that, when these children become parents, they may continue the cycle with their own children. 24
Emotional Abuse
Emotional child abuse is maltreatment resulting in impaired psychological growth and development. 21 It involves words, actions, and indifference.
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