Healthcare Training Institute - Quality Education since 1979
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Emotional and psychological damage
Definitions that incorporate outcome factors such as emotional or psychological damage to the child are problematic and potentially tautological (McGee & Wolfe, 1991). An operational definition useful in empirical research should distinguish the predictor (i.e. parental behavior) from the criterion (i.e., psychological harm). Therefore there is a need to develop an operational definition independent of outcome so that the effects of the abuse can be established empirically. A useful distinction used in deriving definitions of childhood maltreatment that avoids such circularity is the "consequences" model versus the "standard of care" model (Garbarino, 1991). Definitions of abuse that incorporate outcomes for the child are examples of consequences models, as in the case of definitions of physical abuse that depend on evidence of physical injury. These are perhaps more relevant to child protection practice than research criteria. For example, in the UK, mandated intervention requires evidence of "significant harm," which includes both parental action and observable harm to the child (Glaser & Prior, 1997). In contrast, a standard of care model defines abuse in terms of what society deems to be unacceptable treatment of a child, whether evidence of damage to the child is present or not: "The definition, while informed by theory and research, must be formulated according to societal standards of appropriate parental behavior" (Barnett et al., 1991, p. 24). In this vein, McGee and Wolfe (1991) argue for a probabilistic model of psychological abuse, based on the potential for harm to a child rather than the observable harm. In the new measure of psychological abuse outlined in this report, actual or observable harm is irrelevant to the judgment of whether an act is one of abuse or not: it is the likelihood of damage that is assessed.
The first aim of this article is to develop an operational definition of psychological abuse. Given some of the difficulties just described, this might be considered "working" rather than "definitive" with results contributing to a later "firming up" of the definition and replications in new series. In sympathy with Haugaard's position (1991), we agree that it may be worth delaying the formulation of a final definition of psychological abuse until results from empirical studies are sufficient to clarify which parent-child interactions result in psychological harm. The definition we offered here is derived in part from existing literature on the topic, but also from scrutiny of psychological abuse examples gleaned inductively from hundreds of retrospective accounts of childhood gathered in the course of a program of research stretching back over many years (Bifulco & Moran, 1998). The proposed working definition is as follows:
Psychological abuse is concerned with cruelty demonstrated by verbal and nonverbal acts, repeated or singular, intended or not, from a close other in a position of power or responsibility over the child. These have potential for damaging the social, cognitive, emotional, or physical development of the child and are demonstrated by behaviors which are humiliating/degrading, terrorizing, extremely rejecting, depriving of basic needs or valued objects, inflicting marked distress/discomfort, corrupting/exploiting, cognitively disorientating, or emotionally blackmailing. The perpetrator behaviors involved in psychological abuse exclude physical or sexual attack, although psychological abuse may accompany these. They also exclude those forms of maltreatment identified as neglect, antipathy, role reversal, high discipline, or lax supervision, as these fall into alternative categories.
In terms of differentiation from existing abuse categories, the most controversial may be that of antipathy--a negative ongoing relationship with the parent where the latter is critical, cold, hostile, or rejecting on a day-to-day basis. Although antipathy is identified as emotional abuse in other categorizations, it is contrasted by its established definition within the lack of care domain (Andrews & Brown 1988; Bifulco & Moran, 1998; Parker, Tupling, & Brown, 1979), its overlap with more normalized family behavior, and its rare inclusion as behavior relevant for mandated intervention and child protection, which typically does not reach the identifiable abusive peaks and categories of psychological abuse outlined in the literature and in the present report. Therefore verbally aggressive parental behavior and other negative interaction with parents is differentiated from psychological abuse in this report.
The second aim of this article is to introduce a new scale designed to study psychological abuse in conjunction with other forms of neglect, abuse, and poor parenting. There are relatively few published measures of psychological abuse, and nearly all are self-report questionnaires. An exception is the Psychological Maltreatment Rating Scale (PMRS; Brassard, Hart, & Hardy, 1993), which is designed for rating mother-child interaction during a 15-minute videotaped teaching task. Other alternatives to self-report include scrutiny of case files (McGee & Wolfe, 1991) and the multiclassification of Barnett and colleagues (1991). A self-report measure that soleley assesses psychological abuse is the Psychological Maltreatment Scales (PMS; Briere & Runtz, 1988; Varia & Abidin, 1999). This measures uses a Likert scale to endorse seven statements of parental behavior toward a child under age 16 for an average year in childhood, including "yelled at you," "criticized you," "made you feel guilty," and "ridiculed or humiliated you." Most other measures are extensions to existing childhood measures such as the Child Abuse and Trauma Scale (CATS; Sanders & Becker-Lausen, 1995). This is a 38-item questionnaire for use with adults that assesses various aspects of adversity in childhood. Seven items have been incorporated, aimed at tapping psychological abuse in childhood (Kent & Waller, 1998). Another measure modified to incorporate childhood psychological abuse is the Child Abuse Questionnaire (CAQ) as used by Gross and Keller (1992) to examine psychological abuse in relation to depression, self-esteem, and attribution styles. An Australian measure, the Comprehensive Child Maltreatment Scales (CCMS; Higgins & McCabe, 2001), is a self-report scale that covers five types of childhood maltreatment, including psychological abuse. However, in addition to these extensions of self-report measures adding specific items to reflect psychological abuse, other investigators have used existing measures of neglect or physical abuse to answer questions about psychological abuse. Thus a widely used measure of care and control in childhood (Parental Bonding Instrument) has been relabeled in terms of emotional abuse for some analyses with no increase of items (Mullen et al., 1996). Similarly, the Conflict Tactics Scale (CTS; Straus, 1979) has been used in terms of subscales relating to parent-to-child verbal aggression in relation to psychosocial problems in the children, but again without broader psychologically abusive categories (Vissing, Straus, Gelles, & Harrop, 1991).
Examination of the items that have been added to existing measures of childhood experience suggests that they may often be assessing other related but previously categorized forms of maltreatment, such as parental neglect or antipathy, which may lead to an overinclusiveness in prevalence figures and to unreliable assessments of the relationship of psychological abuse to other forms of abuse and neglect. It may also confound results concerning the differential effects of psychological and other abuse in relation to outcomes such as depression in adulthood or suicidal behavior, as discussed in a companion article (Bifulco et al., 2002).
The proposed new measure differs from existing measures of psychological abuse in its administration. It is a semistructured interview designed for use with adults, and involves investigator-based judgements of childhood history gathered retrospectively. Narrative, chronological accounts of childhood experience are collected on the basis of extensive probing questioning, and the classification and severity assessment are determined by trained researchers according to predetermined criteria. This has many similarities to a diagnostic clinical interview. The new assessment is an extension of an existing measure of childhood, the CECA (Bifulco, Brown, & Harris, 1994), a semistructured interviewing instrument originally developed in the 1980s to assess experiences such as physical and sexual abuse, neglect, antipathy, role reversal, supervision, and discipline. As an addition to an existing measure, the psychological abuse component has the benefit of being assessed in relation to, and distinct from, other forms of abuse using the same scaling procedures. As with the other forms of maltreatment that the CECA covers, the new measure treats psychological abuse as a continuous variable, as recommended by authors such as McGee and Wolfe (1991). However, it also identifies categories of perpetrator behavior to aid in identification of relevant items.
The use of an interview rather than a questionnaire for the assessment of psychological abuse has the advantage of flexibility in identifying psychologically abusive behaviors which are notorious not only for being varied but also at times idiosyncratic. The format of a semistructured interview with open questions thus allows for exploration of both typical and atypical parental behaviors, which may not lend themselves easily to itemization on a questionnaire. The use of investigator or "expert" judgment rather than respondent judgment in assessing inclusion and severity of psychological abuse has advantages of avoiding underassessment due to respondent unawareness of its definition or normalization of "odd" parental behavior. Investigator-based measurement allows the investigator to decide on the inclusion of an item as psychological abuse, using anchoring examples as a guide. Thus the same thresholds for inclusion and severity of examples can then be applied consistently across samples.
The CECA interview involves detailed questioning regarding relationship with, and behavior of, biological parents and surrogate parents who have responsibility for the participant before age 17, for any period lasting 12 months or more. To facilitate recall, experiences are asked about in chronological order. Most of the relevant experiences are rated on a 4-point scale of severity ranging from "1-marked" for the most severe to "4-little/none" for the least negative experience. Ratings rely on "objective" details of behavior impinging on the child based on collecting details of specific incidents, their frequency, age at which they occurred, who was involved, and so on, regardless of the individual's responses to those experiences or current feelings about them. A manual containing hundreds of benchmark examples is available to interviewers to assist rating and regular researcher trainings held by the UK research team (Bifulco, Brown, Neubauer, Moran, & Harris, 1994). Reliability of the instrument is high, with interrater agreement reaching above 0.78 (Kw, weighted Kappa; Cohen 1968) on all scales (Bifulco, Brown, & Harris, 1994). Validity in terms of interrespondent agreement (e.g., sisters reporting on each others' childhood experience) is also good, reaching an average of 0.60 Kw across numerous scales (Bifulco, Brown, Lillie, & Jarvis, 1997). The following types of childhood experience are included in the CECA and are here differentiated from psychological abuse.
Parental neglect. Neglect reflects parental lack of interest in the child's material care, health, friendships, schoolwork, or career plans, or being emotionally unavailable when the child is distressed. Severity of neglect is determined on the range of such indicators being present and rated on a 4-point scale from "marked" through "little/none." Each parent is rated independently and an overall assessment is made.
Parental antipathy. The amount of dislike, rejection, irritation, and coldness shown by parents and surrogate parents is rated as antipathy. Information regarding critical and rejecting comments and verbal aggression directed at the subject is taken into account, as are behavioral instances of rejection or "scapegoating" the child. Severity is again reflected on a 4-point scale.
Role reversal. The extent to which parents require the child to takeover a parental or adult role is identified as role reversal. This includes taking on responsibility in the household for running the home (washing, cooking, ironing) and for looking after younger siblings. It also includes the parent using the child as confidant or support figure, bearer of family secrets, and source of comfort for the parent when distressed. Severity is determined by the number of areas in which such role reversal occurs and its frequency. It is rated on a 4-point scale.
Parental discipline. Discipline imposed by parents or surrogate parents is rated using information regarding the presence and enforcement of rules about manners and behavior, socializing, clothing, smoking, and drinking. The scaling differs from those just described, in that moderate is regarded as the most acceptable form of discipline and is distinguished from high, low, or variable levels. Thus the scale points used are "1-marked," "2-moderate," "3-1ax," "4-variable."
Parental supervision. The extent to which parents monitor the child's behavior and maintain safety is defined as supervision. This includes the child being left home alone, being allowed out unsupervised or late at night, or in dangerous surroundings. The scaling is the same as for the discipline scale.
Physical abuse. Physical abuse from any household member, including mothers, fathers, surrogate parents, older siblings, or other adults living in the home, is assessed. Each instance of abuse by a different perpetrator is rated independently. A number of features of assaults are asked about, including frequency of attacks, use of implements or weapons, number of hits, age at time of attack, and injuries sustained. This information was used to derive a rating of severity of physical abuse on a 4-point scale.
Sexual abuse. Unlike other forms of maltreatment, incidents of sexual abuse are included regardless of whether the perpetrator was a household member or not. Each abuse by a different perpetrator is rated separately. As with physical abuse, a rating of severity on a 4-point scale is derived based on a number of features of the assault, such as frequency and duration, age of victim at time of abuse, relationship to perpetrator, and intrusiveness of the sexual contact.
Feeling shame. In addition to objective characteristics of maltreatment, a rating of subjective feeling of shame in childhood was included. This involves feelings of shame, embarrassment, or stigma for any aspect of childhood, including appearance (e.g., shabbiness, unfashionable clothes, uncleanness), family characteristics (e.g., parents drinking, fighting, causing scenes at school), and social deprivation (e.g., poverty, deprived home conditions). This is rated on a 4-point scale of severity.
The origins of the CECA interview lie in a protocol first designed in UK in the early 1980s when the effects of early maternal loss and lack of care on adult depression were investigated (Harris, Brown, & Bifulco, 1986). The basic measure at that stage included care and control scales such as neglect, role reversal, supervision, and discipline from birth or surrogate parents. The measure was subsequently used on a large representative series of inner-London mothers where scales for abuse (physical and sexual) and antipathy (hostile parenting) were added. The interviews involved collecting extensive narratives about individual's childhood experiences before age 17. The biographical information was transcribed and then ratings were made of the level of severity of each different childhood experience. During the course of using the measure over 10 years on subsequent series of women, it became apparent that some experiences of abuse were not sufficiently covered in the existing scales, particularly psychological abusive experience involving coercive control and sadistic behavior. For example, while it was common to hear about parents who were critical, disrespectful, scapegoating, cold, or rejecting, the CECA investigators also learned about a child who had confessed to a fear of the dark being locked in a room with no light bulb, about another whose pet was destroyed in front of her for some minor misdemeanor, and about a child whose sole photograph of her dead mother was torn to shreds by a cold and controlling stepmother. Such incidents seemed to raise the level of cruelty and control to a new level.
To assess incidents as psychologically abusive, the trained CECA raters considered for inclusion any communications to the child that were cruel, overcontrolling, or manipulative, including both verbal and nonverbal behavior from the perpetrator. It was decided to set a high threshold for inclusion of abusive behaviors, relevant to long-term effects and to psychopathological outcomes, and to differentiate them from those already covered in related scales. Evidence of the perpetrator's apparent premeditated strategy in "designing" a punishment or means of control specifically tailored to the child's fears and vulnerabilities would make inclusion as psychological abuse easier to determine. One woman we interviewed claimed that her stepfather would spend the day thinking of new ways to torment her in the evenings when he returned home, as evidenced by the many new varieties of abuse he would impose. Malevolent intent often appeared evident in the detailed descriptions of childhood experiences, as, for example, in the case of a father who told his young daughter that he would derive great pleasure from withholding her life-saving medication and watching her die slowly. However, perpetrator strategy was at times unclear, even though the nature of the abusive behavior toward the child in terms of categories identified qualified: Explicit malevolent perpetrator strategy was regarded as a sufficient but not a necessary feature for defining such abuse.
Based on the examples to emerge from the participants' accounts of childhood recounted in the course of the CECA interview, an overall assessment of severity was determined and a taxonomy of nine psychologically abusive behaviors was generated.
- Moran, P., Bifulco, A., Ball, C., Jacobs, C., & Benaim, K. (2002). Exploring Psychological Abuse in Childhood: Developing a New Interview Scale. Bulletin of the Menninger Clinic, 66(3).
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