essay about mental abuse

• Research article
• Open access
• Published: 17 March 2021

The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment

• Camila Monteiro Fabricio Gama 1 ,
• Liana Catarina Lima Portugal 1 ,
• Raquel Menezes Gonçalves 1 ,
• Sérgio de Souza Junior 1 ,
• Liliane Maria Pereira Vilete 2 ,
• Mauro Vitor Mendlowicz 2 , 3 ,
• Ivan Figueira 2 ,
• Eliane Volchan 4 ,
• Isabel Antunes David 1 ,
• Leticia de Oliveira 1 &
• Mirtes Garcia Pereira 1  

BMC Psychiatry volume  21 , Article number:  156 ( 2021 ) Cite this article

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Childhood maltreatment (CM) is unfortunately widespread globally and has been linked with an increased risk of a variety of psychiatric disorders in adults, including posttraumatic stress disorder (PTSD). These associations are well established in the literature for some maltreatment forms, such as sexual and physical abuse. However, the effects of emotional maltreatment are much less explored, even though this type figures among the most common forms of childhood maltreatment. Thus, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on revictimization and PTSD symptom severity using a nonclinical college student sample.

Five hundred and two graduate and undergraduate students participated in the study by completing questionnaires assessing lifetime traumatic experiences in general, maltreatment during childhood and PTSD symptoms. Bivariate and multivariate negative binomial regressions were applied to examine the associations among childhood maltreatment, revictimization, and PTSD symptom severity.

Our results showed that using bivariate models, all types of CM were significantly associated with revictimization and PTSD symptom severity. Multivariate models showed that emotional abuse was the type of maltreatment associated with the highest incidence rates of revictimization and PTSD symptom severity.

Conclusions

These data provide additional evidence of the harmful effects of childhood maltreatment and its long-term consequences for individuals’ mental health. Notably, the findings highlight the importance of studying the impacts of emotional abuse, which seems to be a highly prevalent, understudied, and chronic form of maltreatment that is as toxic as other maltreatment forms.

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Stressful experiences in childhood, especially those involving childhood maltreatment, began to be studied in the late 1970s and early 1980s [ 1 ]. Childhood maltreatment consists of abusive or neglectful acts perpetrated by parents or caregivers having the potential to “harm or threaten a child” [ 2 ]. Five subtypes of childhood maltreatment are commonly recognized: physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect. In terms of prevalence, a worldwide meta-analysis estimated rates of 12.7% for sexual abuse, 16.3% for physical neglect, 18.4% for emotional neglect, 22.6% for physical abuse, and 36.3% for emotional abuse [ 3 ]. These data indicate that childhood maltreatment is globally widespread, affecting the lives of millions of children. Exposure to childhood maltreatment has been associated with a variety of psychiatric disorders in adults, such as depression and anxiety disorders [ 4 ], bipolar disorder [ 5 , 6 ], eating disorders [ 7 ], personality disorders [ 8 ] and trauma-related disorders, such as posttraumatic stress disorder (PTSD) [ 9 ].

Associations between childhood maltreatment and posttraumatic stress disorder

As a severe mental disorder that involves exposure to real or threatening death events, serious injury, or sexual violence, PTSD profoundly impairs cognitive and behavioural functioning. The main symptoms are reexperiencing, avoidance, negative mood and cognitions, and hyperarousal [ 10 ]. Trauma exposure is highly prevalent: epidemiological surveys suggest that approximately 70% of their samples reported lifetime exposure to at least one traumatic event [ 11 , 12 ]. However, the prevalence of PTSD among the general population is less than 10% [ 13 , 14 ]. Studies that explore the factors that might be related to an increased vulnerability to PTSD are crucial [ 15 ], and childhood maltreatment seems to be an important risk factor for PTSD development [ 16 , 17 , 18 , 19 , 20 , 21 ] and severity [ 9 , 22 , 23 , 24 , 25 , 26 ].

The link between childhood physical and sexual abuse and PTSD is well established in the literature [ 24 , 27 , 28 , 29 , 30 , 31 ], especially when investigated individually. However, studies exploring the impact of all childhood maltreatment types conjointly on PTSD symptomatology are sparse. Furthermore, childhood emotional maltreatment is much less explored as a potential vulnerability factor, not only to PTSD but also to psychiatric disorders in general (see [ 32 ] for a review). As mentioned before, it is important to highlight that emotional maltreatment not only figures among the most common forms of childhood maltreatment [ 3 , 9 , 23 ] but is also significantly associated with depressive symptoms [ 33 , 34 , 35 , 36 ], substance use disorders [ 37 ] and suicide risk [ 38 , 39 ]. Nevertheless, emotional maltreatment rarely prompts specific actions for child protection. Thus, it is urgent to expand knowledge about the consequences of childhood emotional maltreatment, individually or conjointly with all other maltreatment types, on mental health. Particularly its role as a factor for PTSD vulnerability, considering the high prevalence of lifetime trauma exposure in the population [ 12 ] and the abundant evidence that other forms of maltreatment are a risk factor for this disorder.

Associations between childhood maltreatment and Revictimization

Early caregiver-child relationships establish a critical foundation for lifelong learning and can have permanent sequelae. The lack of security in a maltreatment environment increases the risk for further trauma exposure [ 40 , 41 ]. In fact, many studies have highlighted that childhood maltreatment is predictive of revictimization, which refers to the exposure of individuals who were victimized during childhood to subsequent traumatic events [ 42 ]. For instance, in a sample of substantiated childhood maltreatment victims, sexual and physical abuse experiences predicted revictimization [ 42 , 43 ]. Similar results were found for male psychiatric inpatients [ 44 ] and in a community sample [ 45 ] for physical and sexual abuse. Emotional and sexual abuse during childhood predicted adult rape in college women [ 46 ]. Recently, a study suggested that all types of abuse and neglect, except for emotional neglect that was not investigated, were significantly associated with higher levels of revictimization in a sample of adolescent girls involved with the child welfare system [ 47 ]. Important differences in the characteristics of the samples used to probe the association between childhood maltreatment and revictimization, such as gender, age at investigation, and education level, make it more difficult to generalize the results to other populations. Dias et al. [ 23 ] was the only study that investigated the impact of all maltreatment types conjointly and found evidence that emotional abuse is significantly associated with revictimization and PTSD symptoms in a convenience sample from a European high-income country. Geographic and economic factors seem to play an important role in worldwide estimates of childhood maltreatment [ 48 ]. Thus, it is necessary to expand knowledge about how different forms of childhood maltreatment are related to revictimization and PTSD severity in other cultural contexts. Here, we explored the impact of all childhood maltreatment types on PTSD severity and revictimization in a nonclinical and relatively healthy sample from a South American middle-income country and exposed to a wide variety of forms of childhood maltreatment. According to Viola et al. [ 48 ], among all continents, South America has the highest rates of childhood maltreatment severity. Studies carried out with non-clinical samples present many advantages given that they reduce the biases of more severe cases, higher prevalence of psychiatric disorders, medication, and higher levels of functional impairment. For the purpose of this article, we consider a broader definition of revictimization, referring to individuals who were victimized during childhood and exposed to any subsequent type of traumatic event occurring during adolescence or adult life, not only a specific adverse experience.

In summary, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on the severity of PTSD symptoms using a nonclinical Brazilian college student sample. Additionally, we explored the association of childhood maltreatment and revictimization. We hypothesize that those who experienced childhood maltreatment are more prone to experience other traumatic events and their harmful consequences and present higher levels of PTSD symptoms when facing another trauma later in life. We also hypothesize that all childhood maltreatment types, including emotional maltreatment, will impact mental health, predicting revictimization and PTSD symptoms for another trauma. Exploring the impact of emotional maltreatment is particularly relevant considering its high prevalence and the fact that it is the least visible form of maltreatment experienced by a child.

Participants

A sample of five hundred and two volunteers (mean age 21.2; SD = 4.01) participated in the survey. All participants were graduate or undergraduate students at Federal Fluminense University and at Federal University of Rio de Janeiro, Rio de Janeiro – Brazil. They were recruited through a brief announcement in their classrooms, and all interested students stayed in class and received numbered questionnaires. Then, they were instructed to read the consent terms, which guaranteed anonymity and freedom to end participation. After completing all the questionnaires, participants were instructed to put them into a box, with no individual identification.

The inclusion criterion was being 18 years old or older, and the only exclusion criterion was failing to fill out all the questionnaires. Fifty-nine participants who did not fully complete the questionnaire battery were excluded, leaving an “original sample” of 443 participants. The characteristics of this sample are described in Table  1 . This was the sample used for revictimization analysis.

This study was approved by the Ethics Review Board of the Federal University of Rio de Janeiro, process number CAAE 56431116.5.0000.5263, and all methods were carried out in accordance with relevant guidelines and national regulations. Each participant gave written informed consent prior to participation.

Trauma History Questionnaire (THQ)

Translated and adapted to Portuguese [ 49 ] from the original [ 50 ], the Trauma History Questionnaire (THQ) is a self-report questionnaire that examines exposure to different types of traumatic events, from urban violence crimes to sexual assault and natural disasters. The scale is composed of 23 items divided into three clusters (crime-related events, trauma and disaster in general, and sexual and physical experiences) that investigate potentially traumatic events through yes/no questions and further investigate frequency and approximate age at the time of exposure. The questionnaire also contains an open-ended question that allows participants to specify other extraordinarily stressful situations or events that they have experienced.

In this study, one subitem was added to all the questionnaire items to determine the intensity of the worst event (0 = not stressful at all; 5 = extremely stressful). For all the analyses involving the THQ, we included only the traumatic events that occurred after 12 years of age (i.e., after childhood according to local laws and the NIH definitions cited above) and with an intensity score ≥ 3 (mild to extremely stressful). The test-retest reliability results in a psychometric evaluation study of trauma and PTSD indicated moderate to high coefficients [ 51 ].

Posttraumatic stress disorder checklist for DSM-5 (PCL-5)

Posttraumatic stress symptoms were assessed using the PCL-5, which was developed by the National Center for PTSD in accordance with the DSM-5 [ 10 , 52 ]. Translated and adapted to Portuguese [ 53 ], the PCL-5 is a 20-item self-report questionnaire that measures the four cluster symptoms of PTSD: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Each item in the PCL-5 questionnaire is rated on a 5-point Likert scale (from 0= “Not at all” to 4 = “Extremely”). Symptom severity can be calculated by summing the items in each of the four clusters or summing all 20 items. In this case, the severity score ranges from zero to 80 points. For our study, we opted to consider the total score to analyse symptom severity [ 52 ]. Participants were instructed to consider one worst event previously reported in the THQ, as they indicated how each item of the PCL-5 bothered them in the last month.

The psychometric properties of the PCL-5 have been assessed in different cultural contexts and samples, presenting satisfactory to high internal consistency, very good to high test-retest reliability and strong convergent and discriminant validity [ 54 , 55 , 56 , 57 ].

Childhood Trauma Questionnaire - Short Form (CTQ-SF)

Childhood maltreatment (CM) was quantitatively assessed with the 28-item Childhood Trauma Questionnaire (CTQ) [ 58 , 59 ] that was translated and adapted to Portuguese [ 60 ]. It measures childhood exposure to physical, emotional and sexual abuse and physical and emotional neglect. The instrument has five items exploring each of these five subtypes of CM, yielding 25 items for analysis and three more items to investigate minimization and denial. Participants respond to each item on a scale from 1 (“Never”) to 5 (“Always”), which indicates the frequency with which they had these experiences. Responses are converted into a maltreatment severity subtype: “None to Minimal”, “Low to Moderate”, “Moderate to Severe” or “Severe to Extreme” [ 58 ].

We used the Bernstein and Fink [ 58 ] cut-off points for “Low to Moderate” severity to classify the presence of CM (physical abuse≥8; sexual abuse ≥6; emotional abuse ≥9; physical neglect ≥8; emotional neglect ≥10) [ 58 ]. Thus, the presence of maltreatment was considered if a participant had a CTQ score equal to or higher than the low to moderate cut-off point for each maltreatment type.

• Revictimization

We considered revictimization as any subsequent type of traumatic event occurring during adolescence or adult life in victims of childhood maltreatment. Revictimization was measured by summing the quantity of types of traumatic events reported in the THQ with an intensity greater than or equal to 3 that occurred after the age of 12 years. Thus, events that met these criteria were summed and provided a final revictimization score for each volunteer.

It is important to mention that we assessed childhood maltreatment using the CTQ scale and that participants were instructed to answer the questionnaire based only on their childhood experiences (not including adolescence or adult life). Childhood is locally defined as the period before the age of 12 years (Brazil, Law 8069 - Child and Adolescence Statute) [ 61 , 62 ]. Additionally, questionnaires investigating childhood versus later periods of life were presented in different parts in the questionnaire booklet (see Fig.  1 and procedures subsection). The instruction to consider only events that occurred during childhood was reinforced in the beginning of the second part (Childhood maltreatment part). When measuring revictimization, we considered only traumas occurring above the age of 12 years in the THQ. This procedure was important to avoid an overlap between events considered childhood maltreatment and those included in revictimization scores.

Diagram describing the specific order of the scales in the questionnaire battery. The basic sociodemographic questionnaire was the first presented, succeeded by two parts. Part one was composed of the Trauma History Questionnaire (THQ) [ 49 , 50 ] and Posttraumatic Stress Disorder Checklist 5 (PCL-5) [ 52 , 53 ], and part two contained the Childhood Trauma Questionnaire (CTQ) [ 58 , 59 , 60 ]. At the end of the THQ, participants had to indicate the event that they considered the most traumatic in their life and answer the PCL-5 based on this event

To investigate the association between childhood maltreatment and revictimization, we used the original sample of 443 participants.

Childhood maltreatment and PTSD severity

Additional exclusion criteria were applied to investigate the effects of different forms of childhood maltreatment on the prediction of PTSD severity for a subsequent trauma (that occurred during adolescence or adulthood). Participants were excluded if they did not report an index traumatic event in one of the Trauma History Questionnaire clusters (see the Measures section below) or if the index traumatic event reported occurred before 12 years of age ( n  = 181). The rationale was to include only participants with an index trauma that met PTSD criterion A and that occurred after 12 years of age. This age cut-off was set to guarantee that the PTSD symptoms were related to the index for trauma that occurred after childhood, following local definitions of the age range for childhood [ 61 , 62 ].

Thus, the final sample for the analysis that examined the influence of childhood maltreatment on PTSD severity (“PTSD symptoms sample”) to a subsequent trauma comprised 262 volunteers. Note that this additional exclusion was applied exclusively to the PTSD symptom severity analysis.

The questionnaires were distributed in classrooms, and volunteers took approximately 1 h and 20 min to complete them. Each questionnaire was composed of a self-report basic sociodemographic survey collecting data on sex, age, religion, educational level, family income and previous and current diagnosed disorders, followed by three self-report scales. As shown in Fig. 1 , the scales were grouped into two parts. In the first part, participants were instructed to complete the questionnaires in accordance with their lifetime experiences. Volunteers completed the (I) THQ and (II) PCL-5. At the end of the THQ, participants were asked to indicate the event that they considered the most traumatic in their life. Participants answered the PCL-5 based on the traumatic event identified as the worst in the THQ. In the second part, participants were instructed to fill out the questionnaire according to their childhood experiences and completed the (III) Childhood Trauma Questionnaire - Short Form (CTQ-SF). They were asked to report responses on as many experiences as they could remember.

Statistical analysis

First, we calculated the average age of the participants and the proportions for sex, absence of any type of childhood maltreatment, presence of at least one type of childhood maltreatment and presence of each type of childhood maltreatment. We considered maltreatment as present if the participant had a CTQ score equal to or higher than the “low to moderate” cut-off point, according to Bernstein and Fink’s [ 58 ] cut-off points, for each maltreatment type. The average quantity of traumatic events according to the THQ self-reports was also computed.

Normality tests were carried out to investigate the distribution profile of the dependent variables. The Shapiro–Wilk test indicated that the number of types of traumatic events and the PCL-5 scores did not follow a normal distribution (quantity of traumatic events: W = 0.97; p  < 0.000; PCL-5: W = 0.92; p  < 0.000).

Negative binomial models were used to address the problem of overdispersed count data. The exponentiated regression coefficients provide the incidence ratio, which is interpreted as an increase or decrease in the dependent variable in terms of percentage for each unit change of the independent variable. We performed bivariate and multivariate negative binomial regressions to examine the influence of childhood maltreatment with respect to two outcomes: revictimization (measured as the quantity of types of traumatic events after childhood, i.e., 12 years old, with an intensity score ≥ 3 reported in the THQ) and PTSD severity for a subsequent trauma (PCL-5 score based on the worst traumatic event reported in one of the THQ clusters and that occurred after childhood, i.e., 12 years old). Age, gender and socioeconomic status were included as potential confounders in the multivariate models.

The independent variable of interest was the presence of childhood maltreatment reported in the CTQ, and the dependent variables were the number of types of traumatic events after 12 years old reported in the THQ and the PCL-5 score for the worst traumatic event. In the modelling processes for the two outcomes, we followed the same strategy. First, we performed bivariate analysis to examine the influence of each form of childhood maltreatment on the prediction of revictimization or PTSD severity later in life. The forms with p -values less than 0.20 and with confidence intervals that did not present a null value (i.e., CI did not include 1.0) were selected for inclusion in the multivariate model. Those with p-values less than 0.10 and with confidence intervals that did not present a null value were retained in the model.

All statistical analyses were performed using the Stata 12.0 package, and statistical significance was established at p  < 0.05.

Childhood maltreatment and revictimization

Original sample characteristics.

Information on participants’ age, sex, childhood maltreatment exposure, and quantity of types of traumatic events is provided in Table 1 . As shown, the original sample ( N  = 443) was mainly female (79%), and 74% reported the presence of at least one type of childhood maltreatment. Emotional abuse and emotional neglect presented the highest frequencies of exposure. The mean number of types of traumatic events that occurred after 12 years of age was 5.6 (SE = 0.1). Furthermore, Fig.  2 and Table  2 depicts the percentage of volunteers from the original sample who reported a single type of childhood maltreatment as well as the overlap between the maltreatment types. Overall, the co-occurrence of different types of maltreatment was common. For emotional abuse, we observed a slightly higher percentage of participants who reported a single type of maltreatment.

Venn diagram illustrating the percentage of single types and the overlap of types of childhood maltreatment in the original sample ( n  = 443). This diagram was partially constructed using an online tool available at ( http://bioinformatics.psb.ugent.be/cgi-bin/liste/Venn/calculate_venn.htpl )

For mean CTQ total scores and subscales scores see supplemental material Table S1 .

Frequency of traumatic events occurring during adolescence/adulthood in the original sample

The percentage of volunteers who reported an intensity of three or higher for at least one question in each of the THQ clusters is presented in Table  3 . Note that the same volunteer can report an intensity of three or higher for questions in more than one cluster.

The highest rate of exposure was found for the “Trauma and disaster in general” cluster, with almost 90% of the sample reporting at least one event in this cluster, followed by 65.2% of the sample reporting at least one event in the “Crime-related events” cluster and 32.3% in the “Sexual and physical experiences” cluster.

Only traumas reported as occurring at ≥12 years old were included. The percentage was calculated by dividing the number of volunteers who reported an intensity of 3 or higher for at least one item in each cluster by the number of volunteers in the original sample.

Predicting revictimization

We used the original sample to investigate the influence of different forms of childhood maltreatment on the prediction of revictimization (number of types of traumatic events after childhood reported in the THQ). We performed five bivariate negative binomial regressions to investigate whether each type of childhood maltreatment was associated with revictimization (number of types of traumatic events occurring after childhood). As shown in Table  4 (bivariate model), all types of childhood maltreatment caused an increase in the incidence of revictimization. Note that emotional abuse had the highest impact in this sample, causing a 52% increase in the incidence rate of revictimization for participants who were exposed to this maltreatment compared to those who were not exposed. In other words, participants exposed to emotional abuse during childhood had on average 52% more types of traumatic events (with an intensity rating of 3 or higher) that occurred after 12 years of age.

When all the maltreatment forms were included in the same model but without controlling for confounders, only sexual and emotional abuse significantly predicted the risk for revictimization (Table 4 – raw multivariate model). When gender, age and socioeconomic status were included as potential confounders, sexual ( p  < 0.041, 95% CI [1.01–1.30]) and emotional abuse ( p  < 0.000, 95% CI [1.23–1.59]) remained statistically significant (Table 4 - adjusted multivariate model). Emotional abuse showed the highest impact in this sample, causing a 40% increase in the average number of types of subsequent (after 12 years old) traumatic events.

Childhood maltreatment and PTSD symptom severity

Characteristics of the ptsd symptom sample.

The association between the occurrence of childhood maltreatment and PTSD symptom severity for a subsequent trauma was investigated in a subsample of participants, the PTSD symptom sample. For this analysis, only the participants who answered the PCL-5 based on a traumatic event reported in one of the THQ clusters that occurred after childhood (after 12 years old) were included (262 volunteers). Table  5 shows the characteristics of this sample in terms of age, sex, childhood maltreatment exposure, and mean PTSD score. Note that for this subsample, emotional abuse and emotional neglect also presented the highest frequencies of occurrence among the maltreatment types. The frequency of lifetime traumatic events considered the most traumatic and used to answer the PCL-5 is shown in Table  6 .

Predicting PTSD symptom severity

To investigate the association between each type of childhood maltreatment and PTSD symptom severity for a subsequent trauma, we ran five bivariate negative binomial regressions. As shown in Table  7 (bivariate model), all types of childhood maltreatment significantly predicted PTSD severity for a subsequent trauma. These results show that all forms of childhood maltreatment caused an increase in the average PCL-5 scores for another trauma occurring in adolescence/adulthood. Note that emotional abuse had the highest impact, being associated with an increase of 94% in the incidence rate of PTSD symptoms.

When all the childhood maltreatment forms were entered in the same model, emotional and sexual abuse remained significant predictors of PTSD severity for a subsequent trauma (that occurred after childhood), causing increments of 76 and 56%, respectively, in the incidence rate of PTSD symptoms (Table 7 – raw multivariate model). Physical neglect was associated with a more moderate effect. When control variables (age, gender and socioeconomic status) were included in the model, emotional abuse and sexual abuse remained significant, and emotional abuse still showed the highest impact in this sample, causing a 77% increase in the average posttraumatic stress symptoms (Table 7 – adjusted multivariate model).

For completeness, the results of the bivariate and multivariate models for revictimization and PTSD symptom prediction, but considering CTQ scores as continuous variables, are presented in the supplemental material (Tables S2 and S3 respectively).

This study aimed to investigate whether the presence of childhood maltreatment, especially emotional abuse maltreatment, could predict revictimization and PTSD severity symptoms for a subsequent traumatic event in adolescence and young adulthood. Our main results demonstrate that each maltreatment subtype, when individually analysed in bivariate regressions, was significantly associated with revictimization and with PTSD symptom severity. Moreover, when all the forms of maltreatment were investigated together in a multivariate regression model, emotional and sexual abuse remained significant predictors of revictimization and PTSD severity symptoms. Importantly, emotional abuse was associated with the largest increases in the number of types of subsequent traumatic events and the highest incident rates of PTSD symptoms, highlighting the long-term consequences of emotional maltreatment in a nonclinical sample of Brazilian college students.

In addition, 74% of our sample was exposed to at least one form of childhood maltreatment, and 50.3% of students reported being exposed to two or more types of childhood maltreatment. In fact, among all continents, South America, and specifically Brazil, has been reported to have the highest rates of estimated childhood maltreatment [ 48 ]. Additionally, in our sample, emotional maltreatment was the most common form of maltreatment, with prevalence rates of 59 and 42% for emotional abuse and emotional neglect, respectively. These results are in line with a meta-analysis of worldwide prevalence that showed that emotional abuse is a universal problem [ 3 ] and with a previous study by Grassi-Oliveira and Stein [ 9 ] that also showed that emotional abuse was the most prevalent childhood maltreatment type in a low-income Brazilian sample.

In line with the literature, our data revealed that childhood maltreatment is associated with revictimization. Individuals who were victimized during their childhood reported a higher number of types of traumatic events that occurred later during adolescence/adulthood. The association of childhood maltreatment and revictimization was present for each subtype of maltreatment when analysed individually, but only emotional and sexual abuse remained significant predictors for revictimization when all subtypes were included in the same regression model. Consistent with our findings, other studies also reported that particular types of childhood maltreatment are associated with subsequent revictimization [ 42 , 43 , 44 , 45 , 46 , 47 ]. However, the majority of the studies focused primarily on childhood physical and sexual abuse, including substantiated cases, and/or did not investigate all five types of childhood maltreatment reported here. One exception is the study by Dias et al. [ 23 ], which also explored all forms of maltreatment and found that individuals who experienced emotional or physical abuse had higher risks for revictimization than those who did not.

Remarkably, in our sample, emotional abuse was the maltreatment subtype that showed the highest impact, causing an increase of 40% in the average number of types of subsequent traumatic events reported by individuals. In fact, if CTQ scores for each maltreatment are considered a continuous independent variable in the multivariate model for revictimization prediction, instead of a categorical presence/absence variable, emotional abuse is the only significant predictor of revictimization after controlling for potential confounders (see supplemental material ). One possible explanation of why adverse situations related to childhood maltreatment lead to revictimization is that experiencing these events impairs the cognitive processing of emotional situations and compromises the acquisition of emotional-regulation capacities and interpersonal skills [ 63 ]. In fact, it was demonstrated that trauma exposure during childhood impairs neural processing of salient emotional stimuli and is associated with a failure to differentiate between nonthreat and threat-related stimuli [ 64 ]. Interestingly, Burns and colleagues [ 65 ] showed that emotional abuse was strongly related to emotional regulation difficulties, suggesting that emotion regulation skills might be more likely to be negatively impacted by emotional abuse than by other forms of maltreatment due to the former’s more chronic nature.

In addition to diminished risk detection skills, childhood maltreatment may lead to long-term dysregulation of the functioning of biological stress responses and hamper the implementation of typical defensive responses at imminent risk of victimization [ 66 ]. Arguments of dysfunction in the brain’s normal fear/defence circuit and impaired defensive engagement due to cumulative traumatization were also proposed by Lang and McTeague [ 67 ]. In their study, PTSD patients who had experienced recurrent traumatic exposure were among the least reactive to emotional stimuli and often reported a history of repeated childhood maltreatment exposure. It is important to mention that revictimization involves many other aspects in addition to the individual difficulties mentioned above. Interpersonal and sociocultural factors certainly contribute to an increased risk of experiencing other traumatic events. For example, cultural patterns and belief systems (ex. rigid gender roles) tend to create an environment that puts the victim in an unprotected situation, which in turn facilitates revictimization. In addition, family of origin functioning, characteristics of the initial maltreatment (ex. frequency, age of onset), community (ex. lack of family support), lack of resources, lack of security in a maltreatment environment and practices that normalize victim blaming were also identified as risk factors for further trauma exposure [ 40 , 41 , 68 , 69 ].

Additionally, experiencing adverse situations during childhood has been consistently identified as a potential risk factor for mental health problems, including PTSD. Indeed, our results showed that all maltreatment subtypes, when individually analysed in bivariate regression models, were significantly associated with an increase in PTSD symptoms. This finding is consistent with several previous studies reporting that childhood maltreatment is associated with increased PTSD symptoms [ 9 , 22 , 23 , 24 , 25 , 26 ]. Moreover, we showed that when all the forms of maltreatment were investigated together in a multivariate regression model, emotional and sexual abuse remained significant predictors of PTSD severity symptoms. There is abundant evidence confirming the negative consequences of sexual abuse during childhood [ 28 , 32 , 70 , 71 ], but much less attention is given to emotional abuse. Remarkably, emotional abuse was the form of maltreatment that caused the highest increase in the incidence rate of PTSD symptoms in our sample. In the same vein, it was also reported that emotional abuse had the largest effect on the prediction of PTSD severity [ 23 ] and psychological symptoms [ 72 ] in a Portuguese community sample.

One of the most important symptoms of PTSD is the re-experiencing of the traumatic event, which has been linked to an inability to downregulate negative emotions [ 73 ], an overreaction to and a failure to recover from unpleasant events [ 74 , 75 , 76 , 77 ]. Accordingly, increased brain reactivity to negative stimuli [ 78 ] and difficulty with emotion regulation [ 79 ] were related to posttraumatic stress symptom severity in trauma-exposed undergraduate students. One of the pathways by which childhood maltreatment might lead to increased risk for PTSD is that childhood maltreatment could cause impairments in the ability to understand and regulate emotions, and emotional abuse in particular emerged as the strongest predictor of emotion dysregulation [ 65 ]. As emphasized by this study, emotional abuse usually occurs more frequently than other forms of maltreatment, and this might overwhelm an individual’s capacity to effectively regulate emotions, as he or she is chronically exposed to situations involving negative affect [ 65 ]. Taken together, these findings support the urgent need to identify and treat individuals who suffer emotional maltreatment due to its high probability of being associated with poor mental health in adulthood.

Limitations

This study presents some limitations. As a cross-sectional study, the retrospective design may have led to recall bias. Individuals were asked to report PTSD symptoms based on their worst trauma, and only individuals who reported an index trauma that occurred after childhood were included in the analysis. However, considering the youthfulness of the participants, it is conceivable that the posttraumatic symptomatology reported is based on both childhood and adult traumas and not solely on adult trauma. It is also important to keep in mind that the co-occurrence of different types of childhood maltreatment might have influenced our results. Furthermore, the sample was predominantly female, which might have inflated our results, as recent studies have shown that the prevalence of emotional abuse is higher for women than for men [ 34 , 80 , 81 ]. All sources of data were obtained using the same method, self-report questionnaires, which could lead to common method variance. Strategies such as creating a psychological separation among measurements, protecting the anonymity of the respondents, and minimizing evaluation apprehension were carefully implemented in our procedures to minimize this problem [ 82 ]. The external validity of the findings is limited due to the homogeneity of the present sample, and the results might not be generalizable to clinical populations. Nevertheless, this study can provide important insights into how harmful untimely experiences can be in a traumatized young student sample. In addition, the homogeneity of this sample may suggest that similar results could be found for samples with similar characteristics.

In sum, this study provides additional knowledge on the harmful effects of childhood maltreatment and its long-term consequences for individuals’ mental health. Particularly, it highlights the importance of studying the consequences of emotional abuse, which seems to be a universal and chronic form of maltreatment that has a strong impact across the lifespan and that may be more harmful than other types of maltreatment. Emotional abuse needs to be studied further, and research on it has lagged behind that on other forms of childhood maltreatment. One key aspect of emotional abuse research is its lack of consideration in the diagnosis of PTSD. Considering that the concept of trauma encompasses different traumatic experiences not previously considered traumas but that are also harmful, future reformulations of the definition of traumatic events could contemplate emotional abuse.

In addition, the focus on emotional abuse might encourage the development of prevention and treatment strategies. By understanding how implicit memories of emotional abuse episodes impact future emotional regulation capacity, we might prevent the harmful effects of this type of abuse on intergenerational attachment styles, which can lead to societal problems such as parental violence, marital violence, and mental health disorders. Accordingly, the improvement of intervention strategies for memory reconsolidation and reprocessing of those events could have an immense impact on society.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to local ethics committee restrictions but are available from the corresponding author on reasonable request.

Abbreviations

Confidence Interval

• Childhood maltreatment

Childhood Trauma Questionnaire - Short Form

Incidence Rate Ratio

Sample number

Posttraumatic Stress Disorder Checklist for DSM-5

Posttraumatic Stress Disorder

Standard error

Trauma History Questionnaire

Shapiro-Wilk Test

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Acknowledgements

We thank Dr. Coutinho for his valuable help with the statistical analysis and description. This work was supported in part by federal and state Brazilian research agencies (CAPES 001, CAPES/PRINT, CNPq and FAPERJ).

This work (data collection, analysis and writing) was supported in part by federal and state Brazilian research agencies (CNPq and FAPERJ).

Scholarships were awarded by the federal Brazilian research agency CAPES 614 001, CAPES/PRINT.

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Additional file 1: table s1..

Mean CTQ total scores and subscales scores (original sample). Table S2. The Impact of Childhood Maltreatment on Revictimization: Bivariate and Multivariate Negative Binomial Regression Model (using CTQ scores) . Table S3. Predicting PTSD Symptoms: Bivariate and Multivariate Negative Binomial Regression for the Prediction of PTSD Severity (using CTQ scores).

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Gama, C.M.F., Portugal, L.C.L., Gonçalves, R.M. et al. The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment. BMC Psychiatry 21 , 156 (2021). https://doi.org/10.1186/s12888-021-03134-0

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Physical and sexual abuse greatly exacerbate the risk of substance use disorders . Abuse has particularly far-reaching effects when it occurs during childhood. Please learn more about treatment here .

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• Verbal: They may verbally abuse them by calling them names, tell them they are stupid, have no worth or will not amount to anything on their own.
• Physical: They may become physically violent, inflicting pain, bruises, broken bones and other physical wounds (visible and hidden both).
• Sexual: They may rape or sexually assault their victims.
• Negligence: Alternatively they may neglect dependent victims, disavowing any responsibilities they may have towards those victims, and causing damage through lack of action rather than through a harmful, manipulative action itself.

Abuse is a commonplace event in modern times, taking on many different forms, including physical, sexual, emotional, and verbal abuse, occurring in many different contexts, including the home (domestic violence, spouse rape, incest), the workplace (sexual harassment), and in institutional (elder abuse, bullying) and religious and community (hate crime) settings. It touches victims across the lifespan from children through elders. Abuse is a serious social and cultural problem affecting everyone whether as a victim of abuse, a perpetrator, a friend or confidant of an abused person looking for ways to be helpful, or simply as someone who is angered by injustice and wants to work for positive change.

If you are currently being abused, or have been abused in the past, you should know that you do not suffer alone. Right now millions of people around the world struggle to maintain dignity, safety and self-worth in the face of ongoing abuse. Millions more people struggle to recover from wounds they have sustained during past abuse. You should also know that help is available for victims of abuse, although it is not always easy to access. Community abuse resources (such as domestic violence shelters), mental health professionals, law enforcement, and various other organizations, websites and printed resources can provide instruction and assistance for people who need help removing themselves from abusive situations.

Victims of abuse often find themselves dealing with serious psychological and physical consequences of having been abused. There are various forms of counseling, psychotherapy, medical and self-help resources available for people who have been abused and want assistance and support for managing problems and issues they have developed as a result of being abused Such post-abuse issues are sometimes called 'abuse sequela' by health professionals. While no therapy is capable of erasing the effects of abuse, such resources can provide real and meaningful assistance in helping to minimize the negative effects of abuse. Helpful abuse-related resources can be found throughout this document, in the appendix of abuse-related resources provided at the end of this document, and in the lists of other (non-document) resources collected within this abuse topic center.

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Some people aren't sure if they are being or have been abused. They may know that they have been harmed, but they may think that they deserved that harm, for instance, or perhaps think instead that some degree of harm is acceptable or reasonable, or just inevitable. Though it is not possible for us to give you a definite answer to any questions you may have about what is abuse and what is not abuse, consider that people who haven't been abused don't tend to spend much time wondering whether they have been abused, while a many people who have been abused (or are being abused) do wonder about it. If you are upset enough to wonder about it, it is likely (although not definite) that you have been abused. We'll explore the definition of abuse in greater detail later in this document.

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• Childhood Sex Abuse of Girls: Implications For Adulthood
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• When Children Are Beaten, The Aftermath
• Why Do Adults Stay In Abusive Relationships?
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Intimate partner violence: A loop of abuse, depression and victimization

Marianna mazza.

Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy. moc.liamtoh@azzamannairam

Giuseppe Marano

Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy

Angela Gonsalez del Castillo

Service of Clinical Psychology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy

Daniela Chieffo

Laura monti, delfina janiri, lorenzo moccia, gabriele sani.

Corresponding author: Marianna Mazza, MD, PhD, Assistant Professor, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, Rome 00168, Italy. moc.liamtoh@azzamannairam

Intimate partner violence has been recognized as a serious public health issue. Exposure to violence contributes to the genesis of, and exacerbates, mental health conditions, and existing mental health problems increase vulnerability to partner violence, a loop that imprisons victims and perpetuates the abuse. A recently described phenomenon is when male violence against females occurs within intimate relationships during youth, and it is termed adolescent or teen dating violence. In this narrative review, factors associated with intimate partner violence and consequences of exposure of children to parental domestic violence are discussed, along with possible intensification of violence against women with the spread of coronavirus disease 2019 pandemic and subsequent lockdown. Intervention programs with a multicomponent approach involving many health care settings and research have a pivotal role in developing additional strategies for addressing violence and to provide tailored interventions to victims. Prevention policy with a particular attention on healthy child and adolescent development is mandatory in the struggle against all forms of violence.

Core Tip: Intimate partner violence represents a serious public health issue. Exposure to violence contributes to the genesis of, and exacerbates, mental health conditions, and existing mental health problems increase vulnerability to partner violence. A recently described phenomenon is when male violence against females occurs within intimate relationships during youth, and it is termed adolescent or teen dating violence. Coronavirus disease 2019 pandemic is causing a tremendous impact on women's possible exposure to violence. Possible interventions against violence are discussed.

INTRODUCTION

Intimate partner violence is described as physical violence, sexual violence, stalking, or psychological aggression by a current or former intimate partner. It represents a serious public health issue. It has been estimated that more than 30% of women in the United States have experienced intimate partner violence, and it represents the leading cause of homicide death for women. Prevalence is higher among young women (18 to 24 years of age), among racial and ethnic minority groups, and among people with mental and physical disabilities[ 1 ]. Psychological violence is estimated to be the most common subtype of intimate partner violence (compared to physical and sexual violence) in the United States and Europe[ 2 ].

In women of reproductive age, intimate partner violence has been linked with poor reproductive health and poor sexual health (unintended pregnancy and sexually transmitted infections) and heightened risks of obstetrical and gynecologic complications (pregnancy-associated death, preterm birth, low birth weight) and represents a risk factor for peripartum depression and substance abuse[ 1 ]. There are specific physical injuries in women that can be considered as indicators of intimate partner violence: Contusions, lacerations, and fractures (especially in the head, neck and face) and are frequently reported by patients as domestic accidents. Partner violence has been associated with many mental health consequences: Depression, anxiety, post-traumatic stress disorder, eating disorders, suicidal behavior, alcohol or drug abuse, sexual problems, problems with concentration, somatization, social, educational, or occupational difficulties, as well as feelings of blame and guilt or reproach. It is also linked to several and often disabling physical health problems (chronic pain, gastrointestinal problems, sexually transmitted infections, traumatic brain injury, cardiovascular diseases).

Exposure to violence can contribute on one side to the genesis of psychopathological conditions or can exacerbate mental health conditions, but on the other side existing mental health problems can increase vulnerability and predisposition to partner violence.

It has been estimated that emotional violence is the most common form of intimate partner violence across all continents worldwide[ 3 ]. Factors associated with intimate partner violence originate from multiple levels: Individual, relationship, community, and societal level[ 4 ]. Subjects who are at greater risk of experiencing intimate partner violence more likely come from a lower education background and poorer socio-economic status (with difficulty of access to resources and greater acceptance towards violence), have a history or a current substance abuse, and have been exposed to prior abuse or violence (with a history of abuse reinforcing the normative nature of violence and developing violence-condoning attitude). For example, many immigrant women have to cope with issues regarding their cultural integration into another society while at the same time concurrently feeling related and profoundly bounded by cultures and traditions from their countries of origin. Dependence on one’s partner, difficulties in language proficiency, financial problems, lack of social support, and uncertain legal status can leave these subjects feeling fragile and socially isolated and can prevent them from seeking assistance; besides, women linked to particular cultural backgrounds may refuse to acknowledge certain acts and behaviors as abusive due to beliefs and traditions regarding familial obligations and culturally prescribed gender roles[ 5 ].

People with mental illness may have a heightened risk of becoming victims of domestic violence and can be reluctant to disclose abuse. On the other hand, mental ill-health can also be a consequence of victimization and can involve post-traumatic stress disorder, depression, suicidality, and alcohol or substance misuse: Physical sequalae of abuse are added to psychological morbidity[ 6 ].

EXPOSURE OF CHILDREN TO PARENTAL DOMESTIC VIOLENCE

It has been outlined by recent research that the presence of intimate partner violence often compromises a child’s attachment to primary caregivers, which results in an additional risk factor for social, emotional, and psychological impairment[ 7 ]. A child can be exposed to domestic violence also through the awareness that violence occurs between parents, regardless of whether the child directly witnesses it. Infancy is a critical period of developing a secure attachment, and infants spend most of the time with caregivers, in a relationship of close proximity to them and high and obliged dependence from them; in addition, younger children have not completely strengthened the cognitive ability to discern between intimate partner violence as a threat to caregiver or to the self. As a consequence, the situation of violence in the household can indirectly impact on the child because it compromises the caregiving system in the parent. The presence of intimate partner violence increases a child’s risk of developing a wide variety of negative outcomes (internalizing symptoms, externalizing behaviors, problems with perceptual and cognitive functioning, academic difficulties, interpersonal difficulties). Possible consequences can be affected by the child’s age, relationships with other caregivers, and period of exposure to violence.

Violence against young girls causes physical and psychological effects, which can manifest as mild anxiety symptoms, apprehension, flashbacks, or feeling ashamed or worried to more severe anxiety signs, including a variety of sleep or eating disorders, post-traumatic symptoms, and even thoughts of self-harm and suicide. The inaction of a valid support system may further worsen this complex situation[ 8 ].

Children exposed to parental domestic violence are predisposed to physical and mental health disorders and are subjected to an increased risk of become a victim or a perpetrator of intimate partner violence in adolescence and adulthood[ 9 ]. Besides, adverse childhood experiences, such as child abuse, maltreatment, substance abuse in the household, incarceration of household members, and emotional or physical neglect, have long-term consequences with poorer physical, mental, individual behavioral, and social/interactional outcomes: The larger the number of adverse childhood experiences, the higher the odds of worst physical and mental health outcomes, including heart disease, stroke, asthma, diabetes, and mental distress[ 10 ]. Adolescence is a critical developmental period characterized by puberty, progressive autonomy from parents and family, changes in social relationships, and often the beginning of romantic relationships. Child sexual abuse, child physical abuse, witnessing parental intimate partner violence, exposure to school-related violence ( e.g. , bullying), and community violence ( e.g. , racism or discrimination) during childhood are potentially related to future intimate partner violence. Recently, it has been demonstrated that adverse childhood experiences in adolescence are predictive of interpersonal violence 15 years later[ 10 ].

Teen dating violence

When male violence against females occurs within intimate relationships during youth, it is termed adolescent or teen dating violence, occurring in individuals aged 10-24 years, including early, middle, and late adolescence, and described as physical, sexual, or psychological/emotional abuse, comprising threats, towards a dating partner. Six forms of teen dating violence have been assessed: Threatening behaviors, verbal/emotional abuse, relational abuse, physical abuse, sexual abuse, and stalking.

The cultivation of emotional relationships during adolescence are pivotal to the progressive growth of interpersonal communication skills, autonomy, and self-perceived competence, but together with affective and behavioral vulnerability experienced during adolescence, a variety of individual, social, and community risk factors may favor the emergence of adolescent dating violence[ 11 ]. Victims of teen dating violence may develop adverse health outcomes such as increased sexual risk behaviors, suicidality, unhealthy behaviors ( e.g. , lack of physical activity and negative weight-controlling behaviors), inauspicious mental health outcomes, substance use, injuries, victimization, and death. Additionally, it is common for adolescents who experience dating violence to struggle with their academics, drop out of school, or skip school to avoid seeing their partner.

Risk factors for perpetration of adolescent dating violence seem to be a history of experiencing, witnessing, and/or initiating abuse within the home, school, and community; childhood trauma in the form of physical and emotional abuse or neglect (due to personality anxiety traits formed during childhood, so that the individual feels a lack of security in the relationship and worries about being left by the partner); sexism and gender roles present in society; bullying; developing and formulating ineffective interpersonal communication and conflict resolutions skills during adolescence; alcohol or substance use during adolescence; attachment insecurities (anxiety and avoidance) expressed as anger, hostility, aggression, and emotional dysregulation[ 12 ]. Recent research suggests that there are multiple form of adolescent dating violence and that males may be victimized at similar rates as females[ 13 ]. Increasingly high rates of technology usage, as well as diffusion of apps and social media platforms, has created more opportunities for cyber teen violence dating (typically people who are no longer with their dating partner perpetrate this form of violence against an ex-partner).

Abusive behavior in adolescent dating relationships is associated with a risk of intimate partner violence later in adulthood[ 14 ].

Violence during coronavirus disease 2019 pandemic

Coronavirus disease 2019 (COVID-19) has had a dreadful impact on the world’s economy, and women are forced to take on additional risks as they are already disadvantaged and vulnerable, especially in rural and remote settings[ 8 ]. Sexuality suffers because it has to deal with the arrogance of a death drive rekindled by the current pandemic condition. A life in which less libido is exchanged stably than one would like can become unbearable. But the libido, in the forms of stasis and engorgement, can turn, in the unconscious, into anguish and give rise to internal conflicts that inevitably end up resulting in the relationship with the other[ 15 ]. As the COVID-19 pandemic has intensified, its effects diversified by gender have begun to gain attention[ 16 ]. During the institutional lockdown, victims of domestic violence were required to remain closed with partners and without help or support: In such scenario there is a great chance that abusive situations can further aggravate, with a possible increase of domestic homicides or murder-suicides or deviant behaviors towards children. Increased concerns about domestic violence have been expressed in many countries. The reasons for this include social isolation, exposure to economic and psychological stressors, increase in negative coping mechanisms (such as alcohol or drugs misuse), and inability to access usual health and social services[ 6 ]. School closure due to lockdown can potentiate the risk for children to witness violence, exploitation, and abuse at home and away from help[ 8 ].

As the outbreak of COVID-19 has developed, referral rates to mental health and psychology services have declined, despite a likely increase in psychological distress, victimization, and mental illness. It is well-known that intimate partner violence has short-term and long-term effects on physical and mental-health of affected subjects and in particular might increase the risk of cardiovascular disease in women, by indirect (chronic inflammation or dysregulation of the hypothalamic pituitary axis as a consequence of chronic stress) and indirect pathways (coping strategies used by victims of abuse to deal with stress, such as smoking and overeating, and higher incidence of depressive disorders correlated to chronically elevated levels of cortisol, catecholamines, and inflammatory markers, all of which promote the development and progression of cardiovascular disease)[ 17 ].

Psychological distress linked with the pandemic itself, arising in response to fears about personal and familial infection as well as the sequelae of social distancing and quarantine measures, add worry about possible consequences of intimate partner violence during this global pandemic.

Particularly during the COVID-19 pandemic, programs are necessary to provide funding sources to guarantee telephone or remote counseling services or psychological assistance hotlines to manage and attempt to prevent crisis situations[ 18 , 19 ]. The use of mobile health and telemedicine to support safely subjects experiencing violence must be urgently improved, together with other strategies to reach women at risk in settings where access to mobile phones or the internet is limited or completely lacking. We must learn lessons from the past epidemics and also from the present about errors and defeats to recognize and address gender related effects of outbreaks[ 16 ].

Prevention and management of the violence against women of all ages should be expected and potentiated as a pivotal service in the COVID-19 response plan.

Possible interventions against violence

Lifetime and current intimate partner violence is common and unacceptably high. It has been outlined that approximately 1 in 4 women becomes a victim of violence at some point in their life regardless of their age, economic status, or ethnicity. Domestic violence against women is a well-recognized health concern and has serious negative impact on women’s lives. It is important to stress the fact that most of the factors associated with violence against women are preventable. Studies assessing screening and interventions practice in primary care services for women who experience intimate partner violence have demonstrated that clinical programs can mitigate the risk of subsequent violence[ 20 ]. In addition, interventional studies have stressed that gender-norms transformation through behavioral change and communication focused program can promote gender equality norm and avert domestic violence against women[ 21 ].

Intimate partner violence is often not obvious, and patients may present with nonspecific signs and symptoms. Clinicians must be aware of the red flags of domestic violence and incorporate the principles of trauma-informed care into their practice. This means asking about violence or risk of violence when it is safe and appropriate, in a private discussion and in a compassionate and nonjudgmental way, discussing needs, preferences, and immediate options. It is necessary to support the subject’s autonomy, provide emotional and practical support, and personalize responses and possible solutions to the individual patient[ 22 ].

For pregnant women suspected or known to be exposed to partner violence, it is mandatory to consider a pregnancy high-risk and to provide prenatal assessment and counseling for the mother and home-visitation programs in the child’s first years. Screening in primary care for mental health disorders such as depression or anxiety should reasonably include an inquiry about current and previous intimate partner violence. In parallel, current or past intimate partner violence should be appropriately included in the differential diagnosis of many medical and behavioral health conditions, particularly in women[ 1 ]. It should be taken into account the fact that violence victims may not disclose their experience immediately but in the context of multiple queries and a trusting relationship. It results important that a multicomponent approach involving many health care settings, training of staff, clinical specific tools of assessment (including multiple violence domains: Physical, sexual, emotional/psychological), established workflows, connection to follow-up social services, and legal services can be dedicated and promoted to improve the prevention and response and care to the problem of intimate partner violence and its serious consequences. It has been observed that women have the tendency to remain with violent partners due to a variety of reasons, including social norms, worry for children, and economic issues. Immigrant women require a specific culturally-tailored approach and may need specific advocacy and interventions that also focus on financial abuse and are finalized to economic empowerment, including individual mental health counseling (when the shame and stigma associated to intimate partner violence in many ethnic communities increase the reluctance to discuss in groups) and services provided in community member’s native language or in intervention delivery settings (shared community environments including churches, mosques, temples)[ 5 ].

Interventions integrating legal framework and programs that focus on transformation of traditional gender-norms are of great importance in order to prevent violence against women of all ages. There is an increasing need of intervention programs and techniques to reduce violence among offenders (group therapy or counseling aimed to work on impulsive and angry behavior or inability to control emotions) with a particular focus on trauma and substance abuse[ 23 ]. Since it has been observed that men with mental health problems (in particular depression, anxiety, alcohol or drug use disorder, attention deficit hyperactivity disorder, personality disorders) carry a higher probability to perpetrate domestic violence against women, treatment for any co-existing mental illness and in particular substance abuse or misuse should be prioritized to reduce risk[ 24 ].

Also, research has a pivotal role in developing additional strategies for addressing violence and to provide personalized interventions to victims. For example, qualitative studies exploring the emotional impacts of intimate partner sexual violence on women are scarce. Understanding should be deepened of the so-called invisible impacts of violence, described as the emotional repercussions (sense of powerlessness, helplessness, shame, ongoing fear of men) that are difficult to quantify and measure but may be a trigger for mental health outcomes, such as post-traumatic stress disorder, anxiety, and depression[ 25 ]. Research can guide attachment- and family-based interventions for families impacted by interpersonal violence. Besides, there is an urgent need for rigorous research to understand better which interventions are most effective and tailored for ethnic minority populations.

Last but not least, prevention is mandatory: Interventions focusing on community and domestic health and violence prevention and, focusing on high-risk and disadvantaged socio-economic groups (such as institutionalized children or adolescents), with a particular attention on healthy child and adolescent development, may greatly contribute to lower intimate partner violence victimization in adulthood by correcting attitudes on violence and improving help-seeking behavior (Table ​ (Table1). 1 ).

Proposed interventions against intimate partner violence

COVID-19: Coronavirus disease 2019.

Conflict-of-interest statement: Authors declare no conflict of interest.

Manuscript source: Invited manuscript

Peer-review started: December 31, 2020

First decision: April 21, 2021

Article in press: May 17, 2021

Specialty type: Psychiatry

Country/Territory of origin: Italy

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C

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P-Reviewer: Zafrakas M S-Editor: Fan JR L-Editor: Filipodia P-Editor: Li JH

Contributor Information

Marianna Mazza, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy. moc.liamtoh@azzamannairam .

Giuseppe Marano, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Angela Gonsalez del Castillo, Service of Clinical Psychology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Daniela Chieffo, Service of Clinical Psychology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Laura Monti, Service of Clinical Psychology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Delfina Janiri, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Lorenzo Moccia, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Gabriele Sani, Department of Neurosciences, Section of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy.

Narrating Trauma—From No Words to Your Words

Healing trauma involves transforming the unspeakable into a story you can tell..

Posted December 13, 2020

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“Trauma defies language; it resists being communicated.” ( Chris N van der Merwe & Pumla Gobodo-MadiKizela)

What is a Traumatic Event?

A traumatic event is most often one that is threatening to the life or bodily integrity of self or a loved one. It may include combat, sexual and physical assault, death of a child, suicide of a loved one, accidents, being held hostage, imprisoned, or tortured, natural and man-made disasters, as well the diagnosis of a life-threatening illness.

The Nature of Traumatic Memory

In most cases, the memory of the traumatic event is not like our memory for ordinary events that can be told as a narrative with a beginning, middle, and end.

Traumatic memories are often choppy, disorganized, and non-sequential with little change over time. They are the imprints and shards of trauma that we need to transform.

Having been at ground zero on 9/11, a firefighter struggled with the feel and taste of dust in his mouth and the image of a woman’s head and hair partially buried in concrete.

A rape victim was perplexed in the ER when told she could call a family member. What would she say? She had no words for what had happened.

A victim of clergy trauma who had almost no memory of the details of his childhood abuse, became nauseous whenever he stepped into a church.

Why Are There Are No Words?

Neurobiological Impact

• In the acute or immediate aftermath of traumatic events, most people don’t have a coherent story of what has happened because they have been surviving.
• In face of danger, our human psychobiology takes over. The right hemisphere of our brain associated with survival behaviors and emotional expression is activated and the left verbal-linguistic part of our brain is suppressed.
• With Autonomic Nervous System hyperarousal , we experience increased heart rate and respiration, cold and pale skin, dilated pupils, and raised blood pressure. Our body has prepared us to respond with the survival reflexes of fight, flight, and freeze.
• Often misunderstood, the freezing response is instinctive to our survival. It is a form of dissociation, such that time slows down and there is a feeling of an altered reality with pain and fear frozen. For the prisoner, the rape victim, and the child victim—it is the escape when there is no escape.

Psychological Impact

Adding to the activation of human survival reflexes in the face of trauma, there are often psychological reasons that keep us from finding the words for what has happened.

Self-Protection

Months and even years after a traumatic event, people can become so terrified of re-experiencing the horror of a traumatic event that they will avoid any triggers of memory. Protecting themselves from pain with avoidance, they are unable to see in the triggered memory, the dream or flashback an opportunity to “make meaning”—to find the words, to begin to heal.

Protection of Others

Some never put words to the feelings, sensory images, or somatic glimpses of their traumatic experience because they try to protect others from what they have faced. Combat Vets fear contaminating their partners. Rape victims fear shaming their families. Children of the Holocaust experienced the intergenerational horror despite a code of silence.

Social/Interpersonal Impact

In the face of family or widespread disaster, many see so much pain that they overlook their entitlement to bear witness, to put words to their own traumatic experience.

“Who am I to speak ? L ook how others have suffered.”

Described as the “ forgotten bereaved ,” siblings who have lost a brother or sister to suicide rarely feel entitled to put words to their pain. Confused, guilty for not saving their sibling , adrift without parents who are lost in grief , they don’t want to add to the pain. They remain painfully silent.

Finding Your Words— Transforming Trauma

Establish Physical and Psychological Safety

• Safety is essential to remembering and transforming trauma. It can be secured differently for different people.
• For some, the passage of time allows enough psychological distance and life experience to respond to a trigger with less terror and more capacity to tell their story.
• For others, their mastery as an adult serves as the buffer for helplessness and allows them to re-connect with a traumatized self.

An adult finds a voice in a group of child abuse survivors and pieces together what was too much for a child to know.

After sixteen years of silence, a rape victim informs the world by publishing her story.

Utilize Positive Connections

Trauma theorist, Judith Herman tells us that, “The action of telling the story in the safety of a protected relationship can actually produce a change in abnormal processing of the traumatic memory.”

• Connection on both conscious and unconscious levels makes it easier to heal trauma. For some, human connection with friends, trusted relatives, or a partner can be the safe context for an unfolding story.
• Connection with a professional therapist from any number of models ( cognitive behavioral therapy , trauma-focused therapy, psychodynamic therapy, prolonged exposure, etc.) can be crucial in transforming trauma. Within a protected space with a trusted therapist who is there to listen, observe and contain what cannot yet be fully articulated, trauma can often be glimpsed in dreams , identified in patterns, and remembered in a different way.
• Healing in a group is a powerful use of connection. Groups of many types offer an opportunity for validation, bearing witness, altruistic giving, and containing the unspeakable aspects of trauma.
• Nothing is more powerful than to see members silently bear witness with their tears or hear someone say:

"Your story is my story — I blamed myself too.”

“You just said what I feel — I couldn’t say it.”

Working From the Body Out

Narrating trauma may start with your body. Given the psychobiology of human survival, what we often cannot say or remember is held within our body.

• Exercise, dance therapy, yoga, etc. serve in the reduction of trauma symptoms because they allow the movement we are wired to experience in face of danger and they re-set a positive connection to our personal experience of bodily sensations.
• Trauma experts like Peter Levine in his book, An Unspoken Voice , recommend that we work from “the bottom up” i.e., that we attend to the sensations, senses, images, postures, and behaviors associated with the aftermath of trauma to unlock the hidden unspoken traumatic story and release the healing potential.
• Creative Modalities Tell the Story

Art, music, writing, and drama draw upon many parts of our brain and in so doing offer expressions of trauma never encoded as words. They are conduits to the healing narrative.

• Those writing about their trauma are often driven by a powerful voice that can write of things that can’t be said aloud. In Operation Homecoming by Andrew Carroll, the writings of thousands of troops and their families give voice to the insider’s experience of war.
• Many, such as the authors of Narrating the Healing , see value not only in writing one’s narrative but sharing it and reading the narratives of others as a way to experience the complexities of trauma at a distance—as a way to find the words for what was has been too painful to say.

The story that we cannot tell — haunts us but never helps us.

Suzanne B. Phillips, Psy.D., ABPP, a psychologist and host of “Psych Up Live” on International Talk Radio, formerly taught at Long Island University Post and is the author of three books including Healing Together for Couples.

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At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

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Understanding Child Abuse and Neglect (1993)

Chapter: 1 introduction, 1 introduction.

Child maltreatment is a devastating social problem in American society. In 1990, over 2 million cases of child abuse and neglect were reported to social service agencies. In the period 1979 through 1988, about 2,000 child deaths (ages 0-17) were recorded annually as a result of abuse and neglect (McClain et al., 1993), and an additional 160,000 cases resulted in serious injuries in 1990 alone (Daro and McCurdy, 1991). However tragic and sensational, the counts of deaths and serious injuries provide limited insight into the pervasive long-term social, behavioral, and cognitive consequences of child abuse and neglect. Reports of child maltreatment alone also reveal little about the interactions among individuals, families, communities, and society that lead to such incidents.

American society has not yet recognized the complex origins or the profound consequences of child victimization. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, are expensive and are often subsidized by governmental funds. The General Accounting Office (1991) has estimated that these services cost more than $500 million annually. Equally disturbing, research suggests that child maltreatment cases are highly related to social problems such as juvenile delinquency, substance abuse, and violence, which require additional services and severely affect the quality of life for many American families.

The Importance Of Child Maltreatment Research

The challenges of conducting research in the field of child maltreatment are enormous. Although we understand comparatively little about the causes, definitions, treatment, and prevention of child abuse and neglect, we do know enough to recognize that the origins and consequences of child victimization are not confined to the months or years in which reported incidents actually occurred. For those who survive, the long-term consequences of child maltreatment appear to be more damaging to victims and their families, and more costly for society, than the immediate or acute injuries themselves. Yet little is invested in understanding the factors that predispose, mitigate, or prevent the behavioral and social consequences of child maltreatment.

The panel has identified five key reasons why child maltreatment research should be viewed as a central nexus of more comprehensive research activity.

Research On Child Maltreatment Is Currently Undervalued And Undeveloped

Research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, so-

cial welfare, and criminal violence. Although no specific theory about the causes of child abuse and neglect has been substantially replicated across studies, significant progress has been gained in the past few decades in identifying the dimensions of complex phenomena that contribute to the origins of child maltreatment.

Efforts to improve the quality of research on any group of children are dependent on the value that society assigns to the potential inherent in young lives. Although more adults are available in American society today as service providers to care for children than was the case in 1960, a disturbing number of recent reports have concluded that American children are in trouble (Fuchs and Reklis, 1992; National Commission on Children, 1991; Children's Defense Fund, 1991).

Efforts to encourage greater investments in research on children will be futile unless broader structural and social issues can be addressed within our society. Research on general problems of violence, substance addiction, social inequality, unemployment, poor education, and the treatment of children in the social services system is incomplete without attention to child maltreatment issues. Research on child maltreatment can play a key role in informing major social policy decisions concerning the services that should be made available to children, especially children in families or neighborhoods that experience significant stress and violence.

As a nation, we already have developed laws and regulatory approaches to reduce and prevent childhood injuries and deaths through actions such as restricting hot water temperatures and requiring mandatory child restraints in automobiles. These important precedents suggest how research on risk factors can provide informed guidance for social efforts to protect all of America's children in both familial and other settings.

Not only has our society invested relatively little in research on children, but we also have invested even less in research on children whose families are characterized by multiple problems, such as poverty, substance abuse, violence, welfare dependency, and child maltreatment. In part, this slower development is influenced by the complexities of research on major social problems. But the state of research on this topic could be advanced more rapidly with increased investment of funds. In the competition for scarce research funds, the underinvestment in child maltreatment research needs to be understood in the context of bias, prejudice, and the lack of a clear political constituency for children in general and disadvantaged children in particular (Children's Defense Fund, 1991; National Commission on Children, 1991). Factors such as racism, ethnic discrimination, sexism, class bias, institutional and professional jealousies, and social inequities influence the development of our national research agenda (Bell, 1992, Huston, 1991).

The evolving research agenda has also struggled with limitations im-

posed by attempting to transfer the results of sample-specific studies to diverse groups of individuals. The roles of culture, ethnic values, and economic factors pervade the development of parenting practices and family dynamics. In setting a research agenda for this field, ethnic diversity and multiple cultural perspectives are essential to improve the quality of the research program and to overcome systematic biases that have restricted its development.

Researchers must address ethical and legal issues that present unique obligations and dilemmas regarding selection of subjects, provision of services, and disclosure of data. For example, researchers who discover an undetected incident of child abuse in the course of an interview are required by state laws to disclose the identities of the victim and offender(s), if known, to appropriate child welfare officials. These mandatory reporting requirements, adopted in the interests of protecting children, may actually cause long-term damage to children by restricting the scope of research studies and discouraging scientists from developing the knowledge base necessary to guide social interventions.

Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can improve the quality of social service efforts and public policy decisions affecting the health and welfare of abused and neglected children and their families. Most important, collaborative long-term research ventures are necessary to diminish social, professional, and institutional prejudices that have restricted the development of a comprehensive knowledge base that can improve understanding of, and response to, child maltreatment.

Dimensions Of Child Abuse And Neglect

The human dimensions of child maltreatment are enormous and tragic. The U.S. Advisory Board on Child Abuse and Neglect has called the problem of child maltreatment ''an epidemic" in American society, one that requires a critical national emergency response.

The scale and severity of child abuse and neglect has caused various public and private organizations to mobilize efforts to raise public awareness of individual cases and societal trends, to improve the reporting and tracking of child maltreatment cases, to strengthen the responses of social service systems, and to develop an effective and fair system for protecting and offering services to victims while also punishing adults who deliberately harm children or place them in danger. Over the past several decades, a growing number of state and federal funding programs, governmental reports, specialized journals, and research centers, as well as national and international societies and conferences, have examined various dimensions of the problem of child maltreatment.

The results of these efforts have been inconsistent and uneven. In addressing aspects of each new revelation of abuse or each promising new intervention, research efforts often have become diffuse, fragmented, specific, and narrow. What is lacking is a coordinated approach and a general conceptual framework that can add new depth to our understanding of child maltreatment. A coordinated approach can accommodate diverse perspectives while providing direction and guidance in establishing research priorities and synthesizing research knowledge. Organizational mechanisms are also needed to facilitate the application and integration of research on child maltreatment in related areas such as child development, family violence, substance abuse, and juvenile delinquency.

Child maltreatment is not a new problem, yet concerted service, research, and policy attention toward it is just beginning. Although isolated studies of child maltreatment appeared in the medical and sociological literature in the first half of the twentieth century, the publication of "The Battered Child Syndrome" by C. Henry Kempe and associates (1962) is generally considered the first definitive paper in the field in the United States. The efforts of Kempe and others to publicize disturbing medical experience with child abuse and neglect led to the passage of the first Child Abuse Prevention and Treatment Act in 1974 (P.L. 93-247). The act, which has been amended several times (most recently in 1992), established a governmental program designed to guide and consolidate national and state data collection efforts regarding reports of child abuse and neglect, conduct national surveys of household violence, and sponsor research and demonstration programs to prevent, identify, and treat child abuse and neglect.

However, the federal government's leadership role in building a research base in this area has been complicated by changes and inconsistencies in research plans and priorities, limited funding, politicized peer review, fragmentation of effort among various federal agencies, poorly scheduled proposal review deadlines, and bias introduced by competing institutional objectives. 1 The lack of comprehensive, long-term planning for a research base has resulted in a field characterized by contradictions, conflict, and fragmentation. The role of the National Center for Child Abuse and Neglect as the lead federal agency in supporting research in this field has been sharply criticized (U.S. Advisory Board, 1991). Many observers believe that the federal government lacks leadership, funding, and an effective research program for studies on child maltreatment.

The Complexity Of Child Maltreatment

Child maltreatment was originally seen in the form of "the battered child," often portrayed in terms of physical abuse. Today, four general categories of child maltreatment are generally recognized: (1) physical

abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category covers a range of behaviors, as discussed in Chapter 2.

These four categories have become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment, with uneven development of research within each area and poor integration of knowledge across areas. Each category has developed its own typology and framework of reference terms, revealing certain similarities (such as the importance of developmental perspectives in considering the consequences of maltreatment) but also important differences (such as the predatory behavior associated with some forms of sexual abuse that do not appear in the etiology of other forms of child maltreatment).

In addition to the category of child maltreatment, the duration, source, intensity, timing, and situational context of incidents of child victimization are now recognized as important factors in studying the origin and consequences of child maltreatment. Yet information about these factors is rarely requested or recorded by social agencies or health professionals in the process of identifying or documenting reports of child maltreatment. Furthermore, research is often weakened by variation in research definitions of child maltreatment, bias in the recruitment of research subjects, the absence of information regarding circumstances surrounding maltreatment reports, the absence of measures to assess selected variables under study, and the absence of a developmental perspective in many research studies.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent. Relatively little is known about areas of similarity and differences in terms of causes, consequences, prevention, and treatment of selected types of child abuse and neglect. Inconsistencies in definitions often preclude comparative analyses of clinical studies. For example, studies of sexual abuse have indicated wide variations in its prevalence, often as a result of differences in the types of behavior that might be included in the definition adopted by each research investigator. Emotional abuse is also a matter of controversy in some quarters, primarily because of broad variations in its definition.

Research on child maltreatment is also complicated by the fragmentation of services and responses by which our society addresses specific reports of child maltreatment. Cases may involve children who are victims or witnesses to single or repeated incidents of child abuse and neglect. Sadly, child maltreatment often involves various family members, relatives, or other individuals who reside in the homes or neighborhoods of the affected children. Adult figures may be perpetrators of offensive incidents or mediators in intervention or prevention efforts.

The importance of the social ecological framework of the child has only recently been recognized in studies of maltreatment. Responses to child abuse and neglect involve a variety of social institutions, including commu-

nities, schools, hospitals, churches, youth associations, the media, and other social structures that provide services for children. Such groups and organizations present special intervention opportunities to reduce the scale and scope of the problem of child maltreatment, but their activities are often poorly documented and uncoordinated. Finally, governmental offices at the local, state, and federal levels have legal and social obligations to develop programs and resources to address child maltreatment, and their role is critical in developing a research agenda for this field.

In the past, the research agenda has been determined predominantly by pragmatic needs in the development and delivery of treatment and prevention services rather than by theoretical paradigms, a process that facilitates short-term studies of specialized research priorities but impedes the development of a well-organized, coherent body of scientific knowledge that can contribute over time to understanding fundamental principles and issues. As a result, the research in this field has been generally viewed by the scientific community as fragmented, diffuse, decentralized, and of poor quality.

Selection of Research Studies

The research literature in the field of child maltreatment is immense—over 2000 items are included in the panel's research bibliography, a portion of which is referenced in this report. Despite this quantity of literature, researchers generally agree that the quality of research on child maltreatment is relatively weak in comparison to health and social science research studies in areas such as family systems and child development. Only a few prospective studies of child maltreatment have been undertaken, and most studies rely on the use of clinical samples (which may exclude important segments of the research population) or adult memories. Both types of samples are problematic and can produce biased results. Clinical samples may not be representative of all cases of child maltreatment. For example, we know from epidemiologic studies of disease of cases that were derived from hospital records that, unless the phenomenon of interest always comes to a service provider for treatment, there exist undetected and untreated cases in the general population that are often quite different from those who have sought treatment. Similarly, when studies rely on adult memories of childhood experiences, recall bias is always an issue. Longitudinal studies are quite rare, and some studies that are described as longitudinal actually consist of hybrid designs followed over time.

To ensure some measure of quality, the panel relied largely on studies that had been published in the peer-reviewed scientific literature. More rigorous scientific criteria (such as the use of appropriate theory and methodology in the conduct of the study) were considered by the panel, but were not adopted because little of the existing work would meet such selection

criteria. Given the early stage of development of this field of research, the panel believes that even weak studies contain some useful information, especially when they suggest clinical insights, a new perspective, or a point of departure from commonly held assumptions. Thus, the report draws out issues based on clinical studies or studies that lack sufficient control samples, but the panel refrains from drawing inferences based on this literature.

The panel believes that future research reviews of the child maltreatment literature would benefit from the identification of explicit criteria that could guide the selection of exemplary research studies, such as the following:

For the most part, only a few studies will score well in each of the above categories. It becomes problematic, therefore, to rate the value of studies which may score high in one category but not in others.

The panel has relied primarily on studies conducted in the past decade, since earlier research work may not meet contemporary standards of methodological rigor. However, citations to earlier studies are included in this report where they are thought to be particularly useful and when research investigators provided careful assessments and analysis of issues such as definition, interrelationships of various types of abuse, and the social context of child maltreatment.

A Comparison With Other Fields of Family and Child Research

A comparison with the field of studies on family functioning may illustrate another point about the status of the studies on child maltreatment. The literature on normal family functioning or socialization effects differs in many respects from the literature on child abuse and neglect. Family sociology research has a coherent body of literature and reasonable consensus about what constitutes high-quality parenting in middle-class, predominantly White populations. Family functioning studies have focused predominantly on large, nonclinical populations, exploring styles of parenting and parenting practices that generate different kinds and levels of competence, mental health, and character in children. Studies of family functioning have tended to follow cohorts of subjects over long periods to identify the effects of variations in childrearing practices and patterns on children's

competence and adjustment that are not a function of social class and circumstances.

By contrast, the vast and burgeoning literature on child abuse and neglect is applied research concerned largely with the adverse effects of personal and social pathology on children. The research is often derived from very small samples selected by clinicians and case workers. Research is generally cross-sectional, and almost without exception the samples use impoverished families characterized by multiple problems, including substance abuse, unemployment, transient housing, and so forth. Until recently, researchers demonstrated little regard for incorporating appropriate ethnic and cultural variables in comparison and control groups. In the past decade, significant improvements have occurred in the development of child maltreatment research, but key problems remain in the area of definitions, study designs, and the use of instrumentation.

As the nature of research on child abuse and neglect has evolved over time, scientists and practitioners have likewise changed. The psychopathologic model of child maltreatment has been expanded to include models that stress the interactions of individual, family, neighborhood, and larger social systems. The role of ethnic and cultural issues are acquiring an emerging importance in formulating parent-child and family-community relationships. Earlier simplistic conceptionalizations of perpetrator-victim relationships are evolving into multiple-focus research projects that examine antecedents in family histories, current situational relationships, ecological and neighborhood issues, and interactional qualities of relationships between parent-child and offender-victim. In addition, emphases in treatment, social service, and legal programs combine aspects of both law enforcement and therapy, reflecting an international trend away from punishment, toward assistance, for families in trouble.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families in the U.S. Department of Health and Human Services requested that the National Academy of Sciences convene a study panel to undertake a comprehensive examination of the theoretical and pragmatic research needs in the area of child maltreatment. The Panel on Research on Child Abuse and Neglect was asked specifically to:

The report resulting from this study provides recommendations for allocating existing research funds and also suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected. By focusing this report on research priorities and the needs of the research community, the panel's efforts were distinguished from related activities, such as the reports of the U.S. Advisory Board on Child Abuse and Neglect, which concentrate on the policy issues in the field of child maltreatment.

The request for recommendations for research priorities recognizes that existing studies on child maltreatment require careful evaluation to improve the evolution of the field and to build appropriate levels of human and financial resources for these complex research problems. Through this review, the panel has examined the strengths and weaknesses of past research and identified areas of knowledge that represent the greatest promise for advancing understanding of, and dealing more effectively with, the problem of child maltreatment.

In conducting this review, the panel has recognized the special status of studies of child maltreatment. The experience of child abuse or neglect from any perspective, including victim, perpetrator, professional, or witness, elicits strong emotions that may distort the design, interpretation, or support of empirical studies. The role of the media in dramatizing selected cases of child maltreatment has increased public awareness, but it has also produced a climate in which scientific objectivity may be sacrificed in the name of urgency or humane service. Many concerned citizens, legislators, child advocates, and others think we already know enough to address the root causes of child maltreatment. Critical evaluations of treatment and prevention services are not supported due to both a lack of funding and a lack of appreciation for the role that scientific analysis can play in improving the quality of existing services and identifying new opportunities for interventions. The existing research base is small in volume and spread over a wide variety of topics. The contrast between the importance of the problem and the difficulty of approaching it has encouraged the panel to proceed carefully, thoroughly distinguishing suppositions from facts when they appear.

Research on child maltreatment is at a crossroads—we are now in a position to merge this research field with others to incorporate multiple perspectives, broaden research samples, and focus on fundamental issues that have the potential to strengthen, reform, or replace existing public policy and social programs. We have arrived at a point where we can

recognize the complex interplay of forces in the origins and consequences of child abuse and neglect. We also recognize the limitations of our knowledge about the effects of different forms of social interventions (e.g., home visitations, foster care, family treatment programs) for changing the developmental pathways of abuse victims and their families.

The Importance Of A Child-Oriented Framework

The field of child maltreatment studies has often divided research into the types of child maltreatment under consideration (such as physical and sexual abuse, child neglect, and emotional maltreatment). Within each category, researchers and practitioners have examined underlying causes or etiology, consequences, forms of treatment or other interventions, and prevention programs. Each category has developed its own typology and framework of reference terms, and researchers within each category often publish in separate journals and attend separate professional meetings.

Over a decade ago, the National Research Council Committee on Child Development Research and Public Policy published a report titled Services for Children: An Agenda for Research (1981). Commenting on the development of various government services for children, the report noted that observations of children's needs were increasingly distorted by the "unmanageably complex, expensive, and confusing" categorical service structure that had produced fragmented and sometimes contradictory programs to address child health and nutrition requirements (p. 15-16). The committee concluded that the actual experiences of children and their families in different segments of society and the conditions of their homes, neighborhoods, and communities needed more systematic study. The report further noted that we need to learn more about who are the important people in children's lives, including parents, siblings, extended family, friends, and caretakers outside the family, and what these people do for children, when, and where.

These same conclusions can be applied to studies of child maltreatment. Our panel considered, but did not endorse, a framework that would emphasize differences in the categories of child abuse or neglect. We also considered a framework that would highlight differences in the current system of detecting, investigating, or responding to child maltreatment. In contrast to conceptualizing this report in terms of categories of maltreatment or responses of the social system to child maltreatment, the panel presents a child-oriented research agenda that emphasizes the importance of knowing more about the backgrounds and experiences of developing children and their families, within a broader social context that includes their friends, neighborhoods, and communities. This framework stresses the importance of knowing more about the qualitative differences between children who suffer episodic experiences of abuse or neglect and those for whom mal-

treatment is a chronic part of their lives. And this approach highlights the need to know more about circumstances that affect the consequences, and therefore the treatment, of child maltreatment, especially circumstances that may be affected by family, cultural, or ethnic factors that often remain hidden in small, isolated studies.

An Ecological Developmental Perspective

The panel has adopted an ecological developmental perspective to examine factors in the child, family, or society that can exacerbate or mitigate the incidence and destructive consequences of child maltreatment. In the panel's view, this perspective reflects the understanding that development is a process involving transactions between the growing child and the social environment or ecology in which development takes place. Positive and negative factors merit attention in shaping a research agenda on child maltreatment. We have adopted a perspective that recognizes that dysfunctional families are often part of a dysfunctional environment.

The relevance of child maltreatment research to child development studies and other research fields is only now being examined. New methodologies and new theories of child maltreatment that incorporate a developmental perspective can provide opportunities for researchers to consider the interaction of multiple factors, rather than focusing on single causes or short-term effects. What is required is the mobilization of new structures of support and resources to concentrate research efforts on significant areas that offer the greatest promise of improving our understanding of, and our responses to, child abuse and neglect.

Our report extends beyond what is, to what could be, in a society that fosters healthy development in children and families. We cannot simply build a research agenda for the existing social system; we need to develop one that independently challenges the system to adapt to new perspectives, new insights, and new discoveries.

The fundamental theme of the report is the recognition that research efforts to address child maltreatment should be enhanced and incorporated into a long-term plan to improve the quality of children's lives and the lives of their families. By placing maltreatment within the framework of healthy development, for example, we can identify unique sources of intervention for infants, preschool children, school-age children, and adolescents.

Each stage of development presents challenges that must be resolved in order for a child to achieve productive forms of thinking, perceiving, and behaving as an adult. The special needs of a newborn infant significantly differ from those of a toddler or preschool child. Children in the early years of elementary school have different skills and distinct experiential levels from those of preadolescent years. Adolescent boys and girls demon-

strate a range of awkward and exploratory behaviors as they acquire basic social skills necessary to move forward into adult life. Most important, developmental research has identified the significant influences of family, schools, peers, neighborhoods, and the broader society in supporting or constricting child development.

Understanding the phenomenon of child abuse and neglect within a developmental perspective poses special challenges. As noted earlier, research literature on child abuse and neglect is generally organized by the category or type of maltreatment; integrated efforts have not yet been achieved. For example, research has not yet compared and contrasted the causes of physical and sexual abuse of a preschool child or the differences between emotional maltreatment of toddlers and adolescents, although all these examples fall within the domain of child maltreatment. A broader conceptual framework for research will elicit data that can facilitate such comparative analyses.

By placing research in the framework of factors that foster healthy development, the ecological developmental perspective can enhance understanding of the research agenda for child abuse and neglect. The developmental perspective can improve the quality of treatment and prevention programs, which often focus on particular groups, such as young mothers who demonstrate risk factors for abuse of newborns, or sexual offenders who molest children. There has been little effort to cut across the categorical lines established within these studies to understand points of convergence or divergence in studies on child abuse and neglect.

The ecological developmental perspective can also improve our understanding of the consequences of child abuse and neglect, which may occur with increased or diminished intensity over a developmental cycle, or in different settings such as the family or the school. Initial effects may be easily identified and addressed if the abuse is detected early in the child's development, and medical and psychological services are available for the victim and the family. Undetected incidents, or childhood experiences discovered later in adult life, require different forms of treatment and intervention. In many cases, incidents of abuse and neglect may go undetected and unreported, yet the child victim may display aggression, delinquency, substance addiction, or other problem behaviors that stimulate responses within the social system.

Finally, an ecological developmental perspective can enhance intervention and prevention programs by identifying different requirements and potential effects for different age groups. Children at separate stages of their developmental cycle have special coping mechanisms that present barriers to—and opportunities for—the treatment and prevention of child abuse and neglect. Intervention programs need to consider the extent to which children may have already experienced some form of maltreatment in order to

evaluate successful outcomes. In addition, the perspective facilitates evaluation of which settings are the most promising locus for interventions.

Previous Reports

A series of national reports associated with the health and welfare of children have been published in the past decade, many of which have identified the issue of child abuse and neglect as one that deserves sustained attention and creative programmatic solutions. In their 1991 report, Beyond Rhetoric , the National Commission on Children noted that the fragmentation of social services has resulted in the nation's children being served on the basis of their most obvious condition or problem rather than being served on the basis of multiple needs. Although the needs of these children are often the same and are often broader than the mission of any single agency emotionally disturbed children are often served by the mental health system, delinquent children by the juvenile justice system, and abused or neglected children by the protective services system (National Commission on Children, 1991). In their report, the commission called for the protection of abused and neglected children through more comprehensive child protective services, with a strong emphasis on efforts to keep children with their families or to provide permanent placement for those removed from their homes.

In setting health goals for the year 2000, the Public Health Service recognized the problem of child maltreatment and recommended improvements in reporting and diagnostic services, and prevention and educational interventions (U.S. Public Health Service, 1990). For example, the report, Health People 2000 , described the four types of child maltreatment and recommended that the rising incidence (identified as 25.2 per 1,000 in 1986) should be reversed to less than 25.2 in the year 2000. These public health targets are stated as reversing increasing trends rather than achieving specific reductions because of difficulties in obtaining valid and reliable measures of child maltreatment. The report also included recommendations to expand the implementation of state level review systems for unexplained child deaths, and to increase the number of states in which at least 50 percent of children who are victims of physical or sexual abuse receive appropriate treatment and follow-up evaluations as a means of breaking the intergenerational cycle of abuse.

The U.S. Advisory Board on Child Abuse and Neglect issued reports in 1990 and 1991 which include national policy and research recommendations. The 1991 report presented a range of research options for action, highlighting the following priorities (U.S. Advisory Board on Child Abuse and Neglect, 1991:110-113):

This report differs from those described above because its primary focus is on establishing a research agenda for the field of studies on child abuse and neglect. In contrast to the mandate of the U.S. Advisory Board on Child Abuse and Neglect, the panel was not asked to prepare policy recommendations for federal and state governments in developing child maltreatment legislation and programs. The panel is clearly aware of the need for services for abused and neglected children and of the difficult policy issues that must be considered by the Congress, the federal government, the states, and municipal governments in responding to the distress of children and families in crisis. The charge to this panel was to design a research agenda that would foster the development of scientific knowledge that would provide fundamental insights into the causes, identification, incidence, consequences, treatment, and prevention of child maltreatment. This knowledge can enable public and private officials to execute their responsibilities more effectively, more equitably, and more compassionately and empower families and communities to resolve their problems and conflicts in a manner that strengthens their internal resources and reduces the need for external interventions.

Report Overview

Early studies on child abuse and neglect evolved from a medical or pathogenic model, and research focused on specific contributing factors or causal sources within the individual offender to be discovered, addressed, and prevented. With the development of research on child maltreatment over the past several decades, however, the complexity of the phenomena encompassed by the terms child abuse and neglect or child maltreatment has become apparent. Clinical studies that began with small sample sizes and weak methodological designs have gradually evolved into larger and longer-term projects with hundreds of research subjects and sound instrumentation.

Although the pathogenic model remains popular among the general public in explaining the sources of child maltreatment, it is limited by its primary focus on risk and protective factors within the individual. Research investigators now recognize that individual behaviors are often influenced by factors in the family, community, and society as a whole. Elements from these systems are now being integrated into more complex theories that analyze the roles of interacting risk and protective factors to explain and understand the phenomena associated with child maltreatment.

In the past, research on child abuse and neglect has developed within a categorical framework that classifies the research by the type of maltreatment typically as reported in administrative records. Although the quality of research within different categories of child abuse and neglect is uneven and problems of definitions, data collection, and study design continue to characterize much research in this field, the panel concluded that enough progress has been achieved to integrate the four categories of maltreatment into a child-oriented framework that could analyze the similarities and differences of research findings. Rather than encouraging the continuation of a categorical approach that would separate research on physical or sexual abuse, for example, the panel sought to develop for research sponsors and the research community a set of priorities that would foster the integration of scientific findings, encourage the development of comparative analyses, and also distinguish key research themes in such areas as identification, incidence, etiology, prevention, consequences, and treatment. This approach recognizes the need for the construction of collaborative, long-term efforts between public and private research sponsors and research investigators to strengthen the knowledge base, to integrate studies that have evolved for different types of child maltreatment, and eventually to reduce the problem of child maltreatment. This approach also highlights the connections that need to be made between research on the causes and the prevention of child maltreatment, for the more we learn about the origins of child abuse and neglect, the more effective we can be in seeking to prevent it. In the same manner, the report emphasises the connections that need to be made between research on the consequences and treatment of child maltreatment, for knowledge about the effects of child abuse and neglect can guide the development of interventions to address these effects.

In constructing this report, the panel has considered eight broad areas: Identification and definitions of child abuse and neglect (Chapter 2) Incidence: The scope of the problem (Chapter 3) Etiology of child maltreatment (Chapter 4) Prevention of child maltreatment (Chapter 5) Consequences of child maltreatment (Chapter 6) Treatment of child maltreatment (Chapter 7)

Human resources, instrumentation, and research infrastructure (Chapter 8) Ethical and legal issue in child maltreatment research (Chapter 9)

Each chapter includes key research recommendations within the topic under review. The final chapter of the report (Chapter 10) establishes a framework of research priorities derived by the panel from these recommendations. The four main categories identified within this framework—research on the nature and scope of child maltreatment; research on the origins and consequences of child maltreatment; research on the strengths and limitations of existing interventions; and the need for a science policy for child maltreatment research—provide the priorities that the panel has selected as the most important to address in the decade ahead.

1. The panel received an anecdotal report, for example, that one federal research agency systematically changed titles of its research awards over a decade ago, replacing phrases such as child abuse with references to maternal and child health care, after political sensitivities developed regarding the appropriateness of its research program in this area.

Bell, D.A. 1992 Faces at the Bottom of the Well: The Permanence of Racism . New York: Basic Books.

Children's Defense Fund 1991 The State of America's Children . Washington, DC: The Children's Defense Fund.

Daro, D. 1988 Confronting Child Abuse: Research for Effective Program Design . New York: The Free Press, Macmillan. Cited in the General Accounting Office, 1992. Child Abuse: Prevention Programs Need Greater Emphasis. GAO/HRD-92-99.

Daro, D., and K. McCurdy 1991 Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1990 Annual Fifty State Survey . Chicago: National Committee for Prevention of Child Abuse.

Fuchs, V.R., and D.M. Reklis 1992 America's children: Economic perspectives and policy options. Science 255:41-46.

General Accounting Office 1991 Child Abuse Prevention: Status of the Challenge Grant Program . May. GAO:HRD91-95. Washington, DC.

Huston, A.C., ed. 1991 Children in Poverty: Child Development and Public Policy . New York: Cambridge University Press.

Kempe, C.H., F.N. Silverman, B. Steele, W. Droegemueller, and H.R. Silver 1962 The battered child syndrome. Journal of the American Medical Association 181(1): 17-24.

McClain, P.W., J.J. Sacks, R.G. Froehlke, and B.G. Ewigman 1993 Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 91(2):338-343.

National Commission on Children 1991 Beyond Rhetoric: A New American Agenda for Children and Families . Washington, DC: U.S. Government Printing Office.

National Research Council 1981 Services for Children: An Agenda for Research . Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

U.S. Advisory Board on Child Abuse and Neglect 1990 Child Abuse and Neglect: Critical First Steps in Response to a National Emergency . August. Washington, DC: U.S. Department of Health and Human Services. August. 1991 Creating Caring Communities . September. Washington, DC: U.S. Department of Health and Human Services.

U.S. Public Health Service 1990 Violent and abusive behavior. Pp. 226-247 (Chapter 7) in Healthy People 2000 Report . Washington, DC: U.S. Department of Health and Human Services.

The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

• Definitions and scope —exploring standardized classifications, analysis of incidence and prevalence trends, and more.
• Etiology, consequences, treatment, and prevention —analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.
• Infrastructure and ethics —including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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127 Captivating Child Abuse Essay Ideas, Research Questions & Essay Examples

Child abuse is one of the crucial problems that has been overlooked for many centuries. At the same time, it is an extremely sensitive issue and should be recognized and reduced as much as possible.

In this article, you will find child abuse research topics and ideas to use in your essay.

Let’s start!

📝 The Child Abuse Essay Structure

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Child abuse is one of the most problematic topics in today’s society. Writing child abuse essays may be challenging because it requires analyzing sensitive issues.

The problem refers to physical, psychological, or sexual mistreatment of children. It is vital to discuss this acute issue in studies and essays on child abuse.

Before working on your essay, you should select a topic for discussion. Here are some child abuse essay topics that we can suggest:

• The problem of child abuse in the US (Canada, the UK)
• Child abuse: Types and definitions
• Child neglect crimes and their causes
• Current solutions to the problem of sexual abuse of children
• The importance of child maltreatment prevention programs
• Child abuse: Legal implications
• Consequences of child abuse and neglect

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• Child Abuse in the Victorian Era in Great Britain This was unacceptable in the eyes of the factory owners resulting in the implementation of the practice of children being sent into the mechanisms of machines while they were still operating since they were supposedly […]
• Ethical Dilemma of Child Abuse In the above example, a nurse has to apply rational judgment to analyze the extent and threats when making decisions in the best interest of the victim of child abuse.
• Daniel Valerio Child Abuse In the end, it was an electrician who identified the typical signs of abuse in Daniel that finally led police to investigate, thereby exposing the weakness and ineffectiveness of the Dual Track System; the child […]
• Child Abuse: Preventive Measures My artifact is an infographic that communicates the various forms of child abuse and how to report them to the necessary authorities.
• Physical Child Abuse Usually the child is unaware of the abuse due to the na ve state of mind or innocence. Physical abuse also lowers the social-economic status and thus high chances of neglect or abuse due to […]
• Problem of Child Abuse The most common form of child abuse in America and in most parts of the world is child abuse. The cost of child abuse is dire to both the children, healthcare organizations, parents, and the […]
• The Prevention of Child Abuse From the interview conducted with the school administrator of the local elementary school and the director of a local preschool, it is clear that both institutions have some advocacy plans for the prevention of child […]
• Hidden Epidemic of Child Abuse and Neglect Child abuse should be perceived as a form of deviant behavior to which researchers give different explanations: biological, psychological, socio-cultural.
• Child Abuse: History and Causes The purpose of this paper is to explore the history, and causes of child abuse as well as the legislation implemented to address its cases.
• Effects of Child Abuse and Neglect Antisocial behaviour is one of the outcomes of child abuse and parental neglect that may be disclosed in a variety of forms.
• Child Abuse Issues and Its Effects The recognition of child abuse signs is a very important step as it is wrong to believe that child maltreatment takes place because of the presence of a single sing or poor understanding of child […]
• Child Abuse and Capstone Project This is why the problem of child abuse remains to be crucial for analysis, as people have to understand its urgency and effects on human behavior.
• Child Abuse: Altruistic Behavior Intervention plays a crucial role in the prevention of child abuse, as it helps to eliminate the possibility of the recurrence of events.
• Child Abuse Versus Elder Abuse The second distinction is that older people frequently encounter issues that might lead to abuse or neglect, particularly in nursing homes, such as mental disability, loneliness, and physical limitation.
• The Relationship Between Child Abuse and Embitterment Disorder Some emotions, like the dread of tests in school or sibling rivalry and conflicts, are a regular part of growing up.
• Trafficking Causes Child Abuse and Neglect The dissociation of children from their families and the exposure to intense trauma they are subjected to during and after trafficking may cause the minors to have attachment problems.
• Child Abuse and Maltreatment Discussion Additionally, this may cause a child’s behavior to change, such as making a sad or melancholy face or becoming furious with parents or other adults. When it comes to emotional abuse, a child may feel […]
• Impact of Child Abuse on Adulthood: An Idea Worth Spreading A frequent argument of those who do not want to recognize the scale of the problem of abuse in the world is “Beating is a sign of love!”.
• Effects of Child Abuse on Adults Second, she was so irrationally averse to the idea of having children that I knew immediately that it would be a contentious point in her future relationships.
• Domestic Violence, Child Abuse, or Elder Abuse In every health facility, a nurse who notices the signs of abuse and domestic violence must report them to the relevant authorities.
• Child Abuse: Screening Methods and Creating Financial Programs When the reporting is mandatory, it is easy to follow its guidelines which should be carefully elaborated not to be harsh on parents and at the same time offer protection to a child.
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• Discussion of Child Abuse: Case of COVID-19 In Cincinnati, 3-year-old Nylo Lattimore was missed in December 2020, and only after 143 days, the child’s body was discovered in the Ohio River.
• Child Abuse Allegations: Multidisciplinary Team Approach In children with allegations of child abuse, what is the effectiveness of the multidisciplinary team approach compared to the non-multidisciplinary team approach on prosecution rates, mental health referrals, and provision of medical examinations?
• Criminal Justice System: Child Abuse During the consideration of cases as part of a grand jury, citizens perform some functions of the preliminary investigation bodies.
• Promoting Child Abuse Prevention Services in Oahu, Hawaii, and the US The primary goal the Hui Hawaii organization is trying to achieve is to improve the well-being of American children by preventing abuse, neglect, and depression.
• Child Abuse in Singapore The second reason for child abuse in Singapore to continue being one of the most underreported illegal offenses is the country’s collectivist culture.
• Protocol for Pre-Testing the Child Abuse and Neglect Public Health Policy Based on the above, it is necessary to identify the conditions of child abuse like the quality of family relations and improper upbringing.
• Child Abuse: Term Definition However, there is a component that is not so clearly represented in other crimes: a third party, who has observed the abuse or the consequences of abuse has the legal obligation and reasonable cause of […]
• Discipline and Child Abuse: Motivation and Goals The first proof of the justice and reasonableness of discipline is that it is permitted by law to be considered to be the most authoritative source to consult.
• Sociological Perspective on “Punishment” as a Major Contributor to Child Abuse This is done with the aim of ensuring that the child is disciplined and is perceived as a legitimate punishment. This has offered a loophole to parents to abuse the child in the name of […]
• Critical Statistical Data Regarding the Issues Related to Child Abuse Due to acts of abuse children suffer greatly and it will not be wrong to say that these experiences are definitely engraved into the child’s personality.
• Socio-Economic Standing and Propensity for Child Abuse Physicians were the first to notice and report evidence of child abuse and neglect in the 1960s. The UNICEF corroborates the relationship of poverty with child abuse, neglect, and maltreatment.
• Child Abuse and Culture: Juan’s Case Analysis The following is the list of reflective insights that I came to while getting myself familiarized with Juan’s case and analyzing this case’s discursive implications: When addressing the issue of children being suspected to have […]
• New Jersey’s Bill on Child Abuse and Neglect The legislation’s impact is expected to be large because it is targeted at raising awareness of the pervasive issue of child abuse and encouraging the public to stay active and not to disregard any signs […]
• Child Abuse in the UAE and Explaining Theories The interest of carrying out the study on child abuse is based on the fact that it is a critical issue in any society, especially due to the actual and possible consequences on the child […]
• Child Abuse and Neglect and Family Practice Model Also, psychological violence can be either the only form of violence or the consequence of psychological or sexual abuse or neglect. Inadequate evaluation of the child’s capabilities and overstated requirements can also be a form […]
• Child Abuse and Protective Act in Idaho Also, abandonment is recognized in Idaho’s definition of child abuse, and, according to the Act, it means the failure of the parent or the guardian to foster a normal relationship with the child.
• Child Abuse and Neglect: Drug and Alcohol Problems The families of individuals who have committed a drug related offense should be investigated in order to ensure the practice is acceptable and capable of supporting the needs of more societies.
• Child Abuse as a Result of Insufficient Policies According to Latzman and Latzman, child abuse may be manifested in the use of excessive physical force when disciplining a child or an adolescent.
• Child Abuse and Neglect A church/synagogue/mosque retreat activity for parents and they children can be beneficial in strengthening parents to deal with the issues of child abuse and neglect.
• Child Abuse Problem The study of the problem of child abuse has begun in the 60s with focusing attention to children problems. In such a case the early recognition of child abuse is of great importance.
• The Causes and Effects of Child Abuse The main problem of the project is the presence of a number of effects of child abuse and parental neglect on children, their development, and communication with the world.
• A True Nature of the Effects of Child Abuse and Neglect in a Society The outcomes of child abuse usually depend on a variety of factors like the age of a child, the type of relation between a child and a perpetrator, and, of course, the type of maltreatment.
• A True Nature of the Effects of Child Abuse A society is in need of powerful and effective research that can prove the necessity to introduce the issue of child abuse and its effects as a leading problem the solution of which requires the […]
• Child Abuse Problems and Its Effects on a Future Child’s Life In fact, there were the three main challenges in writing the literature review just completed that were overcome due to the ability to organize the work, follow the suggestions of the experts, and keep in […]
• Effects of Child Abuse The nature of the effects of child abuse, their consequences in a society, and the most appropriate preventive methods should be considered.
• The Effects of Child Abuse: Capstone Project Time Line The development of a Capstone Project will become a new step in solving the problem and thinking about the possible ways of improvement the situation and creation the most appropriate living conditions for children.
• Introducing Improvements to Children Abuse Reporting System The paper is connected with the analysis of the quality of the current child abuse report systems because of the serious problems in the sphere of childcare.
• Biological Underpinnings Behind Child Abuse The dimension of the baby’s head is also seen to decrease in quantity from on third of the whole body at birth, to a quarter at the age of two years and to an eighth […]
• Cause and Effect of Child Abuse Parental response to the children is also presented in a form of abuse of the rights of the children, as they feel neglected or disowned.
• Abuse in Childhood Common Among Alcohol Addicts Dwelling upon the impact of the violence and abuse during childhood, the connection with the further disabilities and disorders is obvious.
• Child Abuse: A Case for Imposing Harsher Punishments to Child Abusers While harsh punishments appear to offer a solution to the problem, this measure may be detrimental to the welfare of the child in the case where the abuser is its guardian.
• Child Abuse and Neglect Children in Court The objective of this paper was to determine the level of knowledge and nature of attitudes among maltreated children who appeared in court during their detention case hearings.
• Randomized Trial of Cognitive-Behavioral Therapy for Chronic Post-Traumatic Stress Disorders in Adult Female Survivors of Childhood Sexual Abuse However, in spite of the fact that there exist a wealth of clinical literature on treatment methodologies of victims of sexual abuse, the evidence base concerning the treatment of victims of childhood sexual abuse exhibiting […]
• Child Sexual Abuse: Impact and Consequences Due to the adverse consequences of sexual abuse, efforts to have Jody share her ordeal and get immediate help would be my priority.
• Educational Program on Child Abuse The report “Initial reliability and validity of a new retrospective measure of child abuse and neglect” by Bernstein, Fink and Handelsman provides the findings of the consistency and validity of some of the conservative measures […]
• Public Health Media Campaign Proposal for Child Abuse
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• The Reasons and Three Most Common Factors Contributing to Child Abuse in Our Society
• Child Abuse and Its Effects on Social and Personality Development
• Neo-Liberal and Neo-Conservative Perspectives on Child Abuse
• Physical and Behavioural Indicators of Possible Child Abuse
• Defining Child Abuse and Its Different Forms in the 21st Century
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• State the Possible Types, Signs and Symptoms of Child Abuse and Why It Is Important to Follow the Policies and Procedures of the Work Place
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• Describing Child Abuse, Its Different Forms, and Solutions to the Problem
• Child Abuse: The Four Major Types of Abuse, Statistics, Prevention, and Treatment
• Causes and Risk Factors Behind Child Abuse
• Child Abuse, Cause, and Effect on the Rest of Their Lives
• Child Abuse Has Severe Negative Psychological Effects on Children
• Child Abuse and the Professional Network Working Within the Child Protec
• Child Abuse Prevention and Control: Can Physical, Sexual or Psychological Abuse Be Controlled Within the Household?
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• Child Abuse: Victim Rights & the Role of Legal Representative
• Child Abuse and the Legal System – Developmental Forensic Psychology: Unveiling Four Common Misconceptions
• Parent Stress Factors and Child Abuse: A Tutoring Proposal
• Approaching Child Abuse From a Multi-Dimensional Perspective
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• Suspected Child Abuse and the Teacher´S Role in Reporting It
• Child Abuse and Its Correlation to Poverty
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• Relationship Between Domestic Violence and Child Abuse and How to Protect the Children From It
• Child Abuse Saddest and Most Tragic Problem Today
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• Why Should People Care About Child Abuse?
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• How to Protect Children From Abuse and Neglect?
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• How Can the Community Stop Child Abuse and Neglect?
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• How Do the Government and Society Have a Responsibility to Help Child Abuse Victims?
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IvyPanda. (2024, March 2). 127 Captivating Child Abuse Essay Ideas, Research Questions & Essay Examples. https://ivypanda.com/essays/topic/child-abuse-essay-examples/

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What Is Verbal Abuse?

Sherri Gordon, CLC is a published author, certified professional life coach, and bullying prevention expert. She's also the former editor of Columbus Parent and has countless years of experience writing and researching health and social issues.

Akeem Marsh, MD, is a board-certified child, adolescent, and adult psychiatrist who has dedicated his career to working with medically underserved communities.

Verywell / Laura Porter

Frequently Asked Questions

Verbal abuse is a type of emotional abuse. It is when someone uses their words to assault, dominate, ridicule, manipulate, and/or degrade another person and negatively impact that person's psychological health. Verbal abuse is a means of controlling and maintaining power over another person.

Most people assume that if they were being verbally abused they would know about it. After all, verbal abuse often involves yelling, put-downs, name-calling, and belittling behaviors. But there is more to verbal abuse than people realize. Some people are verbally abused on a regular basis without even recognizing that it’s happening.

Verbal abuse can occur in any type of relationship: romantic relationships, parent-child relationships, family relationships, and co-worker relationships.

Verbal abuse sometimes precedes physical abuse; however, this is not always the case. Verbal abuse can exist without physical abuse. The effects of verbal abuse can be just as damaging as those of physical abuse.

This article covers what verbal abuse is, the signs and impact of verbal abuse, as well as how to seek help if you are coping with the effects of verbal abuse.

Click Play to Learn More About Verbal Abuse

This video has been medically reviewed by Rachel Goldman, PhD, FTOS .

Signs of Verbal Abuse

Verbal abuse involves using words to name call, bully, demean, frighten, intimidate, or control another person. This can include overt verbal abuse such as yelling, screaming, or swearing. Such behaviors are attempts to gain power, and the goal is to control and intimidate you into submission. As a result, it is abusive and should not be tolerated or excused. 

However, verbal abuse can also be much more subtle. Victims of verbal abuse often question whether or not what they are experiencing is truly abusive. They also wonder whether or not it is a big deal.

Some signs that you are experiencing verbal abuse include:

• You are afraid of your abuser
• You feel like you have to walk on eggshells around the other person
• You feel like you cannot share things about yourself with them for fear that they will mock or ridicule you
• You're afraid to go out in public with them because of what they will say about you in front of other people
• You feel threatened
• You feel as if you are constantly being put down about how you look, think, act, dress, or talk
• You feel inferior or ashamed about who you are
• They yell at you but then suggest that you are overly sensitive or that you don't have a sense of humor
• They overreact to small problems and then blame you for the resulting argument
• They suggest that they are the victim and try to make you feel guilty about something they accuse you of doing
• They hide this verbal abuse when you are around other people but act completely different when you are alone

Verbal abuse can also be used to harass people by humiliating, insulting, criticizing, or demeaning them using words. This can often be used as a way to intimidate or bully people in a variety of settings, including in relationships and the workplace.

People engage in verbal abuse for a variety of reasons. Family history, past experiences, personality, and mental illness are a few factors that can play a role.

The goal of the abuser is to control you by making you feel bad about who you are.

Types of Verbal Abuse

When someone is being verbally abused, the person attacking them may use overt forms of abuse like engaging in name-calling and making threats, but also more insidious methods like gaslighting or constantly correcting, interrupting, putting down, and demeaning them.

Even prolonged silent treatment is a form of verbal abuse. When this happens, the person is attempting to control and punish the victim by refusing to talk to them.

For some people, especially those who experience verbal abuse in the home or experienced it as a child, it can often be overlooked because verbal assaults feel like a normal way to communicate. But they are anything but normal and can have lasting consequences.

Verbal abuse can take many different forms, including:

• Blaming : This type involves making the victim believe they are responsible for the abusive behavior or that they bring the verbal abuse upon themselves.
• Condescension : While often disguised as humor, sarcastic comments that are intended to belittle and demean the other person can be a form of verbal abuse.
• Criticism : This involves harsh and persistent remarks that are meant to make the person feel bad about themselves and are not constructive but deliberate and hurtful. Criticism can be painful in public or private, particularly if the person is simply being mean and has no intention of being constructive. 
• Gaslighting : This is a type of insidious, and sometimes covert, emotional abuse where the abuser makes the target question their judgments and reality.
• Humiliation : When you are insulted in public by a peer, a friend, a family member, or a dating partner, this can be particularly painful.
• Judging : This type of verbal abuse involves looking down on the victim, not accepting them for who they are, or holding them to unrealistic expectations.
• Manipulation : Using words to manipulate and control the other person is also a type of verbal abuse. This can include making statements like, "If you really loved me, you wouldn't talk to other people about our relationship," or using guilt trips to get you to do certain things
• Name-calling : Abusive, derogatory language, or insults that chip away at the target’s self-esteem, sense of self-worth, and self-concept. Anytime someone engages in name-calling, it is a form of verbal abuse. Even if the names are said in a neutral voice, this is not an acceptable treatment of another person.
• Ridicule : Typically, verbally abusive people will make you the butt of their jokes . This can be done in private or in person. But if you don't find it funny, then it is not harmless fun. What's more, verbally abusive people usually select jokes that attack an area where you feel vulnerable or weak.
• Threats : This involves statements meant to frighten, control, and manipulate the victim into compliance. No threat should ever be taken lightly. When people make threats, they are trying to control and manipulate you . Remember, there is no better way to control someone than to make them fearful in some way.
• Withholding : This type of verbal abuse involves a refusal to give affection or attention, including talking to you, looking at you, or even being in the same room with you. Examples of withholding or ignoring include stonewalling or giving someone the silent treatment.

While not an exhaustive list, these are several examples of the common types of verbal abuse that can occur.

Impact of Verbal Abuse

Verbal abuse can impact every element of life, from academic performance to relationships to success at work. Just like any other form of abuse or bullying, verbal abuse has both short- and long-term consequences, including:

• Changes in mood
• Chronic stress
• Decreased self-esteem
• Feelings of shame, guilt, and hopelessness
• Post-traumatic stress disorder (PTSD)
• Social withdrawal and isolation
• Substance use

When verbal abuse is particularly severe, it can impact whether or not people can see themselves as being successful in any area of life. Those who experience verbal abuse as children may experience feelings of worthlessness, difficulty trusting others, and problems regulating their emotions as adults.

A number of studies have shown that children who are verbally abused, either at home or by their peers at school, are at a greater risk for depression and anxiety as adults.

It is not uncommon for a person who is verbally abused to feel inadequate, stupid, and worthless. In some cases. they are explicitly told they are these things by the person abusing them.

Verbal abuse can be particularly confusing because the partner may not be abusive all of the time and their behavior likely emerged slowly over time. In this way, verbal abuse can be insidious and subtle.

As a result, when the abuser is loving and gentle, the victim can forget about the negative behavior. Ultimately, the victim ends up ignoring the pattern of verbal abuse or makes excuses for the behavior, saying that the abuser is just stressed or going through a tough time right now.

What to Do About Verbal Abuse

The first step in dealing with verbal abuse is to recognize the abuse. If you were able to identify any type of verbal abuse in your relationship, it's important to acknowledge that first and foremost.

By being honest about what you are experiencing, you can begin to take steps to regain control. While you need to consider your individual situation and circumstances, these tips can help if you find yourself in a verbally abusive relationship.

Set Boundaries

Firmly tell the verbally abusive person that they may no longer criticize, judge or shame you, name-call, threaten you, and so on. Then, tell them what will happen if they continue this abusive behavior.

For instance, tell them that if they scream or swear at you, the conversation will be over and you will leave the room. The key is to follow through; don't set boundaries you have no intention of keeping.

Limit Exposure

If possible, take time away from the verbally abusive person and spend time with people who love and support you. Limiting exposure with the person can give you space to reevaluate your relationship. Surrounding yourself with a network of friends and family will help you feel less lonely and isolated and remind you of what a healthy relationship should look like .

End the Relationship

If there are no signs that the verbal abuse will end, or that the person has any intention of working on their behavior, you will likely need to take steps to end the relationship.

Before doing so, share your thoughts and ideas with a trusted friend, family member, or counselor. You may also want to come up with a safety plan in case the abuse escalates when you break things off.

Healing from a verbally abusive relationship may not be something you can do on your own. Reach out to trusted loved ones for support, and consider talking to a therapist who can help you process your emotions and develop healthy coping skills for dealing with the short- and long-term consequences of verbal abuse.

If you or a loved one are a victim of domestic violence, contact the  National Domestic Violence Hotline  at  1-800-799-7233  for confidential assistance from trained advocates.

For more mental health resources, see our  National Helpline Database .

A Word From Verywell

Although the effects of verbal abuse can be significant, there is still hope. Once a person recognizes verbal abuse in their lives, they can start making informed decisions about which friendships and dating relationships are healthy and which are toxic, fake, or abusive. They also can learn to stand up to verbal bullying.

Remember, verbal abuse doesn't have to leave a lasting impact. With intervention, victims can overcome and cope with the bullying they have experienced. 

Try to call out the abuse when it happens by requesting the person stop the behavior. If they don't listen, safely remove yourself from the situation. Consider limiting your interactions with this person and/or ending the relationship.

Verbal abuse is a form of emotional abuse where someone uses their words to invoke fear in another person and gain control over them. Types of verbal abuse include name-calling, criticizing, gaslighting, and threatening.

Keep a record of verbal abuse incidents, writing down the type of abuse, when and where it occurred, and the impact of the abuse, such as mental distress. It may be helpful to talk to any witnesses of the abuse and ask if they are willing to testify on your behalf, if necessary.

Talk to the abuser and request they stop their behavior. Document incidents of abuse and inform the human resources department. Bullying isn't covered by federal law, but workplace discrimination and harassment are. Seek legal advice if your workplace isn't supportive of your claims.

The first step is to put an end to the verbal abuse you're experiencing. Seek the help of a qualified mental healthcare professional, and confide in trusted family and friends. With support, you can recover from verbal abuse.

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Shdaifat EA, Al Amer MM, Jamama AA. Verbal abuse and psychological disorders among nursing student interns in KSA .  J Taibah Univ Med Sci . 2020;15(1):66-74. doi:10.1016/j.jtumed.2019.12.007

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U.S. Equal Employment Opportunity Commission. What is employment discrimination? .

U.S. Equal Employment Opportunity Commission. Harassment .

By Sherri Gordon Sherri Gordon, CLC is a published author, certified professional life coach, and bullying prevention expert. She's also the former editor of Columbus Parent and has countless years of experience writing and researching health and social issues.

Up to 40pc of mental health conditions are linked to child abuse and neglect, study finds

In 1996, Ange McAuley was just 11 years old when ABC's Four Corners profiled her family living on Brisbane's outskirts.

At the time her mother was pregnant with her sixth child and her father had long ago moved back to Perth.

WARNING: This story contains details that may be distressing to some readers.

It was a story about child protection and the program was profiling the role of community volunteers helping her mother, who had been in and out of mental health wards.

Ange was the eldest and it fell to her to get her younger siblings ready for school.

By the time the new baby arrived, she would stay home and change nappies.

"It was pretty crazy back then — I wasn't going to school a lot," she said.

By that age she was already holding a secret — she'd been sexually abused at age six by her stepfather, who would later be convicted of the crime.

"Back in the nineties, a lot of people kept stuff hidden and it wasn't spoken about outside of the family," she said.

"I've carried all these big burdens that weren't even mine. Sexual abuse happened to me. I didn't ask for it."

She says the trauma triggered a lifetime of mental health problems from substance abuse and self-harm as a teen, right through to post-natal depression.

Hidden source of our mental health crisis

A new study from the University of Sydney's Matilda Centre has established just how much Australia's mental health crisis can be traced back to this kind of childhood abuse and neglect.

The research has found that childhood maltreatment is responsible for up to 41 per cent of common mental health conditions including anxiety, depression, substance abuse, self-harm and suicide attempts.

The research, which draws on a 2023 meta-analysis of 34 research studies covering 54,000 people, found maltreatment accounted for 41 per cent of suicide attempts in Australia, 35 per cent of self-harm cases and 21 per cent of depression episodes.

It defined childhood maltreatment as physical, sexual, emotional abuse, emotional or physical neglect and domestic violence before the age of 18.

Lead researcher Lucy Grummitt said it is the first piece of work to quantify the direct impact of child abuse on long-term mental health. 

It found if childhood maltreatment was eradicated it would avert more than 1.8 million cases of depression, anxiety and substance use disorders.

"It shows just how many people in Australia are suffering from mental health conditions that are potentially preventable," she said.

Dr Grummitt said they found in the year 2023 child maltreatment in Australia accounted for 66,143 years of life lost and 118,493 years lived with disability because of the associated mental health conditions.

"We know that when a child is exposed to this level of stress or trauma, it does trigger a lot of changes in the brain and body," Dr Grummitt said.

"Things like altering the body's stress response will make a child hyper-vigilant to threat. It can lead to difficulties with emotion regulation, being able to cope with difficult emotions."

While some areas of maltreatment are trending down, figures from the landmark Australian child maltreatment study last year show rising rates of sexual abuse by adolescents and emotional abuse.

That study found more than one in three females and one in seven males aged 16 to 24 had experienced childhood sexual abuse.

Dr Grummit says childhood trauma can affect how the brain processes emotions once children become teens.

"It could be teenagers struggling to really cope with difficult emotions and certainly trauma can play a huge role in causing those difficult emotions," she said.

Mental health scars emerge early

For Ange, the trauma of her early years first showed itself in adolescence when she started acting out — she remembers punching walls and cars, binge drinking and using drugs.

"I would get angry and just scream," she said.

"I used to talk back to the teachers. I didn't finish school. Mum kicked me out a lot as a teenager. I was back and forth between mum and dad's."

By the time she disclosed her abuse, she was self-harming and at one point tried to take her own life.

"I was just done," she said.

"I was sick of having to get up every day. I didn't want to do it anymore."

Later on, she would have inappropriate relationships with much older men and suffered from depression, including post-natal depression.

"It's definitely affected relationships, it's affected my friendships, it's affected my intimate relationships," she said.

"Flashbacks can come in at the most inappropriate times — you're back in that moment and you feel guilt and shame.

"I feel like it's held me back a lot."

Calls for mental health 'immunisation'

Dr Grummitt said childhood abuse and neglect should be treated as a national public health priority.

In Australia, suicide is the leading cause of death for young people. 

"It's critical that we are investing in prevention rather than putting all our investments into treatment of mental health problems," she said.

Her team has suggested child development and mental health check-ins become a regular feature across a person's lifetime and have proposed a mental health "immunisation schedule".

Chief executive of mental health charity Prevention United, Stephen Carbone, said they estimate that less than 1 per cent of mental health funding goes toward prevention.

"There's been a big steady increase in per capita funding for mental health over the last 30 years but that hasn't translated into reductions," Dr Carbone, a GP, said. 

"You're not going to be able to prevent mental health conditions unless you start to tackle some of these big causes, in particular child maltreatment."

He said most of Australia's child protection system was about reacting to problems rather than trying to prevent them.

"If you're not tackling the upstream risk factors or putting in place protective factors you just keep getting more and more young people experiencing problems and services being overwhelmed," he said.

Now a mother of two teens herself, Ange says she wants to break the cycle and has been going to therapy regularly to help identify and avoid destructive patterns that she's seen herself fall into.

"I love my girls so much and I want better for them."

• X (formerly Twitter)

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Home — Essay Samples — Nursing & Health — Drug Addiction — Mental Health and Drug Abuse

Mental Health and Drug Abuse

• Categories: Drug Addiction

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Words: 463 |

Published: Jan 31, 2024

Words: 463 | Page: 1 | 3 min read

Table of contents

The prevalence of mental health disorders, the link between mental health disorders and drug abuse, the impact of drug abuse on mental health, factors influencing comorbidity of mental health disorders and drug abuse, treatment approaches for individuals with co-occurring disorders, prevention strategies for individuals at risk.

• World Health Organization. (2021). Mental Health. https://www.who.int/health-topics/mental-health#tab=tab_1
• National Institute on Drug Abuse. (2021). Comorbidity: Substance Use Disorders and Other Mental Illnesses. https://www.drugabuse.gov/publications/drugfacts/comorbidity-substance-use-disorders-other-mental-illnesses
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.

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Why am I lonely? Lack of social connections hurts Americans' mental health.

Tens of millions of people don’t have relationships that provide meaning in daily life. no amount of federal money − no number of mental health workers or programs − will solve that problem..

We need a new way to think about mental health − one that recognizes every person’s role in tackling the crisis that surrounds us.

We all know this crisis exists. After the COVID-19 pandemic, record numbers of people have reported mental health challenges. About 20% of U.S. adults − nearly 60 million Americans − have a diagnosable mental illness. Nearly 40% of high school students − and half of high school girls − say their mental health has struggled in recent years. Anxiety, depression and suicide have soared. So has addiction , which about 1 in 5 Americans now struggle with.

Amid this crisis, government at all levels is desperately trying to make a difference, mainly through new programs and funding streams. President Joe Biden’s proposed 2024 budget, for instance, envisions a  44% increase in federal spending on the Substance Abuse and Mental Health Services Administration. In the State of the Union address, he called for funding “ more mental health workers .”

We need more than increased spending to help with the mental health problem

And states like Florida and Virginia are now spending record amounts on mental health services.

Yet more money and more workers aren’t silver bullets. It’s true that America has just one mental health professional for every 350 people who need help , but there’s no credible path to close that gap. Even if we could, more than half of  people with mental health challenges still avoid care because of social stigma.

That helps explain why  big federal funding increases  before the pandemic didn’t make much of a difference − mental health challenges continued to rise.

Clearly, some root cause is going unaddressed.

Hence the need for a new approach. The mental health advocates and substance abuse experts whom my organization has worked with over the past decade show the way. They prove that the mental health crisis isn’t just a clinical crisis. It’s really a crisis of community.

To be sure, clinical settings and clinical tools are essential for many people with mental health disorders. But it’s also true that mental health is ultimately about psychological well-being. Everyone is looking for a life of meaning, and finding that life requires a supportive community.

Americans increasingly feel isolated and lonely

The famous psychologist Abraham Maslow said it better than I can. Based on his experience treating tens of thousands of patients, he realized that mental health challenges ultimately arise when people’s deeper needs aren’t met. Most notably, when people lack relationships, belonging and love, they get lonely, leading to anxiety and depression. Left unchecked, loneliness can ruin someone’s life.

What’s happening in America supports Maslow’s theory. Last year, the U.S. surgeon general  called loneliness an “epidemic,” and an  American Psychiatric Association poll conducted this January found that a third of of adults say they have experienced feelings of loneliness at least once a week over the past year.

About  30% of millennials have zero best friends , while Generation Z has been called “the loneliest generation.” The situation is so bad that some in Gen Z have posted  “friendship applications” on social media .

My generation's isolation is real: Gen Z doesn't care about sports. That's part of a bigger problem.

No wonder mental health is plummeting. Tens of millions of people don’t have the relationships that provide meaning in daily life. No amount of federal money − no number of mental health workers or programs − will solve that problem. The real solution is communities coming together and people reaching out to one another, in a spirit of mutual support.

I’ve seen this truth play out nationwide.

The Phoenix , which promotes sobriety and fights social isolation, is helping thousands of people beat substance abuse through a supportive community that’s often focused on physical fitness.

The Confess Project is training barbers and beauty industry professionals to be sort of paraprofessional mental health counselors, forging stronger bonds with millions of people through their everyday work, particularly among communities of color that have stigmas related to mental health.

Then there’s  Give an Hour , in which mental health professionals help train people to be informal “peer supporters.”

Relationships, mental health support make a difference

It turns out that the combination of relationships and mental health support makes a remarkable difference.

These efforts are promising − but not nearly enough. Loneliness continues to soar, and with rising political polarization and social-media-driven isolation, this crisis looks set to continue getting worse.

Help fight depression and anxiety: Parents need help regulating their children's social media

As it does, more and more Americans will experience mental health challenges. While many will certainly need clinical help, let’s realize that the worst thing we can do is to expect others to solve this crisis.

The best thing we can do is to come alongside them ourselves.

Evan Feinberg is chair of the Stand Together Foundation and senior vice president of Stand Together .