Unseen wounds: The contribution of psychological maltreatment to child and adolescent mental health and risk outcomes.
Abstract
For this study, we evaluated the independent and additive predictive effects of psychological maltreat-ment on an array of behavioral problems, symptoms, and disorders in a large national sample of clinic-referred children and adolescents drawn from the National Child Traumatic Stress Network Core Data Set (CDS; see Layne, Briggs-King, & Courtois, 2014). We analyzed a subsample of 5,616 youth with lifetime histories of 1 or more of 3 forms of maltreatment: psychological maltreatment (emotional abuse or emotional neglect), physical abuse, and sexual abuse. Measures included the University of California, Los Angeles Posttraumatic Stress Disorder–Reaction Index (Steinberg et al., 2004), Child Behavior Checklist (Achenbach & Rescorla, 2004), and 27 diagnostic and CDS-specific clinical severity indicators. Psychologically maltreated youth exhibited equivalent or greater baseline levels of behavioral problems, symptoms, and disorders compared with physically or sexually abused youth on most indicators. The co-occurrence of psychological maltreatment with physical or sexual abuse was linked to the exacerbation of most outcomes. We found that the clinical profiles of psychologically maltreated youth overlapped with, yet were distinct from, those of physically and/or sexually abused youth. Despite its high prevalence in the CDS, psychological maltreatment was rarely the focus of intervention for youth in this large national sample. We discuss implications for child mental health policy; educational outreach
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Emotional abuse and neglect often occur in combination with physical and sexual abuse but have been found to have adverse biopsychosocial effects that are distinct from those of physical or sexual abuse.
“Emotional abuse and neglect often occur in combination with physical and sexual abuse but have been found to have adverse biopsychosocial effects that are distinct from those of physical or sexual abuse [159, 165].”
From Complex PTSD and borderline personality disorder (2021) · cites this paper as [159]
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Traumatic Stress in Overview: Definition, Context, Scope, and Long-Term Outcomes
Gerhart, J. I., Canetti, D., & Hobfoll, S. E. (2015) · Springer eBooks · doi:10.1007/978-3-319-18866-9_1 · Cited by 38 · see citing works
“Risk factor caravans are especially salient in the co-occurrence of childhood abuse, as sexual and physical abuses are frequently accompanied by psychological maltreatment that further impacts adjustment and well-being (Spinazzola et al., 2014).”
BackgroundTlapek, S. M., Auslander, W., Edmond, T. E., Gerke, D. R., Schrag, R. V., & Threlfall, J. M. (2016) · Children and Youth Services Review · doi:10.1016/j.childyouth.2016.11.026 · Cited by 38 · see citing works
Tottenham, N. (2020) · Development and Psychopathology · doi:10.1017/s0954579420001169 · Cited by 38 · see citing works
“…are more “invisible” than others (e.g., emotional maltreatment might be more difficult to measure than physical maltreatment; Wolfe & McGee, 1994), despite emotional maltreatment’s highly pernicious nature and its high comorbidity with most other forms of maltreatment (Spinazzola et al., 2014).”
BackgroundMorin, E. L., Howell, B. R., Feczko, E., Earl, E., Pincus, M., Reding, K., Kovacs-Balint, Z. A., Meyer, J. S., Styner, M., Fair, D., et al. (2020) · Development and Psychopathology · doi:10.1017/s0954579420001133 · Cited by 37 · see citing works
“…maltreatment, early life stress, prefrontal cortex, rhesus monkey (Received 31 January 2020; revised 16 May 2020; accepted 19 May 2020) 2014; Spinazzola et al., 2014; Steinberg et al., 2014), form and severity of maltreatment (i.e., physical abuse, neglect, sexual abuse -which are often…”
BackgroundInfluentialLavi, I., Manor-Binyamini, I., Seibert, E., Katz, L. F., Ozer, E. J., & Gross, J. J. (2018) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2018.11.016 · Cited by 36 · see citing works
Gender‐Moderated Pathways From Childhood Abuse and Neglect to Late‐Adolescent Substance Use
Kobulsky, J. M., Yoon, S., Bright, C. L., Lee, G., & Nam, B. (2018) · Journal of Traumatic Stress · doi:10.1002/jts.22326 · Cited by 36 · see citing works
Hosokawa, R., & Katsura, T. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18136924 · Cited by 41 · see citing works
A daily process examination of the relationship between childhood trauma and stress-reactivity
Weltz, S. M., Armeli, S., Ford, J. D., & Tennen, H. A. (2016) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2016.08.005 · Cited by 35 · see citing works
Self-citationImproving Access to Trauma-Informed Adoption Services: Applying a Developmental Trauma Framework
Hartinger-Saunders, R. M., Jones, A. S., & Rittner, B. A. (2016) · Journal of Child & Adolescent Trauma · doi:10.1007/s40653-016-0104-1 · Cited by 34 · see citing works
“…comprehensive study using data from a large national sample found that foster children with exposure to all three common forms of maltreatment (sexual abuse, physically abuse, and psychological maltreatment) correlated with high levels PTSD and associated sequelae of PTSD (Spinazzola et al. 2014).”
BackgroundInfluentialLassri, D., Luyten, P., Cohen, G., & Shahar, G. (2016) · Psychological Trauma · doi:10.1037/tra0000134 · Cited by 35 · see citing works
“CEM is highly prevalent, as demonstrated in both clinical and nonclinical samples, including college students (Egeland, 2009; Scher, Forde, McQuaid, & Stein, 2004; Spinazzola et al., 2014).”
BackgroundChildhood Maltreatment and Early Developmental Vulnerabilities at Age 5 Years
Green, M. J., Tzoumakis, S., McIntyre, B., Kariuki, M., Laurens, K. R., Dean, K., Chilvers, M., Harris, F. A. J., Butler, M., Brinkman, S. A., et al. (2017) · Child Development · doi:10.1111/cdev.12928 · Cited by 32 · see citing works
Hodgdon, H., Liebman, R. E., Martin, L., Suvak, M. K., Beserra, K., Rosenblum, W., & Spinazzola, J. (2018) · Journal of Traumatic Stress · doi:10.1002/jts.22267 · Cited by 32 · see citing works
“…of caregiver trauma, notably sexual, physical, and psychological maltreatment (the individual and combined contributions of which have been linked to greater severity of PTS symptoms; Spinazzola et al., 2014), the association between later-occurring and acute forms of trauma and PTS is reduced.”
BackgroundSelf-citationGabrielli, J., Jackson, Y., Tunno, A. M., & Hambrick, E. P. (2017) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2017.02.020 · Cited by 31 · see citing works
“Indeed, a recent study by Spinazzola et al. (2014) identified that psychological maltreatment accounts for a significant proportion of the variance in mental health outcomes for youth, above and beyond effects of physical and sexual abuse and thus, should be considered along with measures of…”
BackgroundMethodWatts, J. R., Leeman, M. S., O’Sullivan, D., Castleberry, J. J., & Baniya, G. (2020) · Rehabilitation Counseling Bulletin · doi:10.1177/0034355220925889 · Cited by 30 · see citing works
“Spinazzola et al. (2014) conducted a study (N = 5,616) examining the impact of CEM on children and adolescents and found that CEM significantly contributed to multiple negative health outcomes including but not limited to anxiety, depression, suicidality, sleep disorders, attachment disorders, and…”
BackgroundChildhood abuse, pregnancy-related anxiety and the mediating role of resilience and social support
Brunton, R., Wood, T., & Dryer, R. (2020) · Journal of Health Psychology · doi:10.1177/1359105320968140 · Cited by 30 · see citing works
“Given that children who experience psychological abuse and neglect may experience similar and at times more severe mental health outcomes than those who experience physical or sexual abuse (Spinazzola et al., 2014), it would be important to examine all forms of abuse in regards to pregnancy-related anxiety.”
BackgroundKwok, S. Y. C. L., & Fang, S. (2021) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2021.105435 · Cited by 30 · see citing works
Effects of early maternal care on adolescent attention bias to threat in nonhuman primates
Morin, E. L., Howell, B., Meyer, J. S., & Sánchez, M. M. (2019) · Developmental Cognitive Neuroscience · doi:10.1016/j.dcn.2019.100643 · Cited by 27 · see citing works
Adolescent Neglect and Health Risk
Kobulsky, J. M., Villodas, M. T., Yoon, D., Wildfeuer, R., Steinberg, L. D., & Dubowitz, H. (2021) · Child Maltreatment · doi:10.1177/10775595211049795 · Cited by 31 · see citing works
“This supports prior research demonstrating the harm caused by emotional abuse as similar to or even greater than that associated with physical or sexual abuse (Spinazzola et al., 2014).”
ResultGoldenson, J., Brodsky, S. L., & Perlin, M. L. (2021) · Psychology Public Policy and Law · doi:10.1037/law0000339 · Cited by 29 · see citing works
Lien, C. A., Rosen, T., Bloemen, E. M., Abrams, R. C., Pavlou, M., & Lachs, M. S. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14524 · Cited by 29 · see citing works
“Interpersonal trauma in childhood including physical abuse, sexual abuse, and neglect have been shown to increase risks of severe mood disorders and behavioral disturbances in adolescence and adulthood.(21,22) Interpersonal trauma occurring in late life may also predispose to behavioral disturbances.”
BackgroundWaldron, J. C., Scarpa, A., & Kim‐Spoon, J. (2018) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2018.03.023 · Cited by 29 · see citing works
A Study Space Analysis and Narrative Review of Trauma-Informed Mediators of Dating Violence
Cascardi, M. A., & Jouriles, E. N. (2016) · Trauma Violence & Abuse · doi:10.1177/1524838016659485 · Cited by 29 · see citing works
“Childhood emotional abuse, alone or in combination with physical or sexual maltreatment, has been shown to have a particularly insidious influence on relationship development, as it has the potential to evoke fear, undermine self-worth, and adversely affect beliefs about the stability and security of close relationshi…”
BackgroundHatkevich, C. E., Sumlin, E. D., & Sharp, C. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.630697 · Cited by 27 · see citing works
Boudoukha, A. H., Ouagazzal, O., & Goutaudier, N. (2016) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000243 · Cited by 26 · see citing works
Psychological maltreatment: An operationalized definition and path toward application
Slep, A. M. S., Glaser, D., & Manly, J. T. (2022) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2022.105882 · Cited by 26 · see citing works
“There is empirical evidence which points to the serious harm emanating from PM to the child and later in adulthood (e.g., Abajobir, et al., 2017a; Abajobir, et al., 2017b; Brassard, 2019; Egeland, Sroufe, & Erickson, 1983; Geoffroy, Pereira, Li, & Power, 2016; Norman et al., 2012; Spinazzola et al., 2014).”
BackgroundLin, X., Zhang, Y., Chi, P., Ding, W., Heath, M. A., Fang, X., & Xu, S. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.01810 · Cited by 26 · see citing works
“Previous studies have demonstrated that family dysfunction is closely linked to children emotional problems that are related to ODD, such as anger, hostility, depression, and acute stress (Spertus et al., 2003; Spinazzola et al., 2014).”
BackgroundLocascio, M., Infurna, M. R., Guarnaccia, C., Mancuso, L., Bifulco, A. T., & Giannone, F. (2018) · Journal of Interpersonal Violence · doi:10.1177/0886260518794512 · Cited by 25 · see citing works
“, psychopathological symptoms, interpersonal problems in adult couple relationships, low self-esteem), compared with physical or sexual abuse (Infurna et al., 2016; Paradis & Boucher, 2010; Schneider, Ross, Graham, & Zielinski, 2005; Spertus, Yehuda, Wong, Halligan, & Seremetis, 2003; Spinazzola et al., 2014).”
BackgroundWalters, G., & Espelage, D. L. (2018) · International Journal of Child Abuse & Neglect · doi:10.1016/j.chiabu.2018.05.006 · Cited by 23 · see citing works
Cascardi, M. A., & Jouriles, E. N. (2018) · Elsevier eBooks · doi:10.1016/b978-0-12-811797-2.00007-4 · Cited by 26 · see citing works
Traumatic invalidation in the Jewish community after October 7
Bar-Halpern, M., & Wolfman, J. (2025) · Journal of Human Behavior in the Social Environment · doi:10.1080/10911359.2025.2503441 · Cited by 24 · see citing works
“…have just as much—or even more—of a negative impact on mental health as other events that do meet the American Psychiatric Association’s criteria for a traumatic event such as threat of death or serious injury (American Psychiatric Association, 2022; Mechanic et al., 2008; Spinazzola et al., 2014).”
Green, M. J., Tzoumakis, S., Laurens, K. R., Dean, K., Kariuki, M., Harris, F. A. J., Brinkman, S. A., & Carr, V. J. (2018) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867418814943 · Cited by 24 · see citing works
Bürgin, D., Clemens, V., Witt, A., Sachser, C., Jud, A., Brähler, E., Strauss, B., Petrowski, K., Schmid, M., & Fegert, J. (2023) · International Journal of Child Abuse & Neglect · doi:10.1016/j.chiabu.2023.106382 · Cited by 23 · see citing works
The association between recent abuse and menopausal symptom bother
Vegunta, S., Kuhle, C. L., Kling, J. M., Files, J. A., Kapoor, E., David, P. S., Rullo, J., Sood, R., Thielen, J. M., Jatoi, A., et al. (2016) · Menopause The Journal of The North American Menopause Society · doi:10.1097/gme.0000000000000578 · Cited by 24 · see citing works
“Childhood and lifetime abuse are related to an increase in psychiatric disorders such as posttraumatic stress disorder, eating disorders, increased suicide attempts, and drug and alcohol abuse in adulthood.(7) Sexual abuse is associated with increased utilization of health care services, overall poor health status, lo…”
BackgroundPrevalence of Adverse Childhood Experiences Among Veterans
Laird, C. W., & Alexander, P. (2019) · Clinical Social Work Journal · doi:10.1007/s10615-019-00703-5 · Cited by 23 · see citing works
Steinberg, A. M., Layne, C. M., Briggs, E. C., Liang, L.-J. F., Brymer, M. J., Belin, T. R., Fairbank, J. A., & Pynoos, R. S. (2019) · Psychiatry · doi:10.1080/00332747.2018.1560584 · Cited by 22 · see citing works
“…these indicators have proven useful across a range of studies in clarifying relations between trauma exposure and adolescent risk-taking behavior (Layne et al., 2014), relations between sexual abuse and functional impairment (Kisiel et al., 2014), behavioral and functional profiles of…”
BackgroundSelf-citationScheffers, F., van Vugt, E., Lanctôt, N., & Lemieux, A. (2019) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2019.03.022 · Cited by 22 · see citing works
Lin, X., Li, Y., Xu, S., Ding, W., Zhou, Q., Du, H., & Chi, P. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.02062 · Cited by 24 · see citing works
Child maltreatment risk mediates the association between maternal and child empathy
Meidan, A., & Uzefovsky, F. (2020) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2020.104523 · Cited by 23 · see citing works
Baiden, P., Onyeaka, H., Aneni, K., Wood, B. M., LaBrenz, C. A., Muoghalu, C., Peoples, J. E., Szlyk, H. S., Gobodzo, E. C., Baiden, J. F., et al. (2023) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2023.109894 · Cited by 22 · see citing works
Teachers’ Intention to Report Child Maltreatment: Testing Theoretically Derived Predictions
Christodoulou, A.-D., Abakoumkin, G., & Tseliou, E. (2019) · Child & Youth Care Forum · doi:10.1007/s10566-019-09492-x · Cited by 21 · see citing works
Mertens, Y. L., Racioppi, A., Sheinbaum, T., Kwapil, T. R., & Neus Barrantes-vidal, A. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1888539 · Cited by 22 · see citing works
“Emotional abuse is an often overlooked but highly prevalent and detrimental form of abuse (Spinazzola et al., 2014; Stoltenborgh, Bakermans-Kranenburg, Alink, & Van Ijzendoorn, 2012) and may be of particular relevance to psychosis vulnerability in samples in which sexual and physical abuse are less…”
BackgroundHeterogeneity in caregiving-related early adversity: Creating stable dimensions and subtypes
Nikolaidis, A., Heleniak, C. M., Fields, A., Bloom, P. A., VanTieghem, M., Vannucci, A., Camacho, N. L., Choy, T., Gibson, L., Harmon, C., et al. (2022) · Development and Psychopathology · doi:10.1017/s0954579421001668 · Cited by 21 · see citing works
Building Healthy Children: A preventive intervention for high-risk young families
Demeusy, E. M., Handley, E. D., Manly, J. T., Sturm, R., & Toth, S. L. (2021) · Development and Psychopathology · doi:10.1017/s0954579420001625 · Cited by 22 · see citing works
“This study found that psychological maltreatment was as, if not more, potent of a predictor for childhood maladjustment as sexual abuse, physical abuse, and the combination of the two, across a range of outcomes (Spinazzola et al., 2014).”
BackgroundLo, C. K. M., Ho, F. K. W., Yan, E., Yu, L., Chan, K. L., & Ip, P. (2019) · Journal of Interpersonal Violence · doi:10.1177/0886260519835880 · Cited by 20 · see citing works
“Our findings support the idea that more attention, in terms of identification and intervention, should be given to psychological aggression and neglect, because they are usually underrecognized (Glaser, 2002; Spinazzola et al., 2014).”
ResultWatts, J. R., O’Sullivan, D., Panlilio, C. C., & Daniels, A. D. (2020) · Journal of Addictions & Offender Counseling · doi:10.1002/jaoc.12073 · Cited by 20 · see citing works
Early trauma and psychosocial outcomes among college students
Colburn, A. R., Kremer, K. P., & Jackson, D. B. (2021) · Children and Youth Services Review · doi:10.1016/j.childyouth.2021.106052 · Cited by 23 · see citing works
Childhood psychological maltreatment, sense of self, and PTSD symptoms in emerging adulthood
Watts, J. R., Lazzareschi, N. R., Liu, Y., & O’Sullivan, D. (2022) · Journal of Counseling & Development · doi:10.1002/jcad.12455 · Cited by 19 · see citing works
Assessing for bruises on the soul: identifying and evidencing childhood emotional abuse
North, G. (2019) · Journal of Social Welfare and Family Law · doi:10.1080/09649069.2019.1627086 · Cited by 19 · see citing works
“Emotional abuse has less of a profile in the public awareness than other forms of abuse, as it is not considered so serious a ‘social taboo’ (Spinazzola et al. 2014).”
BackgroundKwak, Y., Mihalec-Adkins, B. P., Mishra, A. A., & Christ, S. L. (2017) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2017.09.026 · Cited by 19 · see citing works
Child abuse and wellbeing: Examining the roles of self-compassion and fear of self.
Collins, S. M., Orth, T., Brunton, R., & Dryer, R. (2023) · International Journal of Child Abuse & Neglect · doi:10.1016/j.chiabu.2023.106089 · Cited by 21 · see citing works
“However, its impact is no less destructive (Spinazzola et al., 2014).”
BackgroundMarqués-Feixa, L., Moya, J., Romero, S., Santamarina-Pérez, P., Martín-González, N. S., Mas, A., Rapado‐Castro, M., Blasco-Fontecilla, H., Zorrilla, E. P., Forner-Puntonet, M., et al. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.03.088 · Cited by 18 · see citing works
Differences in developmental problems between victims of different types of child maltreatment
Bijlsma, A. M. E., Assink, M., Overbeek, G. J., van Geffen, M., & van der Put, C. E. (2022) · Journal of Public Child Welfare · doi:10.1080/15548732.2022.2044429 · Cited by 18 · see citing works
“…outcomes, such as social problems and attention problems, for victims of multitype maltreatment compared to victims of single type maltreatment (Arata et al., 2007; Clemmons et al., 2003; Edwards et al., 2003; Gross & Keller, 1992; Huguenel et al., 2021; Ney et al., 1994; Spinazzola et al., 2014).”
BackgroundResultInfluentialTreves-Kagan, S., Ayadi, A. M. E., Morris, J. L., Graham, L. M., Grignon, J. S., Ntswane, L., Gilvydis, J. M., Barnhart, S., & Lippman, S. A. (2019) · Journal of Interpersonal Violence · doi:10.1177/0886260519827661 · Cited by 18 · see citing works
“Research should also explore the age of onset of violence victimization, perpetrator characteristics, and additional types of abuse, such as psychological maltreatment in childhood (Kisiel et al., 2014; Spinazzola et al., 2014; Walsh, Blaustein, Knight, Spinazzola, & Van Der Kolk, 2007).”
BackgroundMultiple trauma exposure and psychosocial functioning in Singaporean children in out-of-home care.
Liu, D., Chu, C. M., Neo, L. H., Ang, R. P.-H., Tan, M. Y. L., & Chu, J. (2015) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000098 · Cited by 17 · see citing works
Mathews, B., & Dube, S. R. (2024) · Child Protection and Practice · doi:10.1016/j.chipro.2024.100093 · Cited by 16 · see citing works
- Authors
- Spinazzola, J., Hodgdon, H., Liang, L.-J., Ford, J. D., Layne, C. M., Pynoos, R., Briggs, E. C., Stolbach, B., & Kisiel, C.
- Affiliations
- Justice Resource Institute (US)
- University of California, Los Angeles (US)
- University of Chicago (US)
- Northwestern University (US)
- ORCID
- Venue
- Psychological Trauma: Theory, Research, Practice, and Policy
- Published
- 2014
- Volume
- 6
- Issue
- Suppl 1
- Pages
- S18-S28
- ISSN
- 1942-9681 (ISSN-L)
- 1942-969X
- OpenAlex
- W2123420814
- Cited by
- 297
- References
- 47
- Citations by year
- 2026: 28 · 2025: 34 · 2024: 23 · 2023: 23 · 2022: 39 · 2021: 32 · 2020: 22 · 2019: 23 · 2018: 18 · 2017: 18 · 2016: 25 · 2015: 9 · 2014: 2
- FWCI
- 21.24
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychological Trauma Theory Research Practice and Policy (publishedVersion)
- Funders
- U. S. Department of Health and Human Services (3U79SM054284-10S and 1U79SM059314-03)
- Substance Abuse and Mental Health Services Administration
- Center for Mental Health Services
- Topics
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Social Sciences › Safety Research › Child Welfare and Adoption
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Keywords
- psychological maltreatment, emotional abuse, emotional neglect, child abuse, adolescent mental health, behavioral problems, post-traumatic stress disorder, physical abuse, sexual abuse, clinic-referred children, National Child Traumatic Stress Network, child mental health policy
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