Child Mistreatment: Psychological Consequences and Development Processes

The issue on family maltreatment of children, is increasingly being paid attention to and is the result of a different consideration than in the past of what is defined as maltreatment, the phenomenon, both socially and clinically, has given rise to a set of studies that highlight how the public is less clueless and more sensitive, even those forms of mistreatment and abuse that are less obvious, but nevertheless devastating to the psychosocial balance of the child, are also examined, his awareness has come about, thanks to the psychological and social sciences, which have helped to create a vision within the family and society, as a bearer of rights. In this article, the effects of maltreatment and abuse on child development will be examined.

Advances in psychological and social sciences have helped create a new view of the child within the family and society. The path to recognition has been long and tortuous; before the Constitution, the minor was considered as an object subject to the will of adults who could decide on his or her own life and death. With the passage of time, there have been important legislative interventions, which have recognized the minor's rights, his or her own autonomy and ability to establish relationships freely. Among the most relevant legislative initiatives, we can mention: the Declaration of the Rights of the Child, approved by the U.N. General Assembly on November 20, 1959. This document reaffirms the same principles as the Geneva Declaration, further calling on states both to recognize these principles and to apply and provide for their dissemination [1]. The International Convention on the Rights of the Child, stipulated by the UN in 1989, which establishes the obligation to protect children from violations of the rights set forth in the 1959 Declaration, and finally the Optional Protocol to the Convention on the Rights of the Child on the Sale, Prostitution of Children and Representative Pornography of Children, stipulated on September 6, 2000, and ratified by Italy through Law No. 46 of March 11, 2002 [2], articles 2 and 3 of the Constitution, state that “The Republic recognizes and guarantees the inviolable rights of man, both as an individual and in the social formations where his personality takes place...” “It is the duty of the Republic to remove obstacles of an economic and social order, which, by effectively limiting the freedom and equality of citizens, prevent the full development of the human person...” [3], also emphasize the child's right to education, which may include a set of other important rights such as: that to life, autonomy, equality and socialization. Also deserving of attention are Articles 29, 30 and 31 of the Italian Constitution, which recognize the family as a natural society founded on marriage and “the centrality of the person of the child, who has the right with respect to the parent to be maintained, instructed and educated” [4]. It is also stated in these articles, that in the case of incapacity, the state has an obligation to provide for the fulfillment of their duties, again emphasizing the need to consider and respond to the multiple needs of the child, to recognize the child's rights and respond to the guardianship function. Kempe introduced the expression “child abuse and neglect,” which is still in use today” [5] to describe the maltreatment scenario, and given the interest in the phenomenon, important changes have been introduced, such as the increasing number of professions interested in the study of this issue, the broadening of the operational modalities considered appropriate to deal with it, and a greater sensitivity no longer only on physical maltreatment, but also on other forms of abuse such as psychological and sexual abuse that significantly affect, the psycho-physical growth of the child.

In the 4th Criminological Colloquium of the Council of Europe, Strasbourg, 1978, child maltreatment is defined as “the set of acts and failures which seriously disturb the child, affect his bodily integrity, physical, affective, intellectual and moral development, the manifestations of which are neglect and/or injury of a physical and/or psychological and/or sexual nature by a family member or others who care for the child” [6]. The National Center of Child Abuse and Neglect in 1981 defined child maltreatment as “[...] that situation in which, through intentional acts or gross inattention to the child's basic needs, the behavior of a parent or substitute or other adult caring for the child has caused harm or impairment that could have been foreseen and avoided or has materially contributed to the prolongation of an existing harm or impairment” [7]. The Fifth International Congress on Abused and Neglected Children (Montreal 1984) defined abuse as “any act of omission or authoritarianism that endangers or impairs the health or emotional development of a child, including physical violence and unreasonably severe corporal punishment, sexual acts, exploitation in the work environment, and disregard for the child's emotionality” [8]. WHO stated in 1999 that “child abuse or maltreatment is defined as all forms of physical and emotional ill care (ill treatment), sexual abuse, neglect or negligent treatment, commercial or other exploitation, which result in actual or potential harm to a child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power” [9]. Childhood abuse, takes many forms and is divided into: maltreatment, treatment pathology, sexual abuse and witnessing violence. 

Maltreatment can be distinguished into physical and psychological

Physical maltreatment is a form of visible violence in which parents or caregivers cause him physical injury or expose him to serious risk of being physically abused. Physical mistreatment is related to psychological mistreatment, to which generally adults (parents or other figures) instead of protecting the child humiliate, devalue, and ignore him or her disregard his or her emotional needs by neglecting the empathic relationship that should be established between parents and children, and subject him or her to psychological violence in a repetitive and constant manner over time. This type of violence causes damage to the child's personality, incentivizes the child to adopt aggressive modes in problem solving and interactions with others, has low self-esteem, on his perception of the world [10,11].

Pathology of care

Pathology of care is “the inadequacy or insufficiency of physical and/or psychological care provided to the child, in relation to his or her developmental moment, by those who are legally responsible for it” Montecchi) [2]. Parents, are incapable of responding to the physical and psychological needs of the child negatively affecting his or her growth path, are unable to assist them, protect them, stimulate them, give them affection and preserve them from dangerous situations. The juvenile is exposed to malnutrition, school difficulties, failure to educate them to respect the rules of behavior and peaceful coexistence, inability to establish lasting bonds and take on deviant attitudes. Modalities of care pathology include: neglect, dysuria and overcare. “Physical neglect” refers to deficient physical care with respect to a child's age and developmental needs. “Psychological neglect” refers to a failure to pay attention to the child's emotional and emotional needs with respect to his or her developmental needs.

• Care neglect or maltreatment is the provision of care to the child that is not appropriate to the child's developmental stage.
• Overcare is “excessive care of the child's physical state, characterized by persistent and harmful medicalization” [12].
• It usually includes Munchausen syndrome by proxy: the parent, usually the mother, subjects the child to unnecessary health investigations and treatment for episodes of illness that are the result of her own distorted belief and causes the child severe physical and mental harm;
• Chemical abuse: indicates excessive administration of pharmacological or chemical substances to the child by the mother who has delusional ideas;
• Medical shopping: is a form of over-care, in which parents have exaggerated concern for their child's health that they seek reassurance by consulting various doctors.
  

Sexual abuse

Sexual abuse “refers to the involvement of children in sexual activities that include not only heterosexual and full homosexual relationships, but also sex games, pornography, prostitution, and acts that use the child to procure sexual pleasure for self or eventual partner” [13].

Three types of abuse can be distinguished based on the relationship between victim and abuser:

• Intrafamilial-intradomestic, when the abuse is carried out by a member of the child's family living in the same household (mother/father, siblings, etc.);
• Intrafamilial extradomestic, when the abuser is still a member of the child's household but does not live with the child (cousins, grandparents, etc.);
• Extrafamilial, when the abuser is a person outside the child's household (acquaintances, neighbours, family friends, etc.) [2].
  

The CISMAI (Italian coordination of services against child maltreatment and abuse ) in 2005 defined intra-familial witnessing violence as “the experience by the child of any form of maltreatment carried out through acts of physical, verbal, psychological, sexual, and economic violence on reference figures or other affectively significant adult or minor figures. The child may experience this directly or indirectly, including witnessing violence by minors on other minors and/or other family members and abandonment and mistreatment of domestic animals” [14]. This type of abuse, has only recently been considered, affects all minors who witness family violence. Although not directly victims of abuse, the minors concerned, living in an atmosphere filled with hatred and violence, may grow up with serious psychological and physical problems (such as anxiety, fear, shame, depression, passivity, difficulty relating, cruelty to animals, hyperactivity) [15]. In the case of separation, the child, a victim of the situation, “is denied the opportunity to retain both parents, but in addition is forced to act the active exclusion of one of them, as if this were his or her spontaneous and autonomous choice” [16]. Children, experience separation and conflict as a trauma and may suffer consequences on the psychic sphere; blaming themselves for the situation they are experiencing, they may find it difficult to develop intimate relationships, take on deviant behaviours and in some cases take on the role of “parenting their parents” [16], they become the container of the confidences and fears of both parents. The consequences, may be, on the physical sphere and manifest eating and sleeping disorders, poor school performance, low self-esteem, behavioural and learning disorders, to prevent these serious consequences parents, must recognize the suffering of their child and taking care of him, despite the difficult situation [17].

The consequences of maltreatment on the child's mental and physical development. Maltreatment is a traumatic experience for a child's growth. The various research conducted in recent years has recognized a wide variety of disorders related to childhood experiences of abuse and maltreatment, which can vary in severity. “The different forms of maltreatment to which children may be exposed can produce a negative impact on development in both the short and long term, to the extent that they represent real traumatic events that, depending on the case, may take on the characteristics of acute or chronic trauma and whose effects may persist over time and manifest late consequences even in adolescence and adulthood” [18]. Children who are victims or witnesses of maltreatment situations, face repeated experiences of rejection or hostility with their attachment figure, the latter plays a major role in influencing the child's beliefs and expectations, towards themselves, others and the world, they develop a negative self-image characterized by: low self-esteem, distorted perception of their own social skills, difficulty in expressing discomfort and suffering, poor social adjustment, they perceive a lack of love from their parents and hold themselves primarily responsible for the condition they are experiencing caused by their behaviour or their being in totality [19]. Feeling guilty is a common reaction experienced by those who have experienced violence, and, feeling responsible for what has happened “relieves the child of the feeling of feeling totally passive and powerless, that is, it allows him or her to attempt to master the suffering due to abandonment, loss or an otherwise traumatic situation” [20].

"Post-traumatic stress disorder (PTSD) is a psychopathological condition classified in the DSM V. Post-traumatic stress disorder is a disorder that typically develops after a particularly traumatic event, an event that has endangered the health and physical or psychological integrity of the individual. It is characterized by particularly disabling symptoms, such as very intense and frequent anxiety, decreased mood, intrusive thoughts, images, or memories of the traumatic event, and often a very intense emotional experience, as if one were reliving the traumatic episode [21]. Post-traumatic stress disorder manifests in different ways, but the main characteristic is the development of a range of anxiety-depressive symptoms following a traumatic event. In some patients the prevailing symptoms, are fear, avoidance and anxiety, a decline in mood and anhedonia are also observed, other people, may have dissociative symptoms, often a combination of these symptoms is observed in PTSD patients. The symptoms of post-traumatic stress disorder can be divided, into four categories: intrusive symptoms, avoidance strategies, alterations in mood and thoughts, and increased psychomotor activation state. These four categories represent 4 of the criteria defined by the DSM-5 for the diagnosis of PTSD [22].

Intrusive symptoms in PTSD

Intrusive symptoms involve memories of the traumatic event. They are defined as intrusive because the subject feels that he or she is not in control and is powerless; they present themselves to the subject's consciousness in a disturbing and involuntary manner [23]. They may occur, during the day or even at night, in the form of dreams or nightmares; psychological distress symptoms may be present in the presence of a stimulus that recalls the traumatic episode (such as an image or sound). Another symptom of post-traumatic stress disorder is the use of avoidance strategies to avoid coming into contact with any stimulus reminiscent of the trauma. Subjects tend to avoid places, situations, or people that remind them of the traumatic event [24]. This avoidance can reduce the subject's attendance and avoidance of places that are particularly important to him or her (e.g., places that remind him or her of the traumatic event), progressively reducing his or her quality of life [25].

Alterations in thinking or mood

Patients with PTSD may have no recollection of the traumatic event (post traumatic amnesia) [26] or may develop negative ideas about themselves, others and the world, the consequence being a decline in mood, or feeling emotionally distant from everyone or no longer being able to experience positive emotions. These patients, may show symptoms of hyperarousal and heightened reactivity, may show themselves to be angry and irritable, to the point of violent and destructive behaviour, live in a constant state of anxiety, sleep problems, and alterations in attention and memory [27]. These symptoms can be particularly disturbing and negatively affect the quality of life of individuals it is therefore desirable that the traumatic event, be addressed within a psychotherapeutic setting. Therefore, it is important to address the traumatic event within a psychotherapeutic setting. In order to make a diagnosis of post-traumatic stress disorder, the DSM-5, the Diagnostic and Statistical Manual of Mental Disorders (source, Diagnostic and Statistical Manual of Mental Disorders, V edition), proposes certain criteria to guide the clinician in making the diagnosis. The DSM-5 criteria for PTSD cover adults as well as adolescents and children over 6 years of age. Below 6 years of age, the diagnostic criteria change.

Several studies, have found it to be the disorder with a higher prevalence among children and adolescents who have suffered adverse childhood experiences [28]. The negative effects, affect the immune system and the regulation of sleep-wake rhythms, and may increase the risk of heart problems [29]. In some cases, depression results in suicide or suicide attempts; Plunkett [30] through interviews with 183 young victims of sexual abuse found a frequency of suicide attempts 13 times higher than the frequency relative to the population of the same age (32% of abused attempted suicide) and an even higher frequency of suicidal thinking (43% of abused).

Substance abuse

From the studies of several authors [31], Fergusson and Lynskey; [32,33] Miller and Downs; [34] Nelson [35], Wilsnack [36], found that individuals who report episodes of childhood abuse are the most likely to abuse alcohol. “Abuse is defined as a pathological pattern of substance use that gives rise to recurrent and significant harmful consequences, leads to impairment and/or clinically significant distress” [37]. Mistreatment also has negative consequences on cognition and school performance from early childhood and as an adult, job failure as evidenced by the studies of Eckenrode [38] and Wodarski [39] who reported that the consequences, affect not only abused children, but also neglected children, the results, are also confirmed by the research of Trickett and McBride-Chang, [40] and Shonk and Cicchetti [41], state that the cause of school failure and behavioural problems is due to the family environment in which children live, who as adults, by virtue of the deficiencies suffered will lack the skills needed to cope with the difficulties of life. According to their assumption is ascribable to the negative influence exerted by maltreatment on the development of individual skills, therefore, the family environment in which the child lives is primarily responsible for the child's failures at school. Based on this assumption, it is necessary not according to their assumption is attributable to the negative influence exerted by maltreatment on the development of individual skills, so the family environment in which the child lives is primarily responsible for the child's failures in school. Based on this assumption, it is necessary not to underestimate this risk factor since children who suffer such situations may find themselves as adults lacking the skills necessary to cope with the difficulties of life.

Consequences on the social and behavioural spheres

Research shows that maltreated children are at greater risk of developing behavioural disorders, embarking on a career of deviance, and inflicting violence on others, both in adolescence and adulthood. Maltreated children show higher levels of aggression and social isolation than non-maltreated children (Herrenkohl and Herrenkohl, [42] Sternberg [43] Rogosch and Cicchetti) [44]. To elaborate on the effects that maltreatment causes on the social and behavioral spheres, I think it is appropriate to report below the analyses made on this topic and that child neuropsychiatrist M. Malacrea has well highlighted in her article “Adverse Childhood Experiences (ESI): theoretical premises” [45]. Haskett e Kistner, [46] Darwish, Esquivel, Houtz e Alfonso [47] have shown how maltreatment has an effect on preschoolers' interactions, maltreated individuals prefer to isolate themselves, have poor skills in establishing relationships with peers, have difficulty maintaining self-control, and exhibit behavior problems. Kim and Cicchetti [48] found that when abused children have difficulty managing their emotions, they are more at risk of developing problematic relationships with peers. For these very reasons, peers consider them undesirable as playmates. This rejection is felt by children very early, from their earliest interactions, and in most cases will be repeated throughout their infliction of violence on others, both in adolescence and adulthood. Bolger and Patterson, [49] in their study identified a link between rejection and chronicity of maltreatment: the longer the maltreatment persists over the years, the greater the likelihood that children will be rejected by peers, which would be traced to the presence of behavioural problems such as aggression or antisocial behaviour and consequently lead to exclusion. Hoffman-Plotkin and Twentyman's studies [50] have attentuated neglect and highlighted that neglected children are, characterized by a lower number of social interactions than individuals who have experienced other forms of maltreatment, Kendall-Tackett and Eckenrode's studies [51] show the result that neglected children exhibit poor academic performance and that their disciplinary and interpersonal problems steadily increase throughout the school years. Maltreatment on aggressive behaviours are much more pronounced in male subjects. The study by Alessandri and Lewis [52] has, shown how abused girls express more shame in cases of failure and less pride in cases of success, unlike boys who demonstrate lower levels of both shame and pride, from this it is possible to draw the conclusions that the negative outcomes of maltreatment affect the behavioural system more in males, compared to the emotional system in females.

Consequences for psychophysical health

Early studies of physically abused children revealed significant neuropsychological disabilities, including growth retardation, damage to the central nervous system, mental retardation, speech and learning disorders, and poor school performance. Various forms of ill-treatment have been linked to an increase in body mass index and increased eating disorders (obesity, anorexia, bulimia) during childhood, adolescence and adulthood [53]. Lack of treatment (defined as inattention to things like adequate food and clothing) predicts body mass index at younger age, while lack of alertness (defined as lack of parental availability) predicts body mass index at older age. The results of the study by Widom and colleagues [54] showed that abused children risk contracting diseases such as diabetes, hepatitis, kidney problems, poor functioning of the lungs, and higher-than-average vision problems. In addition, studies of sexual abuse show that abused children are more likely to contract diseases such as hepatitis C and venereal. In conclusion, these findings provide clear evidence that the abuse and early abandonment of children affects their state of health and well-being, thus increasing their risk of developing serious diseases [55] Koenig and Clark; [56] Senn [57]. All these consequences, evident already in childhood, persist most of the time, throughout the course of life causing serious problems in the ability to adapt and social interaction of the individual.

The research highlights cases of children who live in unfavourable family and social conditions or who have experienced particularly stressful events, but who are still able to adapt to such contexts without developing any pathology [58]. The researchers investigated possible protective factors and focused on the characteristics of the child or the environment, Garmezy, called these factors "protective" (e.g. individual endowment, environmental conditions, biological predispositions and positive events), factors that protect the child and reduce the harmful effects that critical events could cause [59]. What allows any individual to adapt to the adverse events of life is called resilience. It comes from the Latin resilire which means "jump back, bounce" in psychology, indicates the ability of some people not to succumb to the traumatic, harmful, stressful events to which they are subjected, but to move forward with courage and serenity until you reach an optimal level of adaptation, Cyrulnik and Malaguti, [60] define resilience as the «ability to return with elasticity to an initial situation in order to deal with and overcome a high trauma and, subsequently, absorb it», Thomsen, considers it as the competence of a person to remain constant or recover despite adversity, strong people draw strength both internally and from the environment to overcome challenges» [61], people with a high level of resilience successfully manage adverse situations, overcome difficulties that arise in the course of life, facing adversities, which become a strengthening element, rather than weakening, in literature are reported cases of resilient people endowed with a docile and confident temperament of the individual that allows him to be well-liked is a person, who accepts the help that is offered to him from outside, has a good foundation of self-esteem, addresses problems with self-awareness and in controlling the management of emotions, has a good ability to interact,  good intelligence and excellent creative abilities [62]. All supported by factors such as family factors (for example, the presence of a reassuring environment or a safe attachment figure in childhood) factors related to the context (for example to have significant ties with people outside their core such as teachers, the group of peers, friends, who with their being affectionate and caring allow them to grow in a healthy way by offering a peaceful and stable relationship.

In the light of the foregoing and the above, and being aware to date of the negative and complex consequences of abuse, we can say that prevention is an activity that can be useful and effective, but at the same time, requires the shared commitment of several actors working in the interinstitutional framework. When we talk about prevention in cases of child abuse and/or adolescence, one of the services that has greater relevance is undoubtedly the school context. In fact, school is an institution that, after the family unit, plays a fundamental role in the life of the child and at the same time represents the environment in which the child spends most of his time. This institution, in addition to having an educational function, represents an agency of socialization and has always been considered a privileged observatory for the detection of children at risk. School workers have a better chance of detecting attitudes and behaviours, or by the stories that the child himself reports, 'the presence in the family of risky educational habits and styles for its development». The teacher is the main interlocutor of the family and at the same time of the child and therefore it is essential that he has adequate empathic skills strong preventive potential, enhancing the kindergarten. This means improving the attention of educators towards children, avoiding disqualifying attitudes towards parents and children, and encouraging the establishment of relations between family and school, based as much as possible on mutual relationships of trust and collaboration. This is due to the fact that the educators of kindergartens and kindergartens have a privileged relationship with families, because in the first years of the child’s life parents are often insecure in the management of their parental functions and uncertain about what educational modality to implement towards the child; educators can carry out an important preventive action.

It is essential to support the school in this important work of prevention, so that, by establishing a good relationship with the family, it ensures that the damage to which the child is exposed is limited or, if this does not happen, signals the situation to the judicial authority. A further step towards making prevention the common objective of the whole community is «the widespread dissemination of more rigorous information and less anecdotal and chronicle on the issue of child abuse at the level of public opinion». Building an opinion must be promoted public that is not limited to being alarmed by the scandals and family crimes told by the mass media, public opinion must acquire 'a social awareness and policy of the heavy consequences that job loss, housing insecurity, the inclusion of the family in a foreign culture, may have for the children». A greater amount of resources should be invested mainly in prevention activities, since they are «potentially able to generate future savings» and have the advantage of intervening preventively on defined risk cases. However, it is necessary for adults to become aware of their responsibility towards children, because otherwise preventive activities «Specifically planned they risk to see compromised their effectiveness or not to find a fabric of shared thoughts on which to graft». 

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