ARTICLE
Emotional Maltreatment
Gail Hornor, DNP, RNC, CPNP
ABSTRACT
Child abuse is a problem that affects the lives of many
American children. The public is often bombarded with in-
formation regarding horrific cases of physical and sexual
abuse. Emotional maltreatment, however, has been slow to
achieve recognition as a serious social problem for a variety
of reasons. Compared with physical or sexual abuse,
emotional maltreatment is more difficult to identify and
define, and good epidemiological data are not available.
An erroneous perception also exists that the sequelae of
emotional maltreatment are less severe than that of physical
and/or sexual abuse. Prompt identification of emotional
maltreatment, appropriate intervention and referral, and
reporting of concerns to child protective services are essen-
tial to the health and well-being of the child. This article
will define emotional maltreatment, discuss consequences
of emotional maltreatment, and provide implications for
pediatric nurse practitioner practice. J Pediatr Health Care.
(2012) 26, 436-442.
KEY WORDS
Emotional maltreatment, child abuse
Child abuse is a problem that affects the lives of many
American children. According to the U.S. Department of
Health & Human Services (2010), in 2009 more than
825,000 American children were victims of abuse.
Despite the scope of the problem, the recognition of
child abuse as a social problem in the United States
is relatively recent. Physical abuse was the first form
of child abuse to receive professional and public recog-
Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children’s
Hospital, Center for Family Safety and Healing, Columbus, OH.
Conflicts of interest: None to report.
Correspondence: Gail Hornor, DNP, RNC, CPNP, Nationwide
Children’s Hospital, Center for Family Safety and Healing, 655 E
Livingston Ave, Columbus, OH 43205; e-mail: g.hornor@
nationwidechildrens.org.
0891-5245/$36.00
Copyright Q 2012 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
Published online March 3, 2011.
http://dx.doi.org/10.1016/j.pedhc.2011.05.004
436 Volume 26  Number 6
nition, largely because of the publication by Kempe,
Silverman, Steele, Droegemueller, and Silver (1962)
that first described the battered child syndrome. It was
not until the 1970s that sexual abuse began receiving
professional awareness in the United States, reflecting
a generalized societal recognition of the problem
(Hornor, 2008a). Today, the public is often bombarded
with information regarding horrific cases of physical
and sexual abuse. Emotional maltreatment, on the
other hand, has been slow to achieve recognition as
a serious social problem for a variety of reasons.
Emotional maltreatment is more difficult to identify
and define than is physical or sexual abuse, and good
epidemiological data regarding emotional maltreatment
are not available. The erroneous perception also exists
that the sequelae of emotional maltreatment are less
severe compared with those of physical and/or sexual
abuse (Egeland, 2009). Emotional maltreatment may
actually be the most prevalent form of child abuse, but
it is also the most hidden, under-reported, and least stud-
ied form of abuse (Barnet, Miller-Perrin, & Perrin, 2005).
DEFINITION
Emotional or psychological maltreatment is defined as
a repeated pattern of damaging interactions between
a child and one or more parents/caregivers that
becomes typical of the
relationship (Kairys & Emotional
Johnson, 2002). The maltreatment may
pattern may be chronic
and pervasive or in
coexist with or be
some situations stimu- a consequence of
lated by a potentiating physical or sexual
factor such as parental
use of alcohol or drugs.
abuse, but it also
Emotional maltreat- can exist as
ment may coexist with a separate entity.
or be a consequence
of physical or sexual abuse, but it also can exist as
a separate entity.
Children who experience emotional abuse feel
worthless, damaged, unloved, unwanted, or endan-
gered. They feel of value only if they meet the needs
of another person. These feelings are a result of interac-
tions with their parent or parents. The following
Journal of Pediatric Health Care
behaviors may be emotionally abusive, especially if
they are severe or repetitive (Kairys & Johnson, 2002):
1. Spurning: Belittling, degrading, shaming, or
ridiculing a child; criticizing or punishing a child
in a way that singles him or her out; humiliating
a child
2. Frightening or terrorizing: Committing or
threatening to perpetrate violence or life-
threatening acts against a child, a childÕs loved
ones, or a childÕs treasured objects
3. Corruption: Encouraging the development of
inappropriate behaviors by modeling, encourag-
ing, or permitting developmentally inappropri-
ate or antisocial behaviors such as alcohol or
drug use, sexual activity/pornography, or inap-
propriate language; and encouraging or forcing
the abandonment of developmentally appropri-
ate autonomy or interfering with cognitive
development
4. Absence of emotional responsiveness: Ignor-
ing a child or never expressing affection, caring,
and love for a child
5. Rejection: Avoiding a child or pushing him or her
away
6. Isolation: Placing unreasonable limitations upon
freedom of movement or social interaction
7. Inconsistent parenting: Placing conflicting de-
mands and expectations on a child
8. Neglect: Failing to provide for a childÕs mental
health, medical, and educational needs
9. Domestic violence: Allowing a child to witness
domestic violence
Emotional maltreatment also can be differentiated
into two broad categories: emotional abuse and emo-
tional neglect (Egeland, 2009). Both categories can be
subtle and much more difficult to identify than sexual
abuse, physical abuse, or neglect. Emotional abuse
can be thought of as an act of commission: verbal
hostility, taunting, belittling, and rejection. Emotional
neglect, on the other hand, is an act of omission: a failure
to meet the emotional needs of the child. A parent who
is emotionally unavailable, detached, avoidant, and
unresponsive to their childÕs needs or desires can be
described as emotionally neglectful (Egeland, 2009).
Epidemiology
According to the U.S. Department of Health & Human
Services (2010), of the 825,000 children who were
maltreated in 2009, 78.3% experienced neglect; 17.8%,
physical abuse; 9.5%, sexual abuse; and 7.6%, emo-
tional maltreatment. Thus nearly 63,000 American
children were reported to child protective services
(CPS) with a concern of emotional maltreatment. The
reported numbers of children experiencing emotional
maltreatment may represent only the tip of the iceberg.
Based on retrospective studies of adults who were
www.jpedhc.org
asked if they had experienced emotional maltreatment
as a child, the numbers become significantly higher.
In a community sample of adults, the prevalence of
childhood emotional abuse was reported as 14% for
women and 10% for men (Scher, Forde, McQuaid, &
Stein, 2004).
The U.S. Department of Health & Human Services
(2010) has submitted a report to Congress on findings
from the Fourth National Incidence Study of Child
Abuse and Neglect (NIS-4). Mandated by Congress,
the NIS-4 measured the incidence and prevalence of
child maltreatment and aimed to estimate the current
national incidence, severity, and demographic distribu-
tion of child maltreatment based on standardized
research definitions. The NIS-4 also assessed changes
since NIS-3 data collection in 1993. Two sets of standard
definitions of child maltreatment were used by NIS-4:
the ‘‘Harm Standard’’ and the ‘‘Endangerment Standard.’’
Children experiencing harm or injury from the abuse
or neglect were identified under the Harm Standard.
The Endangerment Standard included all children
identified under the Harm Standard, plus children
who experienced abuse or neglect that put them at
risk for harm.
Interestingly, a 26% decline in the rate of overall
Harm Standard maltreatment was found when compar-
ing NIS-4 data to NIS-3 data. However, under the
Endangerment Standard, the overall incidence of
children who experienced maltreatment showed no
statistically reliable change. Even though significant
decreases in the overall incidence of abuse and all spe-
cific categories of abuse were noted, these decreases
were offset by a significant increase in the incidence
of emotional neglect.
It has been stated that emotional maltreatment can be
difficult to identify. To this end, Trickett, Mennen, Kim,
and Sang (2009) used a framework to examine and
describe the nature of emotional maltreatment experi-
enced by a sample of children (303) identified as mal-
treated by CPS. CPS had identified 9% of the sample
as being emotionally maltreated; while utilizing a frame-
work that examined the entire case record of each child,
48% of the children were found to have experienced
emotional maltreatment. The Maltreatment Case Re-
cord Abstraction Instrument was the framework uti-
lized, which allowed for examination of the entire
case record utilizing markers specific for emotional
maltreatment.
Comorbidities
Multiple forms of child maltreatment and other negative
childhood experiences often occur concurrently. A
landmark study describing this interrelatedness was
the Adverse Childhood Experiences study (Dong
et al., 2004). In a survey of nearly 9000 adult members
of a health plan who completed a survey about adverse
childhood experiences, 25% reported childhood
November/December 2012 437
emotional maltreatment (10% reported emotional
abuse and 15% reported emotional neglect). Among
persons reporting emotional abuse, 80% also reported
experiencing physical abuse; 42%, sexual abuse; and
58%, neglect. Conversely, persons reporting emotional
neglect also reported experiencing physical abuse
(40%), sexual abuse (36%), and neglect (37%). Emo-
tional maltreatment was strongly associated with
parental substance abuse (49%), parental mental illness
(44%), parental separation/divorce (44%), and parental
domestic violence (35%), and less so with parental
crime (12%).
CONSEQUENCES OF EMOTIONAL
MALTREATMENT
Experiencing child abuse has been linked to a variety
of negative consequences, including post-traumatic
stress, depression, suicide, substance abuse, and obe-
sity (Hornor, 2010). Emotional maltreatment can result
from experiencing physical or sexual abuse, but chil-
dren who are not physically or sexually abused can
be emotionally maltreated. Children who experience
emotional maltreatment undergo a unique form of
abuse. The weapons used against them are not visible
such as hands, belts, cords, or sexual acts, but rather
ugly, hurting words or cold, uncaring silence. Although
no physical pain or sexual contact is ever endured, the
consequences can be just as severe and long-lasting.
One possible result of early childhood emotional
maltreatment is reactive attachment disorder (RAD;
Hornor, 2008b). RAD is defined as markedly disturbed
and developmentally inappropriate social relatedness
that usually begins before the age of 5 years. RAD can
present as a persistent failure to initiate or respond in
a developmentally appropriate fashion to most social
situations. The child avoids or resists comforting or
exhibits a frozen watchfulness; he or she appears to
be unable to or has great difficulty forming relation-
ships with anyone. Conversely, RAD also can present
as excessive familiarity with strangers or a lack of selec-
tivity in the choice of attachment figures—that is, the
child may form attachments to just about anyone. These
manifest behaviors are exhibited after pathogenic care,
consisting of the persistent disregard of the childÕs basic
emotional needs for comfort, stimulation, and affec-
tion; persistent disregard of the childÕs basic physical
needs; and/or repeated changes of primary caregivers
that prevent the formation of stable attachments
(American Psychiatric Association, 2000).
The long-term impact of emotional maltreatment has
not been studied widely, but recent studies have begun
to document its long-term consequences. Emotional
maltreatment has been linked with increased depres-
sion, anxiety, somatic complaints, and difficulties in
interpersonal relationships (Spertus, Wong, Halligan,
& Seremetis, 2003). Further complicating research into
the consequences of emotional maltreatment is the
438 Volume 26  Number 6
high co-occurrence rate of emotional maltreatment
with other forms of maltreatment, such as physical
abuse and neglect. Often it is difficult to separate the
effects of various types of maltreatment (Higgins &
McCabe, 2000; Arata, Langhinrichsen-Rohling,
Bowers, & OÕFarrill-Swails, 2005).
van Harmelen and colleagues (2010) studied the re-
lationship between experiencing child abuse and the
development of depressive and/or anxiety disorders
later in life; they also
separated forms of Emotional
abuse and examined
physical abuse, sexual
maltreatment, even
abuse, and emotional more than physical
maltreatment and their and sexual abuse,
associations with de-
pression and anxiety.
may predispose
Nearly 3000 adults a person to
with a current or past developing
diagnosis of major de-
pressive disorder and/
depression or
or an anxiety disorder anxiety.
were interviewed to as-
sess a history of emotional maltreatment, physical
abuse, and/or sexual abuse before the age of 16 years;
a history of multiple incidents was required to meet the
definition of child abuse for the study. Of all adults re-
porting child abuse, 93% reported experiencing emo-
tional maltreatment. Nearly one third (31%) of adults
who reported emotional maltreatment also reported
physical abuse and 29% also reported sexual abuse.
Emotional maltreatment, when compared with physi-
cal and/or sexual abuse, had the strongest link with
enhanced automatic (and explicit) self-depression
and self-anxiety associations. Emotional maltreatment,
even more than physical and sexual abuse, may predis-
pose a person to developing depression or anxiety.
Specific behaviors have been included in the defini-
tion of emotional maltreatment. Allen (2008) examined
the impact of five forms of emotional maltreatment on
emotional adjustment in early adulthood: spurning,
terrorizing, exploiting, ignoring, and isolating. More
than 230 college students between the ages of 18 and
22 years participated in the study, with their ethnicity
being predominantly European American (92%); 59%
were women. Allen (2008) found each form of emo-
tional maltreatment to be significantly related to the
other forms of emotional maltreatment and physical
abuse. The strongest relationship was noted between
isolating and ignoring, with the weakest relationship
between ignoring and witnessing family violence.
Each form of psychological symptomatology was sig-
nificantly correlated with a number of types of emo-
tional maltreatment. Somatic complaints, anxiety, and
depression were each significantly associated with deg-
radation, terrorizing, ignoring, and witnessing family
violence. Borderline features were significantly related
Journal of Pediatric Health Care
to degradation, terrorizing, and ignoring. None of the
forms of psychological symptomatology were associ-
ated with being isolated. Experiencing acts of terroriz-
ing at the hands of caregivers was significantly
predictive of somatic complaints and anxiety in early
adulthood. The frequency of being ignored by care-
givers in childhood was predictive of current depres-
sion and borderline personality features. Childhood
degradation predicted current features of borderline
personality features. Physical abuse in the absence of
the various forms of emotional maltreatment was signif-
icantly predictive for only somatic complaints. AllenÕs
work is significant in that it is the first study that
examined the impact of specific forms of childhood
emotional maltreatment on different types of psycho-
logical impairment in early adulthood.
Anger and aggression are potentially destructive
forms of psychological problems in adulthood. Allen
(2010) examined the impact of long-term child emo-
tional abuse on aggression using the same sample
previously described. Allen specifically tested the
self-capacities of interpersonal relatedness, identity,
and affect regulation as mediators for the impact of
emotional abuse on aggression in adulthood. Results
suggested that emotional abuse is significantly predic-
tive of participantsÕ self-reported increased levels of
various forms of aggression. Emotional abuse also was
significantly correlated with all of the self-capacities
(identity, interpersonal relatedness, and affect regula-
tion) and was found to be a significant independent
predictor of interpersonal problems and affect dysregu-
lation. Detrimental alterations of self-capacities were
found to predict aggression. It is possible that experi-
encing emotional maltreatment teaches the child inef-
fective ways of relating to others; the child then
develops poor relationship skills that increase the likeli-
hood of interpersonal problems as an adult. Problem-
atic relationships result in an increased likelihood of
verbal and/or physical aggression. Also, experiencing
emotional abuse may result in an inability to develop
adequate emotional regulation skills, which increases
the risk of persons being unable to rid themselves of
negative feelings of anger, predisposing them to overt
forms of aggression.
Anger and aggression can manifest itself as teen dat-
ing violence. Teens as young as seventh grade report
engaging in dating violence, with emotional abuse
being the most common form of violence (Sears,
Byers, & Price, 2007). Wekerle and colleagues (2009)
examined the predictive value of child emotional mal-
treatment for understanding teen dating violence and
adolescent post-traumatic stress disorder (PTSD) symp-
tomatology. A random sample of 408 adolescents
engaged with CPS participated in the study; 52% were
girls, with a mean age of 16 years. Ethnicity was diverse.
Findings indicated clearly that teens involved with CPS
are at high risk for dating violence; 65% of girls and
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46% of boys reported experiencing teen dating vio-
lence. Emotional abuse was found to be a significant
predictor of dating violence and PTSD symptomatology
among both girls and boys. Male emotional abuse per-
petration and female emotional abuse victimization
was found to be significantly mediated by PTSD symp-
tomatology. Thus, when considering emotional abuse
and its potential for negative impact upon relationship
development, the victim of emotional abuse is made to
feel worthless and the victimÕs thoughts, feelings, and
behaviors are ignored or condemned. Emotional mal-
treatment, like other forms of maltreatment, teaches
children that not all relationships are positively rein-
forcing and to expect punishment in relationships.
Relationships become a source of negative affect, fear,
or anger and lack positive affect and joy.
Childhood emotional maltreatment may threaten the
security of attachment relationships and yield maladap-
tive models of self and self in relation to others. Wright,
Crawford, and Del Castillo (2009) explored the extent
to which experiencing emotional abuse and emotional
neglect by parents uniquely contributed to young adult
maladaptive long-term outcome in terms of symptoms
of anxiety, depression, and dissociation. Three hun-
dred students at a Midwestern university (53% of
whom were women and 94% of whom had European
American ancestry, with a mean age of 20 years) partic-
ipated in a study over five semesters. Findings revealed
that perceptions of childhood emotional abuse and
neglect each continued to exert an influence on later
symptoms of anxiety and depression even after control-
ling for gender, income, parental alcoholism, and other
forms of child abuse. This relationship was mediated by
schemas of vulnerability to harm, shame, and self-
sacrifice. Only emotional neglect was related to later
symptoms of dissociation and was mediated by
schemas of shame and vulnerability to harm. Experi-
encing child sexual abuse also was a significant predic-
tor of later anxiety, depression, and dissociation. Wright
et al. (2009) suggest that how a person evaluates and in-
ternalizes experiences may be even more important
than the events themselves in determining the extent
to which these experiences exert a long-term impact.
Emotional maltreatment may result in global, negative
beliefs about the self.
The effects of emotional maltreatment can be dis-
abling and enduring and should be carefully assessed.
Shaffer, Yates, and Egeland (2009) examined if and
how different forms of emotional maltreatment contrib-
uted to adolescent adjustment via aggression and social
withdrawal in middle childhood. Participants for the
study were drawn from the Minnesota Longitudinal
Study of Parents and Children, a prospective, longitudi-
nal study that began in 1975. Low-income women in
their first trimester of pregnancy were recruited through
a public health prenatal clinic. Data for the study were
drawn from assessments completed when the focal
November/December 2012 439
children (196) ranged in age from 24 months to sixth Most often it is the childÕs behaviors or psychological
grade. Mothers were observed interacting with their difficulties that first raise the concern of possible
children at several points in early childhood. Data maltreatment or some form of other problems within
from the observations were utilized by coders to the family. On occasion, parent-child interactions ob-
identify mothers as emotionally neglectful or abusive. served in the clinical setting raise the concern of possi-
Emotionally neglectful mothers were emotionally dis- ble emotional maltreatment. Most often, however,
tant and unresponsive to the childÕs bids for comfort additional information is necessary when making the
and help. Mothers identified as emotionally abusive diagnosis of suspected emotional maltreatment, includ-
were verbally hostile with their child, often making crit- ing reports from schools, mental health counselors,
ical or sarcastic comments. Middle childhood outcomes child care workers, and other professionals involved
were assessed using the Teacher Report Form of the with the family.
Child Behavior Checklist, which is designed to measure For all children presenting with behavioral concerns,
childrenÕs problem behavior and adaptive functioning. a thorough psychosocial history should be obtained.
Adolescent self-esteem and peer competence were The accompanying
derived from teacher reports using a measure designed parent should be in- Most often it is the
for the study. Of the 196 child participants (43% of formed that because
whom were girls), 13% were identified as emotionally family problems, vio-
childÕs behaviors or
neglected and 22% as emotionally abused. Only 4% lence, and abuse are psychological
were identified as both. Both emotional neglect and common in our soci- difficulties that first
emotional abuse were associated with increased ag- ety, these questions
gression and social withdrawal in middle childhood are asked of all
raise the concern of
and lower emotional competence in early adolescence, families. A family tree possible
especially for boys. can be drawn that pro- maltreatment or
vides invaluable famil-
IMPLICATIONS FOR PRACTICE ial information,
some form of other
It is clear that emotional maltreatment can have seri- including the parental problems within the
ous negative consequences for children. Prompt iden- names and ages, mari- family.
tification and appropriate intervention are necessary tal status, childÕs cur-
to decrease long-term sequelae for children. It is rent living situation,
important to note that prior to entering school, the pe- number of siblings, and number of partners each parent
diatric nurse practitioner (PNP) or other health care has had children with. Box 1 lists psychosocial informa-
provider may be the only professional who has regu- tion that should be gathered. Possible maltreatment of
lar contact with the patient, and therefore their obser- all forms should be explored, along with parental disci-
vations of child/parent interactions can be crucial to pline practices. The parent should be asked if he or she
the identification of emotional maltreatment. How- has ever had concerns regarding physical, sexual, or
ever, diagnosing emotional maltreatment can be emotional maltreatment or if the child had ever been
difficult. The diagnosis can be facilitated when a docu- in contact with anyone known to physically or sexually
mented event or series of events has had a significant abuse a child. Emotional maltreatment is much more
effect on the childÕs emotional welfare such as a con- difficult to screen for; Box 2 provides examples of
tentious parental separation/divorce with subsequent
abandonment by one parent. Typically, the events
that result in emotional maltreatment are much more BOX 1. Psychosocial history
subtle and more difficult for the PNP to identify. As
1. Maternal age and current employment status
with all forms of child maltreatment, PNPs must be 2. Paternal age and current employment status
aware of their own cultural biases related to emotional 3. Living arrangement/marital status
maltreatment and be respectful of behaviors that may 4. Educational level of parents/any cognitive delays/
be unique to the childÕs culture, which are different mental retardation
from their own cultural beliefs yet not abusive in 5. Past or present parental drug/alcohol concern
nature. 6. Past or present parental mental health concern
Well-child visits should include anticipatory guid- 7. Parental domestic violence concerns
ance regarding child emotional maltreatment. The 8. Previous involvement with child protective services
dangers of verbal aggression such as calling the child for the family
belittling names, cursing, or threatening to give the 9. Parental involvement with law enforcement
10. History of child maltreatment (sexual abuse, phys-
child away should be discussed with parents (Kairys
ical abuse, or involvement with child protective
& Johnson, 2002). The importance of consistency in services) within the family—mother and/or father
parental love, acceptance, and attention should be victimized as a child
stressed.

440 Volume 26  Number 6 Journal of Pediatric Health Care


BOX 2. Questions for parents
1. What kind of child is __________________?
2. Is he/she easy to care for?
3. Tell me something good/positive about
_______________________ .
4. What is hard/difficult about
__________________________?
5. What is easy about _________________________?
questions to ask parents to gather information regard-
ing their feelings about parenting the child.
Children should be asked screening questions regard-
ing discipline practices and sexual abuse. Children can
be asked to identify their private parts and asked if
anyone has ever touched, tickled, kissed, hurt, or put
anything in their private places. Children also can be
screened for exposure to domestic violence; for exam-
ple, children can be asked what happens when mommy
and daddy argue—is there any hitting or kicking? Box 3
provides examples of questions to ask children to
gather information about familial relationships.
A thorough physical examination must be com-
pleted, including an ano-genital examination. One
should closely assess for injuries that raise the concern
for possible physical or sexual abuse. The childÕs
growth chart may yield valuable information; weight
loss or gain may be one of the few physical symptoms
of emotional maltreatment.
PNPs should gather and process information gar-
nered from observations of child-parent interactions,
familial psychosocial history, child maltreatment
screening questions asked of the parent and child,
the physical examination, and reports from other in-
volved professionals such as teachers or child care
workers. If the processed information raises a concern
of suspected child maltreatment of any form, including
suspected emotional maltreatment, a report must be
made to CPS. Your concerns and your need to report
must be discussed with the parents.
The maltreatment must stop before healing
from emotional maltreatment can occur. Children
BOX 3. Questions for children
1. How are things at home? At your dadÕs?
2. How do you get along with mom/dad/step-dad/
step-mom?
3. Tell me something you like to do with mom/dad/
step-dad/step-mom.
4. Tell me something you like about mom/dad/step-
dad/step-mom.
5. Tell me something you donÕt like about mom/dad/
step-dad/step-mom.
6. Does anyone make you feel scared, sad, or dumb?
www.jpedhc.org
experiencing emotional maltreatment need to be as-
sessed by a mental health therapist who is competent
in trauma-based cognitive behavioral therapy to deter-
mine the need for ongoing therapy. Adults perpetrating
the emotional maltreatment also are in need of therapy
so they can understand and change their own behavior.
Parenting classes may be of benefit. At a time deemed
appropriate by the mental health therapist, family ther-
apy or parent-child therapy may be necessary to ensure
appropriate parent-child interaction. Child advocacy
centers are an excellent source of appropriate local
resources for mental health therapy and/or parenting
classes.
Emotional maltreatment is often more nebulous than
physical or sexual abuse and much more difficult to
identify. PNPs, because of their unique relationships
with families, are truly in a prime position to identify
concerns of suspected emotional maltreatment and
intervene appropriately. PNPs should know their fami-
liesÕ psychosocial histories and ask screening questions
regarding all forms of maltreatment. Anticipatory guid-
ance related to emotional maltreatment should be
provided. For children presenting with emotional or
behavioral issues, emotional maltreatment should
always be in the differential diagnosis and must be
assessed. The input of other professionals involved
with the family, such as teachers, child care workers,
or counselors, may be needed for the PNP to solidify
a concern of suspected emotional maltreatment. If
a concern of suspected emotional maltreatment is iden-
tified, the concern should be reported to CPS so that
a more intensive investigation can transpire. By prompt
identification of emotional maltreatment, timely report-
ing of concerns to CPS, and appropriate referral for
mental health therapy and other community resources,
PNPs can truly make a difference in the lives of patients
and families.
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