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A systematic review of the emotional, behavioural and cognitive features exhibited by school-aged children experiencing neglect or emotional abuse

S. A. Maguire,* B. Williams,† A. M. Naughton,‡ L. E. Cowley,* V. Tempest,* M. K. Mann,§ M. Teague¶ and A. M. Kemp*

*College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK †ST6 Community Child Health, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK ‡Safeguarding Children Service, Public Health Wales NHS Trust, Cardiff, UK §Support Unit for Research Evidence, Cardiff University, Cardiff, UK, and ¶Masters in Education Programme, Cardiff University, Cardiff, UK

Accepted for publication 30 November 2014

Keywords emotional maltreatment, evidence-based practice, neglect

Correspondence: Sabine A. Maguire, College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff CF14 4XY, UK E-mail: [email protected]

Abstract Background Interventions to minimize the long-term consequences of neglect or emotional abuse

rely on prompt identification of these children. This systematic review of world literature

(1947–2012) identifies features that children aged 5–14 years experiencing neglect or emotional

abuse, as opposed to physical or sexual abuse, may exhibit.

Methods Searching 18 databases, utilizing over 100 keywords, supplemented by hand searching,

13,210 articles were identified and 111 underwent full critical appraisal by two independent trained

reviewers.

Results The 30 included studies highlighted behavioural features (15 studies), externalizing

features being the most prominent (8/9 studies) and internalizing features noted in 4/6 studies.

Four studies identified attention deficit hyperactivity disorder (ADHD) associated features:

impulsivity, inattention or hyperactivity. Child difficulties in initiating or developing friendships were

noted in seven studies. Of 13 studies addressing emotional well-being, three highlighted low

self-esteem, with a perception of external control (1), or depression (6) including suicidality (1).

A negative internal working model of the mother increased the likelihood of depression (1). In

assessing cognition or academic performance, lower general intelligence (3/4) and reduced literacy

and numeracy (2) were reported, but no observable effect on memory (3).

Conclusions School-aged children presenting with poor academic performance, ADHD

symptomatology or abnormal behaviours warrant assessment of neglect or emotional abuse as a

potential underlying cause.

Introduction

Child neglect is the most ubiquitous form of child maltreat- ment, a significant public health concern and has devastating short- and long-term consequences for children (Burgess et al. 2012). In addition, the greater prevalence and deleterious effects

of childhood emotional abuse (EA) have been clearly docu- mented (Gardner 2008; Stoltenborgh et al. 2012; NSPCC 2013a). EA entails persistent disregard of a child’s emotional and psychological needs, and although it has been described as a distinct type of maltreatment, there is often substantial overlap with varying forms of neglect (Iwaniec 2006; Gardner

Review Article doi:10.1111/cch.12227

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2008). As schools are legally obliged to take responsibility for ‘safeguarding and promoting the welfare of children and young people’ (Great Britain 2002), it is important that identifiable features of school-aged children experiencing neglect or EA are drawn from the current scientific literature.

Education staff come into contact with children on an almost daily basis and are thus in an ideal position to observe the children’s behaviour and demeanour and make themselves available to those who may want to confide in them (Gilbert et al. 2009; Burgess et al. 2012; McGarry & Buckley 2013; NSPCC 2013b; King & Scott 2014). However, international literature shows that teachers worldwide are uncomfortable with the practice of informing child protection authorities of known or suspected maltreatment (Gilbert et al. 2009; McGarry & Buckley 2013), even where mandated to do so (Smith 2010). Reasons cited include a lack of knowledge about the indicators of neglect, a lack of confidence concerning what represents reasonable grounds for suspicion, a desire to convey lower levels of concern or fear that features overlap with other childhood conditions (Gilbert et al. 2009; Burgess et al. 2012). Whereas physical or sexual abuse might be limited to acts of commission, neglect and EA are inherently more difficult to identify as neglect implies acts of omission and EA represents a sustained pattern of maladaptive interaction with the caregiver.

It is well established that both child maltreatment impacts not only on daily life but also on a range of developmental events (De Paúl & Arruabarrena 1995; Finzi et al. 2003); thus, a number of researchers have emphasized the importance of adopting a developmental perspective when investigating any aspect of child maltreatment (Kendall-Tackett & Eckenrode 1996; Manly et al. 2001; Ayoub et al. 2006). The developmental approach concedes that over time, children are exposed to new experiences and must negotiate specific developmental tasks, which are dynamically integrated as increasingly complex abil- ities evolve (Manly et al. 2001). This process is influenced by a number of elements, including risk and protective factors; the interaction between the child, family and environment; and relations between and within social, biological and psychologi- cal systems (Manly et al. 2001). Difficulty negotiating earlier developmental tasks impacts on a child’s ability to negotiate subsequent tasks (Aber & Allen 1987).

This systematic review aims to identify the scientific evi- dence behind the observable features in children aged 5–14 completed years who are experiencing neglect and/or EA, in the absence of physical or sexual abuse, to aid in their prompt recognition and gain an understanding of the behaviours they may exhibit.

Methods

The systematic review was carried out by Core Info: Cardiff Child Protection Systematic Reviews (www.core-info.cardiff.ac .uk) following a well-established methodology.

An all language literature search across 18 bibliographic databases (Appendix S1) was conducted to identify original articles published from database inception to August 2012. The search strategy (Appendix S2) was developed across the Ovid MEDLINE database using a combination of Medical Subject Headings and free text, which was then modified for the remaining databases. The search was limited to included studies from Organisation for Economic Co-Operation and Develop- ment countries. These countries are likely to have a comparable economy; hence, the studies would be more likely to be of equal relevance across settings. Supplementary searching was carried out to include non-indexed journals, relevant organizations, web sites, consultation with subject experts and relevant refer- ences of all full-text articles.

Identified articles, once scanned for duplicates and relevancy, were transferred to a purpose-built Microsoft Access database. Where applicable, authors were contacted for primary data and confirmation of information such as data duplication across publications, age range of subjects or the confirmation of neglect/EA as appropriate. Relevant studies with an English- language version available were scanned for eligibility by the lead researcher and selected for review.

A panel of paediatricians, social workers, psychologists, teachers and child protection researchers conducted two inde- pendent reviews of all relevant articles (Appendix S3). All reviewers underwent critical appraisal training purposefully designed for this review and used standardized forms based on criteria defined by the National Health Service’s Centre for Reviews and Dissemination (2009) and supplemented by sys- tematic review advisory guidance [Polgar & Thomas 1995; Rychetnik & Frommer 2002; Weaver et al. 2002; Weightman et al. 2004; Critical Appraisal Skills Programme (CASP) (http:// www.casp-uk.net)]. A third review was undertaken to resolve any disagreements.

Inclusion criteria were all primary studies of children aged 5–14 years (where the majority of children were aged 6–12 years) experiencing neglect and/or EA, in the absence of physi- cal or sexual abuse, for which the authors explicitly recorded emotional, behavioural or cognitive features in the child. We used the World Health Organization’s (2002) definitions of neglect and EA. We used the American Professional Society on the Abuse of Children’s (1995) definition of psychological maltreatment as this encompasses both EA and emotional

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http://www.core-info.cardiff.ac.uk

http://www.casp-uk.net

neglect. Because there is no universal UK or world definition of educational neglect, we derived a working definition from the American Humane Association, the Public Health Agency of Canada (2010) and Horwath (2007) (Fig. 1).

To minimize the risk of circularity, we used a quality ranking of confirmation of neglect/EA for the studies based on stand- ards derived for previous systematic reviews including studies ranked A–C (Fig. 1). The quality standards achieved by the included studies are detailed in Table 1. Of 111 full-text articles reviewed, 30 articles from 26 studies were included (Fig. 2).

Results

The 30 included articles reported data from 26 studies (Appen- dix S4), with more than one article published from some studies leading to overlapping data (Table 2). Because of this, and the widely varying age bands among included studies, a valid meta- analysis could not be performed. Although the studies span the age range of 5–14 years, the majority addressed children aged 7–11 years, and thus are summarized by key features.

Behavioural features

Fifteen studies (18 publications) addressed behavioural features (Reidy 1977; Kaufman & Cicchetti 1989; Reyome 1993; Kaufman et al. 1994; Manly et al. 1994, 2001; De Paúl & Arruabarrena 1995; Kendall-Tackett & Eckenrode 1996; Shields & Cicchetti 1998; Bolger & Patterson 2001; Finzi et al. 2001, 2002, 2003; Kantor et al. 2004; Cullerton-Sen et al. 2008; Valentino et al. 2008a; Fishbein et al. 2009; Alink et al. 2012). Fourteen different measures of child behaviour were used (Appendix S4). Kantor and colleagues (2004) set out to validate a neglect rating scale in two age groups: 6–9 and 10–15 years, identifying that older neglected children exhibited significantly more behavioural problems than controls, and their proposed neglect rating scale performed better for the older children.

The most commonly recorded behavioural issue among chil- dren experiencing neglect (Reidy 1977; Reyome 1993; Manly et al. 1994, 2001; De Paúl & Arruabarrena 1995; Cullerton-Sen et al. 2008) or EA (Kaufman et al. 1994; Manly et al. 2001; Cullerton-Sen et al. 2008) was externalizing, i.e. aggressive, assaultive, destructive, antisocial/delinquent behaviour. One study showed a significant difference between neglected and lower middle-class controls, which was no longer sustained when the neglected children were compared with lower socio- economic subjects (Reyome 1993). Only one study showed no difference in aggressive behaviour between neglected/EA children and controls utilizing a combined peer/teacher rating;

Definitions of Neglect Used for the Purpose of This Review Definition of Neglect Neglect refers to the failure of a parent to provide for the development of the child – where the parent is in a position to do so – in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions. Neglect is thus distinguished from circumstances of poverty in that neglect can occur only in cases where reasonable resources are available to the family or caregiver. (World Health Organization 2002)

Definition of Emotional Abuse Emotional abuse includes the failure of a caregiver to provide an appropriate and supportive environment, and includes acts that have an adverse effect on the emotional health and development of a child. Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other non-physical forms of hostile treatment. (World Health Organization 2002)

Definition of Psychological Maltreatment Psychosocial evaluation of suspected psychological maltreatment in children and adolescents Practice Guidelines Six forms of psychological maltreatment:

• Spurning (verbal and non-verbal hostile rejecting/degrading) • Terrorizing (behaviour that threatens or is likely to physically harm the child or place the child or

the child’s loved objects in danger) • Exploiting/corrupting (encouraging the child to develop inappropriate behaviours) • Denying emotional responsiveness (ignoring the child’s need to interact, failing to express

positive effect to the child, showing no emotion in interactions with the child) • Isolating (denying the child opportunities for interacting/communicating with peers or adults) • Mental, health, medical, and educational neglect (ignoring or failing to ensure provision for the

child’s needs) (American Professional Society on the Abuse of Children 1995)

*In the absence of an identifiable UK/World definition of educational neglect, we have developed our own for the purposes of the review: Educational neglect involves one or more of the following: The parent or caregiver’s -

• Failure to enrol a child of mandatory school age in school • Failure to comply with state requirements regarding school attendance • Failure to access/provide appropriate home schooling • Failure to avail of recommended special educational provision • Failure to cooperate with treatment if the child is experiencing mental, emotional or

developmental problems associated with school, and treatment is offered • Failure to show an interest in the child’s education at school and support their learning • Failure to provide a stimulating environment • Repeatedly keeping the child at home, thus failing to comply with state requirements • Allowing the child or youth to engage in chronic truancy

Adapted from: [American Humane Association (http:// www.americanhumane.org/children/stop- child-abuse/fact-sheets/child-neglect.html)]/(Public Health Agency of Canada 2010)/ (Horwath 2007)

Inclusion Criteria

• Primary studies of children aged 6–12 completed years* • Documented features of the impact of neglect/emotional abuse on the child during the period

of exposure to neglect/emotional abuse • Confirmed cases of neglect/emotional abuse

(A-C Quality Standards for Confirmation of Neglect/Emotional Abuse) • Studies conducted in Organisation for Economic Co-operation and Development (OECD)

(http://www.oecd.org/about/membersandpartners/list-oecd-member-countries.htm) countries

Exclusion Criteria

• Studies of adults or of children aged under 6 years or aged 13 and over* - either exclusively or where relevant data cannot be extracted

• Studies relating to secondary carer - either exclusively or where relevant data relating to primary carer cannot be extracted

• Studies relating to non-OECD country/ies - either exclusively or where relevant data relating to OECD country/ies cannot be extracted

• Studies of sexual or physical abuse alone, or studies combining sexual or physical abuse and neglect/emotional abuse, where the data from the neglect/emotional abuse cases could not be extracted

• Studies of management or complications of neglect • Studies addressing outcomes of neglect and/or emotional abuse measured in adults or

children aged under 6 years or aged 13 and over* – either exclusively or where relevant data cannot be extracted

• Studies with no data/documentation relating to impact on child (emotional, behavioural, psychological, developmental)

• Single case studies/case series of fewer than three cases/formal consensus/expert opinions/personal practice/review articles/systematic reviews

• Neglect/Emotional Abuse defined by unreferenced criteria/tool, not specified in our standards (D Quality Standards for Confirmation of Neglect/Emotional Abuse )

* studies included if majority of cases fall within 6 to 12 completed years

Ranking Quality standards for confirmation of neglect/emotional abuse

A1 Neglect/Emotional Abuse confirmed at Child Protection case conference, multi- disciplinary assessment, including social services or Court proceedings, or described by the child, or admitted by the perpetrator or independently witnessed

A2 Diagnosis of Neglect/Emotional Abuse by clinical psychologist, psychiatrist or other mental health specialist

B Neglect/Emotional Abuse confirmed by referenced criteria/tool

C Neglect/Emotional Abuse defined by unreferenced criteria/tool as specified in our standards (Action for Children)

D Neglect/Emotional Abuse defined by unreferenced criteria/tool, not specified in our standards (Action for Children)

Figure 1. Inclusion criteria and quality standards for confirmation of neglect/psychological maltreatment/emotional abuse.

Systematic review of school-aged neglect/emotional abuse 643

however, the neglected/EA children showed less pro-social behaviour (Alink et al. 2012). A further study exploring school records (Kendall-Tackett & Eckenrode 1996) noted that neglected children aged 11–14 years had more disciplinary problems and more suspensions than control children in the same school. Some authors did not identify a significant relationship between externalizing behaviour and neglect (Kaufman & Cicchetti 1989; Shields & Cicchetti 1998; Finzi et al. 2001, 2002; Alink et al. 2012). For some studies, any effect of neglect or EA is mitigated when factors such as earlier age of onset (Manly et al. 2001), gender (boys more physical aggres- sion, girls more relational aggression) (Cullerton-Sen et al. 2008), ethnicity (Cullerton-Sen et al. 2008) or socio-economic status (Finzi et al. 2001) are entered into the analysis. Likewise,

the timing, frequency, severity and chronicity of maltreatment may also be influential (Manly et al. 1994).

Six studies explored internalizing features (withdrawn, somatic complaints, anxiety/depression) (Kaufman & Cicchetti 1989; Reyome 1993; De Paúl & Arruabarrena 1995; Bolger & Patterson 2001; Manly et al. 2001; Valentino et al. 2008a) among neglected or emotionally abused children versus matched con- trols. Four found an association with children experiencing neglect (Reyome 1993; Bolger & Patterson 2001; Valentino et al. 2008a) or EA and neglect (Manly et al. 2001), showing more internalizing features. Bolger and Patterson (2001) highlighted that for these children, the internalizing features appeared to be linked to a sense of ‘external control’, i.e. those children who were more withdrawn felt that they could not influence what

Table 1. Quality standards applicable to comparative studies

Study Match Age Gender Ethnicity Socio-economic status

Marital status IQ/education

Family size

Cullerton-Sen et al. 2008 USA

x ! ! ! !

De Paúl & Arruabarrena 1995 Spain

! ! ! ! ! Maternal education !

Edwards et al. 2005 USA

x ! ! ! x

Finzi et al. 2001 Israel

x ! x x

Finzi et al. 2002 Israel

x ! x x

Finzi et al. 2003 Israel

x ! x x

Kaufman & Cicchetti 1989 USA

! ! ! ! ! ! !

Kendall-Tackett & Eckenrode 1996 USA

! ! !

Kim & Cicchetti 2010 USA

Manly et al. 1994 USA

! ! ! ! Maternal education

Manly et al. 2001 USA

! x ! x x x

Nolin & Ethier 2007 Canada

! ! ! !

Reidy 1977 USA

x ! ! ! !

Reyome 1993 USA

! ! !

Toth & Cicchetti 1996 USA

x ! ! ! ! !

Valentino et al. 2008a USA

x ! ! x ! ! !

Valentino et al. 2008b USA

x ! ! x ! !

Valentino et al. 2009 USA

x ! ! ! ! ! x

!, feature considered and well matched; x, feature considered but not matched; empty cell, feature not considered; IQ, intelligence quotient.

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happened to them in life, rather this was a result of others. Another study noted that the neglected children with negative maternal schema have more internalizing symptoms than those with a positive maternal schema (Valentino et al. 2008a). The other two studies did not find any association between neglect and internalizing symptoms (Kaufman & Cicchetti 1989; De Paúl & Arruabarrena 1995).

Four studies exploring behavioural features associated with attention deficit hyperactivity disorder (ADHD), i.e. impulsivity, inattention, hyperactivity (De Paúl & Arruabarrena 1995; Manly et al. 2001; Finzi et al. 2002, 2003; Fishbein et al. 2009), noted they were more frequent in children who were neglected or emotionally maltreated. Both Finzi and colleagues (2003) (children aged 6–12 years) and Fishbein and colleagues (2009) (10–12 years) noted that the neglected children had more dif-

Independent third review where disagreement over eligibility and/or

evidence type (n = 74)

Duplicate/irrelevant citations removed (n = 8185)

S cr

ee ni

ng E

lig ib

ili ty

In cl

ud ed

Full-text articles assessed for eligibility and critically appraised (2 independent reviews‡)

(n = 111)

Full-text articles scanned for relevancy (n = 575)

Citations identified, 1946 – August 2012 (n = 13 210)

Databases† n = 12 667 Hand search journals, web sites† n = 279 References n = 155 Miscellaneous n = 109 (e.g. experts, other in-house reviews)

Citations and abstracts scanned for relevancy (n = 5025)

References of full-text articles checked

Id en

tif ic

at io

Articles (n = 30) from studies (n = 26)

Excluded (n = 545)**

Does not address question n = 376 Age n = 175 Secondary carer n = 7 Non-OECD country n = 8 Survivors n = 17 Outcomes n = 56 Sexual or physical abuse n = 136 No data relating to impact on child n = 46 Inadequate confirmation of neglect n = 62 Review article n = 77 Case study/small case series (<3) n = 7

** A study may be excluded for more than one reason

Figure 2. Study selection and review process*. *Flow diagram based on PRISMA guidance, http://www.prisma-statement.org. †See Appendix S1. ‡Panel of trained reviewers – see Acknowledgements.

Table 2. Included articles with overlapping data

Studies with overlapping or partially overlapping data (according to our records and information provided by authors)

Bolger & Patterson 2001: behaviour/emotion and Bolger et al. 1998: peer interaction

Edwards et al. 2005: emotion and Shipman et al. 2005: emotion Finzi et al. 2002: behaviour/attachment/peer interaction/emotion, Finzi et al.

2003: behaviour/peer/emotion, and Finzi et al. 2001: behaviour/ attachment

Manly et al. 2001: behaviour/peer and Manly et al. 1994: behaviour/peer Manly et al. 2001: behaviour/peer and Kim & Cicchetti 2006: emotion Manly et al. 2001: behaviour/peer and Kim & Cicchetti 2010: peer/emotion Manly et al. 2001: behaviour/peer and Lynch & Cicchetti 1998: emotion Manly et al. 2001: behaviour/peer and Shields & Cicchetti 1998: behaviour/

emotion

Systematic review of school-aged neglect/emotional abuse 645

http://www.prisma-statement.org

ficulty with impulse control than controls, with impulsivity being even more marked for those who had experienced severe EA. Likewise, in a large American study (ages 5.5–11.5 years), both neglected and emotionally maltreated children showed lower ego resiliency and greater ego under control (manifesting as impulsivity) than controls (Manly et al. 2001). A Spanish study (5–11 years) found neglected children had significantly more problems with attention and showed more delinquent behaviours than controls (De Paúl & Arruabarrena 1995).

Attachment

One study (Finzi et al. 2001, 2002) used the Attachment Style Classification Questionnaire and identified predominantly secure attachment in non-abused children 68.9% (24/35), whereas the neglected children showed anxious ambivalent attachment in 73.5% (28/38), with no correlation to aggression levels.

Peer interaction and social behaviour

Seven studies (nine publications) explored the social behaviour and friendships of children experiencing neglect and/or EA (Kaufman & Cicchetti 1989; Manly et al. 1994, 2001; De Paúl & Arruabarrena 1995; Bolger et al. 1998; Kinard 1999; Finzi et al. 2002, 2003; Kim & Cicchetti 2010). Overall, these children have poor social skills and difficulty in making or developing friend- ships. Kim and Cicchetti (2010) in a longitudinal study of 6- to 12-year-old children showed that emotional maltreatment in particular was more predictive of peer rejection as the children got older. Manly and colleagues (1994, 2001), in two separate studies, assessed children aged 5–11 years and found that the physically neglected children exhibited greater problems in social competence than the controls whereas the control children rated those who were experiencing neglect or emotional mal- treatment as being more aggressive. Likewise, De Paúl and Arruabarrena (1995) found that physically neglected children (5–11 years) had more problems establishing and maintaining relationships with their peers than controls. A further study found that the neglected and the emotionally maltreated chil- dren had fewer reciprocated playmates (i.e. if child A named child B as their best friend, would child B also name A as their best friend), which correlated with low self-esteem among these children. Those who were emotionally maltreated at a young age were less likely to have a best friend. Children who experienced more chronic maltreatment were less popular and gained fewer friends over time in comparison with controls (Bolger et al. 1998). In a case control study of Israeli children aged 6–12 years,

the neglected children were significantly more likely to use com- pensation in a social setting, e.g. by playing the ‘joker’ or trying to be the ‘strong guy’ in class, and generally socially overdoing it (Finzi et al. 2003). They also exhibit a strong desire to please (Finzi et al. 2002) and a yearning for proximity to others.

Only two studies found no differences in peer nomination scores among neglected or EA children compared with controls unless physical abuse co-existed (Kaufman & Cicchetti 1989; Kinard 1999). However, there were very few ‘exclusively’ neglected or emotionally abused children, which may have influenced the results (Kaufman & Cicchetti 1989).

Emotional well-being

There were 13 studies (15 publications) reporting emotional features in neglected children (Kaufman & Cicchetti 1989; Kaufman et al. 1994; Lynch & Cicchetti 1998; Shields & Cicchetti 1998; Bolger & Patterson 2001; Finzi et al. 2002, 2003; Kantor et al. 2004; Edwards et al. 2005; Shipman et al. 2005; Kim & Cicchetti 2006, 2010; Valentino et al. 2008a,b; Fishbein et al. 2009).

Three studies (Kaufman & Cicchetti 1989; Lynch & Cicchetti 1998; Kim & Cicchetti 2006) found neglected children had lower self-esteem. Lynch and Cicchetti (1998) (7- to 12-year-olds) found that the more severe the neglect, the lower the child’s self-esteem, and those from violent neighbourhoods experi- enced more severe forms of neglect. Kaufman and Cicchetti (1989) noted that while non-maltreated children rated higher on self-esteem than the matched maltreated groups, neglected or EA children had similar decreases in self-esteem. In a longitudinal study of the relationship between early maltreatment experi- ences, self-esteem and later maladjustment (Kim & Cicchetti 2006), emotional maltreatment was strongly associated with low levels of self-esteem at the initial stage of the study and was predictive of changes in self-esteem over time in comparison with controls.

Bolger and Patterson (2001) measured perception of control to ascertain children’s beliefs about the centre of control in successes or achievements in their lives in neglected children compared with controls. Perceived internal control was not asso- ciated with maltreatment, yet neglect was significantly related to higher scores for perceived external control (powerful others) that mediated the relationship between neglect and increased internalizing. Neglected children may also have difficulty accu- rately attributing or regulating their emotions in comparison with non-maltreated children (Lynch & Cicchetti 1998).

Five studies explored the relationship between neglect and depression (Kaufman et al. 1994; Toth & Cicchetti 1996; Lynch

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& Cicchetti 1998; Kantor et al. 2004; Kim & Cicchetti 2006; Valentino et al. 2008a). Physical neglect was associated with higher levels of depressive symptoms as was emotional mal- treatment (Kim & Cicchetti 2006), but only the latter was pre- dictive of changes in depressive symptoms over time. Kaufman and colleagues (1994), utilizing standardized tools based on normative data, noted that depressive symptomatology was related to both physical abuse and emotional maltreatment but with emotional maltreatment being the greater contribu- tor to the variance (80%). Both Lynch and Cicchetti (1998) and Kantor and colleagues (2004) observed that the severity of neglect related positively to depressive symptomatology in comparison with controls. Toth and Cicchetti (1996) explored depressive symptomatology in connection to the child’s rela- tionship to their mother and noted that neglected children did exhibit more depressive symptoms than controls particularly among those with a confused pattern of relatedness (insecure attachment) to their mother. In a study of children’s memory and other internal processes (Valentino et al. 2008a), neglected children with negative maternal schema showed higher depression scores. Finzi and colleagues (2002) found that sui- cidal behaviour and suicidal expression, in children as young as 6, were similar among neglect and control groups.

In Valentino and colleagues’ (2008b) study, the impact of maltreatment on memory was explored through the use of chi- ldren’s self-schema in comparison with controls. Younger neglected children (7–9 years) were more likely to have a posi- tive self-schema in association with increased rates of dissocia- tion. However in a study of children aged 6–12 years (Finzi et al. 2003) ego defences of rejection, denial, projection and introjections among neglected children were equal or margin- ally worse than the control group.

Three studies explored emotion regulation (Shields & Cicchetti 1998; Shipman et al. 2005; Kim & Cicchetti 2010). Shields and Cicchetti (1998) found no difference between neglect and controls. Likewise, Kim and Cicchetti (2010) found no differences between neglect, physical and sexual abuse groups, but when EA co-occurred with these forms of maltreat- ment, there was an increase in emotion dys-regulation in com- parison with controls. In comparison with controls, neglected children had fewer adaptive emotion regulation skills, less use of effective coping strategies and were more likely to inhibit the expression of negative emotions with a trend towards more emotional lability (mood, dys-regulated negative affect, inap- propriate affective displays) (Shipman et al. 2005).

Neglected children demonstrated lower levels of emotional understanding than their peers but this was not related to any particular emotion in the Edwards and colleagues (2005) pub-

lication, whereas in another publication from the same study (Shipman et al. 2005) the neglected children had a lower under- standing of negative emotions (anger and sadness). A related study (Fishbein et al. 2009) of Latino children demonstrated that children experiencing emotional and physical neglect were less able to accurately attribute emotions, utilizing standardized tools derived from normative data.

Intellectual function and academic performance

A total of 12 studies reported findings of cognition and aca- demic performance in children being neglected and/or EA (Reyome 1993; Kaufman et al. 1994; De Paúl & Arruabarrena 1995; Kendall-Tackett & Eckenrode 1996; Toth & Cicchetti 1996; Kinard 2001; Kantor et al. 2004; Nolin & Ethier 2007; Valentino et al. 2008a,b, 2009; Fishbein et al. 2009).

A wide variety of tools were used to assess the academic ability of children across the studies (Appendix S4). In three out of four of the relevant studies, the neglected children showed lower general intelligence (Reyome 1993; Kaufman et al. 1994; Kantor et al. 2004; Fishbein et al. 2009). Fishbein and colleagues (2009) found that children experiencing emotional or physical neglect had lower general intelligence and poorer executive decision in comparison with normative data. Kaufman and colleagues (1994) found a direct correlation between the severity of neglect and intelligence quotient (IQ), with those suffering the most severe form of neglect having the lowest IQ (P < 0.01). Likewise, Kantor and colleagues (2004) found that the neglected children had lower overall scores than the controls, with the physically neglected children demonstrating the lowest intellectual perfor- mance. They also demonstrated that the more severe the neglect, the lower the children’s receptive vocabulary (6–9 years). However, Reyome (1993) did not demonstrate any difference in cognitive function among neglected children versus controls, although they relied solely on a non-verbal measure, ‘self- drawing’, for assessment in contrast to most studies.

Two studies addressed numeracy and literacy skills (Reyome 1993; Kendall-Tackett & Eckenrode 1996), both of which showed worse performance among neglected children than controls. One found those suffering neglect alone, or co-occurring neglect and abuse, scored significantly lower in combined mathematics and reading grades than controls (Kendall-Tackett & Eckenrode 1996). The other (Reyome 1993) demonstrated significantly lower scores in mathematics, spelling and English than classroom controls. A further study evaluated noted that neglected children had significantly worse overall academic performance (De Paúl & Arruabarrena 1995).

Systematic review of school-aged neglect/emotional abuse 647

Three studies analysed the need for children to repeat grades in school, all of whom identified a significant association with neglect. One study identified that the highest number of grade repetitions were found in children being neglected with co-occurring physical abuse (Kendall-Tackett & Eckenrode 1996), but children being neglected alone also had more grade repetitions than controls (Reyome 1993; De Paúl & Arruabarrena 1995; Kendall-Tackett & Eckenrode 1996). One study noted that 57.1% of children who were neglected repeated a grade compared with only 8.3% of the controls (De Paúl & Arruabarrena 1995). Among neglected children 27.3% required special educational support versus none of the controls (De Paúl & Arruabarrena 1995). Reyome (1993) found that almost twice as many neglected children required special education services compared with controls.

Nolin and Ethier (2007) identified that neglected children achieved significantly poorer results than controls on manual dexterity, auditory attention and visual motor integration, flexibility and complex attention tasks requiring all of these skills. Interestingly, children being neglected were better at problem solving, abstraction and planning than non-maltreated children.

Kinard (2001) was the only study where neglected children did not exhibit any significant difference in achievement scores, special education or grade retention in comparison with con- trols, although the children had a less positive perception of their scholastic competence, which was significantly related to the frequency with which they had been reported for neglect and older age at first report. Toth and Cicchetti (1996) did not demonstrate any difference in self-perceived scholastic compe- tence between neglected children and controls, although there were only six neglected children in this study.

Memory

Three studies addressed different aspects of memory (Valentino et al. 2008a,b, 2009) in comparison with non-maltreated con- trols. Overall the neglected children did not exhibit memory deficits in comparison with controls. In one study, neglected children did not differ from controls with regard to true or false recall, although both groups had poor recall. However, the neglected children (7–14 years) had lower positive false recall compared with non-maltreated (i.e. in ‘recalling’ words they had not in fact heard, they were less likely to describe a positive word), but only the younger children (7–9 years) had more negative false recall, consistent with their low self-esteem (Valentino et al. 2008b).

Discussion

This systematic review confirms that school-aged children experiencing neglect or EA exhibit far reaching impacts on their behavioural, emotional, cognitive and social development. Posi- tive associations described included externalizing and internal- izing behaviours, ADHD phenotype, an inability to regulate emotions, and diminished IQ, literacy, numeracy and language skills. The manifestations of which included low self-esteem, depression, difficulty initiating or maintaining friendships, and low school attainment.

Although several studies concluded that externalizing behav- iour was prevalent among the neglected children, there were some influential variables proposed. It is recognized that the earlier the onset of neglect, and its chronicity, the greater the association with later childhood aggression (Manly et al. 1994; Kotch et al. 2008). Cullerton-Sen and colleagues (2008) were the only study to propose that there was a gender association of maltreatment subtype and aggression, i.e. girls are more likely to show relational aggression and boys physical aggression. Given known influences of ethnicity and poverty with neglect, it is reassuring that all of the studies within this review considered these confounders and either controlled for them or analysed their data stratifying for these factors. Not all studies supported the association with externalizing behaviour (Kaufman & Cicchetti 1989; Shields & Cicchetti 1998; Finzi et al. 2001, 2002; Alink et al. 2012). Finzi and colleagues (2002) hypothesized that neglected children in yearning for proximity with others, com- bined with fear of rejection, may lower their aggression levels. This would be consistent with the notion that anxious ambiva- lent style of attachment found in these neglected children pre- dicts the tendency to undertake the victim role (Troy & Sroufe 1987; Wekerle & Wolfe 1998).

The few studies (Kaufman & Cicchetti 1989; Reyome 1993; De Paúl & Arruabarrena 1995; Bolger & Patterson 2001; Manly et al. 2001; Valentino et al. 2008a) reporting significant associations between neglect and internalizing features found that these related to the perception of the degree of control the children felt they had over their lives, consistent with the emotional features found in these children. An association between neglect and perception of control by powerful others was described; where it was explored, this association mediated the relationship between neglect and increased internalizing problems, suggesting that the more you lack control over bad events, the more you lose moti- vation to change, which impacts on the experience of negative emotions such as anxiety (Bolger & Patterson 2001).

A strong association between neglect and EA with ADHD phenotype was established. These behaviours may contribute

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to difficulty in the school setting, with more neglected children being reprimanded and suspended than their non-maltreated peers. It is clearly important when assessing any child for pos- sible ADHD to actively explore the possibility of neglect or EA as a potential differential diagnosis; likewise, in those children in whom features are a manifestation of neglect or EA, this needs to be addressed in addition to managing the child’s symptoms.

Neglected children demonstrated lower IQ, poorer literacy, numeracy and language skills than their non-maltreated peers in all but one of the studies assessing this. However, neglected children were superior at problem solving, which would be consistent with these children being left alone to deal with their environment. A higher number of neglected children repeated grades at school or required additional support (including spe- cialist teaching facilities), emphasizing the significant cost to the child and the statutory agencies of neglect, and reiterating the need to identify these children as early as possible to maximize their potential.

Neglected children demonstrated less pro-social behaviours, thus finding establishing and maintaining friendships more dif- ficult than their non-maltreated peers. One study (Manly et al. 1994, 2001) focused on exploring the possible variables impact- ing on behaviour and peer interactions, i.e. frequency, severity, chronicity and maltreatment subtype, highlighting that all of these factors contribute to the outcome for children. The authors emphasized that although they had assigned the children to a ‘unique’ maltreatment subgroup, in practice many children experience polyvictimization, which may explain some of the variance in findings between studies. The behaviour problems and low self-esteem experienced by neglected children may con- tribute to their difficulties in developing friendships. They may attempt to compensate in a social situation by playing a particu- lar role, e.g. the joker (Finzi et al. 2003); however, this behaviour may serve to further isolate them from their peers. This has implications for education as schools that include the develop- ment of relationship skills in the personal and social develop- ment curriculum may be able to help neglected children to build more effective friendships with their peers. Likewise, supporting neglected children in the development of their social skills may help them to fit into the class community and could thus impact on their ability to achieve in education, as well as potentially contributing to peer relationships.

From a developmental perspective, adequate school perfor- mance and integration into the school environment both represent pertinent milestones for school-aged children (Kendall-Tackett & Eckenrode 1996). A developmental approach to the investigation of abuse and neglect in infancy

and early childhood was applied in a seminal longitudinal study conducted by Egeland and colleagues as part of the Minnesota Mother-Child project (Egeland & Sroufe 1981; Egeland et al. 1983; Erickson et al. 1989). The researchers described a pattern of declining functioning in neglected children. At both 42 and 56 months of age, children who were neglected exhibited more difficulty completing a variety of tasks in comparison with other maltreated children or controls. Significantly, the same children displayed difficulties in the cognitive, behavioural and social domains at school age, revealing more developmental problems than the other cohorts (Erickson et al. 1989). Indeed, behavioural difficulties in younger children arising as a result of social information processing deficits have been found to con- tinue into school age (Dodge & Price 1994). Of note, in the Minnesota study, every child in the neglected cohort had been enrolled onto a special education programme by the time they were 7–8 years old (Egeland 1991).

All of the findings of this systematic review have direct rel- evance to teachers and other education staff. Although experi- enced teachers have witnessed neglected children’s externalizing or internalizing behaviour, with the resulting disruption in the classroom, lack of engagement and very low levels of achieve- ment for some children may not be surprised by the review findings. However, by recognizing and intervening early in the lives of neglected children, teachers can help them to achieve better outcomes in education (Downey 2007). Recognizing the effects of neglect or EA on children helps to explain why class- rooms can be difficult and frightening places for these children. Consistent with the enhanced problem-solving skills that the children demonstrated (Nolin & Ethier 2007), the children may sometimes appear more independent than their peers; however, they may also have difficulty with classroom routines that are different to anything they have experienced before, and be wholly unprepared to learn when they start school. The limited understanding, poor language and communication skills and lack of experience of positive routines place neglected and abused children at a great disadvantage in school (Kendall-Tackett & Eckenrode 1996; Fishbein et al. 2009), potentially worsening their outcome. It is worrying that recent evaluations of the outcome of education referrals to child protection services highlight that children with emotional, behavioural and cognitive impairment are more likely to be recognized by education staff, yet substantiation of education referrals is lower than other professionals (King & Scott 2014). This raises the question whether education referrals are not afforded the same credibility as referrals from other profession- als, despite the fact that the children referred by education staff suffered from severe and chronic abuse or neglect, and were

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more likely to be previously known to children’s services than those referred by other professionals.

This review has implications for healthcare professionals, both in terms of child development teams when they are assess- ing children who may come to attention due to behavioural problems, features of autistic spectrum disorder etc., and when children are identified as having additional learning needs, to ensure that neglect and EA are considered as differentials within the assessment by child psychiatrists and community paediatri- cians. In addition, the behavioural, emotional, social and cog- nitive problems that neglected or emotionally abused children may exhibit should be communicated to those who are involved in placing or providing foster care to these children. Any child who is being seen for assessment of possible maltreatment should have an active assessment for features of neglect or EA, which will often co-exist with other forms of physical abuse.

Low self-esteem, depressive symptomatology and an inability to accurately attribute and regulate emotions were all found to be higher among neglected children (Lynch & Cicchetti 1998). The finding that younger neglected children (7–9 years) are more likely to have positive self-schema in association with increased rates of dissociation is consistent with research (Black et al. 1994) that younger maltreated children overestimate their own sense of competence and peer acceptance, and have inflated levels of perceived self-efficacy in conflicted peer inter- actions compared with controls (Kim & Cicchetti 2003). This may be explained by the defensive processing suggested by Vondra and colleagues (1989) to increase the younger child’s sense of personal control and competence. In this way they can avoid the negative aspects of the self and therefore present a ‘false representation of self ’. However, Valentino and colleagues’ (2008b) study reminds us to be aware when assessing neglected children to consider potential false self-behaviours, which may mask underlying psychopathology and self-system disturbance.

There were a number of limitations in this review. Although the majority of studies addressed the 7–11 year age band, the wide range of age bands meant that it was impossible to separate our results into narrower age groups. As is frequently the case in research relating to neglect, the definition of neglect was highly variable in the studies. We restricted this review to those chil- dren who experienced neglect and/or EA, without co-existent physical or sexual abuse, as our aim was to draw attention to this group of children who often go unrecognized. In practice, many children experience neglect in combination with physical or sexual abuse; thus, sample sizes included in this review were frequently small. The majority of included studies addressed neglect, with far fewer considering EA. Unfortunately, although many studies used the same tools, e.g. CBCL, they chose to

report their findings in a selected way, which combined with the overlapping age ranges, precluded a valid meta-analysis of these features.

Disappointingly, only a single study (Sobsey et al. 1997) con- sidered disabled children, and this did not meet the inclusion criteria as they did not describe any of the specific features observed among the neglected children. Future research should be directed to exploring the features of neglect or EA among children with disability or learning difficulties, who are an espe- cially vulnerable group.

Conclusion

The pervasive impact of neglect, or EA, is clearly seen among school-aged children, and the combination of externalizing behaviour, low self-esteem, poor social skills and features of ADHD are likely to be strong contributors to the poor academic performance and school difficulties they face. Many of these children may be known to education, health or social services due to their behavioural or emotional issues; the key is for professionals to actively consider neglect or EA as a possible cause of their difficulties, regardless of their backgrounds or social circumstances. A sensitive and informed discussion with the child themselves may reveal the experiences and home cir- cumstances that they are living with. Ensuring that these chil- dren are given the opportunity to attend school may provide one environment within which their needs and concerns may be met, and where they will find respect and support.

Key messages

• Neglected or emotionally abused (EA) children of school age may exhibit a wide range of effects, including external- izing behaviour, depression, difficulty in developing or maintaining friendships, reduced IQ and poor school performance

• Children being assessed for behavioural difficulties, including aggression or ADHD, should have neglect/EA actively considered and explored

• Education staff are uniquely positioned to recognize and assist children with neglect/EA, manifesting behavioural, social and academic consequences

• Medical and social care staff assessing or supporting chil- dren with children with neglect/EA should be aware of the full impact of this to better plan for and support these children, whether they remain at home or enter out of home care

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Funding

Grateful thanks to the National Society for Prevention of Cruelty to Children (NSPCC) for funding this work.

Conflict of interest

There is no conflict of interest.

Acknowledgements

Grateful thanks to Laura Harding for editorial assistance and to all of our additional reviewers (Katherine Gale, Evender Harran, Nia John, Katina Kontos, Zarah Newman, Diane Nuttall, Ruth Paradice, Shona Perry, Ingrid Prosser, Alicia Rawlinson, Jane Rodgers, Catrin Simpson).

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Supporting information

Additional Supporting Information may be found in the online version of this article at the publisher’s web-site:

Appendix S1. Bibliographic databases, journals and web sites searched. Appendix S2. Search terms. Appendix S3. Critical appraisal form. Appendix S4. Included studies.

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