Psychosocial Evaluation-Suspected Psychological

Cultic Studies Journal, Volume 13, Number 2, 1996, pages 153-170

Psychosocial Evaluation of Suspected Psychological Maltreatment in Children and Adolescents

American Professional Society on the Abuse of Children

Abstract

The document addresses definitional issues, prevalence of psychological maltreatment of children, short- and long-term effects, confidentiality and privilege, informed consent, training issues, assessment considerations, reporting issues, legal testimony, and reference materials.

I. Statement of Purpose

The purpose of these guidelines is to provide guidance for professionals evaluating children to determine whether they are or have been victims of psychological maltreatment. The results of such evaluations may be used to assist in case planning, legal decision making, and treatment planning. The guidelines concern psychological maltreatment that occurs in isolation as well as psychological maltreatment that occurs in conjunction with other forms of abuse and neglect.

The guidelines apply primarily to forensic assessments of psychological maltreatment. Professionals providing treatment and performing non-forensic assessments may also find the guidelines helpful.

The guidelines will be modified as research and practice evolve. Because each child is unique, the guidelines will not apply equally or exactly to all children. Assessment of psychological maltreatment is complex, and professionals must have the flexibility to exercise clinical judgment in individual cases.

The guidelines are not intended to serve as a rigid blueprint for practice, nor are they intended to establish a legal standard of care to which professionals must adhere. Rather, the guidelines provide a model of desirable professional practice.

II. Meaning of Key Terms

This section defines some key terms employed in the guidelines. The definitions should be read in conjunction with definitions provided in applicable Federal and State laws.

“Child maltreatment” means the physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment of a child by a person who is responsible for the child’s welfare under circumstances which indicate harm to the child’s health or welfare. This definition is drawn from the Federal Child Abuse Prevention and Treatment Act 42, United States Code '5106g(4). See also 45 C.F.R. '1340.2(d). “Child maltreatment” includes child abuse and child neglect. Definitions specific to a particular state will generally be found in one or more of its civil or criminal statutes.

“Forensic assessment,” for the purpose of these guidelines, means a psychosocial assessment that is conducted wholly or in part for use in legal proceedings.^[2] For example, a psychosocial assessment conducted at the request of a juvenile court judge for use in legal proceedings is a “forensic assessment.” Psychosocial assessments that are not conducted for use in legal proceedings may nevertheless be relevant to such proceedings.

“Intervention,” in this context, means action on behalf of a child who may be psychologically maltreated. Intervention is a broad concept. Some forms of intervention involve official action by government agencies such as child protective services and juvenile courts. Examples of official intervention include investigations conducted by child protective services agencies and juvenile court orders designed to protect children from psychological maltreatment. Some official intervention is taken over the objection of caregivers, and represents the legal authority of government to intervene in families. Other official intervention can be received on a voluntary basis. In addition to official action on behalf of children, intervention includes a wide range of acts by professionals in public and private sectors. Examples of nonofficial intervention include providing therapy for children and referring caregivers to appropriate agencies.

“Psychological maltreatment” means a repeated pattern of caregiver behavior or extreme incident(s) that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another’s needs. The term “psychological,” instead of “emotional,” is used because it better incorporates the cognitive, affective, and interpersonal conditions that are the primary concomitants of this form of child maltreatment. Professionals should be aware of legal definitions of psychological maltreatment that are applicable in their community. Psychological maltreatment includes acts of commission (e.g., verbal attack by a caregiver), as well as acts of omission (e.g, emotional unavailability of a caregiver). Definitions specific to a particular state will generally be found in one or more of its civil or criminal statutes.

“Psychosocial assessment” means a systematic process of gathering information and forming a professional opinion regarding whether or not a child has been or is being subjected to psychological maltreatment. Psychosocial assessments are broadly concerned with understanding developmental, familial, and historical factors that might be associated with psychological maltreatment. The results of a psychosocial assessment might be used to assist in legal decision making and in treatment planning. In the guidelines, the terms “assessment” and “evaluation” are used interchangeably, and have the same meaning. Some psychosocial assessments are “forensic assessments” as that term is defined in the guidelines.

III. Prevalence of Psychological Maltreatment

Psychological maltreatment can occur alone, without cooccurrence of other forms of child abuse or neglect. Approximately 10% of reports to child protective services are for psychological maltreatment alone. Although psychological maltreatment occurs in isolation, it is often associated with other forms of maltreatment and is commonly considered to be embedded in all forms of child abuse and neglect. Thus, children who are physically abused, sexually abused, or neglected, in most cases, are also psychologically maltreated.

Psychological maltreatment, in standalone occurrences, is the third most common form of maltreatment reported in the United States. Although there are no fully accurate national statistics on the prevalence of psychological maltreatment, this form of maltreatment is likely to be underreported and widespread.

IV. Short and LongTerm Effects of Psychological Maltreatment

Psychological maltreatment produces both acute and longterm negative effects. Research establishes a connection between psychological mal-treatment and attachment disorders, limitations in cognitive ability and problem solving, poor academic achievement, poor peer relationships, behavior problems, anxiety disorders (especially PTSD), and antisocial behavior (see Hart, Brassard & Karlson, in press, for extensive references).

Other forms of child maltreatment are also associated with the foregoing effects (see Briere, Berliner, Bulkley, Jenny, & Reid, in press). An assessment of suspected psychological maltreatment should attempt to differentiate effects caused primarily by psychological maltreatment from

effects caused by other factors, including other forms of maltreatment.

V. Confidentiality and Privilege

Professionals conducting forensic assessments should be aware of basic legal principles in their jurisdictions governing confidentiality and privileged communications with caregivers, children, and others.

Professionals should maintain confidentiality and privilege to the extent reasonably possible.

In the forensic context, confidentiality and privilege are often limited. For example, when a professional conducts an assessment at the request of a judge, the professional’s findings and report may not be confidential, and communications between the professional and the subject of the assessment may not be privileged from disclosure in legal proceedings. Professionals should be aware of applicable limitations on confidentiality and privilege, and should inform appropriate individuals of such limitations.

VI. Informed Consent

Professionals conducting forensic assessments should be aware of legal and ethical principles governing informed consent. Informed consent should be obtained unless such consent is unnecessary because of the forensic nature of the assessment.

Whether or not informed consent is obtained, the professional should advise persons being assessed of the purpose of the assessment and the intended uses of any report or testimony resulting from the assessment.

In forensic situations where informed consent is required but the person being assessed is incapable of giving such consent, the professional should consult with legal counsel or the judge regarding the appropriate way to proceed.

VII. Training and Experience of Professionals Conducting Assessments

A professional conducting a forensic assessment should possess an advanced mental health degree in a recognized discipline or an advanced health services degree with training and substantial experience in mental health. The professional should hold the licensure or credentials required to practice in the jurisdiction.

Child protective service employees who meet the experience standards set forth in this section, but who are not licensed or credentialed in a mental health discipline, may carry out forensic assessment functions under the supervision of a mental health professional meeting the criteria outlined in this paragraph.

The professional should have broad experience in evaluation and treatment of both functional and dysfunctional children and families. The professional should possess a minimum of two years of experience with abused and neglected children. Two or more years of experience with nonmaltreated children is desirable. The professional should also have specialized training in or knowledge of child development and psychological maltreatment. The professional should be familiar with current literature on psychological maltreatment. If the professional lacks the experience described in this paragraph, appropriate supervision by someone with such experience is required.

The professional should have experience conducting forensic assessments and testifying in court. The professional should be familiar with the forensic implications of interviews of children and adults, including the importance of proper interviewing and documentation. If the professional lacks the experience described in this paragraph, appropriate supervision is required.

The professional should approach the assessment with an open mind regarding what, if anything, might have happened to the child.

If a multidisciplinary team of specialists conducts an assessment, it is advisable for one member of the team to assume the responsibility to coordinate the assessment process, integrate findings, and develop any report. Where the opinions of team members differ, it is recommended that this be identified in reports provided.

VIII. Assessment Considerations

A. Global Assessment Considerations

Psychological maltreatment is often accompanied by or embedded in other forms of child abuse and neglect. Thus, when professionals evaluate possible physical abuse, sexual abuse, or neglect, it is recommended that psychological maltreatment also be considered.

The goal of forensic assessments is often to determine for a court of law whether a caregiver has maltreated or is psychologically maltreating a child and, if so, whether the severity of maltreatment is related to existing or future harm to the child.

Acts of maltreatment are in themselves deplorable regardless of the degree to which a child is damaged by them or is coping with them; however, depending on the cause of action or type of proceeding, laws and practices of many states require evidence of both acts and harm (extant or predicted) for case determinations. Therefore, these guidelines deal with both acts and harm.

Psychological maltreatment is a repeated pattern or extreme incident(s) of caregiver behavior that convey the message that a child is worthless, flawed, unloved, unwanted, endangered, or only valuable in meeting someone else’s needs. Virtually every caregiver, at some point, sends such unfortunate messages. There are few perfect caregivers. Most psychological maltreatment occurs when such negative messages pass from isolated incidents to a consistent caregiving style.

Psychological maltreatment can occur as part of a onetime incident, such as a painful divorce. For example, a parent who is depressed and traumatized by a bitter custody battle might terrorize a child with threats about the child’s future.

In some cases, psychological maltreatment occurs only when some specific, recurring triggering event occurs. For example, with an alcoholic or drug-addicted caregiver, psychological maltreatment may occur only when the caregiver is intoxicated.

Some psychological maltreatment is chronic, regular, and embedded in the child’s daily existence. An example is a caregiver who levels a daily barrage of verbal abuse at a child.

Child behavior often provides evidence of psychological maltreatment. One must be cautious, however, about inferring causation from behavior. Multiple pathways lead to particular behaviors. When considering the possibility of psychological maltreatment, the professional should rule out other factors such as psychological trauma unrelated to maltreatment, inherited or congenital vulnerabilities, and various forms of mental illness.

Professionals should understand the influence of base rates on the diagnostic value of specific behaviors. For example, posttraumatic stress disorder (PTSD) is more prevalent in inner-city neighborhoods with high crime rates than in most suburban and rural areas. Thus, children living in dangerous neighborhoods may have a higher incidence of PTSD than children living in safer environments (Osofsky & Jackson, 1994). Presence of PTSD symptoms in a child living in a dangerous neighborhood may be the result of environmental influences rather than caregiverperpetrated psychological maltreatment.

Although child behaviors can yield useful information, behavior alone is not a sufficient basis to determine whether psychological maltreatment has occurred. Moreover, some victims of psychological maltreatment demonstrate no detectable signs or symptoms. Evaluators should consider various influences on caregiverchild and family interaction, and should investigate as many sources of information as possible.

B. The Child’s Developmental Level

An assessment for possible psychological maltreatment should include consideration of the child’s developmental level. The caregiverchild relationship should be considered within a developmental framework that takes into account the primary developmental tasks of the child and the related tasks placed upon the caregiver. For example, one of an infant’s primary developmental tasks is to form a secure attachment with an adult caregiver, learning in the process to trust others to provide a stable, loving, nurturing, responsive environment, and to believe in his/her ability to solicit that care.

A caregiver who predominantly rejects a child’s bids for attention (for comfort, play, or assistance) negatively shapes a child’s sense of self, worthiness, competence, efficacy, and trust in others.

Professionals may use the list of Developmental Tasks contained in Table 1 (below) to assist in the assessment process.

Table 1. Developmental Tasks

C. Forms and Severity of Psychological Maltreatment

This subsection discusses forms and severity of psychological maltreatment.

1. Forms of Psychological Maltreatment

Table 2 describes six forms of psychological maltreatment. These forms find support in research and clinical experience. The forms are intended to help professionals analyze cases. A child’s maltreatment experiences may be categorized by one or more of these forms and will not necessarily fit simply or completely within one form. The six forms of psychological maltreatment are: (a) spurning, (b) terrorizing, (c) isolating, (d) exploiting/corrupting, (e) denying emotional responsiveness, and (f) unwarranted denial of mental health care, medical care, or education. These forms are recommended for consideration as complements to the legal and regulatory definition of psychological maltreatment particular to the state.

Table 2. Psychological Maltreatment Forms

A repeated pattern of extreme incident(s) of the conditions described in Table 2 below constitute psychological maltreatment. Such conditions convey the message that the child is worthless, flawed, unloved, endangered, or only valuable in meeting someone else’s needs.

Office for the Study of the Psychological Rights of the Child, Indiana University-Purdue University at Indianapolis, 902 West New York Street, Indianapolis, IN 48202B5155.

2. Levels of Severity

In determining the level of severity of psychological maltreatment, consideration should be given to (a) intensity/extremeness, frequency, chronicity; (b) the degree to which psychological maltreatment pervades the caregiverchild relationship; (c) the number of forms of psychological maltreatment which have been or are being perpetrated; (d) influences in the child’s life that may buffer the child from psychological maltreatment. For example, does the maltreating caregiver also provide nurturance for the child? Does the child have regular access to a nurturing, non-maltreating adult?; (e) salience of the maltreatment given the developmental period(s) in which it occurs and the developmental periods that will follow; and (f) the extent to which negative child developmental outcomes exist, are developing, or are predicted.

3. “Severe Emotional Disturbance” Defined in the Federal Individuals with Disabilities Education Act

This subsection of the guidelines draws on the Federal Individuals with Disabilities Education Act, commonly known as 94B142, and formerly titled the Education of the Handicapped Act. Regulations implementing 94B142 define “severe emotional disturbance.” (See 34 Code of Federal Regulations '300.7(9).) The 94B142 definitions incorporate psychological criteria for (a) major mental disorders, and (b) interpersonal, cognitive, and emotional behavior problems. Professionals assessing children for possible psychological maltreatment will find these definitions of severe emotional disturbance and the standards included in the American Psychiatric Association’s Diagnostic and Statistical Manual(s) of Mental Disorders (i.e., DSM-IIIR and DSM-IV) useful to guide determinations of extant or predicted harm related to psychological maltreatment.

The 94B142 definitions provide:

“Serious emotional disturbance” is defined as follows:

(i) The terms means a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance--

(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors;

(B) An inability to build or maintain satisfactory interpersonal relationship with peers and teachers;

(C) Inappropriate types of behavior or feelings under normal circumstances;

(D) A general pervasive mood of unhappiness or depression; or

(E) A tendency to develop physical symptoms or fears associated with personal or school problems.

D. Assessment Techniques and Sources of Information

1. The childcaregiver relationship

Psychological maltreatment consists primarily of messages a child receives about himself or herself and about important interpersonal relationships. When feasible, the professional should observe the childcaregiver relationship. Because of the chronicity of much psychological maltreatment, repeated observations may be necessary to obtain a representative sample of behavior and to provide grounds on which to recognize patterns of childcaregiver interaction. Although direct observation of the childcaregiver relationship is often useful, such observation is not always necessary to form an opinion regarding psychological maltreatment. Observations of caregiverchild interaction have limitations because parents may not behave in their usual manner when being observed.

The childcaregiver relationship can also be assessed through interviews of the caregiver and the child, review of pertinent records, observations, consultation with other professionals, and collateral reports from siblings, grandparents, school and daycare personnel, neighbors, and others.

2. Child characteristics

Psychological evaluation procedures such as observations, interviews, questionnaires, and projective techniques, with due consideration of their reliability and validity, can provide clarifying and corroborative information about patterns of interaction, care, and treatment and their impact on the child. Deviance or delay in the child’s functioning are assessed through direct observations by the evaluator, testing, the observations of others, and available reports and records (e.g., school, health, therapy).

3. Caregiver/family competencies and risk factors

Evaluation of caregiver competencies and risk factors assists in determining the existence of psychological maltreatment, in developing a prognosis for improvement in the childcaregiver relationship, and in identifying issues to address in treatment. Relevant areas of functioning include (1) caregiver’s representational models or attitudes toward past attachment figures, current partner, and child(ren); (2) personal resources (intelligence, job skills, social skills, personality variables, mental health); (3) social support/resources (marital status, family, friends, financial status, community involvement); and (4) life stresses or transitions in the family.

Assessment of the caregiver usually includes one or more interviews, review of collateral reports and records, and psychological testing.

Interaction with caregivers or members of the extended family should normally be carried out so as to increase the likelihood of voluntary involvement in the assessment and any intervention.

4. Consideration of societal cultural context

A family’s community context and immediate social and economic circumstances should be taken into consideration when evaluating caregiver behavior. The psychological conditions jeopardizing a child’s development may not be under the control of a caregiver. Homelessness, poverty, or living in a violent neighborhood can have an adverse impact on quality of care and child development. Caregivers are not responsible for conditions over which they have no control.

Professionals should be knowledgeable about and sensitive to cultural and ethnic differences in caretaking styles and customs. If the evaluator is not familiar with the cultural context of the child and family, consultation with appropriate experts is required.

IX. Reporting Findings

Professionals conducting forensic assessments typically prepare reports that contain findings and recommendations.

A. Findings of Assessment

The report of a forensic assessment should document all sources of information considered by the professional during the assessment. The report should state the professional’s findings. In appropriate circumstances the report may set forth the professional’s opinion concerning whether a child has [been] or is suffering from psychological maltreatment or other forms of child abuse or neglect. The report may indicate findings consistent or inconsistent with psychological maltreatment.

If the professional concludes that psychological maltreatment has or is occurring, the report should (a) state the form(s) of psychological maltreatment; (b) describe specific occurrences of caregiver behavior that constitute psychological maltreatment; (c) document the severity through reference to intensity/extremeness, frequency, chronicity, pervasiveness, multiplicity of forms, counterbalancing positive treatment, developmental saliency, and probable short and longterm effects of the maltreatment; and (d) describe the relations between the psychological maltreatment and harm to the child.

In some cases the assessment is inconclusive. In such cases the professional should state the reasons for the inconclusive finding, and should indicate whether, in the professional’s judgment, the child is at risk of harm.

B. Recommended Interventions

The report should contain recommendations for appropriate intervention.

X. Testifying in Court

Professionals should always be prepared for the possibility that they will be required to testify in court. Professionals should only provide expert testimony on matters for which they possess special competence that can assist the legal system, and should always acknowledge the limits of their competence.

When called upon to testify in court, professionals have an obligation to testify in a manner that is accurate and fair to all parties. Although straightforward and forceful presentation of findings and recommendations is proper, professionals reporting the results of forensic evaluations should avoid the temptation to become advocates for one side or the other in litigation.

XI. Related Guidelines and References

Guidelines

Professionals conducting forensic assessments and testifying in court should consult guidelines and ethical codes that apply to their particular specialty. The following list is provided as a reference:

• Specialty Guidelines for Forensic Psychologists (1991). Law & Human Behavior, 15, 655B665.

• American Professional Society on the Abuse of Children (1990). Guidelines for Psychosocial Evaluation of Suspected Sexual Abuse in Young Children. Chicago, IL: Author.

• National Association of Social Workers. Code of Ethics of the National Association of Social Workers. Washington, DC: Author.

• American Association for Marriage and Family Therapy (1991). AAMFT Code of Ethics. Washington, DC: Author.

• American Academy of Psychiatry and the Law (1989). AAPL Ethical Guidelines for the Practice of Forensic Psychiatry. Chicago, IL: Author.

References

The following references provide clarification and supportive information for the statements and recommendations presented in these guidelines.

American Psychologist. (1987). Psychology in the public forum (subsection theme: psychological maltreatment). 42, 157B175.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders: Third editionrevised (DSMIIIR). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders: Fourth edition (DSMIV). Washington, DC: Author.

Baily, F.T., & Baily, W.H. (1986). Operational definitions of child emotional maltreatment. Augusta: Maine Department of Social Services.

Brassard, M.R, Germain, R., & Hart, S.N. (Eds.). (1987) . Psychological maltreatment of children and youth. Elmsford, NY: Pergamon Press.

Briere, J, Berliner, L., Bulkley, J., Jenny, C., & Reid, T. (Eds.). (in press). The APSAC handbook on child maltreatment. Newbury Park, CA: Sage.

Development and Psychopathology. (1991). Theme issue on psychological maltreatment. 3.

Garbarino, J., Guttman, E., & Seeley, J. (1986). The psychologically battered child: Strategies for identification, assessment, and intervention. San Francisco: JosseyBass.

Hart, S.N., Brassard, M.R., & Karlson, H. (in press). Psychological maltreatment. In J. Briere, L. Berliner, J. Bulkley, C. Jenny, & T. Reid (Eds.), The APSAC handbook on child maltreatment. Newbury Park, CA: Sage.

Individuals with Disabilities Education Act. 34 Code of Federal Regulations 300.7(9). Washington, DC: U.S. Government Printing Office.

O’Hagan, J. (1993). Emotional and psychological abuse of children. Toronto: University of Toronto Press.

Osofsky, J., & Jackson, B.R. (1994, April). Parenting in violent environments. Zero to Three, 8B11.

School Psychology Review. (1987). Minitheme issue: Psychological maltreatment of children. 16, 126B211.

Wolfe, D. (1991). Preventing physical and emotional abuse of children. New York: Guilford Press.

End Notes

1. These guidelines are reprinted with permission. Copyright 1995 by American Professional Society on the Abuse of Children. All rights reserved.

2. A mental health professional providing solicited therapy typically is not expected to conduct a forensic evaluation in the course of therapy, but, like all professionals, is expected to report maltreatment if it is suspected.

Acknowledgments

These guidelines are the product of the National Psychological Maltreatment Consortium and APSAC’s Task Force on Psychological Maltreatment, chaired by Stuart Hart, Ph.D. and Marla Brassard, Ph.D. Seventy professionals commented on the first draft of these guidelines at the San Diego Conference on Responding to Child Maltreatment in January, 1993. Members of the Consortium and the Task Force, and all APSAC members who participated, are thanked for the significant contributions they have made to the development of these guidelines. John E.B. Myers, J.D., is recognized partially for provision of extensive editorial support. The guidelines will be updated periodically. Any comments or suggestions about them should be directed to APSAC, 407 S. Dearborn, Suite 1300, Chicago, IL 60605.

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American Professional Society on the Abuse of Children (APSAC) is the nation’s only interdisciplinary professional society for those who work in the field of child maltreatment. APSAC’s aim is to ensure that everyone affects by child maltreatment receives the best possible professional response. APSAC provides ongoing professional education in the form of publications and conferences, and through the media and legislative advocacy, educates the public about the complex issues involved in child maltreatment. For further information, contact APSAC at the address noted above, or by telephone 312-554-0166 or E-mail at APSACPubls@aol.com.