Trauma Psychology

Child Maltreatment
The Child Abuse Prevention and Treatment Act (CAPTA) of 2010 defines child maltreatment as:

“Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or
emotional harm, sexual abuse or exploitation, or presents an imminent risk of serious harm.”

Prevalence of child abuse in Pakistan:

According to Sahil's Annual Report (2022) and UNICEF Pakistan:

I. Over 12 children suffer physical or sexual abuse daily.

II. Half a million children face physical abuse annually.

Types of child maltreatment
 There are four primary types of child maltreatment:
I. Physical abuse
II. Sexual abuse
III. Emotional/psychological abuse
IV. Child neglect
 1. Physical Child Abuse
“Physical child abuse is intentionally causing physical harm or injury to a child under 18, characterized by non-
accidental injuries.”

Forms of physical abuse

 Hitting, punching, slapping, shaking, and kicking
 Burning or scalding
 Using objects to inflict pain
 Physical restraint or confinement
 Injuries (e.g., bruises, broken bones, internal injuries)
Signs of physical abuse
 Unexplained and repeated injuries (bruises, cuts, burns)

 Avoiding home or specific individuals

 Leaving home early or returning late

 Wearing excessive clothing to conceal injuries

 Sudden change in behavior or school performance

Risk factors of child physical abuse:
1. Parents/guardian-related factors
 History of abuse: Parents who experienced abuse as children are more likely to abuse their own.
 Substance abuse: Impairs judgment, leading to violent behavior.
 Mental health issues: Conditions like depression, anxiety, or personality disorders may increase the
risk of abuse.
 Poor parenting skills: Lack of knowledge on discipline and stress management.
 Poor impulse control: Inability to manage anger or frustration.
 Negative views of the child: Seeing a child as a burden or troublemaker.
2. Child-related factors
 Age: Younger children (<4 years) are more vulnerable due to dependency and inability to defend
themselves.
 Disabilities and developmental delays: Children with physical, emotional, or cognitive disabilities
face higher risk due to increased care demands and parental stress and frustration.
 Behavioral issues: Children with challenging behavior (aggression, noncompliance, defiance)
provoke frustration in caregivers.
 Gender: Girls are more likely to experience physical abuse than boys due to societal norms, parental
expectations, and gender stereotypes.
3. Family-related factors

 High conflict: Frequent arguing/fighting increases physical abuse risk.

 Domestic violence: Children in homes with domestic violence are more vulnerable.
 Single-parent households: Increased stress on solo parents may lead to physical abuse.

4. Societal factors

 Social isolation: Families who don't have friends or relatives to support them may feel
overwhelmed, which can lead to abuse.

5. Community-related factors

 Economic hardship: Financial struggles increase stress and frustration.

 Unstable neighborhoods: Crime and poor living conditions create danger and insecurity.
 Lack of resources: Limited access to childcare, mental health, and parenting support.
 Underutilization of resources: Stigma, lack of awareness, and distrust prevent resource use.
Medical and mental health effects
 Medical effects

• Physical abuse causes minor and severe injuries.

• Infants are vulnerable to fatal injuries.
• Shaken Baby Syndrome causes brain injuries, blindness, or death.
• Internal injuries may not be visible (damage to soft internal tissues and organs).
 Mental health effects

• Abused children may show aggression towards others.

• They may struggle with social skills and face peer rejection.
• Many experience depression, anxiety, and PTSD.
• Physical abuse can hinder healthy attachment and conflict management.
• Trauma can lead to difficulties in language and academic performance
  Long term effects
• Substance abuse
• Criminal behaviors
• Mental disorders
• Relationship problems

Treatment approaches for physically abused children

1. Parent-Child Interaction Therapy (PCIT; Chaffin et al., 2004)
PCIT is a short-term, evidence-based therapy for young children (2-7 years) and their parents.
Goals:
– Improve parent-child relationship
– Reduce parental aggression
– Enhance communication
– Manage child behavior
 2. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)
TF-CBT is a evidence-based therapy for children (3-18 years) and adolescents exposed to trauma.
Goals:
– Process traumatic experiences
– Manage trauma-related symptoms
– Enhance coping skills
– Improve daily functioning
3. Multisystemic Therapy for Child Abuse and Neglect (MST-CAN; Swenson et al., 2010)
MST-CAN is an evidence-based, intensive family therapy for physically abused or neglected children (6-17
years).
Prevent further abuse by tackling multiple risk factors within family and community.
Goals:
– Prevent further abuse/neglect
– Reduce behavioral problems
– Improve family functioning
– Enhance child safety
2. Emotional/Psychological Child Abuse
“Emotional or psychological abuse is a pattern of behavior that impairs a child's emotional
development, self-esteem, sense of self-worth, or psychological health (Cicchetti & Toth, 2005).”

Emotional abuse, unlike physical abuse, doesn't leave visible scars,

but causes deep, lasting emotional damage.

 Verbal Emotional
Abuse Manipulation

Types of
Control
Isolation Emotional
Abuse

Rejection Humiliation

Terrorizing
1. Verbal Abuse
 Name-calling, insulting, belittling, and constant criticism
 Making the child feel worthless and unloved
2. Emotional Manipulation
 Controlling a child's actions by manipulating their feelings
 Emotional blackmail, guilt-tripping, and gaslighting
3. Isolation
 Restricting social interactions, friends, and family
 Hindering healthy relationships
4. Rejection
 Ignoring and rejecting emotional needs
 Withholding love, affection, and attention
5. Control
 Micromanaging behavior
 Restricting freedom and decision-making

6. Humiliation
 Public shame and embarrassment
 Damaging self-esteem and self-worth
7. Terrorizing
 Threatening punishment, harm, and abandonment
 Creating constant fear and anxiety
Signs of emotional abuse
1. Low self-esteem and confidence
2. Self-doubt
3. Poor relationship or bond with their parent
4. Difficulty trusting others
5. Clinginess
6. Difficulty setting boundaries
7. Emotional reactivity and instability
8. Physical symptoms (headaches, body pain, and stomach issues)
9. Anxiety, depression, or PTSD
Risk factors of emotional abuse
1. Parental/guardian-related factors
 Maternal depression
 Depressed mothers may struggle to emotionally connect with their child
 Increased risk of neglect or abusive behavior
 Parental substance abuse
 Impaired judgment and impulse control due to alcohol or drug use
 Increased likelihood of emotional or physical harm
 Authoritarian parenting style
 Strict and controlling parenting
 Use emotional manipulation or abuse to enforce obedience
2. Child-related factors
• Age: Younger children (<5 years) are more vulnerable due to dependency and inability to defend
themselves.
• Difficult temperament traits: Children with difficult traits (e.g., tantrums, stubbornness) may
frustrate caregivers.
• Disability/illness: Children with disabilities or chronic illnesses face higher abuse risk due to
increased care needs.
3. Family-related factors
• Family conflict: High tension and unresolved conflict increase stress and abuse likelihood.
• Parental conflict Resolution: Destructive methods (yelling, blaming) can escalate into emotional
abuse.
• Family isolation: Lack of social support leads to parental overwhelm and increased abuse risk.
• Financial crisis: Financial stress triggers frustration and abusive behavior toward children..
 4. Community-related factors

• Community violence: High crime and violence increase stress and abuse risk, with children
potentially witnessing or experiencing harm.
• Cultural norms: Normalized or accepted abuse in cultural contexts leaves children vulnerable and
abuse unrecognized.
• Lack of community resources: Insufficient access to childcare, mental health services, and
parenting education leaves families unsupported.

Medical and mental health effects of emotional abuse

• Medical effects: Chronic pain, fatigue, sleep disturbance, and medical illnesses (inflammation,
cardiovascular diseases, hypertension, diabetes, irritable bowl syndrome, gastrointestinal disorders,
and obesity).
• Mental health effects: Distorted self-perception, emotional dysregulation, relationship problems,
and psychological disorders (Depression, anxiety, PTSD, borderline personality disorder, substance
use disorder, suicidal ideation and attempts).
• Long-term consequences: Revictimization, poor academic and career outcomes, social isolation
and loneliness, and intergenerational transmission of emotional abuse.
Treatment approaches for emotional abused children
1. Parent-child interaction therapy (PCIT)
2. Trauma focused cognitive behavioral therapy (TF-CBT)
3. Play therapy
4. Group therapy
5. Parent training and education
3. Child Sexual Abuse
“Any sexual activity with a child under 18, where consent is not given or cannot be given (due to age, disability, and
coercion; WHO, 2022).”

 Child sexual abuse, also known as sexual assault and molestation.

 Child sexual abuse includes:

• Sexual grooming

• Inappropriate or unwanted touch or fondling

• Rape or attempted rape

• Sexual exploitation (e.g., prostitution, pornography)

• Exposure/Exhibitionism

• Voyeurism

• Sexual harassment or coercion

Child sexual abuse in Pakistan (2024)
 Child sexual abuse persists as a grave concern in Pakistan, with a staggering average of 12 cases
reported daily (Sahil, 2023).
 41% of Pakistani children experience sexual abuse (Khan et al., 2020).
 Males are disproportionately affected (44%) compared to females (39%; Khan et al., 2020).

Types of child sexual abuse

There are two types of child sexual abuse:
1. Physical contact
• Involves direct physical contact between the abuser and the child.
• Examples:
– Touching or fondling a child's genitals
– Penetrative acts such as rape or attempted rape.
– Forcing the child to participate in sexual activities.
2. Non-physical contact
 It involves exposure to inappropriate behavior without physical contact.
 Examples:
– Exposing a child to sexual acts or pornography.
– Sexual grooming (manipulating the child to make them more susceptible to abuse).
– Forcing the child to watch or listen to sexual activities.
– Engaging in sexual conversations with the child.
Signs of child sexual abuse
1. Behavioral signs
 Anxiety or depression.
 Inappropriate sexual behavior or knowledge beyond their age.
 Nightmares, bedwetting, or fear of certain people or places.
 Aggressiveness or outbursts of anger.
 Regressive behaviors such as thumb-sucking or fear of being alone.
2. Physical signs
 Difficulty walking or sitting.
 Pain, swelling, or bleeding in the genital or anal area.
 Sexually transmitted infections (STIs)
 Early pregnancy
3. Emotional signs
 Low self-esteem or feelings of guilt and shame
 Detachment from peers or family
 Difficulty trusting others or developing close relationships
 Suicidal thoughts and self harm
Risk factors of child sexual abuse
1. Child-related factors
 Age: Children under 12 are particularly susceptible due to their innocence and limited
understanding of abuse (Finkelhor et al., 2014).
 Gender:
 Globally: Girls are more frequently victimized, but boys are also at risk (Khan et al., 2020).
 Pakistan: Males are disproportionately affected (44%) compared to females (39%; Khan et al., 2020).

 Disability: Children with disabilities face higher risks due to dependence on caregivers,
communication difficulties, and potential exploitation (UNICEF, 2020).
 Family history of abuse: Children from families with a history of abuse are more likely to
experience sexual abuse, as cycles of abuse can perpetuate across generations (Briere & Elliott,
2003).
 Access to children: Perpetrators often exploit roles in jobs or volunteer positions that provide
access to children, such as teachers, coaches, caregivers, youth organization leaders, and
healthcare professionals (Khan et al., 2020).
2. Family-related factors
 Family dysfunction: Households characterized by frequent conflicts, instability, or emotional neglect increase the risk
of sexual abuse (Khan et al., 2020).

 Parental substance abuse: Substance abuse impairs parental judgment and supervision, leaving children vulnerable to
potential abusers (Finkelhor et al., 2014).

 Parental incarceration: Parental absence due to incarceration disrupts family dynamics, increasing children's
vulnerability to abuse from others in their environment (Mersky et al., 2017).

 Single-parent households: Economic or emotional stress in single-parent households can reduce protection for children
and expose them to unsafe individuals (Briere & Elliott, 2003).

3. Community-related factors
 Poverty: Economic hardship leads to unstable living conditions, increasing exposure to unsafe environments and
exploitative individuals (UNICEF, 2020).

 Social isolation: Limited social support and connectedness hinders access to help and services, making children more
vulnerable (Finkelhor et al., 2014).

 Lack of community resources: Insufficient resources for child protection, mental health, and social services impede
prevention and intervention efforts (Mersky et al., 2017).

 Cultural norms tolerating violence: Community norms that minimize or tolerate violence, including sexual abuse,
perpetuate the problem (Khan et al., 2020).
4. Societal factors
 Social stigma: Victims often remain silent due to fear of judgment or isolation, leaving them
unprotected (UNICEF, 2020).
 Limited access to education: Without education, children often remain unaware of personal
boundaries, body autonomy, and help-seeking strategies, thereby increasing their vulnerability (Khan
et al., 2020).
 Weak child protection laws: Societies with ineffective laws fail to safeguard children from abuse
and deny justice to victims (Mersky et al., 2017).
 Technology-facilitated exploitation: The internet and social media's widespread adoption has led
to emerging risks, including online grooming and exploitation, which can target children remotely
(Digital Rights Foundation, 2022).
Effects of child sexual abuse (Briere & Elliott, 2003)
 Short-term effects (0-6 months): Anxiety, depression, post-traumatic stress disorder (PTSD),
emotional dysregulation, serious injury, sleep disturbances, behavioral problems, social withdrawal,
shame and guilt, self blame , and dissociation.
 Long-term effects (6 months-18+ years): Substance abuse, suicidal thoughts and behaviors,
chronic mental health issues, relationship difficulties, sexual dysfunction, personality disorders,
sexually transmitted infections, and early pregnancy.
Treatment approaches for child sexual abuse
 Medical Treatment (Cohen et al., 2012)
 Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2012)
 Child-Parent Psychotherapy (CPP; Lieberman et al., 2015)
 Dialectical Behavior Therapy (DBT; Miller et al., 2017)
 Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2001)
 Play Therapy (Gaensbauer, 2016)
 Group Therapy (Feiring et al, 2010)
 Child Neglect
“Child neglect is the failure to meet a child's basic physical, emotional, and psychological needs,
which can result in harm or risk of harm (World Health Organization, 2016).”

Types of child neglect

Psychological Neglect: Failure Medical Neglect: Failure to

Physical Neglect:: Failure to
to provide psychological provide necessary medical care
provide basic physical needs
support and protection

Educational Neglect:
Failure to provide
Emotional Neglect: Failure to educational opportunities Social Neglect: Failure to provide
provide emotional support and social interaction and community
nurturing connections
Signs of child neglect
 Malnutrition and dehydration
 Poor hygiene (dirty clothes, body order, dirty nails, uncombed hair)
 Inappropriate clothing for the weather
 Frequent absences from school
 Untreated medical issues
 Withdrawal or emotional disturbances
 Lack of supervision or being left alone frequently
 Delay speech and language development
 Poor academic performance
 Social skills deficit
 Unexplained injuries and illnesses
Risk factors of child neglect
 Poverty or economic hardship
 Substance abuse or mental health issues in the parent
 Domestic violence
 Lack of social support or isolation
Effects of child neglect
 Child neglect can lead to long-term developmental issues, emotional difficulties, low self-esteem,
academic problems, and even physical health issues.
 Neglected children may also experience difficulties forming healthy relationships later in life.
Treatment approaches
 Parent child interaction therapy
 Family therapy
 Play therapy
 Trauma focused CBT
 Attachment based therapy
 Parent skills training
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