Early years neglect: systematic review

Child Protection Evidence is a resource for clinicians across the UK and internationally to inform clinical practice, child protection procedures and professional and expert opinion in the legal system.


Neglect has varying definitions across agencies and countries.  However, evidence clearly shows that neglect of infants and young children has far-reaching consequences1,2. For the purposes of this review, we have focused on neglect and emotional abuse in children aged 0 – 6 years using the World Health Organization definitions.  Practitioners often lack confidence in identifying the emotionally neglected / abused infant or toddler and thus there is delay in implementing appropriate interventions3.

This systematic review evaluates the scientific literature on early years neglect in children published up until October 2014 and reflects the findings of eligible studies. The review aims to answer one clinical question:

    • What are the emotional, behavioural and developmental (EBD) features in the child indicative of any type of neglect / emotional abuse?

Key findings:

    • Between 2011 and 2014, 11 further studies have been identified, of which six are high quality case-control studies. These have reinforced the original findings but added further information in relation to the moral and emotional behaviour of the child as well as maternal sensitivity and mother-child interaction
    • We wished to identify features in the primary carer-child relationship; unfortunately there are still no studies relating to fathers in the context of early neglect, thus this review addresses solely mother-child interactions

This systematic review evaluates the scientific literature on early years neglect in children published up until October 2014 and reflects the findings of eligible studies. The review aims to answer one clinical question:

    1. What are the emotional, behavioural and developmental (EBD) features in the child indicative of any type of neglect / emotional abuse?

A literature search was performed using a number of databases for all original articles and conference abstracts published since 1960. Supplementary search techniques were used to identify further relevant references. See Appendix 1 for full methodology including search strategy and inclusion criteria.

Potentially relevant studies underwent full text screening and critical appraisal. To ensure consistency, ranking was used to indicate the level of confidence that abuse had taken place and also for study types.

    • Of 189 studies reviewed from the international literature, 43 articles addressed this question2,4-45
    • These 43 articles all met our inclusion criteria and quality ranking of confirmation of neglect / emotional abuse
    • Age: Detailed age breakdown was not given, thus results are summarised in age bands based on the mean age of the cases
    • Gender: One study addressed gender and found that amongst the maltreated children, girls had the greater delay in syntactic language development18

Influence of ethnicity and socio-economic group

In the case-control studies, the groups were well-matched for ethnicity, maternal education, socio-economic grouping (insurance status for North American studies) and maternal age.

1.1. Identifiable, emotional, behavioural and developmental features in children

Age 0-20 months

Eight studies describe several features in children6,7,10,24,27,38,41,42:

    • Assessment of attachment status, evaluated by Strange Situation46, comparing neglected with abused and / or control children6,7,24
    • Neglected children showed avoidant attachment7,24
    • Neglected children also showed more insecure-disorganised attachment24
    • Neglected children did not show any difference in their play complexity from controls, although play was strongly influenced by cognitive function performance42
    • In interactions with their mother, children demonstrated passive and withdrawn behaviour10
    • Children with neglect and failure to thrive (FTT) had a lower developmental quotient than those with neglect or FTT alone27
    • Language delay was particularly prominent in toddlers whose mothers suffered from depression38
    • One study did not demonstrate delayed cognitive play abilities in neglected / emotionally abused one year old infants in comparison to controls41

Age 20-30 months

Five studies described several features in this age group5,9,12,42,45:

    • Evaluation of neglected toddlers during play demonstrated greater negativity than seen in controls12
    • Neglected children demonstrated less positive social interaction in comparison to abused children or controls9
    • Neglected children were also the most passive, and spent more time alone than the other two groups
    • With increasing test difficulty, neglected children showed greater memory deficits than physically abused children or controls5
    • Again there was no difference between controls and neglected children on play complexity, however play was strongly influenced by cognitive function performance42
    • A longitudinal study of toddlers showed that neglect children exhibited more internalising behaviours45. Some toddlers had co-existent internalising and externalising features, which were correlated to parenting style

Age 3-4 years

Five studies described certain features in this age group 4,11,20,22,45:

    • Developmental delay, in particular language delay, was apparent in the neglected children in comparison to physically abused children or controls4,11
    • Receptive language (auditory comprehension quotient) and expressive language development (verbal ability quotient) were particularly delayed4,11
    • The neglected children showed the lowest scores on auditory and verbal scores11
    • In observing play, both free and with parents, the neglected toddlers had a greater negative affect than physically abused children or controls22
    • There was no demonstrable difference in discriminating emotions between emotionally abused, physically abused or neglected children. An allowance was made for intelligence quotient (IQ). However, all of these groups showed less ability to discriminate emotions than those with normal IQ20
    • One study found that children exhibited slightly elevated externalising behaviour over time, aged 2-3 and 5-6 years. Some children exhibited externalising and internalising behaviour45

Age 4-6 years

Fifteen studies described features in this age group18,21,23,25,26,28,29,30,33,34,35,37,39,44,45:

    • Language delay becomes more evident as children grow older, with neglected children demonstrating more syntactic delays and producing less complex language than controls. The children also showed reduced vocabulary18
    • Maltreated girls showed a greater language delay than maltreated boys18
    • It is notable that the maternal verbal IQ was lower amongst the neglectful mothers, in comparison to controls18
    • Neglectful children showed the least number of social interactions in comparison to controls and abused children21
    • Neglected children also showed cognitive deficits and disruptive behaviour21
    • Teachers rated neglected children’s behaviour as worse than the controls and abused children21
    • Neglected children showed an increase in conduct problems in comparison to abused children and controls (as rated by mothers)30
    • The neglected children’s perception of others showed they were less likely to expect parents to relieve their distress or to relive distress in others, in comparison to abused children or controls26
    • Neglected children were more likely to demonstrate undercontrolled / ambivalent emotional responses to simulated inter-adult aggression28
    • Neglected children had more difficulty discriminating emotional expressions (particularly between angry, sad and fearful expressions) than physically abused children or controls. Neglected children also had a predilection for selecting sad faces29
    • Emotional knowledge, based on labelling, recognising and matching to situations was examined in the context of harsh punitive parenting among neglected and control children. Punitive parenting did not have an impact, however the more severe the neglect, the poorer the child’s emotional knowledge37
    • Low IQ has an influence on emotional knowledge37
    • Neglected children showed low self-esteem and the lowest scores on positive self-representation in comparison to controls, physically or sexually abused children39
    • In assessing attachment, the neglected children demonstrated more avoidant attachment and more disorganised markers, specifically more frightening markers than controls. Overall, neglected children were more insecurely attached than controls35,43
    • Neglected children depicted their mother as being less available to them than controls43
    • Neglected children perceived their relationship with their mothers to be less fulfilling, safe and reliable35
    • Neglected children were more likely to perceive others as hurt, sad or anxious than physically abused children or controls. They perceived themselves as opposing or angry towards others and had a tendency to view themselves as anxious and ashamed44
    • Neglected children showed more dissociation than controls, which was linked to the chronicity of the neglect. Neglected children had poor peer relationships in comparison to controls25
    • Studies of moral development demonstrated that neglected children showed more cheating and less rule-compatible behaviour than controls23
    • In evaluating children’s responses to their own and other children’s ‘moral transgressions’ (the appropriateness of hitting, kicking, or biting another child, causing another child psychological distress, not listening to the teacher or keeping quiet during nap time, or leaving class without permission) neglected children perceived themselves and others as equally deserving of punishment for transgressions34
    • A measure of physiological regulatory capacity, respiratory sinus arrhythmia (RSA) was performed on children prior to and during a parent-child interaction33. The majority of children showed suppression of the RSA when moving from baseline to interacting with their mothers, but there was no difference between neglected children and controls33.

The manifestation of EBD child features through early childhood

Several longitudinal cohort studies described manifestation of EBD child features through early childhood2,8,13,14,15,16,17,19,31,36,40:

    • The attachment pattern demonstrated by neglected children changed from ambivalent-insecure in those aged 12 months to avoidant in those aged 18 months, however some are classified as ‘secure’15,16
    • Children who were anxiously attached at 1-18 months became angry, frustrated and non-compliant with more negative affect than controls by two years of age. The neglected children were worse at coping than both abused children and controls16
    • The emotionally abused children were anxiously attached at 18 months and, by 24 months, showed more anger and frustration than controls16
    • By 42 months, the neglected children showed more apathy / withdrawal and hyperactivity / distractibility16
    • Crittenden et al showed how neglected children aged 12 months onwards displayed aggressive and resistant behaviour towards their carers, particularly up to 2.25 years of age8
    • Psychological neglect at age three was significantly associated with internalising and externalising behaviour. Neglect at age three did not predict changes in the child’s behaviour and development between the ages of three to five years. Cognitive development was markedly impaired by five years of age13
      • By five years of age, teachers noted neglected children experiencing difficult peer relationships
    • Neglected children showed persistent cognitive delay from 18 – 36 months31
    • Children who were neglected prior to the age of four showed greater language delay once aged over four years, compared to controls19
    • Toth et al reported that neglected three to four year old children perceived their parents less positively over time and had more negative self-representations40
    • The Mother Child Interaction Research project (known as the Minnesota study) evaluated developmental sequelae from children aged 3-24 months, separated into an emotionally abused cohort and a neglected cohort. The emotionally abused children showed a lower developmental quotient by 24 months, compared to physically abused, neglected and control children. The neglected children showed a declining function in development and play over time. In addition, they were anxious / avoidant at 18 months, progressing to angry, frustrated and non-compliant by 24 months. These children also had a low coping score17
    • Further results from the Minnesota study focused on children from birth to six years of age. Neglected children at 54 months of age showed greater dependency and by 64 months they showed more self-destructive, inattentive and overactive behaviour.  They were rated by teachers to be anxious, withdrawn, unpopular, aggressive and obsessive-compulsive in comparison to abused children and controls. Teachers rated the children as lacking humour, showing little sensitivity and empathy, as well as being poorer at following directions and expressing themselves in comparison to control groups.  Emotionally abused children followed from age 18 – 42 months showed a mixed pattern of early behaviours, becoming less persistent and showing less enthusiasm for tasks than controls at 42 months2
    • Evaluating neglected children aged four to five years showed poorer emotional knowledge over time, compared to controls, after controlling for IQ36

1.2. Implications for practice

    • Given the delay in language, both receptive and expressive, in neglected / emotionally abused children, it is essential that all practitioners working with pre-school children are trained in normal child development
    • Important attachment disorders are recognised in young infants and toddlers and warrant formal evaluation by professionals trained in infant mental health, as many features described in neglected / emotionally abused children overlap with those found in children suffering from autistic spectrum disorder or attention deficit hyperactivity disorder
    • Careful observation and recording of the infant-carer interaction will help to identify neglected / emotionally abused toddlers at an early stage, enabling appropriate assessment and intervention
    • There are clearly identifiable features in the pre-school child who is being neglected and / or emotionally abused, thus it is incumbent upon all health practitioners working with these children to be aware of the indicators that they may identify

1.3. Research implications

    • Although it is recognised that many children suffer from multiple forms of abuse or neglect, future studies would benefit from clearly delineating the subcategories of children and, in particular, the definitions that have been used for neglect or emotional abuse
    • There is a dearth of literature relating to neglect / emotional abuse from outside North America, and given the cultural context of neglect, further international studies are warranted

1.4. Limitations of review findings

    • Although authors attempted to separate children experiencing “pure neglect” or “emotional abuse”, it is likely that many children were subjected to more than one form of abuse or neglect. Thus the features described may overlap with those found in both emotional abuse and other forms of abuse or neglect
    • Unfortunately the age bands selected for studying the EBD features in children did not precisely match the age bands in those studies focusing on parent-child interactions
    • Included studies predominantly addressed neglect, with relatively less research into emotional abuse of infants and toddlers.

The review identified a number of interesting findings that were outside of the inclusion criteria. These are as follows:

Clinical question 1

Faltering growth

    • One study assessed the catch-up growth of long term physically neglected and emotionally abused pre-school children and determined that the growth failure was reversible after one year in foster care47

Incidence of child neglect

    • A Canadian incidence study during 1998 noted that 40% of investigations were due to neglect and 19% emotional maltreatment48
    • Another Canadian incidence study from 2003 recorded the prevalence of neglect and emotional abuse with relevant associated risk factors49,50
    • The UK Framework for the Assessment of Children in Need and Their Families identifies the statutory basis for assessment in the UK (+ working together to safeguard children)51
    • An American statement on screening for family and intimate partner violence 652
    • For the period 2008-9 the incidence of neglect was 48% and emotional abuse 24% in Wales, UK 753

Prevalence of Emotional Abuse

    • A meta-analysis of 29 studies determined the prevalence of emotional abuse of 3/1000 children for studies using an informant versus 363/1000 using self-report measures54

Consequences of extreme early neglect

    • MRI studies of children experiencing severe institutional neglect demonstrated reduced cerebellar volume55

Long term consequences

    • Early adverse childhood experiences (including emotional abuse) are associated with an increased risk of premature death56
    • Overarching study summarising the conclusions of the Minnesota Study (The Mother Child Interaction Research project) identifying the developmental sequelae of infant maltreatment17
    • Early childhood neglect (aged 0-2 years) is associated with aggression at age 4-8 years57
    • There has been an increase in animal data to suggest that early maltreatment including neglect can affect methylation of brain-derived neurotrophic factor (BDNF) which may lead to altered BDNF gene expression in future offspring. This has been association with perpetuation of abnormal care taking behaviour58


    • The Cleveland Child Abuse Potential Scale (C-CAPS) was piloted to determine if it could effectively distinguish between children who were maltreated, at risk, and controls. The instrument was able to correctly classify 85% of control cases and 76% of Maltreatment cases59

We performed an all-language literature search of original articles, their references and conference abstracts published since 1960.  The initial search strategy was developed across OVID Medline databases using keywords and Medical Subject Headings (MeSH headings) and was modified appropriately to search the remaining bibliographic databases.  The search sensitivity was augmented by the use of a range of supplementary ‘snowballing’ techniques including consultation with subject experts and relevant organisations, and hand searching selected websites, non-indexed journals and the references of all full-text articles.

We limited our search strategy to Organisation for Economic Co-operation and Development populations due to similarities in culture and patterns of health status.

Identified articles, once scanned for duplicates and relevancy, were transferred to a purpose-built Microsoft Access database to coordinate the review and collate critical appraisal data.  Relevant studies with an English-language version available were scanned for eligibility by the lead researcher and selected for review.

Standardised data extraction and critical appraisal forms were based on criteria defined by the National Health Service’s Centre for Reviews and Dissemination60. We also used a selection of systematic review advisory articles to develop our critical appraisal forms36,61,62,63,64. Articles were independently reviewed by two reviewers.  A third review was undertaken to resolve disagreement between the initial reviewers when determining either the evidence type of the article or whether the study met the inclusion criteria.  Decisions related to inclusion and exclusion criteria were guided by Cardiff Child Protection Systematic Reviews, who laid out the basic parameters for selecting the studies.

Our panel of reviewers included paediatricians, psychologists, psychiatrists, social science researchers, information specialists and social workers. All reviewers underwent standardised critical appraisal training, based on the CRD critical appraisal standards36, and this was supported by a dedicated electronic critical appraisal module.

We included all studies addressing neglect, emotional abuse or emotional neglect in children less than six years of age. We combined these latter two conditions since, in practice, these descriptions appear concurrently, and this acknowledges the broader term of ‘psychological maltreatment’ as defined by the American Professional Society on the Abuse of Children (1995)65. Among international definitions of neglect and emotional abuse, we opted for those of the World Health Organization, as follows:

    • Neglect (including emotional neglect) is defined as:

“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 distinguished from circumstances of poverty in that neglect can occur only in cases where reasonable resources are available to the family or caregiver.”66

    • Emotional abuse is defined as:

“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 treatment66”.

Inclusion criteria


Inclusion Exclusion
Children aged 0-5 completed years Studies of sexual abuse
Documented features of the impact of neglect on the child during the period of exposure to neglect Studies of physical abuse alone, or studies combining physical abuse and neglect, where the data from the neglect cases could not be extracted
Studies conducted in Organisation for Economic Co-operation and Development countries Studies of management or complications of neglect
Child / carer interaction documented using standardized recording Studies addressing risk factors for neglect
Studies of the interaction between the child and their primary carer
Confirmation of neglect ranks A- C2

Confirmation of neglect


Ranking Criteria used to define neglect
A1 Neglect/emotional abuse confirmed at child protection case conference, multi-disciplinary assessment, including social services or Court proceedings
A2 Diagnosis of emotional neglect/emotional abuse by clinical psychologist, psychiatrist or other mental health specialist
B Neglect/emotional abuse confirmed by referenced criteria/tool
C1 Neglect/emotional abuse confirmed by unreferenced criteria/tool
C2 Observations of emotionally harmful carer-child interaction (not categorized as neglect/emotional abuse)
D Neglect/emotional abuse/harmful carer-child interaction suspected or stated, with no supporting detail

Search strategy

The below table presents the search terms used in the 2014 Medline database search for early years neglect, truncation and wildcard characters were adapted to the different databases where necessary.


  1. exp Child/

2. exp Child Preschool/

3. exp Infant, Newborn/

4. exp Infant/

5. infancy.ti,ab.

6. child*.ti,ab.

7. infant*.ti,ab.

8. (baby or babies).ti,ab.

9. toddler*.ti,ab.

10. neonat*.ti,ab.

11. (pediatric* or paediatric*).ti,ab.

12. or/1-11

13. limit 12 to (“all infant (birth to 23 months)” or “newborn infant (birth to 1 month)” or “infant (1 to 23 months)” or “preschool child (2 to 5 years)”)

14. (pre-school* or preschool* or preschool-age Child*).ti,ab.

15. 13 or 14

16. (abus* adj neglect*).ti,ab.

17. (maltreat* or mistreat* or deprive* or ignor*).mp.

18. neglected.ti,ab.

19. neglectful.ti,ab.

20. psychological neglect.ti,ab.

21. ((lack* or absen* or fail*) adj3 (care* or childcare)).ti,ab.

22. ((social* or emotional* or psychosocial* or contact or psychological*) adj3 (deprived or deprivation)).ti,ab.

23. overlook*.ti,ab.

24. neglect* psychological*.ti,ab.

25. emotion* neglect*.ti,ab.

26. emotion* abus*.ti,ab.

27. emotion* harm*.ti,ab.

28. child neglect.ti,ab.

29. neglect* child*.ti,ab.

30. emotion* depriv*.ti,ab.

31. emotional trauma.ti,ab.

32. ((neglect* or ignore or deprive*) adj1 (psychologic* or emotion*)).ti,ab.

33. or/16-32

34. Failure to Thrive/

35. (failure to thrive adj5 (emotion* or nonorganic or non-organic)).ti,ab.

36. (failure to thrive adj5 (abus* or neglect* or maltreat* or mistreat* or depriv* or psych)).ti,ab.

37. ((fail* or inadequa*) adj2 emotional support).ti,ab.

38. (unkempt or ungroomed).ti,ab.

39. Psychosocial Deprivation/

40. unhealthy appearance?.ti,ab.

41. exp Internal-External Control/

42. (internal* adj3 extem*).ti,ab.

43. (anxiety or anxious* or anguish*).ti,ab.

44. (withdrawn or apath*).ti,ab.

45. (indifferen* or disinterest*).ti,ab.

46. ((lack* or low or flat*) adj3 (affect or emotion*)).ti,ab.

47. (clingy or clinginess).ti,ab.

48. ((attention or affection* or love) adj3 (inappropriate* or improper* or unsuitabl*)).ti,ab.

49. ((mental or psychological* or emotional*) adj3 (stress* or distress*)).ti,ab.

50. internali?ation.ti,ab.

51. Irritable Mood/

52. ((emotion* or affect*) adj3 (labil* or regulat*)).ti,ab.

53. (aloof or avoid*).ti,ab.

54. Shyness/

55. ((avoid* or withdraw*) adj3 (contact or touch* or physical*)).ti,ab.

56. ((avoid* or withdraw*) adj3 social*).ti,ab.

57. unsociable.ti,ab.

58. ((lack or poor* or avoid*) adj3 communicat*).ti,ab.

59. (watchful or wary or vigilan*).ti,ab.

60. (unhappiness or unhappy).ti,ab.

61. (overly responsible or perfectionis*).ti,ab.


63. Conduct Disorder/

64. Aggression/

65. ((aggression or aggressive*) adj3 (behavio* or escalat*)).ti,ab.

66. acting out.ti,ab.

67. out of control.ti,ab.

68. ((chaotic* or challenging) adj3 behavio*).ti,ab.

69. (bully* or bullie?).ti,ab.

70. Anger/

71. ((destructive* or disruptive*) adj3 behav*).ti,ab.

72. Impulsive Behavior/

73. impulse control.ti,ab.

74. (impulsive* or impulsivity or impulse control).ti,ab.

75. Developmental Disabilities/

76. Child Development/

77. Child Behavior/

78. Infant Behavior/

79. Personality Development/

80. ((chang* or alter* or deviat* or transition?) adj3 personality).ti,ab.

81. Helplessness, Learned/

82. sad.ti,ab.

83. Social Behavior/

84. Attention Deficit Disorder with Hyperactivity/

85. avoidant attention.ti,ab.

86. (normative adj3 avoidance).ti,ab.

87. (abandoned or abandonment?).ti,ab.

88. psychological neglect.ti,ab.

89. ((lack* or absen* or fail*) adj3 (care* or childcare)).ti,ab.

90. ((social* or emotional* or psychosocial* or contact or psychological*) adj3 (deprived or deprivation)).ti,ab.

91. “lack of supervison”.ti,ab.

92. unsupervised.ti,ab.

93. (temper or hostil* pr hypervigilan*).ti,ab.

94. Child Behavior Disorders/

95. (rage of raging or rageful).ti,ab.

96. attun*.ti,ab.

97. Nonverbal Communication/

98. Sensory integration.mp.

99. Dissociat*.ti,ab.

100. *”Dissociative Disorders”/

101. Dysregulation.mp.

102. Affect mirroring.mp.

103. *”Facial Expression”/

104. Mind-mindedness.mp.

105. Object Attachment/

106. attachment.ti,ab.

107. persecut*.ti,ab.

108. Speech delay.mp.

109. Language delay.mp.

110. Language Disorders/

111. Perspective taking.mp.

112. Demanding.mp.

113. Poor concentration.ti,ab.

114. listless*.mp.

115. Isolated.mp.

116. *”Social Isolation”/

117. Inhibited.mp.

118. Reactive Attachment Disorder/

119. Disinhibited.mp.

120. Social skills.mp.

121. Emotional skills.mp.

122. False positive affect.mp.

123. touch sensitive.mp.

124. Apparent compliance.mp.

125. Language comprehension deficit.mp.

126. Grasp of reality.mp.

127. Immatur*.ti,ab.

128. impatien*.ti,ab.

129. Socialization/

130. cognitive delay.mp.

131. cognitive* stimulat*.ti,ab.

132. attachment disorder.mp.

133. eye contact.ti,ab.

134. *Stress, Psychological/

135. stunting of growth.mp.

136. stunt* growth.mp.

137. Hospitalism.ti,ab.

138. environmental retardation.ti,ab.

139. affect deprivation.ti,ab.

140. emotional* depriv*.ti,ab.

141. or/34-140

142. 15 and 33 and 141

143. Family/

144. Mother-Child Relations/

145. Maternal Behavior/

146. Parent-Child Relations/

147. ((parent* or mother or father or maternal or paternal or carer*) adj3 (depression or depressed or depressive or dysthymi? or dysphori?)).ti,ab.

148. ((parent* or mother or father or maternal or paternal or carer*) adj3 mood disorder*).ti,ab.

149. ((parent* or mother or father or maternal or paternal or carer*) adj3 negative mood).ti,ab.

150. ((parent* or mother or father or maternal or paternal or carer*) adj3 partner violence).ti,ab.

151. ((parent* or mother or father or maternal or paternal or carer*) adj3 (anger or angry or angst or rage)).ti,ab.

152. ((parent* or mother or father or maternal or paternal or carer*) adj3 depress*).ti,ab.

153. ((parent* or mother or father or maternal or paternal or carer*) adj3 emotion*).ti,ab.

154. ((parent* or mother or father or maternal or paternal or carer*) adj3 substance abuse).ti,ab.

155. ((parent* or mother or father or maternal or paternal or carer*) adj3 domestic violence).ti,ab.

156. ((parent* or mother or father or maternal or paternal or carer*) adj3 punitive).ti,ab.

157. ((parent* or mother or father or maternal or paternal or carer*) adj3 unavailab*).ti,ab.

158. ((parent* or mother or father or maternal or paternal or carer*) adj3 (instab* or unstab*)).ti,ab.

159. Learning disability/ or Learning disability.mp.

160. (spouse or partner).mp.

161. (Interpersonal violence or IPV).mp.

162. Psychologica* unavailab*.mp.

163. Emotion* inatten*.mp.

164. Emotion* unattach*.mp.

165. Authoritative.mp.

166. Disengaged.mp.

167. Emotion* unavailab*.mp.

168. ((Parent* or mother or father or maternal or paternal) adj1 anger).ti,ab.

169. Rough handl*.mp.

170. Unresponsiv*.mp.

171. Non-physical punishment.mp.

172. “Family Relations”/

173. Interpersonal Relations/

174. (child* adj3 (mock* or taunt* or denigrat* or threat* or hostil*)).mp.

175. Inappropriate expectation*.mp.

176. inappropriate development.mp.

177. (over-protective or over protective*).ti,ab.

178. *”Parenting”/

179. (dysfunctional family or family dysfunction).ti,ab.

180. “Rejection (Psychology)”/

181. Negative attribution*.mp.

182. High criticism.mp.

183. parent* unresponsiv*.mp.

184. Child Rearing/

185. family interact*.ti,ab.

186. home environment*.ti,ab.

187. Neglect* mother*.ti,ab.

188. over* critical.ti,ab.

189. (families or family or dyad).ti,ab.

190. or/143-189

191. 15 and 33 and 190

192. assessment.mp.

193. Diagnosis/

194. diagnostic tool.mp.

195. assessment tool.mp. or “Severity of Illness Index”/

196. Needs Assessment/

197. graded care profile.mp.

198. (identification or identify).ti,ab.

199. Pattern Recognition, Visual/

200. detect*.ti,ab.

201. Classification/

202. Decision Making/

203. Early Diagnosis/

204. screening.mp. or Mass Screening/

205. “Risk Factors”/

206. HOME inventory.mp.

207. Risk Assessment/

208. Risk/

209. or/192-208

210. 15 and 33 and 209

211. Environment/

212. Hostile atmosphere.mp.

213. Environment Design/

214. depriv*.ti,ab.

215. chao*.ti,ab.

216. “Play and Playthings”/

217. Absence of toys.mp.

218. Absence of play.mp.

219. Absence of stimulation.mp.

220. home.ti,ab.

221. buggy.mp.

222. “Walkers”/

223. Infant Equipment/

224. (pram or pushchair).mp.

225. stroller.mp.

226. ((view* or watch*) adj3 television).ti,ab.

227. Social Environment/

228. or/211-227

229. 15 and 33 and 228

230. 142 or 191 or 210 or 229

231. Stress Disorders, Post-Traumatic/

232. sexual abuse.mp. or Sex Offenses/

233. “Child Abuse, Sexual”/

234. (Algeria$ or Egypt$ or Liby$ or Morocc$ or Tunisia$ or Western Sahara$ or Angola$ or Benin or Botswana$ or Burkina Faso or Burundi or Cameroon or Cape Verde or Central African Republic or Chad or Comoros or Congo or Djibouti or Eritrea or Ethiopia$ or Gabon or Gambia$ or Ghana or Guinea or Keny$ or Lesotho or Liberia or Madagasca$ or Malawi or Mali or Mauritania or Mauritius or Mayotte or Mozambiq$ or Namibia$ or Niger or Nigeria$ or Reunion or Rwand$ or Saint Helena or Senegal or Seychelles or Sierra Leone or Somalia or South Africa$ or Sudan or Swaziland or Tanzania or Togo or Ugand$ or Zambia$ or Zimbabw$ or China or Chinese or Hong Kong or Macao or Mongolia$ or Taiwan$ or Belarus or Moldov$ or Russia$ or Ukraine or Afghanistan or Armenia$ or Azerbaijan or Bahrain or Cyprus or Cypriot or Georgia$ or Iran$ or Iraq$ or Israel$ or Jordan$ or Kazakhstan or Kuwait or Kyrgyzstan or Leban$ or Oman or Pakistan$ or Palestin$ or Qatar or Saudi Arabia or Syria$ or Tajikistan or Turkmenistan or United Arab Emirates or Uzbekistan or Yemen or Bangladesh$ or Bhutan or British Indian Ocean Territory or Brunei Darussalam or Cambodia$ or India$ or Indonesia$ or Lao or People’s Democratic Republic or Malaysia$ or Maldives or Myanmar or Nepal or Philippin$ or Singapore or Sri Lanka or Thai$ or Timor Leste or Vietnam or Albania$ or Andorra or Bosnia$ or Herzegovina$ or Bulgaria$ or Croatia$ or Estonia or Faroe Islands or Greenland or Liechtenstein or Lithuani$ or Macedonia or Malta or maltese or Romania or Serbia$ or Montenegro or Slovenia or Svalbard or Argentina$ or Belize or Bolivia$ or Brazil$ or chile or Chilean or Colombia$ or Costa Rica$ or Cuba or Ecuador or El Salvador or French Guiana or Guatemala$ or Guyana or Haiti or Honduras or Jamaica$ or Nicaragua$ or Panama or Paraguay or Peru or Puerto Rico or Suriname or Uruguay or Venezuela or developing countr$ or south America$).ti,sh.

235. “Africa South of the Sahara”/

236. or/231-235

237. 230 not 236

238. limit 237 to yr=”2013 – 2014″

Thirteen databases were searched together with hand searching of particular journals and websites. A complete list of the resources searched can be found below.


Databases Time period searched
ASSIA (Applied Social Sciences Index and Abstracts) 1987 – 2014
CINAHL (Cumulative Index to Nursing and Allied Health Literature) 1982 – 2014
Cochrane Central Register of Controlled Trials 1960 – 2014
EMBASE 1980 – 2014
ERIC (Education Resources Information Center) 1962 – 2014
HMIC (Health Management Information Consortium) 1979 – 2014
IBSS (International Bibliography of the Social Sciences) 1960 – 2014
MEDLINE 1960 – 2014
MEDLINE In-Process and Other Non-Indexed Citations 2006 – 2014
Open SIGLE (System for Information on Grey Literature in Europe) 1980 – 2005*
PsycINFO 1960 – 2014
Pubmed e publications 2014
SCOPUS 1966 – 2014
Social Care Online 2006 – 2014
Social Services Abstracts 2008 – 2013
Sociological abstracts 2008 – 2013
Web of Knowledge — ISI Proceedings 1990 – 2014
Web of Knowledge — ISI Science Citation Index 1970 – 2014
Web of Knowledge — ISI Social Science Citation Index 1970 – 2014
* ceased indexing
† institutional access terminated
 no yield so ceased searching
Journals ‘hand searched’ Time period searched
Child Abuse and Neglect 1979 – 2014
Child Abuse Review 1992 – 2014
Websites searched Date accessed
Centre for Excellence and Outcomes in Children and Young People’s Services(C4EO) 14 October 2014
Child Welfare Information Gateway(CWIG) 14 October 2014
Research in Practice(RIP) From inception – 2009
Social Care Institute for Excellence website 14 October 2014
Translational Research on Child Neglect Consortium (TRCNC) 14 October 2014
Trauma Central 14 October 2014

Pre-review screening and critical appraisal

Papers found in the database and hand searches underwent three rounds of screening before they were included in this update. The first round was a title screen where papers that obviously did not meet the inclusion criteria were excluded. The second was an abstract screen where papers that did not meet the inclusion criteria based on the information provided in the abstract were excluded. In this round the pre-review screening form was completed for each paper. These first two stages were carried out by clinical experts. Finally a full text screen with a critical appraisal was carried out by members of the clinical expert sub-committee. Critical appraisal forms were completed for each of the papers reviewed at this stage. Examples of the pre-review screening and critical appraisal forms used in previous reviews are available on request (clinical.standards@rcpch.ac.uk).

Disclaimer: This is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.

Original reviews and content © Cardiff University, funded by NSPCC

Published by RCPCH July 2017

While the format of each review has been revised to fit the style of the College and amalgamated into a comprehensive document, the content remains unchanged until reviewed and new evidence is identified and added to the evidence-base. Updated content will be indicated on individual review pages.


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Egeland B., Erickson M.F. Psychologically unavailable caregiving. Psychological maltreatment of children and youth 1987: 110-120.


Erickson MF E.B., Pianta R. The effects of maltreatment on the development of young children. In:  ed. Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect. New York: Cambridge University Press; 1989. p. 647-684.


Developing an effective response to neglect and emotional harm to children.


Culp RE W.R., Lawrence H, Letts D, Kelly DJ, Rice ML. Maltreated children’s language and speech development: abused, neglected, and abused and neglected. First Language 1991; 11(33): 377-389


DiLalla DL C.P. Dimensions of maltreated children’s home behavior: A factor analytic approach. Infant Behavior and Development 1990; 13(4): 439-460.


Egeland B S.A. Developmental sequelae of maltreatment in infancy. New Directions for Child and Adolescent Development 1981; 11: 77-92.


Koenig AL C.D., Rogosch FA. Moral development: the association between maltreatment and young children’s prosocial behaviors and moral transgressions. Social Development 2004; 13(1): 87-106


Venet M B.J., Gosselin C, Capuano F. Attachment representations in a sample of neglected preschool-age children. School Psychology International 2007; 28(3): 264-293


Waldinger RJ T.S., Gerber A. Maltreatment and internal representations of relationships: Core relationship themes in the narratives of abused and neglected preschoolers. Social Development 2001; 10(1): 41-58.


Woodruff K. (2012). Assessing developmental pathways of young children investigated for neglect and predictors of persistent problems, University of Maryland, Baltimore


Ainsworth MD B.M., Waters E, Wall S. Patterns of attachment: A psychological study of the Strange Situation. ed.  1978.


Chamberland C F.B., Black T, Trocmé N, Chabot M. Correlates of substantiated emotional maltreatment in the second Canadian Incidence Study. Journal of Family Violence 2012; 27(3): 201-213


Framework for the Assessment of Children in Need and Their Families.  2000.


Local Government Data Unit W. (2009). Local authority child protection registers.


Stoltenborgh M B.-K.M., Alink LRA, van IJzendoorn MH. The universality of childhood emotional abuse: a meta-analysis of worldwide prevalence. Journal of Aggression, Maltreatment & Trauma 2012; 21(8): 870-890


Ezzo F Y.K. Child maltreatment risk inventory: Pilot data for the Cleveland child abuse potential scale. Journal of Family Violence 2012; 27(2): 145-155.


Polgar A T.S. Chapter 22. Critical evaluation of published research in Introduction to research in the health sciences. . In:  ed.  Melbourne: Churchill Livingstone; 1995. p.


A schema for evaluating evidence on public health interventions (version 4)


World report on violence and health 2002.

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