EARLY DEPRIVATION AND TRAUMA

Early childhood trauma generally refers to the traumatic experiences that occur to children
aged 0-6. Because infants' and young children's reactions may be different from older
children's, and because they may not be able to verbalize their reactions to threatening or
dangerous events, many people assume that young age protects children from the impact of
traumatic experiences. A growing body of research has established that young children may
be affected by events that threaten their safety or the safety of their parents/caregivers, and
their symptoms have been well documented. These traumas can be the result of intentional
violence—such as child physical or sexual abuse, or domestic violence—or the result of
natural disaster, accidents, or war. Young children also may experience traumatic stress in
response to painful medical procedures or the sudden loss of a parent/caregiver.

Effects

Traumatic events have a profound sensory impact on young children. Their sense of safety
may be shattered by frightening visual stimuli, loud noises, violent movements, and other
sensations associated with an unpredictable, frightening event. The frightening images tend to
recur in the form of nightmares, new fears, and actions or play that reenact the event. Lacking
an accurate understanding of the relationship between cause and effect, young children
believe that their thoughts, wishes, and fears have the power to become real and can make
things happen. Young children are less able to anticipate danger or to know how to keep
themselves safe, and so are particularly vulnerable to the effects of exposure to trauma. A 2-
year-old who witnesses a traumatic event like his mother being battered may interpret it quite
differently from the way a 5-year-old or an 11-year-old would. Children may blame
themselves or their parents for not preventing a frightening event or for not being able to
change its outcome. These misconceptions of reality compound the negative impact of
traumatic effects on children's development.

Young children who experience trauma are at particular risk because their rapidly developing
brains are very vulnerable. Early childhood trauma has been associated with reduced size of
the brain cortex. This area is responsible for many complex functions including memory,
attention, perceptual awareness, thinking, language, and consciousness. These changes may
affect IQ and the ability to regulate emotions, and the child may become more fearful and
may not feel as safe or as protected.

Young children depend exclusively on parents/caregivers for survival and protection—both

physical and emotional. When trauma also impacts the parent/caregiver, the relationship
between that person and the child may be strongly affected. Without the support of a trusted
parent/caregiver to help them regulate their strong emotions, children may experience
overwhelming stress, with little ability to effectively communicate what they feel or need.
They often develop symptoms that parents/caregivers don't understand and may display
uncharacteristic behaviors that adults may not know how to appropriately respond to.

Symptoms and Behaviors

As with older children, young children experience both behavioral and physiological
symptoms associated with trauma. Unlike older children, young children cannot express in
words whether they feel afraid, overwhelmed, or helpless. Young children suffering from
traumatic stress symptoms generally have difficulty regulating their behaviors and emotions.
They may be clingy and fearful of new situations, easily frightened, difficult to console,
and/or aggressive and impulsive. They may also have difficulty sleeping, lose recently
acquired developmental skills, and show regression in functioning and behavior.

Children aged 0-2 exposed to trauma may Children aged 3-6 exposed to trauma m

 Demonstrate poor verbal skills  Have difficulties focusing or learni

 Exhibit memory problems  Develop learning disabilities
 Scream or cry excessively  Show poor skill development
 Have poor appetite, low weight, or digestive  Act out in social situations
problems  Imitate the abusive/traumatic event
 Be verbally abusive
 Be unable to trust others or make f
 Believe they are to blame for the tr
event
 Lack self-confidence
 Experience stomach aches or heada

Protective Factors: Enhancing Resilience

The effects of traumatic experiences on young children are sobering, but not all children are
affected in the same way, nor to the same degree. Children and families possess
competencies, psychological resources, and resilience--often even in the face of significant
trauma--that can protect them from long-term harm. Research on resilience in children
demonstrates that an essential protective factor is the reliable presence of a positive, caring,
and protective parent or caregiver, who can help shield children against adverse experiences.
They can be a consistent resource for their children, encouraging them to talk about their
experiences, and they can provide reassurance to their children that the adults in their lives
are working to keep them safe.

Instruments for Assessing Traumatic Stress in Young Children

Clinical assessment should include review of the specifics of the traumatic experience
including:

 Reactions of the child and parents/caregivers

 Changes in the child's behavior
  Resources in the environment to stabilize the child and family
 Quality of the child's primary attachment relationships
 Ability of parents/caregivers to facilitate the child's healthy socioemotional,
psychological, and cognitive development

When conducting an assessment of a young child, it is also important to assess developmental

delays (e.g., gross/fine motor, speech/language, sensory processing), which may indicate that
the child could benefit from evaluation and/or services from another professional (e.g.,
occupational therapist, speech/language therapist, physical therapist). It is often helpful to
consult and to work collaboratively with these professionals.

Below is a list of some of the standardized instruments used within the NCTSN to assess
traumatic stress in young children.

 Child Behavior Checklist (CBCL): Achenbach, and Rescorla (2001). Ages 1½–5
 Posttraumatic Stress Disorder Semi-Structured Interview and Observation Record:
Scheeringa and Zeanah (1994). Ages 0–4
 Posttraumatic Symptom Inventory for Children (PT-SIC): Eisen (1997). Ages 4–8
 Preschool Age Psychiatric Assessment (PAPA): Egger and Angold (1999). Ages 2–5
 PTSD Symptoms in Preschool Aged Children (PTSD-PAC): Levendosky, Huth-
Bocks, Semel, and Shapiro (2002). Ages 3–5
 Traumatic Events Screening Inventory-Parent Report Revised (TESI-PRR): Ghosh et
al. (2002). Ages 0–6
 Trauma Symptom Checklist for Young Children (TSCYC): Briere et al. (2001). Ages
3–12
 Violence Exposure Scale for Children-Preschool Version (VEX-PV): Shahinfar, Fox,
and Leavitt (2000). Ages 4–10
 Violence Exposure Scale for Children-Revised Parent Report (VEX-RPR): Shahinfar,
Fox, and Leavitt (2000). For parents of preschool-aged children aged 4–10

several investigative groups have suggested that adverse experiences can be conceptualized
by distinguishing between
inadequate input (neglect/deprivation) and harmful. input (threat/abuse/violence exposure).
Consistent with this view, Humphreys and Zeanah (2015) suggested that deprivation and
trauma represented
distinct deviations from the expectable environment and reviewed evidence linking each to
several types
of psychopathology. Likewise, McLaughlin, Sheridan, and Lambert (2014) proposed that
deprivation
and threat are distinct pathways to psychopathology through known brain circuits. Teicher
and
Samson (2016) recently reviewed evidence for an even greater level of specificity, suggesting
that different forms of abuse can have specific effects on targeted brain regions.
. Cumulative risk in this issue is studied prospectively in a long-term longitudinal study.
Investigations involving inadequate input are
represented by studies of the effects of social neglect and the deprivation involved in
institutional rearing.
The traumas studied in these investigations involve all types of harmful input – witnessing
violence, war
trauma, physical abuse, and sexual abuse. Assessments in the papers that follow include
structural
and functional imaging, event-related potentials, neurocognitive assessments, laboratory
observational
paradigms, structured psychiatric interviews, as well as parent and self-report ratings.
In an important and innovative study of cumulative risk, Reuben et al. (this issue) examined
adverse
childhood experiences in the well-known Dunedin Study sample. They compared
associations of
adverse childhood experiences (ACEs) to physical, cognitive, mental, and social health
outcomes in
adults. This unique longitudinal sample allowed them to compare adverse childhood
experiences assessed both prospectively and retrospectively, overcoming the most important
limitation of the well-known ACE study, which was retrospective

ABUSE AND NEGLECT

What is child abuse and neglect?

Child abuse isn't just about black eyes. While physical abuse is shocking due to the marks it
leaves, not all signs of child abuse are as obvious. Ignoring a child's needs, putting them in
unsupervised, dangerous situations, exposing them to sexual situations, or making them feel
worthless or stupid are also forms of child abuse and neglect—and they can leave deep,
lasting scars on kids.

Regardless of the type of abuse, the result is serious emotional harm. But there is help
available. If you suspect a child is suffering from abuse or neglect, it's important to speak out.
By catching the problem as early as possible, both the child and the abuser can get the help
they need.

Effects of child abuse and neglect

All types of abuse and neglect leave lasting scars. Some of these scars might be physical, but
emotional scarring has long lasting effects throughout life, damaging a child's sense of self,
their future relationships, and ability to function at home, work and school.
The effects of abuse and neglect on a child include:

Lack of trust and relationship difficulties. If you can't trust your parents, who can you trust?
Without this base, it is very difficult to learn to trust people or know who is trustworthy. This
can lead to difficulty maintaining relationships in adulthood. It can also lead to unhealthy
relationships because the adult doesn't know what a good relationship is.
Core feelings of being “worthless.” If you've been told over and over again as a child that you
are stupid or no good, it is very difficult to overcome these core feelings. As they grow up,
abused kids may neglect their education or settle for low-paying jobs because they don't
believe they are worth more. Sexual abuse survivors, with the stigma and shame surrounding
the abuse, often struggle with a feeling of being damaged.
Trouble regulating emotions. Abused children cannot express emotions safely. As a result,
the emotions get stuffed down, coming out in unexpected ways. Adult survivors of child
abuse can struggle with unexplained anxiety, depression, or anger. They may turn to alcohol
or drugs to numb out the painful feelings.

Recognizing the different types of child abuse

Abusive behavior comes in many forms, but the common denominator is the emotional effect
on the child. Whether the abuse is a slap, a harsh comment, stony silence, or not knowing if
there will be dinner on the table, the end result is a child that feels unsafe, uncared for, and
alone.

Emotional abuse

Contrary to some people's beliefs, words can hurt and emotional abuse can severely damage a
child's mental health or social development. Examples of emotional abuse include:

 Constant belittling, shaming, and humiliating.

 Calling names and making negative comparisons to others.
 Telling a child they're “no good,” “worthless,” “bad,” or “a mistake.”
 Frequent yelling, threatening, or bullying.
 Ignoring or rejecting a child as punishment, giving them the silent treatment.
 Limiting physical contact with a child—no hugs, kisses, or other signs of affection.
 Exposing a child to violence against others, whether it is against the other parent, a
sibling, or even a pet.
Child neglect

Neglect—a very common type of child abuse—is a pattern of failing to provide for a child's
basic needs, which include adequate food, clothing, hygiene, or supervision.

Child neglect is not always easy to spot. Sometimes, a parent might become physically or
mentally unable to care for a child, such as in cases of serious illness or injury, or untreated
depression or anxiety. Other times, alcohol or drug abuse may seriously impair judgment and
the ability to keep a child safe.
Physical abuse

This involves physical harm or injury to the child. It may be the result of a deliberate attempt
to hurt the child or excessive physical punishment. Many physically abusive parents insist
that their actions are simply forms of discipline—ways to make children learn to behave. But
there is a big difference between using physical punishment to discipline and physical abuse.

With physical abuse, the following elements are present:

 Unpredictability. The child never knows what is going to set the parent off. There are
no clear boundaries or rules. The child is constantly walking on eggshells, never sure
what behavior will trigger a physical assault.
 Lashing out in anger. Abusive parents act out of anger and the desire to assert control,
not the motivation to lovingly teach the child. The angrier the parent, the more intense
the abuse.
 Using fear to control behavior. Abusive parents may believe that their children need
to fear them in order to behave, so they use physical abuse to “keep their child in
line.” However, what children are really learning is how to avoid being hit, not how to
behave or grow as individuals.
Sexual abuse

 Child sexual abuse is an especially complicated form of abuse because of its layers of
guilt and shame. It's important to recognize that sexual abuse doesn't always involve
body contact. Exposing a child to sexual situations or material is sexually abusive,
whether or not touching is involved. Sexually abused children are often tormented by
shame and guilt. They may feel that they are responsible for the abuse or somehow
brought it upon themselves. This can lead to self-loathing and sexual and relationship
problems as they grow older.
 The shame of sexual abuse makes it very difficult for children to come forward. They
may worry that others won't believe them, will be angry with them, or that it will split
their family apart. Because of these difficulties, false accusations of sexual abuse are
not common,

Warning signs of child abuse and neglect

The warning signs that a child is being abused or neglected can vary according to the type of
abuse inflicted.

Warning signs of emotional abuse

The child may:

 Be excessively withdrawn, fearful, or anxious about doing something wrong.

 Show extremes in behavior (extremely compliant, demanding, passive, aggressive).
 Not seem to be attached to the parent or caregiver.
 Act either inappropriately adult (taking care of other children) or inappropriately
infantile (thumb-sucking, throwing tantrums).
Warning signs of physical abuse

The child may:

 Have frequent injuries or unexplained bruises, welts, or cuts. Their injuries may
appear to have a pattern such as marks from a hand or belt.
 Be always watchful and “on alert,” as if waiting for something bad to happen.
 Shy away from touch, flinch at sudden movements, or seem afraid to go home.
 Wear inappropriate clothing to cover up injuries, such as long-sleeved shirts on hot
days.

Warning signs of child neglect

The child may:

Wear ill-fitting, filthy, or inappropriate clothing for the weather.

Have consistently bad hygiene (unbathed, matted and unwashed hair, noticeable body
odor).
 Have untreated illnesses and physical injuries.
 Be frequently unsupervised or left alone or allowed to play in unsafe situations.
 Be frequently late or missing from school.
Warning signs of sexual abuse in children

The child may:

 Have trouble walking or sitting.

 Display knowledge of sexual acts inappropriate for their age, or even exhibit
seductive behavior.

 Make strong efforts to avoid a specific person, without an obvious reason.

 Not want to change clothes in front of others or participate in physical activities.
 Have an STD or pregnancy, especially if they're under the age of 14.
 Try to run away from home.

Risk factors for child abuse and neglect

While abuse and neglect occurs in all types of families, children are at a much greater risk in
certain situations.

Domestic violence. Even if the abused parent does their best to protect their
children, domestic violence is still extremely damaging. Getting out is the best way to help
your children.

Alcohol and drug abuse. Parents who are drunk or high may be unable to care for their
children, make good parenting decisions, or control often-dangerous impulses. Substance
abuse can also lead to physical abuse.
Untreated mental illness. Parents who are suffering from depression, an anxiety
disorder, bipolar disorder, or another mental illness may have trouble taking care of
themselves, much less their children. A mentally ill or traumatized parent may be distant and
withdrawn from their children, or quick to anger without understanding why. Treatment for
the caregiver means better care for the children.
Lack of parenting skills. Some caregivers never learned the skills necessary for good
parenting. Teen parents, for example, might have unrealistic expectations about how much
care babies and small children need. Or parents who were themselves victims of child abuse
may only know how to raise their children the way they were raised. Parenting classes,
therapy, and caregiver support groups are great resources for learning better parenting skills.
Stress and lack of support. Parenting can be a very time-intensive, stressful job, especially if
you're raising children without support from family and friends, or you're dealing with
relationship problems or financial difficulties. Caring for a child with a disability, special
needs, or difficult behaviors is also a challenge. It's important to get the support you need, so
you are emotionally and physically able to support your child.

How to help an abused or neglected child

What should you do if you suspect that a child is being abused? Or if a child confides in you?
It's normal to feel a little overwhelmed and confused. Child abuse is a difficult subject that
can be hard to accept and even harder to talk about—for both you and the child. When talking
with an abused child, the best way to encourage them is to show calm reassurance and
unconditional support. If you're having trouble finding the words, let your actions speak for
you.

Avoid denial and remain calm. A common reaction to news as unpleasant and shocking as
child abuse is denial. However, if you display denial to a child, or show shock or disgust at
what they are saying, the child may be afraid to continue and will shut down. As hard as it
may be, remain as calm and reassuring as you can.

Don't interrogate. Let the child explain to you in their own words what happened, but don't
interrogate the child or ask leading questions. This may confuse and fluster the child and
make it harder for them to continue their story.

Reassure the child that they did nothing wrong. It takes a lot for a child to come forward
about abuse. Reassure them that you take what they said seriously, and that it is not their
fault.

Safety comes first. If you feel that your safety or the safety of the child would be threatened if
you tried to intervene, leave it to the professionals. You may be able to provide more support
later.

Marital Discord and Divorce

Marital discord: Marital discord references a state of marital dissatisfaction that may include
measures of standing conflict, feeling estranged, or loss of commitment (Beach, 2010).
Marital quality is often measured either by the Marital Satisfaction Inventory (MSI) or the
Dyadic Adjustment Scale (DAS). The MSI is a self-report measure that results in a score of
couples’ interactions such as affective communication, sexual dissatisfaction, aggression,
disagreement about finances, and problem-solving communication (Snyder & Costin, 1994).
DAS is also a self-report measure assessing couples’ compatibility on issues such as life
philosophy, finances, household tasks, sex relations, career decisions, and religion. It also
measures intent for the relationship to succeed, sex activity, positive interactions, and
incidence of argument (Prouty, Markowski, Barnes, 2000).

Marital dissolution: Marital dissolution is defined as the physical and legal separation of a
married couple.

RESOLVING CONFLICT BETWEEN PARENTS

Parental conflict before, during and after a divorce has harmful effects on children (1).
However, there is a clear consensus among researchers and clinicians that the child’s best
interests are served by maintaining a relationship with both parents, except in cases of severe
marital conflict and abuse (2). Unfortunately, many fathers who face a bitter relationship with
their former partner simply drop out of their children’s lives. If that happens, children may
suffer the double disadvantages of the psychological loss of a parent, and the loss of financial
support. A key challenge that faces divorcing parents is, therefore, how to establish a new co-
parental relationship with a former marital partner. Experts advise parents to set aside their
own negative feelings, and develop a collaborative and cooperative business-type relationship
with the person who they may consider to be the source of great personal distress. In recent
years, there has been growing recognition of the benefits for children and parents of
alternatives to the adversarial legal system in the resolution of disputes about shared
parenting after divorce; alternatives include mediation and assessment services

Parents often seek the advice of health care professionals about the timing of their divorce,
and wonder whether there is an age at which children are immune to the negative effects of
parental separation. Children of all ages are sensitive to parental divorce; their reactions are
expressed in ways consistent with their developmental stage (2). Moreover, children are
sensitive to all parental conflict, including suppressed, polite hostility (4). Parents should be
reassured by the research finding that children are also sensitive to the resolution of conflict.
Even very young children are aware that a dispute has been resolved. Furthermore, if children
have the opportunity to witness the resolution of problems, they also benefit by learning
important problem-solving skills. Consequently, the parents’ dilemma is not the timing of the
divorce, but how to resolve conflict with their partner whether they stay together or
separate. Mental health professionals play an important role in helping parents develop a new
co-parental relationship. Parents must learn to establish new boundaries between themselves
and the person with whom they were intimate. They must develop effective communication
and problem-solving skills. Children who have experienced their parents’ divorce display a
range of emotional and behavioural reactions in the months following the event. Following
their parents’ separation, children may regress, display anxiety and depressive symptoms,
appear more irritable, demanding and noncompliant, and experience problems in social
relationships and school performance (5). Parents often feel troubled by and unprepared for
their children’s reactions to a separation and divorce. Children need to know that they are not
responsible for the separation, that they are loved by both parents, and that their needs will be
met. Children’s expression of distress differs from that of adults. For example, compared with
adults, children may be more open to communication through books, workbooks, stories, play
and drawings (6). Parents must achieve a balance between acknowledging and accepting the
expression of negative feelings on the one hand, and providing clear, consistent rules and
structure on the other.

DIFFERENT CUSTODY ARRANGEMENTS

After a separation, parents must decide about their children’s living arrangements and
parental roles. Joint physical custody occurs when both parents share parenting
decisions, and the child lives not more than 60% and not less than 40% of the time with
each parent. Joint legal custody occurs when both parents retain rights to make
parenting decisions; however, the child may live primarily with one parent. Sole legal
custody occurs when one parent loses parental rights to make decisions, but still has
parental obligations to support the child financially. Sole legal custody may be
appropriate if one parent has shown a gross inability to parent or is abusive toward the
other parent. Joint physical custody may present the best or worst of all worlds. It
appears to be most successful when parents have a fundamental respect for one
another, communicate in a clear fashion about their children’s needs, can afford to live
in the same school district, and are able to provide the child with two sets of essentials
so that the child is not burdened by carrying many possessions from home to home.
Joint physical custody may be a nightmare of tense transitions for the child whose
parents have a conflictual relationship. PARENTS’ NEEDS

During the divorce process, adults experience a roller coaster of emotions to which their
children are extremely sensitive. It is crucial that parents avoid overburdening a child
with their own unhappiness or irritability. Furthermore, during the transition period of
separation and divorce, the parenting skills of adults are at a low ebb. Unfortunately, at
a time when children especially need support, warmth and firm, consistent control,
many parents are least equipped to provide it (2). Parents are encouraged to activate
their adult support systems and, if necessary, to seek professional help in their new
parenting roles. Seeing a parent coping well with the challenges of divorce may alleviate
children’s sense of burden or responsibility, and provide an effective model for handling
distress. Problem-solving interventions for parents are effective in helping them cope
with divorce. Children’s groups show some positive effects, but when recovering from
divorce, children take their lead from their parents – if the parents are functioning well,
the child is more likely to do well. Thus, interventions focused uniquely on children may
be of limited usefulness. SHARED PARENTING

Although divorcing partners debate the fairness of how much time children spend with one
parent compared with the other, the quality of the parent-child relationship is more important
than any ratio of time spent with parents. The importance of the child’s relationship with both
parents, and the value of being nurtured by both parents, cannot be overemphasized. Each
parent brings unique qualities to the parent-child relationship, and the child’s life is enriched
by involvement with parents with differing styles, backgrounds and values. The challenge for
divorcing partners is to develop a new relationship that is focused on shared parenting.
Children benefit from the same kind of parenting whether their parents live in one household
or two (ie, they benefit from warmth and structure) (2).

Several strategies can be helpful to parents who adopt a shared parenting role. Children
benefit when there is regular communication between parents that facilitates the exchange of
information regarding the child. For parents who find verbal interaction with one another
difficult, this may take the form of a communication book or e-mail messages. Additionally,
parents are encouraged to view their parenting plans with flexibility by recognizing that their
arrangements will require adaptation and revision as their children grow older and
circumstances change.

Separation

Separation, the removal of children from the caregiver(s) to whom they are attached, has both
positive and negative aspects. From a child protection perspective, separation has several
benefits, the most obvious being the immediate safety of the child. Through this separation,
limits can be established for parental behavior, and the child may get the message that society
will protect him or her, even if the parent will not. Separation also temporarily frees parents
from the burden of child-rearing, allowing them to focus on making the changes necessary
for the child to return home.

Separating a parent and child can also have profoundly negative effects. Even when it is
necessary, research indicates that removing children from their homes interferes with their
development. The more traumatic the separation, the more likely there will be significant
negative developmental consequences.

Repeated separations interfere with the development of healthy attachments and a child's
ability and willingness to enter into intimate relationships in the future. Children who have
suffered traumatic separations from their parents may also display low self-esteem, a general
distrust of others, mood disorders (including depression and anxiety), socio-moral
immaturity, and inadequate social skills. Regressive behavior, such as bedwetting, is a
common response to separation. Cognitive and language delays are also highly correlated
with early traumatic separation.
Social workers in child placement must be continually aware of the magnitude of the changes
children experience when they are removed from their families.

Add

INADEQUETE PARENTING STYLE

our parenting style can affect everything from your child's self-esteem and physical health to
how they relate to others. It's important to ensure your parenting style is supporting healthy
growth and development because the way you interact with your child and how you
discipline them will influence them for the rest of their life. Researchers have identified four
main types of parenting styles:1

 Authoritarian
 Authoritative
 Permissive
 Uninvolved

Each style takes a different approach to raising children, offers different pros and cons, and
can be identified by a number of different characteristics. People often want to know which
parenting style they are using—and which is the best. The truth is that there is no one right
way to parent, but the general parenting style that most experts, including the American
Academy of Pediatrics (AAP), recommend is an authoritative approach.2

Uninvolved parenting — also called neglectful parenting, which obviously carries more
negative connotations — is a style of parenting where parents don’t respond to their child’s
needs or desires beyond the basics of food, clothing, and shelter.

These children receive little guidance, discipline, and nurturing from their parents. And
oftentimes kids are left to raise themselves and make decisions — big and small — on their
own.

It’s a controversial parenting style, and because of this, it’s also easy to pass judgment on
these parents. But whether you’re an uninvolved parent or you know someone who is, it’s
important to remember that this parenting style isn’t always intentional.
The reasons why some parents end up raising their kids this way varies — more on this later.
For now, let’s take a look at some of the characteristics of uninvolved parenting and explore
how this type of parenting can affect children in the long run.

Signs and characteristics of uninvolved parenting

Many parents can identify with being stressed, overworked, and tired. You know what we
mean: when things get out of control, you might brush off your child for a few minutes of
quiet and solitude.

As guilty as you might feel afterwards, these moments aren’t characteristic of uninvolved
parenting. Uninvolved parenting isn’t just a moment of preoccupation with one’s self. Rather,
it’s an ongoing pattern of emotional distance between parent and child.

Signs of an uninvolved parent include the following:

1. Focus on your own problems and desires

Whether it’s work, a social life apart from the kids, or other interests or problems, uninvolved
parents are preoccupied with their own affairs — so much so that they’re unresponsive to the
needs of their children, and make little time for them.

Everything else comes before the kids. And in some instances, parents might outright neglect
or reject their children.

Again, this isn’t always a matter of choosing a night at the club over family game night.
Sometimes, there are issues at play that seem outside of a parent’s control.

2. Lack of an emotional attachment

An emotional connection between parent and child comes naturally for many people. But in
the case of uninvolved parenting, this bond isn’t instinctual or automatic. The parent feels a
disconnect, which severely limits the amount of affection and nurturing they extend to their
child.

3. Lack of interest in child’s activities

Because of a lack of affection, uninvolved parents aren’t interested in their child’s school
work, activities, or events. They might skip their sports games or fail to show up for PTA
meetings.

4. No set rules or expectations for behavior

Uninvolved parents typically lack a discipline style. So unless a child’s behavior affects
them, these parents don’t usually offer any type of correction. They allow the child to act how
they want. And these parents don’t get upset when their child performs poorly in school or
with other activities.

Children require love, attention, and encouragement to thrive. So it’s no surprise that
uninvolved parenting can have a negative effect on a child.

It’s true that kids with uninvolved parents do tend to learn self-reliance and how to take care
of their basic needs at an early age. Still, the drawbacks of this parenting style outweigh the
good.

One major disadvantage of uninvolved parenting is that these children don’t develop an
emotional connection with their uninvolved parent. A lack of affection and attention at a
young age can lead to low self-esteem or emotional neediness in other relationships.

Having an uninvolved parent may even affect a child’s social skills. Noted in background
information for this small 2017 study, some children of uninvolved parents may have
difficulties with social interactions outside the home because uninvolved parents rarely
communicate or engage their children.

The study itself, done in Ghana, Africa, was focused on academic performances of 317
students in homes with varying parenting styles. It concluded that students in authoritarian
homes perform better academically than children of other parenting styles.
Of note, this small study may not be broadly applicable, as parenting styles in different
cultures may lead to different outcomes. Still, children of neglectful parents do have more
challenges regardless of where they are.

Children of uninvolved parents may also lack coping skills. In a 2007 study, researchers
evaluated how different parenting styles affected homesickness in 670 first-year college
students between the ages of 16 and 25.

The study found at those raised by authoritative and permissive parents experienced more
homesickness than those raised by authoritarian and uninvolved parents. But while the two
former groups felt more homesickness, they didn’t express it as much because they had
stronger coping skills.

Yet, the group raised by authoritarian and uninvolved parents who felt less homesickness had
a harder time coping with their feelings. This suggests that being raised in a loving and
nurturing environment (or not) affects how young people adjust to life away from home.

When a child grows up with an emotional detachment from their parent, they may repeat this
parenting style with their own kids. And as a result, they may have the same poor relationship
with their own children.

Authoritarian Parenting

 believe kids should be seen and not heard.

 When it comes to rules, parents believe it's "my way or the highway."
 parents don't take your child's feelings into consideration.

Authoritarian parents believe kids should follow the rules without exception.

Authoritarian parents are famous for saying, "Because I said so," when a child questions the
reasons behind a rule. They are not interested in negotiating and their focus is on obedience.
They also don't allow kids to get involved in problem-solving challenges or obstacles.
Instead, they make the rules and enforce the consequences with little regard for a child's
opinion.2

Authoritarian parents may use punishments instead of discipline. So, rather than teach a child
how to make better choices, they're invested in making kids feel sorry for their mistakes.
Children who grow up with strict authoritarian parents tend to follow rules much of the time.
But, their obedience comes at a price.3
Children of authoritarian parents are at a higher risk of developing self-esteem problems
because their opinions aren't valued.

They may also become hostile or aggressive. Rather than think about how to do things better
in the future, they often focus on the anger they feel toward their parents or themselves for
not living up to parental expectations. Since authoritarian parents are often strict, their
children may grow to become good liars in an effort to avoid punishment.

Authoritative Parentng

Authoritative parents have rules and they use consequences, but they also take their
children's opinions into account. They validate their children's feelings, while also making it
clear that the adults are ultimately in charge. This is the approach backed by research and
experts as the most developmentally healthy and effective parenting style.1

Authoritative parents invest time and energy into preventing behavior problems before they
start. They also use positive discipline strategies to reinforce positive behavior,
like praise and reward systems.

Researchers have found kids who have authoritative parents are most likely to become
responsible adults who feel comfortable self-advocating and expressing their opinions and
feelings.2 Children raised with authoritative discipline tend to be happy and successful.
They're also more likely to be good at making sound decisions and evaluating safety risks on
their own.

Permissive Parenting

 set rules but rarely enforce them.

 don't give out consequences very often.
 think the child will learn best with little interference from the parents.

Permissive parents are lenient. They often only step in when there's a serious problem.

They're quite forgiving and they adopt an attitude of "kids will be kids." When they do use
consequences, they may not make those consequences stick. They might give privileges back
if a child begs or they may allow a child to get out of time-out early if they promise to be
good.

Permissive parents usually take on more of a friend role than a parent role. They often
encourage their children to talk with them about their problems, but they usually don't put
much effort into discouraging poor choices or bad behavior.4

Kids who grow up with permissive parents are more likely to struggle academically.

They may exhibit more behavioral problems as they don't appreciate authority and rules.
They often have low self-esteem and may report a lot of sadness.
They're also at a higher risk for health problems, like obesity, because permissive parents
struggle to limit unhealthy food intake or promote regular exercise or healthy sleep habits.
They are even more likely to have dental cavities because permissive parents often don't
enforce good habits, like ensuring a child brushes their teeth.4

ATTACHMENT

Attachment theory focuses on relationships and bonds (particularly long-term) between

people, including those between a parent and child and between romantic partners. It is a
psychological explanation for the emotional bonds and relationships between people. This
theory suggests that people are born with a need to forge bonds with caregivers as children.
These early bonds may continue to have an influence on attachments throughout life.

History of the Attachment Theory

British psychologist John Bowlby was the first attachment theorist. He described attachment
as a "lasting psychological connectedness between human beings."1

Bowlby was interested in understanding the anxiety and distress that children experience
when separated from their primary caregivers.

Thinkers like Freud suggested that infants become attached to the source of pleasure. Infants,
who are in the oral stage of development, become attached to their mothers because she
fulfills their oral needs.

Some of the earliest behavioral theories suggested that attachment was simply a learned
behavior. These theories proposed that attachment was merely the result of the feeding
relationship between the child and the caregiver. Because the caregiver feeds the child and
provides nourishment, the child becomes attached.

Bowlby observed that feedings did not diminish separation anxiety.2

 Instead, he found that attachment was characterized by clear behavioral and motivation
patterns. When children are frightened, they seek proximity from their primary caregiver in
order to receive both comfort and care.

Understanding Attachment

Attachment is an emotional bond with another person. Bowlby believed that the earliest
bonds formed by children with their caregivers have a tremendous impact that continues
throughout life. He suggested that attachment also serves to keep the infant close to the
mother, thus improving the child's chances of survival.

Bowlby viewed attachment as a product of evolutionary processes.3 While the behavioral

theories of attachment suggested that attachment was a learned process, Bowlby and others
proposed that children are born with an innate drive to form attachments with caregivers.

Throughout history, children who maintained proximity to an attachment figure were more
likely to receive comfort and protection, and therefore more likely to survive to adulthood.
Through the process of natural selection, a motivational system designed to regulate
attachment emerged.

The central theme of attachment theory is that primary caregivers who are available and
responsive to an infant's needs allow the child to develop a sense of security. The infant
learns that the caregiver is dependable, which creates a secure base for the child to then
explore the world.

So what determines successful attachment? Behaviorists suggest that it was food that led to
forming this attachment behavior, but Bowlby and others demonstrated that nurturance and
responsiveness were the primary determinants of attachment.

Ainsworth's "Strange Situation"

In her research in the 1970s, psychologist Mary Ainsworth expanded greatly upon Bowlby's
original work. Her groundbreaking "strange situation" study revealed the profound effects of
attachment on behavior. In the study, researchers observed children between the ages of 12
and 18 months as they responded to a situation in which they were briefly left alone and then
reunited with their mothers.4

Based on the responses the researchers observed, Ainsworth described three major styles of
attachment: secure attachment, ambivalent-insecure attachment, and avoidant-insecure
attachment. Later, researchers Main and Solomon (1986) added a fourth attachment style
called disorganized-insecure attachment based on their own research.5

A number of studies since that time have supported Ainsworth's attachment styles and have
indicated that attachment styles also have an impact on behaviors later in life.
How to Be Less Insecure
Maternal Deprivation Studies
Harry Harlow's infamous studies on maternal deprivation and social isolation during the
1950s and 1960s also explored early bonds. In a series of experiments, Harlow demonstrated
how such bonds emerge and the powerful impact they have on behavior and functioning.6
In one version of his experiment, newborn rhesus monkeys were separated from their birth
mothers and reared by surrogate mothers. The infant monkeys were placed in cages with two
wire-monkey mothers. One of the wire monkeys held a bottle from which the infant monkey
could obtain nourishment, while the other wire monkey was covered with a soft terry cloth.

While the infant monkeys would go to the wire mother to obtain food, they spent most of
their days with the soft cloth mother. When frightened, the baby monkeys would turn to their
cloth-covered mother for comfort and security.

Harlow's work also demonstrated that early attachments were the result of receiving comfort
and care from a caregiver rather than simply the result of being fed.

n her 1982 article on parent-child attachment, published in the journal Social Casework, Peg
Hess states that three conditions must be present for optimal parent-child attachment to occur:
continuity, stability, and mutuality. Continuity involves the caregiver's constancy and
repetition of the parent-child interactions. Stability requires a safe environment where the
parent and child can engage in the bonding process. Mutuality refers to the interactions
between the parent and child that reinforce their importance to each other.

Research has demonstrated that two primary parenting behaviors are most important in
developing an infant's attachment to a caregiver. Optimal attachment occurs when a caregiver
recognizes and responds to the infant's signals and cues, meeting the infant's physical and
emotional needs; and when the caregiver regularly engages the child in lively social
interactions.

Studies of infants raised in institutional settings suggest that neither behavior alone is
sufficient for secure attachment. For example, one study found that institutionalized infants
failed to form strong attachments to caregivers who readily met their physical needs but did
not engage them in social interaction. Conversely, social interactions alone are not enough:
infants often form social attachments to brothers, sisters, fathers, and grandparents who
engage them in pleasurable social activity. Yet, when they are tired, hungry, or distressed,
they often cannot be comforted by anyone other than the caregiver who has historically
recognized and responded to their signals of physical and emotional need (Caye, et al. 1996).

The Stages of Attachment

Researchers Rudolph Schaffer and Peggy Emerson analyzed the number of attachment
relationships that infants form in a longitudinal study with 60 infants. The infants were
observed every four weeks during the first year of life, and then once again at 18 months.

Based on their observations, Schaffer and Emerson outlined four distinct phases of
attachment, including:7

Pre-Attachment Stage

From birth to 3 months, infants do not show any particular attachment to a specific caregiver.
The infant's signals, such as crying and fussing, naturally attract the attention of the
caregiver and the baby's positive responses encourage the caregiver to remain close.
Indiscriminate Attachment

Between 6 weeks of age to 7 months, infants begin to show preferences for primary and
secondary caregivers. Infants develop trust that the caregiver will respond to their needs.
While they still accept care from others, infants start distinguishing between familiar and
unfamiliar people, responding more positively to the primary caregiver.

Discriminate Attachment

At this point, from about 7 to 11 months of age, infants show a strong attachment and
preference for one specific individual. They will protest when separated from the primary
attachment figure (separation anxiety), and begin to display anxiety around strangers
(stranger anxiety).

Multiple Attachments

After approximately 9 months of age, children begin to form strong emotional bonds with
other caregivers beyond the primary attachment figure. This often includes a second parent,
older siblings, and grandparents.

Factors That Influence Attachment

While this process may seem straightforward, there are some factors that can influence how
and when attachments develop, including:

 Opportunity for attachment: Children who do not have a primary care figure, such
as those raised in orphanages, may fail to develop the sense of trust needed to form an
attachment.
 Quality caregiving: When caregivers respond quickly and consistently, children learn
that they can depend on the people who are responsible for their care, which is the
essential foundation for attachment. This is a vital factor.

Attachment Styles

There are four patterns of attachment, including:8

 Ambivalent attachment: These children become very distressed when a parent

leaves. Ambivalent attachment style is considered uncommon, affecting an estimated
7% to 15% of U.S. children. As a result of poor parental availability, these children
cannot depend on their primary caregiver to be there when they need them.
 Avoidant attachment: Children with an avoidant attachment tend to avoid parents or
caregivers, showing no preference between a caregiver and a complete stranger. This
attachment style might be a result of abusive or neglectful caregivers. Children who
are punished for relying on a caregiver will learn to avoid seeking help in the future.
 Disorganized attachment: These children display a confusing mix of behavior,
seeming disoriented, dazed, or confused. They may avoid or resist the parent. Lack of
a clear attachment pattern is likely linked to inconsistent caregiver behavior. In such
cases, parents may serve as both a source of comfort and fear, leading to disorganized
behavior.
  Secure attachment: Children who can depend on their caregivers show distress when
separated and joy when reunited. Although the child may be upset, they feel assured
that the caregiver will return. When frightened, securely attached children are
comfortable seeking reassurance from caregivers. This is the most common
attachment style.

The Lasting Impact of Early Attachment

Children who are securely attached as infants tend to develop stronger self-esteem and better
self-reliance as they grow older. These children also tend to be more independent, perform
better in school, have successful social relationships, and experience less depression and
anxiety.
Research suggests that failure to form secure attachments early in life can have a negative
impact on behavior in later childhood and throughout life.9
Children diagnosed with oppositional defiant disorder(ODD), conduct disorder (CD), or post-
traumatic stress disorder (PTSD) frequently display attachment problems, possibly due to
early abuse, neglect, or trauma. Children adopted after the age of 6 months may have a higher
risk of attachment problems.
Attachment Disorders

In some cases, children may also develop attachment disorders. There are two attachment
disorders that may occur: reactive attachment disorder (RAD) and disinhibited social
engagement disorder (DSED).

 Reactive attachment disorder occurs when children do not form healthy bonds with
caregivers. This is often the result of early childhood neglect or abuse and results in
problems with emotional management and patterns of withdrawal from caregivers.
 Disinhibited social engagement disorderaffects a child's ability to form bonds with
others and often results from trauma, abandonment, abuse, or neglect. It is
characterized by a lack of inhibition around strangers, often leading to excessively
familiar behaviors around people they don't know and a lack of social boundaries.

Adult Attachments

Although attachment styles displayed in adulthood are not necessarily the same as those seen
in infancy, early attachments can have a serious impact on later relationships. Adults who
were securely attached in childhood tend to have good self-esteem, strong romantic
relationships, and the ability to self-disclose to others.

COMMUNICATION STYLE

The way we communicate has a huge impact on how well we are able to form and
maintain relationships, get what we want or need, avoid conflict, and solve
problems. Learning to recognise and understand different communication styles is
key in developing effective communication skills.

There are four major communication styles – assertive, aggressive, passive, and
passive-aggressive. Often, people transition between communication styles
depending on the context of their interaction, the person or people that they are
interacting with, or other internal or external factors like mood or distractions. That
said, people tend to have a ‘default’ communication style that they revert to when
feeling uncomfortable or unprepared.

Assertive communication

An assertive communication style is widely accepted as the most effective

communication style, as it focuses on the needs of both the person communicating,
and the person that they are communicating with. Assertive communicators value
themselves, their time, their rights and needs – as well as those of others. The
motivation behind the assertive communicator is to express their own needs or
desires, while also respecting the needs and desires of the other person.

When people communicate assertively, they are straight forward in expressing their
opinion and advocate for their rights without compromising the rights of anyone
else. You might recognise an assertive communicator as someone who states facts
(without labels or judgments), expresses themselves directly and honestly, checks
on others’ understanding and interpretations, and is confident, calm, firm, fair,
consistent, and attentive. Assertive communicators are also open to criticism,
negotiation or bargaining.

People on the receiving end of an assertive communication style feel that they can
trust the assertive communicator at their word, that they know where they stand,
that they have been listened to, considered, and respected.

Aggressive communication

An aggressive communication style is focused on the needs of the person

communicating, and often disregards the needs of the person being communicated
to. This type of communication is often driven by beliefs such as “I’m right and you
are wrong”, “I’ll get what I want no matter what” and “My needs are more
important than yours”.

This communication style is often seen as threatening, bossy or condescending. You

might recognise an aggressive communicator as someone who seems close minded,
isn’t an effective listener, interrupts or speaks over the others, puts others down, or
uses threats or attacks to get what they want.

People on the receiving end of aggressive communication often feel defensive,

humiliated, hurt, afraid, disrespected, and can resort to fighting back, being
resistant or defiant, alienating the aggressor, or becoming compliant but resentful.

Passive communication

A passive communication style is focused on the needs of the other, rather than the
needs of the person communicating. This type of communication can be driven by
beliefs such as “You are more important than me”, “I shouldn’t say what I really
think or feel” or “I should just keep the peace”. This communication style is driven
by the desire to please others, and avoid conflict.
 A passive communicator often acts indifferently or submits to others desires, rather
than expressing their thoughts and feelings. You might recognise a passive
communicator as someone who struggles to take responsibility for decisions, agrees
or does what others want without question, avoids confrontation, speaks softly or
apologetically, doesn’t express their feelings, speaks indirectly, or doesn’t speak up.

People on the receiving end of passive communication often feel frustrated,

confused about what the communicator wants, or that they can take advantage of the
passive communicator.

Passive-aggressive communication

A passive-aggressive communication style appears passive on the surface, but is

also characterised by the communicator acting out their needs in indirect ways.
This type of communication is driven by beliefs such as “I can’t say what I really
think, but I can show you” or “I’ll please you, but I will get back at you”.

Passive-aggressive communicators have difficulty acknowledging and expressing

their anger, which leads to them feeling stuck, resentful, and unable to directly
address their needs or confront conflict. By using ‘behind the scenes’ ways to deal
with feelings of powerlessness, passive-aggressive communicators often sabotage
themselves when they confuse others with their unclear intentions. You might
recognise a passive-aggressive communicator as someone whose expressions don’t
match their emotions (for example, smiles when they are angry), is indirectly
aggressive, sarcastic, unreliable, patronising, ‘two-faced’, spreads rumours, gives
the ‘silent treatment’, or mutters to themselves rather than confronting another
person.

People on the receiving end of passive-aggressive communication are frequently left

feeling confused, angry, hurt, or resentful.

The Submissive Style

People who use this style are the ones looking to please other people and avoid any conflicts.
People with this type of communication will put the needs of other before theirs because they
see other people needs as being more important than theirs. They will not contribute much
because they don’t see it as being good enough as that of other people because they think the
other people have more rights than them.
Using this method will leave you feeling inferior and you will have a hard time with your
colleagues and friends. Being a doormat is never the best option and harmful to self-esteem.
People using submissive communication style always feel apologetic and try their best to
avoid confrontation. They will yield to other people’s preferences and are not able to express
their feelings and desires.
They tend to balm others for events and will always feel like they are the victim. They will
also find it hard to take responsibility or make decisions.
The other person on the receiving end will feel guilty, frustrated, and exasperated. They will
see this as an opportunity to take advantage of you and again resentment can build distancing
you from others.

The Manipulative Style

This style is scheming, calculating, and shrewd. People who use this style are very skilled at
controlling or influencing other for their own advantage. They have spoken words that hide
underlying messages, and the other person doesn’t know what it is. Manipulating can seem
like an effective method to get your way, but it comes at an expense. People who do this
don’t have regard for other people and are focused on what they are going to get in the end.
These types of people don’t ask directly for their needs to be met, they guilt other people.
They can even employ artificial tears to make it look even more real. They use “hang dog”
expression, making it much harder to say no to them. Their voice is envious, patronizing,
high pitch, and ingratiating.
People on the receiving end will feel guilt and be ready to help them in any way they can.
They can start to develop feelings of frustrations and resentfulness, and can end up getting
annoyed, angry, or irritated. It is hard to know where manipulative people stand, making it
harder to work with them.

Direct
This is a style where the speaker doesn’t mask the message he wants to pass across. This
involves the use of clear language that can be easily understood by the other person. There
are times when the receiving party doesn’t want to hear something, but using a direct style
will mean providing them with all the information but might be received in a more harsh
way. It is much easier to know where a person stands when they use direct communication.
The culture of the person can sometimes determine the right style to use in the situation.
The person on the receiving end will be able to know what you are saying without having to
beat around the bush. It is also a good style to use when there is a limited time.

Indirect
This is the opposite of direct communication. People employing this style tend to mask their
intentions and needs. It is hard to know what they are looking to achieve. It can be hard for a
person decipher what you are trying to communicate, especially if they are not accustomed to
a particular group or culture. This can sometimes employ the use of facial expressions or
subtle signs. If say you don’t approve a certain habit by a co-worker, you may emit loud
exasperated sighs or glare at the person whenever they do it. The person on the receiving end
may not necessarily understand what is wrong and might end up thinking that you don’t like
them for no particular reason. This can cause a lot of problems especially if you are supposed
to work on something together.

Expressed Emotion as a Precipitant of Relapse in Psychological Disorders

One of the main contributors to relapse in psychological disorders is expressed emotion.

Expressed emotion is the critical, hostile, and emotionally over-involved attitude that
relatives have toward a family member with a disorder. The expressed emotion can be high or
low, which is decided by a taped interview known as the Camberwell Family Interview. This
interview is a way to watch verbal and nonverbal answers to make an accurate assessment.
High expressed emotion involves more criticism, hostility, and emotional over-involvement
than low expressed emotion. Family members high in expressed emotion cause relapse in
psychological disorders such as schizophrenia, alcoholism, children with learning disabilities,
and bipolar disorder. The stress from negative criticism and pity becomes a burden on the
person with a disorder, and the only way to cope is relapse.

Defining Expressed Emotion

Expressed emotion is a huge factor during the recovery process of those diagnosed with
psychological illnesses. The three attitudes pertaining to expressed emotion are known as
hostile, critical, and emotional over-involvement. These attitudes of the relatives determine
the direction of the illness after treatment. The relatives influence the outcome of the disorder
through negative comments and nonverbal actions. These particular interactions between
family members that are dealing with a patient with a psychological disorder are stressful on
the recovering patient. The stress from the family for the patient to recover and end certain
behaviors causes the person a relapse in their illness. They do not know what else to do
during this sensitive time of recovery because of the criticism and pity from others. This
negativity from loved ones does not help the family member to improve the state of their
health (Vaughn & Leff, 1976).

Hostility
The hostile attitudes of expressed emotion are negative toward the person with the disorder.
The family members put blame on this person because of the disorder. The family perceives
the person as the one who is in control of the course of the illness. The relatives feel that the
family member is being selfish by choosing not to get better since the illness is an internal
conflict. The patient is held accountable for any kind of negative incident that occurs within
the family and is constantly blamed for the problems of the family. They have a hard time
problem solving within the family because the answer to most problems is settled with the
disorder being the cause (Brewin, MacCarthy, Duda, & Vaughn, 1991).
Criticalness
The critical attitudes of expressed emotion are combinations of hostile and emotional over-
involvement. The family members are more open to view other aspects that contribute to the
mental illness and the behavior. These attitudes are more open minded than the previous
because they view more than one cause of the disorder (Brewin et al., 1991). However, there
is still negative criticism even though other contributions are viewed and accepted by the
relatives. Critical expressed emotion from siblings and parents are the cause of future and
increasing problems for the patient. Parents who are critical influence their children to be the
same way towards the disorder (Bullock, Bank, & Buraston, 2002).
Emotional Over-Involvement
Contrarily, relatives may express their opinion on the mental illness with emotional over-
involvement. The family members blame themselves for everything instead of the patient.
They feel that everything is their fault and become over involved with the one who has the
illness. Any negative occurrence is felt to be their own fault not because of the disorder itself;
they feel the disorder is not in the control of the patient themselves. The attitude shows that
the relative is open minded about the illness but results in the relative becoming too involved
because there is a feeling of pity toward the family member. Emotional over-involvement
demonstrates a different side compared to hostile and critical attitudes but is still similar with
the negative affect that causes a relapse. The relative becomes so overbearing that the patient
can no longer live with this kind of stress from pity, and falls back into their illness as a way
cope (Lopez et al., 2004).

Expressed emotion is a measure of how well relatives of a psychological patient express their
attitude towards them while they are not present (Hooley & Hoffman, 1999). In order to
measure this expressed emotion, the family is interviewed to carefully watch their
expressions and comments while answering questions. This interview is known as the
Camberwell Family Interview. The family is taped so that the right type of expressed emotion
is carefully concluded by someone that has training in coding the attitude being expressed.
The tape is watched closely, particularly to see how critical the remarks are towards the
recovery process and anything having to do with the disorder of the patient. There are two
outcomes of the opinion of the relative: high expressed emotion or low expressed emotion.
This is determined by the amount of critical comments made by the relative. High Expressed
emotion is when the relative makes six or more critical comments during the interview. Low
expressed emotion is considered to be less than six critical (Hooley & Hiller, 2000). Those
who have high expressed emotion tend to be more negative than the ones who are low. The
interview helps to find out if the environment that the patient will live in after rehabilitation
might contribute to a relapse.

Measuring Expressed Emotion

There is a scale that is used in the Camberwell Family Interview of the family to categorize.
The three major expressed emotion scales are critical, hostility, and emotional over-
involvement that are used to determine whether the expressed emotion is high or low (Hooley
& Hoffman 1999). All of the scales are taken into consideration while watching the tape of
the relatives that were interviewed. The answers and reactions of the family members are
carefully observed. Those in the interview with high expressed emotion were considered very
critical and not very tolerant of the feelings of the patient (Hooley, 1986). This attitude comes
across too strong for someone who is trying to make progress in an illness. The person with
the illness now has to deal with their own sickness and the criticism from those needed for
support through these tough times.
High Expressed Emotion
Once the taped is watched and carefully analyzed, the type of expressed emotion is decided.
Those who are decided to have high expressed emotion are very critical and hostile. They do
not know any other way to help support the family member because they feel like they are
helping. They feel that the illness is internal and can be controlled by this person. The only
way they feel that the person will change their behavior is through criticism which actually
causes the relapse. (Wendel, Miklowitz, Richards, & George, 2000). Those with high
expressed emotion also criticize behaviors that do not relate to the psychological disorder but
more to the unique person. A person's attitude toward a person, especially when they are very
critical, takes a long time to change their way of thinking. High expressed emotion is more
likely to cause a relapse than low expressed emotion because of the aggressive verbal
criticisms they made (Weisman, Nuechlerlein, Goldstein, & Snyder, 1998).
Low Expressed Emotion
Low expressed emotion differs from high expressed emotion in that the relatives are more
conservative with their criticism. Relatives feel that the family member does not have control
over the disorder and sympathize with them. This is because there is also more information
about disorders in which some relatives have more knowledge of the illness than others,
which makes them more understanding and less critical. Families also vary because some do
not have to put up with difficult family members that have a mental disorder. These are some
reasons for expressed emotion to be low instead of high. The family is more educated and
accepting of the disorder than those of high expressed emotion (Weisman et al., 1998). The
disorder is accepted to be external, not internal and out of the control of the patient. The
relatives may have some criticism about the disorder and the behavior, but they do not always
express it towards them (Wendel et al., 2000). Low expressed emotion is a different stress
from high expressed emotion because it is less stress toward the patient.

There is another way to measure the amount of expressed emotion that is in a household, and
it is taken from the point of view of the patient. The perception of everyone around them
shows how they feel about what is thought of them and the disorder they have. A study was
conducted with patients who have schizophrenia that will live in the same house as their
parents. The patients would rate their parents according to a scale of care and protection.
Those who rated their parents with high protection or low care were found to have a harder
time with the illness if there too much contact with their parents (Cutting & Docherty, 2000).
The parents come across too strong or not strong enough for those who are dealing with
schizophrenia. This causes the child to think that the parent does not care about their
independence. They feel that the parent does not trust their judgments on making the right
decisions. This sort of attitude from a parent causes them to relapse and have trouble
improving their health.

Parents can cause their child to relapse because of their behavior toward the child. Those who
blame themselves for their child's illness are higher in emotional over-involvement,
commonly found in females (Peterson & Docherty, 2004). They become too involved with
their child because they feel like it is their fault that the illness exists. This type of emotion is
overwhelming for someone who is trying to improve their life. The parent shows a lot of
concern toward the child, but it does not necessarily mean that this is productive for them.
The over involvement causes the child to feel trapped because they feel like they can not do
anything independently. This adds onto the entrapment they have with the psychological
disorder that they are trying to handle. The overbearing parents make the child feel helpless
because they do not have control; therefore, they fall back into bad habits of their illnesses.
Illnesses such as bulimia, anorexia, alcoholism, schizophrenia, and others are triggered by
these types of behaviors from parents and other relatives. The child may feel like the outsider
of their family because of the excessive attention they receive as a result of their disorder.
The behavior of everyone around them influences their decision to relapse or progress.

Precipitating Relapse

Alcoholism
There are many psychological disorders that everyone has heard of through readings,
experiences with the disorders, or interactions with people diagnosed with one. A common
disorder is alcoholism, is the addiction to and consumption of too much alcohol. Many people
go through rehabilitation to stop the addiction because it has taken control of their lives.
When they are released, the toughest part is getting back into the world, where alcohol is
available and the influence of familiar people and places. In a study by O'Farrell, Hooley,
Fals-Stewart, and Cutter it was shown that a relapse is more likely to occur with patients that
have spouses of high expressed emotion more than those that have low expressed emotion. A
cycle forms because of the constant criticism of past experiences of drinking which causes a
relapse. A spouse of high expressed emotion is likely to complain about the drinking before
the rehabilitation which causes the start of drinking again. This creates more criticism toward
the spouse and in addition causes a set back where the person does not care to get better
again. This cycle creates problems between the spouse and patient that could easily be
avoided with less critical comments and complaints. Again, the high expressed emotion
causes relapse quicker than those with lower expressed emotion because they are less
verbally critical of the spouse's drinking problem. The fewer negative comments a spouse
makes, the longer time there is before a relapse (1998). The comments made by the spouse
affects the future outcome of the addiction.
Learning Disabilities
The high expressed emotion is more common in families than low expressed emotion. In a
study by Lam, Giles, and Lavander (2003), it was found that 62% of children came from
households of high expressed emotion. The study was conducted on children who go to
school for a learning disability. The parents talked about the simple tasks of going to the
bathroom that the child could not successfully do by themselves. This environment of high
expressed contributes to the progress of the children with a learning disability. They are
affected socially because of the stress that they have from their parents about simple abilities
that they can not do on their own. The attitude from the parents affect the child and cause
more problems. Most parents are emotionally over involved with the child because of the
learning disability. The stress to improve becomes a big problem for both the parent and child
(Lam et al., 2003).
Bipolar Disorder
The outcome of expressed emotion from relatives varies from one disorder to the next. The
mental disorders known as schizophrenia and bipolar differ in the verbal and nonverbal
aspect throughout the Camberwell Family Interview. The parents of patients with
schizophrenia are negative toward them both with and without the use of words. However,
parents of bipolar patients are supported through talk and similar facial expressions with the
relative. Bipolar patients with relatives of high expressed emotion tend to participate in
negative interactions along with family members. Low expressed emotion families have
fewer negative interactions with one another. The expressed emotion from relatives
contributes to the change of state from manic to depression in bipolar disorders. The criticism
and facial expressions of the relatives and patient decide the path of the mental disorder.
Bipolar patients relapse from one extreme to the other, relapsing within their illness.
(Simoneau, Miklowitz, & Saleem, 1998).
Schizophrenia
Culture also shapes the behavior of each person along with ideas and thoughts of the world
around them. Some of these influences can be negative while others are positive. This is true
with relatives of patients with illnesses such as schizophrenia, where they feel like the world
is watching them, causing them to compel their relative to get over the illness (Lopez et al.,
2004). The influence of society takes a role in many people's lives because of humanistic
desire to fit in. The feeling of belonging needs to be very strong because of the fear of being
rejected. These feelings start to take over some people's lives, most damagingly in their
home, where they should feel the most comfortable. Criticism of family members to act a
certain way toward the ill relative is a form of high expressed emotion. The remarks from
relatives can be overwhelming because they fear seeming different from society. This can
lead to secrecy of what is going on with the patient because the family does not want to stick
out from everyone around them. The pressure from the family and society contributes to
relapse because the patient cannot handle all of pressure. The family's criticism makes the
relative feel like everything is their fault and they cannot make things right so they feel
helpless. They have nowhere to turn to for help because the family's negativity; therefore,
they relapse back into the same thing the family is being critical about (Lopez et al., 2004).
Effects on the Family
Everyone in a family is affected by the illness of one member because it changes their
lifestyle. Relatives themselves become psychologically distressed because of all the stress
from the illness (Chambless, Bryan, Aiken, Steketee, & Hooley, 2001). This stress from the
patient starts to influence daily activities because it is very much a part of their life. The
illness takes over the lives of everyone in the family, even if they are not the ones with the
disorder. Siblings of the patient who are living with the parents and the patient after
rehabilitation are also affected by the expressed emotion in the environment. This is not
helpful for the family as a whole and the patient because the stress will send the patient back
into their disorder. Once the criticism starts, it is hard to change the way of the relatives act,
causing more stress because of the impending relapse. The family starts to fall apart and
create more problems for themselves than because of the ubiquity of a mental illness.
 Discussion

Patients are more likely to relapse when there is high expressed emotion present in their
living environment. The stress from remarks and attitudes of the family is overwhelming
because they feel like the cause of all the problems. The patient falls back into bad habits and
forms a cycle of relapse and rehabilitation. The only way to escape this vortex is for the
family to go through therapy together to prevent the criticism and relapse. This is how that
everyone gets better together and improves the health of each other with less stress and
aggravation. Families learn to accept that the family member has an illness and needs their
help to improve. Educating the family about mental illnesses is one way that expressed
emotion can become lower and no longer an issue. Knowledge of the disorder will help them
to understand and recognize certain behaviors. The family will be more understanding of the
needs and demands of the disorder. Family conflicts will be lowered a great deal and
interactions between the relatives will be healthier.

FAMILY BURDEN

amily burden is a term that encompasses all of the challenges that may exist for an
individual who lives with someone who has experienced a significant illness , particularly
a long-term illness. Even if the illness does not require that the family member provide
care for their loved one, the emotional toll that the illness can have on the family is part
of the overall burden. Additionally, any caregiving responsibilities and financial,
relational, and personal effects are considered part of family burden. Because family
caregiving is becoming increasingly popular and more individuals are living for longer
periods with physical and mental illnesses, it is imperative to understand how family
burden affects the caregivers and even significant others who do not have to provide
care. Therefore, Edel Ennis of the School of Psychology at the University of Ulster in the
UK recently conducted a study that explored the relationship between family health,
family burden, and participant psychological well-being.
Ennis considered the type of illness, noting that some illnesses such as bipolar, dementia,
and Alzheimer’s are particularly emotionally taxing on family members, the relationship
between the participant and ill family member, marital status, income, and gender. After
examining over 3,000 participants, Ennis found a direct and distinct relationship between
family burden and individual mental health. Specifically, the higher the perceived family
burden was; the worse the psychological well-being of the participant. For women, high
family burden was related to increased risk for depression. For men and women, low
income, and singlehood were risk factors for increased stress and poor mood. Ennis
believes that limited finances and lack of other people in the home to provide support
could explain this finding.
One result that was unexpected was that the participant’s relationship to the ill family
member did not affect overall psychological well-being. Previous research has suggested
that caring for a spouse is often more emotionally depleting than caring for a parent or
child. However, in this study, that was not the case. But, Ennis did find that
younger caregiverswere more vulnerable to negative psychological outcomes. For all the
participants, higher family burden was reported for family member mental health
problems versus physical health problems. In conclusion, this study shows that
individuals living with an ill family member, even those who do not directly provide
care, are at risk for psychological problems and should be targeted for interventions.
Ennis added, “This is essential given the increasing numbers of individuals requiring
additional support, and the increasing reliance on the family to provide this support.”

Family burden refers to “all the difficulties and challenges experienced by families as a
consequence of someone’s illness” [6]. Family burden may relate to caring/caregiving to
some extent, but the two constructs are not identical. Caring is typically conceptualised as
involving the provision of practical assistance such as help with personal care, medication
management, activities of daily living, or financial management [7], whereas family burden
encompasses subjective elements such as emotional difficulties and challenges as well as
practical/objective elements. Furthermore, family burden focuses on difficulties and
challenges experienced as a consequence of someone’s illness, or more specifically a
caregiving role [6], whereas caring/caregiving is accepted to have both positive and negative
elements [8,9].

Due to the practical and economic importance of family care for vulnerable individuals
[10,11], understanding the relationship between family burden and mental health and
working towards the protection of the wellbeing of the relatives of ill individuals is essential.
Also, caregiver quality of life relates to patient outcome; for example, perceived high burden
amongst caregivers of bipolar patients can adversely affect patient outcome [12].
Consequences of caregiving are typically explained through theoretical stress and coping
models [13]. Perceived burden is positively associated with many difficulties amongst
caregivers [14]. Adverse social outcomes associated with caregiving stress or family burden
include financial costs, exclusion and discrimination at work, and social isolation [15].
Adverse physical outcomes include poor health [15,16], often through stress and physical
injury [15], which may be especially evident among older carers, dementia caregivers and
men [16]. Higher risk of stroke has also been shown, particularly among male spouse
caregivers [9].

Caregiving/support responsibilities have been associated with increased depression [17,18],

particularly among middle aged employed women [17]. Longitudinal evidence shows the
caregiver depression levels elevate with increases in caregiver stressors such as caregiver
physical health symptoms, activity restriction etc. [18]. Gonzalez et al. identified caregivers
at risk as those with high care demands, low income and depressive symptoms [19]. The
mental health of caregivers is essential to consider, as depression in caregivers is the main
cause of a premature or acute ending of home care for dementia sufferers [20].
The need for effective intervention strategies and support services for those caring for ill
individuals has been identified as a pressing issue for public policy [10], and as was noted
earlier, the burden of this often falls within the family. However, scientific research within
this domain has suffered from several caveats, which are addressed by the current study.
Firstly, due to financial and logistical issues [10], studies have been primarily based on
convenience as opposed to random samples. However, random samples may be best practice
as convenience samples possibly overestimate the strength of associations between caregiver
burden and physical and mental health [10,21]. Secondly, the current study uses
psychometrically valid measures of mental health to focus on the broader domain of family
burden as opposed to focusing exclusively on the experience of primary caregivers.

Thirdly, examinations of family burden have typically focused on one category of illness
[21], whereas preliminary comparisons suggest the importance of considering differences in
burden across categories of illnesses [13,21-23]. Compared with physical illnesses, mental
illnesses bring comparable subjective (practical) burden levels but higher subjective
(emotional) burden [13,21], with differences in burden and depression also documented
across cancer, schizophrenia and Alzheimer’s disease caregivers [23]. Meta-analysis found
the presence versus absence of dementia mediated the relationship between the care provided,
the care receivers’ physical impairments, and burden and depression of the caregivers [22].
The authors themselves have each acknowledged limitations with their sample selections,
however upcoming research from the NCSR suggests confirmation of this trend [24]. Finally,
the evidence suggests the importance of considering kinship with regard to perceived burden,
with a meta-analysis of relevant studies concluding that care of spouses is associated with
greater burden in comparison with care of children, parents or siblings [25].

EMOTIONAL ADAPTATION

For almost everyone, the life course is marked by a series of life transitions—major,
relatively permanent changes in our physical or psychological environment that demand the
establishment of new behavior patterns and/or ways of conceptualizing the world and the life
tasks that confront us. Studies of individuals coping with specific life changes have often
pointed to the disorganizing, and sometimes permanently debilitating, effects of life
transitions (e.g., Gleser, Green, and Winget, 1981; Lindemann, 1944, 1979). From one
perspective, major life changes represent just those instances when our cognitive schemas fail
us: by definition, the novelty and importance of major life changes provide demands for new
coping patterns and a wealth of new information which, at least initially, exceeds our ability
to assimilate it (Block, 1983; Mandler, 1975, 1982). The result is, at least, temporary
cognitive disequilibrium and emotional distress until schemas can be revised and new modes
of coping can be developed.