In general, all physically or sexually abused children are also emotionally abused. Children whose physical needs are not met, as a result of family dysfunction described above, are generally emotionally abused. Emotional abuse can also occur when physical needs are excessively provided. This includes overprotection of children, overfeeding leading to obesity, and excessive medical care or Munchausen Syndrome by Proxy, described below.
Developmental, behavioral, and emotional needs that are unmet can also result in emotional abuse. Make the diagnosis when the lack of caregiver stimulation results in developmental delays. A child that is overly criticized may be subject to psychological abuse. Sustained and repetitive psychological abuse that damages the developmental potential of the child may include domestic violence, desertion (abandonment), and exploitation.
Lack of affection, resulting in rejection of the child or open verbal hostility towards the child, can be considered emotional neglect. Emotional neglect is difficult to diagnose because it requires that an emotional or psychological problem be diagnosed in a child and that the caregiver be the direct cause of that problem. In most cases of family dysfunction, making a clear determination of the cause of emotional problems is difficult.
Munchausen Syndrome by Proxy
The diagnosis of factitious disorder by proxy or Munchausen Syndrome by Proxy is rare. It results when a parent, usually the mother, or other caregiver fabricates or induces illness(es) in a child. The diagnosis is best made with the support of consultation from a medical professional with expertise in child abuse diagnosis and treatment. Assessment is often difficult because of the elaborate deceptive control of the caregiver. The medical provider is often an integral part of the abuse and, therefore, this problem has also been called "medical abuse." The interactions of the parent, child, and medical provider are a necessary triad in order for the problem to exist.
Consider Munchausen Syndrome by Proxy when a child presents with a medical problem that seems to baffle even the best diagnostician. Common medical problems that may present include apnea, seizures, bleeding disorders, hypoglycemia, and somatic symptoms, such as headaches and abdominal pain. In addition, the caregiver presents as a "perfect" parent and will stay obsessively by the child's side throughout hospitalizations or evaluations. The keys to diagnosing this syndrome are to be alert to signs of deception; consider the possibility of fabrication when medical tests or examinations do not support the history; and review all medical records, especially those from other medical sites, to look for patterns in presentation.
Some hospitals have used covert video surveillance in the inpatient setting to diagnose Munchausen Syndrome by Proxy. If inpatient video monitoring is going to be used, it is important to develop a specific hospital protocol.