Maltreatment 2152 Rejection and withdrawal of affection. No warmth or cuddles are offered to
the child, who is continually spurned when he or she makes overtures.
This may lead to desperate emotional frustration and impaired close
relationships, sometimes with deep distrust of intimacy and consequent
withdrawal, or a desperate need for intimacy at any cost. Where a sibling
is treated very differently, this exacerbates the feeling of rejection and
differentially rejected children have a particularly poor prognosis.
3 Deprivation of attention. The child is ignored, especially when he is quiet
or behaving constructively; when he seeks someone to play with or
approval for an achievement, it is withheld. This leads to less socially
acceptable behaviour, and to more antisocial behaviour and aggression.
4 Inconsistency. Behaviour that is accepted at one moment receives crush-
ing criticism and heavy punishment the next; a parent who is warm and
welcoming in the morning is cold and rejecting in the afternoon. This
leads to confusion and inability to predict or trust.
5 Threats of abandonment. For what may be very minor acts of perceived
misbehaviour, the child is threatened with expulsion from the home,
and may have his suitcase packed, be driven to social services, and so
on. The constant fear of abandonment precludes the development of a
secure base for the building of relationships and often leads to anxious
attachments.
6 Inappropriate stresses and demands. A child may see his depressed mother
repeatedly being beaten by her partner, or taking an overdose. He may
be told he is the reason his parents got divorced, and be used as a football
in the ensuing acrimony, being asked to take sides, pass messages, act as
peacemaker, and give comfort and protection.
Sexual abuse
One definition specifies sexual abuse as: ‘the involvement of dependent,
developmentally immature children and adolescents in sexual activities
that they do not fully comprehend, and to which they are unable to give
informed consent, and that violate the social taboos of family roles’. There
is a range of severity of acts with a corresponding range of prevalence. Thus
‘non-contact’ abuse such as exhibitionism is reported to have occurred
at some time in childhood by around half of all women. ‘Contact’ abuse
including fondling is reported to have occurred in childhood by 15–20% of
women, whereas penetrative acts with vaginal, anal or oral involvement
are reported by around 2%. All of these figures are imprecise because of
difficulties in ascertainment. Community surveys suggest that females are
more often abused than males, with a ratio of 2 or 3:1, but in clinically
referred samples the female preponderance is greater, at around 4 or 5:1.
In clinical samples of sexually abused children there is a small excess of
children from socio-economically deprived backgrounds, but this gradient
is far less marked than for physical abuse and neglect, and is virtually
absent in community surveys.
Sexual abuse can come to attention in many ways. The most common
is the child or adolescent disclosing the abuse, usually to a friend, a