MONDAY, July 30 (HealthDay News) -- Constantly belittling, threatening or ignoring children can be as damaging to their mental health as physical or sexual abuse, according to a new report from a pediatricians' group.

But, with no bruises to spot, pediatricians, teachers and family members may have trouble recognizing these and other forms of psychological abuse. Not only are there no obvious physical scars, there is no universally agreed-upon definition of what constitutes psychological maltreatment of children, and a fine line can exist between not-so-great parenting and outright abuse, experts say.

"The main message for child health clinicians and people working with children is that psychological maltreatment is just as harmful as other types of maltreatment," said report co-author Dr. Harriet MacMillan, a professor in the departments of psychiatry, behavioral neurosciences and pediatrics at McMaster University in Ontario, Canada.

"We know that exposure to other types of maltreatment like physical and sexual abuse can be associated with a broad range of types of impairment in physical and mental health, and cognitive and social development," she said. "Similarly, we see these types of impairments associated with psychological maltreatment."

The American Academy of Pediatrics' report is published online July 30 and in the August print issue of Pediatrics.

Estimating the prevalence of the problem is difficult, in part because of the lack of a universally accepted definition of psychological abuse, MacMillan said. Studies in Britain and the United States estimate that 8 percent to 9 percent of women and 4 percent of men report severe psychological abuse during childhood.

Psychological maltreatment of children can take many forms. It can include chronically belittling, humiliating or ridiculing a child for showing normal emotions. There is also neglect, such as leaving an infant alone in a crib all day, except for feeding or changing.

Other forms of psychological maltreatment can include withholding love and warmth from a child, putting children in dangerous or chaotic situations, having rigid or unrealistic expectations accompanied by threats if not met, or confining a child and restricting social interactions. Limiting a child's access to necessary health care for reasons other than affordability is another example, according to the report.

Sometimes, but not always, psychological abuse goes hand in hand with physical abuse.

"I once had a child who talked about being hit by his dad," MacMillan said. "The child said that the dad says things about me that make me feel badly, worse than the hitting."

One of the keys to spotting abuse is the pervasiveness of it, experts say. A single bad parenting day probably isn't abuse. But near-constant ridicule, telling a child he or she is unloved and unwanted, is abuse, MacMillan said.

Similarly, there is "suboptimal" parenting -- in other words, no one is going to nominate these moms or dads for parent of the year vs. parenting that is so damaging it rises to the level of abuse.

Telling the two apart can be difficult, experts say.

"Psychological abuse is so insidious, and is not as easily recognized by the victim or other family members," said Alec Miller, chief of child and adolescent psychology at Montefiore Medical Center, in New York City.

"If you see someone getting beaten, we all know it's against the law," Miller said. "It's demarcated as illegal and very unhealthy. Some of these other things are a little more slippery. If there is no bruising physically, it's harder to be convinced there is abuse."

Research shows the effects of psychological abuse and neglect can be profound and long-lasting, ranging from problems with brain development and a failure to grow properly, to problems with behavior and relating to others.

Some parents who are psychologically abusive aren't even aware that their words and actions are harming their child, experts said.

For example, consider parents going through a very difficult divorce. "The child is subjected to major conflict between the parents and told all sorts of things about the other parent and made to choose an allegiance," MacMillan said. "These sorts of things can be psychologically abusive to a child."

Suspected cases of psychological should be reported to child protective services, the authors say. They also urge pediatricians to look for signs of emotional maltreatment in their patients.

More information

The U.S. Department of Health and Human Services has information on recognizing the signs of child abuse.

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