1. No category

Supplementary Online Content
Naughton AM, Maguire SA, Mann MK, Lumb RC, Tempest V, Gracias S, Kemp AM.
Emotional, behavioral, and developmental features indicative of neglect or emotional
abuse in preschool children: a systematic review. JAMA Pediatr. Published online
June 1, 2013. doi:10.1001/jamapediatrics.2013.192.
eAppendix 1. Definitions of emotional abuse and neglect.
eAppendix 2. Bibliographic databases, journals, and websites searched (with date
parameters).
eAppendix 3. Search terms used for both the initial search and the update (keywords
and phrases used).
eAppendix 4. Study selection process.
eAppendix 5. Critical appraisal form.
eAppendix 6. Inclusion criteria and ranking of abuse.
eAppendix 7. Quality standards reached by included studies.
eAppendix 8. Details of included studies.
eReferences
eAppendix 9. Assessment tools used by study authors.
eAppendix 10. Patterns of attachment.
This supplementary material has been provided by the authors to give readers
additional information about their work.
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 1. Definitions of Emotional Abuse and Neglect
Psychosocial evaluation of suspected psychological maltreatment in children and adolescents
Practice Guidelines (American Professional Society on the Abuse of Children 1995)
Six forms of psychological maltreatment:
 Spurning (verbal and nonverbal hostile rejecting/degrading)
 Terrorizing (behavior that threatens or is likely to physically harm the child or the place the child
or the child’s loved objects in danger)
 Exploiting / corrupting (encouraging the child to develop inappropriate behaviors)
 Denying emotional responsiveness (ignoring the child’s need to interact, failing to express
positive effect to the child, showing no emotion in interactions with the child)
 Isolating (denying the child opportunities for interacting/communicating with peers or adults)
 Mental, health, medical, and educational neglect (ignoring or failing to ensure provision for the
child’s needs)
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 2. Bibliographic Databases, Journals, and Websites Searched (With Date
Parameters)
Databases
ASSIA (Applied Social Sciences Index and Abstracts)
CINAHL (Cumulative Index to Nursing and Allied Health
Literature)
Cochrane Central Register of Controlled Trials
EMBASE
ERIC (Education Resources Information Center)
HMIC (Health Management Information Consortium)
IBSS (International Bibliography of the Social Sciences)
MEDLINE
MEDLINE In-Process and Other Non-Indexed Citations
Open SIGLE (System for Information on Grey Literature in
Europe)
PsycINFO
SCOPUS
Social Care Online
Social Services Abstracts
Sociological abstracts
Web of Knowledge — ISI Proceedings
Web of Knowledge — ISI Science Citation Index
Web of Knowledge — ISI Social Science Citation Index
†
Institutional access terminated
*
Ceased indexing
Journals hand searched
Child Abuse and Neglect
Child Abuse Review
Websites searched
Centre for Excellence and Outcomes in Children and Young
People’s Services(C4EO) www.c4eo.org.uk
Child Welfare Information Gateway(CWIG)
http://www.childwelfare.gov/search/pubs_search.cfm
Research in Practice(RIP)
http://www.rip.org.uk
Social Care Institute for Excellence website
http://www.scie.org.uk/index.asp
Translational Research on Child Neglect Consortium (TRCNC)
http://www.trcnconsortium.com/index.htm
Trauma Central
http://www.traumacentral.net/TC_brucedperry.htm
†
Institutional access terminated
Period searched
1987–2011
1982–2011
1960–2011
1980–2011
1962–2011
1979–2011
1960–2009†
1960–2011
2006–2011
1980–2005*
1960–2011
1966–2011
2006–2011
2008–2011
2008–2011
1990–2011
1970–2011
1970–2011
Period searched
1979–2011
1992–2011
Dates accessed
From inception to
2011
From inception to
2011
From inception to
2009†
From inception to
2011
From inception to
2011
From inception to
2011
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 3. Search Terms Used for Both the Initial Search and the Update
(Keywords and Phrases Used)
Set 1 (Population set)
exp Child/
exp Child Preschool/
exp Infant, Newborn/
exp Infant/
infancy
child*
infant*
baby or babies
toddler*
neonat*
pediatric* or paediatric*
or/1-11
limit 12 to "all infant birth to 23 months" or
"newborn infant birth to 1 month" or "infant 1 to 23
months" or "preschool child 2 to 5 years"
pre-school* or preschool* or preschool-age Child*
Set 3 (Emotional neglect features set)
Failure to Thrive/
failure to thrive adj5 emotion* or nonorganic or
non-organic
failure to thrive adj5 abus* or neglect* or maltreat*
or mistreat* or depriv* or psych
fail* or inadequa* adj2 emotional support
unkempt or ungroomed
Psychosocial Deprivation/
unhealthy appearance?
exp Internal-External Control/
internal* adj3 extem*
anxiety or anxious* or anguish*
withdrawn or apath*
indifferen* or disinterest*
lack* or low or flat* adj3 affect or emotion*
clingy or clinginess
attention or affection* or love adj3 inappropriate*
or improper* or unsuitabl*
mental or psychological* or emotional* adj3
stress* or distress*
internali?ation
Irritable Mood/
emotion* or affect* adj3 labil* or regulat*
aloof or avoid*
Shyness/
avoid* or withdraw* adj3 contact or touch* or
physical*
avoid* or withdraw* adj3 social*
unsociable
lack or poor* or avoid* adj3 communicat*
watchful or wary or vigilan*
unhappiness or unhappy
overly responsible or perfectionis*
Set 2 (Abuse/neglect set)
abus* adj neglect*
maltreat* or mistreat* or deprive* or ignor*
neglected
neglectful
psychological neglect
lack* or absen* or fail* adj3 care* or childcare
social* or emotional* or psychosocial* or contact
or psychological* adj3 deprived or deprivation
overlook*
neglect* psychological*
emotion* neglect*
emotion* abus*
emotion* harm*
child neglect
neglect* child*
emotion* depriv*
emotional trauma
neglect* or ignore or deprive* adj1 psychologic*
or emotion*
avoidant attention
normative adj3 avoidance
abandoned or abandonment?
psychological neglect
lack* or absen* or fail* adj3 care* or childcare
social* or emotional* or psychosocial* or contact
or psychological* adj3 deprived or deprivation
"lack of supervison"
unsupervised
temper or hostil* pr hypervigilan*
Child Behavior Disorders/
rage of raging or rageful
attun*
Nonverbal Communication/
Sensory integration
Dissociat*
*"Dissociative Disorders"/
Dysregulation
Affect mirroring
*"Facial Expression"/
Mind-mindedness
Object Attachment/
attachment
persecut*
Speech delay
Language delay
Language Disorders/
Perspective taking
Demanding
Poor concentration
listless*
Isolated
*"Social Isolation"/
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
"ATTENTION DEFICIT and DISRUPTIVE
BEHAVIOR DISORDERS"/
Conduct Disorder/
Aggression/
aggression or aggressive* adj3 behavio* or
escalat*
acting out
out of control
chaotic* or challenging adj3 behavio*
bully* or bullie?
Anger/
destructive* or disruptive* adj3 behav*
Impulsive Behavior/
impulse control
impulsive* or impulsivity or impulse control
Developmental Disabilities/
Child Development/
Child Behavior/
Infant Behavior/
Personality Development/
chang* or alter* or deviat* or transition? adj3
personality
Helplessness, Learned/
sad
Social Behavior/
Attention Deficit Disorder with Hyperactivity/
Set 4 (Parent/carer set)
Family/
Mother-Child Relations/
Maternal Behavior/
Parent-Child Relations/
parent* or mother or father or maternal or
paternal or carer* adj3 depression or depressed
or depressive or dysthymi? or dysphori?
parent* or mother or father or maternal or
paternal or carer* adj3 mood disorder*
parent* or mother or father or maternal or
paternal or carer* adj3 negative mood
parent* or mother or father or maternal or
paternal or carer* adj3 partner violence
parent* or mother or father or maternal or
paternal or carer* adj3 anger or angry or angst or
rage
parent* or mother or father or maternal or
paternal or carer* adj3 depress*
parent* or mother or father or maternal or
paternal or carer* adj3 emotion*
parent* or mother or father or maternal or
paternal or carer* adj3 substance abuse
parent* or mother or father or maternal or
paternal or carer* adj3 domestic violence
parent* or mother or father or maternal or
paternal or carer* adj3 punitive
parent* or mother or father or maternal or
paternal or carer* adj3 unavailab*
parent* or mother or father or maternal or
Inhibited
Reactive Attachment Disorder/
Disinhibited
Social skills
Emotional skills
False positive affect
touch sensitive
Apparent compliance
Language comprehension deficit
Grasp of reality
Immatur*
impatien*
Socialization/
cognitive delay
cognitive* stimulat*
attachment disorder
eye contact
*Stress, Psychological/
stunting of growth
stunt* growth
Hospitalism
environmental retardation
affect deprivation
emotional* depriv*
spouse or partner
Interpersonal violence or IPV
Psychologica* unavailab*
Emotion* inatten*
Emotion* unattach*
Authoritative
Disengaged
Emotion* unavailab*
Parent* or mother or father or maternal or
paternal adj1 anger
Rough handl*
Unresponsiv*
Non-physical punishment
"Family Relations"/
Interpersonal Relations/
child* adj3 mock* or taunt* or denigrat* or threat*
or hostil*
inappropriate expectation*
inappropriate development
over-protective or over protective*
*"Parenting"/
dysfunctional family or family dysfunction
"Rejection Psychology"/
Negative attribution*
High criticism
parent* unresponsiv*
Child Rearing/
family interact*
home environment*
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
paternal or carer* adj3 instab* or unstab*
Learning disability/ or Learning disability
Neglect* mother*
over* critical
families or family or dyad
Set 5 (Assessment set)
assessment
Diagnosis/
diagnostic tool
assessment tool or "Severity of Illness Index"/
Needs Assessment/
graded care profile
identification or identify
Pattern Recognition, Visual/
detect*
Classification/
Decision Making/
Early Diagnosis/
screening or Mass Screening/
"Risk Factors"/
HOME inventory
Risk Assessment/
Risk/
Set 6 (Environment set)
Environment/
Hostile atmosphere
Environment Design/
depriv*
chao*
"Play and Playthings"/
Absence of toys
Absence of play
Absence of stimulation
home
buggy
"Walkers"/
Infant Equipment/
pram or pushchair
stroller
view* or watch* adj3 television
Social Environment/
Search Limits
Stress Disorders, Post-Traumatic/
sexual abuse or Sex Offenses/
"Child Abuse, Sexual"/
Algeria$ or Egypt$ or Liby$ or Morocc$ or Tunisia$ or Western Sahara$ or Angola$ or Benin or
Botswana$ or Burkina Faso or Burundi or Cameroon or Cape Verde or Central African Republic or
Chad or Comoros or Congo or Djibouti or Eritrea or Ethiopia$ or Gabon or Gambia$ or Ghana or
Guinea or Keny$ or Lesotho or Liberia or Madagasca$ or Malawi or Mali or Mauritania or Mauritius or
Mayotte or Mozambiq$ or Namibia$ or Niger or Nigeria$ or Reunion or Rwand$ or Saint Helena or
Senegal or Seychelles or Sierra Leone or Somalia or South Africa$ or Sudan or Swaziland or
Tanzania or Togo or Ugand$ or Zambia$ or Zimbabw$ or China or Chinese or Hong Kong or Macao
or Mongolia$ or Taiwan$ or Belarus or Moldov$ or Russia$ or Ukraine or Afghanistan or Armenia$ or
Azerbaijan or Bahrain or Cyprus or Cypriot or Georgia$ or Iran$ or Iraq$ or Jordan$ or Kazakhstan or
Kuwait or Kyrgyzstan or Leban$ or Oman or Pakistan$ or Palestin$ or Qatar or Saudi Arabia or Syria$
or Tajikistan or Turkmenistan or United Arab Emirates or Uzbekistan or Yemen or Bangladesh$ or
Bhutan or British Indian Ocean Territory or Brunei Darussalam or Cambodia$ or India$ or Indonesia$
or Lao or People's Democratic Republic or Malaysia$ or Maldives or Myanmar or Nepal or Philippin$
or Singapore or Sri Lanka or Thai$ or Timor Leste or Vietnam or Albania$ or Andorra or Bosnia$ or
Herzegovina$ or Bulgaria$ or Croatia$ or Faroe Islands or Greenland or Liechtenstein or Lithuani$ or
Macedonia or Malta or maltese or Romania or Serbia$ or Montenegro or Svalbard or Argentina$ or
Belize or Bolivia$ or Brazil$ or Colombia$ or Costa Rica$ or Cuba or Ecuador or El Salvador or
French Guiana or Guatemala$ or Guyana or Haiti or Honduras or Jamaica$ or Nicaragua$ or Panama
or Paraguay or Peru or Puerto Rico or Suriname or Uruguay or Venezuela or developing countr$ or
south America$.ti,sh.
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 5. Critical Appraisal Form
Welsh Child Protection Systematic Review Group
CONEG: Child PrOtection NEGlect
Critical Appraisal Form
Reviewer’s name &
Blackboard username:
Date:
First Author Surname & Unique Reference Number (please insert):
What is/are the research question(s) posed by the study?
Section A. EVIDENCE TYPE (STUDY DESIGN)
Please only tick the study design which applies to the data set that is of interest to our CONEG
review.
Please provide your opinion on Evidence Type, even if this differs from what has been stated in the
study
Yes
Case series (3 or more cases)
Qualitative (please specify what)
Yes
Case-control
Cross-sectional
Uncontrolled before and after study
Prospective cohort/ longitudinal
Retrospective cohort study
Interrupted time series
Section B. KEY QUESTIONS



Please tick which question this study addresses - more than one
question may apply
All questions relate to
 children aged 0-5 completed years (5 yrs & 365 days)
 primary carers
 developed countries (OECD)
 primary research
If none of the questions apply (option 4), the study should be
EXCLUDED - NB. please provide further detail in Section C
Yes ✓
Comment
1. What emotional, behavioural, psychological, developmental,
physiological features in the child indicate any type of neglect?
2. What emotional, behavioural, psychological, developmental,
physiological features in the child indicate emotional abuse?
3. What features in the child-primary carer interaction demonstrate
emotional neglect and/or emotional abuse?
(e.g unavailability, hostility etc., developmentally inappropriate interactions
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
[e.g. domestic violence], failure to recognise individual, failure to promote
socialisation)
If you have selected any of the above questions, please continue to Section C
4. Study relates to none of the areas listed above (does not address key Qs)
Please provide further
detail in Section C, then
proceed to Section F
© 2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Section C. EXCLUSION CRITERIA
Study DOES NOT ADDRESS any key Q
 If you have specified the study does not address any of the key Qs (Section B, option 4), please work through the
criteria below and tick any which apply.
 If none of the listed criteria apply, please provide a brief explanation of your decision below (10).
 The study is EXCLUDED
Study ADDRESSES one or more key Q
 If you have specified the study addresses one or more key Q (Section B), please work through the criteria 1-9 and
tick any which apply.
 If you select any category/ies, the study should be EXCLUDED
Yes ✓
Comment
1. AGE
Study relates to adults or to children aged 6 and over – either exclusively or where
relevant data* relating to children aged 0-5 completed years cannot be extracted
2. CARER
Study relates to secondary carer - either exclusively or where relevant data* relating
to primary carer cannot be extracted
3. COUNTRY
Study relates to non-OECD country/ies - either exclusively or where relevant data*
relating to OECD country/ies cannot be extracted
4. SURVIVORS
Study addresses management or complications faced by survivors of neglect and
/ or emotional abuse – either exclusively or where relevant data* cannot be extracted
5. OUTCOMES
Study addresses outcomes of neglect and / or emotional abuse measured in
adults or children aged 6 or over – either exclusively or where relevant data* cannot
be extracted
6. ANTE-NATAL
Study addresses ante-natal features – either exclusively or where relevant data*
cannot be extracted
7. SEXUAL / PHYSICAL ABUSE
Study addresses sexual abuse or physical abuse – either exclusively or where
relevant data* cannot be extracted
8. CHILD IMPACT
No data / documentation relating to impact on child (emotional, behavioural,
psychological, developmental)
9. STUDY DESIGN
Single case study OR 2 cases
Case series (3 or more), where only 1 or 2 cases meet inclusion criteria**
(please highlight this in Section F)
Formal consensus / expert opinion / personal practice / review article
(a study may still be included if it ALSO contains relevant PRIMARY data)
10. If you have specified that the STUDY DOES NOT ADDRESS ANY KEY QUESTION (Section B – option 4), but this
was NOT for any of the above criteria, please briefly detail your reasoning here:
If the study is EXCLUDED, please go directly to Section F
If you have NOT selected any criteria & have selected one or more key Q (Section B),
please continue to Section D
* Relevant data means data which addresses any key Q & meets inclusion criteria
** A case series study may be included overall, even if NOT ALL cases meet the inclusion criteria. However,
there must be a minimum of 3 included cases, and it must be possible to extract the data relating to these.
Page 10 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Section D. SECURITY OF DIAGNOSIS OF (EMOTIONAL) NEGLECT AND / OR EMOTIONAL
ABUSE
How has neglect and / or emotional abuse been identified / confirmed
in the abused / neglected children?
 Please tick any of the following criteria which apply
 Please select more than one if necessary
A1
Neglect / Emotional Abuse confirmed at Child Protection case
conference, multi-disciplinary assessment, including social services
or Court proceedings
A2
Diagnosis of Emotional Neglect / Emotional Abuse by clinical
psychologist, psychiatrist or other mental health specialist
B
Neglect / Emotional Abuse confirmed by referenced criteria / tool
C1
Neglect / Emotional Abuse defined by unreferenced criteria / tool
C2
Observations of emotionally harmful carer-child interaction (not
categorised as neglect / emotional abuse)
D
Yes ✓
Comment
Neglect / Emotional Abuse / Harmful Carer-Child Interaction
suspected or stated, with no supporting detail

 Category D is EXCLUDED
If a study has a mixture of cases, including some from category D, the study may be included if you can
extract the details of the A, B or C cases
 If the study is EXCLUDED, please go directly to Section F
 If you have selected A, B or C alone OR you have extractable cases from categories A, B or C, please
continue to Section E
Page 11 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Culp10
1991 USA
Retrospective Cohort
No significant
difference between the
groups on
demographic variables
41 Neglect
13 Neglect / Physical
Abuse
20 Physical Abuse
Total: 37 F : 37 M
Neglect group
(mean): 41.5 months
(SD 11.2)
Neglect / Physical
Abuse group
(mean): 41.2 months
(SD 10.6)
Abuse group
(mean): 42.5 months
(SD 12.6)
DiLalla11
1990 USA
Case-control
Total: 2-48 months
Matched on: age,
(mean 26 months)
gender, race,
(SD 12.7)
demographic
variables, low income,
development, number
of children in the home
41 Neglect
51 Neglect / Abuse
28 Control
Total: 58 F : 62 M
Child negativity was strongly associated with
caregiver hostility for neglect and abuse groups
(p<0.01).
Neglect children had significantly less positive social
interaction compared with controls (p<0.001).
Neglectful parents showed the least positive social
interaction (p<0.001)
Dubowitz12
2002 USA
37 months (mean)
Prospective Cohort
(SD 2.3) total group
Longitudinal
No difference between implied neglected
the groups on race,
age, or socioeconomic status
136 Maltreated
children
30% from a FTT clinic
26% High risk HIV
clinic
44% General Pediatric
clinic
Total: 63 F : 73 M
At age three psychological neglect significantly
associated with children’s internalizing (p<0.01) and
externalizing behavior problems (lying / aggression)
(p<0.001) when controlled for maternal depression
and socio-economic risk related to poverty age three
years.
Neglect measured at age three did not predict
changes in children’s development and behavior
between ages 3 - 5. Cumulative Neglect Index was
associated with internalizing problems (depression /
passivity) (p<0.001)
Neglect group had the lowest scores on auditory and
verbal scores on the Preschool Language Scale
(p<0.01), and lowest scores on Profile language
subscale (p<0.01). Neglect most strongly associated
with expressive and receptive language delay. All
three groups were delayed cognitively but no
significant inter-group variability
Page 26 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
English18
2005 USA
Age
Retrospective Cohort Total: 0 - 4 years
Matched on: age,
ethnicity and family
socio-economic status
212 Children
Maltreated)
Sex
Results
109 F : 103 M
Withdrawn, social, aggressive, delinquent and
thought problems associated with failure to provide
food and frequent location transitions (p<0.001).
Anxiety, depression attention problems associated
with failure to provide adequate hygiene (p<0.001)
Impairment in communication (expressive language)
associated with dirty, unsafe, residence (dilapidated)
(p<0.001) and with failure to provide shelter.
Receptive language impairment associated with
untreated emotional or behavioral problems
(p<0.005).
Problems in social domain associated with failure to
provide shelter (p<0.001).
Verbal aggression and verbally aggressive discipline
associated with child anxiety, depression (p<0.001),
attention problems (p<0.001), delinquent (p<0.001),
and aggressive behaviors (p<0.001), somatic
complaints (p<0.005)
Page 29 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Questions to assist with the critical appraisal of a QUALITATIVE STUDY
Please tick the appropriate column ✓
(please answer the main questions only – the bullet points are guidance as to
which issues to consider)
1. Is the study relevant to your research question?
2. Does the paper address a clearly focused issue?
 Are the aims of the investigation clearly stated?
3. Is the choice of a qualitative method appropriate?
Consider:
 What was this study exploring (e.g. behaviour /reasoning / beliefs)?
 Do you think a quantitative approach could equally / better address this
issue?
4. Was the author’s position clearly stated?
Consider:
 Has the researcher described his/her perspective?
 Has the researcher examined his/her role, potential bias and influence?
5. Were the sampling / recruitment strategy clearly described and
justified?
Check to see whether:
 the method of sampling is stated or described
 the investigators sampled the most useful or productive range of
individuals and settings relevant to their question
 the characteristics of those included in the study are defined (and are
comparable to the wider population)
6. Was there an adequate description of the method of data
collection given?
Consider:
 Is the method of data collection described and justified?
 How were the data collected (e.g. audiotape / videotape / field notes)?
 If interviews were used, were the questions pre-tested?
 If observation was used, is the context described and were
observations made in a variety of circumstances?
7. Were the procedures for data analysis / interpretation described
and justified? Was the data analysis sufficiently rigorous?
Check to see whether:
 a description is given of how the themes and concepts were identified
in the data
 the analysis was performed by more than one researcher
 negative / discrepant results were taken into account
 the data were fed back to the participants for comment
 saturation of the data has been discussed
8. Are the results credible? Are the findings well presented and
meaningful?
Consider:
 Were sequences from the original data presented (e.g. quotations) and
were these fairly selected?
 Is it possible to determine the source of the data presented (e.g.
numbering of abstracts)?
 How much of the information collected is available for independent
assessment?
 Are the explanations for the results plausible and coherent?
 Are the results of the study compared with those from other studies?
9. Were all important outcomes/ results considered?
10. Did the results address the research question (as outlined in the
paper)?
OVERALL, DO YOU THINK THIS STUDY IS SIGNIFICANTLY FLAWED?
COMMENTS
Yes
No
Unclear
/ Not
known
Not
applicable
If you have completed this table, please continue to Section F
If not, please continue to next table and complete if relevant to study type chosen
Page 14 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Questions to assist with the critical appraisal of a RANDOMIZED CONTROLLED TRIAL (RCT)
Please tick the appropriate column ✓
(please answer the main questions only – the bullet points are guidance as to
which issues to consider)
Yes
No
Unclear
/ Not
known
Not
applicable
1. Is the trial relevant to the needs of the study?
2. Did the trial address a clearly focussed issue in terms of:

The population studied?

The intervention given?

The outcome considered?
3. Was the assignments of children/ families to intervention
randomised?
4. Were all the patients who entered the trial properly accounted for
at its conclusion?

Was follow-up complete?

Were patients analysed in the groups to which they were randomised?
5. Were patients, health / social care workers and study personnel
‘blind’ to treatment?

Patients?

Health / social care workers?

Study personnel?
6. Were the groups similar at the start of the trial?

In terms of all the factors that might be relevant to the outcome: age,
sex, social class, lifestyle, developmental progress
7. Aside from the intervention, were the groups treated equally?
8. Have the results of the study been clearly presented?
9. Are the data in the tables or graphs and the text consistent?
10. Were the statistical methods used appropriately?
11. Were all important outcomes/ results considered?
OVERALL, DO YOU THINK THIS STUDY IS SIGNIFICANTLY FLAWED?
COMMENTS
If you have completed this table, please continue to Section F
Page 15 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Section F. FINAL DECISION
Please tick the appropriate column ✓
Yes
No
Comment
Is the study included?
Key points meriting inclusion (list strengths)
Weaknesses, potential confounders and study limitations (if study is INCLUDED)
Please tick the appropriate column ✓
Yes
No
Comment
If included, does the study address any ‘risk factors’
relating to the primary carer or environment?
e.g absence of toys, domestic violence, substance
misuse, mental ill-health
If you have EXCLUDED the study, do you
nevertheless think it contains some useful information
which addresses the key questions?
Additional Comments
Thank you for completing this review.
Please now return by email to [email protected]
If you are not able to return by email, please post to:
VANESSA TEMPEST / REBECCA LUMB
Welsh Child Protection Systematic Review Group
Child Health
Wales College of Medicine, Biology, Health and Life Sciences
Cardiff University
Heath Park
Cardiff
CF14 4XN
Tel:
029 2074 2160
Page 16 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 6. Inclusion Criteria and Ranking of Abuse
Inclusion criteria
 Children aged 0-5 completed years
 Documented features of the impact of neglect/emotional abuse on the child during the period
of exposure to neglect
 Studies conducted in Organisation for Economic Co-operation and Development countries
 Carer-child interaction documented using standardized recording
 Studies of the interaction between the child and their primary carer
Exclusion criteria
 Studies of sexual abuse
 Studies of physical abuse alone, or studies combining physical abuse and neglect/emotional
abuse, where the data from the neglect/emotional abuse cases could not be extracted
 Studies of management or complications of neglect/emotional abuse
 Studies addressing risk factors for neglect/emotional abuse
Ranking
Criteria used to define neglect / emotional abuse
A1
Neglect/emotional abuse confirmed at child protection case conference, multidisciplinary assessment, including social services or Court proceedings
A2
Diagnosis of emotional neglect/emotional abuse by clinical psychologist, psychiatrist or
other mental health specialist
B
Neglect/emotional abuse confirmed by referenced criteria/tool
C1
Neglect/emotional abuse confirmed by unreferenced criteria/tool
C2
Observations of emotionally harmful carer-child interaction (not categorized as
neglect/emotional abuse)
D
Neglect/emotional abuse/harmful carer-child interaction suspected or stated, with no
supporting detail
Page 17 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 7. Quality Standards Reached by Included Studies
Author, Year
and Country
Allen1
1982 USA
Cheatham2
2010 USA
Christopoulos3
1988 USA
Cicchetti4
2006 USA
Crittenden5
1992 USA
Crittenden6
1988 USA
7
Crittenden
1984 USA
Crittenden8
1985 USA
Crittenden9
1983 USA
Culp10
1991 USA
DiLalla11
1990 USA
Dubowitz12
2002 USA
Dubowitz13
2004 USA
Egeland14
CaseCohort
Cohort
Rank of Cases/Controls Matched on 4 Demographic
Control (Prospective) (Retrospective Abuse Features (Age, Sex, Ethnicity, and Income)
)


A1
Except income


A1


A1



C1



A1



C1


A1

More case mothers had learning difficulties


A1
Differed significantly on some demographic variables
11% neglect mothers were married, 50% control
mothers married, 72 % neglect mothers had mental
retardation vs. 6% control

A1


A1



B



B



C1



A1



Independent
Observer



Page 18 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year
and Country
CaseCohort
Cohort
Rank of Cases/Controls Matched on 4 Demographic
Control (Prospective) (Retrospective Abuse Features (Age, Sex, Ethnicity, and Income)
)
1981 USA
Egeland15
1983 USA
Egeland16
1981 USA
Eigsti17
2004 USA
English18
2005 USA
Erickson19
1989 USA
Fagan20
1993 USA
21
Frodi
1984 USA
Hoffman22
Plotkin
1984 USA
Koenig23
2000 USA
Koenig24
2004 USA
Lamb25
1985 USA
Macfie26
2001 USA
Independent
Observer

C1



C1

A1
Child care rating scale used to identify cases and
controls. Groups differed on age, marital status and
educational attainment. Did control for economic level,
number of deliveries, birth weight and gestational age
was same between the two groups

B

x
C1



C1

Control mothers were better educated


A1 C1


A1
Does not state if specifically matched but came from
local day care centers and also of low socio-economic
group. One third of each of the groups was black the
rest were white


A1 A2 B 


A1



A2



A1 A2

x
Teacher report
on standardized





Page 19 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year
and Country
27
CaseCohort
Cohort
Rank of Cases/Controls Matched on 4 Demographic
Control (Prospective) (Retrospective Abuse Features (Age, Sex, Ethnicity, and Income)
)
Independent
Observer
rating scale


A1


B
Maughan
2002 USA
Mustillo30
2011 USA

A1
Controls matched on gender, ethnicity, socio-economic
status, but did differ on child age (tended to be slightly
older) and maternal education and maternal similarities
score on Wechsler Adult Intelligence Scale

Pianta31
1989 USA
Pollak32
2000 USA
Pollitt33
1975 USA
Rohrbeck34
1986 USA

A2

x
Self-report on
standardized rating
scale


A2 /B



C2


A1

Controls from a higher income group

Macfie
1999 USA
Mackner28
1997 USA
29
Scarborough35
2009 USA
Sullivan36
2008
Sylvestre37
2010 Canada
Toth38
2000 USA
Toth39

A1

A1

A1




x
Parent and teacher
rating



A1


B


A1


Page 20 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year
and Country
1997 USA
Valentino40
2006 USA
Venet41
2007 Canada
Waldinger42
2001 USA
CaseCohort
Cohort
Rank of Cases/Controls Matched on 4 Demographic
Control (Prospective) (Retrospective Abuse Features (Age, Sex, Ethnicity, and Income)
)
Independent
Observer

B



C1
Only matched for age and gender


A1


Page 21 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 8. Details of Included Studies
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Allen1
1982 USA
Case-control
Matched on: age,
gender, ethnicity,
presence of father
figure in the home
7 Neglect
31 Neglect / Abuse
13 Abuse
28 Control
Neglect group:
2 .5 - 5 years (mean
47 months), but no
significant difference
between the mean
ages of the groups
Neglect group: 4 F :
3M
Abuse group: 3 F :
10 M
Abuse / Neglect
group: 10 F : 21 M
Control group: 18 F :
10 M
Neglect was found to have a significant association
with receptive language (auditory comprehension
quotient) and expressive language development
(verbal ability quotient), i.e. neglected children had
reduced comprehension and expressive language
abilities (p<0.001)
Cheatham2
2010 USA
Case-control
Well matched on: age,
gender, ethnicity,
developmental level
59 Neglect
46 Abuse
105 Maltreated
46 Control
Neglect group
(mean): 21.01
months
Abuse group
(mean): 21.25
months
Maltreated group
(mean): 21.11
months
Control group
(mean): 21.02
months
Neglect group: 32 F Neglected children experienced deficits in
: 27 M
performance on memory testing as compared with
Abuse group: 26 F : abused and matched controls (p<0.001)
20 M
Maltreated group: 58
F : 47 M
Control group: 22 F :
24 M
Christopoulos3
1988 USA
Case-control
Matched on: age,
gender, ethnicity,
maternal age, birth
order
10 Neglect
10 Physical Abuse
10 Control
Neglect group
(mean): 12.1 months
Abuse group
(mean): 11.5 months
Control group
(mean): 12.5 months
Neglect group: 5 F :
5M
Abuse group: 2 F : 8
M
Control group: 5 F :
5M
Mothers who neglected their infants used
significantly fewer commands (p<0.01), provided
their children with less positive feedback comments,
used fewer acceptances of praise.
61% of all utterances produced by neglectful
mothers were commands (p<0.01).
The neglect group had a slightly higher proportion of
acceptance phrases than the abusive group (p<0.05)
Page 22 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Maltreatment group:
77 F : 60 M
Non-Maltreatment
group: 24 F : 28 M
The vast majority of cases in the maltreatment
groups were classified as disorganized on Strange
Situation or 123 / 137 (p<0.001)
Mothers reported that they experienced their infants
as less reinforcing, accepting and adaptable and
more demanding (p<0.01)
Mothers in maltreatment group rated as substantially
lower in maternal sensitivity to their infants compared
with non-maltreating mothers (p<0.001)
Cicchetti4
2006 USA
Case-control
Total (mean): 13.31
Comparable on:
months (SD 0.81)
gender, ethnicity,
income, maternal age,
marital status,
137 Maltreated group,
consisted of 84.6%
(116) Neglect, 69.2%
(95) Emotionally
Maltreated
Crittenden5
1992 USA
Case-control
Total: 1 - 48 months Total: 89 F : 93 M
Matched on: age,
(mean 24 months)
gender, race, birth
complications,
handicapping
conditions
25 Neglect
61 Neglect / Abuse
25 Abuse
32 Marginal Maltreated
39 Control
Each child’s strange situation was scored on four
interactive scales (Ainsworth 1978). These four
scales were used to define three major patterns of
attachment: secure B, insecure avoidant A and
insecure ambivalent C, and eight sub-patterns. A 4th
pattern avoidant / ambivalent A/C and two subpatterns were identified as associated with
maltreatment. Neglect children generally displayed
avoidant (A) or avoidant / ambivalent (A/C2) forms of
attachment. They spent the least time with adults
(p<0.02) and the most time alone (p<0.005), and
were the most passive with their mothers (p<0.001).
Neglected children tended to be isolated during free
play (p<0.01), and less likely to engage in fighting
with siblings (p<0.001)
Page 23 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Crittenden6
1988 USA
7
Crittenden
1984 USA
Age
Sex
Total:1 - 36 months Total: 53 F : 52 M
Case-control
(mean 18.5 months)
Matched on: age,
gender, income, birth
complications,
handicapping
conditions of the
infants
20 Neglect
28 Neglect / Abuse
18 Abuse
14 Marginal Maltreated
25 Control
Case-control
Matched on: age,
socio-economic group,
educational
background
10 Neglect
10 Abuse
10 Infants of Mentally
Retarded (sic) Mothers
10 Infants of Low
Income Mothers
10 Infants of Deaf
Mothers
10 Control (middle
class)
Neglect group: 9 18 months (mean
13.1 months)
Abuse group: 9 - 18
months (mean 14
months)
Mentally Retarded
(sic) group: 9 - 16
months (mean 12.6
months)
Low Income group:
9 - 18 months (mean
13.0 months)
Deaf group: 9 - 18
months (mean 13.9
months)
Control group: 9 - 18
months (mean 13.4
months)
Neglect group: 8 F :
2M
Abuse group: 4 F : 6
M
Mentally Retarded
group: 5 F : 5 M
Low Income group:
4F:6M
Deaf group: 6 F : 4
M
Control group: 5 F :
5M
Results
Neglected children were more passive initially but as
they became older (12 months onwards up to 2 and
¼) their negative and resistant behavior increased.
Unresponsive mothers (i.e. who do not demonstrate
controlling features or hostility) who neglect their
children have infants who, as they grow in to toddlers
from one year old, learn to display their anger rather
than inhibit it in comparison with abused children
(p<0.001)
Neglecting mothers seemed to be withdrawn and
uninvolved with their infants; they expressed little or
no affection to their children and initiated few
activities with them. Involvement in their infants play
was sporadic and quite minimal( p<0.001)
Page 24 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Crittenden8
1985 USA
Total: 2 - 48 months Gender not stated
Longitudinal
(mean 24 months)
The groups differed
significantly from each
other on variables
relevant to network
relationships (maternal
age, marital status,
education and mental
retardation)
121 Mother Infant
Dyads
18 Neglect
30 Neglect / Abuse
22 Abuse
22 Marginally
Maltreated
29 Adequate / Control
Crittenden9
1985 USA
Case-control
Matched on: age,
ethnicity, race, marital
status, maternal age,
maternal education,
maternal emotional
disturbance or mental
retardation
21 Neglect
21 Neglect / Abuse
17 Abuse
22 Problematic
13 Control
Total: 2 - 24 months Total: 40 F : 33 M
(mean 13.7 months)
Results
Insecure avoidant status seen in neglected infants
Neglecting mothers more likely to impart to children
sense of helplessness despair and scarcity
(p=0.008)
Neglected infants had predominantly passive
behavior pattern of interaction with their mothers (12
out of 20) (p<0.001).
Neglected infants showed insecure avoidant (8/11)
or very passive distress (3/11) in the quality of their
attachment to their mothers (p<0.001).
Neglected infants mean DQ 79.9 (lowest)
Compared with abused infants DQ 83, Problematic
infants DQ 90 and adequate infants DQ 100
(p<0.004)
Page 25 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Culp10
1991 USA
Retrospective Cohort
No significant
difference between the
groups on
demographic variables
41 Neglect
13 Neglect / Physical
Abuse
20 Physical Abuse
Total: 37 F : 37 M
Neglect group
(mean): 41.5 months
(SD 11.2)
Neglect / Physical
Abuse group
(mean): 41.2 months
(SD 10.6)
Abuse group
(mean): 42.5 months
(SD 12.6)
DiLalla11
1990 USA
Case-control
Total: 2-48 months
Matched on: age,
(mean 26 months)
gender, race,
(SD 12.7)
demographic
variables, low income,
development, number
of children in the home
41 Neglect
51 Neglect / Abuse
28 Control
Total: 58 F : 62 M
Child negativity was strongly associated with
caregiver hostility for neglect and abuse groups
(p<0.01).
Neglect children had significantly less positive social
interaction compared with controls (p<0.001).
Neglectful parents showed the least positive social
interaction (p<0.001)
Dubowitz12
2002 USA
37 months (mean)
Prospective Cohort
(SD 2.3) total group
Longitudinal
No difference between implied neglected
the groups on race,
age, or socioeconomic status
136 Maltreated
children
30% from a FTT clinic
26% High risk HIV
clinic
44% General Pediatric
clinic
Total: 63 F : 73 M
At age three psychological neglect significantly
associated with children’s internalizing (p<0.01) and
externalizing behavior problems (lying / aggression)
(p<0.001) when controlled for maternal depression
and socio-economic risk related to poverty age three
years.
Neglect measured at age three did not predict
changes in children’s development and behavior
between ages 3 - 5. Cumulative Neglect Index was
associated with internalizing problems (depression /
passivity) (p<0.001)
Neglect group had the lowest scores on auditory and
verbal scores on the Preschool Language Scale
(p<0.01), and lowest scores on Profile language
subscale (p<0.01). Neglect most strongly associated
with expressive and receptive language delay. All
three groups were delayed cognitively but no
significant inter-group variability
Page 26 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Dubowitz13
2004 USA
Assessed at 5 years 50% M (of 173) = 86
Prospective Cohort
and then again at 6
Matched on: age,
years
gender, race, social
class
173 Children, all
Neglect (appears to be
the same recruitment
practice as for
Dubowitz56)
Environmental neglect was significantly related to
behavior problems internalizing and externalizing as
reported by mothers but not reported by teachers
(p<0.001).
More difficulties with peer relations with
psychological neglect, at age six on teacher report
(p<0.01)
Egeland14
1981 USA
Prospective Cohort
Matched on: age,
gender, socioeconomic group,
maternal age
24 Neglect
19 Emotional Neglect
19 Emotional Abuse
85 Control
All groups assessed Not stated
at these ages (3, 6,
12, 18, 24 months)
so 3 - 24 months
On problem solving, the pure neglect group showed
more anger (p<0.01).
Emotional Abuse infants showed frustration and
anger earlier in the problem solving tasks at 24
months (p<0.01).
43% of Emotional Abuse group classified as type A
at 12 months, 85% type A by 18 months
14% classified as D and none classified as securely
attached at 18 months.
29% Neglect classified as secure at 12 months
57% classified as C but by 18 months there were no
Cs but 50% had become As.
Low coping scores indicating a tendency to become
disorganized in the face of challenge with minimum
stressi (p<0.05)
Egeland15
1983 USA
Prospective Cohort
Matched on: age,
gender, socioeconomic group,
maternal age
24 Neglect
19 Emotional Neglect
19 Emotional Abuse
85 Control
Total: Task One: 42
months, Task Two:
56 months
Not stated
Emotionally neglected children of mothers who were
psychologically unavailable showed marked
increases in maladaptive patterns of functioning from
infancy through preschool.
Noncompliant, angry and avoidant of their mothers
(p<0.01).
Neglected children had the most difficulty pulling
themselves together to deal with various tasks
(p<0.01). They lacked self esteem and agency
necessary to cope with various tasks (p<0.01)
Page 27 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Egeland16
1981 USA
Total: 0 - 12 months Not stated
Prospective Cohort
Groups differed on:
age, marital status and
educational
attainment. However
they did control for
economic level, and
the number of
deliveries, birth weight
and gestational age
was the same in the
two groups
24 Severe Neglect
3 Neglect / Physical
Abuse
4 Physical Abuse
33 Control
Eigsti17
2004 USA
Case-control
Matched on: age,
gender, ethnicity,
family income,
maternal education
9 Neglect
9 Neglect / Physical
Abuse
16 Emotional Abuse
14 Control
Total Maltreatment
group: 55 - 59
months (mean 57
months, 20 days)
Total Maltreatment
group combined: 9 F
: 10 M
Control group: 7 F :
7M
Results
50% of the neglected children were rated as C at 12
months compared to only 9% of controls (p=0.008)
At 18 months the neglect group shifted from a C type
to A (37% as opposed to 14% at 12 months) types
but some are also classified as secure (47% as
opposed to 36% at 12 months)
There is a 52% change overall in the ‘inadequate
care’ group between 12 and 18 months, showing
substantial instability in attachment classification
(p<0.05)
Maltreated children showed a 16 month delay in
syntactic development language compared with 13
months for controls
Girls had the greater delay on the IPSyn score 76.7
compared with boys 82.7
Scores on PPVT were lower in maltreated groups
(Mean=87.9, SD 14.2), compared with controls
(Mean=102.1, SD 22.8) p<.04
Mothers in the maltreating groups produced a small
number of utterances p=0.025, spoke less
frequently, with fewer two category utterances Yes /
No questions p=.04 and produced fewer complex
multi clause utterances p=0.04
Maternal verbal IQ scores correlated significantly
with child PPVT, p=0.02score
And with child IPSyn score p=0.04
Page 28 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
English18
2005 USA
Age
Retrospective Cohort Total: 0 - 4 years
Matched on: age,
ethnicity and family
socio-economic status
212 Children
Maltreated)
Sex
Results
109 F : 103 M
Withdrawn, social, aggressive, delinquent and
thought problems associated with failure to provide
food and frequent location transitions (p<0.001).
Anxiety, depression attention problems associated
with failure to provide adequate hygiene (p<0.001)
Impairment in communication (expressive language)
associated with dirty, unsafe, residence (dilapidated)
(p<0.001) and with failure to provide shelter.
Receptive language impairment associated with
untreated emotional or behavioral problems
(p<0.005).
Problems in social domain associated with failure to
provide shelter (p<0.001).
Verbal aggression and verbally aggressive discipline
associated with child anxiety, depression (p<0.001),
attention problems (p<0.001), delinquent (p<0.001),
and aggressive behaviors (p<0.001), somatic
complaints (p<0.005)
Page 29 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Erickson19
1989 USA
Age
Total: 54 months
Prospective Cohort
and 64 months
Matched on: age,
gender, ethnicity,
socio-economic status,
maternal age
17 Neglect
16 Emotional Neglect
16 Physical Abuse
11 Sexual Abuse
65 Control
Sex
Results
Neglect group: 8 F :
9M
Emotional Neglect
group: 7 F : 9 M
Physical Abuse
group: 7 F : 9 M
Sexual Abuse
group: 7 F : 4 M
Teacher report on Neglect children:
Impatient, disrespectful, self destructive, nervous
and overactive, aggressive and obsessivecompulsive, presented more problems than the
control or the Physical Abuse groups.
Teachers rated the Emotional Neglect group
consistently as aggressive and nervous (p<0.01) on
both the rating scales, they had the highest scores
on externalizing scale (p<0.01)
Extremely inattentive, uninvolved, anxious and
withdrawn (p<0.001) (CBCL internalizing scale more
than Emotional Neglect group). Very low in positive
affect (p<0.001).
Neglect children had lower scores on WIPPSI for
comprehension (p<0.001), vocabulary and animal
house subtests as well as for the total tests
compared with controls, Emotional Neglect and
Sexual Abuse groups.
Teachers rated Neglect children as having more
difficulty comprehending school work (p<0.01),
lacking creative initiative (p<0.01), low in reading,
poorer at following directions (p<0.05) and
expressing themselves (p<0.05).
11/17 (65%) referred for special help in Kindergarten
Emotional Neglect children had lower scores on
block design (p=0.06) and overall lower total scores
on WIPPSI though not as significant as neglect
children. 6/16 (37%) referred for special help in
kindergarten.
Neglect children were unpopular (p<0.01), lower in
social competence (p<0.001), lacking leadership
skills (p<0.001).
Emotional Neglect children lower in social
competence (p<0.05)
Page 30 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Fagan20
1993 USA
Case-control
Matched on: age,
gender, race, income
17 Neglect
10 Control
Total: 1 - 3 years
Neglect group: 8 F :
(mean 27.5 months) 9 M
Mothers are less developmentally appropriate to
their children (less attuned) in free play (p<0.05)
Neglecting mothers were significantly less
responsive to children than adequately rearing
mothers (p<0.01) even when controlling for mother’s
education level. Suggests that mothers are less
competent in understanding and responding to their
children in developmentally appropriate ways.
Frodi21
1984 USA
Case-control
Demographically
comparable for
ethnicity and socioeconomic groups,
other details not given
12 Neglect
8 Abuse
21 Low Normal IQ
Controls
19 High Normal IQ
Controls
3 - 5 years (mean
for Neglect group:
47.7 months)
Group differences were significant (p<0.01) with
neglected children scoring the lowest. When IQ was
entered as a co-variate there were no differences
between the neglect, abuse and low –normal groups
on their ability to discriminate emotion in others.
Hoffman-Plotkin22 Case-control
1984 USA
Well matched on: age,
gender, race, family
income, education,
marital status
14 Neglect
14 Physical Abuse
14 Control
Total: 3 - 6 years
Neglect group
(mean): 50.6 months
(SD 11.6)
Abuse group
(mean): 49.1 months
(SD 9.2)
Control group
(mean): 50.6 months
(SD 8.8)
Sex
Neglect group: 4 F
:10 M
Abuse group: 5 F : 9
M
Control group: 5 F :
9M
Results
Disruptive behavior correlated with aggression and
teacher discipline for the neglected children
(p<0.01).
Neglected children had lower scores on cognitive
functioning compared with normal controls.
Significant on all standardized tests (p<0.05).
Neglected children engaged in the least number of
Interactions with other children especially pro-social
behavior with children and social interactions
(p<0.05)
Page 31 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Koenig23
2000 USA
Case-control
Demographically
comparable group of
low income, nonmaltreating families
46 Maltreated
26 Neglect
43 Control
Maltreated group: 23 Maltreated group
were 3 years and 23 Total: 43 F : 46 M
were 4 years
Neglected children demonstrated significantly more
negative affect (anger) (p<0.01) than either
physically abused or non maltreated children.
Koenig24
2004 USA
Case-control
Demographically
comparable group of
low income, nonmaltreating families
26 Neglect
28 Abuse
28 Control
Neglect group
(mean): 62.85
months (SD 4.78)
Neglect group: 13 F
: 13 M
Neglected children engaged in significantly more
cheating behavior (p<0.01) and less rule compatible
behavior (p<0.05)
Lamb25
1985 USA
Case-control
Matched closely on:
age, gender, ethnicity,
maternal and paternal
education and
occupation
16 Neglect
32 Control
Neglect group: 8.7 37.8 months (mean
18.4 months)
Not stated
10 of the 16 children in the Neglect group showed
insecure avoidant attachment by classification
(p<0.005).
Three were secure and three were type C resistant.
Macfie26
2001 USA
Case-control
Matched on: age
gender, ethnicity,
socio-economic status,
maternal age, number
of people in the home
155 Maltreated
60 Neglect
43 Control
Neglect group: 3
years, 7 months - 6
years (mean 5
years) (SD 6
months)
Maltreated group: 43 Neglected group showed significantly more
F : 112 M
dissociation than the non-maltreated group
(p<0.001)
Page 32 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Macfie27
1999 USA
Case-control
Matched on: age
gender, race, family
income, education,
number of adults in the
home
21 Neglect
59 Abuse
27 Control
Total: 3 years,10
Total: 41 F : 66 M
months - 5 years,10
months (SD 5
months)
Neglected children portrayed the children (Story
Stem) as responding less often to relieve distress in
other children (p<0.01)
Mackner
1997 USA
Case-control
Matched on: gender,
ethnicity, socioeconomic status
Differed on child age
(Controls tended to be
slightly older) and
maternal education
and maternal
similarities score on
WAIS
23 Neglect
27 Neglect / FTT
70 FTT
57 Control
Neglect group
(mean): 16.35
months (SD 5.91)
Neglect / FTT group
(mean): 14.18
months (SD 5.3)
Neglect group: 11 F
: 12 M
Neglect / FTT group:
7 F : 20 M
The cognitive performance of the group with Neglect
and FTT (mean adjusted MDI = 85.45, SD 13.62)
was significantly below that of the children in the
neglect only (mean adjusted MDI= 97.72, SD 12.25)
(p<0.01), FTT only (mean adjusted MDI= 97.38, SD
13.79) and the comparison (no neglect or FTT
group) Mean adjusted MDI = 100.81, SD 16.4.
Maughan29
2002 USA
Case-control
Matched on: age,
gender, ethnicity,
income, language
development
37 Neglect
51 Control
Total: 4 - 6 years
(mean 5.31 years)
(SD 1.11)
Maltreatment group
(88): 47 F : 41 M
Neglect increased the odds of under
controlled/ambivalent emotion response regulation
patterns (running around room, apparent happiness)
by a factor of 7.5 (p<0.001), and over controlled /
unresponsive emotion regulation patterns by a factor
of 5.9 (p<0.01).
28
Sex
Results
Page 33 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Mustillo30
2011 USA
Prospective Cohort
573 Neglect
Neglect group: 2 - 5
years
260 F : 313 M
Depression in parents was associated with an
increased probability of neglectful parenting (p<0.01)
which had a significant effect on the child’s emotional
and behavioral problems (p<0.01)
Pianta31
1989 USA
Case-control
Matched on: age,
gender, socioeconomic status,
family income,
maternal age
24 Neglect
19 Emotional Neglect
19 Emotional Abuse
85 Control
Total: 3 - 24 months Not stated
Pollak32
2000 USA
Case-control
Matched on: age,
gender, socioeconomic status
Experiment One:
17 Neglect
16 Physical Abuse
15 Control
Experiment Two:
15 Neglect
13 Physical Abuse
11 Control
Total: 3.3 - 5.6 years
(median 52.7
months overall)
Neglect group
(median): 53.7
months
Physical Abuse
group (median): 52
months
Control group
(median): 51.9
months
Neglect group: 8 F :
9M
Physical Abuse
group: 4 F : 12 M
Control group: 7 F :
8M
Emotionally abusive mothers chronically found fault
with their children and criticized them in a harsh
fashion. In the problem solving task at 24 months,
children would be met with insults, blatant hostility
(angry tone) when they asked for
assistance.(p<0.01)
Psychologically unavailable mothers ignored their
child’s cues for assistance, offered no
encouragement even if the child was failing, and
looked comfortable even when the child was highly
frustrated.(p<0.05)
Neglected children showed less accurate recognition
of anger (p<.05), Significantly less recognition of
disgust than controls (p<.01).
More difficulty discriminating between emotional
expression compared with Physical Abuse
Lower response standard (bias) for selecting sad
faces.
Perceived less distinction between angry/ sad and
fearful expressions
Page 34 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Pollitt33
1975 USA
34
Age
Sex
Neglect group:12 Not stated
Case-control
60 months (mean 36
Matched on: age,
gender, race, maternal months)
education, but controls
from a higher income
group
14 Neglect (a child
with non organic basis
for FTT, with weight
and height below 3rd
centile)
15 Control
Rohrbeck
1986 USA
Case-control
Matched on: age,
gender, race, socioeconomic status,
education, marital
status, number of
children in the home,
no difference in gross
family income
12 Neglect
12 Abuse
14 Control
Neglect group
(mean): 57.55
months (SD 6.59)
Neglect group: 5 F :
7M
Scarborough35
2009 USA
Prospective Cohort
997 Neglect
479 F : 518 M
Grouped into 12
month cohorts:
0 - 12 months = 629
13 - 24 months =
221
25 - 36 months =
147
Results
Mothers of the FTT children were less likely to relate
to their children (p<0.01), were less affectionate in
comparison with the control mothers, who used more
positive verbal instruction, praise, and positive
contact with their children (p<0.01). Controls had
twice as many recorded instances of positive affect
than index cases
Neglectful mothers rated their children as having
more conduct problems; Mean parent and teacher
ratings of neglected children were in the direction of
greater dysfunction than either the abused or control
children (rated on 11 out of 12 scales) (p<0.05)
Developmental delay in preschool children (0 - 36
months) was predicted by neglectful care (failure to
provide for basic needs rather than failure to
supervise) (p<0.05)
Page 35 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Sullivan36
2008 USA
Age
Sex
Results
Prospective Cohort
4 years, and seen
Matched on: age,
again age 5 years
gender, ethnicity,
maternal employment,
maternal education,
marital status, family
state assistance
12 Neglect
19 Control
Original group of 19 Neglected children have early deficits in emotional
neglect (9 F : 10 M) knowledge across all three components labeling
but complete data
(p<0.01), visual recognition and matching context.
only available on 12
and gender
breakdown not
given.
Sylvestre
2010 Canada
Cross Sectional
68 Neglect
Neglect group: 2 36 months (mean
16.7 months)
Neglect group: 31 F
: 37 M
Language development delay in neglected child is
better explained by the specificity of risk factors
(maternal history of maltreatment in childhood
(p=0.08), depression (p=0.06) and mother’s weak
acceptability level towards the child (p=0.06)) rather
than cumulative risk model.
Toth38
2000 USA
Longitudinal
Prospective
Matched on: ethnicity,
gender, socioeconomic status,
maternal education,
marital status,
maternal age
56 Maltreated,
13 Neglect
Time 1: 3 years, 10
months (mean),
Time 2: 4 years, 9
months (mean)
16 F : 40 M
At Time 2 the neglected children evidenced more
negative self-representations than did nonmaltreated children, t (74.18) = 3.65 (p<.001)
37
Page 36 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Age
Sex
Results
Toth39
1997 USA
Total: 3.8 years - 5.8 Maltreatment group:
Case-control
years (mean 5
29 F : 51 M
Matched on: age,
years)
gender, ethnicity,
socio-economic status,
marital status of
mother, number of
adults in the home,
number of children in
the home
21 Neglect
36 Physical Abuse
23 Sexual Abuse
27 Control
Valentino40
2006 USA
Case-control
Matched on: age,
gender, ethnicity,
marital status,
maternal age, apart
from some difference
on family size
47 Mixed Neglect /
Emotional Abuse
52 Control
Neglect / Emotional 58.7% F : 41.3% M
Abuse group
(mean): 2.06 months
(SD 0.72 months)
Infants from neglecting families did not differ
significantly on any of the measures from the other
maltreatment groups (p=ns)
Venet41
2007 Canada
Case-control
Matched on: age,
gender
39 Neglect
35 Control
Neglect group: 18 F
Neglect group
(mean): 60.2 months : 21 M
Neglected children displayed more overall
disorganized markers, specifically more frightening
markers (p<0.01) and also depicted their mothers as
being absent or less available compared with
controls (p<0.05).
Neglected showed a significant difference in
attachment representations even when socioeconomic status and maternal stress were controlled
(p<0.05).
Neglected group had a significantly higher proportion
of avoidant attachment classification (p<0.01)
Neglected children had the lowest positive self
representation compared with Sexual Abuse,
Physical Abuse and Controls (p<0.01)
Neglected children had more negative maternal
representations compared with controls, though not
as marked as Physical Abuse children (p<0.001)
Page 37 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
Author, Year and Study
Country
Design/Population
Waldinger42
2001 USA
Age
Case-control
Total: 4.33 - 5.8
Matched on: age,
years (mean 5.10
gender, minority status years) (SD 0.34)
(sic), family income,
education, number of
adults in the home
9 Neglect
22 Control
Sex
Results
Neglect group: 1 F :
8M
Children represent themselves as angry and
opposing others more frequently than non
maltreating (p<0.05)
Neglect children more likely to represent the other
child as sad, hurt or anxious (p<0.01) and more likely
to see self as shamed or anxious (p=0.06)
Page 38 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eReferences
1. Allen RE, Oliver JM. The effects of child maltreatment on language development. Child Abuse Negl.
1982;6(3):299-305.
2. Cheatham CL, Larkina M, Bauer PJ, Toth SL, Cicchetti D. Declarative memory in abused and neglected
infants. Adv Child Dev Behav. 2010;38:161-182.
3. Christopoulos C, Bonvillian JD, Crittenden PM. Maternal language input and child maltreatment. Infant
Ment Health J. 1988;9(4):272-286.
4. Cicchetti D, Rogosch FA, Toth SL. Fostering secure attachment in infants in maltreating families
through preventive interventions. Dev Psychopathol. 2006;18(3):623-649.
5. Crittenden PM. Children’s strategies for coping with adverse home environments: an interpretation
using attachment theory. Child Abuse Negl. 1992;16(3):329-343.
6. Crittenden PM, DiLalla DL. Compulsive compliance: the development of an inhibitory coping strategy in
infancy. J Abnorm Child Psychol. 1988;16(5):585-599.
7. Crittenden PM, Bonvillian JD. The relationship between maternal risk status and maternal sensitivity.
Am J Orthopsychiatry. 1984;54(2):250-262.
8. Crittenden PM. Social networks, quality of child rearing, and child development. Child Dev.
1985;56(5):1299-1313.
9. Crittenden PM. Maltreated infants: vulnerability and resilience. J Child Psychol Psychiatry.
1985;26(1):85-96.
10. Culp RE, Watkins RV, Lawrence H, Letts D, Kelly DJ, Rice ML. Maltreated children's language and
speech development: abused, neglected, and abused and neglected. First Lang. 1991;11(33):377389.
11. DiLalla DL, Crittenden PM. Dimensions of maltreated children's home behavior: a factor analytic
approach. Infant Behav Dev. 1990;13(4):439-460.
12. Dubowitz H, Papas MA, Black MM, Starr RHJ Jr. Child neglect: outcomes in high-risk urban
preschoolers. Pediatrics. 2002;109(6):1100-1107.
13. Dubowitz H, Pitts SC, Black MM. Measurement of three major subtypes of child neglect. Child
Maltreat. 2004;9(4):344-356.
Page 39 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
14. Egeland B, Sroufe A. Developmental sequelae of maltreatment in infancy. New Dir Child Adolesc Dev.
1981;(11):77-92.
15. Egeland B, Sroufe LA, Erickson M. The developmental consequence of different patterns of
maltreatment. Child Abuse Negl. 1983;7(4):459-469.
16. Egeland B, Sroufe LA. Attachment and early maltreatment. Child Dev. 1981;52(1):44-52.
17. Eigsti IM, Cicchetti D. The impact of child maltreatment on expressive syntax at 60 months. Dev Sci.
2004;7(1):88-102.
18. English DJ, Thompson R, Graham JC, Briggs EC. Toward a definition of neglect in young children.
Child Maltreat. 2005;10(2):190-206.
19. Erickson MF, Egeland B, Pianta R. The effects of maltreatment on the development of young children.
In: Cicchetti D, Carlson V, eds. Child Maltreatment: Theory and Research on the Causes and
Consequences of Child Abuse and Neglect. New York, NY: Cambridge University Press; 1989:647684.
20. Fagan J, Dore MM. Mother-child play interaction in neglecting and non-neglecting mothers. Early Child
Dev Care. 1993;87:59-68.
21. Frodi A, Smetana J. Abused, neglected, and nonmaltreated preschoolers’ ability to discriminate
emotions in others: the effects of IQ. Child Abuse Negl. 1984;8(4):459-465.
22. Hoffman-Plotkin D, Twentyman CT. A multimodal assessment of behavioral and cognitive deficits in
abused and neglected preschoolers. Child Dev. 1984;55(3):794-802.
23. Koenig AL, Cicchetti D, Rogosch FA. Child compliance/noncompliance and maternal contributors to
internalization in maltreating and nonmaltreating dyads. Child Dev. 2000;71(4):1018-1032.
24. Koenig AL, Cicchetti D, Rogosch FA. Moral development: the association between maltreatment and
young children's prosocial behaviors and moral transgressions. Soc Dev. 2004;13(1):87-106.
25. Lamb ME, Gaensbauer TJ, Malkin CM, Schultz LA. The effects of child maltreatment on security of
infant-adult attachment. Infant Behav Dev. 1985;8(1):35-45.
26. Macfie J, Cicchetti D, Toth SL. Dissociation in maltreated versus nonmaltreated preschool-aged
children. Child Abuse Negl. 2001;25(9):1253-1267.
Page 40 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
27. Macfie J, Toth SL, Rogosch FA, Robinson J, Emde RN, Cicchetti D. Effect of maltreatment on
preschoolers’ narrative representations of responses to relieve distress and of role reversal. Dev
Psychol. 1999;35(2):460-465.
28. Mackner LM, Starr RHJ Jr, Black MM. The cumulative effect of neglect and failure to thrive on
cognitive functioning. Child Abuse Negl. 1997;21(7):691-700.
29. Maughan A, Cicchetti D. Impact of child maltreatment and interadult violence on children’s emotion
regulation abilities and socioemotional adjustment. Child Dev. 2002;73(5):1525-1542.
30. Mustillo SA, Dorsey S, Conover K, Burns BJ. Parental depression and child outcomes: the mediating
effects of abuse and neglect. J Marriage Fam. 2011;73(1):164-180.
31. Pianta R, Egeland B, Erickson MF. The antecedents of maltreatment: tesults of the Mother-Child
Interaction Research Project. In: Cicchetti D, Carlson V, eds. Child Maltreatment: Theory and
Research on the Causes and Consequences of Child Abuse and Neglect. New York, NY: Cambridge
University Press; 1989:203-253.
32. Pollak SD, Cicchetti D, Hornung K, Reed A. Recognizing emotion in faces: developmental effects of
child abuse and neglect. Dev Psychol. 2000;36(5):679-688.
33. Pollitt E, Eichler AW, Chan CK. Psychosocial development and behavior of mothers of failure-to-thrive
children. Am J Orthopsychiatry. 1975;45(4):525-537.
34. Rohrbeck CA, Twentyman CT. Multimodal assessment of impulsiveness in abusing, neglecting, and
nonmaltreating mothers and their preschool children. J Consult Clin Psychol. 1986;54(2):231-236.
35. Scarborough AA, Lloyd EC, Barth RP. Maltreated infants and toddlers: predictors of developmental
delay. J Dev Behav Pediatr. 2009;30(6):489-498.
36. Sullivan MW, Bennett DS, Carpenter K, Lewis M. Emotion knowledge in young neglected children.
Child Maltreat. 2008;13(3):301-306.
37. Sylvestre A, Mérette C. Language delay in severely neglected children: a cumulative or specific effect
of risk factors? Child Abuse Negl. 2010;34(6):414-428.
38. Toth SL, Cicchetti D, Macfie J, Maughan A, VanMeenen K. Narrative representations of caregivers and
self in maltreated pre-schoolers. Attach Hum Dev. 2000;2(3):271-305.
Page 41 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
39. Toth SL, Cicchetti D, Macfie J, Emde RN. Representations of self and other in the narratives of
neglected, physically abused, and sexually abused preschoolers. Dev Psychopathol. 1997;9(4):781796.
40. Valentino K, Cicchetti D, Toth SL, Rogosch FA. Mother-child play and emerging social behaviors
among infants from maltreating families. Dev Psychol. 2006;42(3):474-485.
41. Venet M, Bureau J, Gosselin C, Capuano F. Attachment representations in a sample of neglected
preschool-age children. Sch Psychol Int. 2007;28(3):264-293.</jrn
42. Waldinger RJ, Toth SL, Gerber A. Maltreatment and internal representations of relationships: core
relationship themes in the narratives of abused and neglected preschoolers. Soc Dev.
2001;10(1):41-58.
Page 42 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 9. Assessment Tools Used by Study Authors
1. Preschool Language Scale Manual (Zimmerman, Steiner and Pond, 1979)
2. Bayley Scales of Infant Development - Second Edition (Bayley, 1993)
3. Imitation Paradigm (Bauer Wenner et al, 2000)
4. Demographic Interview (Cicchetti and Carlson, 1989)
5. Childhood Trauma questionnaire (Bernstein, Fink, Handelsmann and Foote, 1994)
6. Perceptions of Adult Attachment Scale (Lichtenstein and Cassidy, 1991)
7. Maternal Behaviour Q-set (Pederson and Moran, 1995)
8. Adult-Adolescent Parenting Inventory (Bavolek, 1984)
9. Social Support Behaviours Scale (Vaux Riedel and Stewart, 1987)
10. Parenting Stress Inventory (Abdin, 1990)
11. Strange Situation(Ainsworth et al, 1978)
12. Parent professional relationship checklist (Crittenden, 1985)
13. Goldman-Fristoe Test of Articulation (1972)
14. Early Intervention Development Profile (Schafer and Moesch, 1981)
15. McCarthy scales of child abilities(McCarthy, 1972)
16. CARE Index(Crittenden, 1988)
17. Crittenden devised scale(Crittenden and Snell, 1983)
18. Extended Home Observation coding system (DiLalla and Crittenden, 1990)
19. Home Observation for Measurement of the Environment (Caldwell and Bradley, 1979)
20. Diagnostic Interview Schedule 3rd edition
21. Child Well Being Scales (Magura and Moses, 1986)
22. Perceived neighbourhood scale (Martinez, 2000)
23. Stanford Binet Intelligence Scale 4th edition
24. Child Behaviour Checklist (Achenbach, 1991)
25. Centre for epidemiological studies depression scale (CES-D)
26. Child care rating scale(Egeland, 1985)
27. Barrier Box and Teaching Tasks (Egeland, 1982)
28. Index of productive syntax (Scarborough, 1990)
29. Peabody picture vocabulary test (Revised Dunn, 1981)
30. Wechsler Adult Intelligence Scale (1995)
31. Tool MRRA, interviewer rating of condition of residence (LONGSCAN 1991)
32. Life experiences survey (Sarason, 1978)
33. SEPA: separation from caregiver (LONGSCAN 1991)
34. Conflict tactics scale Discipline methods (Strauss, 1997)
35. LECA: Child life events (LONGSCAN 1992)
36. CSUA: Service utilisation (LONSCAN 1991)
37. Tool RNA: emotional maltreatment allegations coding of maltreatment referrals (LONGSCAN
1997)
38. Battelle Developmental Inventory Screening Test (Newborg, 1984)
Page 43 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
39. Barrier box and learning tasks (Egeland, 1983)
40. Wechsler Preschool and Primary Scale of Intelligence (1964)
41. Devereux Elementary School behaviour rating scale(Spivack and Swift, 1967)
42. Parent/care giver involvement scale (Farran,Kasari, Cornfort and Joy, 1986)
43. Borke interpersonal awareness (Borke, 1971)
44. Rothenberg social sensitivity test (Rothenberg, 1970)
45. Merrill Palmer Scale of Mental Tests
46. Child Behaviour Form (Lorion, 1981)
47. ABA semi structured free play (Cicchetti and Becghly, 1987)
48. Mc Arthur story stem battery (Bretherton et al, 1990)
49. Experimenter distress paradigm (Miller et al, 1996)
50. Stealing Paradigm(Koenig, 2004)
51. Donation Paradigm (Eisenberg, 1999)
52. Cheating game (Kochanska, 1996)
53. Narrative story stem task (Kochanska, 1996)
54. Child Dissociative Checklist (Putman, Helmers and Trickett, 1993)
55. Composite International Diagnostic Interview (Kessler, Andrews et al, 1998)
56. Emotion Recognition Task (Dashiell, 1927, adapted Ribordy, 1988)
57. Emotion Discrimination task (Borod, 1990)
58. Emotion differentiation task (Borod, 1990)
59. Childhood level of living scale (Polansky, 1968)
60. Connors parent and teacher rating scales (1968)
61. Delay of gratification task (Kansas, 1986)
62. Reflection impulsivity scale for preschoolers (Wright, 1971)
63. Vineland Screener (Sparrow et al, 1993)
64. Kaufmann Brief Intelligence Test (1990)
65. Test of non verbal intelligence for children to estimate IQ (Brown et al, 1997)
66. Rossetti Infant –Toddler language scale (Rossetti, 1990)
67. Knowledge of development questionnaire (MacPhee, 1981)
68. Family assessment device (Epstein et al, 1983)
69. Communication simulation questionnaire (Sylvestre et al, 1998)
70. Perceived adequacy of resources scale (Rowland et al, 1985)
71. Child structural play scale (Nicolich, 1977)
72. Parental Stress Index (Bigras, 1996)
73. Core conflictual relationship theme method (Luborsky and Crits-Christoph, 1990)
74. Disorganisation scales (George and Solomon, 1996)
75. Attachment Story Stem Completion Task (Bretherton, Ridgeway and Cassidy, 1990)
76. Auxological anthropometry method (Cameron, 1986)
Page 44 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014
eAppendix 10. Patterns of Attachment (ABC Classification)
Secure (B)
Insecure
Ambivalent or
resistant (C)
Insecure
Avoidant(A)
Disorganized(D)
Children use their caregiver as a secure base for exploration. They miss him/her
on separation, but are easily soothed on reunion, greeting the caregiver with
smiles, words or gestures
Children are either excessively fretful or passive, and fail to explore their
surroundings. They are distressed at separation and on reunion are not
comforted, alternating bids for contact with angry rejection, or becoming passive.
Children explore readily and are minimally responsive to separation, actively
avoiding the caregiver on reunion, sometimes arching away and seeking comfort
in toys.
Children lack any coherent style of response to separation or reunion, showing
incomplete or contradictory behaviors, including fear, depression, confusion.
83
84
Adapted from Ainsworth 1978 & Main 1991
Page 45 of 45 Downloaded From: http://archpedi.jamanetwork.com/ on 10/28/2014