Childhood Maltreatment: Emotional Consequences and Potential Intervention

Lead Research Organisation: King's College London
Department Name: Psychology


Childhood maltreatment, which includes the abuse and neglect of children and young people, is a significant problem that occurs in all countries in the world. Early maltreatment has serious, long-lasting consequences on an individual's health and well-being, but can also impact economic growth. Most estimates of the prevalence of childhood maltreatment have come from surveys conducted in high-income countries, with outstanding questions remaining on the nature and extent of child abuse and neglect among lower-income countries and, within these countries, among the most disadvantaged sectors. The evidence base is poor because of cultural stigma associated with childhood maltreatment and cultural norms around the acceptability of abuse as a form of discipline and punishment. Moreover, the economic context of these countries enables the general exploitation of children in the labour force. This could not only increase the likelihood of other forms of abuse and neglect but also make their presence less transparent. The first major goal of our research is to study the frequency of different forms of abuse and neglect among working children and young people in North India and Nepal. This work will directly contribute to our understanding of the scope of the problem and facilitate, among governmental and non-governmental organisations, specific recommendations for preventing violence against children, which are key ongoing priorities for the World Health Organisation and United Nations. Dissemination of our findings locally will also enable gradual change in attitudes and perceptions, shifting cultural norms and practices. Although the effects of childhood maltreatment on later-life health and functioning are well-documented, the pathways by which early-life adversity increases vulnerability on these negative outcomes are less well-understood. Prior research suggests that early adversity affects how the brain develops, particularly how it responds to, and manages stress. We do not know much about how these effects on the brain affect the way we process emotional information and think about the world - even though cognitive factors are directly targeted in psychological therapies. The second major goal of our research is to investigate how childhood abuse and neglect alters the processing of emotional information. We expect that as early maltreatment can leave scars on the developing brain, this affects the way that its victims attend to threatening information (showing vigilance for threat cues) and appraise ambiguous information (showing a tendency to interpret situations negatively or with hostile intent). These negative patterns of thinking may then increase the likelihood of developing anxiety, depression and aggressive responses towards stressful events - and even reinforce these negative problems. Although these disturbed patterns of thinking have been reported in physically abused children and young people, these studies have largely been conducted in high-income countries. Identifying these cognitive-emotional disturbances in maltreated young people from lower-income countries lays the foundation for developing a novel treatment tool to directly target these negative thought patterns in young people from these poorer countries.
Developing and piloting a novel training intervention tool to encourage more adaptive ways of processing emotional information is the third major goal of our research. Specifically, cognitive bias modification is a technique used to correct negative thinking patterns, and therefore negative responses towards stress. It has been successfully used in adults with mood and anxiety problems, and in children and young people with emotional and aggressive problems. We will adapt this programme for use in maltreated young people and test whether this programme modifies negative thought patterns and, in doing so, normalises dysfunctional brain circuits, so that they resemble those of non-abused young people.

Technical Summary

Childhood maltreatment is a significant global problem. Most estimates of prevalence are from surveys in high-income countries with less known about the scope of childhood maltreatment in lower income countries. The first objective of our research is to investigate the frequency of different forms and severity of child abuse and neglect and co-occurring psychopathology in India and Nepal. We will target child and adolescent labourers, as these represent one of the most disadvantaged sectors of society, with high rates of maltreatment. The second objective of our research is to extend our understanding of the cognitive phenotype of childhood maltreatment. Prior work (mostly from high-income countries) finds that child maltreatment - in particular physical abuse - are associated with greater attention capture by, and difficulties directing attention away from threatening cues. Physically-abused youth also show distorted appraisal styles, selecting more threatening or hostile interpretations of ambiguous information. Many of these studies do not consider the confounding effects of mood, anxiety or trauma symptoms. We will investigate whether in Indian and Nepalese youth, physical abuse is also associated with differences in attention and appraisal biases relative to their non-physically abused peers after controlling for co-occurring psychopathology. These data lay the groundwork for considering novel strategies for targeting distorted information-processing in physically abused youth. Cognitive bias modification (CBM) training has been used successfully to reduce attention and appraisal differences among anxious and aggressive children and young people, with changes in behaviour. In adults, training has resulted in brain-based changes in regions involved in emotion. Our last objective is to extend CBM investigations to physically-abused youth in the UK, India and Nepal and investigate the neural substrates of training changes.

Planned Impact

The cumulative economic and social burden of childhood maltreatment is extremely high. In addition to the costs associated with the immediate effects on children and young people such as hospitalisation, there are major indirect long-term effects of child abuse and neglect, including but not limited to mental health and health care, juvenile delinquency and the adult criminal justice system, poor family relationships, and lost productivity to the society. The knowledge gained from this project will throw new light on the kind and frequency of abuse and neglect of child labourers belonging mostly to poor families (a disadvantaged sector of the society) and the negative cognitive and emotional consequences that follow significant physical (and possibly other kinds of) abuse. The availability, through this project, of a novel, ecologically-valid, easily accessible cognitive bias modification training programme capable of challenging emotional disturbances that very likely mediate the effects of early physical abuse on later mental health and problem behaviours in physically abused adolescents will be a major development with positive implications for victims and their families/care givers. However, in order to fully realise the study's findings and implications, a plan to effectively communicate and disseminate our findings to health and educational professionals, various local, national and international organisations concerned with child development and welfare, and the whole society will be needed. If funded, we are fully committed to maximising the impact of our research and ensuring effective channels of dissemination to all potential beneficiaries.

Studies 1 and 2, which investigate the scale and nature of abuse and neglect in child and adolescent labourers in India and Nepal, will be of interest to public health scientists and basic cognitive neuroscientists as (i) they fill a gap in our knowledge of the incidence of childhood maltreatment from low-income countries and (ii) extend our understanding of the cognitive-emotional disturbances that occur in the aftermath of early-life adversity. Our findings will also hold practical significance for non-governmental and governmental organisations involved in policies about child welfare, preventing violence against children and the use of children and young people in the labour force. We will work with these bodies to ensure maximal awareness of our findings, which in the long-run will gradually eliminate stigma and cultural norms that enable abuse and neglect to be hidden.

Studies 3 and 4 which investigate the effectiveness of a novel, cognitive training intervention will be relevant to scientists involved in the development and trialling of effective, easily-accessible therapeutic tools - and to those with an interest in neuroplasticity during development. As well as these academic channels, we aim to increase the dissemination of our findings to those who may be involved in directly translating these in clinical or educational settings.

Given the subject matter, we anticipate that the findings of studies 1-4 will attract interest, debate, and campaigning among the general public and insight for children and young people who have mental health problems or who have been exposed to early abuse and neglect. Engaging the general public and young people in particular in the science of child maltreatment is one of our major priorities.


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Krebs G (2018) Research Review: Cognitive bias modification of interpretations in youth and its effect on anxiety: a meta-analysis. in Journal of child psychology and psychiatry, and allied disciplines

Description "Child labour" - the employment of children and young people in the workforce in a way that contravenes global legal parameters - is a pressing human rights issue. Particularly prevalent in many Asian LMICs, where around 20% of young people are employed illegally, child labour deprives young people of their childhood and youth, as well as their education, future opportunities and prosperity. While eliminating child labour is an increasing focus of inter-governmental and non-governmental organisations (NGOs), until these efforts completely succeed, the provision of support to young people currently working illegally or those who have been rescued, is an urgent practical task. To date, our research has revealed 3 key findings that have been published in academic journals and disseminated to audiences in India and Nepal. Two other findings are currently being prepared for publication and will be described in the next reporting period.

First, our research has uncovered widespread exposure to violence in 200 rescued adolescent labourers in India and Nepal. These victimisation experiences in turn were associated with mental illness particularly affective disorders. Specifically, rescued labourers in Nepal with a history of maltreatment were more likely to report symptoms consistent with generalised anxiety disorder, post-traumatic stress disorder, and major depressive disorder than those without a history of maltreatment. Similarly, Indian rescued labourers who had experienced physical and/or emotional abuse were more likely to report symptoms consistent with a diagnosis of specific phobia, panic attacks, dysthymia, and major depressive disorder.

Second, our data also showed an under-recognition among staff working at care-homes of these emotional symptoms. Thus, while a third of young people reported symptoms consistent with a diagnosis of social phobia with a tenth reporting symptoms of generalised anxiety disorder, care-home staff only rated around 1% of the sample as manifesting symptoms consistent with these disorders. This discrepancy did not characterise more overt behavioural problems such as attention deficit hyperactivity disorder and conduct disorder, where rates were more comparable across raters. As recognition of symptoms of mental illness is one of the prerequisites to early referral of at-risk young people for professional help, our work highlights the importance of supporting care-home employees to learn more about mental illnesses in young people.

Finally, as untreated affective disorders in general youth populations impact social, educational and occupational functioning, and other serious mental and physical health problems, our work highlights the importance of intervening to treat the early "emotional wounds" of adolescent labourers early before they become entrenched and associated with negative trajectories and outcomes. Yet, there are few effective and accessible interventions that can be delivered in these low resource settings for marginalised young people - which is especially concerning given that our other work (as yet unpublished) shows that their symptoms are more complex and difficult to treat. To begin to address this, we have begun to a) investigate the mechanisms that mediate between childhood victimisation and later symptoms (data currently being prepared for publication) and b) develop and evaluate (for feasibility and acceptability) interventions that target these mediating mechanisms (cognitive processes of threatening information). We piloted this intervention first, through a case series of socially anxious young people in the UK and second, through a case series of young people in the UK and Nepal who had experienced early-life victimisation. Both case series (which have been published) indicate feasibility and acceptability. Based on these initial data, we carried out a feasibility randomised controlled trial in India and Nepal that is currently being analysed.
Exploitation Route It would be beneficial to understand more about the wider impact (psychosocial and economic) of elevated mental health problems in child labourers, particularly, how they may further deprive young people from potential future job opportunities and prosperity.

Other methods for treating early-emerging emotional problems should also be developed and trialed, with a view to developing those that can be cheaply administered and embedded in current local service infrastructure.

Finally, more needs to be done around creating psychoeducation packages on mental illness for employees working with young people who have been rescued from child labour or are currently illegally employed; these initiatives could also be implemented in a wider dissemination plan around mental health and illness in Nepal and India.
Sectors Education,Healthcare,Government, Democracy and Justice

Description Public Engagement small grant funding scheme
Amount £746 (GBP)
Organisation King's College London 
Sector Academic/University
Country United Kingdom
Start 01/2016 
End 01/2017
Title Development of Nepali and Hindi versions of questionnaire measures of child behavioural and emotional problems 
Description We have translated (and back translated) the Strength and Difficulties Questionnaire in Hindi and Nepali for wider use by the research community. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2016 
Provided To Others? Yes  
Impact This tool is now widely available from the website of the original publisher. 
Description Attention biases in anxiety: methodological innovations and clinical implications 
Organisation National Institutes of Health (NIH)
Country United States 
Sector Public 
PI Contribution Our team are currently convening a consortium of researchers working in the area of attention biases and anxiety; this will enable us to discuss the most effective assessment and intervention tools around attention biases in relation to anxiety problems in community and clinic samples, but also in samples who have experienced early-life adversity
Collaborator Contribution We have initiated links with leading experts in this area to convene a 3-day closed expert meeting on the study of attention biases in anxiety.
Impact Our first meeting will be in September 2017
Start Year 2017
Description Sharing research protocol with Haifa University researcher 
Organisation University of Haifa
Country Israel 
Sector Academic/University 
PI Contribution We have shared our research protocol with collaborator at Haifa University to run a similar study in her clinic in Israel, targeting both maltreated Arab and Jewish young people. We have successfully applied for the Daniel Turnberg Fellowship Scheme 2017 for her to visit the UK to work together on the data.
Collaborator Contribution We have helped to shape the research protocol used by our collaborator; we have also shared our tasks and programs.
Impact Successful application to the Daniel Turnberg Fellowship Scheme 2017
Start Year 2017
Description Meeting with government officials from the Central Child Welfare Board in Nepal 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We presented our study findings to members of the Central Child Welfare Board in Nepal; members were especially interested in the development of general training packages to support employees working with vulnerable young people - to give them more training and guidance over the recognition of mental health needs of their clients.
Year(s) Of Engagement Activity 2019
Description One-day International symposium on Childhood Maltreatment and Mental Health, Varanasi, India 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Third sector organisations
Results and Impact The goal of this one-day symposium was to disseminate information around the project findings, particularly those in India. Delegates included representatives from many non-governmental and (local) governmental organisations, as well as practitioners with a professional interest in the mental health consequences amongst victims of childhood maltreatment (arising often through illegal employment of work). After three keynote talks by the India PI (R Pandey), the UK co-I (V Kumari) and the State President of the Indian Medical Association and President of the Indian Academy of Pediatrics (Dr. Ashok Rai), there was a panel discussion to facilitate discussion around the practical difficulties faced by agencies in providing due care and/or assessment of children with history of child-work/abuse, and potential solutions.
Year(s) Of Engagement Activity 2020
Description Press conference for national media outlets 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact We organised a press conference in Kathmandu with representatives from around 10 different media outlets in Nepal. The junior and senior research fellows from the Nepal team read out a statement around the frequency of victimisation experiences and mental illness in rescued child labourers in Kathmandu. They also described the research team's objectives of developing and evaluating accessible interventions that could be embedded within existing services that are delivered by non-governmental organisations to reach these vulnerable young people. Journalists were then given the opportunity to ask questions.
Year(s) Of Engagement Activity 2019
Description School visit in Shrewsbury 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact Around 150 pupils attended the talk at the school which focused on mental health problems in particular anxiety. There was a lot of interest from the school staff and interesting questions from pupils.
Year(s) Of Engagement Activity 2016