Background
Psychological maltreatment is the most prevalent form of child abuse and is increasingly recognized as an essential component of child maltreatment and the unifying concept that connects cognitive, affective, and interpersonal problems related to physical abuse, sexual abuse, and neglect [
1]. Psychological maltreatment involves repeated interactions between a parent and child that are often verbal in nature that negatively affect the emotional, social, cognitive or even physical development of a child [
2]. These interactions typically include acts of commission as well as omission, such as spurning, terrorizing, isolating, exploiting and denying emotional responsiveness [
3].
Psychological maltreatment is believed to negatively affect the emotional, social and cognitive development of a child, making them more prone to substance abuse and other forms of psychopathology [
4]. Psychological maltreatment is thought to be the most common form of maltreatment and encompasses both emotional abuses as well as emotional neglect and also tends to accompany other forms of maltreatment, such as physical and sexual abuse [
5].
Emotional abuse refers to verbal assaults on a child’s sense of worth or well-being, or any humiliating, demeaning, or threatening behaviour directed toward a child by an older person [
6].
Emotional neglect is defined as failure of caretakers to provide a child’s basic psychological and emotional needs, such as love, encouragement, belonging and support [
7]. Emotional abuse can hurt to the same amount as physical abuse as it is not easy to identify, given that its effect may not be seen physically since the marks are on the inside instead of the outside [
7] .It is commonly understood that there exist a few well designed and approved measures of childhood emotional abuse. Children with emotional child abuse become extremely loyal to their parents because of the fear of being punished in cases where they report abuse or think that this type of abuse or have a feeling that this is part of the normal way of life [
8].
Indications of emotionally abused child include unsuitable way of behaving that may be associated with actions showing immaturity or more mature in relations to the child’s age [
9]. Overall change in behavior distraction of activities, clinging or impulsively seeking affection and attention forcefulness, unsupportiveness, bedwetting or loss of ability for bowel control (after a child has been trained), and damaging or disruptive behavior, constantly being sad and withdrawn) [
10]. Moreover, this may also be indicated with poor relationships with age group peers, lacking of self-confidence and self-assurance, uncommon fears for the child’s age such as fear of going home, being left alone, specific objects, or inability to react with emotion or develop an emotional bond with others, are also indicators. It is important to understand that any of the above behaviors may also be seen in normal children, but a change in pattern of these behaviors is a strong indicator of emotional abuse [
11]. Emotional abuse and physical abuse may occur and may be induced by the same reasons, parents may become susceptible to being involved in the maltreatment in cases where stress in their lives have circumstances associated with stress in their lives or stress levels that are way up beyond their control [
12].
Such dispositions in parents may lead to decreased capacity for consideration and handling of their children affairs as expected of them which may result in slowed mental growth or mental retardation, psychopathology, alcoholism, drug abuse and unrealistic ideas about their children’s needs or sadistic psychosis [
13].
It also occurs that the abuser’s goal may be to control. Nevertheless, a single factor may not lead to abuse, but a collection of many factors may lead to creation of social and emotional burdens that may result in emotional abuse [
14].
The known types of problems that can contribute to emotional abuse by parents may be related to social problems that can result in family stress such as joblessness, scarcity or poverty, segregation from relatives and friends, separation, death, adolescent parents, health crises, illness of a family member, incapacity of one of the family members or even drug and alcohol abuse within the family and mental health problems (mental incapacity, depression) [
15].
The implications of emotional child abuse can be grave and long-standing. A number of research studies have concluded that psychopathologic signs are more likely to result in children who are emotionally abused. As a result, children with this effect may experience long-term depression, disaffection, anxiety, low self-esteem and unstable relationships or failure to show empathy to their counterparts [
16]. During their childhood, victims of abuse may fail to flourish or their growing progress may be halted or slowed. Some may find it difficult to adjust emotionally and psychologically [
17].
Some adolescents often find it difficult to trust, participate and a get the happiness in their relationships with others as a result of the abuse during childhood. Later in adulthood they may have trouble knowing and appreciating the needs and feelings of their own children and end up emotionally abusing them as well [
18].
Emotional Neglect comes as a result of a parent’s inability to respond well
enough to a child’s emotional needs, sometimes
associated to mistreatment and abuse. Whereas mistreatment and abuse are parental
acts, emotional neglect is a parent’s
failure to act. It’s a failure and sometimes inability to notice, attend to, or responds appropriately to a child’s feelings. Given that it is an
act of omission, it’s not easily visible, noticeable or memorable [
19].
Neglect is the white space in the family picture, the background rather than the foreground. As much as it is often overlooked it does silent harm and damage to the concerned children [
20]. Emotionally neglected children in turn grow up to a set of struggles. Since their emotions were not made valid by their parents in adulthood, they are likely to face a struggle identifying their own emotions. Understanding their own feelings as well as those of others may even be more difficult, this is because an important part of themselves and their emotional self has been denied and this may lead to a feeling of disconnect, unfulfillment or emptiness [
21]. Trusting and relying upon others becomes even difficult to them, sometimes they may have a feeling of being different from others and a feeling that something that is wrong but do not know what it is that is wrong [
22].
In another way parents can emotionally neglect their children without knowing what damage they are causing to their children. Being neglected may lead to struggle with self-disciplines in adulthood.
It occurs that at the end, most often during adulthood those who experienced neglect do not have the childhood memories and therefore their difficulties are blamed on themselves rather than on their parents’ failures [
23].
Today emotional neglect has been ignored. This is because it’s not easily noticed and cannot be recalled by its victims. It has in many ways been overshadowed by the more visible childhood events, such as abuse and trauma [
23].
Emotional abuse and neglect have been reported to cause significant harm to the child’s development, and this harm extends into adolescence and adult life [
24]. Unlike cases involving physical or sexual abuse, emotional abuse and neglect are believed to be the least likely to be reported by victims; victims are rarely able to demonstrate visible proof and therefore lack a sense of legitimacy [
25]. Meta-analyses on the prevalence of different types of maltreatment have reported 17.7% for physical abuse, 26.7% for psychological abuse, 11.8% for sexual abuse and 16.3% for neglect [
26].
Globally, the prevalence of psychological maltreatment has been estimated to be 36% of children [
26]. One study in Turkey found that approximately 51% of children were psychologically maltreated [
27]. According to agency reports, the prevalence of psychological maltreatment in England, the USA and Canada ranged from 11 to 34% [
28]. A high prevalence ranging from 31.3 to 68.5% has been reported in East Asia and the Pacific Region [
29].
Previous studies e.g., [
30,
31] have reported a strong positive correlation between psychological maltreatment and low self-esteem.
This correlation between low self-esteem and psychological maltreatment is derived by the fact that psychological maltreatment in children can negatively affect the cognitive, social and emotional development of a child.
Self-esteem can be explained as continued self-evaluation and self-belief that one is strong, worthy, famous and successful [
32]. Individuals with high self-esteem feel quite positive about their characteristics and competencies, which can positively influence well-being, while low self-esteem can lead to many emotional and behavioural problems [
33].
Many studies have also evaluated the relationship between self-esteem and emotional and behavioural problems [
34] . Findings from these studies suggest that individuals with more emotional and behavioural problems have lower self-esteem. Parents play a keyhole in the development of self-esteem, which reflects individuals’ evaluations of themselves and their competencies [
35]. Psychological maltreatment experiences include parental acts that negatively affect mental health and development [
36]. Psychological maltreatment is also associated with psychological distress, which is largely defined as a state of emotional suffering characterized by symptoms of depression (e.g., lost interest; sadness; hopelessness) and anxiety (e.g., restlessness; feeling tense) [
37]. Psychological distress is reported to be an indicator of the mental health of the population in public health [
38].
The psychological maltreatment of children is widespread in developing countries including Tanzania and is believed to affect the overall psychological adjustment of the child [
10]. As a result, victims may experience psychological distress, with symptoms of low self-esteem, depression and anxiety that may result in substance abuse [
39].
However, it has been suggested that in a cultural environment where harsh disciplining techniques are accepted, the adverse impact on recipients may be minimal [
40].
Studies conducted in sub-Saharan countries have reported that many children are exposed to high levels of psychological maltreatment [
41]. Experiences from Tanzania show that parents often employ harsh physical and emotional discipline practices and believe that they do not harm their children [
42].
Several studies conducted in most developing countries show a strong relationship between exposure to psychological maltreatment and low self-esteem [
43]. Psychological maltreatment, including emotional abuse and neglect, is extremely common in Tanzania, yet not as broadly researched as sexual and physical abuse [
44].
Decades of research on psychological maltreatment in childhood have resulted in publications on the subject in the developed countries, especially the U.S. and Europe. To our knowledge, no research or publication has been done on the relationship between psychological maltreatment and self-esteem in childhood in many developing countries. Studies have shown that witnessing domestic violence has a negative impact on a child’s well-being and healthy development, especially in relation to psychological aspects such as low self-esteem [
45].
This study aims to cover that knowledge gap and address the relationship between self-esteem and psychological maltreatment in childhood in developing countries. We conducted our study in five different cities in Tanzania, East Africa.
Discussion
Psychological maltreatment in children represents the most challenging and prevalent form of child abuse and neglect worldwide [
53], but until recently, it has received relatively little attention in developing countries such as Tanzania. In this study, the presence of psychological maltreatment during childhood was reported in 76.6% of cases, emotional abuse was reported in 24.7% of the participants, while emotional neglect was reported in 51.9%, which is comparable with that reported in developing countries [
54] but higher than that observed in many other studies in developed countries [
55]. The prevalence of psychological maltreatment in the present study may be underestimated because this form of child maltreatment is mostly underreported to authorities for fear of being arrested by the police. Also, psychological maltreatment is often not recognized when other forms of maltreatment, such as physical and sexual abuse, coexist [
56]. The prevalence rates of psychological maltreatment may also be underestimated because they capture a wide range of parenting behaviours, and there is little to no consensus across studies as to what phenomena should be included [
57].
Psychological maltreatment consists of both emotional abuse as well as emotional neglect [
58,
59]. In the present study, the prevalence of emotional neglect was higher among male participants than female participants, this finding agrees with what has previously been reported [
60], emotional abuse was reported in 24.7% of the participants, while emotional neglect was reported in 51.9% of cases. The prevalence of emotional abuse was higher among female participants than their male counterparts. The reason for the underlying vulnerabilities and gender influence on children with emotional abuse and neglect is unclear, and this requires further investigation.
Although psychological maltreatment is the most common form of childhood maltreatment in developing countries such as Tanzania, no participants who were psychologically maltreated sought professional treatment. This observation may be attributed to the lack of awareness and poor knowledge regarding which childhood experiences constitute psychological maltreatment. This calls for urgent preventive measures to reduce the occurrence of childhood psychological maltreatment so as to reduce the potential adverse consequences of psychological maltreatment that occurs during adolescence and adulthood.
Psychological maltreatment is strongly associated with low self-esteem in adolescents [
16]. This finding agrees with our study, which found that childhood psychological maltreatment was statistically significantly associated with self-esteem during adolescence. Parenting style plays a crucial role in a child’s social, cognitive and emotional development. A negative parenting style involving psychological maltreatment may result in low self-esteem in adolescents that continues to adulthood [
17].
The results reported here agree with previously published studies, demonstrating correlation between childhood exposure to psychological maltreatment and self-esteem. Children exposed to high levels of psychological maltreatment have been reported to show low level of self-esteem during adolescence. For a psychologically maltreated child, the negative impacts are believed to occur when the child internalizes the harsh treatment, including the negative messages from parents and/or care givers [
18]. This results in insecurities, and the child develops maladaptive interpersonal schemas, which lead to dysfunctional behaviours [
61].
Children in such situations tend to believe that they are worthless and that the world is unsafe and perceive everybody as abusive [
19]. Those with low self-esteem tend to be more self-conscious and isolate themselves from others [
62].
There are some limitations of the study that should be noted: first, the cross-sectional study design does not allow for the establishment of a causal relationship; therefore, only the association between psychological maltreatment and self-esteem was established in this study.
Second, the study participants included secondary school students from randomly selected secondary schools in five regions in Tanzania; therefore, the results cannot be generalized to the Tanzanian population as a whole. Third, additional consideration should be given to the tendency of participants to under- or over-report incidents of maltreatment. Thus, the results must be interpreted with caution.