Association of Childhood Emotional Maltreatment with Adolescents’ Psychopathology: A Systematic Review and Meta-Analysis

Abstract

Childhood Emotional Maltreatment (CEM) is a significant but under-studied risk factor for impaired mental health, with adolescents being particularly susceptible. This systematic review and meta-analysis, prospectively registered in PROSPERO as CRD42022383005, aims to synthesize the findings of studies investigating the association between CEM and adolescent psychopathology, making it the first attempt to the best of our knowledge. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search (PubMed, Scopus, PsycINFO, Science Direct, Embase, and ProQuest) yielded 12,224 studies, from which 72 were included in the qualitative synthesis. The meta-analysis was conducted on 76 effect sizes (ranging from 0.01 to 0.57) extracted from 56 studies. The assessment of publication bias utilized funnel plots, Egger’s regression test, and the trim and fill method, if required. Additionally, a predictor analysis investigated the influence of study-level variables on the CEM-psychopathology association. Results revealed a significant positive correlation between CEM and adolescent psychopathology (Pooled association: 0.24–0.41) Furthermore, assessment of publication bias indicated no significant bias. The predictor analysis suggested minimal influence of study-level variables. The study underscores the urgent need to address CEM as a crucial risk factor for adolescent psychopathology. The significant positive correlation between CEM and psychopathological outcomes highlights the detrimental effects of CEM on adolescents. Awareness, prevention efforts, and targeted interventions are essential to mitigate these effects. Further studies with culturally diverse and larger sample sizes are required, with emphasis on methodological rigor, given that most of the identified studies showed a high risk of bias.

Keywords

child abuse neglect cultural contexts mental health and violence children exposed to domestic violence domestic violence

Introduction

Childhood Emotional Maltreatment (CEM), a deeply concealed form of Childhood Maltreatment (CM), carries the potential to shape an individual’s mental trajectory. Often, studies deal with physical and sexual maltreatment while ignoring CEM (Cecil et al., 2017). The American Professional Society (American Professional Society on the Abuse of Children, 1995) defines CEM as a continuous pattern of disturbing behavior perpetuated by caregivers that conveys to the child that he/she is flawed, unloved, endangered, unwanted, or useless. CEM is a conceptually broad term, as several terms are used interchangeably to refer to CEM. These terms range from emotional abuse to emotional maltreatment, psychological abuse, psychological maltreatment, verbal abuse, emotional violence, psychologically battered child, and mental cruelty (Doyle, 1997). It includes all the active and passive acts of caregivers or other important figures ranging from spurning, intimidating and terrorizing, confining and isolating, exploiting and corrupting, denigrating emotional needs, and neglecting health needs (American Professional Society on the Abuse of Children, 1995). Different reasons for neglecting CEM have been discussed. For example, emotional abuse has been suggested to be encompassed by other forms of CM and might not represent a unitary construct (Petrenko et al., 2012). Yet, while emotional abuse typically does not occur in isolation, it seems to—significantly and independently of other types of CM—negative affect symptoms in adolescents (Arata et al., 2007). Additionally, studies are investigating the specific effects of CEM while adjusting for other types of CM (Chang et al., 2021; Taillieu et al., 2016).

CEM includes two subtypes of maltreatment: childhood emotional abuse (CEA) and childhood emotional neglect (CEN) (Bernstein et al., 2003). CEA is defined as verbal assault or psychological violence targeting a child’s worthlessness or well-being, or any other type of demeaning and belittling behavior perpetuated by caregivers or other important figures, whereas CEN is defined as caregiver’s or other important figure’s failure to be responsive toward emotional or psychological needs of the child such as love, affection, attention, support, belonging and nurturance (Bernstein et al., 2003; Cao et al., 2020). CEA is further considered an active form of CEM, including acts of commission, whereas CEN is considered a passive form of CEM, consisting of acts of omission (Taillieu et al., 2016).

CEM and Psychopathology

CEM is one of the most prevalent forms of CM (Cecil et al., 2017). It might occur alone, in the absence of other forms of CM (American Professional Society on the Abuse of Children:. . .—Google Scholar, 1995; Arata et al., 2007), but it also has a high risk of co-occurrence with other types of CM such as sexual or physical abuse (Bifulco et al., 2002; Finzi-Dottan & Karu, 2006). Research has documented its direct association with decreased self-esteem (Mwakanyamale & Yizhen, 2019), which might contribute to severe mental health issues in later life (Fasciano et al., 2021; Greger et al., 2017). Previous studies have demonstrated a link between CEM and depression and anxiety (Auslander et al., 2018; Harper & Arias, 2004; Wang et al., 2021), suicidal behaviors (Ahouanse et al., 2022; Buser & Hackney, 2012), post-traumatic stress disorder (Auslander et al., 2018), personality problems (Bounoua et al., 2015; Charak et al., 2018), and addiction (Brahmand et al., 2016; Musetti et al., 2021). Associations of CEM with mental health problems were found in adults (Bifulco et al., 2002; Feinson & Hornik-Lurie, 2016; Janiri et al., 2021), adolescents (Bouchard et al., 2008; Bounoua et al., 2015; Charak et al., 2018) and college students (Batstra et al., 2012; Calmes et al., 2013).

There is no certainty of how CEM leads to developing psychopathology, as studies have been very inconsistent in describing the mechanism. However, there are several possible pathways, which could be the expectant mechanism of developing psychopathology. Liu et al. (2023) suggested that emotionally abused children used fewer cognitive reappraisal strategies for emotion regulation, which led to sleep problems. Other possible pathways include self-esteem (Theran & Han, 2013; Zhang et al., 2023), maladaptive coping mechanisms, such as cognitive avoidance, experiential avoidance, and emotional suppression (Kadivari et al., 2023), and altering brain development trajectories (Teicher et al., 2016). On the other hand, increased self-esteem, self-worth, self-confidence, and resilience in emotionally maltreated children buffer the relationship with developing psychopathology (Chen et al., 2022).

Several systematic reviews and meta-analyses have been conducted investigating CEM and adult psychopathological outcomes, such as the influence of CEM on adult mental health (Xiao et al., 2021), the role of CEM in adult romantic relationships (Cao et al., 2020), and impact on psychosis in adulthood (Grindey & Bradshaw, 2022). Additional meta-analysis included the prevalence and universality of CEA (Stoltenborgh et al., 2012). Another systematic review and a narrative review were conducted without specifying the population on the mediating factors between CEM and depression (Li et al., 2020), CEA and depression and anxiety (measured five forms of maltreatment including physical, sexual, emotional, intimate partner violence, and neglect) (Gardner et al., 2019) and the connection between CEN and cardiovascular disease (Salzmann et al., 2022).

Maguire et al. (2015) systematically reviewed emotional, behavioral, and cognitive features in emotionally abused children and found that the children exhibited poor academic performance, Attention-deficit/Hyperactivity Disorder (ADHD) symptomatology, and suicidality. Schønning et al. (2022) suggested that CM (collectively sexual, physical, and emotional abuse and neglect) is a strong predictor of insomnia symptoms, shorter sleep duration, and nightmares in children and adolescents. Angelakis et al. (2020) found that CEN and CEA are strong factors of suicide attempts in young people.

All the previous systematic reviews and/or meta-analyses either focused on CM collectively or took some specific psychopathological outcome in adolescents. Remarkably, no systematic review and/or meta-analysis has yet delved into the adolescent’s domain, a critical period where mental health problems can manifest and potentially persist throughout the lifespan (Auslander et al., 2018; Shakoor et al., 2018; Spiegel et al., 2022), leaving an urgent need to examine the intricate relationship between CEM and the psychopathological landscape of adolescents. Furthermore, adolescence is often a time when mental health disorders first manifest (Borschmann & Patton, 2018), making it a crucial period for early identification and intervention. To the best of our knowledge, this study is the first comprehensive attempt to systematically review and meta-analyze investigating the association between CEM and adolescents’ psychopathology, using the standard diagnoses of DSM and ICD were determined. This was achieved through either self-reported questionnaires, third-party assessments, or clinical interviews that utilized validated measures for mental health scoring. By synthesizing and analyzing the existing empirical evidence, this study aims to fill the void, providing valuable insights into the impact of CEM on adolescents’ psychopathological issues and paving the way for timely interventions and tailored treatment strategies that can transform the lives of affected adolescents.

The present study investigated multiple objectives. The primary objective of the study is to investigate the pooled association between CEM and various psychopathological problems among adolescents, including depression, anxiety, self-harm behaviors, and other psychopathological issues. The secondary objective of the study includes assessing moderator variables that may influence the association between CEA and adolescent psychopathology. Additionally, the study aims to assess the heterogeneity between different studies regarding the association of CEA with adolescent psychopathology. By examining potential sources of heterogeneity, the study seeks to understand the differences in findings across studies and identify possible reasons for such heterogeneity.

Method

Protocol and Registration

The current study is a systematic review and meta-analysis that follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009). It was prospectively registered in PROSPERO as CRD42022383005.

Eligibility Criteria

The eligibility criteria for the study were defined based on (PECO) framework, including Population, Exposure, Comparison, and Outcome (Morgan et al., 2018). The eligibility criteria were defined as follows: Population: Participants’ average age needed to be less than 20, allowing for the inclusion of borderline studies in terms of age (Siddaway et al., 2019, p. 759). Exposure: participants were exposed to CEM of any type. Comparison: Only CEM-exposed adolescents, the participants exposed to emotional neglect/abuse in their childhood versus adolescents who are exposed to other types of maltreatment, and CEM-exposed, non-exposed adolescents versus adolescents who are not exposed to any type of maltreatment. Outcome: adolescent psychopathology, including depression, anxiety, self-harm behaviors, and other detected mental health issues, assessed using valid and reliable measures as outlined in standard diagnoses systems of DSM and ICD. Study design: Observational studies of cross-sectional, longitudinal, and case-control studies. Other eligible criteria include studies in English due to reviewers limited language command.

Exclusion criteria comprised other study types, including trials and qualitative papers, as well as descriptive or opinion-based studies. Studies were excluded if CEM was not exclusively discussed or if the results regarding CEM were unclear. Incomplete data that prevented the calculation of effect sizes were excluded unless additional information could be obtained from the authors upon contact. Finally, any type of review papers summarizing or synthesizing existing literature were excluded to focus on primary research studies.

Information Sources

Different academic databases, including PubMed, Web of Science, PsycINFO, Science Direct, Embase, and Scopus were used for collecting sample papers. ProQuest was used for gray literature. Different seemingly related terms were used as Mesh terms and keywords from previously published reviews and original papers. Backward and forward referencing were also used for collecting studies. Different journals of related works like Trauma, Violence, & Abuse, J Clin Child Adolesc Psychol, J Interpers Violence, and Child Abuse Negl, etc. were also searched. In addition to these, we contacted different authors actively working in the area for their published/unpublished works.

Search Strategy

Two main search components were selected from the PECO component. For example, Two PECO-S components of Exposure (CEM) and Outcome (Psychopathology) were especially important for developing the search strategy. The keywords, which were used to search different academic databases, are given in Supplemental Appendix 1. The terms were confined to title/abstract only and MeSH terms were also used. Boolean operator OR was used between each term of CEM and psychopathology separately, whereas AND was used to combine terms of both the variables.

Study Selection

All collected papers were saved in Zotero, software (Zotero | Your personal research assistant) used for bibliography and data cleaning. Duplicate items were deleted. Data cleaning was performed based on the abstract title and age (9–20) followed by formal screening based on inclusion and exclusion criteria. Two co-authors independently reviewed to assess eligible studies and disagreements were resolved through discussion among authors.

Data Collection Process and Data Items

Two reviewers extracted data using a pre-decided information extraction sheet. It included first author, year of publication, geographical location, mean age with SD, sample size, gender distribution, study design, clinical or non-clinical population, type of CM, dimension of CM or CEM, duration of abuse, preparator, measurement of CEM and psychopathology, type of psychopathology, outcomes of CEM. In case of missing geographical location of the study, the place of first author was considered in place of the study location. The authors of the study were contacted through email in case of lacking information.

Study Risk of Bias Assessment

First author independently assessed the quality of the studies, and two other reviewers helped with data verification. It was done using the Newcastle-Ottawa Scale (NOS) for cross-sectional (Herzog et al., 2013), case-control studies, and cohort studies, which take selection, comparability, and outcomes into account. NOS scores are arbitrarily categorized into high risk of bias if the study gets less than five points and low risk of bias in case of more than five points.

Effect Measures

For the effect size calculations, correlation statistics reported in the studies were extracted. In cases where the reported statistics differed from correlation (r), they were converted to correlation (r) using appropriate methods. The escalc function in R was utilized to transform correlation coefficients into standardized scores and standard variances. The magnitude of a Fisher’s z value is defined as follows: at 0.1 is weak, between 0.11 and 0.29 is weak to moderate, 0.3 is moderate, 0.31 and 0.49 is moderate to strong, and ≥0.5 is strong.

Data Synthesis

The data synthesis and analysis were conducted using various statistical packages in R 4.2.1, including “dmetar,” “tidyverse,” “metafor,” and “meta” (Harrer et al., 2021). In the qualitative synthesis phase, demographic details from the 72 included studies were synthesized to provide an overview of the study populations.

The random effects model was employed, acknowledging the potential heterogeneity across studies due to variations in population, study design, and measurements. Heterogeneity variance (τ^2, τ²) was assessed using the Restricted Maximum Likelihood method. Confidence intervals around the pooled effect estimates were calculated with Knapp-Hartung adjustments. The I² statistic was utilized to evaluate the degree of heterogeneity among the included studies. Additionally, prediction intervals were computed to estimate the range of effect sizes expected in future studies. An overall forest plot was generated to visually represent the effect sizes and their corresponding confidence intervals. Sensitivity analysis was conducted using jackknife sensitivity analysis (leave one study method) method to check outlier studies and if there is any study that is severely affecting effect sizes. Predictor analysis was also performed to assess the moderating role of study-level variables, which included year of publication, age of participants, gender, and risk of bias in individual studies.

It is important to note that the meta-analysis specifically focused on the following categories due to their significance in the emerged results: CEA and depression, CEN and depression, CEM and depression, CEA and anxiety, CEN and anxiety, CEA and post-traumatic stress disorder (PTSD), CEA and suicidal ideation (SI). These categories were selected from the larger pool of studies included in the qualitative synthesis phase. The chosen categories were determined based on their prominence in the literature and their relevance to the association between child emotional maltreatment and adolescent psychopathology.

Reporting Risk of Bias

Publication bias was assessed using a funnel plot to examine the symmetry of the effect sizes. Egger’s regression test was employed for a quantitative assessment of publication bias, and if identified, the Trim and Fill method was used to adjust for potential missing studies. The Trim and Fill method estimates the potential missing studies and incorporates them into the meta-analysis by “trimming” the asymmetrical studies and “filling” the missing studies on the other side of the funnel plot. This adjustment helps to provide a more balanced estimate of the effect size, considering the potential publication bias.

Results

Study Selection

A total of 11,254 (PRISMA chart is given in Figure 1) records were identified from academic databases, and an additional 970 records were sourced from other sources, including journals, forward and backward referencing, and author contact. After removing duplicate records (n = 3,648) and excluding records based on title, abstract, and age criteria (9–20) (n = 8,405), a total of 99 reports were excluded for various reasons, including 73 studies that did not separately measure CEM, while 7 reports had incomplete information or inappropriate statistics. Additionally, nine reports did not measure any specific mental health conditions related to CEM, four reports focused on construct-related problems for CEM, and six reports addressed other topics such as subjective happiness, maternal CEM, and prevalence of CEM. A total of 72 studies were included in the systematic review, and out of those, 56 studies (76 effect sizes) were included in the meta-analysis (Table 1). Out of 72, 42 were from Backward referencing only, showing how necessary backward referencing is in the search strategy.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses flow diagram for systematic reviews (Page et al., 2020).

Table 1.

Summarized Characteristics of Included Studies Based on Different CEM Adolescents’ Psychopathology.

Authors (Year)	n	r	Gender	RoB	Age	Population
CEA and anxiety
Cecil et al. (2017)	204	0.46	53	5	18.85	Community
De-Oliver et al. (2018)	347	0.38	48	6	13.28	Community
Hamilton et al. (2013)	225	0.18	59	2	12.84	Community
Hankin (2005)	652	0.18	32.2	1	18.7	Student
Hankin (2005)	75	0.13	45.3	1	18.6	Student
Lai et al. (2022)	238	0.146	53.8	4	13.6	Student
Negrif (2020)	454	0.21	32.26	5	18.49	Community
Reis et al. (2023)	654	0.46	52.9	3	14.34	Student
Rimular and Berzenski (2022)	467	0.335	66.6	4	19.48	Student
Yogit et al. (2018)	325	0.21	68.62	3	15.29	Clinical
Zhang et al. (2022)	9830	0.5	47.36	6	14.24	Student
Bounoua (2015)	176	0.3	41.7	4	16.06	Community
CEA and depression
Auslander et al. (2018)	234	0.39	100	5	14.9	Clinical
Cecil et al. (2017)	204	0.48	53	5	18.85	Community
Courtney et al. (2008b)	195	0.475	78.5	3	16.3	Clinical
Courtney et al. (2008)	92	0.308	81.5	1	17.48	Clinical
De-Oliver et al. (2018)	347	0.57	48	6	13.28	Community
Gerke et al. (2006)	417	0.29	100	3	19.9	Student
Hamilton et al. (2013)	225	0.38	59	2	12.84	Community
Hankin. (2005)	652	0.25	32.2	1	18.7	Student
Hankin (2005)	75	0.12	45.3	1	18.6	Student
Liu et al. (2017)	2469	0.342	72.3	4	18.76	Student
McQuide et al. (2019)	475	0.48	72.21	3	19.45	Student
Miller et al. (2017)	682	0.52	60.82	2	11.83	Community
Negrif (2020)	454	0.3	32.26	5	18.49	Community
Padilla and Calvette (2014)	1316	0.35	45	2	13.42	Community
Reis et al. (2023)	654	0.549	52.9	3	14.34	Student
Sen et al. (2022)	961	0.18	51.2	5	15.21	Student
Sekowski et al. (2020)	112	0.467	73	3	15.36	Clinical
Tanaka et al. (2011)	561	0.22	52.9	5	15.8	Community
Theran and Han (2013)	257	0.02	100	3	19.74	Student
Wang et al. (2019)	5726	0.198	50.3	7	14.81	Student
Wang et al. (2021)	3600	0.43	48.9	7	13.23	Community
Yogit et al. (2018)	325	0.22	68.62	3	15.29	Clinical
Zhang et al. (2022)	9071	0.55	47.36	6	14.24	Student
Zhang et al. (2022)	946	0.34	34.35	4	9.77	Student
CEA and suicide ideation
Chen et al. (2021)	697	0.154	63.89	6	13.74	Community
Duprey et al. (2020)	1354	0.05	51.48	4	16.32	Community
Wang et al. (2021)	3600	0.23	48.9	7	13.23	Community
Hoeve et al. (2015)	767	0.33	0	5	16.7	Clinical
Li et al. (2023)	262	0.46	75.6	4	15.22	Clinical
Miller et al. (2017)	682	0.29	47.97	2	11.83	Community
CEA and PTSD
Auslander et al. (2018)	234	0.45	100	5	14.9	Clinical
Cecil et al. (2017)	204	0.54	53	5	18.85	Community
Theran et al. (2013)	257	0.1	100	3	19.74	Student
Negrif (2020)	454	0.31	32.26	5	18.49	Community
Nothling et al. (2019)	215	0.49	60.9	3	14.9	Community
Sullivan et al. (2006)	89	0.54	65.12	4	16	Clinical
CEM and depression
Emirtekin (2020)	443	0.23	60	4	15.95	Student
Harper and Arias (2004)	294	0.27	59	3	19	Student
Igarashi et al. (2010)	243	0.32	81.5	0	19	Student
Wang et al. (2020)	1592	0.5	48.9	5	13.23	Community
Wu et al. (2022)	1280	0.48	53.9	5	16.9	Student
Zhou and Zhen (2022)	1680	0.28	46.9	2	14.3	Student
CEN and anxiety
Cecil et al. (2017)	204	0.28	53	5	18.85	Community
De-Oliver et al. (2018)	347	0.4	48	6	13.28	Community
Hamilton et al. (2013)	225	0.01	59	2	12.84	Community
Lai et al. (2022)	238	0.087	53.8	4	13.6	Student
Negrif (2020)	454	0.24	32.26	5	18.49	Community
Reis et al. (2023)	654	0.173	52.9	3	14.34	Student
Zhang et al. (2022)	9830	0.45	47.36	6	14.24	Student
CEN and depression
Cecil et al. (2017)	204	0.34	53	5	18.85	Community
De-Oliver et al. (2018)	347	0.34	48	6	13.28	Community
Dong et al. (2022)	848	0.504	42.3	4	16.26	Student
Gerke et al. (2006)	417	0.25	100	3	19.9	Student
Gomez et al. (2015)	74	0.24	37.8	4	15.6	Clinical
Hamilton et al. (2013)	225	0.23	59	2	12.84	Community
Liu et al. (2017)	2469	0.305	72.3	4	18.76	Student
Negrif (2020)	454	0.42	32.26	5	18.49	Community
Reis et al. (2023)	654	0.329	52.9	3	14.34	Student
Sen et al. (2022)	961	0.42	51.2	5	15.21	Student
Sekowski et al. (2020)	112	0.425	73	3	15.36	Clinical
Tanaka et al. (2011)	561	0.27	52.9	5	15.8	Community
Wang et al. (2019)	5726	0.171	50.3	7	14.81	Student
Wang et al. (2021)	3600	0.28	48.9	7	13.23	Community
Zhang et al. (2022)	9071	0.52	47.36	6	14.24	Student

Note. CEA = childhood emotional abuse; CEM = Childhood Emotional Maltreatment; CEN = childhood emotional neglect; n = sample size; PTSD = post-traumatic stress disorder; r = correlation coefficient; RoB = Risk of Bias.

Study Characteristics

The majority of the studies utilized convenience/purposive sampling, with a few exceptions, for example, random sampling (Allen et al., 2013) and snowball sampling (Hamilton et al., 2013). The studies were conducted between 2004 and 2023, with sample sizes ranging from 51 to 75,715.

Regarding the composition of the study samples, most studies included a mixed-sex distribution, while (Brahmand et al., 2016; Hoeve et al., 2015) focused solely on male participants, and a few studies specifically included only female participants (Auslander et al., 2018; Gay et al., 2013; Gerke et al., 2006; Theran & Han, 2013). The age of the participants ranged from 9.77 to 19.74 years. Among the included studies, 18 utilized a clinical sample, 18 used a general population sample, and the remaining studies focused on students.

In terms of research design, 19 studies employed longitudinal data, while the rest utilized a cross-sectional approach using a case-control design. The measurement of CM varied across the studies, with most studies assessing CEA. Additionally, several studies measured other types of maltreatment, including childhood physical abuse/neglect, sexual abuse, and emotional neglect.

The most used scale to assess CM was the Childhood Trauma Questionnaire. Other scales used in the measurement of CM included the Comprehensive Child Maltreatment Scale, Children Self-Report, Child Abuse and Trauma Scale, and Child Protective Services records, among others.

The range of adolescent psychopathology measures varied across the included studies and will be detailed in the subsequent section. It is important to note that all the studies measured maltreatment in childhood, which typically occurred before the age of 18. However, for the purpose of this review, data up to the age of 20 were considered. Furthermore, in the majority of the studies, CEM was reported to be perpetrated by family members or caregivers. Among the included studies, 25 were conducted in China and 22 in the United States, and the remaining studies were distributed across other countries, with a smaller number of studies conducted in each.

Risk of Bias in Studies

The risk of bias for cross-sectional studies is given in Supplemental Appendix 2, whereas for cohort studies, it is given in Supplemental Appendix 3. Most of the studies were in the category of high risk of bias as they got less than 5 stars in bias assessment.

Results of Individual Studies

CEM and Adolescents Psychopathology

CEM and Depression

Thirty-three studies (6 clinical populations) measured the association of depression and CEM, out of which 24 studies measured CEA and depression, 15 studies measured CEN and depression, whereas 6 studies combined both constructs and measured CEM and depression in general. Studies found that out of all the maltreatment types CEA emerged as the sole independent predictor of depression (Cecil et al., 2017; de Oliveira et al., 2018; Hankin, 2005; Igarashi et al., 2010; Negriff, 2020; Reis et al., 2023; Y. Xiao et al., 2022; R. Zhang et al., 2022; Y. Zhang et al., 2022), whereas (Liu et al., 2017) found that CEN is the strongest factor of depression. Another study tested the relationship through mediation and found that CEN and depression are partly mediated by self-compassion, and they also found that friendship reduces the severity of depression and CEN. Emirtekin et al. (2019) found that CEM was directly and indirectly associated with PSU via BID, depression, BID-related depression, and BID-related social anxiety. Some found that CEA and depression were significantly associated even after controlling for other study variables (Gerke et al., 2006; Gomez et al., 2015; Sen et al., 2022). Hamilton et al. (2013) found in a racially diverse community sample that CEA was a non-specific predictor of an increase in depressive symptoms. Harper and Arias (2004) found that shame moderated the association between CEM and depression among women. McQuaid et al. (2019) found that the association is moderated by IL-1β SNP and it varies according to sex. Others found that the association between CEM and suicide ideation is mediated by depression (Miller et al., 2017; Sekowski et al., 2020). Padilla Paredes and Calvete (2014) suggested depression as a consequence of CEA in connection with cognitive vulnerability, whereas Dong et al. (2022) investigated the relationship in addition to self-compassion and friendship quality. Hierarchical regression shows that low self-compassion abused people exhibit high depressive symptoms (Tanaka et al., 2011). G. F. Wang et al. (2019) suggested that CEA and CEN significantly mediated the association between a child’s physical disability and depressive symptoms. Wu et al. (2022) suggested that depression mediated the relationship between CEM and internet gaming addiction. Yiğit et al. (2021) found that maladaptive schemas mediated the relationship. Rest studies measured the direct association between CEM/CEA/CEN and depression (Auslander et al., 2018; Courtney et al., 2008; Theran & Han, 2013; Wang et al., 2021; X. Y. Wang et al., 2022; Zhou & Zhen, 2022). The extracted correlation value of the studies ranged from 0.02 to 0.57.

CEM and Anxiety

A total of 14 studies (2 clinical populations) measured CEM and anxiety, 12 studies measured anxiety directly, whereas one study measured anxiety sensitivity (Bounoua et al., 2015) and another one measured anxiousness (Charak et al., 2018). Twelve studies measured CEA and anxiety, whereas seven studies measured CEN and anxiety. Most of the studies investigated a direct connection between anxiety and CEM, some studies suggesting CEA as a sole indicator of anxiety (Cecil et al., 2017; Guo et al., 2021; Hankin, 2005; Lai et al., 2022; Negriff, 2020; Reis et al., 2023; Rimular & Berzenski, 2022; Y. Zhang et al., 2022). Rest studies examined the relationship in connection with third variables, for example, borderline personality disorder (BPD), hopelessness, reactive aggression, disconnection/rejection, and impaired autonomy (Bounoua et al., 2015; Hamilton et al., 2013; Hoeve et al., 2015; Yiğit et al., 2021). The correlation values of these studies ranged from 0.01 to 0.46.

CEM and Personality Disorders

A total of 10 studies (4 clinical samples) measured CEM and personality-related features. Allen (2008) suggested that BPD characteristics, affective dysregulation, identity problems, and paranoia mediated a relationship between all types of CM and suicide potential; another study (Bounoua et al., 2015) suggested significant indirect effects of CEA on BPD features via anxiety sensitivity and via baseline depression (Igarashi et al., 2010), via reflective functions (Quek et al., 2017). Three studies measured callous/unemotional personality traits and their dimensions (Carlson et al., 2015; Chang et al., 2021; Charak et al., 2018), whereas studies measured association in terms of neuroticism/psychoticism, autistic/schizotypal personality, and identity diffusion respectively (X. Li et al., 2014; Liu et al., 2017; Penner et al., 2019). The correlation values ranged from 0.04 to .46.

CEM and Suicide/Non-Suicidal Self-Injury-Related Behaviors

A total of 16 studies (4 clinical populations) discussed suicide/Non-suicidal self-injury. Out of 17, 6 studies discussed CEA and SI, 3 CEN and SI, 3 non-suicidal self-injury directly (Glassman et al., 2007; Madden et al., 2018; S. Wang et al., 2020), 2 suicide attempts, one suicide potential and one suicide intensity. Six studies measured direct association between SI and CEA/CEN (X. Chen et al., 2021; Gong et al., 2020; Guo et al, 2018; X. Li et al., 2023; Miller et al., 2017; X. Y. Wang et al., 2022), whereas three studies measured it in combination of parental support, internalizing/externalizing problems, rumination, and reactive aggression (Ahouanse et al., 2022; Duprey et al., 2020; Hoeve et al., 2015; Wu et al, 2022). The correlation values ranged from .05 to .39.

CEM and PTSD

Total seven studies discussed CEA/CEN and PTSD (four clinical populations), whereas five studies discussed direct association (Biedermann et al., 2017; de Oliveira et al., 2018; Moore et al., 2013; Negriff, 2020; Sullivan et al., 2006) whereas a study discussed it as mediator between CEM and re-victimization (Auslander et al., 2018) and another one discussed it in combination with authenticity in close relationship (Theran & Han, 2013). The correlation values ranged from .1 to .54.

CEM and Substance Abuse

A total of six studies (three clinical populations) measured substance abuse-related issues. Out of six, three used substance use (Brahmand et al., 2016; Buckle et al., 2005; Tanaka et al., 2011), three alcohol use (de Oliveira et al., 2018; Hoeve et al., 2015; Tanaka et al., 2011), and a study measured cannabis use (Baiden et al., 2014). The correlation values ranged from .01 to .42. (Brahmand et al. measured five dimensions of substance use).

CEM and Other Mental Disorders

Apart from the abovementioned adolescent’s psychopathological issues, studies used a cluster of different disorders as the direct association of CEM. These include alexithymia (X. Li et al., 2023), social anxiety (Emirtekin et al., 2019; Wu et al., 2022), intimate partner violence victimization (Gay et al., 2013), bulimic symptoms (Gerke et al., 2006), ADHD (Gonzalez & Méndez-Pounds, 2018), eating disorder (Mills et al., 2015), insomnia (X. Li et al., 2023), bipolar and mood disorder (McCarthy et al., 2020), GAD and panic (Mccullough et al., 2010), social avoidance and narcissism (Charak et al., 2018), dissociation (de Oliveira et al., 2018; Gerke et al., 2006), internet addiction (Musetti et al., 2021; Wu et al., 2022), nomophobia (Y. Chen et al., 2021), cyberbullying offending (Emirtekin et al., 2020; X. Wang et al., 2021), internalizing problems (Buckle et al., 2005; Cecil et al., 2017; Jung, 2021; Reis et al., 2023), and externalizing problems (Buckle et al., 2005; Jung, 2021; Negriff, 2020), and psychosis (Beasley et al., 2021).

Results of Synthesis

Meta-analyses were conducted for domains including CEA and depression, CEN and depression, CEM and depression, CEA and anxiety, CEN and anxiety, CEA and PTSD, and CEA and suicide ideation. Meta-analytic results are presented in Table 2. The table includes the domain, number of studies in each domain, participants in each domain, pooled association, 95% confidence interval, prediction interval CI, I², and sensitivity analysis. Pooled association ranged from 0.24 to 0.41 and I² ranged from 88.4% to 98%. Forest plots are presented in Figures 2 to 6.

Table 2.

Meta-Analytic and Publication Bias Findings.

Domains	k _P	N _P	Results of Meta-Analysis					Publication Bias			Sensitivity Analysis
Domains	k _P	N _P	ES _P	95% CI	PI	τ²	I² (%)	Funnel Plot	Eggers’ Test p	Trim and Fill	Sensitivity Analysis
CEA and Depression	24	30,050	0.36	[0.30, 0.42]	0.04–0.61	.03	97.4	symmetry	.29		No
CEN and Depression	15	25,723	0.34	[0.28, 0.40]	0.09–0.55	.11	98	symmetry	.57		No
CEM and Depression	6	5,532	0.35	[0.22, 0.47]	−0.03–0.65	.02	94.6	Symmetry	.43		No
CEA and Anxiety	12	13,647	0.30	[0.21, 0.39]	−0.01–0.57	.02	95.2	Asymmetry	.0001	Seven studies added. (overestimated)	No
CEN and Anxiety	7	11,952	0.24	[0.09, 0.39]	−0.20–0.60	.03	96.2	Asymmetry	.01	Four studies added. (Overestimated)	No
CEA and PTSD	6	1,453	0.41	[0.22, 0.57]	−0.13–0.76	.03	88.4	Symmetry	.29		No
CEA and Suicide Ideation	6	7,362	0.25	[0.10, 0.40]	−0.18–0.60	.02	93.6	Symmetric	.50		No

Note. CEA = childhood emotional abuse; CEM = Childhood Emotional Maltreatment; CEN = childhood emotional neglect; CI = confidence interval; ES_P = pooled effect size; k_P = Number of studies; N_P = pooled sample size; PI = prediction interval; PTSD = post-traumatic stress disorder.

Figure 2.

Forest plot for childhood emotional abuse and depression.

Figure 3.

Forest plot childhood emotional neglect and depression.

Figure 4.

Forest plot for childhood emotional abuse and anxiety.

Figure 5.

Forest plot for childhood emotional neglect and anxiety.

Figure 6.

Forest plot for childhood emotional abuse and post-traumatic stress disorder.

Publication Bias

Table 2 also assesses publication bias in each domain of adolescent psychopathology and forest plots (Figures 7 –10) and Egger’s regression test findings suggest that symmetry was observed in all domains except for CEA and anxiety and CEN and anxiety, for which Trim and Fill method was used. For CEA and anxiety, the trim-and-fill method (Figure 9) found that seven additional studies are required that may have been missing. The then pooled estimate became 0.47 (95% CI [0.35, 0.58]; τ² = .09 (95% CI [0.048, 0.2]); I² = 96.5%; Q statistics = 508.57, p < .0001). Whereas for CEN and anxiety, the trim-and-fill method (Figure 10) suggested that four more potential studies are missing with the pooled association of 0.43 (95% CI [0.2334, 0.5895], p = .0009; τ² = .10 (95% CI [0.0488, 0.3275]); I² = 97.1%; Q statistics = 348.25, p < .0001).

Figure 7.

Funnel plot for childhood emotional abuse and depression.

Figure 8.

Funnel plot for childhood emotional neglect and depression.

Figure 9.

Funnel plot for childhood emotional abuse and anxiety.

Figure 10.

Funnel plots for childhood emotional neglect and anxiety.

Predictor Variables

Moderator analysis was conducted to assess if study-level moderators (age of participants, gender, risk of bias, and year of publication) have any moderating role in the association of CEM and adolescent psychopathology. We conducted predictor analysis for CEA and depression, CEN and depression, CEM and depression, CEA and anxiety, CEN and anxiety, CEA and suicide ideation, and CEA and PTSD. We found (Table 3) that moderator variables don’t have significant effects except that risk of bias in the association of CEN and anxiety (p = .0012) and year of publication in the association of CEN and depression (p = .0374), meaning that each score increase in methodological quality of studies was associated with .10 increase in pooled estimated correlation of CEN and anxiety and thus, CEN and anxiety was stronger in low risk of bias studies and the variable accounted for 69.12% of variance in the association. Each score increase in study years was associated with a 0.02 increase in the pooled estimated correlation of CEN and depression. So the association between CEN and depression became stronger in recent studies, accounting for 20.83% of the variance in the association of CEN and depression. Only one model, CEN and anxiety was collectively significant (QM [df = 4] = 7.1107, p-value = .0075).

Table 3.

Predictor Analysis (Studies).

	Coefficient	SE	I ²	Adj R²	τ²	p-Value
CEA and PTSD (6)			94.56%	.00%	.0400	.6657
Year	−0.0094	0.0192				.6241
Gender	−0.0026	0.0038				.4904
Age	−0.0560	0.0441				.2040
Risk of bias	0.0587	0.1025				.5672
CEA and anxiety (12)			87.31%	4.96%	.0147	.3287
Year	0.0035	0.115				.7601
Gender	0.0007	0.0042				.8678
Age	0.0024	0.0169				.8896
Risk of bias	0.0410	0.0368				.2648
CEN and anxiety (7)			80.85%	69.12%	.0071	.0075
Year	0.0034	0.0126				.7812
Gender	0.0018	0.0069				.7952
Age	−0.0045	0.0207				.8278
Risk of bias	0.1026	0.0317				.0012
CEA and depression (24)			96.31%	.85%	.0184	.3369
Year	0.0085	0.0074				.2700
Gender	0.0004	0.0016				.8202
Age	−0.0129	0.0129				.3177
Risk of bias	−0.0081	0.0210				.6992
CEN and depression (15)			93.52%	20.83%	.0080	.1302
Year	0.0155	0.0074				.0374
Gender	−0.0008	0.0023				.7437
Age	0.0140	0.0134				.2971
Risk of bias	−0.170	0.200				.3961
CEM and depression (6)			96.02%	.00%	.403	.9636
Year	0.0008	0.0204				.9683
Gender	0.0040	0.0138				.7732
Age	−0.0155	0.0790				.8445
Risk of bias	0.0397	0.0672				.5544
CEA and suicide ideation (6)			98.17%	.00%	.0621	.9632
Year	0.1693	0.2331				.4677
gender	−0.196	0.0270				.4690
Age	−0.628	0.1056				.5521
Risk of bias	−0.1135	0.1481				.4436

Note. CEA = childhood emotional abuse; CEM = Childhood Emotional Maltreatment; CEN = childhood emotional neglect; PTSD = post-traumatic stress disorder.

Discussion

The present systematic review and meta-analysis examined the association between CEM and its subtypes (CEA and CEN) and various mental health outcomes. Results show a significant positive association between CEA and depression, with a moderate effect size. Similarly, a significant positive association was found between CEN and depression, albeit with a slightly lower effect size. The association between CEM and depression was also significant, suggesting that emotional maltreatment is linked to increased depressive symptoms in adolescents. Furthermore, a significant positive association was observed between CEA and anxiety. The association between CEN and anxiety was also significant, although with a slightly lower effect size. Additionally, CEA was significantly associated with PTSD and SI, suggesting that emotional abuse contributes to an increased risk of developing post-traumatic stress disorder and suicidal thoughts during adolescence.

Predictors

Findings of the meta-regression analysis suggest that most of the variables, including gender, age, year of publication, and risk of bias, exhibited a statistically insignificant association with the outcomes. Thus, the heterogeneity observed in the meta-analysis is unlikely to be explained by these specific study-level factors. It is important to note that while the analyzed variables did not demonstrate a significant influence on the outcomes, this does not negate their potential importance in other contexts. Furthermore, it is crucial to consider additional factors (e.g., variations in study design, population characteristics, or intervention protocols) that were not included in the current meta-regression model, as they may contribute to the observed heterogeneity.

Our findings (Figure 11, using Mermaid Diagram) are consistent with other studies investigating CEM and adult psychopathology. For example, Xiao et al. (2022) conducted a systematic review and meta-analysis and found that CEM is linked with different mental health problems, including depression, anxiety, substance abuse, SI or attempts, personality disorders, and eating disorders. Another systematic review and meta-analysis suggested that CEM leads to different mental health problems, including depression, anxiety, and drug use (Norman et al., 2012).

Figure 11.

Overall findings of the study.

Interpretation and Implications

The findings align with existing literature and theoretical frameworks that emphasize the detrimental effects of emotional maltreatment and its subtypes on the mental health of adolescents (Arata et al., 2007; Bounoua et al., 2015; Hamilton et al., 2013). Nevertheless, it’s crucial to highlight that our analysis revealed only nominal differences between CEA and CEN concerning their associations with psychopathological outcomes, specifically depression and anxiety. The limited number of studies exploring CEN in relation to distinct psychopathological outcomes, coupled with inconsistencies in how CEN was operationalized—some studies treating it as part of CEM, while others exclusively measuring neglect encompassing both physical and emotional aspects—leaves us uncertain about the actual distinction between CEA and CEN and whether both exhibit equifinality or multifinality (Luyten et al., 2008). Given the similarity in our findings, we cautiously posit both CEA and CEN as instances of equifinality, leading us to the conclusion that the implications of CEA, CEN, and CEM are essentially similar.

The significant associations found between CEM, CEA, and CEN with depression, anxiety, PTSD, and SI underscore the importance of recognizing and addressing these forms of emotional maltreatment in clinical practice and policy. More specifically, clinicians should be aware of the potential long-term consequences of emotional maltreatment and incorporate evidence-based approaches (Hamarman & Bernet, 2000; Morelen & Shaffer, 2012) when treating children and adolescents with mental health problems. Additionally, the identification and prevention of emotional abuse and neglect should be prioritized in child protection policies and interventions.

The consistent result of adolescent psychopathology with adult psychopathology has certain implications, including commonalities of CEM (both dimensions of CEA and CEN) effects irrespective of age, inferring that developing psychopathological outcomes may persist into adulthood with same or increasing intensity. Consistent findings also highlight the necessity of early identification and intervention, which will prevent psychopathological outcomes persistent in adulthood. In addition to these, the finding also highlights the adoption of adult evidence-based approaches for adolescents.

Comprehensive training of child protection professionals, counselors, and social workers for identification and intervention is required to recognize the signs of emotional maltreatment. Additionally, multi-agency collaboration between mental health professionals, child protection services, schools, and other relevant agencies is necessary for advancing a clear guideline for reporting and intervention.

The present study has several limitations that need to be considered. First, a high risk of bias was observed in most of the included studies, which may have influenced the overall effect sizes and the generalizability of the findings. Second, substantial heterogeneity was observed among the studies, indicating potential variations in sample characteristics, assessment measures, and a low number of studies assessing the outcome using different approaches and techniques, including self-report versus parent report measurements and cross-sectional and longitudinal approaches. Third, a limitation of this study is the inclusion of only English language studies due to the author’s limited knowledge of other languages, which may have introduced a language bias. Finally, the findings of moderate effect size based on the mere association of CEM and adolescent’s psychopathology do not give a clear picture of mechanisms, moderating and/or mediating the relationship. Multiple research studies suggested that individual strengths of self-worth, self-confidence, resilience, self-compassion, and adolescent friendship weaken the relationship (Chen et al., 2022; Dong et al., 2022). On the other hand, re-victimization, hopelessness, number of maltreatment types co-occurred, and rejection strengthen the association (Auslander et al., 2018; Courtney, 2008; De-oliveria, 2018; Gay et al., 2013). Future research should aim to address these limitations and include studies in multiple languages to provide a more comprehensive understanding of the association between emotional maltreatment and mental health outcomes.

Recommendations

This meta-analysis represents the first systematic review and meta-analysis to specifically examine the association between CEM and adolescent psychopathology. Given the high prevalence and detrimental impact of emotional abuse and neglect, further research is warranted to enhance our understanding of these phenomena.

Future studies should aim to address the limitations identified in this meta-analysis. It is crucial to conduct well-designed prospective studies with larger sample sizes and rigorous methodologies to strengthen the evidence base. Additionally, researchers should strive to utilize standardized measures of emotional abuse, neglect, and maltreatment to facilitate comparability across studies. Furthermore, investigating potential protective factors (self-esteem, autonomy, satisfaction, and adjustment), cultural and parental factors (parenting styles, attachment styles, cultural influence, role of religiosity), participant characteristics (more research including participants from non-WEIRD, that is, from non-Western, Educated, Industrialized, Rich, and Democratic countries, is needed), and resilience mechanisms that mitigate the negative effects of emotional abuse and neglect are of importance for future research. Identifying interventions and preventive strategies that effectively target emotional maltreatment is essential for promoting the well-being of adolescents around the world.

Conclusion

The study provides the first synthesis of the association between CEM and adolescent psychopathology, revealing a moderate correlation and minimal influence of study-level variables, with no significant publication bias detected. Overall, this systematic review and meta-analysis contribute to the growing body of evidence on the impact of emotional maltreatment on adolescent mental health. The findings highlight the urgency of addressing emotional abuse and neglect as critical public health issues, with implications for clinical practice, policy development, and further research in this field.

Critical Findings of the Review

The study conducted the first comprehensive synthesis of research on CEM and its association with adolescent psychopathology, providing valuable insights into this under-studied area.

The findings revealed a significant and moderate correlation between CEM and various mental health outcomes in adolescents, including depression, anxiety, SI, and post-traumatic stress disorder.

Study-level variables, for example, age, gender, publication year, and risk of bias were found to have minimal influence on the association between CEM and adolescent psychopathology, suggesting that this relationship is robust and consistent across different study contexts.

The assessment of publication bias indicated no significant bias, enhancing the credibility and reliability of the study’s findings.

Implications for Practice, Policy, and Research

In clinical practice, it is crucial for clinicians to be aware of the harmful effects of CEM on the mental health of adolescents. Interventions for children and adolescents experiencing emotional maltreatment should be based on evidence-based approaches.

Child protection policies and interventions should prioritize the identification and prevention of emotional abuse and neglect. This can be achieved through raising awareness, providing support services, and implementing preventive strategies to address emotional maltreatment.

The study highlights prospective future research on addressing the limitations identified in this study. Prospective studies with larger sample sizes and rigorous methodologies are necessary to strengthen the evidence base. Standardized measures of emotional abuse, neglect, and maltreatment should be utilized to ensure comparability across studies. Additionally, researchers should explore potential protective factors, cultural and parental influences, participant characteristics, and resilience mechanisms associated with emotional abuse and neglect.

Diversity considerations should be incorporated into research by including participants from non-WEIRD groups and diverse cultural backgrounds. This will enable a more comprehensive understanding of the relationship between emotional maltreatment and mental health outcomes across different populations.

Supplemental Material

sj-docx-1-tva-10.1177_15248380241233538 – Supplemental material for Association of Childhood Emotional Maltreatment with Adolescents’ Psychopathology: A Systematic Review and Meta-Analysis

Supplemental material, sj-docx-1-tva-10.1177_15248380241233538 for Association of Childhood Emotional Maltreatment with Adolescents’ Psychopathology: A Systematic Review and Meta-Analysis by Mohammad Hashim, Zainab Alimoradi, Amir Pakpour, Monique Pfaltz, Sameer Ansari, Resham Asif and Naved Iqbal in Trauma, Violence, & Abuse

Footnotes

Acknowledgment and Credits

We thank our team for their critical comments on the manuscripts.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Mohammad Hashim

Naved Iqbal

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Mohammad Hashim is a prospective PhD candidate at Jamia Millia Islamia, New Delhi. His interest areas include child maltreatment and adverse childhood experiences.

Zainab Alimoradi is associate professor at Qazvin University of Medical Sciences, Iran. She has expertise in systematic review and meta-analysis.

Amir Pakpour is professor at School of Health and Welfare, Jönköping University. His area of expertise includes health psychology and Social Psychology

Monique Pfaltz is professor of clinical psychology at Mid-Sweden University. She has expertise in the field of child maltreatment and co-leading Global Collaboration on Traumatic Stress.

Sameer Ansari is PhD students at Jamia Millia Islamia, New Delhi. His interest areas include health psychology and cyber psychology.

Resham Asif is a PhD student at Jamia Millia Islamia, New Delhi. Her interest areas include human development taking attachment orientation into account.

Naved Iqbal is professor of psychology at Jamia Millia Islamia, New Delhi. He has expertise in the field of health and clinical psychology. Prof Iqbal is also associated with Global Collaboration on Traumatic Stress.

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