When the term childhood trauma is mentioned, your mind may first turn to physical or sexual abuse. However, another form of trauma that is often overlooked is neglect. Unlike abuse, neglect is not a visible physical act, which can make its harmful impact easier to assess. Indifference is defined as a “General and persistent failure of the caregiver to meet the child's basic material and/or psychological needs, limiting or impairing the adequate development of the child's physical and mental health” (Infurna et al., 2016).
Studies have shown that neglect is quite common, although estimates vary widely. For example, the NSPCC estimates that approximately 1 in 10 children have experienced neglect in their lifetime (NSPCC, 2021), warning that this is likely to be an underestimate.
The link between childhood exposure to traumatic events and the development of mental illness is now well established with several studies showing that exposure to traumatic events increases the likelihood of developing mental illness (McKay et al., 2021). However, there are fewer studies examining the effects of neglect (Stickley et al., 2020).
To better understand the prevalence of neglect in individuals diagnosed with a psychiatric disorder, Silva et al., (2024) conducted a systematic review. Their aim was to assess whether there were any significant differences in the prevalence of neglect among people with major psychiatric diagnoses.
Is neglect more common in some psychiatric disorders than in others?
Methods
The authors searched three electronic databases to identify quantitative papers assessing the prevalence of childhood neglect trauma in adults diagnosed with a psychiatric disorder. A list of psychiatric disorders (diagnosed using DSM-5 or ICD-11) was of interest for review: post-traumatic stress disorder (PTSD), anxiety disorder, obsessive-compulsive disorder (OCD), major depressive disorder (MDD), eating disorders (ED), bipolar disorder (BD), mood disorders, schizophrenia (SCZ), schizophrenia spectrum disorders, personality disorders (PD), and mixed psychiatric disorders.
Childhood neglect is further divided into three categories:
- indefinite neglect (Ne),
- emotional neglect (EN) and
- physical neglect (PN).
Studies were excluded if they were not published in English, had a child/adolescent sample, did not have a valid assessment, or had a sample outside the target diagnostic categories. Studies were screened and reviewed by at least two independent investigators at each stage of the screening process.
Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist (Munn et al., 2014), a validated measure for assessing study quality. A simple meta-regression model was performed for the meta-analysis.
Results
122 studies were included in the meta-analysis, most of which were conducted in Europe (42.6%). There were a total of 57,638 participants across all studies, and the combined age was 41. The most common diagnoses were Major Depressive Disorder (27.0%), Bipolar Disorder (14.8%), and Eating Disorder (12.3%). Most studies reported both emotional and physical neglect (99/122). About two-thirds of the studies had a moderate risk of bias, and about one-third had a low risk of bias.
Unspecified neglect (None)
As there were only 15 studies examining undiagnosed neglect, the findings were not as robust as the other two categories. Within 15 studies the overall prevalence rate was 46.6%. Although they found a lower prevalence rate in the Major Depressive Disorder group compared to other psychiatric diagnoses (listed in methods), they found no significant difference between psychiatric diagnoses. Ne was most common in the PTSD group.
Emotional neglect (less)
The the overall prevalence rate of emotional neglect was 43.1%. Participants with Bipolar Disorder and Major Depressive Disorder had a significantly lower prevalence of emotional neglect compared to other psychiatric diagnoses (listed in methods). Similar to unspecified neglect, the highest rates of emotional neglect were found in the PTSD group. In contrast to Ne, there were also high rates in the OCD and “personality disorder” group.
Physical neglect (Pn)
There was physical neglect Lowest prevalence rates of the three, 34.8%. As with the other two types of neglect, the Major Depressive Disorder and Bipolar Disorder group had the lowest prevalence of physical neglect compared to other psychiatric diagnoses (listed in methods). In addition to the two groups, there was a low prevalence of physical neglect for individuals with psychotic disorders and eating disorders. The highest rates were in the OCD, personality disorder and PTSD groups.
At least one-third of the participants in this study reported experiencing at least one form of childhood neglect.
Results
A meta-analysis attempted to estimate the prevalence rates of neglect in various psychiatric disorders. The main finding was a lower prevalence of apathy in those diagnosed with bipolar disorder and major depressive disorder and a higher prevalence in those with PTSD, OCD, and personality disorder, although this was not confirmed by the meta-analysis.
This review suggests that people with a diagnosis of PTSD, OCD, or personality disorder have a higher prevalence rate of neglect.
Strengths and limitations
Strengths:
- The authors performed meta-regression models to determine the moderator effect for all variables, including age, sex, recruitment location, risk of bias, and year of publication. Thus, they accounted for the potential moderating effects of demographic variables such as age and gender, and the models found no significant effects.
Limitations:
- The authors did not include measures of interrater reliability. Although the verification process appears robust, quantification of agreement would be informative.
- The study included only studies published in English, which limits the findings. As the majority of studies were conducted in either Europe or North America, studies not originally published in English may also have increased diversity.
- Although there have been several studies measuring multiple types of neglect, results for multiple types of neglect have not been reported. This could have yielded interesting findings as combined neglect experiences may have had different effects compared to isolated neglect experiences.
The review did not examine studies in which multiple types of neglect were experienced. This can have a significantly different impact on isolated neglect experiences.
Implications for practice
Overall, the findings indicate a relatively high prevalence of childhood neglect among the various psychiatric disorders, with more than one-third of individuals reporting at least one form of neglect. This means that practitioners need to consider the impact of neglect on individuals' presentation. However, rates may differ between diagnoses, with prevalence rates particularly high for individuals with PTSD, personality disorder, and OCD, and particularly low for individuals with major depressive disorder and bipolar disorder, although this difference has not been confirmed.
Additionally, the type of neglect may be important, as the prevalence rate for unspecified neglect has reached almost 50%. This suggests that practitioners can go further and consider different types of neglect. However, there was high heterogeneity across studies and more research is needed.
The systematic review provides a good foundation for future research, as it is the first of its kind to summarize and compare prevalence rates across different psychiatric disorders. Future studies could build on this by providing more detailed information on the difference between diagnoses. This systematic review did not aim to identify causal processes, but showed that neglect is common. Therefore, future research should further investigate the relationship between childhood neglect and the development of specific psychiatric disorders.
Childhood neglect is likely to be an important factor in an individual's history of maltreatment, and practitioners should take this into account.
Statement of interest
None to declare.
Connections
Primary paper
Silva, R., Oliva, F., Barlati, S., Perusi, G., Meattini, M., Dashi, E., Colombi, N., Vaona, A., Carletto, S. and Minelli, A. ( 2024). Childhood neglect, neglect trauma. A systematic review and meta-analysis of its prevalence in psychiatric disorders. Psychiatry Research(online) 335, p. 115881.
Other references
Carr, CP, Maria, C., Stingel, AM, Lemgruber, VB, and Juruena, MF (2013). The Role of Early Life Stress in Adult Psychiatric Disorders. Journal of Nervous and Mental Diseases(online) 201(12), p.1007–1020.
Infurna, M.R., Reichl, C., Parzer, P., Schimmenti, A., Bifulco, A., and Kaess, M. (2016). Relationships between depression and specific experiences of childhood abuse and neglect: a meta-analysis. Journal of Affective Disorders(online) 190, pp. 47–55.
Mandelli, Petrelli, C. and A. Serretti (2015). The role of specific early trauma in adult depression: A meta-analysis of the published literature. Childhood trauma and adult depression. European Psychiatry(online) 30(6), pp. 665–680.
McKay, MT, Cannon, M., Chambers, D., Conroy, RM, Coughlan, H., Dodd, P., Healy, C., O'Donnell, L. and Clarke, MC (2020). Childhood trauma and adult mental disorder: A systematic review and meta-analysis of longitudinal cohort studies. Scandinavian Journal of Psychiatry(online) 143(3), p.189–205.
Munn, Z., Moola, S., Riitano, D., & Lisy, K. (2014). Developing a Critical Appraisal Tool for Use in Systematic Reviews: Addressing Issues of Dissemination.International Journal of Health Policy and Management,3(3), 123-128. doi: 10.15171/ijhpm.2014.71
NSPCC (2021). Carelessness. (online) NSPCC. (Accessed 16 October 2024).
Stickley, A., Waldman, K., Sumiyoshi, T., Narita, Z., Shirama, A., Shin, JI and Oh, H. (2020). Childhood physical neglect and psychotic experiences: Findings from the National Comorbidity Study Replication. Early Intervention in Psychiatry.