Motivation and emotion/Book/2018/Childhood neglect and emotion

Childhood neglect and emotion:
What are the emotional consequences of childhood neglect?

Overview

Neglect is a broad term that is used to describe the deprivation of an individual's needs (Parkinson, Bromfield, McDougall, & Salveron, 2017). In childhood, needs are primarily met through parents or guardians. For this reason, children are at greater risk for their needs to be neglected. The estimated global prevalence of physical neglect is 163 per 1,000 children and the prevalence of emotional neglect is 184 per 1,000 children (Stoltenborgh, Bakermans-Kranenburg, & IJzendoorn, 2013). The emotional consequences of neglect are severe and can come in many different variations.

These emotional consequences from neglect include (but are not limited to): dysfunctions in emotional regulation, relationship problems, lack of empathy, psychopathic tendencies, depression and anxiety. However, before these effects are explored it is important to be clear that neglect can occur through many ways, not just physical needs. There are five types of neglect, namely, physical, emotional, medical, supervisory and educational.

Emotional consequences

To fully understand the emotional consequences of childhood neglect, one must understand why a child would have emotional reactions to neglect. Emotions can be seen as a radar to evaluate experiences and decide on an action (Cole, Martin, & Dennis, 2004). Emotions motivate, energise, and guide adaptive functioning of an individual (Morris, Silk, Steinberg, Myers, & Robinson, 2007). Considering the emotional responses of children who are neglected, two functions for emotion seem to be clear; emotions are used for coping and social interaction (Cole et al., 2004).

Coping

Emotions help children cope with neglect. Coping has been described as action regulation under stress (Skinner & Zimmer-Gembeck, 2016). Due to a lack of support and responsiveness from caregivers, emotionally neglected children create coping strategies, that can be ineffective. These strategies can be an excessive dependency on others or independency from others (Jacobsen & McKinney, 2015). Maguire and colleagues (2015) suggest that children who have been neglected have fewer emotional coping strategies than non-neglected children. Ineffective coping skills can lead to many emotional problems, as will be shown in this chapter.

Social interaction

Emotions not only allow a child to cope with neglect, they also can be used for social interaction. In infancy and childhood humans lack the ability to express their needs. Therefore, they must use emotions to socially interact with others, especially with parents, to express their feelings and have their needs met (Soltis, 2004). For example, a crying baby is not doing this for sheer annoyance, it is trying to tell you that it is hungry and needs food, or that it is upset and needs comfort. In later life, it is much the same. People may not scream and whinge to get attention, but they may shed tears or pull a sad face (Thomas & Bifulco, 2012). This is the bodies way of saying to others "Hey, I need support". In cases of neglect, the child does not gain this remedy by using emotional expressiveness, hence why in some cases they become emotionless. They have been taught that being emotional does not create a social interaction, therefore it has lost its purpose.

Case study 1.1

Jimmy frequently gets extremely agitated whenever he is asked about his homework. His teacher assumes that Jimmy is being lazy. Jimmy doesn’t understand any of the class work. He has tried to get help from his Mum, but she works most nights and Jimmy is left alone. He is frustrated that he can’t get it done. His teacher doesn’t understand, so he gets mad at his teacher for not helping him. In this example, Jimmy uses his anger to socially communicate that something is wrong, and to cope with the frustration of not being able to keep up with school work. Due to his neglect at home, he uses ineffective coping strategies, like anger, which does not communicate what he needs.

Maternal deprivation theory

John Bowlby is known for his work on the very well-known Attachment Theory. Attachment Theory presents that the emotional connection between a parent and a child is rooted in the evolutionary function of protection (Duniec, & Raz, 2011). Maternal Deprivation Hypothesis stemmed from Attachment Theory and is a salient idea for the emotional consequences of childhood neglect. The hypothesis suggests that one needs a continuous, warm and intimate relationship with their mother (or a mother figure) to have healthy psychological and emotional development (Duniec, & Raz, 2011).

Bowlby argued that the consequences of Maternal Deprivation can consist of struggles in creating stable relationships and lack of affect (as seen in his 44 Juvenile Thieves Study). The Maternal Deprivation hypothesis was based on cases of neglect that Bowlby observed through homeless children (Duniec, & Raz, 2011).

This theory is limited by only considering the effects of the lack of maternal, rather than paternal attachment. This was famously pointed out in 1972 by Rutter, who claimed that as long as a child had attachment to a parental figure they benefited from the influence (Duniec, & Raz, 2011). However, in more recent studies it seems that many researchers still continue to place higher value on the mother-child relationship and the development of negative emotional consequences, such as psychopathy (Gao et al., 2010).

Whether maternal, paternal or both together have greater influence on a child’s development, it is clear from this theory that neglect, which is the essence of deprivation of attachment, has considerable emotional consequences on the child.

Consequences

The emotional consequences of childhood neglect can vary enormously. However, for the purposes of this book chapter the following consequences have been chosen for examination as they are what is most common in the literature.

Emotional regulation

Dysfunctional caregiving behaviour has an impact on the child’s ability to regulate emotions (Kim, & Cicchetti, 2010). Emotional regulation is the ability to deal with ongoing emotional experiences and cope with them by inhibiting, initiating or monitoring the emotion in a socially acceptable manner (Cole et al., 2004).

Emotional regulation is developed through parent-child interactions. This interplay can consist of the parent and child reading facial cues and vocal tones, which is then matched or mimicked (Cole et al., 2004). This interaction is explored more thoroughly in the famous experiment called the ‘Still Face Paradigm’ by Edward Tronich. For the child, this gives the stepping stones to reading and reciprocating emotions. The key to the success of these interactions is the predictable and systematic ways the emotions are responded to (Cole et al., 2004).

In childhood neglect, this interaction will be lacking, therefore the child does not have the opportunity to learn or practice emotional regulation at its most basic level. Emotional regulation has been shown to be a key feature of being able to gain positive peer relationships (Kim & Cicchetti, 2010). Therefore, children who are neglected will struggle to regulate their emotions and this results in relationship challenges.

Relationships

In many ways, the relationship with parental figures in early life is the most important. Object Relations Theory suggests that these relationships guide all the other attachments one will make in their life, such as social, romantic or being excessively independent or dependant on others.

Social dysfunctions have been noted in many children who have experienced neglect. Kim and Cicchetti (2010) found that overall neglected or maltreated children experienced more peer rejection than their non-maltreated peers. Many reasons have been given for this, which all centre around emotional regulation. An example of this is the child who cries easily, and hence children make fun of him and don’t want to play with the ‘cry baby’. Research has found differences in the emotional outcomes of the type of neglect the children were exposed to (Maguire et al., 2015). Such that, children who were physically neglected were more lacking in social competence which included behaviours such as initiating friendships, perspective taking and empathy. Whereas children who were emotionally neglected show more aggressive emotional reactions (Maguire et al., 2015). This again outlines emotional regulation issues, such as the child who punches their opponent when losing a soccer game in the playground instead of controlling his emotions, is not likely to be asked the following day to play again. In addition to this, Young, Lennie and Minnis (2011) found that emotionally neglected children were more socially withdrawn and had limited peer interactions. The reason that these children may have trouble socially can be linked to a combination of emotional regulation issues aroused from attachment issues. Overall, children who are neglected lack the ability and experience, from parents, to regulate themselves in a socially acceptable way that enhances social connectedness.

Romantic

This trend of relationship struggles extends from social to romantic attachments in later life. Labella and colleagues (2017) conducted a longitudinal study with 267 participants from birth to middle adulthood. Their results suggest that those who experienced neglect had poorer romantic competency and in addition exhibited more relational violence. In 1970 psychologists Ainsworth and Bell conducted a study which was called Strange Situation Classification. This research, has shown that children who experience emotional neglect tend to display insecure or ambivalent attachment styles towards caregivers and into adulthood (Crittenden et al. 2007). Those who have anxious–ambivalent attachment style, seek out intimidate relationships but are hesitant to be close to someone and worry their feelings will not be reciprocated. Whereas, with avoidant attachment styles, individuals tend to not seek out close relationship and are unable or unwilling to emotionally share with others (Schimmenti, & Bifulco, 2015). This combination of traits and emotional reactions to love, make it difficult for individuals to be romantically competent (Labella et al., 2017).

Dependency vs. independency

Children who are neglected have shown to be overly independent, such as socially withdrawn or excessively dependent (Jacobsen & McKinney, 2015). Children who are exposed to significantly neglectful environments are at an increased risk for two attachment disorders, as defined in the DSM-V (Zeanah & Gleason, 2015). The first is called Reactive Attachment Disorder (RAD). RAD outlines extreme independence as it is characterised by social withdrawal and unresponsiveness to social support. This disorder is linked to insecure attachment to parental figures in childhood. The other disorder is called Disinhibited Social Engagement Disorder, which is quite the opposite. This is when children are highly dependent on others. Those with this disorder tend to become overly friendly with strangers. These two disorders have been identified in children who experienced neglect in a Romanian orphanage (Smyke et al., 2002). Although, overall it appears that RAD is the more common emotional reaction from neglect than Disinhibited Social Engagement disorder (Petersen, Joseph, & Feit, 2013).

Empathy

Empathy is an essential part of relationships. Empathy allows for an individual to infer what others are thinking and adjust their behaviour accordingly (Baron-Cohen & Wheelwright, 2004). The development of empathy can be traced back to maternal attachment in childhood. Researchers have suggested that parenting contains two factors: care and overprotection (Lyons, Brewer, & Bethell, 2017). In cases of neglect where children are likely to receive neither, the child has to be concerned with self and seek ways to serve their own needs. Whereas, parents that give children a supportive environment, allow the child to move away from their own needs and allows them to explore the needs of others (Lyons et al., 2017). Lack of empathy for another's emotion can lead to other disorders later in life, such as psychopathic tendencies (Gao et al., 2010).

Psychopathy

Childhood neglect has been linked with psychopathic tendencies (Watts, Donahue, Lilienfeld, & Latzman, 2017). Psychopathy is characterised by manipulativeness, apathy, lack of affect, impulsivity, and aggression (Gao et al., 2010). In the past, the association between Maternal Deprivation, seen in cases such as neglect, and the development of psychopathic tendencies has been explored by Bowlby in his 44 Juvenile Thieves Study. From this study on juvenile offenders who had experienced maternal deprivation, Bowlby coined the term ‘Affectionless Psychopath’.

So, from this perspective, children who have low mother-child bonding become unemotional, uncaring adults. But why does not being hugged enough, or interacted with as a child, result in emotional consequences, such as psychopathic tendencies? One explanation is that parental deprivation actually creates dysfunctions in a brain structure called the hypothalamic–pituitary– adrenal axis (HPA-axis) (Cima, Smeets, & Jelicic, 2008). This brain structure helps control stress reactions. Without proper HPA-axis function the individual cortisol levels reduce and this results in aggressive tendencies seen in psychopathy (Cima, Smeets, & Jelicic, 2008). Dysfunction in the HPA-axis has also been linked to affective disorders, such as depression (Shea et al., 2005).

Case study 1.2

' The coldest heart ' (True Story, from ‘ The Boy Who was Raised as a Dog ’ by Perry & Szalavitz (2008).

Two brothers, Leon and Frank could not be more different. Frank is outgoing and academically gifted. Leon, on the other hand, is cold, uncaring and manipulative. Leon is currently in jail for the murder of two young girls.

How can these two brothers, who came from the same parents, have such different emotional outcomes? Well, when Leon was born his parents moved from a small town, where his extended family lived, to a city where his mother knew no one. Most days his father would go to work and becoming overwhelmed with being so isolated his mother struggled with his care. Some days, getting so frustrated with his constant cries, she would leave him in the cot and go for walks around the city with Frank. Eventually, without his cries being responded to with soothing from a parent, he stopped crying. Frank, the older child, had a very different early life. He grew up in the small town, where his mother had a lot of support from family and friends. Frank's every need or fuss was tended to with love and care. It seems a subtle difference in parenting, however, the comparison between emotional consequences speaks for itself.

Depression

Depression is rooted in the emotional feeling of sadness (Bonanno, Goorin, & Coifman, 2008). Motivationally these two are slightly different. Sadness motivates restorative actions and seeks out social interaction. In childhood and throughout life sadness can be a good thing, because it communicates to people, especially parents, that an individual needs emotional support. Depression has little motivational benefits, and usually includes a withdrawal from social situations. This takes away the opportunity for social support and in turn, makes an individual feel more depressed. Wang and colleagues (2014) found neurological abnormalities in victims of childhood neglect which leads to dysfunctional emotional development which can cause depressive symptoms. This study compared non-neglected and neglected participants, which is a strength over many other studies that fail to compare their results to a neurotypical sample.

The role of shame proneness has also been explored as an emotional factor for depressive symptoms in children who have experienced neglect. Shame is defined as a state of mind where the individual feels that they themselves as a whole are defective (Bennett, Sullivan, & Lewis, 2010). This is because when a parent creates a hostile environment, void of warmth and acceptance, the child internalises this into a negative view of self. It’s like ‘No one cared for me, because I’m not worth being cared for’. This negative perception for self is a key factor in shame development, which in turn can lead to depressive symptoms (Bennett et al., 2010).

Anxiety

Anxiety is rooted in the emotional feeling of prolonged fear. However, there are differences between each. Fear is experienced when an impending threat is present. Anxiety, on the other hand, does not need an identifiable threat. In cases of neglect, a child may fear their safety due to a lack of supervision. As the child turns into an adult, they become able to look after themselves, the threat is then taken away. However, the fear for safety may still remain, which is expressed through anxiety.

Schimmenti and Bifulco (2015) suggest that the anxiety experienced in adulthood as an emotional consequence of childhood neglect can be linked back to attachment styles. The authors base their suggestion on Bowlby’s 1973 work, which stated that anxiety disorders in adulthood are traceable to the unavailability of parental nurturance in times of stress. In more recent studies, Teicher and Samson (2016) found an association with decreased amygdala volume and experience of childhood neglect. In addition, the authors also outline that children who have experienced neglect have heightened threat arousal (amygdala activity) to negative or perceived negative facial emotions. This gives an explanation of why people who experience childhood neglect have the emotional consequence of anxiety, as the amygdala controls the fear response in humans. Therefore, heighten threat detection leads people to be on high alert for threat or stressful stimuli, which is common in anxiety symptomology.

PTSD

Post-traumatic stress disorder (PTSD) is associated with fear. It follows after a traumatic event and includes symptoms of re-experiencing, avoidance, altered arousal and negative changes in mood and cognition (APA, 2013). Literature has outlined PTSD's association with childhood neglect (Lueger-Schuster et al., 2018). However, neglected children can experience many of the symptoms of PTSD, but they may not fulfill criterion A for PTSD (Spertus et al., 2003). Throughout the literature, there is a significant overlap with childhood neglect and abuse (Maguire et al., 2015). This makes it difficult to fully assess the direct effects of neglect, as some effects could be due to abuse. This would explain the relationship between neglect and PTSD symptomology, as abuse may be a mediating factor. Future research needs to design measures to separate these two forms of child maltreatment and further define the relationship of PTSD and neglect.

Quiz

Test your knowledge from this chapter

Conclusion

The emotional consequences of childhood neglect have been shown to cause problems for an individual and their relationships. Bowlby's Maternal Deprivation Hypothesis explains that attachment and lack of maternal interaction, seen in childhood neglect, is the cause of emotional consequences. Childhood neglect has been shown to affect emotional regulation, which can affect social relationships, especially in childhood, and romantic relationships in later life. In addition, attachment and coping strategies resulting from neglect can include excessive dependency or independence (Jacobsen & McKinney, 2015). Empathy plays a large role in relationships but also lack of empathy leads onto psychopathic tendencies (Gao et al., 2010). The emotions of sadness and fear in childhood may translate into anxiety and depressive disorders. Anxiety appears to have neurological explanation due to heightened threat response (Teicher & Samson, 2016). The role of the emotional feeling of shame and the results on self, give insight into the causes of depression from childhood neglect (Bennett et al., 2010). This chapter aimed to educate on the emotional consequences of childhood neglect, although, this is to be taken as an overview, it does not account for individual differences or health problems that people may present. This information serves all people, but especially health professionals, teachers, and parents. The hope is that an individual may read this and gain an awareness of the emotional consequences of childhood neglect.

References

Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67. https://doi.org/10.2307/1127388

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Baron-Cohen, S., & Wheelwright, S. (2004). The empathy quotient: an investigation of adults with Asperger syndrome or high functioning autism, and normal sex differences. Journal of Autism and Developmental Disorders, 34 (2), 163–175. https://doi.org/10.1023/B:JADD.0000022607.19833.00

Bennett, D., Sullivan, M., & Lewis, M. (2010). Neglected Children, Shame-Proneness, and Depressive Symptoms. Child Maltreatment, 15, 305–314. https://doi.org/10.1177/1077559510379634

Bonanno, G. A., Goorin, L., & Coifman, K. G. (2008). Handbook of emotions (3rd ed.). Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.472.7583&rep=rep1&type=pdf#page=813

Bowlby, J. (1973). Attachment and loss: vol 2. Separation: Anxiety and anger. New York: Basic Books.

Cole, P., Martin, S., & Dennis, T. (2004). Emotion Regulation as a Scientific Construct: Methodological Challenges and Directions for Child Development Research. Child Development, 75, 317–333. https://doi.org/10.1111/j.1467-8624.2004.00673.x

Cima, M., Smeets, T., & Jelicic, M. (2008). Self-reported trauma, cortisol levels, and aggression in psychopathic and non-psychopathic prison inmates. Biological psychology, 78, 75-86. https://doi.org/10.1016/j.biopsycho.2007.12.011

Crittenden, P., Claussen, A., & Kozlowska, K. (2007). Choosing a Valid Assessment of Attachment for Clinical Use: A Comparative Study. Australian and New Zealand Journal of Family Therapy, 28, 78–87. https://doi.org/10.1375/anft.28.2.78

Duniec, E., & Raz, M. (2011). Vitamins for the soul: John Bowlby’s thesis of maternal deprivation, biomedical metaphors and the deficiency model of disease. History of Psychiatry, 22, 93–107. https://doi.org/10.1177/0957154X10389741

Gao, Y., Raine, A., Chan, F., Venables, P. H., & Mednick, S. (2010). Early maternal and paternal bonding, childhood physical abuse and adult psychopathic personality. Psychological Medicine, 40, 1007-1016. http://doi.org/10.1017/S0033291709991279

Jacobsen, S., & McKinney, C. (2015). A music therapy tool for assessing parent–child Interaction in cases of emotional neglect. Journal of Child and Family Studies, 24, 2164–2173. http://doi.org/10.1007/s10826-014-0019-0

Kim, J., & Cicchetti, D. (2010). Longitudinal pathways linking child maltreatment, emotion regulation, peer relations, and psychopathology. Journal of Child Psychology And Psychiatry, 51, 706–716. http://doi.org/10.1111/j.1469-7610.2009.02202.x

Labella, M., Johnson, W., Martin, J., Ruiz, S., Shankman, J., Englund, M., … Simpson, J. (2017). Multiple Dimensions of Childhood Abuse and Neglect Prospectively Predict Poorer Adult Romantic Functioning. Personality and Social Psychology Bulletin, 44, 238–251. https://doi.org/10.1177/0146167217736049

Lueger-Schuster, B., Knefel, M., Glück, T., Jagsch, R., Kantor, V., & Weindl, D. (2018). Child abuse and neglect in institutional settings, cumulative lifetime traumatization, and psychopathological long-term correlates in adult survivors: The Vienna Institutional Abuse Study. Child Abuse & Neglect, 76 . Retrieved from http://search.proquest.com/docview/2019062834/

Lyons, M., Brewer, G., & Bethell, E. (2017). Sex-Specific Effect of Recalled Parenting on Affective and Cognitive Empathy in Adulthood. (Article)(Report). Current Psychology, 36, 236–241. http://doi.org/10.1007/s12144-015-9405-z

Maguire, S., Williams, B., Naughton, A., Cowley, L., Tempest, V., Mann, M., Teague, M., et al. (2015). A systematic review of the emotional, behavioural and cognitive features exhibited by school‐aged children experiencing neglect or emotional abuse. Child: Care, Health and Development, 41. http://doi.org/10.1111/cch.12227.

Morris, A., Silk, J., Steinberg, L., Myers, S., & Robinson, L. (2007). The Role of the Family Context in the Development of Emotion Regulation. Social Development, 16, 361–388. http://doi.org/10.1111/j.1467-9507.2007.00389.x

Parkinson, S., Bromfield, L., McDougall, S., & Salveron, M. (2017). Child neglect: Key concepts and risk factors. Retrieved from Australian Centre for Childhood Protection: http://www.unisa.edu.au/Global/EASS/Research/ACCP/Child%20Neglect,Key%20concept%20and%20risk%20factors%20report.pdf

Perry, B. D., & Szalavitz, M. (2008). The boy who was raised as a dog: And other stories from a child psychiatrist's notebook: what traumatized children can teach us about loss, love, and healing. New York: Basic Books.

Petersen, A. C., Joseph, J., & Feit, M. (2013). New Directions in Child Abuse and Neglect Research (pp. xiii, 428). National Academies Press. https://doi.org/10.17226/18331

Rehan, W., Antfolk, J., Johansson, A., Jern, P., & Santtila, P. (2017). Experiences of severe childhood maltreatment, depression, anxiety and alcohol abuse among adults in Finland. (Research Article)(Report). PLoS ONE, 12, e0177252. http://doi.org/10.1371/journal.pone.0177252

Schimmenti, A., & Bifulco, A. (2015). Linking lack of care in childhood to anxiety disorders in emerging adulthood: the role of attachment styles. Child and Adolescent Mental Health, 20, 41–48. http://doi.org/10.1111/camh.12051

Shea, A., Walsh, C., Macmillan, H., & Steiner, M. (2005). Child maltreatment and HPA axis dysregulation: relationship to major depressive disorder and post traumatic stress disorder in females. Psychoneuroendocrinology, 30 , 162–178. http://doi.org/10.1016/j.psyneuen.2004.07.001

Skinner, E. A., & Zimmer-Gembeck, M. J. (2016). Coping as action regulation under stress. In The Development of Coping, (pp. 3-25). Springer, Cham. https://doi.org/10.1007/978-3-319-41740-0_1

Soltis, J. (2004). The signal functions of early infant crying. Behavioral and Brain Sciences, 27, 443-458. https://doi.org/10.1017/S0140525X0400010X

Smyke, A. T., Dumitrescu, A., & Zeanah, C. H. (2002). Attachment disturbances in young children. I: The continuum of caretaking casualty. Journal of the American Academy of Child & Adolescent Psychiatry, 41 (8), 972-982. http://doi.org/10.1097/00004583-200208000-00016

Spertus, I., Yehuda, R., Wong, C., Halligan, S., & Seremetis, S. (2003). Childhood emotional abuse and neglect as predictors of psychological and physical symptoms in women presenting to a primary care practice. Child Abuse & Neglect: The International Journal, 27, 1247–1258. http://doi.org/10.1016/j.chiabu.2003.05.001

Stoltenborgh, M., Bakermans-Kranenburg, M., & IJzendoorn, M. (2013). The neglect of child neglect: a meta-analytic review of the prevalence of neglect. Social Psychiatry and Psychiatric Epidemiology, 48, 345–355. http://doi.org/10.1007/s00127-012-0549-y

Teicher, M., & Samson, J. (2016). Annual research review: Enduring neurobiological effects of childhood abuse and neglect. Journal of Child Psychology and Psychiatry, 57. https://doi.org/10.1111/jcpp.12507

Thomas, G., & Bifulco, A. (2012). Understanding adult attachment in family relationships: Research, assessment and intervention. Routledge.

Wang, L., Dai, Z., Peng, H., Tan, L., Ding, Y., He, Z., … Li, L. (2014). Overlapping and segregated resting‐state functional connectivity in patients with major depressive disorder with and without childhood neglect. Human Brain Mapping, 35 , 1154–1166. https://doi.org/10.1002/hbm.22241

Watts, A., Donahue, K., Lilienfeld, S., & Latzman, R. (2017). Gender moderates psychopathic traits’ relations with self-reported childhood maltreatment. Personality and Individual Differences, 119, 175–180. https://doi.org/10.1016/j.paid.2017.07.011

Young, R., Lennie, S., & Minnis, H. (2011). Children’s perception of parental emotional neglect and control and psychopathology. Journal of Child Psychology and Psychiatry, 52, 889–897. https://doi.org/10.1111/j.1469-7610.2011.02390.x

Zeanah, C., & Gleason, M. (2015). Annual Research Review: Attachment disorders in early childhood – clinical presentation, causes, correlates, and treatment. Journal of Child Psychology and Psychiatry, 56, 207-222. https://doi.org/10.1111/jcpp.12347}}

External links