When the term childhood trauma is mentioned, your mind may first turn to physical or sexual abuse. However, another form of trauma often overlooked is neglect. Unlike abuse, neglect isn’t a visible physical act, which can make it easy to underestimate its harmful impact. Neglect is defined as a “general and persistent failure of the caregiver in providing a child’s basic material and/or psychological needs, limiting or impairing the adequate development of a child’s physical and mental health” (Infurna et al., 2016).
Studies have found that neglect is quite common, though the estimations vary considerably. For example, the NSPCC roughly calculates that 1 in 10 children have experienced neglect in their life (NSPCC, 2021), with the caveat that this is likely to be an underestimation.
The association between exposure to childhood 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 illnesses (McKay et al., 2021). However, there are fewer studies that explore the impact of neglect (Stickley et al., 2020).
To get a better understanding of the prevalence of neglect in individuals diagnosed with a psychiatric disorder, Silva et al., (2024) conducted a systematic review. Their aim was to evaluate whether there are any significant differences in the prevalence of neglect between people with the main psychiatric diagnoses.
Is neglect more common in some psychiatric disorders compared to others?
Methods
The authors searched three electronic databases to identify quantitative papers that assessed the prevalence of childhood neglect trauma in adults with a diagnosed psychiatric disorder. The list of psychiatric disorders (diagnosed using either the DSM-5 or ICD-11) which were of interest to the review were: post-traumatic stress disorder (PTSD), anxiety disorders, 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 was further divided into three categories:
- unspecified neglect (Ne),
- emotional neglect (EN), and
- physical neglect (PN).
Studies were excluded if they were not published in English, had a sample of children/adolescents, had no valid assessment, or had a sample outside of the targeted diagnostic categories. Studies were screened and reviewed by at least two independent researchers at every 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 measurement to assess study quality. For the meta-analysis, a simple meta-regression model was performed.
Results
122 studies were included in the meta-analysis with the majority conducted in Europe (42.6%). There were a total of 57,638 participants across all the studies and the pooled age was 41 years. The most common diagnosis was Major Depressive Disorder (27.0%), followed by Bipolar Disorder (14.8%), and Eating Disorders (12.3%). Most studies reported data on both emotional and physical neglect (99/122). Around two thirds of studies had a moderate risk of bias, while around a third had a low risk of bias.
Unspecified neglect (Ne)
As there were only 15 studies that investigated unspecified neglect, the findings were not as robust as the other two categories. Within the 15 studies, the pooled prevalence rate was 46.6%. They found that there was no significant difference between psychiatric diagnoses, although they did find a lower prevalence rate in the Major Depressive Disorder group compared to the other psychiatric diagnoses (listed in methods). Ne was most prevalent in the PTSD group.
Emotional Neglect (En)
The pooled prevalence rate for emotional neglect was 43.1%. There was a significantly lower prevalence of emotional neglect in participants with Bipolar Disorder and Major Depressive Disorder compared to the other psychiatric diagnoses (listed in methods). Similar to unspecified neglect, the highest rates of emotional neglect were found in the PTSD group. Unlike Ne, however, there were also high rates in the OCD and ‘personality disorder’ group.
Physical Neglect (Pn)
Physical neglect had the lowest prevalence rates of the three, at 34.8%. Similarly to the other two types of neglect, the Major Depressive Disorder and Bipolar Disorder group had the lowest prevalence level of physical neglect compared to the other psychiatric diagnoses (listed in methods). As well as the two groups, there were also low prevalence levels 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 a third of participants in this study reported experiencing at least one type of childhood neglect.
Conclusions
The meta-analysis sought to assess the prevalence rates of neglect maltreatment in a variety of psychiatric disorders. The main finding was a lower prevalence of neglect in individuals diagnosed with bipolar disorder and major depressive disorder, and a higher prevalence in those with PTSD, OCD, and personality disorders, though this was not confirmed by the meta-analysis.
This review suggests that people with a diagnosis of PTSD, OCD or personality disorders have higher prevalence rates of neglect.
Strengths and limitations
Strengths:
- The authors conducted meta-regression models to determine the moderator effect for all variables, including age, sex, place of recruitment, risk of bias, and year of publication. Thus, they accounted for potential moderating effects of demographic variables such as age and sex, with the models determining that there was no significant impact.
Limitations:
- The authors did not include measurements of inter-rater reliability. While the screening process seemed robust, a quantitative measurement of agreement would have been informative.
- Only studies published in English were included in the study, which limits the findings. As the majority of the studies were conducted in either Europe or North-America, including studies not originally published in English may have increased the diversity.
- Although there were a few studies which measured multiple types of neglect, the results for multiple neglect types was not reported. As combined neglect experiences could have had a different impact compared to isolated neglect experiences, this could have yielded interesting findings.
The review did not explore studies where multiple types of neglect had been experienced. This could have a significantly different impact to isolated neglect experiences.
Implications for practice
Overall, the findings indicate a relatively high prevalence rate of childhood neglect across a variety of psychiatric disorders, with over a third of individuals reporting at least one type of neglect. This implies that practitioners should consider the impact of neglect on an individuals’ presentation. However, the rates may differ between diagnoses, with prevalence rates particularly high for individuals with PTSD, personality disorders, and OCD, and particularly low for individuals with major depressive disorder and bipolar disorder, though this difference was not confirmed.
Additionally, the type of neglect may be important, as the prevalence rate went up to almost 50% for unspecified neglect. This suggests that practitioners could go further and consider the different types of neglect. However, there was high heterogeneity in studies and more research needs to be done.
The systematic review sets up a good foundation for further research, as it is the first of its kind to summarise and compare prevalence rates across a variety of different psychiatric disorders. Future research can build on this, going into further detail on the difference between diagnoses. This systematic review did not aim to determine causal processes but did show that neglect is common. Future studies should therefore explore the relationship between childhood neglect and the development of specific psychiatric disorders in more detail.
Childhood neglect is likely to be an important factor in an individual’s history of maltreatment and practitioners should bear this in mind.
Statement of interests
None to declare.
Links
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, the neglected trauma. A systematic review and meta-analysis of its prevalence in psychiatric disorders. Psychiatry Research, [online] 335, p.115881.
Other references
Carr, C.P., Maria, C., Stingel, A.M., Lemgruber, V.B. and Juruena, M.F. (2013). The Role of Early Life Stress in Adult Psychiatric Disorders. The Journal of Nervous and Mental Disease, [online] 201(12), pp.1007–1020.
Infurna, M.R., Reichl, C., Parzer, P., Schimmenti, A., Bifulco, A. and Kaess, M. (2016). Associations between depression and specific childhood experiences of 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 published literature. Childhood trauma and adult depression. European Psychiatry, [online] 30(6), pp.665–680.
McKay, M.T., Cannon, M., Chambers, D., Conroy, R.M., Coughlan, H., Dodd, P., Healy, C., O’Donnell, L. and Clarke, M.C. (2020). Childhood trauma and adult mental disorder: A systematic review and meta‐analysis of longitudinal cohort studies. Acta Psychiatrica Scandinavica, [online] 143(3), pp.189–205.
Munn, Z., Moola, S., Riitano, D., & Lisy, K. (2014). The Development of a Critical Appraisal Tool for Use in Systematic Reviews: Addressing Questions of Prevalence. International Journal of Health Policy and Management, 3(3), 123-128. doi: 10.15171/ijhpm.2014.71
NSPCC (2021). Neglect. [online] NSPCC. [Accessed 16 Oct. 2024].
Stickley, A., Waldman, K., Sumiyoshi, T., Narita, Z., Shirama, A., Shin, J.I. and Oh, H. (2020). Childhood physical neglect and psychotic experiences: Findings from the National Comorbidity Survey Replication. Early Intervention in Psychiatry.
