Here’s an irony for you: neglect is neglected. In discussions of childhood maltreatment, neglect hovers in the background, included categorically (“abuse and neglect”) but rarely the main focus despite being more prevalent than abuse and just as damaging.[1] The reasons aren’t hard to spot. First, abuse and neglect often occur together, so it’s not always possible (or useful) to distinguish them. Second, what’s missing from a child’s life is harder to see than what’s pressing down on it, so neglect is easy to overlook–both for researchers and for those affected. Third, neglect tends to be quiet and gradual, so it doesn’t get much media attention. Lacking the drama, the specificity, and the moral clarity of abuse, it doesn’t generate the reporting or the TV programming that drive public discussion. Fortunately, psychologists have begun noticing the neglect of neglect and have begun correcting it, making this a perfect time to bring the topic into the foreground.

First some definition: I’ll focus mainly on emotional neglect (EN), which is characterized by long-term parental unavailability, unresponsiveness, and inattention. Parents (or principal caregivers) may be physically unavailable because of a job, migration, divorce, incarceration, or death. Or they may be physically present but emotionally unavailable: mentally or physically ill, struggling with addiction, stretched thin by other dependents, overwhelmed with work, or preoccupied by an outside interest. They may simply be so impaired by EN themselves that they have no idea how to nurture their children. EN does not necessarily indicate bad parents making bad choices; it just means not providing the interaction necessary for a child’s emotional, cognitive, and social development.

As infants, then children, we need consistent interaction with another human being to develop normally. These interactions give us working models of ourselves and our relationship to others, models that affect our experiences and our perceptions for the rest of our lives. These internal models become prototypes for our adult relationships, not because we magically “attract” the people and situations we grew up with, but because these models shape our expectations of others and of ourselves. For example, children whose emotional cues are routinely ignored may see the world as indifferent or hostile to them and see themselves as powerless. Without countervailing influences, they may develop into adults who expect negative outcomes and give up easily, generating a record of failure that repeatedly confirms their pessimism. And they may never become consciously aware of this feedback loop.

Infants are so vulnerable to EN that it can kill them, even if their physical needs are met. When their caregivers respond sensitively–soothing them when they cry, smiling when they smile, repeating sounds that make them laugh–babies gain a sense of security, agency, and social connection. These allow them to learn emotional regulation or how to manage their negative feelings. When caregivers don’t respond to them or respond erratically, babies feel stressed, helpless, and disconnected. They may be overwhelmed by negative feelings–or learn to manage them in ways that prove maladaptive later in life, such as cutting themselves off emotionally.

For a tiny glimpse of this process, we can revisit Dr. Edward Tronick’s classic “Still Face Experiment,” in which a normally responsive parent briefly ignores an infant, provoking visible agitation. To regain the parent’s attention, the baby tries smiling, vocalizing, pointing, kicking, waving, and shrieking before bursting into tears. If the parent remains unresponsive, the baby gives up completely, turning away with a forlorn expression. Specialists in child development believe this experiment demonstrates that even very young infants adjust their emotions and their behavior in response to their primary caregivers. Over time, repeated adjustments become patterns of engagement or non-engagement that affect both personality and the physical structure of the child’s brain.[2]

Older children are no less reliant on interaction with caregivers. Cuddling, responsive play, verbal affection, and patient, interested conversation are vital to continued development. In the absence of love and attention, the growth of children’s brains (and of their bodies) slows down, even when they are well-nourished and physically tended. Tragically, modern catastrophes have produced such populations, and neuroscientists have been able to assess them. A 15-year study of abandoned children in Romania reveals that deprivation of emotional nurture reduces white matter in brain areas affecting cognition, emotion, attention, and executive function. Here in the US, EN is now so pervasive and severe that Nobel-Prize-winning economist James Heckman claims we can solve “the biggest problems facing America” including economic weakness, social inequality, crime, addiction, “lifestyle” illnesses, educational failure, and unemployment, just by tackling childhood neglect. I agree, by the way.

What are the effects of EN, and how do they differ from the effects of physical, sexual, and emotional abuse?[3] All are major risk factors for psychopathology, but EN tends to produce more “internalizing” problems, such as depression and anxiety, rather than “externalizing” problems, such as aggression. Neglect predicts more difficulty with social interaction, along with lower levels of the bonding hormone oxytocin. Fear and avoidance of social situations may persist well into adulthood and exacerbate mental health problems such as depression. EN is also linked with larger cognitive and academic deficits than is abuse. Especially in adolescence, neglect is slightly more associated with substance misuse and  cigarette smoking. Like abuse, it’s often a factor in obesity, particularly binge eating disorder. It commonly impairs emotional clarity in young people and may persist as a lifelong difficulty identifying and expressing feelings, a condition known as alexithymia. Sufferers often experience a persistent numbness or hollowness, rather than feelings such as sorrow or joy. In extreme cases, EN may contribute to the callousness and lack of emotion that prefigure psychopathy. Untreated, all of these problems may last a lifetime. Even in old age, having suffered childhood EN raises the risk of psychopathology, especially depression and anxiety, along with specific medical problems such as stroke.

What, exactly, constitutes EN? No caregiver can (or should) be perfectly attuned and instantly responsive to a child at all times. As they grow, children must learn to meet some of their own emotional needs and to cope with not having other needs met. In addition, the older they get, the more children turn to peers and adults outside the home for validation and affection. What’s needed from parents is a pattern of regular attunement and responsiveness pegged to the age of the child. Some experts have tried to measure what “regular” means and have come up with an average threshold: thirty percent of the time, more in infancy and less later on. Thirty percent seems a pretty low bar, so why is EN becoming so widespread?

There are the obvious reasons we have already mentioned. The mother struggling with an alcohol use disorder passes out halfway through “Paddington 2,” and her five-year-old son finishes watching alone, pulls a blanket over his sleeping mother, and tucks himself into bed. The single father, coming home exhausted from a double shift and facing a third shift of domestic chores, hears the dryer buzz and walks away from his daughter, who is trying to tell him about a classmate who called her a “skank.” An underpaid nanny scoops up a fussing baby and holds him in her lap, as instructed, but what the nanny-cam can’t see is that she feels no affection for the child or interest in why he is fussing beyond how to make him stop. All of these patterns and many more replay across the country thousands of times each day. Sometimes the signs of EN are right there, if you know how to look. The baby on the nanny’s cold lap, for example, might become a “good baby” who rarely fusses–not a sign of contentment, as some might assume, but a sign that the infant recognizes his caregiver’s indifference and has begun to withdraw.

In addition to the obvious sources of EN are covert sources. Topping this list are narcissistic parents, especially narcissistic mothers, as EN by a woman causes greater psychological distress. Narcissists see other people instrumentally, in terms of what they can do for (or to) them. A child’s behavior either enhances the narcissist’s self-image, or it doesn’t, and that binary governs all interactions between them. There are many types of narcissists, some of whom resemble engaged, nurturing parents, but the bottom line is always that they don’t see their children as independent people but as positive or negative reflections of themselves. They don’t attune, respond, or love because all of those actions start with the recognition of an “I” and a “you” who is separate. At some level, the children of a narcissist grasp that they are functionally invisible to that person, which affects the internalized model of the self that grounds their identity, emotional health, and social relations. If they’re lucky, they’re truly seen by another caregiver; if not, they may struggle to see themselves clearly for the rest of their lives.

Unfortunately, the people most affected by childhood EN often have no idea how profoundly it has shaped them–and continues to influence their lives. If they also suffered physical or sexual abuse, they may overlook the effects of EN, and if EN was the primary form of maltreatment, they may simply wonder why they feel so damaged when their histories seem so uneventful. Dr. Jonice Webb addresses this latter group in her book Running on Empty: Overcome Your Childhood Emotional Neglect. Though I have some reservations about the book,[4] it offers a lot of easy-to-digest information on how to recognize EN in your family of origin and in your adult problems, accompanied by a profusion of anecdotes in which different readers can see reflections of their own experiences. In addition, the book offers practical guidance about what to do in order to feel better and function better–guidance both for you and for your therapist.

I’ll admit I’m nervous about EN in the generation now growing up. The problems I’ve already mentioned are getting worse: parents forced to work too much, inadequate child care, rising levels of addiction, family separation, and a ragged social safety net, for starters. Without policies such as adequate parental leave and universal early childhood education, more and more kids will grow up without the attention they need to become functional adults. In addition, there are new challenges we barely understand, including the deliberate hijacking of our attention by information technologies. Emotional nurture requires focus, and ours is increasingly split between what we’re doing in the real world and what’s happening online. I can’t help wondering how many parents regularly keep one eye on their children and another on their cell phones and what cumulative effect that split focus might be having on those children.

Last year, a YouTuber posted her own version of the “Still Face Experiment.” Instead of simply going blank-faced, as in the classic experiment, Lise-Lotte Austad picked up her cell phone and began texting. Like Tronick’s subjects, her baby tried smiling, vocalizing, kicking, and waving her arms to win back mom’s attention. Having failed, the baby burst into tears, at which point Austad put the phone down to focus on her child. I think her video is a clever comment on the danger our fractured attention poses to our children’s development; I just hope that most parents follow her example in knowing when to ditch the phone.

[1] Different researchers make different claims about the relative severity of different kinds of abuse and neglect. I think such comparisons are useful only insofar as they challenge harmful assumptions, such as the popular belief that physical and sexual abuse are more serious than other forms of child maltreatment. Some experts do claim that EN is “more damaging psychologically than any other form of mistreatment,” or that it’s tied with physical abuse as a predictor of adult psychiatric disorders, but I much prefer the more measured phrasing of a recent dissertation: “compared to other types of abuse, [emotional] neglect has received the least scientific and public attention, but is at least as damaging as physical or sexual abuse in the long term.” Quoted from Marleen Wildschut, Survivors of early childhood trauma and emotional neglect: who are they and what’s their diagnosis? University of Amsterdam Department of Psychiatry, December 2018.

[2] For example, a pattern of EN blunts ventral striatum development predicting depressive symptoms. The ventral striatum supports learning and responsiveness to rewards, and dysfunction in the VS produces symptoms such as apathy and anhedonia. In addition, infants lacking sensitive and consistent emotional nurture suffer high stress levels, even if their physical needs are met, and the overproduction of cortisol leads to cell death in the brain.

[3] Most of the information in this paragraph is drawn from Kathryn L. Hilyard and David A. Wolfe (2002), “Child neglect: developmental issues and outcomes,” Child Abuse & Neglect 26, 679-695 and Robert Young, Susan Lennie, and Helen Minnis (2011), “Children’s perceptions of parental emotional neglect and control and psychopathology,” The Journal of Child Psychology and Psychiatry 52, 889-897.

[4] Running on Empty is a useful primer on EN and its effects. I use the word “primer” very consciously; it’s written for people who know nothing about EN, and it’s written at about an eighth-grade level. People who know more about psychology will dispute the author’s claim to have discovered EN, which is unfair to the (admittedly few) psychologists who have published on the topic. And, like many self-help books, RoE lacks adequate bibliography and casts its diagnostic net so widely that it risks pathologizing normal human feelings and behavior. That said, it offers an insightful look at a problem that has been too little studied and written about. If you recognize yourself in this blog post, I recommend that you read the book, use its diagnostic apparatus, and work with the suggestions the author gives.

Donna Bevan-Lee is a Seattle psychotherapist and the author of a new book, Iron Legacy: Childhood Trauma and Adult Transformation. She blogs at www.donnabevanlee.com.