Early recognition of infants and young children whose development is rendered vulnerable by neglect, exposure to trauma, or direct abuse is an important step. Living in the presence of parental violence is one particularly common situation, in which young infants may not be considered as victims. Emotional neglect (Erickson & Egeland, 1996) has only latterly acquired the recognition it deserves, as has the fact that maternal depression is one common context in which this occurs.
Zeanah, Boris, and Larrieu ( 1997) rightly point out the complex interactions between risk and protective factors that must be encompassed in the understanding of the development of psychopathology. They also point to the care-giving relationship as the mediator of both extrinsic and intrinsic risk factors. When, in child maltreatment, the caregiver also abuses or neglects the child, the mediating relationship itself is the source of risk.
As has been illustrated, the process of early brain development is constantly modified by external events which impact on that process. These environmental factors commence their influence in utero.
In this review, only the contribution of the environment post-natally was considered. There are pragmatic reasons for this choice, since one purpose of this review is to point to areas of possible intervention to minimise harm to the child's development.
As is evident, in the field of child abuse and neglect there is not infrequently a conflict between the interests of the parent or abuser and the child, which at times requires the legal mandating of intervention in favour of the child.
At least in the U.K., there are situations in which we currently have no means other than education to intervene effectively in such undesirable practices as drug and alcohol abuse in pregnancy, despite evidence of the harmful consequences to the development of the future child (Jacobson & Jacobson, 1994; Mayes, Bornstein, Chawarska, Haynes, & Granger, 1996). Thus, in a recent case in the U.K., the Court of Appeal adjudicated that the rights and wishes of the mother prevail over those of her unborn child, even if the expression of these wishes will be to the detriment of the future child (St George's Healthcare NHS Trust v. S., 1998).
Nevertheless, it is possible to recognise active foetal abuse. Condon (1987) found that 8% of 112 pregnant women and 4% of their male partners acknowledged the urge to hurt or punish their unborn child.
Kent, Laidlaw, and Brockington ( 1997) describe five depressed, pregnant women who repeatedly actively punched their own pregnant abdomen, as well as acknowledging negative feelings towards their unborn child. All the mothers had contemplated or actively sought termination of the pregnancy. Three of these mother--child relationships remained very troubled after birth.
As the authors point out, active enquiry about possible foetal abuse, even in the absence of clear maternal depression, is indicated. This would allow for the possibility of actual prevention of very early child neglect or abuse. In rats, at least, adoption has been shown to reverse the effects of prenatal stress (Maccari et al., 1995).
It is important to continue to study factors leading to positive outcomes for these children.
For instance, using the concepts developed by Block and Block ( 1980), Cicchetti, Rogosch, Lynch, and Holt (1993) found that ego-resiliency, ego-overcontrol, and self-esteem each contributed to better overall adjustment in a group of 129 disadvantaged, maltreated children aged 8-13 years. However, only ego-overcontrol differentiated between the maltreated and a disadvantaged, non-maltreated comparison group.
This is encouraging, since it is probably more feasible to encourage children to develop strategies of gaining control over their actions and responses than to become more flexible. However, as Block and Block point out, both ego-control and ego-resilience are likely to be temperamentally determined. Moreover, self-esteem is a resultant of both good nurturance (Harter, 1983) and personal efficacy and achievement and, while predictive of good adjustment, self-esteem is therefore both dependent on some contributors to good outcome and an independent contributor to outcome.
In the light of the stability of resilient and non-resilient functioning (Cicchetti & Rogosch, 1997), which may be partially explained by the poor quality of attachment relationships found in maltreated children (Cicchetti & Bamett, 1991), self-organization by the child needs to be encouraged and fostered by those intervening in abuse and neglect.
This needs to include the construction of a coherent account by the child of her or his own experiences. Future prospective research will need to continue to test the hypothesis that a greater and earlier direct investment in children who are maltreated leads to enduring improvement in their functioning.