Neonatal and infantile abuse in a family settings

Neonatal mistreatment consists of one or more inadequate behaviors, possibly repeated over time, with or without a precise criminal design, towards an infant under the age of two months and involves a substantial risk of causing physical injury and/or emotional. What the victim of abuse is older will talk about child maltreatment, although the substance of deviant or clinically relevant behaviors remains practically unchanged [1].

abuse and falls within the symptomatic framework of the "pedophilic paraphilic disorder". The risk of sexual abuse is increased in children cared for by multiple people or by a parent who has several sexual partners "emotional abuse", consisting of infl icting emotional trauma through the use of words or actions (not necessarily capable of causing physical damage). Specifi c forms include scolding a child by screaming or shouting, despising him by diminishing his abilities and accomplishments, intimidating and terrorizing him with threats, and exploitation or corruption by encouraging him to deviant or criminal behavior. Emotional abuse also occurs when words or attentions are omitted or denied, substantially becoming emotional negligence (for example, ignoring or rejecting a child or isolating it from possible interactions with other children or adults). In neonatal age and early childhood, emotional abuse can attenuate emotional expressiveness and reduce interest in the environment, making the infant seemingly unaffected and insensitive to stimuli. Emotional abuse, if perpetrated over the months, especially in early and second childhood, often leads to a developmental defi cit that can be incorrectly diagnosed as intellectual disability or organic disease. A delay in the development of social and linguistic skills often results from inadequate stimulation and parental interactions. The child victim of emotional abuse can be insecure, anxious, distrustful, superfi cial in interpersonal relationships, passive, and excessively worried about pleasing adults. Children who are rejected can have very low self-esteem, maintaining this pattern even in adulthood, reinforcing it in the negative. Children who are terrifi ed or threatened may appear afraid and avoidant. The emotional consequence on the child generally becomes evident in school age, when he develops diffi culties in establishing relationships with the teacher and with the group of peers. Frequently, the emotional consequences are appreciated only after the child is placed in another environment, or after aberrant behaviors fade and are replaced by more acceptable behaviors. The emotional picture also includes a particular form of delegated hyper attention, called "Munchausen syndrome by proxy": parents (mostly mothers), who usually enjoy a very positive reputation among medical personnel, invent symptoms that their child, at what they say, should have (fever, cramps, bleeding, etc.) or provoke them with the most varied manipulations. Both things cause numerous analyzes and unnecessary medical interventions. The mother is thus placed at the center of attention as a reference person worried about her son who suffers from an unknown disease and who consequently cannot be helped. In this way, he obtains a gain of attention secondary to the "illness" of his son.
"Neglect", consisting in the inability to respond or meet the basic needs of the child, physical, emotional, educational and medical, both in the hypothesis of neglect (poor care) and in hyper-cure (other than episodes of manic or fi ctitious disorder) and neglect (distorted or unsuitable treatment). Neglect, referring precisely to the phenomenon of neglect, differs from abuse because it generally occurs without malicious intent and therefore without the conscience and the will to cause harm or endanger the person. In this sense, negligence can consist both in the implementation of a physical modality (the inability to provide adequate levels of nutrition, clothing, shelter, supervision, and protection from potential damage), and affective (the inability to provide affection or love or other types of emotional support), educational (the inability to enroll a child in school, ensure school attendance, or provide education at home) and/or health care (the inability to ensure appropriate care or treatment for the child necessary for trauma or physical or mental disorders or even the failure to provide preventive care which, by aggravating themselves, expose the infant to health risks It must be said, however, that often these forms of mistreatment coexist and the overlap in clinical and judicial practice is very frequent.
According to the most accredited statistics, the most common risk factors are therefore the presence of clinically relevant psychopathologies of the parents of minors, social isolation and marginalization, work, housing, and economic diffi culties, too early a motherhood or rapid succession of various pregnancies, the state of unwanted or otherwise unforeseen gestation, social and/or emotional insecurity, previous personal experiences of abuse or neglect, delinquency or conduct deviant socially, domestic violence, physical pathologies of the infant and too demanding expectations from parents [3,4].

Socio-environmental and family variables
In the fi rst years of life, the infant is completely immersed in the family and environmental context, and therefore the risk of being abused or neglected is statistically more likely in those dysfunctional families or degraded and socially deviant environments. The factual circumstances described in the anamnesis, based on the narratives of the infant's family members, must always be compared with the socioenvironmental and family factors of reference, to discriminate between socially accepted behaviors (albeit to the limit) and dysfunctional behaviors in able to cause danger (neglect) or damage (abuse) to the infant. Undoubtedly, severe corporal punishment constitutes "physical abuse", but for lesser degrees of physical and emotional punishment, the socially accepted boundary varies from one culture to another [5]. It is much easier to defi ne neglect or abuse in an infant who already has a socially acceptable age to interact with other peers (for example school age): in these hypotheses, the comparison is simpler, since he is living in an "extended" social context concerning the family only, certain behaviors are immediately detectable and therefore analyzed; in the newborn, also missing the verbal and narrative component, any deviant or clinically relevant behaviors can be analyzed only if there are witnesses able to narrate the episodes that have occurred or traumatic clinical fi ndings on the infant's body in total or partial discrepancy with the narrations of the parents or caregiver. The assessment becomes complicated when the socio-environmental context of the families of reference is degraded or deviant: in such circumstances, it often happens that behaviors normally considered by national law as dysfunctional or abusive concerning corrective means, such as slapping (which integrates the crime of beatings) or physical aggression (which integrates the crime of injury, according to gravity), are instead considered socially accepted or even educational [6].
In the same way, some religious and cultural practices, such as female genital mutilation, socially accepted in some African cultural contexts, are so extreme as to constitute an abuse in hundreds of other western and eastern contexts. As is the case with some folk remedies, such as coining, cupping, and irritating compresses, which can often create lesions of the epidermal layer, but which hardly cross the border between acceptable cultural practices, neglect, and abuse [7].
Even strictly religious beliefs, such as the ban on transfusions between patients not belonging to Jehovah's faith, can be real abuse, but only in the hypothesis that the proposed clinical treatments are life-saving, resulting in the death of a child [8].
Instead, the personal belief, collectively accepted, of certain health practices, useful and necessary, but experienced as harmful and dangerous, as happens with mandatory vaccinations, is completely different: in such cases, based on the cultural and social context of reference, there is discussion case by case, on the need or not to provide for civil, criminal and administrative sanctions for offenders, in addition to the danger of possibly losing parental authority over minor children, for confi rmed neglect of health obligations [9].

Deviant and psychopathological behavior
Each of the four hypotheses of abuse indicated above (physical, sexual, emotional and neglect) has a negative psychological impact on the victim of abuse, both on the stage of normal psycho-emotional development and on the consolidation of behaviors that will then better defi ne the character and therefore the personality, causing specifi c relevant clinical conditions capable of impacting the infant's mature mental health. Children who are frequently victims of abuse are often afraid, irritable, and sleep in a fragmented and disturbed way. They may have symptoms of depression, post-traumatic stress reactions, or anxiety.
Sometimes victims of abuse show symptoms similar to those of Attention Defi cit Hyperactivity Syndrome and are mistakenly diagnosed with it. Violent or suicidal behavior can occur, especially in pre-adolescent victims. Generally, mistreatment can be attributed to the loss of impulse control in the parents or the infant's caregiver. And this can happen for several factors [10]:

a) Character and personality components:
Parents' childhood itself may have been lacking in affection and warmth, may not have led to the development of adequate self-esteem or emotional maturity, and in many cases involve forms of victimization in episodes of abuse. Parents who perpetrate abuse or episodes of serious neglect could pour the frustrations and fears resulting from the hardships they suffered into children or consider their child as a source of unlimited and unconditional affection, seeking in him the support they have never received, creating made a relationship based on unrealistic expectations that children have to make up for. The disappointment of expectations, feelings of inadequacy, poor control of impulses, and more or less diagnosed psychopathologies (such as depression, bipolar disorder, and personality disorders) can explain these behaviors etiologically.

b) Use of narcotics and/or alcoholic substances: They can
trigger impulsive and uncontrolled behavior towards their children, further decompensating their fragile position, increasing the risk of episodes of abuse.

c) Strong intolerance to frustration:
The conduct of the child, especially in the fi rst months of life, up to three or four years of age, can be particularly irritable, demanding or hyperactive and can provoke the anger of the parents, especially in those subjects who have a low tolerance to frustration or who are emotionally unstable.

d) Total or partial lack of a stable and lasting emotional bond, with a lack of commonality of common family goals and objectives:
At times, strong emotional ties do not develop between parents and between parents and children and this lack of bonding commonly occurs in the case of premature or sick infants, separated early from their parents, or with children who are not biologically their own, further increasing the risk of abusive episodes.

e) Situational and socio-environmental stress:
Any family tensions, health problems, fi nancial diffi culties, lack of emotional support from close family members or friends, and interpersonal misunderstandings can exacerbate episodes of abuse.
The analysis of the behavior of all the actors involved in the narrated episodes is therefore extremely important, in particular of the parents, family members or more generally of the caregiver, to more easily distinguish the hypotheses of socially accepted and/or tolerated behavior or episodes which deserve special attention, because they are dysfunctional (and therefore deviant) or even manifestly pathological. If a person Citation: Perrotta G (2020) Neonatal and infantile abuse in a family settings. Open J Pediatr Child Health 5(1): 034-042. DOI: https://dx.doi.org/10.17352/ojpch.000028 engages in behavior that moves away from the dominant social models and the current legislation, it is said that he is "deviant". All social groups create norms and try to enforce them, as the norms indicate the right and wrong types of behavior, also based on the moral of the group of origin. Generally, people who live within a given society tend to internalize their common rules and reference social models; therefore social infl uence leads to conformism, that is, to the tendency to approve the rules and opinions of "experts" with respect for the community. In the common representation, deviance and crime are concepts that refer to the idea of social maladjustment; in reality, crime can also have a more detached connotation from the degraded contexts of the city suburbs (for example, economic crimes). The notion deviance recalls the sociological notion of "anomia", introduced by the French Durkheim, towards the end of the 19th century, and means "absence of norms", that is, a state of confl ict between the expectations of the regulations and the reality experienced by the subject, a discrepancy between the objectives that the subject wants to achieve and the reality that society offers to achieve them. So anomaly exists when people engage in behavior without rules and morality, hostile to social norms, we can, therefore, understand anomaly as the antithesis of solidarity, the most extreme consequence of which is for example suicide, in to which a detachment and a total rejection from the community is chosen; on the other hand, deviance does not completely go beyond the rules and social hostility is never absolute [11,12].
From a more strictly psychological point of view, however, there are several explanatory models of "deviant behavior" [13][14][15]; among the main ones:

a) Biological-constitutional model: A biological determinant
at the basis of the deviant behavior is assumed, a more or less marked trend of genetic origin, and any correlations are sought between the genetic or somatic characteristics of the individual and his behaviors.

b) Psychoanalytic model:
In this context, the propensity to deviant behavior can be traced back to a process of non-ideal psychological growth: the formation of the superego, that is, the construction of behaviors, values, taboos, and teachings learned from the relationship with parents, is occurred incompletely with consequent lack of control of the drives, or by identifi cation with criminal fi gures. More recent psychoanalytic theories trace the criminal conduct back to emotional disturbances matured in the very fi rst years of life, in the relationship with the mother fi gure, or to socioeconomic and affective contexts of serious deprivation. c) Behaviorist model: According to this model, social norms are learned through associations between a certain behavior and its consequences. So if a child commits a wrong act, he will receive penalties from his parents and this will allow correct learning of the rules. However, some people are unable to treasure certain conditions, due to personal characteristics that lead them to assume deviant behaviors more easily, for example, extroverts.
The English psychologist Eysenck, who lived in our century, was also interested in the study of personalities and analyzing that of the "extroverts", asserted that these are rather insensitive to conditioning. with conscience and will, systematic and repeated over time, according to the scheme they devised. In this circumstance, the time factor is essential to prevent one or more episodes from culminating in the death event. As we know, the family is the basic nucleus in which we all normally grow up and which leaves us with a very profound imprint, regardless of subjective awareness. By forming a new family we tend to repeat the internal operating models that we learned as children, whether they are right or wrong. A "functional family" will promote the correct development of its members, allowing everyone to show their individuality; a "dysfunctional family" instead will create a toxic environment that will intellectually or emotionally invalidate its members and become fertile ground for a variety of psychological disorders. It is precisely on the concept of a dysfunctional family that we must stop when we think about families where there is child abuse [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35].

Clinical treatments and parental capacity assessments
The physical examination is therefore the fi rst fundamental   and possible pharmacological contribution.

Conclusions
Prevention of abuse must be included in every visit to the health care services of minors through the education of parents and the identifi cation of risk factors. Families at risk must be referred to appropriate social services. In particular, parents who have been victims of mistreatment in childhood, having a greater risk of becoming abusers of their child, even indirectly, need more widespread support, institutionalized by law. If the infant is neonatal or in any case in early childhood and the injuries are multiple and serious then it is logical to think that the attention should be immediately shifted to the mental health of the parents and / or the caregiver, as they could probably suffer from a clinically relevant psychopathological condition, up to the most severe forms such as personality disorders and psychopathy.