That old saying about sticks and stones breaking bones, but words never hurting — the latter part is untrue.

In the worst-case scenario, many mental health experts say verbal abuse — swearing, name-calling, severe threats and insults, and other hurtful words from peers and parents — can lead to feelings of pain, anxiety, depression and low self-esteem in children.

And although the bruises never show physically, sometimes the pain can last a lifetime.

"Some children are so fortified by home and community and self that it rolls off, they can deal with it," says Coffee, a Kaiser Permanente specialist in behavioral health services at the Ala Moana Building. She also runs her own business, "Open Minds," which specializes in teaching about verbal abuse and anger management.

"Then there are other children who might have deficits in self-esteem, and for them, it (the pain of abusive words) starts sticking. Even the most fortified child can get hurt."

The whole arena of verbal abuse is a vast emotional sea of tangled definitions, legal uncertainties and moral issues. There isn't a family that hasn't grappled with where the lines are: When does criticism cross the line into excessive and painful pressure that hurts rather than helps? When does a parent's discipline or an angry outburst toward a child become verbal abuse? And what signs tell us when a child is wounded enough that it affects his or her well-being and interactions with other people?

The fact that words can inflict harm is the reason experts say it's important to teach children what is appropriate language, and what is not, even in the face of movies, television and the world at large dishing out a steady stream of swearing and angry language.

Difficult to define

Verbal abuse falls into the category of emotional abuse, says Stephanie Hamarman, an assistant professor of psychiatry at the New Jersey Medical School in Newark who has written extensively on the subject of the effect of emotional abuse on children.

Emotional abuse can lead to feelings of worthlessness, depression, even thoughts of suicide.

However, her research emphasizes how very difficult it is to define verbal abuse. That is the reason it's nearly impossible to say how many families are affected by the problem.

Hamarman has attempted to define verbal abuse by degrees. "The idea is, 'How do you tell bad parenting from abuse?'" she said.

The key to figuring out whether verbal abuse is occurring in a family is to determine whether there was an intent to inflict harm, and whether harm has actually been suffered, she said. Those measures are used to divide verbal abuse into categories — mild, moderate and severe. The categories suggest whether treatment or legal action is called for.

"If it's mild, then you're thinking counseling, family therapy, parenting skills training," she said.

A severe level — where the parent intends to inflict harm, and the child is suffering deeply — suggests legal intervention.

Well-timed intervention offers tremendous benefits, Hamarman said. Often in mild to moderate cases, it's just a matter of a caring-but-misguided parent who simply wants to help the child, but doesn't know how. In those situations, talking with a therapist and learning new parenting skills, and giving the child an opportunity to express feelings, can ease many problems.

"The first thing you would look at in the children is their strength and resilience, and what will get them through this and maintain their mental health," said Honolulu child and adolescent psychiatrist Dr. Megan Marumoto. "A lot will depend on how strong and healthy the bonds are in the family."

If a child still feels safe and positive about certain other aspects of family life, then it's likely that the child can be brought to realize that his or her true worth does not change just because the verbally abusive person has said hurtful things, she said.

Medication may also be recommended, depending on the emotional state of the child, Hamarman said.

Some mental health experts are frustrated at the lack of recognition of verbal abuse. In general, Hamarman said, "cases of emotional abuse have not been prosecuted by the legal system."

Under Hawai'i law, there is no mention of verbal or emotional abuse relating to child offenses, "and that makes it difficult to get emphasis put on it," said Dr. Les Barrickman, a child, adolescent and adult psychiatrist who is also an associate professor at the University of Hawai'i medical school. "That's the controversy. Should there be a definition in the law? I'm leaning toward that."

Protections for children

Part of protecting children is to teach them to recognize when they have been made the target of verbal abuse, whether from parents or peers.

"When we talk to children and try to teach them about verbal abuse, we talk about reporting it to a responsible adult, telling the other person not to do it, and then to understand what's going on so they don't internalize it and believe that it's true," Coffee said.

Marumoto added that "it's important to recognize there's something wrong so they don't grow up and do it to others. ... If they don't, then it's likely they will repeat it and become abusers themselves. ...

"When I do workshops," she said, "the adults can remember verbal abuse from their childhoods."

According to Barrickman, the constant negativity from verbal abuse — "such as pounding on someone that they're a bad person"— can lead to low self-esteem, anger, irritability, frustration. Any of those feelings can lead to antisocial behaviors, depression or anxiety, he said.

Marumoto agreed. Verbal abuse can make a person feel intimidated or even scared. They may even feel betrayed, especially if the abuser is a parent.

The damage may start in seemingly insignificant ways, she said, but it can move along a dangerous trajectory. "It can escalate and progress into bigger problems, and maybe even violence," she said "If you look at some of the literature about the kid shooters, many of them say they were the victims of bullies in their schools."

Certainly every person who has been bullied isn't going to turn into a homicidal killer. But when the long-term effects of emotional and physical abuse are compared, Hamarman said, "emotional abuse seems to be a better predictor, from a psychiatric perspective, of long-term functioning."

Reinforcement reminders

Children also need to be taught not to inflict verbal abuse on others.

As Coffee puts together workshops for schools, she has found that teaching behavior skills is like teaching the alphabet — repetition is the key to long-term memory.

"You just don't say 'Be nice,' and a child's nice," she says. "It takes maintenance, vigilance, reinforcement. It requires tending, until they really learn it deeply inside of themselves."

Parents sometimes don't realize all of the reinforcement required to create a child who understands that swearing at people and calling them names is not appropriate. But it has to begin early, Coffee said.

For instance, children should be taught to speak appropriately when they're angry, Marumoto said. That can be a huge challenge — both for the child and the parent.

"You have to have some way to respond to a child's anger," she said. "You can't just shush them. When you listen to the content, they actually have their point. But because adults don't like the way they say it, they never get to explain their point of view. ... In the name of needing respect, we tell children to 'shut up.' But we have to be very careful NOT to shut them up."

The best way to handle such a situation, Coffee said, is to quickly tell the child to calm down, and "talk to me in a soft voice" about what's going on. "Then they can explain what's going on for them," she said.

"That doesn't mean we give in. But it says 'we heard you.' And at least the child got the practice of telling. And they learn that speaking respectfully means speaking softly, not threatening, not blaming, but explaining."