An Academic perspective on

Child abuse in the Netherlands

and Germany

Prof. dr. Elise van de Putte, pediatrician in social pediatrics

Chair of the board of DECCA July 24, 2018

Definition of child abuse

CDC: Child abuse and neglect is any act or series of acts of commission or omission by a parent or other caregiver (e.g., clergy, coach, teacher) that results in harm, potential for harm, or threat of harm to a child.

Joint (professional) forces for child protection

Part I & part II

Part I – the Netherlands •Definition •Epidemiology •Dutch approach •Cooperation youth welfare – health – justice •DECCA – dutch expertise center for child abuse •Three cases

Part II - Germany

Figures in the Netherlands

Year prevalence: 119.000 (NPS 2010, Alink)

Type of Child Abuse and Neglect

Figures 2010 National Prevalence Study

(professionals) Total 119.000

Emotional neglect 36%

Physical neglect 24%

Physical abuse 18%

Emotional abuse 11%

Sexual abuse 4%

Others (Pediatric Condition Falsification)

7%

• Non-mandatory reporting to Child Protection Services (CPS)

• Mandatory code of conduct in case of child abuse suspicion (Meldcode) for all professionals working with children and parents (in healthcare)

• CAN in civil court (via Child Protection Board)

• CAN in criminal court (via Police & Forensics)

Child Protection in The Netherlands: mandatory code of conduct

in case of child abuse suspicion for all medical professionals

Recently implemented (July 2018):

mandatory reporting for imminent offences

Vermoeden op (ernstig) toegebracht letsel bij personen vanaf -9 maanden of een poging daartoe dat als teken van onveiligheid wordt ingeschat. Daaronder vallen tenminste alle letsels die medische behandeling behoeven. TT Poging tot verwurging. TT Wapengebruik. TT (Vermoeden van) seksueel misbruik of seksueel geweld of seksuele exploitatie door iemand uit de huiselijke kring of door iemand tot wie het slachtoffer in een relatie van afhankelijkheid of van onvrijheid staat, en een reële kans op herhaling of onvoldoende zicht daarop. TT Acute bedreiging door een ouder/verzorger om een naaste (waaronder (ex)-partner, kinderen of familielid) te doden, ernstig letsel toe te brengen of hun vrijheid te benemen (opsluiting, familiedrama, eerwraak, vrouwelijke genitale verminking (VGV)). TT Onthouden van direct noodzakelijke zorg, voedsel, medicatie, huisvesting en hulpmiddelen waardoor de gezondheid acuut wordt bedreigd. TT Als een ouder/verzorger (medische) klachten/aandoeningen bij een minderjarige/(zorg)afhankelijke volwassene of oudere verzint, (medische) onderzoeksgegevens of bestaande klachten en afwijkingen vervalst of in het kader van een onderzoek bewust selectief verstrekt of (medische) klachten en afwijkingen die acuut de gezondheid bedreigen, daadwerkelijk veroorzaakt. TT Door het slachtoffer of ouder/pleger zelf onthullen van - en/of hulp vragen voor - een situatie van actuele kindermishandeling en of huiselijk geweld waar hulp onvoldoende oplossing voor biedt. TT Een acuut onveilige situatie ontstaat of zorg dreigt weg te vallen voor een minderjarige of (zorg)afhankelijke volwassene of oudere vanwege een (dreigende) suïcide, automutilatie, acuut psychiatrisch beeld, intoxicatie door alcohol en/of drugs door ouder/verzorger. TT Noodgedwongen vlucht van huis door (dreiging van) huiselijk geweld en/of kindermishandeling. TT Gebruik van alcohol/drugs door zwangere of huiselijk (fysiek) geweld richting zwangere dat acuut de gezondheid van de zwangere en/of de ongeborene bedreigt. TT Blootstellen van een kind aan oorlogsgeweld door te gaan wonen in een oorlogsgebied en/of zich aan te sluiten bij een groepering die aan strijd in oorlogsgebied deelneemt.

Examples: • Inflicted injury with the necessity of medical consultation • Sexual assault (in a dependent relationship) • Abstinence or withdrawal from care, food, medication, care • Human trafficking

(from the age of – 9 months)

Youth Welfare Paid service by Municipality (including child psychiatry!). Safe Home (CPS) is part of Youth Welfare. Offers interventions

Safe Home = Veilig Thuis = Child Protection Services

Part of Youth Welfare. Paid by Municipality. Larger communities work together. Total: 26 Safe Home (CPS)

Health Screening for child abuse is mandatory at Emergency departments (child, parents) • Parental risk factors (suicide,

intoxications, domestic violence) • All forms of child abuse • No standard protocol. Usually: top-to-

toe inspection, history Multidisciplinary child abuse teams are mandatory in each hospital

Cooperation Youth Welfare, Health & Justice

Need for expertise Dutch Expertise Center Child Abuse: DECCA. Paid by Ministry of Health , Welfare & Sports

Centers for Sexual Assault (CSG), 16 in the Netherlands. Paid by Ministry of Justice and Security.

Justice Reporting of cases to the Police via protocol (Safe Home). Paid by Ministry of Justice and Security

Netherlands Forensic Institute

Paid by Ministry of Justice and Security. Forensic laboratory with all facilities

Cooperation Youth Welfare, Health & Justice

Civil court measures • Parents under ‘supervision’ • Parents discharged from ‘responsibility’

(legal guardianship) • Child placed in foster care

Measures by the mayor

• Perpetrator is expelled from home during several weeks

Measures by criminal court

• Mandatory forensic psychiatric and/or medical examination of parents/perpetrator

• Imprisonment

Interventions by Youth Welfare

• Child (individual, group) • Parents (educational counseling, psychiatric

treatment) • Family therapy, counseling, support

Treatment possibilities

• Medically unexplained symptoms

• Wheelchair bound (leg weakness) with painful legs

• Psychiatric diagnoses:

– Obsessive compulsive disorder

– PANDAS: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Infusion with intravenous immunoglobulines. No ‘cure’

• Able to swim and dive in our swimming pool

• Investigations (EMG, neurology, lab): no abnormalities

• Mother: falsified the medical file

• Mother lied about the (absent) parental responsibility of the father

• Severe intergenerational health problems (mother & grandfather) suspected of ‘Munchausen’ syndrome (factitious disorder). Older brother and younger sister were diagnosed with bizarre illnesses

• Severe cases of pediatric condition falsification (fabricated or induced ilness; syn: Munchausen by proxy syndrome; syn: medical child abuse)

• Civil court measures: both girls were ‘foster cared’ by their father

• Criminal court: unsufficient evidence for prosecution of the perpetrator

• Psychiatric treatment of both girls

• Medical treatment, guidance of both girls

Started October 31st 2014

Dutch Expertise Center Child Abuse: DECCA

• Child abuse diagnostics

– Paediatrics

– Forensic medicine

• Child abuse diagnostics

– Paediatrics

– Forensic medicine ●

• Child abuse diagnostics

– Paediatrics

– Forensic medicine ●

• Child abuse diagnostics

– Paediatrics

– Forensic medicine

●

• Child abuse diagnostics

– Paediatrics

– Forensic medicine

●

• Child abuse diagnostics

– Paediatrics

– Forensic medicine

• 24/7 available ●

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●

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DE

Rian Teeuw Annemarie van

Bellegem

Anika Smeijers Machtelt Bouwman Elise van de Putte Ingrid Russel Jopje Ruskamp Frederique van

Berkestijn

Saskia Wolt

Sanne Nijhof Marjo Affourtit Patrycja Puiman Huub Nijs Wouter Karst Rob Bilo Heike Terlingen Selena de Vries Mirjam Kruijsen

Rick van Rijn Rutger Jan

Nievelstein

Simon Robben Femke Kamberg Danielle Riem John Poot Anne-Marie

Laeven

Hugo Heijmans Susanne Petra

DECCA July 2018

• DECCA aims to contribute to the protection of children by accelerating and improving the detection of child abuse, as well as child abuse policy.

• The first and only co-operative structure (NL) that uses a combination of expertise in paediatrics and forensic-medical expertise in determining whether injuries justify a suspicion of child abuse.

• (Tele)diagnostic service:

– Acute situation.

– Primarily based on physical findings.

• Combined paediatric & forensic knowledge:

– Paediatric Condition Falsification.

– Physical abuse.

– Sexual abuse.

– Neglect.

• Anonymous joint advice based on:

– Clinical information.

– Imaging (photo’s & radiology).

Case referral (N=706)

2015 2016 2017

(tele)Advice 132 189 199

Consultation 103 34 49

Total 235 223 248

Profession N (%)

Paediatrician 105 (52,8)

Confidentiality doctor 44 (22,1)

General practitioner 5 (2,5)

Youth healthcare doctor 4 (2)

ER doctor 1 (0,5)

Youth worker 1 (0,5)

Other (psychiatrists!) 38 (19,1)

Total 199 (100 %)

Expertise

Paediatrics 199 (100)

Forensic medicine 199 (100)

Paediatric radiology 72 (36,2)

Paediatric dermatology 5 (2,5)

Paediatric opthalmology 4 (2)

Paediatric neurology 4 (2)

Other (psychiatrists) 6 (3)

Case 2, 16 year old girl

• Girl, 16 years

• History: non resolving ulcus submaxillarian

• Treated for leg thrombosis

• Self induced with scoubidou

• Severely emotionally neglected as a child

Probability of child abuse Frequency (%) Examples

Almost certain 20 (9,6) Confession by perpetrator

Likely 14 (6,7) Abusive headtrauma with subdural

hematoma, retina hemorrhage and

ribfractures

Possible 49 (24,6) Isolated skull fracture without a

history

Unlikely 72 (36,2) Fracture is sufficiently caused by the

history of an accident

Almost certainly not 22 (11,1) Fracture is sufficiently caused by the

history of an witnessed accident

Unclear 31 (15,6)

Total 208

1. Immediate medical care before anything (pediatrician, DECCA)

2. Differentiate injury vs condition (pediatrician, DECCA)

3. Differentiate accidental vs non-accidental injury (pediatrician,

DECCA, CPS)

4. If non-accidental, consider trace evidence gathering (DNA)

(forensic disciplines with police)

5. Child safety? Consultation CPS if suspected child abuse or

multiple/serious risk factors.

Child Protective Services

• Relation DECCA –CPS Veilig Thuis:

– CPS/VT: primary responsible for safety

– DECCA: primary ‘making diagnosis’

• DECCA advice always includes consultation with CPS/VT (according to the mandatory reporting code)

Step 1: make inventory of signals of CAN Step 2: consult colleague, CPS and/or DECCA Step 3: discuss with those involved Step 4: weighing severity/risk, consultation of CPS Step 5: decision: managing (voluntarily)or report to CPS

– Conflict divorce

– Blood in diaper

– Mother suspects sexual abuse of her son by his father

– Mother visits GP and GP refers to DECCA

Dx midline fusion defect (congenital)

Most common questions:

1. What is the likelihood of a non accidental injury regarding this injury? Does history match this specific injury?

2. What additional diagnostics can be helpful?

• Starting point:

– Regional/local if possible

– One of the DECCA centers if necessary

• How?

– 24/7 availability by hotline

• Nationwide

• Pediatrician does ‘triage’

• Teleconsultatie (history, photographs, X-ray)

– Referral to our medical centre (AMC, EMC, UMCU)

– Each case is discussed with forensic examiner, other experts if needed (often ped radiologists)

– DECCA Doctors meet specific quality criteria and permanent education is essential

– Standard procedures

– Parents are informed

– Weekly teleconference discussing all cases, quality assessment

– Registration in database

– DECCA advice same as consultation with academic specialist (3rd line position)

– Responsibility remains with professional seeking advice

– Consult after referral: DECCA is responsible – If report to police already has been made: NFI,

not DECCA

– Multidisciplinary approach of child abuse

– Differentiation between social work (safe home) and expertise for health care professionals

– Lack of expertise for emotional abuse and neglect

– Lack of intervention possibilities

We should focus on:

– Primary prevention (preconceptional)

– Empowerment of the children via schools

Oliver Berthold – pediatrician Full time dedicated to the ‘Medizinische Kinderschutz hotline’ of the DRK Kliniken Berlin Vera Clemens – child and adolescent psychiatrist in training Half time dedicated to the hotline