What are examples of neglect
Neglect and abuse of children: early detection and prevention as a medical task
Neglect, child abuse and sexual abuse of children represent serious forms of child welfare endangerment. According to police crime statistics, 3,542 cases of child abuse were reported in Germany in 2017. However, it can be assumed that there is a high number of unreported crimes, as most of the crimes are committed at home and the victims are mostly infants or toddlers who are not yet able to draw attention to themselves. In Germany, around 5% of all children grow up in families who, according to the criteria of the Mannheim Risk Children Study [PDF], can be described as "high-risk families" for neglect. In 2017, according to the Federal Statistical Office, regular child care was initiated in 38,891 cases due to urgent child abuse or at the request of the child (pursuant to Section 42 (1) No. 1-2 of Book VIII of the Social Code).
Doctors are key people in identifying and diagnosing signs of abuse or neglect in children and adolescents. This gives them the chance to provide the victims with protection, suitable interventions and necessary therapies at an early stage.
There are 4 types of child abuse:
- Physical abuse
- Sexual abuse
- Abuse through neglect
- Mental abuse
All four forms are listed in the ICD 10 in the diagnosis code T74.
However, the diagnosis of child abuse is serious and should therefore be made with great caution and only well documented.
The following anamnestic information can indicate child abuse (Herrmann et al., Child abuse, Springer 2010):
- late presentation of the child in the event of serious injuries
- frequent doctor visits even with changing doctors / clinics
- Presentation of the child despite clear traces of injury due to other, often minor, complaints
- lack of a plausible explanation for injuries
- The course of the injury is explained differently by different people
- inadequate accident mechanism for age or individual level of development
The guidelines of the German Society for Social Pediatrics and Adolescent Medicine as well as the guidelines of the federal states listed below offer support in diagnosis and documentation, show possible practical approaches and give advice on risk assessment. For clinics, the nationwide child protection guidelines of the AG Child Protection in Medicine [PDF] were published by the Child Protection Commission of the German Academy for Pediatric and Adolescent Medicine as a common quality standard in dealing with cases of abuse.
Standardized documentation schemes, such as the documentation sheet from the Kassel Clinic [PDF] *, can be used for diagnosis and documentation. Good documentation is important for possible legal proceedings and protects both the doctor and the legal guardian from false suspicions.
If there is any suspicion, resident paediatricians or clinics can turn to medical child protection clinics, which are now in several cities in Germany. In addition, in cases of doubt, a specialist with experience in this field is available at the youth welfare offices on the basis of Section 4 KKG.
Guidelines "Violence against Children" by federal state **
The guidelines “Violence against Children”, which are now available for all federal states, make a valuable contribution to clarifying possible child abuse. The guides listed below contain:
- Indications of signs of child abuse or neglect,
- Documentation documents (with corresponding documentation sheets)
- Information on the legal bases to be observed
- Notes on available help systems.
Further materials from the state medical associations on the subject of child protection
Federal Child Protection Act:
The Federal Child Protection Act (Bundeskinderschutzgesetz - BKiSchG), which came into force on 01.01.2012, created a nationwide standard of authority for doctors and other professional groups with a duty of confidentiality to involve the youth welfare office in the event of suspected neglect or abuse of a child (Section 4 KKG).
The law provides for a three-stage procedure after significant indications of a child welfare risk have been established:
- Conversation with the child or young person and the legal guardian:
Working towards the use of assistance, provided that this does not jeopardize the effective protection of the child or young person.
- If you are unsure about the assessment of a child welfare risk:
Entitlement to advice from a specialist from the youth welfare office - permission for pseudonymised data transfer
- If the risk of a risk to the child's welfare cannot be averted by talking to 1., the doctor is authorized to call in the youth welfare office by providing the required data. Those affected must be informed of this in advance, unless this would jeopardize the effective protection of the child or young person.
These regulations create greater legal certainty for doctors, since until now, in suspected cases of a child's well-being at risk, they had to decide between medical confidentiality under Section 203 of the Criminal Code on the one hand and the involvement of third parties on the basis of a justified state of emergency under Section 34 of the Criminal Code.
However, the law does not establish a notification requirement for doctors.
In the event of a justifiable state of emergency under Section 34 of the Criminal Code, which requires immediate action, the doctor is still authorized to contact the responsible authorities directly without violating the medical confidentiality obligation under Section 203 of the Criminal Code. Good documentation is also urgently required for this.
Further information on the legal basis can be found here:
Signs of neglect or abuse during screening
The early detection examinations for children offer a good opportunity to advise parents on promoting the health of their children and accompanying support offers. They can also be used to identify early signs of a child's well-being and address them appropriately. In the guidelines of the Federal Committee of Doctors and Health Insurance Funds on the early detection of diseases in children ("Children Guidelines") it says for U7a (34th to 36th month of life): "If there are recognizable signs of child neglect or abuse, the examining doctor must take the necessary steps".
In order to improve early detection options, the federal states have implemented invitation and feedback systems for participation in early detection examinations for children in recent years. This means that in most federal states examining doctors are obliged to report participation in an early detection examination to a designated state office.
Further help to support stressed parents is available:
- Youth welfare offices
- Social welfare offices
- Local networks early help
- Family midwives
- Child Protection Association
- Welfare associations / educational counseling centers
General information on the topic
Statement by the BÄK / KBV on the BKiSchG_2011 [PDF]
Motion for a resolution of the 112th German Medical Association: Draft of the Child Protection Act - clarification of the implementing provisions
Motion for a resolution of the 110th German Medical Association: Early intervention and help for the prevention of child abuse and neglect - binding character of child screening examinations and establishment of a reporting system
National Center for Early Aid
Sexual Abuse Help Portal
Information portal of the Federal Government's Independent Commissioner for Issues relating to Child Sexual Abuse
What can doctors (and dentists) in Germany contribute to the prevention and early detection of child neglect and abuse? [PDF]
Prof. Dr. mult. E. Nagel, Institute for Medical Management and Health Sciences, University of Bayreuth
Working group "Child Protection in Medicine"
* Copyright Springer Verlag, 2008
** (Note: some of the guidelines are currently being revised and therefore do not always reflect the current legal status.)
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