Child Abuse and Neglect and the Burden of the COVID-19 Pandemic on Families: A Series of Cases Consulted at the German Medical Child Protection Hotline.

Increased stress and decreased resources during a lockdown and social distancing can augment the risk for child abuse and neglect during the COVID-19 pandemic.Health practitioners should continue to be prepared for potentially rising numbers of cases of child abuse and neglect.Child protection services and mental health care should be considered essential and be available for adults and children at all times.

Introduction

Since the beginning of the COVID‐19 pandemic, the lives of children and adolescents all over the world have changed unprecedentedly. Due to ‘social distancing,’ curfews and lockdowns, social contacts are often limited to closest family members. In many countries, meeting peers has been forbidden, out‐of‐home leisure time activities have been cancelled and schools have been closed (UNESCO, 2020).

‘Since the beginning of the COVID‐19 pandemic, the lives of children and adolescents all over the world have changed unprecedentedly’

These changes go along with rising pressure on families. Parents are asked to support their children with home schooling and to take care of smaller children while working from home at the same time. Support by grandparents and other social contacts has decreased due to contact restrictions. Professional support by child protection services (CPS) as well as psychiatric and psychotherapeutic services have been reduced or disrupted (Fegert, Berthold, et al., 2020; Fegert, Kehoe, et al., 2020). Economic hardship increases. Quarantine decreases personal freedom and privacy and the possibility to temporarily escape abusive family members is reduced (Brooks et al., 2020; Peterman et al., 2020). Parental mental illness and substance abuse can worsen during stressful episodes, escalating the risk for child abuse and neglect (Brockington et al., 2011; Dubowitz et al., 2011), while social support is preventive (Crouch et al., 2001). At the same time, the pandemic has brought about a severe loss of social control. Access to friends, teachers and similar persons of trust has been limited. Hence, a strong increase in family violence was expected (World Health Organization (WHO), 2020). While an increase of domestic violence was seen globally during the last months (see exemplarily: Leslie and Wilson, 2020), there has been an absence of reports regarding child abuse and neglect. It is of particular importance to assess available information on threats for children and adolescents related to the pandemic to identify which support systems are most needed.

Reporting cases of suspected or substantiated child abuse is not mandatory in Germany for healthcare professionals. Disclosing protected patient data to third parties, including police and federal agencies, is usually prohibited. In the case of reasonable suspicion for child abuse or neglect, medical professionals are, however, authorised to disclose information to CPS under the Act on Cooperation and Information in Matters of Child Protection (KKG), without breaching medical confidentiality. When receiving such information, CPS is legally obligated to extensively assess a child's endangerment, possibly leading to protective measures. Often, these include the installation of social work assistance for the family. However, during the lockdown in March and April 2020, supervision by medical services as well as social work and CPS was reduced in large parts of Germany (Fegert, Berthold, et al., 2020), potentially leading to a significant underreporting and undertreatment of cases of child abuse and neglect.

In order to help evaluate arising problems concerning child maltreatment during the pandemic, this study presents three consultations of the Medical Child Protection Hotline in Germany (MCPH), a nationwide hotline for medical professionals in cases of suspected or substantiated child abuse and neglect.

‘This study presents three consultations of the Medical Child Protection Hotline in Germany’

Method

The MCPH is a nation‐wide hotline, operating 24 hours a day, and is funded by the German Federal Ministry of Family Affairs, Senior Citizens, Women and Youth. Physicians with special expertise in child protection provide consultation for health professionals in cases of suspected or substantiated child abuse and neglect. Besides the medical evaluation of suspected child maltreatment and the significance of physical or psychological findings, the most important subject of consultation is how to further proceed in case of reasonable suspicion, especially whether it is justifiable to report a presented case to CPS. By this, the hotline serves to help health professionals make decisions in unclear situations and to improve communication between health professionals and child welfare services. Since its establishment in 2017, the hotline was able to register more than 2600 contacts from a large variety of medical professions, underlining its acceptance in the field. The WHO has highlighted the MCPH as a positive example of child protection work (Sethi et al., 2018). The project was approved by the ethical committee of the University Hospital of Ulm.

The MCPH remained active during lockdown, being able to receive insights into particular cases of child abuse and neglect during the time of social distancing. The cases reported here are consultations conducted between March 15 and May 20, 2020. During this period, 116 cases were consulted, of which 16 concerned questions that arose due to the pandemic. The three cases were selected by the authors by supposed relevance for child protection professionals.

Cases

Case 1: Consultation of a Child and Adolescent Psychotherapist Treating a Seven‐Year‐Old Boy and his Family

Case Presentation

The caller reported that during a therapy session, her seven‐year‐old patient disclosed that his mother would slap him during homeschooling. Both parents had previously admitted that the current situation in the pandemic was too much to bear. The parents also asked the child and adolescent psychotherapist for counselling sessions for themselves.

‘The caller reported that during a therapy session, her seven‐year‐old patient disclosed that his mother would slap him during homeschooling’

Reasons for the Consultation

First, the therapist was not sure which other professionals she was allowed to involve. Second, she was unsure whether she was obliged to speak with the parents about what the child had disclosed. Finally, she was in doubt whether corporal punishment was considered acceptable parenting or was harmful for the child.

Content of the Consultation

Regarding the issues of confidentiality, the consultant explained how, with the permission of the parents, the caller would be allowed to talk to any other professional, especially the family paediatrician or CPS. According to German law, a breach of confidentiality is only allowed to ensure the protection of the child and only towards CPS. Otherwise, medical professionals are obliged to maintain confidentiality including with other medical professionals.

The consulting professional was further informed that as of the year 2000 corporal punishment was legally banned in Germany, and as of 2015 in 23 out of 47 member states of the Council of Europe (duRivage et al., 2015). Apart from the legal regulations, the detrimental effects of corporal punishment on child development are well‐known (Berlin et al., 2009).

In summary, indicators for an immediate risk of severe harm to the child were not present. The parents were aware of the problem and willing to participate to end the harmful behaviour. Creating a strategy to cope with situations of increased stress was likely to be effective. At this point, the involvement of CPS seemed not to be necessary, but could be in place if the parents were unable or unwilling to work on the problem.

Case 2: Consultation of a Child and Adolescent Psychotherapist Treating a 16‐Year‐Old Girl

The caller had been treating her 16‐year‐old patient for several months because of problems concerning bullying in school. The girl had previously disclosed that her mother would slap her ‘from time to time,’ and that she had some trouble concerning her self‐esteem due to recurring vilifications by her mother. She also claimed to be responsible for housekeeping and for looking after her three‐ and five‐year‐old brothers while the mother would leave home for hours. She allegedly coped with the situation with the help of the therapist.

During the lockdown, the therapist was able to continue therapy via telemedicine. The girl reported frequent and aggravating emotional and physical abuse against her, and she wanted to ‘get out of the family.’

The therapist called the MCPH in order to discuss how she could establish safety for her patient and how she could respond to her wish to ‘get out’ of the family.

‘The therapist called the MCPH in order to discuss how she could establish safety for her patient’

The patient was affected by aggression towards her both in school and at home, and faced further stresses through having to take care of her younger siblings and housekeeping. When children or adolescents themselves report that they need ‘time off’ a stressful situation at home, temporary custody by CPS by request of the child must be considered. The therapist could offer to help her patient establish contact with CPS. In addition, in this case, where siblings are potentially affected by child abuse and neglect as well, CPS should be informed accordingly.

Case 3: Consultation of a Midwife Visiting a Mother and her Young Infant

Before the birth of her now eight‐week‐old infant, regular visits by a midwife had been established by social services for a mother with a ‘mental disorder’ that the caller could not further specify. The midwife, usually helping the mother with day‐to‐day care of the baby, now noticed a peculiar breathing pattern in the infant. She believed an underlying and potentially menacing condition to be possible. To rule this out, she recommended a visit to the paediatrician. The mother consistently refused to follow this suggestion in fear that she might get infected with COVID‐19 in the doctor's practice.

‘The mother consistently refused to follow this suggestion [to visit the paediatrician] in fear that she might get infected with COVID‐19’

The midwife called the MCPH in order to discuss if the mother's behaviour should be considered child neglect and how she should proceed.

At the point of this call, it already seemed to be clear that mother and child were not part of a high‐risk group for a dangerous course of COVID‐19. The midwife was concerned about a newborn that possibly showed signs of a serious condition, for whom immediate medical care was deemed necessary. If the legal guardians were unable or unwilling to take the necessary steps, alternative ways of getting medical attention should be sought that are equally appropriate from a medical point of view but address the parent's reservations. A phone call to the paediatrician could have helped, allowing the paediatrician to explain the steps taken to reduce the risk of infection inside his practice. A scheduled visit without waiting time could be considered. If the mother still refused to ensure safety for the health of her child by visiting her paediatrician, the midwife should strongly consider informing CPS.

Discussion and Conclusions

The decrease of protective resources or the increase of pressure to a usually well‐adjusted system can unbalance a family – child maltreatment usually occurs when risk factors outweigh protective factors (Belsky, 1993). The measures undertaken to control the COVID‐19‐pandemic add to the burden of any family and can contribute to a feeling of constant stress (Brooks et al., 2020). While there has been huge public debate on pandemic‐associated risks for children, specific reports are missing. Therefore, we have presented three cases of healthcare professionals who consulted the MCPH due to suspicion of child abuse or neglect.

The cases – in their essence not unusual for the daily work of the MCPH – illustrate the influence the pandemic in itself and the necessary measures to ‘flatten the curve’ had on particular families. It affected families for which there had not previously been concerns as well as families which already had problems with ongoing or recurrent physical and emotional abuse and neglect.

‘The cases… illustrate the influence the pandemic… had on particular families’

The first case presents an example in which the pandemic led to an exacerbation of violence within the family system. Besides the general need for better training of professionals regarding different types of child abuse and their consequences as well as issues of confidentiality, the case underlines the need for professionals working with families with pre‐existing risk factors. By implementing a timely meeting about the increased needs of such families, further exacerbations and more severe child protection measures can be avoided.

In the second case, the family had pre‐existing issues with problematic parenting behaviour. Presumably, the affected girl normally could have ‘escaped’ the constant emotional abuse by her mother by visiting friends or other family members. This indicates that a certain amount of leisure time activities, social contact with important peers and carefully considered school openings for children and adolescents at risk should be discussed.

The third case shows another aspect of the pandemic that several medical disciplines have to face: patients not visiting a doctors' or therapists' practices due to fear of contracting the virus. The aim in this case was to enable an immediate visit to a healthcare facility while taking care of the mother's anxiety. The case shows that institutions of the public health sector should remain safely accessible for people in need of medical assistance, especially those at risk of a severe course of COVID‐19.

These presented cases give hints as to which support systems are needed during the pandemic and the measures undertaken to prevent it from further spreading. The cases show that families with pre‐existing problems, such as mental health problems of parents or pre‐existing child abuse and neglect in the family, are at risk of escalation. Potential reasons include social isolation, posing a substantial risk factor for child abuse and neglect (Sethi et al., 2013), and economic recessions, leading to the loss of jobs, decreased income and debt, causing higher rates of psychological diseases and substance abuse (Frasquilho et al., 2016), both being risk factors in parents for child abuse and neglect (Clemens et al., 2018). The cases show the importance of easily accessible support such as mental health and child welfare services during lockdown (Fegert, Kehoe, et al., 2020).

‘The cases show that families with pre‐existing problems… are at risk of escalation’

Health practitioners should continue to be prepared for potentially rising numbers of cases of child abuse and neglect. This preparation includes watching for red flags, asking parents and children about violence, offering help and advice for families at risk and considering reaching out to CPS when the safety of a child is not ensured (Fegert, Kehoe, et al., 2020). Professionals can offer advice to caregivers about ways to alleviate stress on them and their children. Regarding how financial struggles and unemployment contribute to stress and an augmented risk of child abuse and neglect (Brooks‐Gunn et al., 2013; Schenck‐Fontaine and Gassman‐Pines, 2020), governments should continue their efforts of supporting the economy in general and especially individuals that lose their jobs due to restrictions imposed by public authorities. Especially for families at risk, including those with children in need of special support, consistent solutions should be found, as to which families have the right of emergency daycare or regular schooling.

As these are particular cases with very particular circumstances, caution must be paid in order not to overgeneralise conclusions. However, the cases presented give valuable insight into the dynamics of the pandemic and how healthcare professionals faced new challenges when other support systems were suddenly unavailable. Even though the MCPH may often help medical personnel struggling to find solutions concerning child protection cases, it is nevertheless vital that the usual structures of support, especially CPS, help lines, but also practitioners of psychological therapy and psychiatry, for children as well as for adults, remain active during lockdown and be considered essential. Politicians should ensure a functioning system of child protection at all times. Emergency pathways for acute cases of child maltreatment and for the treatment of psychiatric or psychological impairment should be established. The risk of child maltreatment during future lockdowns should be taken into account and possibly lead to protective measures especially for children at risk.

‘The risk of child maltreatment during future lockdowns should be taken into account’