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’
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.
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’
We thank the German Federal Ministry of Family Affairs, Senior Citizens, Women and Youth for the funding of the German Medical Child Protection Hotline.
Open Access funding enabled and organized by Projekt DEAL.