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Child Protection and Disease Prevention / Health Promotion

Tanja Jungmann

(last update 05 January 2015)

The term “child protection“ encompasses all legal regulations and measures enacted by both the state and by nongovernmental entities to protect children. This includes the prevention of endangerment to child welfare, neglect of child welfare as well as child abuse.

What exactly a child´s welfare is has yet to be defined definitively. From the legal standpoint, both nationally and internationally, a child´s welfare is a basic norm and one of the most important references in laws pertaining to the rights of children and families. The term implies the overall well-being of children and adolescents as well as their continued development. This includes, among other things, the right of the child to a prosperous development and to be raised to become an independent and socially competent individual. According to Article 6, Section 2 of the German Constitution the parents have the right to raise their own children. The 2005 reform of Para. 8a of the Social Act (SGB VII) regarding child and adolescent welfare explicitly assigns the Youth Welfare Offices the task of protecting children whose welfare is in danger.

The concept of endangerment of child welfare occurs at several different places in the German Civil Code (BGB). The most important mention is in Para. 1666, Section 1, where endangerment to child welfare is described as the continuous or repeated absence of attentive actions on the part of those having legal custody of or those responsible for the child in question, leading to long-term physical, mental and emotional impairments in the child´s development, even to death. Endangerment of child welfare in the sense of neglect is present when the proper caretaking activities are absent which are requisite for the physical and mental development of the child. The law differentiates between physical neglect (food, clothes, hygiene, etc.), cognitive and educational neglect (lack of verbal intercourse, play and other stimulating experiences, delinquency, etc.) and emotional neglect (absence of reactions to a child´s signals, etc.). The latter also includes insufficient supervision of the child. Endangerment of child welfare in the sense of child abuse comprises physical abuse (beating, kicking, etc.), sexual abuse (sexual acts performed on or by the child, etc.) and emotional abuse (degradation, debasement, verbal abuse, etc.) (cf. Deegner & Körner 2005).

No systematic and reliable data are available for Germany on the number of cases of endangerment to child welfare. Since 2012, however, the Youth Welfare Offices are required to submit a report to the official Office of Statistics on every finalized assessment that reveals indications of an endangerment of child welfare and that contains the opinions by several specialists concerning such endangerment. This enables an analysis of the type, extent and result of such opinions as well as the persons or institutions submitting the report. Nevertheless, it is not possible to infer from the number of cases the actual number of children affected. According to the German Office of Statistics (Destatis), in 2012 around 107,000 such proceedings were initiated to determine the endangerment to child welfare. Of these, 17,000 (16%) were considered to be situations involving acute endangerment and 21,000 (20%) latent endangerment. Two thirds of the children (66%) showed signs of neglect. Slightly more than one fourth of the children (26%) showed signs of mental abuse. A similar number of children (24%) displayed signs of physical abuse. And in 5% of the cases, there was evidence of sexual abuse. (Multiple choices were possible.)

In 68,000 cases (64%) the caseworkers came to the conclusion that no endangerment was present, although in 50% of these cases the Youth Welfare Office did register the need for help or support. In 18,000 cases (17%) the police, courts or district attorney informed the Youth Welfare Office about the possibility of endangerment. In some 15,000 cases (14%) the Youth Welfare Office was alerted by neighbors or relatives, and in ca. 14,000 cases (13%) the lead came from schools or preschools. About every 10th lead (11%) was provided anonymously.

One fourth of the children (25%) involved in opinions about endangerment were younger than 3 years of age. Children 3-5 years old made up 20% of the cases. Some 22% of the children in grade-school age (6-9 years) were involved, and 18% of the children were 10-13 years old. The share of adolescents (14-17 years) was 15% (cf. Kaufhold & Pothmann, 2014).

In addition to the overall greater vulnerability of infants and very young children to physical endangerment and their greater dependence on their parents´ care, specific risk factors for an endangerment to child welfare are high-risk births, developmental deficits and disabilities. Increasingly, mental illness, personality factors and overall life circumstances among the parents are becoming serious risk factors. Stress resulting from financial and social disadvantages experienced in the family also plays a major role. The number of situations of endangerment to child welfare ending in the death of a child from age 0-5 years lies around 80-120 per year, putting Germany - despite generally declining numbers - internationally in the mid-range. Health prevention and promotion must be initiated as early as possible because health disorders and behavior detrimental to health affects children not only when they are young, but also hampers their development as adults (e.g., consequential damages, inequality of opportunities).

In order to gather experience and knowledge about early interventions and to implement these as targeted preventive support, in 2005 the German Federal Ministry for Family, Senior Citizens, Women and Youth established as part of the action program “Early Interventions for Parents and Children and Social Early Warning Systems” a number of model projects in the individual federal states, which were then accompanied and evaluated by the National Center for Early Interventions. The primary goal of this action program was to effectively prevent the neglect and abuse of children. It also strived to recognize risks as early as possible and to strengthen the child-raising skills of the parents (early interventions). The results were used to design the National Initiative for Early Interventions that now (since 1 January 2012) serves as the basis for the Child Protection Law.

Preventative measures are categorized according to three aspects (prevention): when the intervention took place (primary, secondary, tertiary), the target group (universal, selective, indicated) and the approach taken (personal, structural). If a case of high endangerment is present, primary interventions become necessary, which are defined as serving to avert or prevent domestic violence and endangerment to child welfare (e.g., information and education, parenting courses such as “Understanding Your Baby” by Gregor and Cierpka (2004) or “It All Depends on How it Begins” (Ziegenhain et al., 2006). These offers are all free of charge and are directed toward effecting a positive change in the parental behavior (personal or behavioral prevention). The goal is to reduce the risks and to provide as many resources as possible during the child´s developmental phase (structural prevention, relationship prevention).

Early-warning system and early interventions often fulfill the criteria for the definition of secondary prevention, that is, early detection of developing violence/abuse as well as targeted interventions in high-risk families. This means being aware of the risk factors for domestic violence and endangerment to child welfare, of the responsibilities among the various authorities, the persons to turn to as well as the different action choices at one´s disposal. The legal protection of child welfare (Para. 8a SGB VIII) also foresees an intensive interdisciplinary cooperation in the early detection of violence/abuse. Early interventions have the goal of expanding the formal means of support, where one can, together with the family, search for the fitting offers. Anyone involved in this work should be prepared for potential secondary-preventive tasks (e.g., through training to become a specialist for child welfare, courses to improve one´s skills for early detection of risks and indications of child endangerment) resulting from the fact that the target group for early interventions are inherently high-risk families (selective prevention). In this regard, family midwives (FamHeb) and family health or child caretakers (FGKiKP) play an important role. The family midwives visit the families and help the parents to adjust to life with a baby. They provide information and advice on caring for, feeding, fostering and supporting a child and attempt to involve all family members in the effort (Lange & Liebald, 2014, p. 10). The family health or child caretakers strengthen the skills of families with handicapped or chronically ill children, premature babies, or children with regulatory disorders, or of families in the midst of other stressful circumstances. They provide parents with information on the milestones of motoric, cognitive, linguistic and socio-emotional development and how to interact with children in order to promote their development. They actively go into the families. But they can also supervise the use of other offers and interventions or broker them if necessary. In this sense, like the family midwives, they are guides in the network of early interventions. For both groups, the family midwives and the family health and child caretakers, it is of utmost importance that they are able to recognize the signs of endangerment to child welfare and to enact professional care to react to such situations (Hahn & Sandner 2014).

Measures of tertiary prevention are necessary when there is already evidence of domestic violence in the family or when further violence is to be expected. The immediate goal is then to avoid repeated incidents, for example, by combining psychological counseling or therapy with participation in self-help groups or temporary changes to the living situation. If the risk for further massive violent acts is great, then the child should be removed from the family (according to Para. 42 SGB VIII). If there is reason to believe or actual evidence of an endangerment to child welfare then those involved should set up an action plan in cooperation with the Social Services and Youth Welfare Agencies. Contacting the Youth Welfare Office, however, should not occur without the knowledge, though sometimes without the consent, of the participant(s). Then an intervention in child welfare occurs. Afterwards care should be extended as part of the early intervention program, at the least the transition should be arranged. Once an intervention has taken place, an offer should be made to continue to accompany the participant(s).

Presently, the path to prevention depends on a great number of different concepts specific to the various municipalities or federal states. The legal stipulations in the 16 federal states of Germany are not uniform by any means and are strongly focused on increasing the number of people who participate in early-detection exams. Many of the federal states prefer binding invitations according to Para. 26 SGB V; this serves to raise the awareness of the existence of health assistance services as important stakeholders in ensuring child health and protection. It can also serve as a good opportunity to take clear responsibility for and strengthen child protection in the scope of health assistance services with the help of state authorities, to promote expedient cooperative structures with child and youth services by demanding the participation of all involved and thus raising the status of child protection to a higher legal status. Besides early-detection exams, parental training and courses can also contribute to improving child protection by bolstering parental skills. Children from socially disadvantaged families are increasingly exhibiting abnormalities in all realms of development as well as health problems such as obesity and an increased risk of accident. A major problem for prevention and intervention is its availability, which makes collecting a complete record nearly impossible. However, health promotion in preschools and in schools - examples being exercise programs, education about healthy nutrition as well as improvement of speech skills - is still being implemented as individual actions.

The above is witness to the fact that, to date, prevention programs have generally been seen as located in the area of neglect, abuse or maltreatment and as having little to do with developmental risks. Thus, besides relying on the compulsory nature of the early-detection exams it is imperative to develop further means that improve the health protection of children and that are directed toward direct home-based structures. These should satisfy the natural interest of parents to receive information, for example, on caring for an infant or on the development of a child during pregnancy and birth, while at the same time addressing the needs of the respective group adequately. NEST materials have proved to be very useful here. These were developed by the Pro Kind Foundation and the National Center for Early Intervention (NZFH) and serve to further the preventative nature of early interventions. The materials prepared are specific to the respective target group and include exact instructions for the specialists implementing them, who can apply them flexibly in order to support families to provide their children with a safe and healthy development. The materials have been prepared as modules and can be used in any number of programs. NEST covers a broad spectrum of themes from early intervention relevant to families from pregnancy to the end of the second year of life. In addition, there are materials specially tailored to families with little education.

Free pediatric exams should continue to be used as one of the major pillars of state-sponsored preventative healthcare since it reaches children much more broadly than other institutions. The existence of expedient forms of cooperation between health assistance and youth welfare services is in any case a better route to improving child protection and has the advantage of providing a clear structure for assuming responsibility (action). International research has shown that how endangerments to child welfare are perceived can be drastically improved through continued education and close cooperation between health assistance and youth welfare services. Yet the final word has not been spoken concerning actions to be taken in concrete cases of child welfare endangerment. Also, the worldwide tendency to register all cases of child welfare endangerment has generally overloaded the child-protection system. There is much to be done in this area.

Deegener, G/Körner, W (Eds.), Kindesmisshandlung und Vernachlässigung. Ein Handbuch. Göttingen 2005.
Fegert et al., Lernen aus problematischen Kinderschutzverläufen, 2008.
Hahn, M/Sandner, E, Kompetenzprofil Familien-Gesundheits- und Kinderkrankenpflegerinnen und -pfleger in den Frühen Hilfen. Köln: Nationales Zentrum Frühe Hilfen (NZFH), 2014.
Kaufhold, G/Pothmann, J (2014), Gefährdungseinschätzungen im Zahlenspiegel - Altersverteilungen, Meldergruppen, Kindeswohlgefährdungen. KOMDAT, 3 (13), 9-12.
Kindler H et al. (Eds.), Handbuch Kindeswohlgefährdung nach § 1666 BGB und Allgemeiner Sozialer Dienst (ASD), DJI, München 2006.
Lange, U/Liebald, C, Der Einsatz von Familienhebammen in Netzwerken Frühen Hilfen. Leitfaden für Kommunen. Köln: Nationales Zentrum für Frühe Hilfen (NZFH) 2014.
Nothhafft S, Landesgesetzliche Regelungen im Bereich des Kinderschutzes bzw. der Gesundheitsvorsorge, DJI, München 2009.
Ziegenhain U et al., Modellprojekt Guter Start ins Kinderleben - Werkbuch Vernetzung - Chancen und Stolpersteine interdisziplinärer Kooperation und Vernetzung im Bereich Früher Hilfen und im Kinderschutz, Nationales Zentrum Frühe Hilfen, Köln, Süddeutsche Verlagsgesellschaft, Ulm 2010.

Internet addresses: (Bundesarbeitsgemeinschaft der Kinderschutzzentren) (Deutscher Kinderschutzbund e.V.) (Nationales Zentrum Frühe Hilfen (NZFH)) (Statistisches Bundesamt) (Bundesinitiative Frühe Hilfen) (NEST-Materialien)

The author thanks Andrea Thomas for her help in the preparation of the previous versions of the key topics.

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The Federal Centre for Health Education (BZgA) is a specialist authority within the portfolio of the Federal Ministry of Health.