Health Council of the Netherlands Treating the effects of child abuse Gezondheidsraad Health Council of the Netherlands To the State Secretary of Health, Welfare and Sport Subject : presentation of advisory report Treating the effects of child abuse Your reference : JZ/JJ-2983817 Our reference : I-413/10/VR/cn/855-B Enclosure(s) : 1 Date : June 28, 2011 Dear State Secretary, I hereby submit the advisory report entitled Treating the effects of child abuse, which was requested by the former Minister for Youth and Families in a request for advice dated 17 February 2010. I have also sent a copy of this advisory report to the Minister of Security and Justice, for information purposes. Every year in the Netherlands, an estimated 100,000 children are abused or neglected, some of whom suffer serious psychological damage. In recent years, much has been done to improve the prevention, detection, and reporting of child abuse. This has led to greater awareness about the seriousness, complexity, and scope of this major social problem. However, there must be a much greater awareness of this issue before we can even start work on a solution. This advisory report addresses the next step: treating the effects of child abuse. The Committee has been forced to conclude that only a few types of evidence-supported treatment are available. This issue is not restricted to the Netherlands, it is a worldwide problem. The fragmentation of care, however, is a Dutch problem. This stands in the way of an integrated approach to the diagnosis and treatment of children, families, and adults who were abused during childhood. Before this situation can be improved, the further encouragement of an evidence-based approach to work is an absolute necessity. It is also vital to create a solid foundation for scientific research, by monitoring and evaluating the procedures used in all of the care P.O.Box 16052 Visiting Address NL-2500 BB The Hague Parnassusplein 5 Telephone +31 (70) 340 59 15 NL-2511 VX The Hague Telefax +31 (70) 340 75 23 The Netherlands E-mail: [email protected] www.healthcouncil.nl Gezondheidsraad Health Council of the Netherlands Subject : presentation of advisory report Treating the effects of child abuse Our reference : I-413/10/VR/cn/855-B Page : 2 Date : June 28, 2011 domains involved. Such practice-based evidence is invaluable for the final scientific support of commonly used interventions. The Academische Werkplaats Kindermishandeling (Academic Collaborative Centre on Child Abuse) of the Haarlem Kinder- en Jeugdtraumacentrum (Centre for Traumatized Children and Adolescents), together with VU University Amsterdam and the Fier Fryslân multidisciplinary centre for the treatment of victims of child abuse are initiatives that will be launched this year. They will integrate the above-mentioned points. Accordingly, the Committee recommends that these initiatives be used as a testing ground for further policy development. The results of these initiatives on the effectiveness of an integrated approach, evidence-based working, and properly preparing the field for better research will not only be applicable to child abuse, but also to the care of juveniles with mental or developmental problems in general. The advisory report has been reviewed by the Standing Committee on Public Health and the Standing Committee on Medicine. I endorse the Committee's recommendations. Yours sincerely, (signed) Professor L.J. Gunning-Schepers President P.O.Box 16052 Visiting Address NL-2500 BB The Hague Parnassusplein 5 Telephone +31 (70) 340 59 15 NL-2511 VX The Hague Telefax +31 (70) 340 75 23 The Netherlands E-mail: [email protected] www.healthcouncil.nl Treating the effects of child abuse to: the State Secretary of Health, Welfare and Sport No. 2011/11E, The Hague, June 28, 2011 The Health Council of the Netherlands, established in 1902, is an independent scientific advisory body. Its remit is “to advise the government and Parliament on the current level of knowledge with respect to public health issues and health (services) research...” (Section 22, Health Act). The Health Council receives most requests for advice from the Ministers of Health, Welfare & Sport, Infrastructure & the Environment, Social Affairs & Employment, Economic Affairs, Agriculture & Innovation, and Education, Culture & Science. The Council can publish advisory reports on its own initiative. It usually does this in order to ask attention for developments or trends that are thought to be relevant to government policy. Most Health Council reports are prepared by multidisciplinary committees of Dutch or, sometimes, foreign experts, appointed in a personal capacity. The reports are available to the public. The Health Council of the Netherlands is a member of the European Science Advisory Network for Health (EuSANH), a network of science advisory bodies in Europe. The Health Council of the Netherlands is a member of the International Network of Agencies for Health Technology Assessment (INAHTA), an international collaboration of organisations engaged with health technology assessment. INAHTA This report can be downloaded from www.healthcouncil.nl. Preferred citation: Health Council of the Netherlands. Treating the effects of child abuse. The Hague: Health Council of the Netherlands, 2011; publication no. 2011/11E. all rights reserved ISBN: 978-90-5549-879-6 Contents Executive summary 11 1 Introduction 17 1.1 Background 17 1.2 Request for advice 18 1.3 Methodology and demarcation 18 1.4 Structure of the advisory report 19 2 Child abuse: a social and clinical problem 21 2.1 Child abuse down through the years 21 2.2 Child abuse, what does it involve? 24 2.3 How prevalent is child abuse? 27 2.4 Under what circumstances does child abuse occur? 29 2.5 Conclusion 31 3 Effects of child abuse 33 3.1 Resilience 33 3.2 Neurophysiology 35 3.3 The impact of abuse on infants and toddlers (aged 0-4) 36 3.4 The impact of abuse on children of school-going age (aged 4-12) 36 3.5 The impact of child abuse on adolescents (aged 12-18) 37 3.6 The impact of child abuse on adults (aged 18 and above) 37 Contents 9 3.7 The relationship between abuse and psychological complaints 39 3.8 Conclusion 40 4 Assessment and treatment of children 43 4.1 What’s going on? Assessment 43 4.2 The elements of assessment 45 4.3 Treatment 49 4.4 Care infrastructure 58 4.5 Research and knowledge infrastructure 63 4.6 Initiatives for collaboration and an integrated approach 65 4.7 Conclusions 67 5 Assessment and treatment of adults 69 5.1 Assessment of adults 69 5.2 Treatment 72 5.3 Care infrastructure 76 5.4 Care needs 77 5.5 Conclusions 80 6 Conclusions and recommendations 83 6.1 The effects of child abuse 83 6.2 Care needs 84 6.3 Evidence-supported interventions for children and adults 86 6.4 Availability and accessibility of evidence-supported interventions 89 6.5 Scientific gaps in the area of treatment 90 6.6 Recommendations 91 Literature 97 Annexes 113 A The request for advice 115 B The Committee 119 C Justification for approach adopted 121 D Experts consulted 125 E Abbreviations 127 10 Treating the effects of child abuse Executive summary Request for advice Child abuse has always been with us and it takes many different forms. It is estimated that more than 100,000 children are abused in the Netherlands each year. In recent years, the government has taken strong measures to improve the prevention, detection, and reporting of child abuse. Given the lack of clarity concerning the available treatment options for juvenile and adult victims of child abuse, the Minister for Youth and Family has requested the Health Council’s advice on this matter. He asked for a summary of the current level of knowledge regarding treatment of the effects of child abuse, and an explanation of the nature of these effects. He further requested an indication of the care requirement, and recommendations on how the care for victims can be improved. Effects of child abuse Child abuse can have a very significant impact on children’s development and on their ability to function, the repercussions of which can continue into adulthood. Abuse adversely affects the development of children’s brains, as well as their physical development. During childhood, the brain is characterised by enormous plasticity, so young children are more easily damaged. In very young children, abuse prevents them from establishing a secure attachment relationship with their parents, which severely impairs their general social abilities in later life. Executive summary 11 Older children may develop behavioural problems and psychiatric disorders, the impact of which continues on into adulthood. It has also been shown that adults who were abused as children are more likely to suffer from chronic disorders like diabetes, cardiovascular diseases, and asthma. Assessment In cases of child abuse it is vital to get an accurate picture of the issues involved. This involves the child’s development, its physical and psychological condition, as well as its safety. Consideration must also be given to factors in its surroundings, such as the social context and role of its parents or guardians, both as individuals and as mentors. At present, many different agencies and professionals are involved in collecting information of this kind. As a result, one or more elements of the assessment are often incomplete. A complete assessment is just as important in the case of adults who were abused as children. This is usually easier, as adults have greater autonomy and are more often able to supply information directly. Treatment Articles in the international scientific literature on well-researched, demonstrably effective treatments for the effects of child abuse are few and far between.