Trauma and child maltreatment: ten years of knowledge development

Marie-José van Hoof: "Symptoms extend beyond the diagnosis of PTSD"

"We have the knowledge that trauma and child abuse are harmful, and therefore we have the responsibility for spreading that knowledge. Let us ensure that all adults realize what children need to grow up safely."

Marie-José van Hoof"If this means that parents themselves have to clean up trouble they are carrying from their past, then it is necessary to do that in the interests of the child," says Marie-José van Hoof, initiator and chair of the jubilant Expert Group of Trauma and child abuse at the Dutch Knowledge Centre for Child and Adolescent Psychiatry.
The Expert Group now celebrates its tenth anniversary. Five child and adolescent psychiatrists work – in consultation with patients and parents – at the improvement of prevention, diagnosis and treatment of the consequences of child abuse. In the past decade the Expert Group has set a quality standard for this in the form of scientifically substantiated, clinical applicable protocols.

Effective prevention
The experts did not stop during their ten-year collaboration. They have mapped all professional care with regard to trauma and child abuse, the Expert Group involved care professionals in the application of the Dutch domestic violence and child abuse protocol, and shared knowledge with national and international organizations and municipalities, and they have contributed to congresses, scientific research and education. The Expert Group was involved in implementing the 'VoorZorg programme', an adaption of the American Nurse Family Partnership (NFP) developed by David Olds one of the few effective, evidence-based prevention methods in child and adolescent mental health care.

One case in every classroom
Promoting thorough knowledge on child abuse among professionals is of great importance, according to expert group chair, Marie-José van Hoof: "Child abuse is a common problem with major social consequences. One in thirty children experience a form of child abuse, so we count a victim in every classroom, on average. This could be domestic violence, sexual abuse, neglect, emotional and physical abuse. The direct consequences of child abuse on the child's psychosocial functioning is reflected in various symptoms, which extend beyond the diagnosis of posttraumatic stress disorder. The clinical profile of these early inter-relationally traumatized children and adolescents consists of PTSD, anxiety and depressive problems, and problems with regulation of emotions, attachment and behaviour. This is best summarized by the concept of developmental trauma disorder, but that definition has not yet been included in the DSM-5. The consequences for mental and physical health are lifelong. We learn more and more about how trauma affects the genes, immunology and the functioning of the brain. Trauma and child abuse are related to diseases such as diabetes, cardiovascular disease and cancer, which lead to premature death in adulthood, such as the ACE study shows."

Billions
"The personal, social and economic impact is high due to problems with education, work, and functioning in relationships", says Van Hoof. "Every year, the consequences of child abuse in the Netherlands lead to billions of additional health costs."
The abuse rate varies by type from 7 to 25 percent of the Dutch population, which means that per million inhabitants the additional child abuse costs range between 88 million for sexual abuse and 395 million for multiple abuse (Speetjens et al., 2016). The Expert Group therefore advocates paying special attention to prevention, early detection – to be followed by rapid, effective trauma treatment of the child and its family.

Simple care structure
for complex issues
Alfons Crijnen
"Prevention begins with a thorough understanding of which adult behaviour is harmful for children", says Alfons Crijnen, child and adolescent psychiatrist and member of the Expert Group. "Adults who are vulnerable and act out of social impotence, need early help. The question is of course: who will be assessing the parents, the quality of their parenting and the parent-child relationship from the preconception and conception onwards? The child's safety obviously needs to have first priority. The Nurse Family Partnership precaution programme has taken great steps here, especially through distinguishing parents with high risk of abuse at a very early stage. That way we can actually achieve prevention. An often underexposed aspect is also the direct support of the young victims: who is talking to the children? In the multidisciplinary approach, we always call for a simple care structure for these complex issues – this should always allow serious attention for the dialogue with the child, by a qualified professional: a child psychiatrist or a psychotherapist." In this regard, Crijnen urges the consistent application of the so-called child check, a part of the mandatory domestic violence and abuse protocol, designed for professionals working with adult patients to ensure the safety of any children involved.

Respond to this story.
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This story: courtesy of the Dutch Association for Child and Adolescent Psychotherapy (VKJP).

  • Publications

    Child abuse: long term economic consequences (Dutch only).
    Kindermishandeling: economische gevolgen op lange termijn
    P. Speetjens, F. Thielen, M. ten Have, R. de Graaf, F. Smit
    Tijdschrift voor psychiatrie, oktober 2016.

    Understanding Interpersonal Trauma in Children: Why We Need a Developmentally Appropriate Trauma Diagnosis
    Wendy D'Andrea, Julian Ford, Bradley Stolbach, Joseph Spinazzola, Bessel A. van der Kolk
    American Journal of Orthopsychiatry, 2012, Vol. 82, No. 2, 187–200.

    Relationship of Childhood Abuse and Household Dysfunction to many of the Leading Causes of Death in Adults – The Adverse Childhood Experiences (ACE) Study
    Vincent J. Felitti Robert F. Anda, Dale Nordenberg, David F. Williamson, Alison M. Spitz, Valerie Edwards, Mary P. Koss, James S. Marks
    American Journal of Preventive Medicine, 1998;14(4).

    Long-term Effects of Child Abuse and Neglect on Emotion Processing in Adulthood
    Joanna Cahall Young, Cathy Patz Widom
    Child abuse and neglect, 2014 Aug; 38(8): 1369-1381.

    Design of a quasi-experiment on the effectiveness and cost-effectiveness of using the child-interview intervention during the investigation following a report of child abuse and/or neglect.
    Snoeren F, Hoefnagels C, Lamers-Winkelman F, Baeten P, Evers SM.
    BioMed Central public health, 2013 Dec 11;13:1164.

    From trauma sensitive knowledge to trauma sensitive action (Dutch only).
    Van traumasensitieve kennis naar traumasensitief handelen
    Ramón Lindauer, Hans Grietens
    Kind & Adolescent, oktober 2014, Volume 35, Issue 3, pp 216-218.

    Leiden University research project on child maltreatment (web page in English).

  • Expert Group

    Members of the Expert Group Trauma and child abuse at the Dutch Knowledge Centre for Child and Adolescent Psychiatry are: Alfons Crijnen (child and adolescent psychiatrist, EMDR and forensic therapist), Irma Hein (child and adolescent psychiatrist and researcher at the University of Amsterdam), Marie-José van Hoof (child and adolescent psychiatrist, psychotrauma therapist, child psychologist and researcher at Leiden University), Cecil Prins (child and adolescent psychiatrist), Frederike Scheper (child and adolescent psychiatrist and researcher at VU University Medical Centre, Amsterdam), and Linda Vogtländer (child and adolescent psychiatrist).
    Former members of the Expert Group are: Ramón Lindauer (professor in child and adolescent psychiatry at the Amsterdam Medical Centre of the University of Amsterdam), and Marcel Schmeets (child and adolescent psychiatrist, psychoanalyst, independent forensic therapist).

    Voorzorg: nurse-
    family partnership
    in the Netherlands

    The Nurse-Family Partnership (University of Colorado, Denver) has inspired Dr Alfons Crijnen to adapt and implement the programme – 'Voorzorg' – in Amsterdam for the prevention of child abuse. Several studies proved the effectiveness of Voorzorg in the Netherlands; maltreatment was significantly lower amongst families that took part in the programme, and additionally the long-term home environments were improved and internalizing behaviours of the children were lower.

  • Organizing knowledge: the method

    The Dutch Knowledge Centre for Child and Adolescent Psychiatry organizes knowledge by inviting groups of specialized experts per disorder: scientists, practitioners, parents and patients gather the best available evidence-based knowledge and turn them into protocols for diagnostics and treatment. These protocols are made available online, tailored in different versions for professionals, parents, children, teachers and municipalities. The protocols for professionals are available in English. Around 80% of the child and adolescent psychiatrists and allied mental health professionals in the Netherlands use these protocols on a daily basis. The international interest in this platform for evidence-based knowledge on child and adolescent psychiatric diagnostics and treatment is growing.

    Go to the protocol for diagnostics and treatment of trauma and child abuse.