In the summer of 2007, a woman was brought by ambulance to the emergency department of the Medical Center Haaglanden, a hospital that serves an inner city area of The Hague in the Netherlands. The woman was drunk and had a severe head injury. Her eight-year-old son was with her.
Hester Diderich, an emergency nurse, and other hospital staff members looked after the boy while they attended to his mother. “We were very nice to him,” Diderich remembers.
After treating the woman’s injuries, they were ready to release her and her son. What happened next led Diderich and her colleagues to realize they needed a better way to protect children and evaluate the risks they face. They created a new process, known as The Hague Protocol (attached to this blog post), and started a study to evaluate it. The protocol is now in use throughout the Netherlands and is being adopted by other European countries as well.
The idea is that hospital emergency departments are places where, by asking adults a few of the right questions, families in which children may be experiencing violence or abuse can be identified with surprising accuracy and ease.
I spoke to Diderich recently about the Hague protocol and its origins.
Rob Waters: Looking back now, this event in 2007 was really a pivotal moment. Tell us how it happened.
Hester Diderich: This mother had a head wound, and we took good care of her and the boy. After a few hours, she was set to leave. The boy climbed on top of us, and the security guard, and asked if he could please stay with us. His mother was screaming at him that he should come with her and we had no clue what to do. He was not our patient, and we couldn’t see any injuries on him, so we let him leave with the mother. We felt bad about that for a few days, then somebody said, “Shouldn’t you have called the Reporting Center for Child Abuse and Neglect (RCCAN) for advice?”
(Note: The RCCAN is a private organization, funded by the Dutch government. It dates back to the 1970s to offer services to families experiencing problems. Professionals can refer cases of suspected child neglect or abuse to the RCCAN, which will conduct interviews and an evaluation and help families get help. Serious cases that may warrant removing a child from the family home are referred to the child protective services agency.)
We called them, and they said we should have called because this was a serious problem. Then we said, “Well, if you think this case is a problem, we have hundreds of patients coming in yearly with these problems — mental illness, alcohol, drug abuse, domestic violence.”
They said, “You should have informed us about all these cases.” That’s when we started to think about adding a pilot on detecting child maltreatment based on assessing parents who visited the Emergency Department.
Rob Waters: So the idea was to evaluate the child’s risk based on the parent’s characteristics and to do that by asking the parent questions?
Hester Diderich: Yes, so we did a pilot. For every adult that visited the Emergency Department, if there had been domestic violence, alcohol abuse, drug abuse, or a patient had been aggressive, or was very mentally ill, we would ask if they’re pregnant, have children under their care, or live in a home with minors. If the answer is yes, we refer the family to the RCCAN without ever seeing the child.
RCCAN then invites these people to come to the office within 12 days. If they have severe mental illness or aggression or drug abuse problems, they visit the family at home because they may not show up. All the other patients get an appointment at the office. They can choose when to come, and bring their partner and children. They each talk with a doctor, a social worker, and a child development specialist.
Rob Waters: Why is this better than trying to screen children to see if they have experienced any abuse or other ACEs?
Hester Diderich: If you screen children, and there is adversity, you have to investigate whether there is maltreatment. Then you have to prove it and then find out who did it — the parent, a teacher, who is it? With parents who come to the emergency department, you already know if there’s a drug problem, or a domestic violence problem. So, the investigation is really short. You're only there to see what help you can offer them; it is a tool for early detection of child maltreatment. So, we did that with 565 cases.
Rob Waters: So 565 parents came to the ER with some kind of trauma?
Hester Diderich: Yes.
Rob Waters: And you found out that they had a child or were pregnant. And they were referred to the RCCAN?
Hester Diderich: Yes, and RCCAN does their investigation. They talk to the professionals — the school or nursery where the kids go, the doctor or psychiatrist or psychologist. Very few parents don’t cooperate — maybe 5% — because everybody wants to tell their side of the story. If they don’t cooperate, the investigation just goes on, so it's not a big dilemma. In severe cases, where the children are in immediate danger, we call the RCCAN but Child Protective Services (CPS) will get involved right away. After their interviews, the RCCAN professionals come to a conclusion: either there is child maltreatment or not. If there is, help is arranged, sometimes through CPS but mostly community-based services.
Rob Waters: So what kinds of support can the RCANN offer these families?
Hester Diderich: The role of the RCCAN is to mobilize the social network around the family and to find the right kinds of support and intervention, because by themselves these parents are not able to take care of children. Parents may be offered help from a psychiatrist or therapist, financial support, or anger management services. Or they might be helped to enroll in a drug or alcohol rehabilitation program. If they refuse or problems are more severe than initially thought, the CPS will get involved.
Rob Waters: So what does this method allow you to do that you couldn't do previously?
Hester Diderich: When we assess whether a child has been maltreated based on seeing a parent, rather than the child, there is a very high positive predictive value. In this pilot study, child maltreatment was confirmed in 91% of these cases referred to the RCCAN. This allows us to get to the family earlier. By doing this early detection, you can intervene with less intensive help than if you wait. In the past, we would not find these children unless they had such severe medical or psychological problems that a teacher, doctor or a psychiatrist think: “This might be child maltreatment. Maybe we should refer the child.” And then you're already so far gone with the parent and child — and it’s harder to help them and these children are already severely damaged.
Rob Waters: The most common problem for these children was witnessing domestic violence. That’s what happened to 40% of them, and 27% had a combination of exposures, usually witnessing violence and experiencing some form of neglect.
Hester Diderich: Right, and most commonly the man is the perpetrator, but that doesn't mean that the woman is not doing harm. But mostly the man inflicts the physical damage and the wife is the one to visit the Emergency Department. A lot of the times the man says, "Well, I never hit my children. I love my children dearly. I only hit her." And they have no clue about the damage that they are actually doing to the child. So, with that category, it’s important to educate the father that if he loves his children, this is as damaging as if he hit the child.
Rob Waters: So since this pilot study was done, the Hague Protocol been implemented nationally?
Hester Diderich: Yes, it became law in 2013, and is also mandated for all mental health professionals working with adult clients and for the whole justice department.
Rob Waters: That means that any doctor who evaluates an adult patient for some kind of trauma is supposed to ask whether there are children under their care?
Hester Diderich: Yeah, so if it's GP or an ambulance professional or a doctor or a nurse and they get a patient with substance abuse, severe mental problems, or domestic violence, they're mandated to ask these questions. If the answer is, "Yes," they're mandated to follow up. They can organize help for the parent and child themselves, in which case they’re responsible for the welfare of the child until a professional that they’ve found takes over. Or they can refer them to the RCCAN, which a lot of professionals choose.
Rob Waters: Is this work being accompanied by any other kinds of education work around ACEs?
Hester Diderich: ACEs are not very well known among professionals, especially among psychiatrists working with adults. They may ask about their patient's childhood and relate it to their problems today. But they don't relate it to the children of these parents right now. They need to realize that this patient may be doing the same thing to their own children that was done to them. If not, these children will be his clients in the future with their own ACES.
Rob Waters: So are things starting to change?
Hester Diderich: Yes, because it's mandatory. If it's not mandatory, there’s no change; I already found that out. Now it’s spreading. I'm doing an international implementation pilot. I already have many European countries joining, finally. We're starting implementation in Belgium. I have pilots coming in Switzerland, Norway, probably Sweden and Germany. I also spoke in the U.S. a few times but it seems impossible to get a pilot started there. These European pilots will start in the emergency department, where the most of these patients come, so the predictive value is very high. If you start international implementation, always start with the emergency department because if they have very good results, they’ll get national funding to start a broader pilot. Ambulance service is also a good place to start.
Rob Waters: What do you think the barrier is in the US?
Hester Diderich: It's like mission impossible. I think the U.S. is very good therapy-wise, because there are so many victims. But prevention — oh, I'm just crying my eyes out. Every time I'm on a panel at a meeting in the U.S., I might speak to six people in the basement about prevention while in the big hall there are thousands of people listening to how they cure the children. But they wouldn't have been that damaged if you just did the Hague Protocol in the first place!
Rob Waters: Right, well, that's always been a major problem in the US — the health system is not geared toward prevention. It's geared towards high-end, expensive, high-tech treatment, right? So, this is kind of a familiar issue in that sense.
Hester Diderich: Yeah, and I don't know why. It costs so much money.
Rob Waters: And in the Netherlands and much of Europe, there is a bigger focus on prevention?
Hester Diderich: Yes. For the government, it's a money thing. A recent Dutch study shows that at 10 years of age, children from parents with an anxiety disorder or depression show none of these symptoms themselves, but at 35 years of age, 65% have the same problems as their parents. Well, that will cost a lot of money, so better intervene at a young age to prevent this from happening.
Rob Waters: And for those children that need treatment, or families that need therapy for the whole family, is that readily available?
Hester Diderich: If you intervene early, and they don't need intensive help, there's a lot available. Most of these children can already be helped, knowing they are not alone and who they can turn to for help. We can provide education sessions where we put 10 children in one classroom and educate them about the illness of the parent. But if you’re talking about children who are abused and need more intensive therapy, there’s always a little wait and the therapy can take years. A key part of intervention is simply making sure there's a social group around the family helping them out.
Rob Waters: Okay. So what’s your hope about where this can go and what impact it can have if it’s fully implemented?
Hester Diderich: I think you can only implement it in countries where you already have a structure to actually help people.
The first piece is the detection part at the emergency department. That has to be equal at all hospitals — they all have to detect based on these three parental characteristics, but what they do after that can depend on the policies and possibilities of each country.
So, the research we’ve done suggests that if you just take the first part and implement it, it can be done everywhere, but the follow-up will differ based on the help you can offer. I do think it’s a protocol that can be implemented everywhere even though I often hear, "Yes, but we don't have RCCAN, so then it doesn't work with us."
If a country already has services in places, use that. And don’t forget: This is early detection based on parental characteristics. So, the investigation part is limited (you don’t have to investigate child abuse from the child’s point of view, where you have to focus on identifying the maltreatment and finding out who did it), because you already know the problem (domestic violence, mental problems or addiction), and the help for the children is mostly not very intensive, because you intervene early.
If you do not implement this early detection tool, you are just waiting for these children to get severely hurt and damaged for life, in other words have high ACE scores.
Rob Waters: Then this passes to the next generation.
Hester Diderich: Right. We have to stop this circle of violence. So, please contact me and join our international pilot at your hospital!
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You can contact Hester Diderich through ACEs Connection, or at h.diderich@kindcheck-ggz.nl
The Hague Protocol and the protocol implementation plan are attached to this blog post.
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