DÄ internationalArchive41/2014Children and Adolescents as Perpetrators and Victims of Violence and Sexual Abuse
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This issue focuses on violent crime committed by children and adolescents and the physical symptoms of sexual abuse. Different though the crimes addressed by Helmut Remschmidt (1) and by Bernd Herrmann et al. (2) are, the subjects have a common factor: the crime usually results from a perpetrator–victim relationship.

The question investigated

Perhaps without exception, both perpetrators and victims of violence and sexual abuse have attended a clinical practice as patients between childhood and the event. Could we as treating physicians have recognized characteristics of a perpetrator or victim and thus prevented the crime? According to accepted wisdom, “Kill once and you’ll kill again!” and “Once a criminal, always a criminal!”—is this true? The question posed to those providing medical certificates as part of examination for courts is whether physical examination reveals evidence for or against sexual abuse. However, is this actually possible on the basis of specific physical symptoms of the child in question?

How common are violent crime and sexual abuse? Is there a “perpetrator profile”?

There has been a downward trend in violent crime committed by children and adolescents in Germany over the last 20 years. Epidemiological information can be obtained from police crime statistics. Perpetrators of violent crime and sexual abuse are overwhelmingly male (around 87% and 96% of suspects respectively). Victims of murder or attempted murder are also more likely to be male (approximately 59%), while victims of sexual abuse are much more likely to be female (76%) (3). Group dynamics play a significant role in violent crime but not in sexual abuse.

Remschmidt (4) presents one of the most important longitudinal studies on 114 child and adolescent perpetrators of violent crime, whose acts resulted in a total of 70 deaths: over an observation period lasting almost 13 years following conviction, approximately one-third of the sample of adolescents and young adults had committed only one violent crime or had been delinquent only during a short period of their lives; some 40%, however, were persisters, and of these a subgroup of “multiple violent perpetrators” (11.4%) not only committed the majority of crimes but were also the most psychopathologically and psychosocially abnormal. Flying in the face of preconceived ideas was the finding that of the total of 114 children and adolescents who had been convicted of murder (42), attempted murder (12), manslaughter, attempted manslaughter, or bodily harm resulting in death (19), not a single one had committed a second killing during the 13-year study period. The finding that a psychiatric disorder was diagnosed in more than 80% of perpetrators during forensic examination is very significant from a psychiatric point of view. A significant indicator for a high risk of becoming a persister is repeated violent crimes before the age of 10.

It is worthy of mention that the risk profiles of both perpetrators who “ran amok” and their parents’ homes were significantly different from those of the other young violent criminals: for example, they did not show any abnormalities in the form of aggression, violent crime, disordered social behavior, or nonviolent crime before the act, and they often used firearms (5).

Large hidden numbers

Sexual abuse is reported in the media on an almost daily basis. Police suspect figures for Germany (3) have indicated between 12 000 and more than 13 000 cases (13.8 to 15.4 cases per 100 000 population) of sexual abuse of children every year since 2006. Convictions, however, are far rarer: there were only 2142 in 2012, for example (6). Many cases are hidden. Sexual abuse occurs in children's homes, in schools—including boarding schools—in activity clubs, and in medical and ecclesiastical institutions. The vast majority of perpetrators come from the child’s immediate environment (suspects: adolescents approximately 18%; adults approximately 66%; children or young adults 16%). The perpetrator is often the father, stepfather, or mother’s partner. There is no specific “perpetrator profile” for the two types of crime addressed in this issue. Unlike violent crimes, which are sometimes unplanned crimes of passion, sexual abuse is planned and the child made to feel complicit by the perpetrator (“If you say anything, Daddy will go to prison…”). Perpetrators of both types of crime come from all social classes.

The fate of the victim

The physical consequences for survivors of violence vary greatly in terms of type and severity of injury. The psychological consequences, though insufficiently researched, are nonspecific and serious.

The possible physical signs of sexual abuse are concisely summarized by Herrmann et al. (2). Their comprehensive review of the literature comes to a sobering conclusion: in more than 90% of examined cases it is impossible to attribute the findings of professional pediatric and adolescent gynecological examination to sexual abuse. Such findings are often normal. The credible word of the child, obtained by a qualified individual, is decisive in first-line diagnosis. This makes it even more important to determine and take into account in medical evaluation the psychological consequences of sexual abuse. These are as follows:

  • Post-traumatic stress disorders
  • Somatization disorders
  • Eating disorders
  • Substance abuse
  • Depression
  • Borderline disorders and suicidal tendencies
  • Disorders in sexual relations.

It has since been confirmed that abuse also correlates with structural and functional cerebral alterations in the long term (79).

Prevention

Prevention of violent crime can serve the following and other purposes (4):

  • Earliest possible intervention, as soon as there are signs of violence
  • Preventive surveillance measures
  • Shorter time from crime to examination to conviction
  • Qualified care at home as an alternative to custody for younger perpetrators, with the possibility of support and qualification
  • Qualified assistance with reintegration into society on release from prison
  • Alcohol prohibition in “social hotspots.”

The four-volume report of the German government’s violence committee remains the go-to guide to understanding the causes of physical violence and to its treatment and prevention (10).

The following measures have been shown to be effective in preventing abuse of children (11): home visits, counseling for parents, sexual abuse prevention programs, systemic interventions.

Greater emphasis should be placed on available information concerning both these areas of crime in clinical training and continuing education.

Conflict of interest statement
The author declares that no conflict of interest exists.

Translated from the original German by Caroline Devitt, M.A.

Corresponding author:
Prof. Dr. med. Andreas Warnke
Maidbronnerstr. 32
97230 Estenfeld, Germany
warnke@kjp.uni-wuerzburg.de

1.
Remschmidt H, Martin M, Niebergall G, Heinzel-Gutenbrunner M:
Violent crime perpetrated by young people—results from a longitudinal legal probation study over a 13 year period. Dtsch Arztebl Int 2014; 111: 685–91. VOLLTEXT
2.
Herrmann B, Banaschak S, Csorba R, Navratil F, Dettmeyer R: Physical investigation in child sex abuse—approaches and current evidence.. Dtsch Arztebl Int 2014; 111: 692–703. VOLLTEXT
3.
Bundeskriminalamt (Hg.): Polizeiliche Kriminalstatistik Bundesrepublik Deutschland Jahrbuch 2013 Wiesbaden: Bundeskriminalamt 2013.
4.
Remschmidt H: Tötungs- und Gewaltdelikte junger Menschen. Ursachen, Begutachtung und Prognose. Heidelberg: Springer 2012.
5.
Bannenberg B: Amok, Ursachen erkennen – Warnsignale verstehen – Katastrophen verhindern. Gütersloh: Gütersloher Verlag 2010.
6.
Statistisches Bundesamt (ed.): Verurteiltenstatistik. Wiesbaden: Statistisches Bundesamt 2013.
7.
Choi J, Jeong B, Rohan ML, Polcari AM, Teicher MH: Preliminary evidence for white matter tract abnormalities in young adults exposed to parental verbal abuse. Biol Psychiatry. 2009; 65: 227–34. CrossRef MEDLINE PubMed Central
8.
Fegert JM: Sexueller Missbrauch an Kindern und Jugendlichen. Bundesgesundheitsbl – Gesundheitsforsch – Gesundheitsschutz 2007, 50: 78–9.
9.
Remschmidt H: The emotional and neurological consequences of abuse. Dtsch Arztebl Int 2011; 108: 285–6. VOLLTEXT
10.
Schwind HD, Baumann J, Lösel F, et al. (Hrg.): Ursachen Prävention und Kontrolle von Gewalt (Bd I–IV). Berlin, Duncker und Humblot 1990.
11.
Mikton C, Butchart A: Child maltreatment prevention: a systematic review of reviews. Bull World Health Organ 2009; 87: 353–61. CrossRef MEDLINE PubMed Central
Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg: em. Prof. Dr. med. Warnke
1.Remschmidt H, Martin M, Niebergall G, Heinzel-Gutenbrunner M:
Violent crime perpetrated by young people—results from a longitudinal legal probation study over a 13 year period. Dtsch Arztebl Int 2014; 111: 685–91. VOLLTEXT
2.Herrmann B, Banaschak S, Csorba R, Navratil F, Dettmeyer R: Physical investigation in child sex abuse—approaches and current evidence.. Dtsch Arztebl Int 2014; 111: 692–703. VOLLTEXT
3.Bundeskriminalamt (Hg.): Polizeiliche Kriminalstatistik Bundesrepublik Deutschland Jahrbuch 2013 Wiesbaden: Bundeskriminalamt 2013.
4.Remschmidt H: Tötungs- und Gewaltdelikte junger Menschen. Ursachen, Begutachtung und Prognose. Heidelberg: Springer 2012.
5.Bannenberg B: Amok, Ursachen erkennen – Warnsignale verstehen – Katastrophen verhindern. Gütersloh: Gütersloher Verlag 2010.
6.Statistisches Bundesamt (ed.): Verurteiltenstatistik. Wiesbaden: Statistisches Bundesamt 2013.
7.Choi J, Jeong B, Rohan ML, Polcari AM, Teicher MH: Preliminary evidence for white matter tract abnormalities in young adults exposed to parental verbal abuse. Biol Psychiatry. 2009; 65: 227–34. CrossRef MEDLINE PubMed Central
8.Fegert JM: Sexueller Missbrauch an Kindern und Jugendlichen. Bundesgesundheitsbl – Gesundheitsforsch – Gesundheitsschutz 2007, 50: 78–9.
9.Remschmidt H: The emotional and neurological consequences of abuse. Dtsch Arztebl Int 2011; 108: 285–6. VOLLTEXT
10.Schwind HD, Baumann J, Lösel F, et al. (Hrg.): Ursachen Prävention und Kontrolle von Gewalt (Bd I–IV). Berlin, Duncker und Humblot 1990.
11.Mikton C, Butchart A: Child maltreatment prevention: a systematic review of reviews. Bull World Health Organ 2009; 87: 353–61. CrossRef MEDLINE PubMed Central