Fighting Tragedies in Dutch Child Welfare with ICT

by Bart Penders and Inge Lecluijze

In 2004, the Netherlands were shocked by the death of “Savanna.” Just a toddler, she was beaten to death by her parents. An investigation afterwards revealed that there appeared to be several signs and reports of child abuse in this case; however, it seemed that nobody had acted on them.

Another similar catastrophe took place in 2006, when the “Maas girl” was found in pieces in the river Meuse (Maas in Dutch). A few years earlier, in 2000, the UK was confronted with the death of a little girl as well. The death of “Victoria Climbié" also paints a picture of child welfare as an institution that failed to respond to available signs and lacks multidisciplinary collaboration.1 Early in 2013, the two Dutch brothers “Ruben” and “Julian” were killed by their father—prompting national mourning, but also questions about whether or not such tragedies may be prevented in the future.

The institution of child welfare as a whole was held responsible for not being able to respond accurately, and these and other tragedies prompted politicians to call for action. This resulted in the development and introduction of early warning ICT infrastructures in child welfare, the so-called child indexes, which aim at early detection of children at risk and an improved quality of care by stimulating collaboration between child welfare professionals.

While the initial response suggests sincere worry for the fate of children in the Netherlands, the ensuing implementation of the child indexes shows a radically different picture starring skewed stimuli, delayed, postponed and even dodged responsibilities, as well as controversial labelling practices of “children at risk.” The ICT infrastructure was thought to be the solution to the tragedies plaguing the child welfare system.

We have been critically following the introduction of the child index for over 5 years now, monitoring its implementation in child welfare. While a detailed account of the research is well beyond the scope of this blog post, we can and will point out a few of the most salient effects of the ill-conceived implementation of the child index.

“Children at risk”

Is every child potentially a child at risk? Since the aim of the child index is to act as an infrastructure, housing each and every concern or risk signal any type of child welfare professional encounters, it would seem so. With legal structures in place enforcing the use of the Index by child welfare professionals, there seems no escape. However, forcing professionals to identify and diagnose risk, requires some consensus about the meaning of risk. Obviously, child abuse falls within these criteria, but what about being overweight or getting dismissed from school? Because of these difficulties, some organisations in Dutch child welfare have decided to enter every child they encounter into the child index. For the same reason, other professionals have decided not to use it at all.


The rules of the system prescribe that once a second risk signal is entered into the system, action is compulsory. Professionals should contact one another and start providing the required care collaboratively and decide who will coordinate the care process. That means that the first professional, who already determined that something is wrong, has to wait for another professional to share his or her concerns through the index. Without professionals entering signals into the system, it cannot create the “match” professionals are looking for. While the rhetoric of the system is directed at improving collaboration, in practice collaborative networks appear to be prerequisites for the system to be able to work in the first place, since professionals must coordinate their use of the Index.


The child index implementation process is supported by all the right terminology: consultations, pilot projects, fine-tuning according to several steps and in various phases—all meticulously planned out in advance. However, the implementation jargon hides the fact that it is implemented top-down with little room for actual improvement as it disseminates into the care field. Embedded in the system is a distrust of professional expertise and autonomy and a redistribution of power from caregiver to child welfare manager, who monitors the number of risk signals professionals have entered from his office.


While the death of these children has offered a powerful momentum for Dutch politicians to implement this system, we cannot help but ask whether it was sufficiently justified to infringe on children’s, parents’ and child welfare professionals’ lives this way. From the beginning the system was associated with unrealistic expectations, including total prevention of any future infanticides and “no child falling between two stools.” It was forced upon child welfare in which smooth implementation plans were a rhetorical lubricant, considering that, for instance, parents and children were never consulted. Moreover, the opportunities to actually help children and families continuously decrease because of budget cuts and permanent reorganizations of child welfare.

Child welfare is an institution under pressure. Public trust in child welfare is heavily influenced by child deaths and the growing pressure upon the institution to provide risk-free lives for all of our children. The real tragedy is that in the pursuit of total risk-prevention, and in the pursuit of better and safer lives for Dutch children, child welfare professionals were stripped of their autonomy, every child is now a potential “child at risk,” and collaboration between caregivers is obstructed by bureaucracy, all without a decent public justification.

Dutch child welfare is being corrupted not because of financial dependencies or external interests. In fact, (almost) everybody works hard and means well. It is a continuous and misplaced trust in ICT, technology and accountancy that gave birth to this tragedy.

About Inge Lecluijze

Inge holds a M.Sc. (2010) in Health Sciences Research from Maastricht University (the Netherlands). During this M.Sc. program she completed a research proposal to study the implementation of a novel ICT infrastructure in Dutch child welfare. She is currently conducting this research as a Ph.D. candidate at Maastricht University. Drawing on insights from Science and Technology Studies, Inge investigates how the implementation process of a novel ICT system in child welfare relates to the construction of “children at risk” and how such an innovation trajectory affects the relationships and trust between State, professionals, parents and children and the quality of care for youth. Inge is mainly doing research at the interface of technology, politics, science and professional practices. She is especially interested in the way ICT infrastructures are constructed, processes of implementation, and how new technologies affect professional practices, especially in the field of child welfare and public health.

1. House of Commons Health Committee, “The Victoria Climbié Inquiry,” Sixth Report of Session 2002-03, HC 570, June 25, 2003, and Nigel Parton, “‘Every Child Matters’: The Shift to Prevention whilst Strengthening Protection in Children’s Services in England,” Children and Youth Services Review 28.2 (2006): 976-992. The political response in the U.K. resembled that in the Netherlands, with the creation of a child index named “ContactPoint.” The U.K. pulled the plug on the system since it caused more problems than it offered solutions.