Silke Pawils

Implementing an Inpatient Social Early Warning System for Child Maltreatment

Objectives: The current article describes the process evaluation of a social early warning system (SEWS) for the prevention of child maltreatment in the federal state of Hamburg. This prevention initiative targets expectant mothers and their partners including an initial screening of risk factors for child maltreatment, a subsequent structured clearing interview further exploring risks and identifying protective factors and an optional referral to the regional health and social care system. Method: The process evaluation was conducted by examining the flow of participants through the different stages of the SEWS as well as asking social education workers, parents, and regional institutions about their satisfaction with the process of the SEWS. Results: The participation rate throughout the SEWS as well as the satisfaction rates were high. Conclusions: The SEWS is a secondary prevention initiative with a substantial difference to other early prevention initiatives, as it aims to facilitate intervention rather than providing it.

[Substance use disorders as a cause and consequence of childhood abuse. Basic research, therapy and prevention in the BMBF-funded CANSAS-Network].

ZusammenfassungSubstanzmissbrauch und -abhängigkeit gehören zu den häufigsten Folgen früher Gewalt und Vernachlässigung. In der Allgemeinbevölkerung findet sich bei 20 % der Erwachsenen, die Misshandlung oder Vernachlässigung in der Kindheit erlebt haben, die Lebenszeitdiagnose einer substanzbezogenen Störung. Etwa 30 % aller Personen, die sich aufgrund einer posttraumatischen Störung in Behandlung begeben, weisen eine Suchterkrankung auf und 24–67 % aller Personen in Suchtbehandlung haben frühe Misshandlung oder Vernachlässigung erlebt.Gleichzeitig wachsen rund 16 % aller in Deutschland lebenden Kinder und Jugendlichen unter 20 Jahren in Familien mit Alkohol- und/oder Drogenabhängigkeit auf. Diese Kinder suchterkrankter Eltern haben, neben anderen Risiken für eine schlechte Entwicklung im kognitiven und psychosozialen Bereich, ein erhöhtes Risiko für Gewalterfahrungen und Vernachlässigung. In Bezug auf beide Perspektiven, substanzbezogene Störungen als Ursache und als Folge früher Gewalt, ist ein besseres Verständnis der relevanten Mediatoren und Risikofaktoren von Bedeutung, um angemessene präventive und therapeutische Ansätze entwickeln zu können. Ziel des BMBF geförderten Forschungsverbundes „CANSAS“ ist es daher: 1.Ein vertieftes Verständnis der Zusammenhänge zwischen den beiden wichtigen Public-Health-Problemen „Substanzmissbrauch“ und „Gewalt“ herzustellen (Grundlagenforschung),2.evidenzbasierte Behandlungsansätze für Betroffene bereitzustellen und für eine Diagnostik von Traumatisierungen bei Suchtkranken im Hilfesystem zu sensibilisieren (Forschung zu Diagnostik und Therapie),3.die systematische Bewertung des Kindeswohls bei Kindern suchtkranker Eltern in der ambulanten Suchthilfe zu verbessern und die Vernetzung der Hilfesysteme „Sucht- und Jugendhilfe“ voranzubringen (Präventions- bzw. Versorgungsforschung). Das CANSAS-Netzwerk bringt dazu in einem interdisziplinären Ansatz Experten aus den Bereichen Traumatherapie, Epidemiologie, Grundlagen-, Versorgungs- und Präventionsforschung sowie aus der ambulanten Suchthilfe zusammen.AbstractSubstance use disorders (SUDs) belong to the most frequent behavioural consequences of childhood abuse and neglect (CAN). In community samples, about 20 % of adults with experiences of abuse or neglect in childhood have a lifetime diagnosis of an SUD. About 30 % of individuals seeking treatment for a post-traumatic disorder have an SUD and 24–67 % of all patients in treatment for an SUD have a history of CAN. About 16 % of all children and adolescents under the age of 20 in Germany grow up in families where an alcohol- and/or drug-dependence is present. The children of parents with SUDs have, in addition to other risks to their development in cognitive and psychosocial domains, an increased risk of experiencing violence and neglect. Regarding both perspectives, SUD as a cause and as a consequence of CAN, a better understanding of relevant mediators and risk factors is necessary to improve prevention and develop adequate treatments. The aims of the BMBF-funded research network CANSAS are: 1.To gain a better understanding of the relationships between these two important public health problems (basic research),2.To provide evidence-based treatments for survivors of CAN with SUDs and to increase the awareness for the necessity to diagnose CAN in patients with SUDs in counselling and treatment facilities (research on diagnostics and therapy),3.To improve the systematic evaluation of child welfare among children of parents with SUDs through counselling services and to promote links between addiction services and youth welfare services (prevention research and health services research). In a multidisciplinary approach, the CANSAS network brings together experts in the fields of trauma treatment, epidemiology, basic research, health services research, prevention research as well as addiction services.

Multimodal and multilevel approaches: key elements in preventive interventions

The social context in which children develop is a key determinant of their health. The social background tells us something about a child’s welfare and chances of growing up healthy. Moreover, it gives us clues as to which target groups should be a particular focus of our attention when implementing preventive interventions (Marmot et al. 2010). Children from low-income families with low education levels generally have poorer health and more psychological problems than their age-matched peers from highincome families with higher education levels. Thus, education level is an important factor. There is a reciprocal relationship between education and health. A recent review of over 50 publications by the World Health Organization revealed some interesting findings (Suhrcke and de Paz 2011) — good general health during childhood has a positive effect on education background and educational attainment. Consequently, poor health has a negative effect on education for the individual child. Children in poor health spend up to one-third more time in the school system than healthy children, and healthy children complete school with higher levels of education. Furthermore, it was shown that poor nutrition and smoking in particular have a negative effect on education. Likewise, the evidence indicates that obesity and overweight are negatively associated with educational outcomes, and that frequent sleeping problems in childhood can hinder academic performance. Conversely, physical activity has a positive impact on academic performance. By comparison, the effects of anxiety and depression on education are under-researched. The authors conclude that the available data provides sufficient evidence for the influence of health on education. Their findings underline the need to invest not only in the education of children, but also in their health and in prevention chains, particularly at the local level, right from the beginning. One-dimensional models do not adequately reflect the complexity of factors involved here. Models for the prevention of overweight and obesity, the etiology of which is not completely understood, made this extremely clear. WeimerJehle, Deuschle and Rehaag, who created a causal loop model to identify key factors for prevention in socially disadvantaged children and adolescents, concluded that there is no one specific factor that can be expected to act as an effective prevention factor for every scenario. Instead, a multi-level perspective is needed which takes into account the specific characteristics of an individual’s environment. Behavioural and structural prevention strategies exist, and Pawils, Atabaki, Metzner, Nocker, Linden, Plaumann and Walter provide an overview of the German and European approaches. Other examples are shown in the different U. Walter (*) Institut fur Epidemiologie, Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany e-mail: Walter.Ulla@MH-Hannover.de

Understanding the role of childhood abuse and neglect as a cause and consequence of substance abuse: the German CANSAS network

ABSTRACT Background: Substance use disorders (SUD) belong to the most frequent behavioural consequences of childhood abuse and neglect (CAN). If parents are concerned, SUD are also an important risk factor for CAN. The relationship between CAN and SUD remains poorly understood. There is a need of adequate treatments for SUD patients suffering from the consequences of CAN, as well as for approaches to prevent CAN by parents with SUD. Objective: To describe the aims and the structure of a German research network on relationships between CAN and SUD (CANSAS network). Method: Descriptive overview of the aims, and the different project clusters of the network. Results: The aims of the CANSAS network are: (1) to examine relationships between SUD and CAN; (2) to examine the effects of an evidence-based treatment for SUD patients with posttraumatic disorders; and (3) to provide SUD services with tools to diagnose CAN, and to assess the risk of maltreatment among parents with SUD. The aims of the network are addressed by six projects in three different project clusters (mediators and risk factors, evidence-based treatment, and improvement of services). Conclusions: It is expected that the CANSAS network will advance the understanding of relationships between early adversity and substance use disorders. It will bring forward the discussion about promising treatments for SUD patients with experiences of CAN. Finally it will provide services with measures to identify patients with CAN, and with tools to break the trans-generational cycle of adversity.

Are experiences of sexual violence related to special needs in patients with substance use disorders? A study in opioid-dependent patients

A history of sexual violence has been related to more complex treatment needs in patients with substance use disorders (SUD). Most of the existing studies, however, included patients with various types of SUD, did not examine gender differences and focused on a small range of clinical domains. Our sample consisted of opioid-dependent outpatients treated during a three-year period in a German metropolitan region. The analysis was based on a local case register and included all patients for whom information on lifetime sexual violence was available (N=3531; 68.3% males). In a case-control design, patients with a history of sexual violence were compared to patients without these experiences regarding a wide range of clinical and social factors indicative of potential needs. Almost two thirds (65.6%) of the female patients and 10.9% of the males reported experiences of sexual violence. Victims differed from non-victims across a variety of domains, including more psychiatric symptoms and suicide attempts, more legal problems, financial and family problems, as well as a higher use of services. In contrast to a previous study among alcohol-dependent patients, no gender differences became apparent. Our findings suggest that experiences of sexual violence are an indicator for more complex needs in opioid-dependent patients of both genders. In addition to integrated trauma-informed approaches, an effort needs to be made to link addiction facilities to further institutions to meet these complex needs.

‘Learning how to ask’: Effectiveness of a training for trauma inquiry and response in substance use disorder healthcare professionals

Context: Exposure to traumatic events should be systematically assessed in health care services so that trauma-related treatment can be offered when appropriate. However, professionals often lack expertise in trauma inquiry and response, and therefore require training in this field. Objective: We aimed to determine whether the “Learning how to ask” training for trauma inquiry and response (Read, Hammersley, & Rudegeair, 2007) is effective in increasing health care professionals’ trauma inquiry behavior. Method: 148 professionals working in outpatient substance use disorder (SUD) services were cluster-randomized into an intervention or a waiting control group. The intervention group received a 1-day training and a refresher session 3 months later, while the control group received no training. The primary outcome was the change from baseline in the frequency of asking clients about traumatic events. Secondary outcomes were professionals’ evaluation of the training, knowledge, attitudes toward and confidence in trauma inquiry and response. Results: Change from baseline in the frequency of asking clients about traumatic events was significantly greater at 3-month and 6-month follow-up in the intervention group compared with the control group (b = 0.43, 95% CI [0.27, 0.59], p < .001). The training was positively evaluated by the participants. Knowledge, positive attitudes toward and confidence in trauma inquiry and response all showed significantly greater increases in the intervention group than in the control group. Conclusions: These findings suggest that health care professionals can acquire skills in trauma inquiry and response from short trainings, which may enhance systematic assessment of traumatic events.

Stellenwert und Umsetzung der Prävention in Deutschland – Eine bundesweite Befragung von Entscheidungsträgern in GKV-Spitzenverband, Bund, Ländern und Kommunen

Representatives of the statutory health insurance (n=46) and policy makers at the local, federal and state level (n=136) were interviewed in 2 nationwide online surveys about the significance and degree of implementation of prevention. The group comparison between the decision-makers shows significant differences in terms of attitudes towards health prevention. The political leaders are demanding an improvement of the GKV-benefit package and the obstacles require the cooperation of urgent attention.

Behavioural and structural prevention to promote the health of socially disadvantaged children and adolescents: an overview of European and German health promotion strategies

IntroductionChildhood and adolescence are significant phases in life,characterized by many physical and psychosocial changes.Diseases and health related attitudes during these sensitivestages of life have a significant and lifelong impact, not onlyon health issues, but also on the overall development (Kuhand Ben-Schlohmo 2005; Power and Kuh 2006). The earlyexperience of health inequalities is a major risk factor forchildren’s and adolescents’ further health development.Thus, the early and efficient prevention of ill-health behav-iours (behavioural prevention) and in relevant social settings(structural prevention) among children and young people,particularly those who are socially disadvantaged, is crucial.Social disadvantage in GermanyDefining social disadvantage is complicated. While somedefinitions emphasize meeting the mental and physical basicneeds (Biermann and Rutzel 1999), others focus on powerand social discrimination (Iben 1997). Most empirical stud-ies, however, define social disadvantage by the socioeco-nomic status.In Germany, life expectancy and quality of life are heavi-ly dependent on income, level of education and occupation(Lampert and Kroll 2010). Differences in income and theproportion of poor people in Germany have increased morerapidly in recent years than in most other ‘Organisation forEconomic Cooperation and Development (OECD)’countries (Organisation for Economic Cooperation andDevelopment 2008). The OECD country comparison(2008) has also shown that social disadvantage and povertyhave become less of a problem for the elderly, but increas-ingly for young people and young families. Gebken (2005)accordingly found that social disadvantage and povertyoccur particularly in young families with several children,with just one parent earning an income, with single parentsand in migrant families.Data from the Socioeconomic Panel (SOEP) in 2008showed that 21% of 13–18-year olds are under particularthreat of poverty. By comparison, the rate for the population

Protective mental health factors in children of parents with alcohol and drug use disorders: A systematic review

Children of parents with drug and alcohol use disorders often grow up under severe stress and are at greater risk of developing psychological and social problems. However, a substantial proportion of affected children adapt to their distressing life conditions and show positive development in terms of their mental health. These children are described as resilient. One difference between resilient and maladapted children is the presence of protective factors. The aim of this systematic review is to provide an overview of the current state of the research concerning protective mental health factors in children of parents with alcohol or drug use disorders (COPAD). For that purpose, the PsychInfo, PubMed, CINAHL and ISI Web of Science databases were searched through January 2017. All the identified publications were screened using previously developed inclusion criteria. The search yielded 3,402 articles. Eleven of these publications (2003–2013) met the criteria for inclusion in the present review. Information on the studies was extracted using an extraction form. A narrative analysis was performed, and the methodological quality was examined using a checklist based on the Mixed Methods Appraisal Tool. The research identified familial, parental, child-related and biological factors that influenced mental health outcomes in affected children (N = 1,376, age range = 1–20 years). Overall, protective mental health factors are understudied in this target group. Most of the included studies were conducted in the United States and employed a cross-sectional design. A comparison of the included cross-sectional and longitudinal studies indicated consistent results related to a secure parent-child attachment. Based on the current state of the research, no causal conclusions with regard to the effectiveness of protective factors can be drawn. To develop effective prevention programs, further longitudinal studies and studies assessing the interactions between risk and protective factors are needed.

Substanzbezogene Störungen als Ursache und als Folge früher Gewalt

ZusammenfassungSubstanzmissbrauch und -abhängigkeit gehören zu den häufigsten Folgen früher Gewalt und Vernachlässigung. In der Allgemeinbevölkerung findet sich bei 20 % der Erwachsenen, die Misshandlung oder Vernachlässigung in der Kindheit erlebt haben, die Lebenszeitdiagnose einer substanzbezogenen Störung. Etwa 30 % aller Personen, die sich aufgrund einer posttraumatischen Störung in Behandlung begeben, weisen eine Suchterkrankung auf und 24–67 % aller Personen in Suchtbehandlung haben frühe Misshandlung oder Vernachlässigung erlebt.Gleichzeitig wachsen rund 16 % aller in Deutschland lebenden Kinder und Jugendlichen unter 20 Jahren in Familien mit Alkohol- und/oder Drogenabhängigkeit auf. Diese Kinder suchterkrankter Eltern haben, neben anderen Risiken für eine schlechte Entwicklung im kognitiven und psychosozialen Bereich, ein erhöhtes Risiko für Gewalterfahrungen und Vernachlässigung. In Bezug auf beide Perspektiven, substanzbezogene Störungen als Ursache und als Folge früher Gewalt, ist ein besseres Verständnis der relevanten Mediatoren und Risikofaktoren von Bedeutung, um angemessene präventive und therapeutische Ansätze entwickeln zu können. Ziel des BMBF geförderten Forschungsverbundes „CANSAS“ ist es daher: 1.Ein vertieftes Verständnis der Zusammenhänge zwischen den beiden wichtigen Public-Health-Problemen „Substanzmissbrauch“ und „Gewalt“ herzustellen (Grundlagenforschung),2.evidenzbasierte Behandlungsansätze für Betroffene bereitzustellen und für eine Diagnostik von Traumatisierungen bei Suchtkranken im Hilfesystem zu sensibilisieren (Forschung zu Diagnostik und Therapie),3.die systematische Bewertung des Kindeswohls bei Kindern suchtkranker Eltern in der ambulanten Suchthilfe zu verbessern und die Vernetzung der Hilfesysteme „Sucht- und Jugendhilfe“ voranzubringen (Präventions- bzw. Versorgungsforschung). Das CANSAS-Netzwerk bringt dazu in einem interdisziplinären Ansatz Experten aus den Bereichen Traumatherapie, Epidemiologie, Grundlagen-, Versorgungs- und Präventionsforschung sowie aus der ambulanten Suchthilfe zusammen.AbstractSubstance use disorders (SUDs) belong to the most frequent behavioural consequences of childhood abuse and neglect (CAN). In community samples, about 20 % of adults with experiences of abuse or neglect in childhood have a lifetime diagnosis of an SUD. About 30 % of individuals seeking treatment for a post-traumatic disorder have an SUD and 24–67 % of all patients in treatment for an SUD have a history of CAN. About 16 % of all children and adolescents under the age of 20 in Germany grow up in families where an alcohol- and/or drug-dependence is present. The children of parents with SUDs have, in addition to other risks to their development in cognitive and psychosocial domains, an increased risk of experiencing violence and neglect. Regarding both perspectives, SUD as a cause and as a consequence of CAN, a better understanding of relevant mediators and risk factors is necessary to improve prevention and develop adequate treatments. The aims of the BMBF-funded research network CANSAS are: 1.To gain a better understanding of the relationships between these two important public health problems (basic research),2.To provide evidence-based treatments for survivors of CAN with SUDs and to increase the awareness for the necessity to diagnose CAN in patients with SUDs in counselling and treatment facilities (research on diagnostics and therapy),3.To improve the systematic evaluation of child welfare among children of parents with SUDs through counselling services and to promote links between addiction services and youth welfare services (prevention research and health services research). In a multidisciplinary approach, the CANSAS network brings together experts in the fields of trauma treatment, epidemiology, basic research, health services research, prevention research as well as addiction services.