Addressing the mental health needs and burdens of children fleeing war: a field update from ongoing mental health and psychosocial support efforts at the Ukrainian border.

Background: The ongoing horrors of the war in Ukraine have led to enormous consequences: loss of life, severe injuries, and mass movements of civilians. Exposure to war, living in conflict zones, and forced displacement increase the risk of experiencing a broad spectrum of direct and indirect burdens towards physical and mental health, in particular among children. Objective: This letter to the editor aims to provide multiple clinical and 'mental health and psychosocial support' (MHPSS) systems' perspectives by experts working in ongoing aid efforts to bridge and disseminate their current observations towards child and adolescent mental health services involved in the mental health response to the current war in Ukraine. Results and Discussion: The diverse perspectives from three mental health professionals involved in the MHPSS response highlight the different burdens and needs of children being confronted with situations of an existential nature. Children live through transformed social situations, deteriorated life conditions, general uncertainty, and encounter numerous losses. As such, war is the ultimate non-normative and existential stressor. The four perspectives highlight the need to: (1) adjust help toward the needs of the beneficiary, (2) understand help efforts as intersubjective human encounters and enable parents and caregivers in these encounters, (3) recognise losses and embrace finding ways to facilitate grief, and (4) continue to address these needs in a coordinated way that follows inter-agency guidelines. Conclusion: Better understanding the needs of refugee children underlines the importance of investing in their future by providing resources for humanitarian aid and psychosocial interventions during sustained emergencies. The perspectives presented in this letter emphasise that psychosocial care is deeply rooted in intersubjective help-encounters and, therefore, a professionalisation of interventions should co-occur with their humanisation and be adapted to subjective needs, varying sociocultural backgrounds, and the individuals themselves with the goal of reducing suffering and fostering well-being. HIGHLIGHTS: The three expert humanitarian aid perspectives highlight the need to: adjust help toward the needs of the beneficiary,understand help efforts as intersubjective human encounters and enable parents and caregivers in these encounters,recognise losses and embrace finding ways to facilitate grief, andcontinue to address these needs in a coordinated way that follows inter-agency guidelines.

Antecedentes: Los horrores que están ocurriendo en la guerra en Ucrania han conducido a consecuencias tremendas en términos de pérdidas de vidas, heridas graves, y de movimientos masivos de ciudadanos. Vivir en zonas de conflicto, estar expuestos a la guerra y ser forzados a desplazarse, aumenta el riesgo de experimentar un amplio espectro de consecuencias directas e indirectas sobre la salud física y mental de las poblaciones afectadas, especialmente en los niños.Objetivo: Esta carta al director busca proveer múltiples perspectivas clínicas y de sistemas de apoyo psicosocial y de salud mental en servicios de urgencia (MHPSS, por sus siglas en inglés) en relación a los esfuerzos de ayuda que se están realizando, y discutirlos con una perspectiva de asistencia informada sobre el trauma, para conectar y diseminar las actuales observaciones de las prácticas clínicas y MHPSS involucradas en la respuesta de salud mental actual.Resultados y discusión: Las diversas perspectivas de tres profesionales de la salud mental involucrados en la respuesta de los MHPSS destacan las diferentes cargas y necesidades de niños que han sido confrontados con situaciones de naturaleza existencial. Los niños viviendo situaciones sociales en transformación, condiciones de vida deterioradas y la incertidumbre general al encontrarse con numerosas pérdidas. Como tal, la guerra es el máximo estresor existencial no normativo. Los cuatro puntos de vista destacan la necesidad de: (1) ajustar la ayuda según las necesidades del beneficiario, (2) comprender los esfuerzos de ayuda como encuentros humanos intersubjetivos e incluir en ellos a los padres y cuidadores, (3) reconocer las pérdidas y adoptar la búsqueda de maneras para facilitar el duelo, y (4) continuar abordando estas necesidades de una forma coordinada que siga guías clínicas interinstitucionales.Conclusión: Una mejor comprensión de las necesidades de los niños refugiados subraya la importancia de invertir en su futuro proveyéndolos de recursos de ayuda humanitaria e intervenciones psicosociales durante emergencias prolongadas. Estas perspectivas presentadas en esta carta enfatizan que el cuidado psicosocial está profundamente arraigado en encuentros de ayuda intersubjetivos y, por lo tanto, debería ocurrir una profesionalización de las intervenciones junto con su humanización, y ser adaptados a las necesidades subjetivas, a los trasfondos socioculturales variados, y a los individuos mismos con el objetivo de disminuir el sufrimiento y fomentando el bienestar.

Childhood maltreatment, depression and their link to adult economic burdens.

Background: Adult depression is a common consequence of adverse childhood experiences. There is also a higher likelihood of being affected by economic burdens after having experienced a traumatic event in childhood. As depression has been associated with economic burden, these long-term sequelae of childhood adversity are likely to interact. Goals: We investigated depression and economic consequences, such as unemployment, lower level of education, lower income as long-term sequelae of adverse childhood experiences in adulthood and their interaction. Methods: Childhood Maltreatment was measured by the German version of the Adverse Childhood Experience (ACE) questionnaire. Depression was measured by the Patient Health Questionnaire (PHQ-2). Logistic regressions were applied to investigate the risks of suffering economic burdens, with depression as a moderator. Results: Depressive symptoms increased with the number of ACEs and were highest in those reporting four or more ACEs, especially amongst those who experienced sexual and emotional abuse, as well as neglect. Moderation analysis showed a significant effect of depression increasing almost all economic burdens. Migration background additionally increased the risk of unemployment and working in a blue-collar job. Female gender decreased the risk of unemployment and working in a blue-collar job, but increased the risk of low income and part-time employment. Conclusion: The moderation effect of depression increased the negative impact of exposure to multiple ACEs on economic life in adulthood. Prevention of ACEs and early intervention are needed to prevent the mental health and economic consequences.

COVID-19-What Price Do Children Pay? An Analysis of Economic and Social Policy Factors.

Numerous studies have addressed the indirect consequences of the COVID-19 pandemic for children such as social isolation or increases in reported child maltreatment. Research on the economic and sociopolitical consequences is scarce as they can only be evaluated with a time lag. To improve our understanding of future, long-term developments in the context of the COVID-19 pandemic, we gathered findings from the still unexploited empirical literature on the aftermath of earlier pandemics, epidemics, and other infectious disease outbreaks. On top of this, we scrutinized research on past economic crises to interpret the link between changes in the economy and the health of children. Many of the side effects of battling the spread of the current pandemic, such as school closures, the stigma of infection, or conflicts about vaccines, are not novel and have already been documented in connection with previous infectious disease outbreaks. Results highlight that changes in the financial situation of families and socio-political challenges affect the situation and daily routine of children and youth in the long term. In consequence, the already pronounced socioeconomic inequalities will likely further increase. On top of this, due to reduced revenues, child protective services are likely to face challenges in the availability of human and financial resources.

"An uncomfortable topic": Health professionals' perspectives on child protection capacities, training offers and the potential need for action in Germany.

BACKGROUND: Child maltreatment, due to its high prevalence and often long-lasting (health and/or psycho-social) consequences, is one of the main reasons for global health inequalities. The medical field offers many opportunities to support affected children. This gives physicians and other health professionals the opportunity to provide protective measures and therapies to affected children at an early stage. However, the level of training concerning child protection is often too low among health professionals. This can affect the quality of care as well as providing the appropriate treatment and thus, the long-term (health) burden. The present work aims to survey the state of knowledge and capacities of health professionals regarding child protection in medicine and elicit health professionals' perspectives who absolved a child protection online course on a potential need for action in Germany. METHODS: From June 2016 until February 2021, 3,360 health professionals were interviewed. Using quantitative and qualitative items, the questionnaire assessed demographic and professional background information as well as assessments regarding the awareness of child protection, abilities in child protection among health professionals and training offers in medicine. RESULTS: The analysis indicates that the topic of child protection in medicine is not as present as the high prevalence of child maltreatment would imply. The majority (94.0%; n = 3.159) of the health professionals stated that they need more knowledge and capacities regarding child protection in medicine. More than half of the health professionals assessed the importance of the issue of child protection as low among health professionals. The reasons cited included child protection as an uncomfortable topic, an unwillingness among managers, and a lack of training on the topic. CONCLUSIONS: There is too little awareness and importance regarding child protection in the medical field in Germany. Hence, it is difficult to ensure adequate care for those affected. Child protection topics should be mandatory in the training curricula of all health professionals, and quality standards for prevention and intervention should be implemented in medical institutions. Furthermore, networking in child protection has to be improved, and medical campaigns should address the topic to sensitize health professionals and society to the issue and to destigmatize the topic.

Impact of war and forced displacement on children's mental health-multilevel, needs-oriented, and trauma-informed approaches.

The infliction of war and military aggression upon children must be considered a violation of their basic human rights and can have a persistent impact on their physical and mental health and well-being, with long-term consequences for their development. Given the recent events in Ukraine with millions on the flight, this scoping policy editorial aims to help guide mental health support for young victims of war through an overview of the direct and indirect burden of war on child mental health. We highlight multilevel, need-oriented, and trauma-informed approaches to regaining and sustaining outer and inner security after exposure to the trauma of war. The impact of war on children is tremendous and pervasive, with multiple implications, including immediate stress-responses, increased risk for specific mental disorders, distress from forced separation from parents, and fear for personal and family's safety. Thus, the experiences that children have to endure during and as consequence of war are in harsh contrast to their developmental needs and their right to grow up in a physically and emotionally safe and predictable environment. Mental health and psychosocial interventions for war-affected children should be multileveled, specifically targeted towards the child's needs, trauma-informed, and strength- and resilience-oriented. Immediate supportive interventions should focus on providing basic physical and emotional resources and care to children to help them regain both external safety and inner security. Screening and assessment of the child's mental health burden and resources are indicated to inform targeted interventions. A growing body of research demonstrates the efficacy and effectiveness of evidence-based interventions, from lower-threshold and short-term group-based interventions to individualized evidence-based psychotherapy. Obviously, supporting children also entails enabling and supporting parents in the care for their children, as well as providing post-migration infrastructures and social environments that foster mental health. Health systems in Europe should undertake a concerted effort to meet the increased mental health needs of refugee children directly exposed and traumatized by the recent war in Ukraine as well as to those indirectly affected by these events. The current crisis necessitates political action and collective engagement, together with guidelines by mental health professionals on how to reduce harm in children either directly or indirectly exposed to war and its consequences.

[Framework for a Group Intervention Aiming at Coping with out-of-home Placement - Focus Groups in Residential Foster Homes]. / Potenzielle Inhalte und Rahmenbedingungen einer Gruppenintervention für Jugendliche zur Aufarbeitung der eigenen Fremdunterbringung.

Out-of-home placement is a critical life event for affected children and adolescents. We explored the potential content and conditions for a group intervention aiming at coping with this critical life event by the means of three focus groups with n = 13 participants. The participants reported feelings of guilt, uncertainty concerning their future, experiences of loss, and lack of confidence. So far, standardized programs for sharing the participants' out-of-home care experiences had not been established in their child welfare programs. Under certain circumstances, the participants were willing to take part in a group intervention for this purpose. The intervention should aim at the autobiographical integration of the out-of-home placement as well as the promotion of general protection factors. Further qualitative research is needed to adjust the intervention in order to fit the needs of the target population.

[Prevalence and Treatment of Posttraumatic Stress Disorder in Germany: An Analysis of Nationwide Health Insurance Data, 2008 vs 2017]. / Prävalenz und Versorgung der Posttraumatischen Belastungsstörung in Deutschland: Eine bundesweite Auswertung von Krankenkassendaten aus den Jahren 2008 und 2017.

OBJECTIVE: To provide German data regarding prevalence and treatment (pharmacotherapy, psychotherapy) for individuals with PTSD. METHODS: Based on BARMER health insurance data, the administrative prevalence of PTSD (ICD-10: F43.1), psychiatric comorbidity, psychotherapy and pharmacotherapy were estimated. Additionally, prevalence trends for years 2008 vs. 2017 were computed. RESULTS: In 2017, the overall PTSD prevalence was 0.7 % (females: 0.9 %, males: 0.4 %), whereas in 2008 it was 0.3 %. 74.4 % of all PTSD cases received psychotherapy, 43.6 % were prescribed an antidepressant (first choice: venlafaxine), and 14.4 % were prescribed an antipsychotic (first choice: quetiapine). CONCLUSION: Within the studied period, the administrative prevalence of PTSD has more than doubled. Still, the prevalence rate found in our study is lower than figures from epidemiological studies, thus indicating room for improvement in diagnosing PTSD.

Monitoring recent trends: The prevalence of disclosure of sexual abuse in a representative sample of the German population based on indicator 16.2.3 of the UN Sustainable Development Goals (SDG).

BACKGROUND: The monitoring of trends is important. The United Nations (UN) have defined indicators to monitor the proportion of young men and women who have experienced sexual abuse before the age of 18 (Indicator 16.2.3) as part of their global agenda, the Sustainable Development Goals (SDG). OBJECTIVE: To examine recent trends in the disclosure of sexual abuse based on the indicator 16.2.3 of the SDG. PARTICIPANTS AND SETTING: A total of 7530 participants across Germany (51.1% female) were included. The participants were between 14 and 94 years old. METHODS: Three representative surveys were conducted using identical methods in 2010 (N = 2504), 2016 (N = 2510) and 2018 (N = 2516). A history of child sexual abuse (CSA) was assessed using the Childhood Trauma Questionnaire (CTQ). The prevalence rates of CSA among the age cohort of 18 to 29-year olds (indicator 16.2.3) were compared across the three waves. RESULTS: There was no significant increase of rates in males in this specific age cohort (2010: 7.6%; 2016: 8.5%; 2018: 6.1%), but there was a significant increase among the females of this age cohort (2010: 12.8%; 2016: 13.5%; 2018: 26.1%). The increase was entirely between the survey in 2016 and 2018. CONCLUSIONS: This is the first study to report on indicator 16.2.3 of UN's SDGs in Germany. The identified increase in rates of sexual abuse among 18-29 year old females might have been triggered by the attention the topic received in the time between 2016 and 2018, especially via social media and the #MeToo debate.

Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality.

BACKGROUND: The coronavirus disease 2019 (COVID-19) is profoundly affecting life around the globe. Isolation, contact restrictions and economic shutdown impose a complete change to the psychosocial environment in affected countries. These measures have the potential to threaten the mental health of children and adolescents significantly. Even though the current crisis can bring with it opportunities for personal growth and family cohesion, disadvantages may outweigh these benefits. Anxiety, lack of peer contact and reduced opportunities for stress regulation are main concerns. Another main threat is an increased risk for parental mental illness, domestic violence and child maltreatment. Especially for children and adolescents with special needs or disadvantages, such as disabilities, trauma experiences, already existing mental health problems, migrant background and low socioeconomic status, this may be a particularly challenging time. To maintain regular and emergency child and adolescent psychiatric treatment during the pandemic is a major challenge but is necessary for limiting long-term consequences for the mental health of children and adolescents. Urgent research questions comprise understanding the mental health effects of social distancing and economic pressure, identifying risk and resilience factors, and preventing long-term consequences, including-but not restricted to-child maltreatment. The efficacy of telepsychiatry is another highly relevant issue is to evaluate the efficacy of telehealth and perfect its applications to child and adolescent psychiatry. CONCLUSION: There are numerous mental health threats associated with the current pandemic and subsequent restrictions. Child and adolescent psychiatrists must ensure continuity of care during all phases of the pandemic. COVID-19-associated mental health risks will disproportionately hit children and adolescents who are already disadvantaged and marginalized. Research is needed to assess the implications of policies enacted to contain the pandemic on mental health of children and adolescents, and to estimate the risk/benefit ratio of measures such as home schooling, in order to be better prepared for future developments.

Affective dysregulation in childhood - optimizing prevention and treatment: protocol of three randomized controlled trials in the ADOPT study.

BACKGROUND: The terms affective dysregulation (AD) and irritability describe transdiagnostic dimensions and are characterized by an excessive reactivity to negative emotional stimuli with an affective (anger) and a behavioral component (aggression). Due to early onset, high prevalence and persistence, as well as developmental comorbidity, AD in childhood is one of the most psychosocially impairing and cost-intensive mental health conditions. AD is especially prevalent in children in the youth welfare service. Despite continuous research, there remains a substantial need for diagnostic approaches and optimization of individualized treatment strategies in order to improve outcomes and reduce the subjective and economic burden. METHODS: The ADOPT (Affective Dysregulation - Optimizing Prevention and Treatment) Consortium integrates internationally established, highly experienced and interdisciplinary research groups. The work program encompasses (a) epidemiology, including prevalence of symptoms and disorders, (b) development and evaluation of screening and assessment tools, (c) stepped care approaches for clinically useful personalized medicine, (d) evaluation of an easily accessible and cost-effective online intervention as indicated prevention (treatment effects, moderation/mediation analysis), and (e) evaluation of an intensive personalized modular outpatient treatment in a cohort of children with AD who live with their parents and in a cohort of children with AD who live in out-of-home care (treatment effects, moderation/mediation analysis). DISCUSSION: The results will lead to significant recommendations for improving treatment within routine clinical care in two cohorts of children with AD and coexisting conditions, especially oppositional-defiant disorder, conduct disorder and disruptive mood dysregulation disorder. TRIAL REGISTRATION: Trial registration ADOPT Online: German Clinical Trials Register (DRKS) DRKS00014963 . Registered 27 June 2018. Trial registration ADOPT Treatment: German Clinical Trials Register (DRKS) DRKS00013317 . Registered 27 September 2018. Trial registration ADOPT Institution: German Clinical Trials Register (DRKS) DRKS00014581 . Registered 04 July 2018.

[Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany]. / Interventionsprogramme bei psychischen Belastungen von Kindern von Militärangehörigen in den USA.

Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany Abstract. Military personnel who have been deployed in war zones or other unstable regions are at an increased risk to develop mental health disorders, including posttraumatic stress disorder. Likewise, their children are at high risk to develop mental health problems as well as emotional and behavioral difficulties. Most research on prevalence of mental health problems as well as on interventions within this group was conducted in the USA. In Germany, no systematic intervention for children of military members focusing on their experiences of deployment exist. The systematic literature review aimed to analyze existing intervention programs in the USA, in particular for children of military members regarding evidence, type and addressed target group (parents, children, both). Compared to the social welfare and health care systems in the USA, the German systems are different. Hence, a second aim was to examine the transferability of these programs to the specific needs of children of German military members (Bundeswehr). 27 intervention programs could be included in the review. Programs, directly or indirectly, are addressing the needs of children of a deployed parent. They are usually focusing on the "emotional cycle of deployment" (phase of preparation of deployment, separation phase of deployment and the return of the deployed parent). The programs mainly focused on parenting skills, family reactions to stress, coping strategies of families, and the feeling of coherence within the family. Only 20 % of the interventions could be assigned to the type of indicated prevention. Nine interventions have shown positive effects (either in RCT or non-experimental designs). Several elements of the programs are transferable to the German situation of children of military members. In particular, contents which address the specific situation of families with a military member are desperately needed in Germany. Transferability is limited by the non-comparability of health care and social welfare systems in the USA and in Germany.

Antidepressant sales and regional variations of suicide mortality in Germany.

Suicides account for over one million deaths per year worldwide with depression among the most important risk factors. Epidemiological research into the relationship between antidepressant utilization and suicide mortality has shown heterogeneous and contradictory results. Different methodological approaches and limitations could at least partially explain varying results. This is the first study assessing the association of suicide mortality and antidepressant sales across Germany using complex statistical approaches in order to control for possible confounding factors including spatial dependency of data. German suicide counts were analyzed on a district level (n = 402) utilizing ecological Poisson regressions within a hierarchical Bayesian framework. Due to significant spatial effects between adjacent districts spatial models were calculated in addition to a baseline non-spatial model. Models were adjusted for several confounders including socioeconomic variables, quality of psychosocial care, and depression prevalence. Separate analyses were performed for Eastern and Western Germany and for different classes of antidepressants (SSRIs and TCAs). Overall antidepressant sales were significantly negatively associated with suicide mortality in the non-spatial baseline model, while after adjusting for spatially structured and unstructured effects the association turned out to be insignificant. In sub-analyses, analogue results were found for SSRIs and TCAs separately. Suicide risk shows a distinct heterogeneous pattern with a pronounced relative risk in Southeast Germany. In conclusion, the results reflect the heterogeneous findings of previous studies on the association between suicide mortality and antidepressant sales and point to the complexity of this hypothesized link. Furthermore, the findings support tailored suicide preventive efforts within high risk areas.

[Structural quality in inpatient and daycare child and adolescent psychiatry- indicators for planning future staff ratios for the era following the Psychiatry Personnel Act]. / Strukturqualität in der stationären und teilstationären Kinder- und Jugendpsychiatrie.

The German Psychiatry Personnel Act, which went into effect in 1990, has led to a decrease in the number of child and adolescent psychiatry inpatient beds, to a decrease in the length of stay, and to an increase in inpatient psychotherapy. Today, this act is outdated~ for a number of reasons, such as changes in the morbidity of the population, the rising number of emergencies, and new professional standards such as documentation. In addition, new legal provisions and conventions (like the UN Convention on the Rights of the Child) necessitate a complete reevaluation. Child and adolescent psychiatry needs a normative act to enable the necessary implementation. Many different rationales are available to support the debate.

[Nonnative guidelines for allocating human resources in child and adolescent psychiatry using average values under convergence conditions instead of price determination - analysis of the data of university hospitals in Germany concerning the costs of calculating day and minute values according to Psych-PV and PEPP-System]. / Normative Vorgaben zum Personaleinsatz in der Kinder- und Jugendpsychiatrie statt Preisfindung anhand von Mittelwerten unter Konvergenzbedingungen.

OBJECTIVE: Despite substantial opposition in the practical field, based on an amendment to the Hospital Financing Act (KHG). the so-called PEPP-System was introduced in child and adolescent psychiatry as a new calculation model. The 2-year moratorium, combined with the rescheduling of the repeal of the psychiatry personnel regulation (Psych-PV) and a convergence phase, provided the German Federal Ministry of Health with additional time to enter a structured dialogue with professional associations. Especially the perspective concerning the regulatory framework is presently unclear. METHOD: In light of this debate, this article provides calculations to illustrate the transformation of the previous personnel regulation into the PEPP-System by means of the data of §21 KHEntgG stemming from the 22 university hospitals of child and adolescent psychiatry and psychotherapy in Germany. In 2013 there was a total of 7,712 cases and 263,694 calculation days. In order to identify a necessary basic reimbursement value th1\t would guarantee a constant quality of patient care, the authors utilize outcomes, cost structures, calculation days, and minute values for individual professional groups according to both systems (Psych-PV and PEPP) based on data from 2013 and the InEK' s analysis of the calculation datasets. CONCLUSIONS: The authors propose a normative agreement on the basic reimbursement value between 270 and 285 EUR. This takes into account the concentration phenomenon and the expansion of services that has occurred since the introduction of the Psych-PV system. Such a normative agreement on structural quality could provide a verifiable framework for the allocation of human resources corresponding to the previous regulations of Psych-PV.

[Evaluation of a training program for child welfare case workers on trauma sequelae in foster children]. / Evaluation eines Projektes zur Sensibilisierung der Jugendhilfe für Traumafolgestörungen bei Pflegekindern.

Foster children are exposed to multiple psychosocial and biological risk factors and have an elevated risk for developmental delays and the development of mental disorders. Many children experienced compromising situations such as neglect, physical abuse, or sexual abuse before out-of-home placement. Consequently, they show a higher need for mental health services than other children. However, out-of-home placement is often considered as the sufficient measure to help these children. Hence this project had the aim to sensitize child welfare agencies and foster parent organisations for the special needs and history of foster children, to provide them with instruments for the assessment of emotional and behaviour problems and to promote the cooperation at the interface between child welfare system and mental health system. Twenty-four child welfare agencies and four foster parent organisations participated. The control group consisted of 16 non-participating child welfare agencies. After one year, participants recorded more often children's social history (p = .023), conducted more often standardized psychosocial assessments (p = .001), assessed more often the medical needs of foster children (p = .029), and informed foster parents more often about behaviour problems of their foster child (p = .034). In summary, child welfare agencies were very interested, could be sensitized for mental disorders following traumata and implemented the offered instruments in their work. Limits of resources could be observed due to the case workers' high case load.