[Rapid assistance for victims of acute violence-Current treatment in outpatient trauma clinics in Germany]. / Schnelle Hilfen für Betroffene von akuter Gewalt ­ aktuelle Versorgung in Traumaambulanzen in Deutschland.

BACKGROUND: Assistance following acute violence was previously regulated by the Victim Compensation Act (OEG). At the beginning of the current year it was replaced by the Social Code XIV (SGB XIV). The SGB XIV defines new groups of beneficiaries, outpatient trauma clinics must be provided nationwide and binding criteria for the quality of care were established. The aim of this study was to map the current status of care in outpatient trauma clinics in accordance with the requirements of the new SGB XIV. With respect to new beneficiaries, the status of services for victims of human trafficking was recorded as an example. METHODS: Outpatient clinics that provide rapid assistance under the OEG or SGB XIV were surveyed on structural and content-related aspects of their work. An online survey consisting of 10 thematic modules was used. Data were obtained from a total of N = 110 outpatient clinics (response rate 50%). RESULTS: The participating outpatient clinics reported a wide range in terms of the number of staff and the number of people seeking counselling. Some of the outpatient clinics reported deficits with respect to structural aspects, such as the waiting time for the initial consultation and specific training in trauma treatment for staff. The majority of outpatient clinics were uncertain about how to deal with victims of human trafficking. DISCUSSION: Outpatient trauma clinics appear to reach their target population and provide appropriate services for their care; however, a significant number of outpatient clinics need to make improvements in order to fulfil the quality criteria of SGB XIV and provide adequate care to new groups of beneficiaries.

Organized sexualized and ritual violence: Results from two representative German samples.

BACKGROUND: Organized sexualized and ritual abuse (ORA), a contentious issue since the 1980s, remains a polarizing topic. Although there is much debate about the existence of this phenomenon, a differentiated perspective is lacking, and no representative study has yet addressed the frequency. OBJECTIVE: This paper aims to investigate the frequency of ORA in Germany using two representative datasets. PARTICIPANTS AND SETTING: Data were collected from representative samples of the German population (N = 2522, N = 2515). Participants aged 16 to 96 years (50 and 53 % female) were recruited. They were selected by a random route procedure and asked to fill out a paper-pencil-questionnaire. METHODS: The four aspects of ORA (severe sexual violence, perpetrator networks, commercial exploitation, ideology) were assessed based on the definition provided by an expert group. Additionally, in the second survey, a direct yes/no question about the experience of ORA as well as details on perpetrators and offense characteristics were surveyed. RESULTS: Frequency of ORA was low. The direct question on ORA was affirmed by 0.5 % (n = 13), while according to the criteria of the definition, only 0.2 % or less of individuals experienced organized sexualized abuse, and <0.1 % experienced ritual abuse. CONCLUSION: Although ORA is discussed thoroughly, frequencies in the German population are low. This may be due to inconsistent terminology and operationalization of definitions with lack of precision. However, an intersection of conspiracy beliefs and the topic of ritual violence sheds another light on this issue that should receive more attention.

A web-based psychological support program for caregivers of children with rare chronic diseases: a randomized controlled trial.

BACKGROUND: Approximately 50% of rare diseases have symptom onset during childhood. A high level of nursing care and an often uncertain prognosis put caregivers of the affected children at high risk for psychological distress. At the same time, their caregivers have limited access to appropriate psychological care. The aim of this study was to evaluate a web-based psychological support program for caregivers of children with chronic rare diseases (WEP-CARE). METHODS: German-speaking parents (recruited between May 2016 and March 2018) caring for children aged 0-25 years with a rare disease showing clinically relevant anxiety symptoms, were assigned to either the WEP-CARE (n = 38) or treatment as usual (n = 36) condition within a randomized controlled trial. The primary outcome measure was parental anxiety, assessed with the Generalized Anxiety Disorder Questionnaire (GAD-7). Secondary outcomes were fear of disease progression, depression, coping, quality of life and user satisfaction. The group differences were tested through repeated-measures analyses of variance. The WEP-CARE group was additionally followed up three months after the treatment. RESULTS: A significant time-group interaction was found for anxiety (F (1,35) = 6.13, p = .016), fear of disease progression (F (1,331) = 18.23, p < .001), depression (F (1,74) = 10.79, p = .002) and coping (F (1,233) = 7.02, p = .010), suggesting superiority of the WEP-CARE group. Sustainability of the treatment gains regarding anxiety, fear of disease progression and coping was confirmed at the 6-month follow-up assessment (p < .01). A significant interaction effect could not be found for quality of life (F(1,2) = 0.016; p = .899). Both participating parents and therapists were satisfied with WEP-CARE. CONCLUSIONS: Our results underline the efficacy and feasibility of WEP-CARE for parents of children with various rare diseases.

Long-term mental health consequences of female- versus male-perpetrated child sexual abuse.

BACKGROUND: Research on child sexual abuse increasingly focuses on sexually offending females; however, there is a lack of research that focuses on the individuals being affected. Studies have suggested that the consequences for those affected by sexually offending males and females are comparable. OBJECTIVE: The aim is to compare mental health consequences of sexual abuse perpetrated by women versus men in quantity and type. PARTICIPANTS AND SETTING: Data was anonymously retrieved from the German-wide contact point "help line sexual abuse" from 2016 to 2021. Details of abuse cases, gender of the offending individuals, and reported mental disorders of the person affected were analyzed. The sample consisted of N = 3351 callers with experiences of child sexual abuse. METHOD: The relationship between gender of the perpetrating person and mental disorders of the victimized person was computed using logistic regression models. To account for rare events data, Firth's logistics regression model was used. RESULTS: The consequences were similar in quantity, albeit different in type. Callers with experiences of female-perpetrated abuse were more likely to report suicidality, non-suicidal self-injury behavior, personality disorders, dissociative identity disorders, alcohol/ drug addiction, and schizophrenia, while people with experiences of male-perpetrated abuse rather reported post-traumatic stress disorder, affective disorders, anxiety disorders, dissociative disorders, eating disorders, externalized disorders, and psychosomatic disorders. CONCLUSIONS: The differences may be due to stigmatization leading to dysfunctional coping mechanisms. Societal gender stereotypes must be reduced, especially within the professional helping system to ensure support for people who have experienced sexual abuse, regardless of gender.

[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.

The immediate impact of lockdown measures on mental health and couples' relationships during the COVID-19 pandemic - results of a representative population survey in Germany.

BACKGROUND: Lockdown measures during the COVID-19 pandemic are expected to have negative effects on mental health and relationship quality. However, little is known about the magnitude of these psychological effects on a population level and for vulnerable subgroups. METHODS: A representative sample (N = 2503; 50.2% female; mean age = 49.5) of the German population was assessed face-to-face during the COVID-19 pandemic (February 10-April 25, 2020). They were examined for differences in mental health (BSI-18) and relationship quality (PFB) in a pre-lockdown and lockdown subsamples. After testing and establishing the measurement models in confirmatory factor analyses, we added covariates as predictors of the factors to the regression model to investigate the impact of the lockdown measures. RESULTS: Overall, participants included after the introduction of lockdown measures reported significantly fewer mental health problems than participants included before the lockdown. Predictor analyses revealed that this effect was larger for participants of younger age and those with higher household income. There was no significant difference in relationship quality between pre-lockdown and lockdown. However, relationship quality improved for younger participants after the lockdown measures started, but deteriorated for older participants. CONCLUSIONS: The German population was found to be largely resilient to the immediate effects of lockdown on mental health and relationship quality. Older participants and those with lower socio-economic status might constitute risk groups during times of lockdown. Further studies in countries affected by more drastic lockdown measures and the long-term consequences of the pandemic are needed to inform decision makers about the psychological effects of lockdown.

Mothers as perpetrators and bystanders of child sexual abuse.

BACKGROUND: In research and literature, little attention has been paid to the role of women, especially mothers, in child sexual abuse. OBJECTIVE: In order to estimate prevalences on mothers as perpetrators and bystanders, data was collected in a German nationwide representative survey. PARTICIPANTS AND SETTING: A total of 2,531 participants (53.3 % female, 14-94 years) were selected by a random route procedure and questioned with a paper-pencil-questionnaire. METHODS: The survey included the Childhood Trauma Questionnaire as well as questions on the perpetrator-victim relationship, bystanders and the awareness within society on the topic of female-perpetrated child sexual abuse. Prevalences were calculated. RESULTS: The prevalence of child sexual abuse (6.6 %) as well as the proportion of female perpetrators (6.6 %) determined in the current survey were low compared to the findings of previous studies. Within the group of female perpetrators, biological mothers accounted for a larger share than biological fathers in the group of male perpetrators. Among the bystanders, the biological mother was named most frequently (24.6 %). CONCLUSION: The general population underestimates the involvement of biological mothers in child sexual abuse. The results confirm that female perpetrators account for a rather small but substantial proportion of the perpetrators of child sexual abuse. Furthermore, the results indicate that mothers play a role in sexual abuse - either as perpetrators or as bystanders - that has been underestimated so far. It is therefore necessary to sensitize professionals and the public to the topic of female perpetrators and especially to the role of mothers in child sexual abuse.

[Protection Against Violence and Abuse in Medical Institutions - Reasons, Prevalence and Implications for Practice]. / Schutz vor Gewalt und Übergriffen in medizinischen Institutionen ­ Ursachen, Häufigkeiten und Implikationen für die Praxis.

Protection Against Violence and Abuse in Medical Institutions - Reasons, Prevalence and Implications for Practice Reported cases of (sexual) abuse in institutions as well as the results of surveys show that violence against children and adolescents, but also against adults, occurs also in medical institutions. There are still few studies on the frequency of these cases. However, the cases that have come to public attention show that medical institutions bear systemic risk factors for such assaults. On the other hand, medical institutions also play an important role in child protection, since many children and adolescents affected by maltreatment including sexual abuse come into contact with the medical system. It is necessary that medical institutions deal with this problem and develop respective institutional protection concepts. A protection concept is a system of measures that ensure better protection against assaults within an organisation. Important steps are analysis of risk factors, structural changes, the creation of plan of procedures and the development of an institutional attitude that assaults are not tolerated. Although the development of protection concepts takes time and resources, it has many advantages for institutions, such as an increased sense of security for professionals, because they know how to proceed in such situation. Now that the obligation to draw up protection concepts is anchored in the quality management guideline of the Federal Joint Committee (G-BA), all hospitals and practices must set out to develop appropriate concepts.

The Predictors of Awareness of Sexual Abuse and Sexual Violence in the Media and the Influence on Actions of the Individuals.

Introduction: The number of reportings on sexual abuse (SA), sexual violence (SV) cases covered in the media has risen a significant amount with most cases involving women and children. The aim of the study is to explore the questions: Are people aware of sexual abuse and sexual violence in the media? What are the predictors of awareness of sexual abuse and sexual violence? Does the awareness of sexual abuse and sexual violence in the media affect the actions of the individuals? Methods: A representative survey of the German-speaking resident population (2020) on physical and mental well-being was used. The participants (N = 2,503: females = 50.9%) were between the ages of 14 and 97 (M = 49.81). The German version of the Adverse Childhood Experiences Questionnaire, The General Habitual Well-Being Questionnaire and questions about own experiences of sexual harassment on the internet, experiences of domestic sexual abuse and different socio-economic variables were used. The outcome variables regarding the awareness of SA and SV in the media, different types of scandals (church, pedophile, USA), #MeToo-debate and the change in actions were used. Frequency analyses and binary regressions were conducted. Results: One thousand five hundred and fifty-five (62.6%) respondents answered yes to being aware of SA and SV in the media. The results show that females, aging, number of children in household, Protestant and Catholic religion, school graduation, own experience(s) of sexual harassment on the internet, own experience(s) of SA in childhood, and Adverse Childhood Experiences have a significant higher association to the awareness of SA and SV in the media. German nationality and Muslim religion have a significant lower association. The variables that most commonly affected the awareness of SA and SV, scandals, debate and the individual actions were age, own experiences of sexual harassment on the internet and the Protestant religion. Conclusion: Advertising more support centers, hotlines and linking this information to sexual abuse cases covered in the media should be considered. Media bystander interventions could be helpful to train people to react appropriately. Further investigation that considers the different types of media and its influence on the awareness of SA and SV is needed.

Evaluation of two family-based intervention programs for children affected by rare disease and their families - research network (CARE-FAM-NET): study protocol for a rater-blinded, randomized, controlled, multicenter trial in a 2x2 factorial design.

BACKGROUND: Families of children with rare diseases (i.e., not more than 5 out of 10,000 people are affected) are often highly burdened with fears, insecurities and concerns regarding the affected child and its siblings. Although families caring for children with rare diseases are known to be at risk for mental disorders, the evaluation of special programs under high methodological standards has not been conducted so far. Moreover, the implementation of interventions for this group into regular care has not yet been accomplished in Germany. The efficacy and cost-effectiveness of a family-based intervention will be assessed. METHODS/DESIGN: The study is a 2x2 factorial randomized controlled multicenter trial conducted at 17 study centers throughout Germany. Participants are families with children and adolescents affected by a rare disease aged 0 to 21 years. Families in the face-to-face intervention CARE-FAM, online intervention WEP-CARE or the combination of both will be treated over a period of roughly 6 months. Topics discussed in the interventions include coping, family relations, and social support. Families in the control condition will receive treatment as usual. The primary efficacy outcome is parental mental health, measured by the Structured Clinical Interview for DSM-IV (SCID-I) by blinded external raters. Further outcomes will be assessed from the parents' as well as the children's perspective. Participants are investigated at baseline, 6, 12 and 18 months after randomization. In addition to the assessment of various psychosocial outcomes, a comprehensive health-economic evaluation will be performed. DISCUSSION: This paper describes the implementation and evaluation of two family-based intervention programs for Children Affected by Rare Disease and their Family's Network (CARE-FAM-NET) in German standard care. A methodologically challenging study design is used to reflect the complexity of the actual medical care situation. This trial could be an important contribution to the improvement of care for this highly burdened group. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00015859 (registered 18 December 2018) and ClinicalTrials.gov : NCT04339465 (registered 8 April 2020). Protocol Version: 15 August 2020 (Version 6.1). Trial status: Recruitment started on 1 January 2019 and will be completed on 31 March 2021.

Possibilities of dissemination of specialist knowledge and acting capacity in the field of child protection in medicine: a qualitative survey.

Objective: The shortage of skilled workers and overloaded schedules make further training of health professionals difficult. In addition, child protection is not a systematic part of medical studies. The evaluation of an online course on child protection in medicine reveals positive feedback but also that the main reason for participants aborting the course is lack of time. Dissemination, as an active, targeted spreading of knowledge, can help to further spread knowledge about child protection in the target group. The aim of this article is to investigate whether and how the contents of the online course can be disseminated by professionals who have completed the online course. Methodology: The data were collected through a quantitative online evaluation and qualitative telephone interviews with doctors who had completed the online course and evaluated it using an interpretive-reductive analysis. Results: The respondents consider the need for further training and dissemination measures on the topic of child protection in medicine to be high. However, lack of time and insufficient relevance of the topic would present obstacles in the implementation of such measures. Meaningfulness and time off work or remuneration would in turn create incentives for implementation. Participants in dissemination measures could be motivated for example by further education points. In addition we were able to identify possible approaches for the implementation of such measures. Conclusion: Various parameters influence the motivation of doctors regarding the implementation/perception of dissemination measures. Based on these, recommendations for action are given for different areas of the health care system, such as supplementing the training curricula and providing ready-made materials for dissemination.

Female-Perpetrated Child Sexual Abuse: Prevalence Rates in Germany.

Research on female-perpetrated child sexual abuse, especially maternal sexual abuse, is scarce. Prevalences are assumed to be lower compared to male-perpetrated abuse; however, representative studies including female perpetrators are rare. Experiences of male- and female-perpetrated child sexual abuse were examined in a representative German sample. Questions included experiences of hands-on and penetrative sexual abuse. The perpetrator-victim relationship was assessed to calculate prevalences of maternal sexual abuse. A total of 2516 participants (54.53% female, 14-91 years) were questioned and prevalences, as well as group differences between victims of male perpetrators compared to female perpetrators, were calculated. Overall, 10.5% of all participants reported experiences of child sexual abuse. Female perpetrators were involved in 9.9% of the cases, i.e. 1.0% of all participants. Victims of female perpetrators were significantly more often male. A quarter of the adult female perpetrators were the mother figure of the child. The findings suggest that the share of female perpetrators in cases of child sexual abuse is rather small; concurrently, female perpetration is insufficiently recognized. Especially male victims seem to be at risk for sexual abuse by female perpetrators. Contacts for children especially within the professional support system need to be aware of the existence of female perpetrators.

The Prevalence of Sexual Abuse in Institutions: Results From a Representative Population-Based Sample in Germany.

The lifetime prevalence of sexual abuse in institutional settings in Germany was examined in a sample representative of the general adult population (N = 2,437). Participants completed a survey on whether they had ever experienced such abuse, its nature (contact, noncontact, forced sexual, intercourse), the type of institution (e.g. school, club), and the relationship of perpetrator to victim (peer, caregiver, staff member). Overall, 3.1% of adult respondents (women: 4.8%, men: 0.8%) reported having experienced some type of sexual abuse in institutions. Adult women reported higher rates of all types than did men, with rates of 3.9% versus 0.8% for contact sexual abuse, 1.2% versus 0.3% for noncontact sexual abuse, and 1.7% versus 0.2% for forced sexual intercourse. We conclude that a remarkable proportion of the general population experiences sexual abuse in institutions, underscoring the need for development of protective strategies. Especially, schools seem to represent good starting points for primary prevention strategies.

[Trauma-focused Cognitive-behavioral Therapy with children and adolescents: Practice, evidence base, and future directions]. / Traumafokussierte kognitive Verhaltenstherapie mit Kindern und Jugendlichen ­ Klinisches Vorgehen, Evidenzbasis und weitere Perspektiven.

Trauma-focused cognitive behavioral therapy (Tf-CBT) is an evidence-based trauma therapy for children and adolescents aged 3­17 years with posttraumatic stress disorder (PTSD). One supportive caregiver is regularly included in the therapeutic process. Tf-CBT consists of eight components and can be summarized by the acronym P.R.A.C.T.I.C.E: Psychoeducation and Parenting skills, Relaxation skills, Affective modulation skills, Cognitive coping skills, Trauma narrative and cognitive processing of the traumatic event(s), In vivo mastery of trauma reminders, Conjoint child-parent sessions, and Enhancing safety and future developmental trajectory. Based on a total of 13 randomized controlled trials, several meta-analyses and systematic reviews confirm the efficacy of Tf-CBT, which received evidence level Ia in several international guidelines and is therefore recommended as first-line treatment for children and adolescents with PTSD.

The Prevalence of Sexual Violence.

BACKGROUND: Sexual violence can cause severe mental and bodily harm. This is the first study of a population-based sample in Germany to assess both the frequency of the subjects' having experienced sexual violence and the frequency of their having manifested sexually aggressive behavior themselves. METHODS: 2513 persons (of whom 2422 were over age 18 and 91 were aged 14 to 18) were asked about their experiences with sexual violence in the past 12 months, either as the person committing sexual violence or as the victim of sexual violence at the hands of other adults or similarly aged adolescents. RESULTS: 0.6% (n = 6) of the men and 1.2% (n = 16) of the women surveyed, and ca. 5% (n = 4) of the adolescents surveyed, reported having been the victim of some kind of sexual violence. 1.5% (n = 15) of the men and 1.0% (n = 13) of the women reported that they themselves had manifested sexually aggressive behavior. Women were overrepresented and adolescents underrepresented in the sample, in comparison with the overall population. CONCLUSION: These findings suggest that the prevalences of experiences of sexual violence and of sexually aggressive behavior are markedly underestimated in official crime statistics, particularly with respect to events in which women commit sexual violence and men are victims of it. Prevalences were assessed in this study from selfreported information; the findings may thus have been distorted by a tendency on the part of the informants to give answers they thought would be socially acceptable, particularly with respect to their own sexually aggressive behavior. Moreover, the small overall number of events complicates the interpretation of the findings.

[Validated Instruments for the Psychological Assessment of Unaccompanied Refugee Minors - a Systematic Review]. / Validierte Verfahren zur psychologischen Diagnostik unbegleiteter minderjähriger Flüchtlinge - eine systematische Übersicht.

The German care system faces a growing number of unaccompanied refugee minors (URM). URM show high levels of traumatization, a variety of psychological symptoms and lack important resilience factors. Therefore an early and valid psychological assessment is important for intervention and service planning. Yet, no systematic review on validated instruments for the assessment of this group exists. Literature search revealed one study about translators in the assessment of URM and five validated instruments for proxy and self-report. These instruments are available in several languages and showed good psychometric properties. It has to be critically stated that all instruments have been validated by a single work group within a single population. Especially with regards to changing definitions of Posttraumatic Stress Disorder within the new (and upcoming) classification systems ICD-11 and DSM-5, increased awareness for diagnostic procedures is necessary. Additionally, more validated instruments for specific psychological disorders in multiple languages are needed. Under an economic perspective the use of open access questionnaires that are available in different languages seems useful, even if they are not especially validated for URM.

Trauma-focused cognitive behavioral therapy with unaccompanied refugee minors: a case series.

BACKGROUND: Unaccompanied refugee minors (URMs) are a group who are vulnerable to developing posttraumatic stress symptoms (PTSS). However, they rarely receive the treatment that is indicated and there are no treatment studies focusing exclusively on this group of adolescents. This case study evaluates the feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) for URMs with PTSS. METHOD: A health care utilization sample of N = 6 was assessed prior to and after treatment with TF-CBT. Therapists were asked to report differences in treatment application and content in comparison to TF-CBT standard protocol. RESULTS: We found moderate to high levels of PTSS at baseline and a clinically significant decrease in symptoms at posttest. Some modifications to the TF-CBT protocol were made with regard to affective modulation which required more sessions than usual whereas fewer caregiver sessions were conducted. CONCLUSION: TF-CBT is feasible in reducing PTSS in severely traumatized URMs. Further research with controlled trials is necessary. TRIAL REGISTRATION: The trial registration: ClinicalTrials.gov Identifier NCT01516827. Registered 13 December 2011.