CANMANAGE

Abuse, maltreatment, neglect of children. Resilience, case management

Sub-project 1: "Case Management Intervention Study"

Prof Dr Lutz Goldbeck

University Hospital Ulm

Clinic for Child and Adolescent Psychiatry and Psychotherapy

Sub-project 2: "Resilience study"

Prof Dr Jörg M. Fegert

Ulm University Hospital

Department of Child and Adolescent Psychiatry and Psychotherapy

Sub-project 3: "Migration and culture-related topics"

Prof Dr Rita Rosner

Catholic University of Eichstätt-Ingolstadt

Chair of Clinical and Biological Psychology

Clinic for Child and Adolescent Psychiatry/Psychotherapy Ulm

Vestische Children's and Adolescent Clinic Datteln

Witten/Herdecke University

Psychiatric Clinic Lüneburg gGmbH Clinic for Child and Adolescent Psychiatry and Psychotherapy

01.04.2012 - 30.06.2017

Victims of child maltreatment have a high risk of developing a variety of different clinical disorders (Buckingham & Daniolos, 2013; Gilbert et al., 2009; De Bellis, 2001a). However, research findings also indicate variability in the development of such symptoms. Some of those affected remain healthy (Afifi & Macmillan, 2011; Bonanno, 2005; Herrman et al., 2011). This phenomenon is usually defined as resilience. To date, little is known about how those affected deal with potentially traumatising experiences and what makes them more vulnerable or resilient with regard to the development of a mental illness. Furthermore, it is also evident that children with clinically relevant trauma-associated disorders are often not in treatment, even though effective treatment methods are available (Harvey & Taylor, 2010). Untreated trauma-related disorders lead to a high individual burden and significant costs for society as a whole (Habetha, Bleich, Weidenhammer, & Fegert, 2012). Although it can be assumed that children and adolescents with a migration background experience maltreatment and its consequences, it is not yet known whether specific efforts to address such families in clinical management lead to better success of interventions.

The CANMANAGE research network focussed on the psychiatric-psychotherapeutic care of maltreated, abused and/or neglected children. The acronym CANMANAGE stands for CAN = ChildAbuseand Neglectand MANAGE = Case Management, Help Process Coordination. The aim of the project was to implement and evaluate a needs-orientated, community-based help process coordination for children and young people following abuse, maltreatment or neglect.

Within the framework of the research network, the three sub-projects worked closely together to research methods for optimising the care of abused, mistreated or neglected children at the interface of different support systems (child and youth welfare, justice, healthcare).

Common tasks of the sub-projects were

• Early identification of children and adolescents with clinically relevant trauma-related disorders

• Investigation of specific risk and resilience factors

• Shortening the interval of untreated trauma-related disorders by implementing a structured, community-based help process coordination.

By the end of the project, N=375 study participants had been recruited across the network. The participants were followed up after 6, 12 and 24 months. A total of 241 participants were followed up after 6 months, 213 participants after 12 months and 107 participants after 24 months. This means that 936 examinations were carried out with children, adolescents and their adult carers across the entire network.

Results: Sub-project 1

Only 19.88% of the study participants were receiving psychiatric or psychotherapeutic services at the time of the survey. The majority of study participants in need of treatment for mental disorders were not receiving therapy at the time of the study. Trauma-specific symptoms in particular were rarely treated: Three quarters of the study participants had clinically relevant post-traumatic stress symptoms (UCLA- overall symptom severity score ≥24), but half of them did not receive any maltreatment-related therapy. Children and adolescents in out-of-home care had a significantly lower level of functioning than their comparison group. Both the number and duration of out-of-home placements, their interaction and the perceived family support were significant predictors of a mental disorder. Sexually victimised children and adolescents had a comparatively higher risk of fulfilling the criteria for a current depressive episode. The significant influence of sexual victimisation on self-reported post-traumatic stress symptoms in the questionnaire was no longer evident when the data was controlled for age and gender effects. It was found that a large proportion of sexually victimised children and adolescents remain invisible to child and youth services, the healthcare system and the justice system (35.7% in this case), even if they disclose themselves to adults.

The case management intervention did not succeed in placing significantly more children and adolescents in evidence-based treatment within six or twelve months than under the conditions of usual care. Subjects assigned to the case management intervention were not placed in evidence-based treatment significantly faster than subjects in the control group. Half of the untreated subjects reported being on waiting lists for treatment or receiving treatment that did not fulfil the criteria for evidence-based treatment for mental disorders. This means that less than 40% of all test persons could be placed in suitable therapy programmes within six months, which suggests that there is an undersupply of appropriate help in the municipalities. A survey of the case management intervention users resulted in a positive evaluation. The intervention was rated as helpful and easy to integrate into everyday working life.

Results: Sub-project 2

Of the 375 initial participants, 94 (approx. 25%) were included in the resilience study after the baseline study. In the overall sample (N = 375), 70.7% of the participating children reported experiences of physical abuse. 50.1% reported emotional abuse, 36.3% experienced sexual abuse, 43.5% reported neglect and 33.1% of participants reported experiencing domestic violence. 59.8% of the participants in the resilience group (N=92) reported having experienced physical abuse at the time of the aptitude test. Emotional abuse was reported by 46.7%, sexual abuse by 29.3% of the resilient group, neglect by 52.2% and domestic violence by 32.6% of the participants.

The latent class analysis revealed a 3 class solution, with the majority of participants categorised in class 1: multiple maltreatment types without sexual abuse (63.1%). The second class included 26.5% of participants and was characterised by multiple types of maltreatment and sexual abuse. The smallest class was class 3 (10.3%), which was mainly characterised by sexual abuse. The participants with a maltreatment profile characterised by multiple types of maltreatment and sexual abuse (class 2) showed significantly worse outcomes in terms of psychopathology and level of functioning compared to the other two classes. Thus, simultaneous exposure to multiple types of maltreatment was associated with poorer outcomes, while the probability of resilience, defined as the absence of psychopathology, was highest in the class characterised by mainly sexual abuse, i.e. with fewer other types of maltreatment.

Based on five indicators (level of functioning, health-related quality of life, prosocial behaviour, mean school grade and total problem score), a latent profile analysis (LPA) was calculated using MPlus. Associated factors (age, gender, complexity of maltreatment, perceived social support and maltreatment-related cognitions) were then analysed using mean comparisons and multinomial logistic regression. The LPA revealed 3 different functional profiles: 1. resilience profile (22.9%) 2. moderate function (49.4%) and 3. dysfunctional function (27.7%). The regression analysis showed that more perceived social support, less negative maltreatment-related cognitions, female gender and lower age were associated with the resilience profile. These are important factors in resilience after maltreatment. Overall, the data indicate that a certain stability of resilience can be observed, even over a period of 24 months. As expected, the number of those classified as stable resilient decreases over time. After 24 months, 75% still show stable resilience.

Unfortunately, the number of cases is not sufficient to identify statistically significant results. Thus, only the initial level of functioning was found to be a predictor of the stability of resilience. However, the results presented also indicate that perceived social support and negative abuse-related cognitions play an important role in the stability and maintenance of resilience.

Subproject 1

Ganser, H. G., Plener, P. L., Witt, A., & Goldbeck, L.(accepted for publication in 2017). Treatment needs after child abuse, maltreatment and neglect: Opportunities for early identification and early intervention. Paediatrics and adolescent medicine.

Ganser, H. G., Münzer, A., Plener, P. L., Witt, A., & Goldbeck, L. (2016). Children and adolescents with experiences of maltreatment: do they get the care they need? Federal Health Journal 59(6), 803-810.

Ganser, H. G., Münzer, A., Seitz, D. C. M., Witt, A., & Goldbeck, L. (2015). Improving access to evidence-based therapies for mentally ill children and adolescents after child maltreatment and abuse. Practice of Child Psychology and Child Psychiatry 64(3), 172-184.

Ganser, H. G., Münzer, A., Witt, A., Plener, P. L., Muche, R., Rosner, R., Hagl, M., & Goldbeck, L.(submitted for publication). Effectiveness of Manualized Case Management onUtilization of Evidence-Based Treatments for Children and Adolescents after Maltreatment: A Randomised Controlled Trial.

Münzer, A., Fegert, J. M., & Goldbeck, L. (2016). Psychological symptoms of sexually victimised children and adolescents compared with other maltreatment subtypes. Journal of Child Sexual Abuse, 25(3), 326-346.

Münzer, A., Fegert, J. M., Witt, A., & Goldbeck, L. (2015). Utilisation of professional help by sexually victimised children and adolescents. Neurology, 1- 2, 26-32.

Münzer, A., Fegert, J. M., Ganser, H. G., Loos, S., Witt, A., & Goldbeck, L. (2014). Please Tell! Barriers to Disclosing Sexual Victimisation and Subsequent Social Support Perceived by Children and Adolescents. Journal of Interpersonal Violence 31(2), 355-77.

Münzer, A., Rosner, R., Ganser, H. G., Naumann, A., Plener, P. L., Witt, A., & Goldbeck, L.(submitted for publication). Usual care for maltreatment-related paediatric Posttraumatic Stress Disorder in Germany.

Stinner, S., Rojas, R., Ganser, H. G., Münzer, A., Witt, A., & Goldbeck, L.(submitted for publication) Associations of out of home placement and mental health after child abuse and neglect.

Further publications:

Ganser, H. G., Fegert, J. M., Eberle-Sejari, R., Münzer, A., Rosner, R., Seitz, D. C. M. et al.(2012). CANMANAGE Intervention Manual: "The case manager at work". (3 ed.). retrieved from canmanage.de/wp/?page_id=1278

Subproject 2

Von Klitzing, K., Goldbeck, L., Brunner, R., Herpertz-Dahlmann, B., Konrad, K., Lohaus, A., Heim, C., Heinrichs, N., Schäfer, I., Folgen von Misshandlung im Kindes- und Jugendalter, Trauma & Gewalt, 2015 9, pp. 122-133.

Witt, A., Münzer, A., Ganser, H.G., Fegert, J.M., Goldbeck, L. Plener, P.L. Experience by children and adolescents of more than one type of maltreatment: Association of different classes of maltreatment profiles with clinical outcome variables. Child Abuse and Neglect, 2016, 57, 1-11.

Witt, A., Münzer, A., Ganser, H.G., Fegert, J.M., Goldbeck, L. Plener, P.L. Data on Maltreatment Profiles and Psychopathology in Children and Adolescents. Under Review, Data in Brief.

Witt, A., Goldbeck, L., Keller, F., Fegert, J.M., Plener, P.L., Resilience in Maltreated Children: A Latent Profile Analysis. Submitted to Journal of Traumatic Stress.

Federal Ministry of Education and Research

Funding reference: 01KR1202A/B

Funding period: 01.04.2012 - 30.06.2017