Traumatisierte Mütter – traumatisierte Kinder?

Gewalterfahrungen und psychische Gesundheit im Verlauf bei unbegleiteten minderjährigen Flüchtlingen in Deutschland

Zusammenfassung. Hintergrund: Über die seelische Gesundheit von minderjährigen Flüchtlingen, die ohne sorgeberechtigte Person nach Deutschland gereist sind, liegen bisher kaum Daten und keinerlei längsschnittliche Untersuchungen vor. Fragestellung: Ziel ist es daher, die psychische Gesundheit im Zusammenhang mit stressvollen Erfahrungen (insbesondere familiäre und organisierte Gewalterfahrungen) sowie deren Entwicklung nach etwa zwei Jahren bei unbegleiteten minderjährig Geflüchteten in Deutschland zu untersuchen. Methode: In einer Querschnittsstudie wurden belastende Erlebnisse sowie posttraumatische, depressive und psychosomatische Symptome bei 57 unbegleiteten und 22 begleiteten minderjährig eingereisten Flüchtlingen mittels strukturierter klinischer Interviews untersucht. Nach durchschnittlich 20 Monaten wurde eine Subgruppe der unbegleiteten Minderjährigen erneut untersucht. Ergebnisse: Ein Drittel der Teilnehmer erfüllte die Kriterien einer PTBS-Diagnose nach DSM-IV. Nach Einbezug einer Gruppe begleiteter minderjähriger Flüchtlinge zeigte sich, dass vor allem organisierte und familiäre Gewalterfahrungen sowie die Dauer der Flucht bedeutsame Prädiktoren hinsichtlich der PTBS-Symptomschwere waren. Für das psychische Wohlbefinden insgesamt waren die erfahrene Gewalt in der Herkunftsfamilie, bestehende Freundschaften und das Vorhandensein von Privatsphäre relevant. Ergebnisse einer Folgeuntersuchung mit einer Teilgruppe der UMF etwa 20 Monate später zeigten, dass die psychische Beeinträchtigung im Durchschnitt unverändert hoch geblieben war. Fazit: Die Möglichkeit einer frühzeitigen psychischen Untersuchung mit Erfassung kindlicher Gewalterlebnisse sowie ein verbesserter Zugang zu einer traumafokussierten Behandlung mit Sprachmittlern sind wichtig, um Leid zu reduzieren und Integration zu ermöglichen.

Begleitete minderjährige Geflüchtete

Zusammenfassung. Aufgrund erhöhter psychopathologischer Vulnerabilität bei minderjährigen Geflüchteten (MG), sind wirksame psychotherapeutische Interventionen versorgungsrelevant. Die Mehrzahl MG flieht im Familienverbund. Die Familie wirkt dabei einerseits als stabilisierende Ressource, anderseits als Stressor, so dass der Einbezug der Eltern in die Therapie von Bedeutung ist. Dieses Reviews gibt einen Überblick über den aktuellen Forschungsstand zur Wirksamkeit psychotherapeutischer Maßnahmen mit Familieneinbezug bei begleiteten minderjährigen Geflüchteten (BMG). Insgesamt konnten fünf Studien identifiziert werden. Für die Kinder wurden in vier der fünf, für die Mütter in zwei der fünf Studien signifikante Effekte berichtet. Insgesamt ist die Befundlage gering und die Qualität der Primärstudien oft unzureichend. Replikationen der Ergebnisse unter Berücksichtigung der methodischen Qualität sowie die Implementierung weiterer Maßnahmen sind notwendig.

Course of Mental Health in Refugees-A One Year Panel Survey

Background: Cross-sectional studies indicate that a substantial proportion of refugees have psychiatric disorders. However, longitudinal studies on the course of psychiatric symptoms and on influencing factors are scarce. The current study investigates the development of symptoms in an untreated refugee sample in Germany and seeks to identify potential predictors. Methods: Over the course of 1 year, 57 refugees participated in monthly assisted self-reports on the phone assessing emotional distress. At the same time, semi-annual, semi-structured clinical interviews focusing on posttraumatic stress disorder (PTSD) and depression were conducted. The overall dropout rate for the year was 23% for the assisted self-reports and 33% for the clinical interviews. Results: Symptoms did not systematically change over the course of the year. On the individual level, a reliable change in PTSD symptoms was observed in 13% who showed improvement and 24% who showed worsening symptoms. Figures for depression symptoms were 24 and 16% respectively. A higher number of traumatic experiences was related to a greater intensity of PTSD symptoms. In addition, postmigrational stressors were associated with a worsening of PTSD symptoms over the course of the year. Emotional distress was associated with current negative life events, unemployment, and frequent visits to physicians. Conclusions: There is on average no improvement or worsening of symptoms over the period of 1 year. However, individual courses vary, and thus show the importance of risk factors. Accordingly, the identification of risk factors such as trauma load and postmigrational stressors can be useful to determine the need of further monitoring and to provide appropriate interventions when necessary.

Evaluation eines migrationsspezifischen Angebots im Case Management von Kindern und Jugendlichen mit Therapiebedarf nach Misshandlung, Missbrauch oder Vernachlässigung

Zusammenfassung. Für Kinder und Jugendliche aus Familien mit Migrationshintergrund (MHG) ist der Zugang zu evidenzbasierter Psychotherapie möglicherweise erschwert. Im Rahmen einer randomisierten und kontrollierten Multicenter-Studie zur Evaluation eines Case Management-Ansatzes für Kinder und Jugendliche, die nach Misshandlung, sexuellem Missbrauch oder Vernachlässigung eine psychische Störung entwickelt haben, wurden zur Projektmitte die beteiligten Case Manager zusätzlich hinsichtlich kultur- und migrationsspezifischer Aspekte geschult und in ihrer Arbeit mit Migrantenfamilien durch übersetzte Materialen und die Finanzierung von Dolmetschern unterstützt. Obwohl mit einem Anteil von 30 % Fällen mit MHG in der Interventionsstudie die anvisierte Zielgruppe erreicht wurde, waren die Fallzahlen im Case Management-Arm mit n = 7 vor der migrationsspezifischen Schulung und n = 8 danach zu gering, um einen klinischen Nutzen der Maßnahmen im Sinne einer besseren Versorgung nachzuweisen.

[Dissemination of psychotherapy modules for traumatized refugees : Experience gained from trauma work in crisis and conflict regions]

With each additional accumulative exposure to severe and traumatic stressors, the likelihood of developing mental health problems and physical diseases increases. Displaced individuals have usually experienced a number of serious threats to health due to organized violence in their home country or attacks during the flight. Frequently, domestic violence adds additional strain to the stressors experienced. The resulting impairments in psychosocial functioning reduce the resources needed for social adjustment and integration. Social exclusion then in turn often further aggravates the existing mental health complications. For the treatment of trauma spectrum disorders, different evidence-based psychotherapies are available. In high-income countries, trained and licensed psychotherapists are typically in positions to apply such interventions; however, even an advanced system with a high capacity, such as the psychotherapeutic care offered in Germany, severely struggles to manage the demands associated with the rapid addition of hundreds of thousands of displaced people. Germany's mental healthcare system at present lacks the resources, both human and technological, to effectively manage the present demands. Systematic scientific studies in resource-poor regions of war and conflict have demonstrated that the dissemination of effective treatment to local personnel, even with limited training, results in substantial improvements in the mental health challenges within the community: Organized as a cascade model, members of the refugee community learn to identify weakened fellow citizens requiring in-depth diagnostic interviews. Educated, bilingual individuals acquainted with their country's healthcare system (e. g. nurses, teachers and social workers) receive training to conduct structured interviews and evidence-based interventions under the supervision of centrally organized licensed psychotherapists. More complex cases are referred to local psychotherapists, psychiatrists or specialized treatment centers. These humanitarian efforts are based on the convention for the protection of human rights and secure the safety, freedom and dignity of these persons.

[Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]

BACKGROUND

Owing to a lack of routine statistics on the health status and medical care of asylum seekers, empirical studies play a major role in the mapping of these aspects.

OBJECTIVES

The aim of this review is to provide a comprehensive overview of the research landscape in this area, synthesizing knowledge from empirical studies and identifying evidence gaps.

METHODS

A three-tiered search strategy included searching for empirical studies in national/international databases and on the internet, screening reference lists, and contacting experts. Studies meeting predefined inclusion criteria were thematically organized and described in a narrative synthesis.

RESULTS

The searches generated 1,190 hits; 52 articles met the inclusion criteria. Of these, 41 were quantitative studies (78.9 %), 10 qualitative (19.2 %), and 1 was a review (1.9 %). A total of 30 primary articles (58.9 %) analyzed mental health aspects, followed by infectious diseases (n = 12, 23.5 %). Qualitative studies, mainly ethnographies and case studies, explored mental health and social determinants of health, providing evidence for the impact of living conditions on health and medical care. Few studies analyzed chronic diseases (n = 3) or childhood illnesses (n = 6). No studies analyzed the health needs or medical care of asylum-seeking women during pregnancy and child birth. In 62.7 % of the primary studies, a single sampling point was used to recruit asylum seekers. Nationwide external validity was given in two quantitative studies.

CONCLUSION

The priority research areas identified are chronic diseases and childhood and maternal health. The divergency and heterogeneity of the studies hamper a comprehensive and comparable acquisition of knowledgeand emphasize the  need for collaborative research to close the existing evidence gaps.

[Psychotherapeutic treatment of accompanied and unaccompanied minor refugees and asylum seekers with trauma-related disorders in Germany]

BACKGROUND

Germany is one of the most important host countries for minor refugees and asylum seekers in Europe. The number of children who leave their home country has significantly risen worldwide in recent years; a further rise is to be expected due to the increasing number of crisis zones. A literature review demonstrates the state of research on traumatization, post-traumatic stress disorders and psychotherapy in minor refugees and asylum seekers.

EXPOSURE TO VIOLENCE AND POST-TRAUMATIC STRESS DISORDERS

Many minor refugees and asylum seekers have made mainly interpersonal traumatic experiences within their home country or during their flight and develop simple or complex post-traumatic stress disorders. Left untreated, there is a risk of chronification.

HEALTH CARE SITUATION

The psychotherapeutic treatment of minor refugees and asylum seekers in Germany takes place primarily in specialized psychosocial treatment centers. For an involvement of therapists in private practices, a reduction of organizational barriers as well as evidence-based treatment methods for interpreter-aided psychotherapy of minor refugees and asylum seekers that also consider their developmental state, are still lacking.

CONCLUSION

In research, as well as in practice, there is further need for an early and systematic identification and treatment of minor refugees and asylum seekers with post-traumatic stress disorders or high risk of disease in Germany.

Are experiences of family and of organized violence predictors of aggression and violent behavior? A study with unaccompanied refugee minors

BACKGROUND

There is strong support for familial abuse as a risk factor for later delinquency and violent offending, whereas empirical evidence about the contribution of experienced organized violence to the cycle of violence is less clear. Nevertheless not all abused children do become violent offenders. This raises the question of which factors influence these children's risk of future aggressive behavior. Recent evidence suggests that the trait of appetitive aggression plays an important role in the prediction of aggressive behavior.

OBJECTIVE

The focus of the study is to investigate whether exposures to 1) organized; and 2) family violence equally contribute to aggressive behavior and how this is related to a trait of appetitive aggression. Furthermore it is of interest to uncover how the severity of posttraumatic stress disorder (PTSD) symptoms modulates associations between violent experiences and aggression.

METHOD

To answer these questions, we investigated unaccompanied refugee minors who had been exposed to varying levels of both violence types. Using structured interviews, experiences of organized and familial violence, self-committed aggressive acts, the trait of appetitive aggression, and PTSD symptoms were assessed in 49 volunteers.

RESULTS

A sequential regression analysis revealed that the trait of appetitive aggression and experienced family violence were independent and significant predictors of self-committed aggressive acts, altogether accounting for 70% of the variance. Exposure to organized violence, however, was not significantly associated with aggressive acts or appetitive aggression. PTSD symptom severity was not correlated with measures of aggression but with the exposure to familial and organized violence.

CONCLUSIONS

Results suggest that in addition to the impact of family violence, an elevated trait of appetitive aggression plays a crucial role in aggressive behavior and should be considered in psychotherapeutic treatment.

Obstetric care providers are able to assess psychosocial risks, identify and refer high-risk pregnant women: validation of a short assessment tool - the KINDEX Greek version

Background

Prenatal assessment for psychosocial risk factors and prevention and intervention is scarce and, in most cases, nonexistent in obstetrical care. In this study we aimed to evaluate if the KINDEX, a short instrument developed in Germany, is a useful tool in the hands of non-trained medical staff, in order to identify and refer women in psychosocial risk to the adequate mental health and social services. We also examined the criterion-related concurrent validity of the tool through a validation interview carried out by an expert clinical psychologist. Our final objective was to achieve the cultural adaptation of the KINDEX Greek Version and to offer a valid tool for the psychosocial risk assessment to the obstetric care providers.

Methods

Two obstetricians and five midwives carried out 93 KINDEX interviews (duration 20 minutes) with pregnant women to assess psychosocial risk factors present during pregnancy. Afterwards they referred women who they identified having two or more psychosocial risk factors to the mental health attention unit of the hospital. During the validation procedure an expert clinical psychologist carried out diagnostic interviews with a randomized subsample of 50 pregnant women based on established diagnostic instruments for stress and psychopathology, like the PSS-14, ESI, PDS, HSCL-25.

Results

Significant correlations between the results obtained through the assessment using the KINDEX and the risk areas of stress, psychopathology and trauma load assessed in the validation interview demonstrate the criterion-related concurrent validity of the KINDEX. The referral accuracy of the medical staff is confirmed through comparisons between pregnant women who have and have not been referred to the mental health attention unit.

Conclusions

Prenatal screenings for psychosocial risks like the KINDEX are feasible in public health settings in Greece. In addition, validity was confirmed in high correlations between the KINDEX results and the results of the validation interviews. The KINDEX Greek version can be considered a valid tool, which can be used by non-trained medical staff providing obstetrical care to identify high-risk women and refer them to adequate mental health and social services. These kind of assessments are indispensable for the promotion of a healthy family environment and child development.

Obstetric care providers assessing psychosocial risk factors during pregnancy: validation of a short screening tool - the KINDEX Spanish Version

BACKGROUND

High levels of stress due to diverse psychosocial factors have a direct impact on the mothers' wellbeing during pregnancy and both direct and indirect effects on the fetus. In most cases, psychosocial risk factors present during pregnancy will not disappear after delivery and might influence the parent-child relationship, affecting the healthy development of the offspring in the long term. We introduce a short innovative prenatal assessment to detect psychosocial risk factors through an easy to use instrument for obstetrical medical staff in the daily clinical practice, the KINDEX Spanish Version.

METHODS

In the present study midwives and gynecologists interviewed one hundred nineteen pregnant women in a public health center using the KINDEX Spanish Version. Sixty-seven women were then randomly selected to participate in an extended standardized validation interview conducted by a clinical psychologist using established questionnaires to assesses current stress (ESI, PSS-14), symptoms of psychopathology (HSCL-25, PDS) and traumatic experiences (PDS, CFV). Ethical approval was granted and informed consent was required for participation in this study.

RESULTS

The KINDEX sum score, as assessed by medical staff, correlated significantly with stress, psychopathology and trauma as measured during the clinical expert interview. The KINDEX shows strong concurrent validity. Its use by medical staff in daily clinical practice is feasible for public health contexts. Certain items in the KINDEX are related to the respective scales assessing the same risks (e.g.PSS-4 as the shorter version of the PSS-14 and items from the ESI) used in the validation interview.

CONCLUSIONS

The KINDEX Spanish Version is a valid tool in the hands of medical staff to identify women with multiple psychosocial risk factors in public health settings. The KINDEX Spanish Version could serve as a base-instrument for the referral of at-risk women to appropriate psychosocial intervention. Such early interventions could prove pivotal in preventing undesirable mother-child relationships and adverse child development.