I accept cookies. Objective: Child welfare agencies in Germany offer children and adolescents in acute familial crisis a short-term placement outside of their families in order to provide immediate safety and protection where needed. However, the aim to provide secure and stress-free surroundings for clearing cannot always be attained. Children and adolescents in these outof- home placements unfortunately present often already with emotional and behavioural symptoms, which, when overlooked due to complexity of the social aspects of the case, are in danger of not being supported adequately.
Material and methods: Case reports of the youth welfare organization were clustered into risk factors present and afterwards analysed. Results: Children and adolescents who are admitted acutely to youth welfare placements present with a high level of stress resulting from an accumulation of individual and familial risk factors. We view this as quite a rigorous test, given the fact that the common design of many international studies of this kind utilises wait-list controls and thus compares "intervention" with "no intervention" [ 35 ]. Although the programme is designed for 8 to 12 year-olds, execeptions were made after screening for children whose developmental status fits in with this age group, allowing for the occasional 7 to 13 year-old.
For each project centre, our research institute randomly assigned participating children either to the intervention condition or to the control condition. At the time this manuscript is drafted, the field phase is ongoing, with baseline data collection already completed.
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The theoretical underpinnings of the programme were derived from existing literature. He or she will then actively react to the situation and, from this feeling of control, as also described in Rotter [ 43 ], will eventually develop inner strength and resilience. In their transactional stress concept, Lazarus and Folkman [ 44 ] also view the individual cognitive processing of stressful situations as critical for the kind of reaction it will evoke.
Hence, interpretation and appraisal are targeted at different times during the intervention. The stress-coping-support model by Velleman and Templeton [ 17 ] adds to this by postulating that stress and distress resulting from substance abuse or dependency of a family member can be positively influenced via constructive coping strategies e. The concept of self-efficacy in Bandura's social-cognitive learning theory [ 45 ] and, again, the development of a sense of agency is important to our intervention considering the feelings of being helpless and overwhelmed with which the children in our target group struggle.
Antonovsky [ 46 ] posits that a sense of coherence is a central influencing factor on health and well-being. A sense of coherence is aquired when certain stimuli or events are experienced as understandable, manageable and meaningful. As children from substance-affected families rarely discuss events in their families with outsiders, coming to see their experience as comparable with the experiences of others in similar situations can in itself contribute substantially to their sense of coherence. Saarni's [ 47 ] concept of emotional competence highlights the need for helping the target group with emotion regulation, especially in difficult situations, but also with knowledge about emotions that might come up in oneself or in the other.
Tuckman's stages of group development [ 48 , 49 ] guide the structuring of sessions within the programme. In addition, we pursued the following goals for the parent modules: 1 to sensitize parents for children's needs and for the effects parental substance use has on children 2 to improve caregivers' self-confidence with regard to parenting skills 3 to motivate parents to seek and accept further help and support in raising their children. In this way, the programme aims at empowering participating children while at the same time providing support and a safe place to be.
In the first step, we reviewed the international literature to identify key features of successful programmes [ 35 ]. From this review, we concluded the following requirements for the programme: 1 The programme needs to address the specific challenges children from substance-affected families face, such as questions on drugs and addiction, on coping with psychological distress resulting from parental substance abuse and on handling difficult situations arising from it.
In the second step, we invited experts in the field such as counsellors and social workers to provide us with material from their previous work with children from substance-affected families. This was adapted after extensively reviewing it at a networking conference visited by practitioners interested in participating in the project and researchers in the field of substance use prevention and treatment.
This process further enhanced the foundation of the programme with regard to content and feasibility. In the third step, we conducted and closely monitored a pilot trial of the programme in one of the participating centres, after which further amendments were made. The resulting detailed manual includes nine weekly minute modules for the children as well as two optional parent sessions. The themes are delivered in an interactive and age-based way, with a large percentage of exercise and role-play.
With regard to structure, special attention is paid to a recurring structure of the sessions and to small rituals, both of which children often lack in a substance-affected home [ 50 ]. Each session follows the same structure, beginning with an exchange on how they feel today, followed by discussing the "homework" from the last session, then introducing the new topic of the day and working on this with a variety of the didactics already mentioned.
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In between learning activities, there also are pure "fun-and-play" activities such as songs or creative exercises. Each session is finished off by a relaxation exercise. The two parent sessions can be attended independently, taking into account that in volatile families like those at hand programme providers cannot assume that parents will come to both, or even one, of the sessions.
The content of the first session, conducted at the beginning of the programme, is to inform parents about the programme their children will be attending and about risk and protective factors children face when growing up in a substance-affected environment. Also, parents share hopes they have for living together with their children and are encouraged regarding parenting skills and their importance for their children. The content of the second session, conducted at the end of the programme, is to inform parents about how the programme went from the trainer perspective, to answer questions about issues that may have come up at home in the course of the programme and to sensitize parents for the needs of children in substance-affected families and how caregivers may be empowered in the future.
Also parents are motivated to seek and accept further support in their parenting role. The manual provides for parent questions, group discussion and practical exercises in both sessions. For the control condition, we developed a similarly standardised manual for a play group named "Bouncy Castle". We described the group as equally attractive to parents and children to minimize recruitment problems resulting from the randomisation. Besides, having children not only on wait-lists but in a regular intervention gives practitioners a means of possible crisis intervention, an option that many participating centres asked for out of ethical considerations.
Trainers are requested to refrain from initiating the discussion of addiction-related topics in the group and to deal with them as briefly as ethically possible if they should come up. Parents in the control condition do not receive a structured intervention, although participating facilities are encouraged to inform them about the programme as well. Eligible institutions for delivering the interventions, i. We also gathered data on their relevant activities in the area by sending out a questionnaire on their work with children from substance-affected families [ 41 ].
All participating centres signed cooperation contracts before delivering the programme and received financial incentives for their participation. As a number of facilities agreed to cooperate, but could not recruit enough participants to conduct the intervention, several efforts had to be made during the entire field phase to engage and train new cooperation partners. In the end, 27 cooperating out-patient counselling centres participated in the project. Centres were almost uniformly distributed across the country with at least one participating centre in nearly every federal state.
Most of the centres were addiction aid facilities and only some were youth and family support services or other groups. Participating facilities recruit participants using their existing recruitment strategies as well as recruitment material provided by the research team flyers, webpage, posters, newspaper advertisements. They conduct intake talks with children and parents, inform them about the content and goal of the programme and screen participating children for eligibility.
Inclusion criteria for children are: 1 age at beginning of the programme between 8 and 12 years, in exceptions after careful screening between 7 and 13 years if developmental phase fits 2 current or recent within the last year substance misuse or dependency in at least one parent 3 children either live with the substance-affected parent or have regular contact with him or her 4 sufficient mastery of the German language both in children and parents to participate in assessments 5 informed written consent of the parents and the children.
Children are excluded from the study if 1 they are diagnosed with or suspected of foetal alcohol spectrum disorder by recruiting staff due to extreme behavioral difficulties or if 2 they have received any kind of addiction-specific treatment relevant to the study goals up to six months prior to the intervention. Quality of relationship between parent and child.
Own development: questions on a thermometer-scale in regard to closeness vs. Knowledge on alcohol, drugs, and substance use problems. Questionnaire for perception of stress and stress management in childhood and adolescence. Mental distress caused by parental substance use. Psychometric scale for general expectation of self-efficacy - adapted version for children. Adaptation of a scale used for measuring self-efficacy in the family [ 59 , 60 ]. Symptom checklist SCLplus [ 63 ].
Parental use of further substance-related aid. Parental sensitivity for the effects of substance use problems on children and children's need. Brief questionnaire for perception of child-raising behaviour parent version. Quality of relationship between parents and child.
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Course instructors in the participating centres complete an extensive documentation on relevant variables adherence, interaction with the group, possible disturbances after each child and parent session. Also, the instructors are required to conduct visual recordings of two out of the nine child sessions chosen by the research team. Children and parents evaluate each session they participate in directly after the session is over. In addition, course instructors and institute managers complete questionnaires on relevant characteristics such as structural data on their institute or professional background.
These data will be used to analyse the quality of manual adherence and to identify possible influencing factors such as instructor qualification or group atmosphere. The sample size for our study is based on a power analysis for detecting small effect sizes. In general, existing literature shows that medium effect sizes can occur, but these studies utilise wait-list controls so that effects may be stronger than in the study at hand.
In addition, in secondary analyses we will examine the data following the intention-to-treat principle to identify possible effects of attrition. A dropout analysis will be conducted. Missing data will be imputed.
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For computations, the SPSS standards software will be used. Whenever possible, standardised instruments are used. All instruments were tested during the pilot of the intervention and experience from these interviews conducted by the researchers was passed on to the student interviewers in a one-day training session.
Interviewers received a detailed guide for data collection and are closely monitored throughout the data collection. Cooperating centres received detailed study guidelines, informal information via telephone, recruitment material and the manuals themselves. The intervention in both conditions is delivered by expert staff in the cooperating institutions, mainly social workers, pedagoges, and psychologists often with additional therapeutic or counselling qualifications.
A prerequisite for becoming a trainer is experience in working with substance-affected families and experience in conducting group formats. Trainers received an intensive one-day training with regard to delivering the intervention and are advised to keep close contact with the research group. At least two trainers are trained per cooperating centre to ensure a stand-in solution in case of illness or absence. Researchers conduct regular supervisory phone calls to ensure ongoing communication about the intervention and its delivery.
The satisfaction of trainers and participants is assessed at the end of each session and will be analysed as part of the process evaluation. Participating centres, all participants and their parents received detailed information on the study goals, procedures, analyses and data reporting prior to participation. Parents and children need to give written consent to be able to participate in the study. Participating families are encouraged to call the research group if they have questions or problems arise.
All procedures are approved by the ethics committee of the Chamber of Physicians in all federal states of Germany where participating centres are located. There is a substantial need for evidence-based programmes targeting children from substance-affected families. By working together with many different institutions, we also hope to gather knowledge on the implementation of such a programme, especially concerning recruitment challenges and the integration of such a programme into the standard processes of outpatient counselling centres.
The study and its intervention have several strengths: First, the intervention is carefully planned and tailored to the needs of children from substance-affected families, taking into account both theoretical foundations and experience of practitioners in the field. Second, the intervention is designed to be delivered by non-therapists and is easy to deliver due to the manual and to its modular structure.
Thus, we view it as a pragmatic, low-threshold programme that can be disseminated widely into different contexts. Third, there is a strict separation between programme deliverers and programme evaluators so that bias is reduced. A further reduction of bias is achieved by gathering not only child self-report data, but also the caregivers' view on children's development.
Fourth, in conducting a 6-month follow-up, we are able to detect sleeper effects and test the stability of effects uncovered in the post-measurement. Fifth: we conduct a rigorous evaluation by comparing the effects of the programme with an intervention of similar dosage, but without addiction-specific content. The limitations of the study must also be mentioned: Due to the volatile nature of the families we target, it may be difficult to motivate them to participate in follow-up assessments.
Also, many substance-affected parents will not let their children participate in the programme, thus creating a selection effect in the sample from the start. Moreover, we view the age range of the participating children as substantial and it must be seen if the programme will be beneficial for all age groups.
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For example, some exercises require writing and reading skills, and trainers have reported that especially younger children still need quite a lot of help in this area. Furthermore, it would be desirable to compare the effects of the programme with a naturalistic sample of children from substance-affected families not receiving any intervention.
It was attempted to recruit this sample, but it quickly became clear that this recruitment challenge would exceed our resources. We also expect that attrition during the interventions will be substantial, because families view a weekly participation of their children in such a programme as a high demand on their daily routine. We try to handle this problem by encouraging our cooperating centres to contact the families if a child does not show up for a session and to support the families in any way they can regarding transportation and logistics. The reasons for dropouts are to be documented and will be analysed within the process evaluation.
We hope to find out whether dropouts are due more to reasons such as time constraints in the family or rather to dissatisfaction with aspects of the programme or both. This analysis can possibly provide insights into the acceptance of the programme.