Table of Contents:
Trauma disorders affect many children and adolescents in Germany and are accompanied by severe impairment of the affected individuals as well as their families. Only a small proportion of affected children and adolescents in Germany receive evidence-based psychotherapy. The identification and treatment of trauma disorders is associated with several challenges on the side of psychotherapists concerning their knowledge, perceived competence, as well as attitudes towards evidence-based psychotherapy, including apprehensions about conducting such a therapy. This PhD thesis presents five studies that address starting points for improving the dissemination and implementation of evidence-based psychotherapy for trauma disorders. Together, they allow conclusions on how to improve mental health care for affected children and adolescents in Germany. Based on a systematic literature review, the first publication provides an overview of the current research on sexual development in children and adolescents who have experienced sexual violence. A total of 127 studies with children and adolescents aged two to 21 years published from 1985 to 2019 were included. They examined eight domains of sexuality: sexual risk behaviors (k = 58), teenage pregnancy (k = 30), sexual offenses (k = 26), beliefs and emotional reactions regarding sex (k = 17), sexual behavior problems (k = 16), sexual transmitted diseases (k = 11), prostitution (k = 5), and physical symptoms (k = 3). Overall, the study evidence is inconsistent and further research is needed. Sexual violence can be identified as a risk factor for sexual risk behavior, teenage pregnancy, and sexual offenses. The second publication examines the impact of sexual violence on sexual risk behavior in children and adolescents. The meta-analysis included 19 studies with children and adolescents between the ages of ten and 19 years. The average proportion of female participants was 77.4 %. Those affected by sexual violence were found to be at increased risk for teenage pregnancy (k = 10), greater number of sexual partners (k = 5), and involvement in prostitution (k = 3). No group difference was evident with respect to alcohol and drug use during sexual intercourse (k = 4) or with respect to condom use (k = 4). The assumption that unfavorable effects of sexual violence on some forms of sexual risk behavior are already evident in childhood and adolescence is supported. The third publication addresses the effectiveness of caregiver-involving interventions for children and adolescents with trauma disorders. The meta-analysis aimed to identify moderators of this effectiveness. Potential moderators were age and gender, symptomatology and symptom severity of the children and adolescents, the type of traumatic event, the intensity and setting of caregiver involvement, the caregivers' relationship with the children and their psychopathology. Based on a systematic literature search, 44 articles were included that examined 19 different interventions with 3 845 children and adolescents aged one to 18 years. In the quantitative analysis, k = 33 studies were included. Greater effectiveness of interventions with caregivers compared to control conditions is found for PTSD, depressive and anxiety symptoms in self-report, and internalizing symptoms in parent-report. At twelve-month post-treatment, a significant effect size is found for self-reported PTSD symptoms. A larger number of participants with female gender and fulfilled diagnostic criteria results in larger effect sizes. The fourth publication examines the role of the perceived therapeutic competence regarding trauma disorders for therapists’ confrontational approach, involvement of caregivers in treatments, secondary traumatic stress and interest in further training. Barriers to routine trauma exploration and continuing education were explored. A total of 323 psychotherapists were recruited for the online survey. 61.3 % had a completed license to practice and 46.9 % of these had a trauma-specific qualification. The perceived competence is positively associated with a confrontational approach and the involvement of caregivers and negatively associated with secondary traumatic stress. Organizational aspects are frequently considered as barriers to continuing education. Fears of suggestion and of causing distress are among the most frequently mentioned barriers to routine trauma exploration.
The fifth publication addresses the German translation and psychometric investigation of the EBPAS-36. Model fit of the original scale’s factor structure was reviewed and compared with two second-order factor structures. Associations with sociodemographic and occupational data as well as organizational/health system implementation climate were examined. Data from 599 psychotherapists were analyzed. The psychometric properties of the EBPAS-36D are satisfactory. The reliability of the total scale is α = .89, that of the twelve subscales ranges from α = .65 to α = .89. Model fit of the original scale’s factor structure is acceptable, fits of the second-order factor structures are even better. The EBPAS-36D allows the prediction of the intention to use EBP beyond age, gender, and working in science. More positive attitudes are reported by participants of female gender, younger age, in training and in organizations with more positive implementation climates. No relationship is found regarding the health care system’s climate.