Lutz Goldbeck University of Ulm, Department of Child and Adolescent Psychiatry & Psychotherapy

1. Improving access to evidence-based treatment
for children and adolescents after child abuse
and neglect through structured case-management:
A randomized controlled trial
Lutz Goldbeck
University of Ulm, Department of Child and Adolescent Psychiatry & Psychotherapy
9th
Congress of the British Association for the Study and Prevention
of Child Abuse and Neglect
Edinburgh, April 12-15, 2015

2. Implementation of Managed Mental Healthcare for
Children and Adolescents after Abuse and Neglect
A needs- and community-based
case-management intervention
April 2012 – March 2016

3. Background
• high prevalence of CAN (lifetime rate >10%)
(Pillhofer, Ziegenhain, Nandi, Fegert & Goldbeck, 2011)
• elevated risk of mental disorders, e.g. >60% in children
placed out of home (Buckingham & Daniolos, 2013; Maniglio, 2009;
Norman et al., 2012 Gilbert et al 2009; Schmid et al., 2008)
• lower levels of functioning (Tanaka, Afifi, Wathen, Boyle & Macmillan,
2014) and less quality of life (Corso, Edwards, Fang & Mercy, 2008)
• neurobiological alterations (de Bellis et al. 2001)
• cumulative effects with prolonged/repeated exposure to
CAN (Felitti et al., 1998)

4. Effective treatments are available!
Meta-analyses Primary studies (N) Outcomes ES
Trask et al. 2011
Agress Viol Behav
16:6-19
35 psychosocial
intervention studies,
after child sexual
abuse (CSA)
PTSS
externalizing
internalizing
0.50
-
0.80
Macdonald et al.
2012
Cochrane Database
Syst. Rev.
10 CBT-studies
N=874
CSA
PTSS
anxiety
0.44
0.23
Gillies et al. 2012
Cochrane Database
Syst Rev
14 RCT studies
N=758 PTSD
after various types of
trauma
PTSS
depression
1.34
0.80

5. Barriers of EBT implementation
Children and families do not overview services
Lack of inter-institutional cooperation (child welfare –
mental health)
Lack of coordinated and targeted referrals
Limited knowledge about EBTs
no EBTs available or long wait-lists
Children on risk dropping out of services
…
Child
Family

6. CANMANAGE: Rational
Support families in
overcoming barriers to
treatment
Improve cooperation of child welfare
and child mental health services
Evidence-based
treatments
Victims of CAN with
mental health
disorders
Strengthen networks

7. Manualized intervention: Case-Management protocol
•designed to help families navigate through
the health care system
•cognitive-behavioral approach,
e.g. problem-solving
•improving cultural competence
to support families with a migration
background
•delivered by child welfare case
manager (trained and supervised)

8. CANMANAGE: RCT inclusion criteria
• age: 4 to 17 years
• substantiated history of child abuse and neglect
(including domestic violence)
• living in a safe environment
• need for treatment (mental disorder according to
ICD-10 Chapter V: F00-F99)

9. Hypotheses
Primary:
• significantly more referrals to EBTs after 6
months compared to usual care (UC)
Secondary:
• significantly faster referrals
• reduced dropout rates
• reduced behavioral and emotional symptoms

10. CANMANAGE: Study design
RANDOM
Exclusion:
no
substained
CAN
Exclusion:
No informed
consent/
assent
Screening
for CAN
CASE
MANAGEMENT
n=60
USUAL
CARE
n=60
Baseline
assess-
ment
6 month
follow-up
Assessment
12 month
follow-up
assessment
24 month
follow-up
Assessment
R
E
C
R
U
I
T
M
E
N
T
Dx
mental
disorder
n=120
Exclusion:
No mental
disorder
• prospective randomized controlled trial
• four time points of assessment
Primary
out-
come

11. Instruments
Semi-structured clinical interview
=> child and caregiver:
– Juvenile Victimization Questionnaire
Interview Version
– K-SADS-PL
Self-report (>8 years) and caregiver-report
questionnaires

12. Randomised N=99
T1 Baseline / Assessed for eligibility
N=303
Excluded n=204
no ICD-10 F-diagnosis (n=88)
no case-management available (n=21)
receiving treatment at baseline (n=77)
other reasons (n=18)
Intervention n=48
did not receive intervention (n=3)
moved (n=2)
other reasons (n=1) total n= 48
usual care n=51
total n=51
Allocation
6 months FU n=31
lost to follow up (n=6)
moved (n=4)
other reasons (n=2)
pending (n=11) total n=48
6 months FU n=31
lost to follow up (n=9)
attempt to contact failed (n=6)
other reasons (n=3)
pending (n=11) total n=51
12 months FU n=21
lost to follow up (n=15)
attempt to contact failed (n=7)
declined (n=5)
other reasons (n=3)
pending (n=15) total n=51
12 months FU n=22
lost to follow up (n=12)
moved (n=5)
declined (n=4)
other reasons (n=3)
pending (n=14) total n=48
T2
T3
24 months FU n=9
lost to follow up (n=9)
moved (n=5)
declined (n=3)
other reasons (n=1)
pending (n=30) total n=48
24 months FU n=8
lost to follow up (n=14)
attempt to contact failed (n=7)
declined (n=5)
other reasons (n=2)
pending (n=29) total n=51
T4
CANMANAGE: Study Flow Chart

13. Study sample
• mean age 10.56 years (SD=3.30)
• male 66%
• migration background 16%
• household income € per month:

14. Study sample: place of residence
N=84

15. Screening population: Out of home
placement
36 %
66 %)
N=84

16. Study sample: types of maltreatment
85% multiple maltreatment types!
61%
73%
48%
58%
33%

17. Study sample:
Present mental health state
64.7%
35.3%
51.1%
48.9%

18. ICD-10
37 %
30 %
26 %
24 %
13 %
8 %
5 %
2.4%
8 %
Comorbid disorders 36.9%
Study sample:
type of mental disorders

19. Baseline information from case workers
Survey of N=181 training participants:
• limited knowledge about mental health after CAN
• rarely standardized mental health assessments in
child welfare
• only 20% evaluate cooperation between child
welfare and the mental health services as positive
• over half of participants rarely or never refer CAN
victims to treatments
• …and among those who do, half do not know what
kind of treatments the therapists deliver

20. Feasibility of intervention
Feedback from case managers (18 months post training):
• can be integrated into the daily work routine
• perceived as supportive
• evaluated as appropriate for the work with professionals‘
clients
• good acceptance of external evaluation of their work
• good adherence to the manual:
on average, >70% of manualized intervention steps applied
Ganser, H. G., Münzer A., Seitz, D. C. M., Witt, A., & Goldbeck, L. (2015).
Prax. Kinderpsychol. Kinderpsychiat., 64(3), 172-187.

21. CANMANAGE case example
• 13 yo. girl and non-abusive mother
• history of sexual and physical abuse by stepfather
• Dx PTSD + major depression
• written feedback and recommendation
• randomized to intervention
• 2 consultations with case manager (child welfare agency)
• barriers: avoidance, no idea how therapy could work,
concerns regarding social consequences of therapy
• problem solving intervention & psycho-education
• at 6 months FU: on Tf-CBT

22. Summary and discussion
• need to implement EBTs
• collaboration between child welfare and mental
health services crucial
• intervention feasible and accepted among case workers
• trauma-focused treatment options useful and
effective beyond PTSD? E.g. in ADHD, CD,…

23. Acknowledgements
• CANMANAGE research team:
G. Berry, H.Ganser, Rima Eberle-Sejari, Jörg M. Fegert, S. Loos,
A. Münzer, P. Plener, R. Rosner, S. Sorger, A. Witt
+ numerous research assistants / independent assessors
• CANMANAGE clinical sites:
R. Dieffenbach, D. Krstovic, A. Naumann, A. Tewes
• Case workers and collaborating agencies
• German Federal Ministry for Education and Research (Funding)
• all participating children, adolescents, and families

24. „ It is not that I'm so smart.
But I stay with the questions much longer.”
Albert Einstein
* 1879 Ulm
Thank you for your attention!