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Zusammenfassung. Belastende Kindheitserlebnisse (adverse childhood experiences; ACE) wie Misshandlung, aber auch das Erleben von Gewalt in der Paarbeziehung der Eltern (häusliche Gewalt) in der Kindheit, können das Leben auf vielfältige Weise beeinträchtigen. Obwohl bekannt ist, dass ACEs häufig gemeinsam auftreten, gibt es kaum Untersuchungen zu der Bedeutung von Kindesmisshandlung bei häuslicher Gewalt und deren Langzeitfolgen. Daher haben wir das Auftreten von Kindesmisshandlung in Abhängigkeit zu dem Erleben von häuslicher Gewalt in einer repräsentativen Stichprobe der deutschen Bevölkerung ( N = 2531) untersucht. Die Ergebnisse zeigen ein deutlich erhöhtes Risiko für alle Formen von Kindesmisshandlung, wenn häusliche Gewalt gegen die Mutter berichtet wurde (Odds Ratios je nach Form der Kindesmisshandlung 4.4 bis 10.3). Für weibliche Teilnehmende stieg das Risiko für sexuellen Missbrauch, körperliche Misshandlung und körperliche Vernachlässigung stärker an als bei männlichen. Der Zusammenhang von häuslicher Gewalt gegen die Mutter mit einer niedrigeren Lebenszufriedenheit im Erwachsenenalter wurde partiell durch Kindesmisshandlung vermittelt, das erhöhte Risiko für eine schlechtere Gesundheit im Erwachsenenalter sogar vollständig. Kindesmisshandlung vermittelt somit einen großen Ateil des Zusammenhanges von schlechterer Gesundheit und geringerer Zufriedenheit bei Erwachsenen, die in der Kindheit häusliche Gewalt erlebt haben. Vor diesem Hintergrund sind ein größeres Bewusstsein für die erhöhten Risiken von Kindern, die in Haushalten mit häuslicher Gewalt aufwachsen, und Unterstützungsangebote, in denen der Kinderschutz eine zentrale Rolle spielt, zu empfehlen.

In the development of narcissism, besides genetic factors, hostile educational conditions, including adverse childhood experiences (ACEs), are discussed as causal factors. ACE may play a causal role in the development of antagonistic behavior due to negative interpersonal experiences. However, studies assessing the role of ACEs in the etiology of narcissism are still inconsistent, particularly regarding grandiose narcissism. This may be due to the complexity of grandiose narcissism, which can be distinguished into agentic (admiration) and antagonistic (rivalry) facets. Understanding the role of early traumatic events in the etiology of grandiose narcissism may be important for psychotherapeutic treatment in both, patients with trauma history and narcissistic patients.We aimed to specify the role of ACEs in grandiose narcissism by differentiating between admiration and rivalry.In a cross-sectional survey conducted from November 2017 to February 2018, a representative sample of the German population above the age of 14 (N = 2531) was selected in a random route approach.Increased numbers of ACEs were associated with higher mean scores for rivalry in females (B = 0.04, p = 0.02) and males (B = 0.08, p 0.01), while no significant associations were seen for admiration. Focusing on individual ACEs, in males, all maltreatment experiences were associated with narcissistic rivalry, with the exception of physical neglect, while in women only emotional maltreatment and emotional neglect were significant. Associations with household dysfunction were shown only in men. There were no significant associations between individual ACEs and admiration.Our results suggest emotional coldness and negative relationship experiences play a role in the development of, in particular, antagonistic and unfavorable narcissistic traits, such as admiration. Therapy with individuals who have experienced ACEs should take into account possible narcissistic personality traits related to ACEs to facilitate successful treatment. Thus, our findings may help building a therapeutic alliance though a better understanding of the development of current behavioral problems for both patient and psychotherapist.

Key Practitioner Messages Increased stress and decreased resources during a lockdown and social distancing can augment the risk for child abuse and neglect during the COVID‐19 pandemic. Health practitioners should continue to be prepared for potentially rising numbers of cases of child abuse and neglect. Child protection services and mental health care should be considered essential and be available for adults and children at all times., publishedVersion

BackgroundLockdown measures during the COVID-19 pandemic are expected to have negative effects on mental health and relationship quality. However, little is known about the magnitude of these psychological effects on a population level and for vulnerable subgroups.MethodsA representative sample (N = 2503; 50.2% female; mean age = 49.5) of the German population was assessed face-to-face during the COVID-19 pandemic (February 10-April 25, 2020). They were examined for differences in mental health (BSI-18) and relationship quality (PFB) in a pre-lockdown and lockdown subsamples. After testing and establishing the measurement models in confirmatory factor analyses, we added covariates as predictors of the factors to the regression model to investigate the impact of the lockdown measures.ResultsOverall, participants included after the introduction of lockdown measures reported significantly fewer mental health problems than participants included before the lockdown. Predictor analyses revealed that this effect was larger for participants of younger age and those with higher household income. There was no significant difference in relationship quality between pre-lockdown and lockdown. However, relationship quality improved for younger participants after the lockdown measures started, but deteriorated for older participants.ConclusionsThe German population was found to be largely resilient to the immediate effects of lockdown on mental health and relationship quality. Older participants and those with lower socio-economic status might constitute risk groups during times of lockdown. Further studies in countries affected by more drastic lockdown measures and the long-term consequences of the pandemic are needed to inform decision makers about the psychological effects of lockdown.

Zusammenfassung. Theoretischer Hintergrund: Im letzten Jahr erreichten mehrere Verdachtsfälle von Professional Sexual Misconduct (PSM) die Medizinische Kinderschutzhotline. Insbesondere meldeten sich Heilberufler_innen, die Hinweise auf einen sexuellen Missbrauch von Kindern/Jugendlichen durch Kolleg_innen hatten und nicht wussten, wie sie vorgehen sollen. Fragestellung: Zusammenstellung der aktuellen Daten zu PSM und sexuellem Missbrauch von Minderjährigen im Gesundheitswesen. Methode: Ausgehend von diesen Anfragen wurde eine selektiven Literaturrecherche zu Definition, Epidemiologie und rechtlichen Rahmenbedingungen von PSM sowie mögliche Hinweise für PSM durch Kolleg_innen durchgeführt. Ergebnisse: PSM durch Angehörige der Gesundheitsberufe stellt ein relevantes Problem dar. Bei Verdacht auf PSM sollten Kolleg_innen nicht mit dem Verdacht konfrontiert werden, sondern die Führungsebene informiert werden. Die Einbeziehung der Strafverfolgungsbehörden sollte sorgfältig abgewogen werden. Eine Berücksichtigung der Bedürfnisse und des Willens der betroffenen Patient_innen ist hierbei zentral. Diskussion und Schlussfolgerung: PSM in der Medizin ist ein hochkomplexes und bisher wenig erforschtes Thema., publishedVersion

BackgroundThe current situation caused by the SARS-CoV-2-pandemic is associated with serious losses for everyone and has worldwide effects on social life, politics, the economy and the media worldwide. Preventive isolation and social distancing strategies faced the families with a large number of different challenges. The current epidemic and quarantine restrictions have a verifiable influence on the emotional and social development of children and adolescents. In the current situation, children of parents who have already been mentally stressed seem particularly at risk.ObjectiveWe aimed to assess the role of maternal daily perceived stress on children’s mental health during SARS-CoV-2-pandemic.MethodA “SARS-CoV-2-pandemic survey" was developed assessing to record the child's mental health since the beginning of the SARS-CoV-2 pandemic. To describe the maternal perceived everyday stress data from a longitudinal survey was used. For estimation we use Tobit models.ResultsOur results show a positive and significant relationship between the maternal perceived everyday stress and both the emotional stress and hyperactivity of the child. In summary, we find the maternal perceived everyday stress to increase child's mental distress.ConclusionsAnalyses illustrate effects on child's mental distress during pandemic everyday life. Future research needs to identify influencing factors both with regard to political, economic and social restrictions in order to prevent mental health of children.

Growing up in a family with one member being affected by mental health problems or substance abuse is an adverse childhood experience which can lead to socioeconomic and health-related impairments in later life. Furthermore, the risk of child maltreatment is increased in affected families, which often adds to the individual risk factors. However, the interdependence between the particular risk factors is not well understood. To examine the correlation between mental health problems or substance abuse and child maltreatment within families and long term consequences for affected children, a cross sectional population representative survey in Germany (N = 2,531) has been conducted. The risk of child maltreatment was 5 to 5.6 times higher if mental illness and 4.9 to 6.9 times higher if substance abuse of a family member was reported. Furthermore, the risk of health problems, including obesity, decreased life satisfaction, lower income, low educational achievement, unemployment and living without a partner was increased if participants grew up in a family affected by mental health problems or substance abuse. All associations were mediated significantly by child maltreatment. These results point towards an urgent need for greater awareness for child protection issues in families affected by mental health problems or substance abuse.

Adverse childhood experiences (ACEs) tend to co-occur. The more forms of childhood adverse are experienced, the higher are the psychological and physical impairments in adulthood. The present study therefore examines the extent to which the experience of parental separation is related to the risk of other forms of ACEs and the extent to which the accumulation of ACEs is related to impairment in adulthood.A cross-sectional analysis of a representative sample of the German population from the age of 18 onwards was performed (N=2466; mean age=49.5 years (18-93); f: 1368 (55.5%); m: 1098 (44.5%)). The demographic data were assessed by interview, the remaining data were collected by questionnaires. Current depressive and anxiety symptoms self-perceived somatic health and life quality were assessed, while ACEs were assessed retrospectively by the Adverse Childhood Experiences (ACE)-Questionnaire.Child maltreatment and mental illness of household members, substance abuse of household members, incarceration of household members and violence against the mother were more frequent when participants reported separation of parents. Parental separation was not associated with an increased rate of psychological impairment and, in women, physical impairment when no other forms of ACEs were present.Children and adolescents whose parents have separated more often experience other forms of ACEs than their peers. It seems to be this accumulation of ACEs that is associated with impairments in adulthood.Belastende Kindheitserlebnisse treten oft gehäuft auf. Je mehr Formen von Kindheitsbelastungen erlebt werden, desto höher sind die psychischen und physischen Beeinträchtigungen im Erwachsenenalter. Die vorliegende Studie untersucht daher, inwieweit das Erleben der elterlichen Trennung mit dem Risiko für andere Formen von Kindheitsbelastungen zusammenhängt und inwieweit die Kumulation von Belastungen in der Kindheit mit Beeinträchtigungen im Erwachsenenalter zusammenhängt.Es erfolgte eine querschnittliche Analyse einer repräsentativen Stichprobe der deutschen Bevölkerung ab dem 18. Lebensjahr (N=2466; mittleres Alter=49,5 Jahre (18–93); f: 1368 (55,5%); m: 1098 (44,5%)). Die Erfassung der demografischen Daten erfolgte durch ein Interview, die restlichen Daten wurden mittels Fragebögen erhoben. Die Einschätzung der depressiven und ängstlichen Symptome und der selbsteingeschätzten somatischen Gesundheit bezog sich auf den Untersuchungszeitpunkt, belastende Kindheitserfahrungen wurden retrospektiv mit dem Adverse Childhood Experiences (ACE)-Fragebogen erfasst.Kindesmisshandlung sowie psychische Erkrankung von Haushaltsmitgliedern, Substanzmittelabusus von Haushaltsmitgliedern und Gefängnisaufenthalt von Haushaltmitgliedern sowie Gewalt gegen die Mutter waren häufiger, wenn die Teilnehmenden von der Trennung der Eltern berichteten. Die Trennung der Eltern war nicht mit einer erhöhten Rate psychischer Beeinträchtigungen und bei Frauen auch für körperliche Beeinträchtigungen assoziiert, wenn keine anderen Formen von Kindheitsbelastungen vorlagen.Kinder und Jugendliche, deren Eltern sich getrennt haben, erleben häufiger auch weitere Formen von Kindheitsbelastungen als Altersgenossen. Gerade diese Kumulation von belastenden Kindheitserlebnissen scheint es zu sein, die mit Beeinträchtigungen im Erwachsenenalter zusammenhängen.

Background The coronavirus disease 2019 (COVID-19) is profoundly affecting life around the globe. Isolation, contact restrictions and economic shutdown impose a complete change to the psychosocial environment in affected countries. These measures have the potential to threaten the mental health of children and adolescents significantly. Even though the current crisis can bring with it opportunities for personal growth and family cohesion, disadvantages may outweigh these benefits. Anxiety, lack of peer contact and reduced opportunities for stress regulation are main concerns. Another main threat is an increased risk for parental mental illness, domestic violence and child maltreatment. Especially for children and adolescents with special needs or disadvantages, such as disabilities, trauma experiences, already existing mental health problems, migrant background and low socioeconomic status, this may be a particularly challenging time. To maintain regular and emergency child and adolescent psychiatric treatment during the pandemic is a major challenge but is necessary for limiting long-term consequences for the mental health of children and adolescents. Urgent research questions comprise understanding the mental health effects of social distancing and economic pressure, identifying risk and resilience factors, and preventing long-term consequences, including—but not restricted to—child maltreatment. The efficacy of telepsychiatry is another highly relevant issue is to evaluate the efficacy of telehealth and perfect its applications to child and adolescent psychiatry. Conclusion There are numerous mental health threats associated with the current pandemic and subsequent restrictions. Child and adolescent psychiatrists must ensure continuity of care during all phases of the pandemic. COVID-19-associated mental health risks will disproportionately hit children and adolescents who are already disadvantaged and marginalized. Research is needed to assess the implications of policies enacted to contain the pandemic on mental health of children and adolescents, and to estimate the risk/benefit ratio of measures such as home schooling, in order to be better prepared for future developments.

Many programs aim to prevent abusive head trauma throughout the USA, Europe, and in many other regions of the world. Most of these programs inform mothers shortly after delivery about the dangers of abusive head trauma. Effectiveness of these programs usually is measured by the increase of knowledge on abusive head trauma. Recent research showed, however that for effective primary prevention, a much broader approach might be necessary. But so far, there is no data that reports the knowledge on key messages on abusive head trauma in the general public as a baseline. We conducted a representative population-based survey on abusive head trauma knowledge in Germany. Whereas the dangers are generally well known, a majority might be ambivalent towards the recommendation to leave a crying infant alone for a few minutes when the caregiver becomes too stressed or frustrated. Furthermore, a majority prefers being informed on abusive head trauma before birth.Conclusion: Future preventive programs should focus on educating adolescents (potential baby sitters) and young adults when they do not yet have children of their own. What is known: • Most programs for primary prevention of abusive head trauma (AHT) focus on mothers shortly after delivery • There are no analyses so far of the quality of education programs in the general public, as educating mothers might not be sufficient to reduce incidence rates What is new: • Our study is the first population-based survey to measure the knowledge on AHT in a representative population sample and to provide the data base for targeted prevention programs. • The introduction of broader prevention programs might be necessary.

Background Minocycline is a lipophilic tetracycline of increasing appeal in neuroscience as it inhibits microglial activation, a mechanism involved in numerous neuropsychiatric disorders. Own data point towards retinoid-mediated effects of minocycline in murine brain and skin, and towards a vicious cycle of neuroinflammation which is driven by microglial activation-induced breakdown of local retinoids such as retinoic acid (RA). We therefore sought to study minocycline’s anti-inflammatory effects on human microglial-like monocyte-derived cells in the context of retinoid signaling. Results As hypothesized, minocycline exposure resulted in a substantial increase of RA levels in the human monocytic cell line THP-1. While pro-inflammatory stimulation with lipopolysaccharides resulted in increased tryptophane-degrading indoleamine-2,3-dioxygenase IDO-expression and TNF-α levels in primary human monocyte-derived microglial-like cells, this effect was attenuated by minocycline only in the presence of retinoids. The anti-inflammatory effects of minocycline on TNF-α expression were completely abolished by a pharmacological blockage of retinoic acid receptors (RARs) using BMS-493 and unaffected by selectively blocking retinoid-X-receptors using UVI-3003. Conclusions Our data indicate for the first time a RA-dependent, anti-inflammatory effect for minocycline in human microglial-like cells via inhibition of local RA turnover. The RA-dependent mode of action for minocycline appears to be predominantly mediated through RAR-signaling.

The atypical antipsychotic clozapine is one of the most potent drugs of its class, yet its precise mechanisms of action remain insufficiently understood. Recent evidence points toward the involvement of endogenous retinoic acid (RA) signaling in the pathophysiology of schizophrenia. Here we investigated whether clozapine may modulate RA-signaling. Effects of clozapine on the catabolism of all-trans RA (at-RA), the biologically most active metabolite of Vitamin A, were assessed in murine and human brain tissue and peripheral blood-derived mononuclear cells (PBMC). In patients with schizophrenia with and without clozapine treatment and matched healthy controls, at-RA serum levels and blood mRNA expression of retinoid-related genes in PBMCs were quantified. Clozapine and its metabolites potently inhibited RA catabolism at clinically relevant concentrations. In PBMC-derived microsomes, we found a large interindividual variability of the sensitivity toward the effects of clozapine. Furthermore, at-RA and retinol serum levels were significantly lower in patients with schizophrenia compared with matched healthy controls. Patients treated with clozapine exhibited significantly higher at-RA serum levels compared with patients treated with other antipsychotics, while retinol levels did not differ between treatment groups. Similarly, in patients without clozapine treatment, mRNA expression of RA-inducible targets CYP26A and STRA6, as well as at-RA/retinol ratio, were significantly reduced. In contrast, clozapine-treated patients did not differ from healthy controls in this regard. Our findings provide the first evidence for altered peripheral retinoid homeostasis in schizophrenia and suggest modulation of RA catabolism as a novel mechanism of action of clozapine, which may be useful in future antipsychotic drug development.

Apolipoprotein E (ApoE) represents a pivotal target in Alzheimer's disease (AD) and is modulated through retinoic acid (RA), an endogenous neuroprotective and anti-inflammatory compound. A major source of ApoE are microglia, which are pathologically activated in AD. Activated microglia are known to block RA signaling. This suggests a vicious cycle between inflammation, RA signaling, and ApoE homeostasis in AD pathogenesis. To test this hypothesis, we investigated effects of RA and proinflammatory activation on ApoE synthesis in primary human macrophage-derived microglial-like cells. Our results indicate that proinflammatory activation attenuates ApoE synthesis, an effect blocked by RA.

Mit hauslicher Gewalt, korperlicher Misshandlung oder Vernachlassigung von Kindern sind im Rettungsdienst tatige Fachkrafte regelmasig konfrontiert. Dies lost haufig Stress und Handlungsunsicherheit aus. Die Versorgungsforschung zeigt, dass die betroffenen Patienten dringend auf entschiedenes und uberlegtes Handeln aller Akteure im Gesundheitswesen, und damit auch des Rettungswesens, angewiesen sind. Die akuten und chronischen Folgen verpasster Intervention sind verheerend, im Extremfall konnen sie todlich sein. Es soll auf vorhandene Defizite und Schwachstellen in der notfallmedizinischen Versorgung betroffener Kinder hingewiesen werden. Die Leser sollen nach der Lekture in der Lage sein, eine orientierende Gefahrdungsabschatzung von Kindern vornehmen zu konnen, sowie wirksame Interventionen und verfugbare Beratungsangebote kennen. Darstellung relevanter Literatur, eigener Erfahrungen und Vorstellung eines bundesweiten Beratungsprojektes. Frakturen und Hamatome haben altersabhangig eine teils hohe Spezifitat fur Misshandlung. Sie sind, wenn sie ohne plausible Anamnese bei einem Kind auftreten, als sog. gewichtige Anhaltspunkte nach dem Bundeskinderschutzgesetz zu werten und erlauben unter den vorgestellten Bedingungen einen Bruch der Schweigepflicht gegenuber dem Jugendamt. Zusatzlich steht seit dem 01.07.2017 zu jedem der oben genannten Schritte ein telefonisches Beratungsangebot durch Arzte zur Verfugung: die Medizinische Kinderschutz-Hotline, die unter der Nummer 0800 19 210 00 rund um die Uhr kostenlos verfugbar ist. Sie richtet sich an Angehorige der Gesundheitsberufe und somit explizit auch an Fachkrafte im Rettungsdienst und berat zu allen Fragen des Kinderschutzes. Weiterbildung und Beratung aller medizinischen Fachkrafte, die mit Kindern zu tun haben, sind der richtige Weg, um die Behandlung von Misshandlung betroffener Kinder zu verbessern.

Authoritarianism becomes respectable in Germany: A risk factor for condoning physical violence toward children?

Background Authoritarianism, firstly described by Horkheimer in 1936, is characterized by submission to authorities, aggression against subordinates and conventionalism. Authoritarianism is discussed as major contributor for right-wing attitudes. Horkheimer hypothesized that authoritarianism has its origin in the experience of harsh parenting and exposure to corporal punishment (CP) by authoritarian parents. The other way around, literature points towards an association between conventionalism and support of CP as disciplinary method, suggesting a role of authoritarianism in the vicious cycle of transgenerational transmission of CP. Objective We aimed to assess the association of authoritarianism, right-wing attitudes and affirmation of CP, focusing particularly the role of authoritarianism and right-wing attitudes in the transgenerational transmission of CP. Participants and Setting: In a cross-sectional survey, a representative sample of the German population above the age of 14 (N = 2524) was selected in a random route approach. Results Authoritarian aggression, authoritarian submission and conventionalism (OR 1.40) such as right-wing self-assessment (OR 1.39) are associated with an increased support of different forms of CP. Moderation analyses reveal an increasing affirmation of CP by those with a history of CP holding authoritarian attitudes and right-wing positions. Conclusions Our results suggest a significant role for sociopolitical attitudes in the affirmation of CP and its transgenerational transmission. Sociopolitical ideology may be an important factor to identify risk groups, but furthermore represents a promising target for preventive interventions that aim to stop the cycle of violence in families, and, subsequently, the dire consequences of CP.

Too often, diagnosis of maltreatment is missed by healthcare professionals - thus denying children in danger from necessary protection. Insufficient knowledge and insecurities towards professional confidentiality and how to approach child protection services may be the reasons for the failure to protect children effectively.In this article, we present how a comprehensive concept by the competence center of child protection in medicine of the state of Baden-Wurttemberg consisting of peer counseling, peer education, and research can add to the prevention of maltreatment. One component is peer counseling through a telephone helpline that is accessible 24/7, the medical child protection hotline. The requests to the helpline are analyzed and add to the generation of tailored content for the education of doctors, psychotherapists, nurses, and other healthcare professionals. As an example, we present the online course "Child protection in medicine - a basic course for all health professionals" (so far available only in German). One common issue when the child protection hotline is called for counseling is abusive head trauma. Research shows that sometimes a diagnosis of abusive head trauma might be missed. This condition is most prevalent in children under the age of 2 and represents one of the most severe forms of physical abuse with high mortality.Inquiries to the medical child protection hotline are constantly increasing, but making the service known nationwide to all healthcare professionals still poses a challenge. The online course is widely used and being constantly improved. The comprehensive concept of peer counseling, education, and research is an important contribution to the improvement of the prevention of child maltreatment.

Background Child maltreatment by caregivers seem to make a significant contribution to general maltreatment rates. Interestingly, research assessing prevalence rates of maltreatment mainly focuses on individual components either in relation to different types of maltreatment or in relation to different types of institutions. Objective The current study assesses prevalence rates for child maltreatment by caregivers in hospitals, rehabilitation centers, facilities for the disabled, schools, Kindergartens, and after-school care or residential care. Participants and setting: In a cross-sectional survey, a representative sample of the German population above the age of 14 (N = 2,516) was selected in a random route approach. Participants were questioned retrospectively for the experience of physical, emotional and sexual abuse and neglect by caregivers in institutions. Results The results demonstrate a relatively high rate of child maltreatment in German institutions. In detail, during inpatient stays in medical institutions, 19.0% of the participants reported to have experienced at least one type of maltreatment by nursing staff. Furthermore, 30.3% reported to have experienced at least one type of maltreatment by teachers during school life and 11.6% reported maltreatment by caregivers in care facilities. A significant number of participants reported multiple forms of maltreatment in all assessed institutions. Younger age of the respondents was associated with lower prevalence rates, which could be attributed to higher awareness for maltreatment in institutions nowadays. Conclusions Our results demonstrate that child maltreatment by caregivers in institutions is a prevalent problem. A higher awareness for caregivers as potential perpetrators of maltreatment in institutions, including schools, medical institutions and care facilities, is needed in order to improve this alarming situation.

BACKGROUND Despite efforts to reduce the incidence of abusive head trauma (AHT), incidence rates remain high. One cause is that prevention programs mostly aim to educate mothers of newborns on AHT and infant crying. However, mothers commonly have already a high knowledge and constitute only a minority among identified AHT perpetrators. The hypothesis was that there are great differences in AHT awareness in different subgroups. To assess awareness of AHT, a population-based study was performed. METHODS A population-based representative sample of the German population aged >14 years (N = 2510) was assessed in a cross-sectional observational survey. The sample was selected in a random route approach between November 2017 and February 2018. RESULTS Overall knowledge of AHT was higher in women (67.9%) than in men (48.8%, p

Background It is well known that physical abuse of children all too often escapes detection. Fractures are among the potential consequences of physical abuse but are also com- mon in childhood because of accidents. A question frequently addressed to the Medical Child Protection Hotline (Medizini- sche Kinderschutzhotline) is how fractures due to abuse can be distinguished from accidental fractures. Methods This review is based on pertinent publications retrieved by a search in PubMed and in the Cochrane Data- base, as well as on the authors' experience in a pediatric emergency department with ca. 29 000 consultations per year and in a child protection outpatient clinic with ca. 100 consultations per year. Results Fractures due to abuse are especially common among infants; their incidence is estimated at 56.8/100 000 among infants less than six months old and 39.8/100 000 among infants aged 6 to 11 months. In consideration of the age of the child, the type of fracture, the history, and other factors, a high probability of abuse can be suspected in many cases, so that further measures can be initiated. Conclusion All physicians involved in the care of children (even if only occasionally) should be aware of the major indicators of likely physical abuse and of the available oppor- tunities for counseling and intervention. Failures to diagnose child abuse are associated with high rates of recurrence and mortality.

Background A substantial amount of youths living in youth residential care demonstrate clinical levels of aggression during the course of their placements, which poses a major risk to care continuity. Yet developmental trajectories of aggressive behavior can vary. Objective We investigated if changes in quality of life (QoL), psychopathological symptoms and perceived self-efficacy predict aggressive behavior trajectories in youths with clinical aggression levels living in closed youth residential care in Germany. Method Youths (n = 63; 76.2% female; ages 11–17, M = 14.4, SD = 1.30) answered well-established questionnaires at two data collection points (T1 and T2) over an average of 6.5 months. Professional caregivers rated youths’ aggressiveness in the ‘aggressive behavior’ subscale of the Child Behavior Checklist (CBCL). Two trajectories were retrospectively identified for youths demonstrating aggressive behavior at or above the borderline clinical range – ‘stable-high’ trajectories with persevering aggressive behavior ratings (CBCL T ≥ 67 at T2) and ‘improved’ trajectories with improved aggressive behavior ratings (CBCL T Results Youths were more likely to belong to the ‘improved’ than ‘stable-high’ aggressive behavior trajectory if they reported greater QoL improvements in regards to relationship with peers (B = 0.89, SE = 0.45, p = 0.014) and managing school requirements (B = 0.69, SE = 0.69, p = 0.010), greater reductions in substance use (B = −0.26, SE = 0.16, p = 0.029) and suicide ideation (B = −0.32, SE = 0.17, p = 0.020), as well as improvements in perceived self-efficacy, dependent on initial aggression level (B = 0.05, SE = 0.03, p = 0.034). Those with ‘improved’ trajectories were also less likely to experience placement disruptions. Conclusion In light of our exploratory findings, incorporating various life domains into closed residential care plans, focusing on emotion regulation, substance use prevention, and providing an environment that encourages self-efficacy could reduce aggressive behavior and subsequent placement disruptions. Implications for youth welfare policy and future research are discussed.

Adverse childhood experiences (ACEs) lead to devastating long-term health consequences that are associated with a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Children and adolescents living in institutional care have an increased risk to experience ACEs, particularly linked to missing continuity of care, and a higher risk for consequences of ACEs such as mental disorders. In order to improve the overall quality of care, it is important to better understand the stress-physiology of this high-risk sample and to identify specific stressors linked to adverse outcomes. Therefore, we assessed ACEs due to missing continuity of care and their association with hair cortisol and DHEA levels in children, adolescents and young adults in institutional care. Results show that ACEs resulting from the family of origin, in detail maternal mental illness, and ACEs due to out-of-home placement, namely frequent change of caregivers, are associated with HPA axis over-activation. HPA axis activation is associated with enhanced mental health problems. These results point towards an association between continuity of care and the stress system of children and adolescents in this high-risk sample. Care concepts that focus on continuity of care might help to reduce these physiological alterations and devastating long-term consequences following ACEs.

Background:Adverse childhood experiences (ACE) exhibit long-lasting consequences on later life and are considered as a major public health problem. ACEs can be divided into household dysfunctions, which affect the child indirectly, and direct maltreatment. As a high correlation between ACEs in general is known, we assessed the risk for child maltreatment associated with the occurrence of household dysfunctions. To provide a better understanding for the mechanisms leading to the deleterious sequelae of ACEs, we furthermore assessed whether the long-term consequences of household dysfunction are mediated by child maltreatment and thereby might be targeted by effective child protection programs.Methods:A representative sample of the German population above the age of 14 (N = 2531) was assessed in a cross-sectional observational population-based survey.Results:The data reveal that mental illness of a household member was associated with significantly increased risks for all child maltreatment subtypes (ORs 4.95–5.55), just as household substance abuse (ORs 5.32–6.98), violence against the mother (ORs 4.43–10.26), incarceration of a household member (ORs 6.11–14.93) and parental separation (OR 3.37–4.87). Child maltreatment partially mediated the association of household mental illness, substance abuse and parental separation with later depression, anxiety, life satisfaction and subjective general health status and completely mediated the associations of intimate partner violence (IPV) and incarceration of a household member with anxiety, depression and subjective health status in adulthood.Conclusions:ACEs linked to household dysfunction are associated with an increased risk for all subtypes of child maltreatment. The assessed widespread consequences of household dysfunction are mediated by child maltreatment. This underlines the role of prevention of child maltreatment in families with household dysfunction and implies child protection as a priority in any interventions.

Wenn Kinder vom Familienhund gebissen werden, sollten sie in der Arztpraxis nicht nur medizinisch versorgt werden. Arzte sollten auch prufen, ob womoglich eine Kindeswohlgefahrdung vorliegt.