START - Development of an Intervention for a First Stabilization and Arousal-modulation for Highly Stressed Minor Refugees This article focuses on the development of an intervention called "Stress-Traumasymptoms- Arousal-Regulation-Treatment" (START), through the process of working with refugeed minors in acute stress during the clearing process immediately on arrival in Germany. START is a short manualized structured intervention for crisis intervention and stabiliziation of children and adolescents suffering from intense stress and acute tension or desperation. It consists of five sessions preferred for group or also single treatment. For easy and widespread applicability we translated the START-Manual in Dari, Arab and English. The language is simple and easily understandable and illustrated by picture material. For children incapable of reading there is also an audio version in the different languages. Some compounds of START are derived from elements of dialectic behavioral therapy (Linehan, 2015; Rathus u. Miller, 2015; Bohus u. Wolf, 2011) and traumafocused cognitive behavioral therapy for children (Cohen, Mannarino, Deblinger, 2009). The manual can be used by psychotherapists, social workers, physicians, school psychologists as well as qualified caretakers, given the highly self-instructive character of the instrument. In clinical settings, children of all cultural backgrounds can and should be included in the group treatment. START was very readily accepted by the refugeed children and adolescents and observed to reduce stress in children and supervising professionals. Its efficacy and effectiveness is currently target of a standardized pre-post evaluation. Clinical implications as well as limitations of the concept are discussed.

Zusammenfassung Die besondere Situation psychisch belasteter und geflüchteter Kinder und Jugendlicher erfordert neue Konzepte in der psychotherapeutischen Versorgung. Geflüchtete Kinder leiden häufig an psychischen und körperlichen Symptomen und sind durch traumatische Erlebnisse nachhaltig belastet. Das strukturierte und manualisierte Kurztherapiemanual "START" -Stress-Traumasymptoms-Arousal-Regulation-Treatment wurde im Rahmen der praktischen Arbeit mit unbegleiteten minderjährigen Flüchtlingen in Clearing-und Erstaufnahmekontexten und der klinischen Versorgung der Kinder-und Jugendpsychiatrie entwickelt. Interventionen aus der Dialektisch-Behavioralen Therapie, Psychotraumatherapie und Alptraumtherapie werden in START integriert. Dabei zielen die Interventionen primär auf eine rasche Stabilisierung und Arousal-Regulation bei emotionaler Belastung und ausgeprägtem Stresserleben. Im zweiten Schritt fokussiert START auf Förderung von Selbstwirksamkeit und die Stärkung von Schutzfaktoren. Der folgende Beitrag gibt einen kurzen Über-blick zur Situation der geflüchteten Kinder und Jugendlichen und beschreibt das START-Konzept hinsichtlich klinischer Implikationen und auch der Limitationen. Schlüsselwörter START -Stress-Traumasymptoms-ArousalRegulation-TreatmentSummary Recent research shows that unaccompanied refugeed minors frequently suffer from sleeping disorder, night mares, hyperarousal and emotion dysregulation due to severe traumatic experiences. Furthermore many are in acute stress during the clearing process on arrival in Germany. START was developed to reduce stress and improve psychosocial functioning in this population. It is a short manualized structured intervention for crisis intervention and stabiliziation of children and adolescents suffering from intense posttraumatic tension or desperation. Compounds of START are derived from elements of dialectic behavioral therapy and traumafocused cognitive behavioral therapy for children. The manual can be used by psychotherapists, social workers, physicians, school psychologists as well as qualified caretakers, given the highly self-instructive character of the instrument. In clinical settings, children of all cultural backgrounds can and should be included in the group treatment. Its efficacy and effectiveness is currently target of a standardized pre-post evaluation. Clinical implications as well as limitations of the concept are discussed. Keywords

Background: The ‘Stress-Trauma-Symptoms-Regulation-Treatment’ (START) is an innovative manualized short-term treatment program for stabilization and stress resilience in emotionally dysregulated adolescents, based on an approach of stress and management and emotional regulation. The current pilot trial aims to assess the feasibility and effectiveness of the START intervention program for improvement of emotion regulation.Methods: Sixty-six adolescents between the age of 13–18 years admitted to a psychiatric unit for acute emotional or behavioral dysregulation took part in the START program for 5 weeks in an open group setting with two sessions per week (70 min/session). Before treatment, we assessed a history of adverse experience with the Child and Adolescent Trauma Screen (CATS) and the Child Posttraumatic Cognitions Inventory (CPTCI). Before and after treatment, the participants completed the FEEL-KJ, a self-report screening instrument of emotional regulation and coping strategies.Results: A large proportion of this sample had experienced traumatic events based on the CATS (75%) and the CPTCI (82%). The mean FEEL-KJ score significantly decreased after the intervention (d = −0.248, p = 0.037), while no difference was observed with regard to mean level of adaptive emotion regulation strategies (d = 0.202, p = 0.207). A positive effect of the intervention was observed on three components of the adaptive FEEL-KJ scale: accepting (d = 0.289, p = 0.08), forgetting (d = 0.271, p = 0.049) and dealing with anger (d = 0.309, p = 0.034).Conclusion: START demonstrates preliminary evidence for improvement in emotional dysregulation after a 5-weeks course of treatment. Therefore, this short-term intervention can possibly be regarded as a tool to improve emotional stability in children with a high load of trauma-related psychopathology. The results are promising and warrant future studies, specifically randomized controlled trials on the effectiveness of START for strengthening resilience at-risk-populations.

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IntroductionNo evaluated therapeutic approaches, that can efficiently be established in routine mental healthcare, are currently available for traumatised adolescent refugees in Germany. This study evaluates the efficacy of the Stress-Traumasymptoms-Arousal-Regulation-Treatment (START) programme to reduce trauma-related symptoms and psychological distress in traumatised adolescent refugees based in Germany.Methods and analysisThis randomised, waiting-list-controlled, multicentre trial with a 12-week follow-up will include 174 refugee minors with partial or full post-traumatic stress disorder who are fluent in either Arabic, Dari, English, German or Somali. Eligible refugee minors will be randomised to the START or waiting-list control groups. The manualised 8-week START programme is based on techniques of dialectical behaviour therapy (DBT), fosters adaptive coping with emotional distress and traumatic symptoms and comprises eight therapy modules and a booster session. Study assessments are planned at baseline, post-treatment (ie, after programme participation or waiting time), booster session at week 12 or 12-week waiting time, and at the 12-week follow-up. Primary and coprimary outcomes are changes in psychological distress and traumatic symptoms at post-treatment and will be analysed as response variables in linear mixed regression models. Secondary outcomes are changes in further trauma-related and other psychopathological symptoms, emotion regulation and intermediate effects of the programme at follow-up. We will also assess effects of the programme with ecological momentary assessments and on neuroendocrine stress parameters using hair cortisol.Ethics and disseminationThis study has been approved by the lead ethics committee of Rhineland-Palatinate and the ethics committees of participating sites. The study results will be disseminated through peer-reviewed publications and scientific conferences.Trial registration numberDRKS00020771.

Zusammenfassung. Fragestellung: Kinder haben ein Recht auf Mitbestimmung. Welche Phasen und Bereiche von Mitbestimmung innerhalb der Kinder- und Jugendpsychiatrie besonders relevant sind, wurde nur selten empirisch untersucht. Somit ist es Ziel der vorliegenden Studie, den Wunsch und das Erleben von Beteiligung für verschiedene Dimensionen der stationären Behandlung in der Kinder- und Jugendpsychiatrie differenziert zu betrachten. Methode: Es wurde eine prospektive multizentrische Fragebogenerhebung durchgeführt. Das Erhebungsinstrument umfasste 100 Fragen, zusammengefasst in 16 Skalen, zum Wunsch und Erleben von Beteiligung innerhalb verschiedener Phasen (Information, Deliberation, Entscheidung), Bereiche (Behandlung, Klinikalltag, Persönliche Freiheiten) und Partizipation im weiteren Sinne (Respekt, Vertrauen). Die Daten wurden deskriptiv und inferenzstatistisch ausgewertet. Ergebnisse: 81 Kinder und Jugendliche aus fünf psychiatrischen Kliniken nahmen an der Studie teil. Insgesamt wünschen sie sich mehr Beteiligung als sie erleben. Je höher die Stufe der Beteiligung, desto größer die Differenz zwischen Wunsch und Erleben. Für Entscheidungen zur Kommunikation mit Familie und Freunden ist der Wunsch nach Beteiligung besonders hoch. Die deutlichste Differenz zwischen Wunsch und Erleben zeigte sich im respektvollen und vertrauensvollen Umgang mit den Kindern und Jugendlichen. Für weibliche Patienten ist diese Differenz noch größer als für männliche. Schlussfolgerung: Partizipation ist mehr als Aufklärung bei Behandlungsentscheidungen. Besonders bei höheren Stufen von Beteiligung und bei Entscheidungen zur Kommunikation mit Familie und Freunden besteht noch Potenzial für den Einbezug der Kinder und Jugendlichen. Ein respekt- und vertrauensvoller Umgang mit den Patientinnen und Patienten, unabhängig von Alter, Geschlecht und Erkrankung, sind dabei die Grundlage.

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