The negative impact of parental substance use on children has been documented by a multitude of studies and reviews, especially for children of alcoholics. It includes physical, psychological and cognitive consequences for children's development. Children and adolescents affected by parental drug use show higher rates of externalizing and internalizing problems such as anxiety disorders and depression [1
], social behaviour disorders [3
], or hyperactivity disorders [4
]. With regard to substance use problems, their records more often show an early onset of substance consumption [6
], earlier drunkenness experiences [8
], increased binge drinking rates [9
] and an elevated risk for developing substance use disorders at a younger age than comparable peers [10
]. Approximately 33 to 40 percent of all children with a substance-using parent will develop a substance use disorder themselves [11
]. Substance problems are transmitted to the next generation via several pathways, especially genetic disposition [12
], exposure to drugs in utero, behavioral and cognitive processes [14
]. Family environmental characteristics such as problematic family relationships, family conflict or absence of supportive parenting [16
] also play an important part. Children from substance-affected families often experience physical violence, emotional abuse, or neglect [17
]. Paradoxically, at the same time they often acquire the same positive expectations about the effects of substance consumption that their substance-abusing parent exhibits [18
]. Learning from the example substance-dependent parents set, children later come to use substances as maladaptive coping strategy in stressful and difficult times [20
]. Behavioural consequences in childhood and adolescence are gender-specific: while females lean toward withdrawal and social isolation, males often show antisocial behaviour [17
]. In general, male children seem to have more difficulties with compensating for family problems resulting from parental alcohol or drug use. They more often develop attention deficit problems, anxiety, depression and early alcohol problems [23
]. However, not all children from substance-affected homes show maladaptive functioning. In fact, about one third of them exhibit no psychosocial problems in spite of the adverse circumstances associated with parental substance use [24
]. These persons are often called "resilient".
Research on resilient children from substance-affected homes shows that these children are different from less well-adapted ones in several ways: First, they are more likely to have social resources outside of their parents such as caring relatives or friends [26
]. Second, they may be less exposed to parental alcohol or drug problems, or their substance-affected parent may have undergone a successful, abstinence-oriented treatment [26
]. Third, they exhibit personality traits that contribute to their resilience such as high stress resistance, good adaptation skills in new situations and high self-efficacy [27
]. Wolin and Wolin [28
] identified seven characteristics of resilient children of substance-abusing parents: Insight, autonomy, robust relationships, initiative, creativity, humour and morality. With regard to interventions, strengthening the resilience of these children-at-risk is often viewed as an important goal. Research on the efficacy of interventions designed specifically for children from substance-affected families has mainly focused on two kindes of interventions: family-focused prevention efforts aimed at increasing supportive and nurturing parenting [29
] and (mainly school-based) peer group programmes that draw on the effects of positive peer influence and mutual support [32
]. The majority of these studies have demonstrated positive programme effects in the area of coping skills, programme-related knowledge and social behaviour [35
]. While these results seem promising, research on selective prevention programmes targeting children of substance abusers still remains rather scarce, especially outside of the United States.
In Germany, it is estimated that approx. 2.65 million children are affected by parental alcohol abuse or depencence until they come of age [36
]. A more recent study concludes that five to six million youth under the age of twenty have at least one parent with alcohol problems [37
]. It is likely that an additional large number of unreported cases exist [38
]. Germany holds a highly differentiated addiction care system for alcohol and drug users that includes low-threshold offers such as outreach work, but also outpatient treatment centres, inpatient treatment services in psychiatric clinics as well as inpatient rehabilitation treatment. Outpatient treatment facilities are widespread, in urban as well as rural areas, and provide low-threshold and cost-free counselling that is funded by the communities, the federal states and/or big welfare organisations. Staff members within these centres have diverse professional backgrounds ranging from social workers, pedagogues, psychologists and psychotherapists to medical staff. Due to their different roots, institutions operate with a variety of philosophies and therapeutical concepts. They can refer clients in need of more intensive care into either outpatient (by a physician) or inpatient substance disorder treatment (detoxification, withdrawal treatment) financed by health insurance. Outpatient walk-in and day clinics specialised in alcohol and drug treatment also exist in larger medical centres. Patients may also enter all of these medical centres directly, without referral. An ideally seamlessly adjoining long-term medical rehabilitation treatment is financed by pension insurance. Therapeutic approaches are usually multimodal, combining different psychotherapeutic approaches and using cognitive-behavioral, behavioral-therapeutic, psychodynamic and systemic or family therapeutic elements. These are applied in a diagnosis-oriented treatment and offered as individual or group therapy. Thus, in the vast majority of all cases, professional assistance for persons with substance-related problems is available and covered by insurance. Often, however, the situation of children is not taken into account when a parent enters the German drug aid system. Even though current data do not exist, statistics from 1998 show that when parents receive addiction treatment or counselling, only ten percent of all children are also treated [39
Recently, the abovementioned findings on the developmental risks for children of substance-affected parents have spurred diverse local efforts to help, especially in out-patient settings. Arenz-Greiving and Kober [40
] estimated in 2007 that about 40-50 interventions for this target group exist in German outpatient centres. These interventions included a wide variety of concepts and settings such as individual counselling, group programmes, parent work, play groups, holiday camps and many others. The authors also found a few inpatient programmes for children of parents receiving alcohol or drug treatment in medical centres. Other than in the United States, for example, schools do not offer selective programmes for children of parents with drug problems for fear of stigmatising them. Taking into account the large number of affected children, however, help for children of parents with alcohol or drug problems is still rare in Germany. In addition, programme deliverers frequently face substantial recruitment challenges that will be detailed in the next section. Many existing programmes are not ongoing, but remain project-type efforts. This is mainly due to funding issues: interventions for children from substance-affected families are not covered by German health insurance, but are funded - often for a limited period of time only - by the communities, the federal states, or regional initiatives. All in all, there are several programmes for these at-risk children, but programme delivery is rather unsystematic due to the mulitfaceted and heterogeneous help system for affected families. Moreover, previous efforts are not evidence-based.
Our own study conducted in 2009 identified 48 outpatient counselling centres that offered prevention programmes for children of substance-using parents [41
]. About half of these children were 8-12 years old. The intervening centres were most often part of either the addiction aid ("Suchthilfe") or from the the area of youth welfare aid ("Jugendhilfe") or from a combined form. With regard to the format of these interventions, group programmes were indicated most frequently (81.8% of the institutions) followed by individual counselling (61.4%) and family counselling (43.2%). Working with parents alongside the children's programme was also reported by 59.1% of the institutions. In recruiting children for the interventions, about two thirds of them were recruited by their parents who were receiving counselling in the centre itself or by other institutions within the centres network. Only few cases were referred into the programme by school or daycare centres, even though it can be assumed that staff in these institutions should often be able to identify children with substance-abusing parents. The majority of all group programmes (80%) were open and continuous, i.e. without any defined starting and ending points. They were also neither manualised nor evaluated [41
]. Therefore, the study at hand will be the first to provide data on the effectiveness of a manualised group programme for children from substance-affected families in Germany.
Objectives and hypotheses
The objective of our study is to assess the effectiveness of the community-based group programme TRAMPOLINE for children aged 8-12 years with at least one substance-abusing parent. The effectiveness of the intervention will be tested two weeks and six months after the intervention. We expect that as a direct result of the intervention, participants in the intervention condition will show a significant improvement in the use of constructive coping strategies (in general and within the family) compared to the control condition. We furthermore hypothesise that this effect will continue or become stronger in the 6-month follow-up data collection point (primary hypothesis). We also expect that exposure to the intervention will lead to other significant improvements in the intervention participants, especially in the area of psychological stress and addiction-related knowledge compared with the control condition (secondary hypothesis). Here also, we expect that these effects will be demonstrated directly after the intervention and in the 6-month follow-up measurement. For the parents, TRAMPOLINE offers an optional two-session accompanying programme. We will explore if these parent modules are also effective in improving caregivers' sensitivity about their children's needs within the substance-abusing family, caregivers' parenting skills, caregivers' feelings of self-competence with regard to parenting skills and caregivers' willingness to accept help from the outside. Another goal of our study is to explore the age- and gender-specific effectiveness of the programme. Given the fairly wide age range of participants and the above-mentioned gender differences in reacting to family problems, programmes like TRAMPOLINE need to be problem-specific and allow for these differences at the same time. Also we will explore regional effects such as differences in urban or rural settings on program success. We further aim at gathering more insight with exploratory analyses on characteristics of our target group, i.e. children from substance-affected families, by applying a broad battery of measurements, because this population is still vastly understudied in Germany. With regard to process evaluation, we will examine whether the intervention is delivered in time and according to defined standards, if the manual is adhered to and whether the programme meets the expectations of caregivers, parents and involved children.
Finally, we are interested in exploring strategies with which programme deliverers meet recruitment challenges. These challenges are manifold: (1) Frequently, affected parents deny their substance use problem. Even if their spouse or other relatives would like to see the child in such a programme, the substance-abusing parent will object to their participation on the grounds that family and parenting are private and should be kept so. (2) Due to the negative consequences of their substance abuse itself, affected parents and their spouses who realise the problem often experience guilt or shame. They also often fear the consequence of the help system intervening if their problems become known, up to the point of fearing that their children will be taken out of the family and placed with foster caregivers. Thus, the issue is frequently treated as a "taboo" within the family, meaning it is not addressed in conversation,and children are not allowed to speak about the problem outside of the family. For many parents, having a child talk about their "problem" in a public health setting is a very high threshold request. (3) Families often face transportation and organisation difficulties, especially in rural areas. If families have to drive extended distances to participate in a programme, this will lower their motivation. For many families a weekly programme in itself can pose a substantial problem of daily routine organisation, especially if this routine is already difficult to handle due to substance problems. Families with lower socioeconomic status and few resources are known to be a difficult target group for psychological interventions. (4) Finally, recruitment challenges are further heightened by the nature of the research project itself. Feelings of distrust toward research and randomisation, negative perceptions and fear of a lack of anonymity and of being "x-rayed" are to be expected during data collection and during the intervention itself. During the project, we developed detailed recruitment strategy recommendations to address these possible barriers to the feasibility of conducting a group programme for children from these families. We will specify these in the discussion section.