What dangers are diabetic methane addicts exposed to?

Mother, child, addiction. To develop the mother-child relationship, taking into account the polytoxicomania of the mother

content

introduction

1 Basic information on addiction, addiction and drugs
1.1 Definitions and criteria
1.1.1 Drugs
1.1.2 Addiction and dependence
1.1.3 Diagnostic criteria for substance use (ICD-10, DSM-IV)
1.2 Drugs and their effects
1.2.1 Legal drugs
1.2.2 Illegal drugs
1.3 Development of addiction and dependence
1.3.1 Development of addiction
1.3.2 From enjoyment to addiction
1.4 The way out of addiction

2 Aspects of developmental psychology
2.1 Development tasks according to Havighurst and Erikson
2.2 Piaget's cognitive development
2.2.1 Sensorimotor stage (1st and 2nd year of life)
2.2.2 Preoperative stage (2 to 7 years of age)
2.3 The development of relationships and bonding according to Bowlby and Ainsworth
2.3.1 Binding / binding behavior according to Bowlby
2.3.2 Types of bindings according to Ainsworth
2.3.3 Phases of the development of the mother-child bond according to Ainsworth
2.4 Development Risks / Risk Factors
2.4.1 Teratogens
2.4.2 Genetically determined risk factors
2.4.3 Social Risk Factors
2.4.4 The importance of psychosocial risk factors in infancy and early childhood

3 women, children and addiction
3.1 Children of parents with addictive substances
3.2 Drugs and pregnancy - effects of drugs on the unborn child
3.2.1 Tobacco / Nicotine
3.2.2 Alcohol
3.2.3 Illegal drugs
3.3 Born addicts - newborns from mothers who are addicted to heroin
3.4 Drugs and upbringing - effects of drug use on the child and the family
3.4.1 Torn between parents
3.4.2 Violence and Crossing Borders
3.4.3 Rules in the family
3.4.4 The “role” as a strategy for survival
3.5 The characterization of interaction patterns in addiction families through role models
3.5.1 The role model according to Wegschneider
3.5.2 The importance of roles for the psychological development of children
3.5.3 Impact of the role characterizations on the family system
3.6 Women-specific addiction work in the drug help system
3.6.1 Why women-specific drug work?
3.6.2 Bella Donna drug counseling center

4 Joint form of housing for drug-dependent mothers (fathers) and their children (child and family support) - Addiction Aid Association Bornheim / Bonn, mother-child facility (father-child)
4.1 Legal basis
4.2 Target audience
4.3 Recording situations
4.4 Goals
4.5 Location and premises
4.6 Personnel key and employee qualification
4.7 Basic services
4.7.1 Stabilization phase: everyday educational aids for the child
4.7.2 Stabilization phase: early intervention for children
4.7.3 Stabilization phase: promoting the mother-child relationship

5 Course of the examination, examination results
5.1 Preparation, hypothesis / question
5.2 Conducting the survey
5.2.1 Aim of the investigation
5.2.2 Data collection (method)
5.2.3 Survey process and period
5.2.4 Description of the study groups
5.3 Evaluation of the survey
5.3.1 Presentation of the interview partners (residents)
5.3.2 Situation and atmosphere during the interviews
5.3.3 Evaluation of the questionnaires
5.4 Evaluation of the survey results with regard to the hypothesis / question of the investigation

6 Possible Consequences for Practice

7 Conclusion

literature

Web sources

Secondary literature

Basic literature for creating the questionnaires

Illustrations

Tables

attachment
Appendix I.
Annex II
Annex III

introduction

In this elaboration, the development of the mother-child relationship (attachment) is examined, taking into account the polytoxicomania (multiple dependency) of the mother in a (partially) inpatient facility of child and youth welfare / drug help.

“Children of addicts are seen as the most overlooked group in the family environment of addiction. ... "[1] Research on the topic of “children dependent on drug parents” shows that parental use of drugs can have a major negative impact on the psychosocial development of one's own children: lack of necessary physical care and attention, delay in socio-emotional and cognitive development[2].

Especially when parents are addicted to drugs (heroin, cocaine, marijuana, etc.) the damage to the child can be massive:

1. The children are often exposed to separations and grow up primarily with only one parent, usually the mother.
2. Premature births, often caused by drug addiction, can lead to increased relationship problems between mother and child. The children often have a problematic temperament, which increases the parenting problems of the parents and can lead to feelings of being overwhelmed.
3. The children are often affected by their parents' drug addiction, especially in the early years of life, so that development deficits can increasingly occur here.
4. The children of drug-dependent parents usually experience strong social isolation and stigmatization, learn less socially beneficial behaviors and thus have a more unstable self-esteem.
5. The children often experience traumatic situations that result from the drug addiction of their parents as a result of the drug addiction (eg prostitution, imprisonment).

Research results on the parental behavior of drug-addicted mothers are briefly outlined below:

There are no differences in the educational attitudes and expectations of drug addict mothers towards the child, but drug addicts women often feel that they are unsuitable mothers and are more concerned about the child's development (possible drug addiction, antisocial behavior) (Colten 1980).

Drug-addicted mothers isolate themselves more than other mothers from the social environment, try to keep outside influences away from their children and to control them (Wellisch & Steinberg 1980).

Behavior in mother-child actions (mothers with methadone substitution): more commanding, provoking and threatening (Bauman & Dougherty 1983).

Drug-addicted mothers are more likely than other mothers to engage in harsh verbal behavior towards their child (yelling and reprimanding child) (Hogan 1998).

Heroin dependent mothers have problems setting and drawing boundaries (Arnold & Steier 1997).

The frequently occurring uncertainties and deficits in the relationship and parenting behavior of the mother-child relationship in drug-addicted mothers, which is proven by research, coincide with the view that often exists in society that drug-addicted women should not have children because these children have no real future, because the mothers are unable to raise the children[3].

This is the basis for developing the hypothesis and question on which this elaboration is based:

Hypothesis:

Mothers who use psychotropic substances,

- and their children are often exposed to separations (e.g. due to changing partners, therapy, foster family)

and

- are not able to give their children the necessary support and security,

so that there is a mutual unstable and insecure attachment and relationship behavior.

Question:

Can multi-dependent mothers develop a safe, constant, and stable relationship with their child (s)? Conversely, can the children develop a good and stable bond with their drug addict mother?

The integration of the (partially) inpatient mother (father) -child facility Bonn or Alfter (aftercare), which has existed since 2003 as part of the child and family support of the Bornheim / Bonn addiction aid association, should be taken into account in this investigation.

aim The present elaboration is, on the one hand, the bonding and relationship behavior between addictive substance-dependent mothers and their children and, on the other hand, the possibilities and efficiency of the above. Establish institution with a view to influencing the mother-child relationship.

The first section of the drafting "Information on addiction, dependence and drugs" relates to the development of addiction and dependence and provides information about how certain substances (drugs) work.

In the second section "Developmental Psychological Aspects" Developmental psychological findings and results are described and explained (development tasks, attachment behavior and types, etc.). Since most of the children who live in the mother-child facility are infants or toddlers, only the developmental psychological data in this age group are taken into account here.

The third section "Women, Children and Addiction" refers to the children of drug dependent parents, the effects of psychotropic substances on the child (pregnancy, postpartum / upbringing). Furthermore, this section deals with the characterization of interaction patterns in addict families through role models and the need for women-specific drug work.

In the further course in section 4 the " Common form of housing for drug-dependent mothers (fathers) and their children (child and family support) " of the Addiction Aid Association Bornheim / Bonn presented (mother-father-child facility): legal basis, goals, services, etc.

Section 5 "Course of the examination, examination results" relates to the development and implementation of the survey and gives the results of the surveys in detail - also with regard to the hypothesis.

Based on the results from the previous section, possible consequences for practice are shown and explained in section 6: "Possible Consequences for Practice".

1 Basic information on addiction, addiction and drugs

1.1 Definitions and criteria

1.1.1 Drugs

In today's everyday language, the term “drug / s” has a negative connotation and is a synonym for narcotics, lawyers speak of narcotics. The term “drug” is defined in the Duden 7 - dictionary of origin - as follows: “The word was used at the end of the 16th century to mean '(animal and vegetable)' raw material from the same condition. French drogue borrowed (...) In the 20th century, 'drug' is also used in the sense of 'medical preparation' and 'drug'. "

This definition does not clearly delimit the term. Basically, one can say that drugs have an intoxicating and partly mind-altering effect and possibly lead to a changed self-perception[4].

1.1.2 Addiction and dependence

Addiction describes obsessive-compulsive cravings for a particular drug or behavior. Addiction is the desire to take this one drug over and over again (substance-related) or to repeat this behavior (substance-independent) in order to achieve a certain sense of well-being and / or to avoid feelings of discomfort[5]. If the emotional and social side effects and consequences are taken into account, then one speaks of dependency (World Health Organization WHO 1965)[6].

The term addiction has a double meaning: illness (e.g. jaundice) and (in common parlance) vice, e.g. B. Greed. It's a fuzzy term because anyone can become addicted[7]. Addiction is not limited to dealing with certain substances, any form of human behavior can become an addiction (e.g. sexual perversions). For this reason, the WHO replaced the term addiction (see first paragraph) with the term dependency.

Further information on this can be found in Section 1.3.2 “From enjoyment to addiction”.

1.1.3 Diagnostic criteria for substance use (ICD-10, DSM-IV)

Recognized mental disorders - including the consumption of psychotropic substances - are recorded in the classification systems DSM-IV and ICD-10[8]:

DSM stands for Diagnostic and Statistical Manual of Mental Disorders and is the classification of the American Psychiatric Association (APA, 1994, Professional Association of American Psychiatrists). The DSM is the standardization of the criteria for the diagnosis of all mental disorders.

ICD is the abbreviation for International Classification of Diseases and was developed by the World Health Organization (WHO). As the international classification of diseases, the ICD is binding for all health professions worldwide and, as a standard, facilitates communication between clinics and doctors.

According to DSM-IV, there are basically two categories of substance use:

- Substance abuse and
- substance addiction[9].

Substance abuse is less severe than addiction and is diagnosed if - over a 12-month period - one of the following characteristics is present as a result of repeated drug use:

- Failure to fulfill important obligations (e.g. absenteeism from work)
- Physical hazard from substance consumption, e.g. driving a car under the influence of drugs
- Confrontation with the law (traffic offenses, etc.)
- continued social and / or interpersonal problems

Substance dependency exists if - based on a period of 12 months - at least three of the following characteristics are present:

- Development of tolerance (desire to increase the dose in order to achieve the desired effect or significantly reduced effect with the same dose)
- Withdrawal symptoms (negative physical and psychological effects if consumption is interrupted or reduced in amount)
- Ingestion of the substance in larger quantities or for longer than intended
- Unsuccessful attempts to reduce substance use
- A large amount of time is required to obtain the substance or to recover from the substance's effect
- Undiminished substance consumption despite knowledge of mental and physical problems that can be caused or exacerbated by the substance
- Restriction or abandonment of social and professional activities due to consumption

In the context of mental illnesses, the International Classification ICD has approximated the tried and tested classification of the DSM and has adopted essential parts[10]:

"Harmful use"

Patterns of use of psychotropic substances that lead to damage to health (physical or psychological)

Diagnostic guidelines

- Diagnosis requires actual harm to the consumer, negative social consequences or acute intoxication or "hangovers" are not sufficient
- Cannot be diagnosed with addiction syndrome ..., psychotic disorder ... or other alcohol-related disorders

Addiction syndrome

Group of physical, behavioral and cognitive phenomena in which the use of a substance (class) has priority over other earlier preferred behaviors; strong, occasionally overpowering desire to consume psychotropic substances; possibly faster relapse after abstinence than with non-dependence

Diagnostic guidelines:

simultaneous presence of ≥ 3 criteria in the last few years:

- Strong desire / compulsion to consume psychotropic substances
- reduced ability to control the start, end and amount of consumption
- physical withdrawal syndrome after termination / reduction
- Proof of tolerance
- progressive neglect of other interests and increasing expenditure of time in favor of consumption
- sustained consumption despite clearly harmful consequences "

1.2 Drugs and their effects

1.2.1 Legal drugs

1.2.1.1 Alcohol

Alcohol as a food, luxury and intoxicant has a millennia-old tradition. Alcohol (ethanol, ethyl alcohol) is a clear, colorless liquid that results from the fermentation of sugar[11]. All sugary foods can be used as basic materials for the production of alcohol (e.g. grapes - wine). The consumption of alcohol can create psychological and physical dependence.

The effect of alcohol depends on the amount, the alcohol concentration and the individual physical and mental state of the person consuming it: stimulating, mood-enhancing, reducing fears and inhibitions, increased willingness to communicate; Irritability, aggression, violence; Disturbances in perception, reduced attention and ability to speak and coordinate.

Chronic alcohol consumption can lead to physical, psychological and social disorders: cell and organ damage (liver, heart, muscles), increased risk of cancer (mouth, esophagus), seizures due to changes in the nervous system, impaired consciousness; Mood swings, anxiety, depression; Relationships diverge, job loss, social conflicts. The children of alcoholic people are particularly affected by the social consequences of alcohol consumption. If alcohol is consumed during pregnancy, it can cause serious harm to the unborn child. Further elaborations on this can be found in Section 4.

1.2.1.2 Medicines

A distinction is made between the following drug groups[12]:

- Sedatives and sleeping pills (tranquilizers, sedatives)
- Stimulants and stimulants (wake-up amines)
- Painkiller

Sleeping pills and sedatives are usually taken in the event of inner restlessness or pathological states of excitement[13]. They have an anxiety-relieving and calming effect and are often used to cope with stress. The use of tranquilizers can lead to reckless behavior (e.g. in traffic).

Sleeping pills and sedatives quickly lead to emotional dependence. When you stop using the drug, there are withdrawal symptoms such as B. Headache, irritability, restlessness and fear. When the drug is taken again, the symptoms recede; an increase in the dose is usually not necessary. In addition, sleeping pills and tranquilizers can only be broken down slowly by the body; it takes about three weeks from the last intake until the drug can no longer be detected in the body. This leads to the fact that z. B. if taken daily, a new dose is added to the remaining dose from the previous day and the drug level continues to rise.

In many cases there is a combined intake with Stimulants and stimulants[14]: After an artificially generated sleep with tablets, the organism is often tired and limp the next morning, many then use the so-called wake-up amines to get going again - in the evening you take a sleeping pill or sedative again to rest to come (vicious circle, addiction to wake-up amine sleeping pills).

The use of stimulants leads to an increased alertness, a reduced need for sleep, an inhibited appetite and an increase in self-esteem.

Painkiller reduce the sensation of pain (basis: opiates, see also section 1.2.2.1 heroin). “The occasional use of painkillers is harmless. The constant use of these drugs is a cause for concern. It is known that people with mental problems or significant stress levels also perceive minor pain as particularly intense. Reaching for the tablet provides a quick remedy. After prolonged, regular use, an emotional dependency arises. A physical dependence - as with some drugs - does not exist with painkillers without additives. But if you do not take it after prolonged abuse, most patients develop very severe headaches. The temptation to start again is then very great. "[15]

1.2.2 Illegal drugs

1.2.2.1 Heroin

Heroin is obtained through chemical processes from the raw opium (milk juice) of the opium poppy (Papaver somniferum L.)[16]. It is a powder that has a numbing and euphoric effect at the same time. Heroin belongs to the group of opiates and opioids and is a derivative of morphine. It creates both psychological and physical addiction and can be injected intravenously or smoked on foil.

Heroin has a calming and relaxing effect, the sensation of pain is reduced. At the same time it has a mind-reducing and strongly euphoric effect. Mental activity is dampened and feelings of fear are eliminated. The consuming person feels happy and satisfied, stresses of everyday life and conflicts are no longer perceived as such.

Regularly prolonged consumption of heroin leads to severe physical and social secondary disorders: physical deterioration, damage to internal organs (liver, stomach, intestines), changes in teeth (caries, tooth loss due to the reduced pain sensation), respiratory diseases (especially lungs), local infections intravenous use; Changes in personality (drug-related crime, prostitution), neglect.

The effects of heroin on the community, particularly with regard to the children of opiate dependent parents, are discussed further in Section 4.

1.2.2.2 Cocaine

Cocaine is a crystal-like powder and is obtained from the leaves of the coca bush (Erythroxylon coca, South America)[17]. It can be snorted, injected or smoked. Cocaine use causes severe psychological dependence.

"From a pharmacological point of view, cocaine works in three ways: It stimulates the psyche very strongly, has an effective local anesthetic effect and constricts the blood vessels."

Cocaine is known as a performance drug and acts on the central nervous system. After ingestion, there is an increase in performance, the physical resilience is increased. Cocaine dampens the feeling of hunger and reduces the feeling of sleep, triggering euphoric feelings. In addition, the consumption causes an increase in desire and potency.

The states of intoxication caused by cocaine usually develop in three phases: a) Euphoric stage (increased drive, increased self-confidence), b) Intoxicating stage (hallucinations, paranoid mood), c) Depressive stage (listlessness, exhaustion, anxiety).

Regular cocaine use can lead to severe physical, psychological and social changes in the medium to long term: weakening of physical resistance, weight loss, damage to blood vessels and internal organs; Moods, sleep disorders, anxiety, depression, drive and concentration disorders, increased irritability, aggressiveness; Personality changes (antisocial behavior, inner restlessness).

The consumption of cocaine during pregnancy can lead to maturation and growth disorders (defective development of the brain and internal organs) in the fetus or even result in premature or stillbirth.

1.3 Development of addiction and dependence

1.3.1 Development of addiction

The development of addiction or drug addiction cannot be traced back to a single cause, it is an interplay of various factors[18]. Depending on whether the present factors are positive or negative (e.g. strong and weak self-esteem), they can protect against or at risk of developing addiction.

Figure not included in this excerpt

Figure 1: Factors in the development of addiction according to Wille 1994

According to R. Wille (1994), the development of addiction is characterized by the following stages (see also Section 2.3.3 “From pleasure to addiction”):

1. Euphoric initial stage
Person: Relief of problems, relaxation / numbness, increased self-esteem, euphoria, expansion of consciousness, avoidance of conflict
Environment: A sense of community, access to a drug clique, recognition, gain in status
Drug: easy availability, underestimation of the negative drug effects, consumption limited to evenings and leisure time

2. Critical habituation stage
Person: Denial of problems and outward projection (externalization), concentration disorders, pain or frustration tolerance decrease
Environment: Conflicts in school and at work due to reduced productivity, concentration on contact with other drug users, problems in drug-free relationships, financial difficulties
Drug: decreasing drug effect through habituation, increase in dose, consumption also during the day, combination with other intoxicants; Control over drug consumption (amount and timing) is still in place

3. Addiction or dependency stage
Person: Withdrawal symptoms determine behavior, personality changes (increased irritability, mood swings), decrease in physical performance, concomitant diseases, decrease in mental performance (difficulty concentrating, forgetfulness)
Environment: Alienation from relatives and friends, social isolation, crime (procurement, prostitution)
Drug: Development of tolerance (increase in dose), loss of control over the intake of the addictive substance (amount and time)

4. Chronic degradation stage
Person: Progressive physical or mental decline (cirrhosis of the liver, stomach ulcers or memory loss, lack of concentration), decline in personality (lack of drive, extreme mood swings)
Environment: increasing social and professional decline (disability, impoverishment), negative feedback from the environment (contempt)
Drug: Drug tolerance decreases due to organ damage, polytoxicomania (multiple consumption, dependence)

1.3.2 From enjoyment to addiction

The path from inconspicuous use to abuse and addiction can take several years[19]:

1. Use
The behavior of the consuming person is inconspicuous and sensible, the substance is used for conscious enjoyment and consumption can be stopped at any time. If enjoyment becomes habit, use can creep over into abuse.

2. Abuse
In the case of abuse, the substance is used by the person consuming it to achieve a specific effect. More is consumed than can be tolerated. There is no longer any self-control to reduce or stop taking, and attempts to be abstinent fail. The addictive substance takes more and more possession of the thinking, feeling and acting of the consuming person. Abuse often results in addiction.

3. Dependency
“It can take years from abuse to addiction. The person concerned often realizes too late that he is dependent. He has an irresistible craving for the addictive substance. He can no longer dispose of the addictive substance because he has lost control of it. The addiction can be emotional and physical. It is pathological and usually in need of treatment because the addict usually cannot free himself from it. As a result, addictive substance dependence causes a multitude of damage in the physical, emotional and spiritual areas. In addition, there is the social harm for the addict and often secondary diseases.
Mental addiction. The addict has a desire, which can no longer be stopped, to consume the addictive substance in order to produce a certain effect (e.g. mood-enhancing, stimulating, dampening).
Physical addiction. Physical dependence can be recognized by the fact that withdrawal symptoms occur when the drug is no longer available in sufficient doses in the body. First and foremost, there are disorders in the autonomic nervous system, which are characterized by sweating, tremors (muscle tremors), loss of appetite, nausea, vomiting, diarrhea. " [20]

1.4 The way out of addiction

The insight, “I'm an addict. I don't want to go on like this. I need help. "Is the first step to free yourself from addiction to (legal or illegal) addictive substances. Now the drug user can turn to a counseling center and seek (professional) support and help[21].

The way out of addiction or dependence is divided into several phases and begins with preparation for therapy, with discussions in a drug counseling center (individual or group discussions) or in a self-help group[22]. After several days or weeks - if the dependent person is ready - the inpatient detox begins in a hospital or in a specialist clinic for addicts. With the help of medication, the body is deprived of the poison, the physical consequences of drug consumption are treated and work is carried out towards weaning (therapy) over several months (duration of the detoxification: approx. One to three weeks). As part of inpatient weaning, mental disorders are treated (individual and group therapy) and alternative behaviors to drug use are taught. The aftercare that follows the weaning is used to overcome the crisis and prepare for everyday (drug-free) everyday life ("social (re) adjustment"[23] ). Follow-up care can be either part-time inpatient or outpatient by z. B. therapeutic residential communities or drug counseling centers take place:

Figure not included in this excerpt

Figure 2: Phases of the treatment of addicts and selected characteristics

(Source: Langfeldt 1996, p. 347, excerpt)

2 Aspects of developmental psychology

2.1 Development tasks according to Havighurst and Erikson

The American sociologist and educationalist Robert Havighurst developed the concept of developmental tasks in the middle of the 20th century[24]. Havighurst assumed that every person has to cope with certain life tasks in the various phases of life, the so-called development tasks. This concept was differentiated and further developed in the course of the next few decades, along with other social scientists, in particular by Erik Erikson (1973): Humans develop throughout their life, from birth to old age.

According to Erikson's concept of developmental tasks, a person's curriculum vitae is divided into a total of eight stages, with only the first three stages of development from the first to the sixth year being considered in more detail in the following, as the focus in section 5 on the evaluation of development the mother-child relationship is between 1 and 6 years old:

Figure not included in this excerpt

Figure 3: Development tasks according to Havighurst and Erikson, stages 1 to 3

The concept of developmental tasks is still of great importance for modern developmental psychology, even if the content has changed over the course of time: “Today, developmental tasks are understood to be a task that at a certain point in development is a socially prescribed norm Individual is brought up. It is adopted by him as a goal or expectation as soon as he has the biological, psychological and social prerequisites to cope with the task. "[25]

To the so-called normative developmental tasks in infancy belong e.g. B.

- Learn to walk
- Using symbols, learning to speak
- Learning to eat independently
- Learn to control body waste
- Breaking away from the symbiotic relationship with the mother (weaning, weaning)
- Building bonds with other caregivers besides the mother
(e.g. to the father, to the siblings, to the educators)
- Acquiring one's own gender role
- Recognizing connections in the social environment
- Learning to relate one's own feelings to parents and siblings

The successful completion of (individual) developmental tasks (coping) depends, on the one hand, on how mature a child is for the task, i.e. to what extent the internal requirements are present; Furthermore, the support that a toddler receives in his coping efforts from outside - from his environment - is also of great importance (coping resources).

2.2 Piaget's cognitive development

The cognitive development theory according to the Swiss developmental psychologist Jean Piaget (* 1896, † 1980) emphasizes the interaction between the investment and environmental factors. In his development theory, Piaget assumes that it is a self-constructive process: The process takes place in the interaction between the subject (infant / child) and the environment, the so-called competent infant.[26]

According to Piaget, thinking develops in stages or phases. Each individual stage forms a whole (with a preparatory and final phase) and prepares the way for the next stage, on which the various elements of the preliminary stage are developed into a new whole. It is not possible to skip a stage, but the individual phases can be run through at different speeds. At each level an increasingly stable equilibrium develops, so that an increasingly competent examination of the environment becomes possible.

The individual cognitive development stages at a glance:

1st sensorimotor stage (1st and 2nd year of life)
2. Preoperative stage (2 to 7 years of age)
3rd stage of the specific operation (7 to 11 years of age)
4th stage of the formal operation (11 or 12 years of age)

Only the first two stages are important for infant development; these are explained in more detail in the following sections.

2.2.1 Sensorimotor stage (1st and 2nd year of life)

According to Piaget, the sensorimotor stage is the preliminary stage to thinking (precursor of cognitive structures). The clearly reflex-controlled behavior of a newborn child develops into the goal-oriented behavior of a two-year-old toddler in six developmental steps:

1st month of life à reflexes change and adapt to new stimuli

2nd to 4th month of life à Primary circular reactions occur: own body feeling

5th to 8th month of life à Secondary circular reactions develop: Environment / object perception

8th to 12th month of life à Behaviors are used in a coordinated and targeted manner

13th to 18th month of life à tertiary circular reactions occur: repetitions, variations

19th to 24th month of life à Transition to thinking begins: behavior transfer, chains of action

In the course of the first two years of life, external exploration (Latin for research) is replaced by internal exploration - thinking. Small children experiment less and less according to the principle of trial and error, but spontaneously think up new ways and solutions and gain new inner ideas in order to cope with a situation.

2.2.2 Preoperative stage (2 to 7 years of age)

According to Piaget, the preoperative stage begins at the beginning of the third year of life, which lasts until about school age. This phase is characterized by the fact that cognitive schemata are becoming more and more differentiated and are divided into different areas.The prerequisite for this development process is the child's ability to replace one object with another - a symbol.

This should be explained in more detail using an example: First of all, in the development of the toddler, a circle is a symbol for all round objects (ball, sphere). In further development, the symbol is increasingly replaced by a symbol or z. B. replaced the word "round". This increasingly differentiating process leads to the fact that the toddler is no longer bound to the directly perceived object and the actions that it can carry out with it. The child now works with their own imagination, which is becoming more and more precise: a ball can be thrown, caught or rolled.

In the preoperative stage, toddlers learn that the connection between object and language (word) is rather arbitrary, that an object can be named with different terms, or that different objects are named with the same word.

With the growing number of terms and meanings, the toddler becomes more and more independent of the immediate present: the child thinks, remembers and anticipates things. These developing mental processes enable the child to adapt more quickly and flexibly to new situations and to establish a connection between the past, present and future, even if the child is still very much tied to his own thinking and feeling in this phase of life.

2.3 The development of relationships and bonding according to Bowlby and Ainsworth

Infants relate to other people from the start[27]. These relationships then have an impact on life and other relationships. For example, if a child has stressful relationships in the family, the likelihood increases that he or she will have difficulty developing relationships outside the home.

The focus here is on the concept of attachment: “Attachment is a specific, emotional bond that forms between one person and another. (...) The emergence of attachment is reflected in a repertoire of attachment behavior, which essentially has the function of maintaining closeness to the attachment person. Examples of attachment behavior are preferential attention, touching, clinging, shouting and crying in the absence of the person concerned or smiling in their presence. "[28]

At this point it should be pointed out that the phenomenon of attachment behavior does not only apply to small children, but generally takes place between individuals. In the context of this elaboration, however, the focus is on the attachment relationships in children.

The explanation and development of attachment goes back primarily to the British psychiatrist John Bowlby and the American social development psychologist Mary Ainsworth, whose theories and concepts are described in more detail below.

2.3.1 Binding / binding behavior according to Bowlby

Bowlby interpreted attachment as an adaptive behavioral system designed to maximize the infant's chances of survival[29]:

- Attachment behavior increases the closeness to a (possible) caregiver and evokes reactions from them.
- Attachment behavior increases the chance for a suffering or injured child to get help.
- Attachment behavior helps ensure that the child can have a secure base (reliability in the social environment).

A common system of interaction (mutual relationship system) develops between mother and child if the mother reacts appropriately to the signals of the newborn child[30]. Infants have a variety of behaviors towards their mother (caregiver) that are designed to create closeness, contact and bonding. Bowlby distinguishes five behaviors in its basic concept, which are described in more detail below:

Suck

The sucking reaction is the first opportunity for a newborn child to come into contact with another person, usually the mother. Sucking means on the one hand to satisfy hunger, on the other hand it is a means of communication. According to Bowlby, the sucking behavior is like a dialogue and is an interaction situation between mother and child: sucking and pause alternate. If the child drinks, the mother remains calm; during the drinking breaks she holds the child in her arms, talks to him and pats him.

Cling

In the first two months of life, the infant develops the grasping reflex, triggered by touching the palms of the hands. A derived meaning of the grasping reflex is holding on to the mother. In addition, there is the creeping reflex, the prying off with the feet in order to come up on the mother's body in order to reach the breast. Both reflexes underline the importance of skin and body contact for building bonds.

Follow

Following the mother - as soon as the motor skills allow it - is important for a young individual for his or her own survival. This active search for contact is a central component of the child's attachment behavior to the mother.

Screaming / crying

Screaming and crying are also a contact signal from a child. A sensitive approach by the mother (caregiver) to the crying or crying child promotes the development of a secure bond.[31]

Smile laugh

According to Bowlby, the smile is also a social signal from a toddler. Usually the sight of a human face is the trigger, closely connected with intense eye contact. Eye contact plays a central role in the mother-child relationship: a mutual exchange develops.

2.3.2 Types of bindings according to Ainsworth

Mary Ainsworth developed the Stranger Situation Test to examine different types of bonds between young children and parents (caregivers)[32]. This test is a standardized procedure used in attachment research to test the reactions of newborn children or infants to being separated from their caregiver and their reaction to strangers:

A child is brought to an observation room together with a caregiver (mother). When the child has got used to the situation, a stranger to the child comes into the room and interacts (play) with the child. The caregiver (mother) then leaves the room, and a short time later the stranger also goes out. The stranger comes back. The caregiver (mother) also re-enters the room and the stranger goes out again.

The social development psychologist M. Ainsworth was able to filter out three main types of attachment relationships as part of the test:

Figure not included in this excerpt

Figure 4: Types of bindings according to Ainsworth, foreign situation test

In most samples, about 70% of toddlers show type B relationships, about 20% type A and 10% type C.

As mentioned earlier, existing relationships have an impact on future relationships. Further studies on the subject of attachment type have shown the following: “In children who were found to have type B attachments during the second year of school, it was found, among other aspects, that they had higher scores in terms of interpersonal skills during their pre-school and kindergarten years , self-efficacy, cognitive development, playing with toys, exploratory skills and motivation to learn. "[33]

2.3.3 Phases of the development of the mother-child bond according to Ainsworth

Ainsworth distinguishes - following Bowlby - four development phases of the mother-child bond:

1. “The pre-attachment phase comprises the first few weeks after the birth. During this time, the child directs his attention to every person who approaches him and shows him behavioral characteristics that have the function of actively making contact. At the end of this phase, the child begins to distinguish between different people, especially between his mother and other people.
2. In the phase of the beginning attachment, the child differentiates not only between known and unknown persons, but also between his trusted caregivers. At the same time, the infant's social behavior repertoire expands, which he uses differently depending on the contact person.
3. Towards the end of the first year of life, the child becomes even more active in making contact with the people he prefers. This is made possible by advances in motor and language development. The child is no longer exclusively fixated on his caregivers, but explores his environment and learns how to handle objects.
4. A new phase of interaction between mother and child is reached when the child overcomes his egocentrism, can adopt the point of view of his mother and learns to understand which feelings and motives guide her actions. ... "[34]

2.4 Development Risks / Risk Factors

In terms of development risks, a distinction is made, from a medical-biological point of view, between harmful influences, the so-called teratogens (Greek, teratogenic: causing deformities), and genetically determined risk factors (defects). A third category - from a developmental point of view - are social risk factors[35].

2.4.1 Teratogens

In research, a distinction is made between exogenous and endogenous teratogens. Under exogenous teratogens one understands damaging influences from outside, these include, among other things. Radiation and the use of medication, alcohol, nicotine, or other drugs. Endogenous teratogens come directly from the mother's organism; B. bacterial infections, anemia, high blood pressure or HIV viruses.

The extent of the impact of factors that cause malformations or malformations depends on when they occur: “The earlier teratogens take effect in embryonic development, the more serious and comprehensive malformations and malformations can be. Damaging influences that occur in the middle trimester of pregnancy often lead to physiological defects, some of which can also affect psychological functions. The effects of teratogens in the last trimester of pregnancy are usually comparatively less serious; they cause z. B. inadequate care of the fetus or trigger a premature birth. "[36]

2.4.2 Genetically determined risk factors

Genetic defects are relatively rare; exact figures are not available. Genetically determined risk factors that can lead to undesirable development of the fetus are z. B. Diabetes, Down syndrome or cystic fibrosis (enzyme defects).

2.4.3 Social Risk Factors

While teratogens and genetic defects are prenatal risk factors, according to the developmental psychologist Hellgard Rauh there are also factors into which children are born: educational level, income, upbringing style, social network, etc. The development of children can be impaired if the social factors are rather unfavorable, z. B. low level of education, low income.

2.4.4 The importance of psychosocial risk factors in infancy and early childhood

The importance of psychosocial risk factors in infancy and early childhood with regard to the development of children from birth to adulthood was investigated in various longitudinal studies. These investigations include, among others. the Mannheim longitudinal study, the Zurich longitudinal study and also the Rostock and Regensburg / Bielefeld longitudinal studies.[37]

One of the most extensive longitudinal studies on the subject is the Kauai Study. The method and results of the study are briefly presented here:

“In 698 children born in 1955 on the island of Kauai in Hawai [sic!], The research team (paediatricians, psychologists, social workers) examined the influence of biological and psychosocial risk factors, critical life events and protective factors on the development of the children. The first data for this study were already collected in the prenatal development period. The development of the children and their living conditions were then recorded after birth at the age of 1, 2, 10, 18, 32 and 40 years.

The parents of these children came from very different ethnic groups (Hawaians, Japanese, Filippinos, Portuguese, Chinese, Koreans and a small group of Europeans). More than half lived in chronic poverty. Most of the fathers were semi-skilled or unskilled workers and the schooling of the mothers was less than eight years. The risk factors increased in 30% of the surviving children in this study population. Their families lived in constant poverty, there were complications with the birth of these children, the parents had significant psychological problems, and there were constant arguments in the families. "[38]

In the Kauai study, the following risk and stress factors, which have a negative and inhibiting effect on the development of the children observed and examined, were determined:

Primary Risk Factors During Childbirth:

- chronic poverty
- the mother's low level of education
- moderate to severe birth complications
- genetic abnormalities
- mental disorders of the parents

Primary stressors affecting childhood and adolescence:

- Longer separation from the primary caregiver in the first year of life
- Birth of a younger brother or sister within the first two years of life
- chronic illnesses and mental disorders of the parents
- chronic family breakdown
- absence of the father
- Parents' unemployment
- Change of residence and school
- Parental divorce, remarriage
- Farewell to or death of family members or close friends
- Admission to a reform home

Overall, the various studies came to similar results, which are outlined below:

Kauai study

"Two thirds of these children, who were already exposed to four or more risk factors at the age of two, developed severe learning or behavioral problems in school, became delinquent and had psychological problems in adolescence."[39]

Mannheim study

“The development-inhibiting influence of stressful family circumstances was shown at the age of eight in significantly lower intelligence values ​​than in the comparison group. The differences between the expansive and introversive types of psychological abnormalities were even clearer. The motor development of these children, on the other hand, was hardly impaired. The impairment of school developments was shown by the fact that children from these socially stressed families attended a special needs school significantly more often (...), were more likely to start school late or have repeated the first grade. "[40]

Zurich longitudinal study

"The socio-economic status determines the intellectual development far more than all currently ascertainable prenatal and perinatal risk factors."[41]

Rostock and Regensburg / Bielefeld study

“In living conditions of poverty and social disadvantage, a child is particularly at risk if it suffers from a lack of food, calories and vitamins or trace elements. Symptoms of illness can then appear, (...) failure to thrive (...); ... Neglect is usually associated with a rejection of the child, for whatever reason, and thus for the child with a lack of emotional closeness, security and the possibility of interactions with the caregivers. This has consequences for physical development (psychosocial short stature), but especially for the development of motor and cognitive skills, not least for emotional reaction and the formation of personality. "[42]

Overall, it becomes clear - even if the results of risk research are only descriptive statements about the connections between risk factors and child development and do not allow any causal conclusions - that the occurrence of risk and stress factors increases the likelihood that disorders will occur in the children's lives. The accumulation of several risks leads to a significant increase in the likelihood that children will become psychologically abnormal and develop disorders.

The Kauai study also shows, however, that a third of the children examined have developed positively despite the risks and stress factors to which they were exposed; The risk factors were offset by protective factors (resilience):

- protective factors in the child (activity, tenderness, independence, problem-solving skills, communication skills)
- protective factors in the family (close bond with a stable person)

Almost all studies come to the following conclusion: The decisive protective factor is a stable emotional relationship between the child and at least one parent or other caregiver.

“Chronic poverty, family disharmony and even parents with psychotic disorders could not disturb or inhibit the positive development of these children if they had the chance to“ build a close bond with at least one competent and stable person who was attuned to their needs. All these children developed a basic trust. "(Quoted in Werner 1997, 196)"[43]

3 women, children and addiction

3.1 Children of parents with addictive substances

Based on scientific findings, children with parents suffering from addictive substances can be characterized as a risk group for negative psychological and social developments (e.g. behavioral disorders and early substance use). Especially for children of alcohol-dependent parents, an up to six-fold increased risk of their own addictive substance consumption was found[44].

The few available research papers on the topic of "children of drug-dependent parents" show that parental drug use can have a strong negative influence on the psychosocial development of children:

- Children of drug-dependent parents are deprived of the necessary physical care and attention.
- Both the cognitive and the socio-emotional development of children are delayed, hindered or permanently destroyed.
- Children whose parents are addicted to drugs are generally raised and influenced in such a way that they themselves become drug users /
-consumers can become.

Children from families with addiction hardly experience family stability, reliability, non-violence and positive affection - important variables for healthy psychological development. You are born with numerous risks, such as:

- unemployment, poverty
- neglect
- single parents (primarily mothers)
- frequent separation experiences
- changing foreign placements
- criminalization and prosecution of parents
- negative effects of the use of other substances
- Parents' lack of parenting skills due to their own experience of deficiency (e.g. trauma)
- Dangers of poisoning and accidents in the parental household

These conditions are more common in families where at least one parent is opiate dependent.

It can be assumed (hypothetically) that growing up with two drug-dependent parents is much more risky than with just one dependent parent.

This aspect has already been confirmed in research on children with alcohol-dependent parents, empirical studies on parents who use illegal substances such as B. Consuming heroin or cocaine does not exist or, according to Klein, has not yet been empirically confirmed.

The following overview provides an outline of how many drug addicts children have - stating the original or secondary sources:

Figure not included in this excerpt

Table 1: How many drug addicts have children? Source: Klein 2003, p. 360

The data can only be taken from individual studies and investigations, since, according to Klein (2003), there are no overview studies on the population of drug addicts. It is estimated that there are around 40,000 to 50,000 children in Germany whose parents are addicted to drugs.

3.2 Drugs and pregnancy - effects of drugs on the unborn child

In Germany, only relatively few women who are addicted to drugs are pregnant[45]. Typical for these pregnancies are the late determination of the pregnancy, few preventive examinations, the unfavorable social conditions and the high rates of concomitant diseases. Pregnancies are also threatened by miscarriages, premature births and birth defects and by the withdrawal syndrome after childbirth.

In the following sections, the consequences of nicotine, alcohol and drug addiction (opiates, stimulants, hallucinogens) on the unborn child according to Dr. Regina Rasenack briefly outlined:

3.2.1 Tobacco / Nicotine

Despite the well-known negative effects of smoking on the unborn child, around a third of all pregnant women are smokers. Consequences of tobacco consumption for the child during pregnancy are: respiratory arrest due to detachment of the uterus, premature births, miscarriages and malnutrition, respiratory diseases, narrowing of the blood vessels or circulatory disorders, behavioral disorders (e.g. ADHD), the increased risk of sudden infant death syndrome ( SIDS), reduced birth weight.

3.2.2 Alcohol

In Germany, one in 300 newborns is damaged by alcohol, around 10% of all pregnant women drink alcohol (alcohol abuse). The harmful influence of alcohol on the child's development is defined by two groups:

- Fetal alcohol syndrome (FAS), full picture: Deficiency development, facial malformations / abnormalities, permanent brain development disorders (intellectual disability), behavioral disorders
- Fetal alcohol effects (FAE), weakened variant: predominantly functional disorders

Typical of alcohol embryopathy are reduced weight, reduced body size and reduced head circumference.

The level of risk of harm to the unborn child depends on the severity of the alcohol dependence; the frequency of fetal alcohol syndrome (FAS) in alcohol-dependent pregnant women is given in the literature as 10% (after: Abel 1995, 1999).

3.2.3 Illegal drugs

Basically typical and very damaging for the development of children are the chaotic living conditions with poor nutrition, unfavorable living conditions, procurement stress and crime, prostitution and the late determination of pregnancy with few preventive examinations that predominate in drug-dependent pregnant women. Infections such as hepatitis B and C and (very rarely) HIV, as well as the frequently existing polytoxicomania and psychiatric diseases have a negative impact on unborn and newborn children.

The Dependence on opiates (heroin, morphine, etc.) is generally low in Germany and therefore low among pregnant women[46]. Heroin itself has no potential to cause malformations (teratogens), but withdrawal during pregnancy can lead to intrauterine fetal death. Further problems during pregnancy are the development of deficiencies, the risk of premature birth and late neurological damage in microcephaly (abnormally small size of the head due to malformation of the brain).

Furthermore, neonatal abstinence syndrome (NAS) is to be expected after birth, which in around 70% of the newborns of opiate-dependent pregnant women leads to a condition in need of therapy (shortness of breath, tremors, diarrhea and vomiting, possibly convulsive seizures). Treatment of withdrawal (via medication) is usually carried out and monitored as an inpatient in the hospital.

The Use of stimulants (cocaine, amphetamines) during pregnancy is even rarer in Germany than opiate addiction[47]. Stimulants basically cause the blood vessels to constrict, which leads to a reduced blood flow throughout the body and thus also in the placenta (uterus). The consequences are the increased incidence of miscarriages and intrauterine fetal deaths. There is also an increased likelihood of malformations (e.g. in the skeletal system). Acute toxic symptoms are to be expected in the first few months after birth and the incidence of sudden infant death syndrome (SIDS) is increased.

The effects of the Hallucinogen consumption (marijuana, LSD, etc.) on the unborn child are similar to those of tobacco addiction. Even if the malformation rate is not increased by taking hallucinogens, the children often suffer from impaired speech and memory performance, and perinatal mortality (= death between the end of pregnancy and shortly after birth) is also increased[48].

3.3 Born addicts - newborns from mothers who are addicted to heroin

“In the life of a heroin addict who finds out that she is pregnant, however, there is usually next to nothing in line with the social expectations of an expectant mother. She often only notices the pregnancy in the fourth or fifth month because, as a result of opiate consumption, she has not had a regular cycle for a long time and did not expect to become pregnant. In the crucial first few months she was not able to adjust to the pregnancy, probably did not live healthily, but smoked, drank, took various drugs and ate poorly. She may have no apartment, no money, no caring husband, and if there is a father for the child at all, it may be someone who is also at the bottom of the social ladder, a junkie. She may have to finance her drug use and livelihood by prostituting herself. She often has no non-drug addicts, no relatives with whom a relationship has been maintained. She is often the child of addicted parents herself, a child who grew up in a home or with a foster family. There is hardly anyone who trusts her to raise a child. And she may never have developed a positive relationship with her body and sexuality. Very many drug addicts women were sexually abused in their childhood (...).

However, a drug addict who becomes pregnant may also have some of these problems. Perhaps she has so far managed to combine her addiction with a job, perhaps she has been able to maintain a bit of independence in the form of her own apartment, perhaps she also has a doctor who “supplies” her with medication when heroin runs out , or which enables her to get out of the procurement stress with the help of a substitute substance. (...)

Despite all this, and although drug addicts - with or without HIV infection - can easily get a medical indication for an abortion after the third month, many choose to have a child. (...)

Pregnancies in women who are addicted to heroin often end one to two months before the expected due date - and especially often when they live in poor social and health conditions. The children of heroin-dependent mothers are also exposed to particular risks at birth. (...)

Often they are underweight tiny creatures that (...) lie in an incubator or in a transparent plastic bed, connected to hoses and cables, so that their mothers hardly dare to touch them. “The babies are shaky, gray and sometimes have cramps, they are particularly restless; In addition, there are small neurological abnormalities, such as particularly high-pitched, high-pitched screaming, ”is how child psychologist Susanne Börner sums up her experiences with heroin babies. (...)

According to Dr. Bert Smit, senior physician in the neonatal ward of the Academisch Medisch Centrum (AMC) Amsterdam, until the physical withdrawal of a heroin baby is over and it can be discharged home. Around eighty percent of the newborns of mothers who are addicted to heroin or methadone are treated with medication because withdrawal symptoms appear, which are now summarized in the term 'neonatal abstinence syndrome' (NAS): among other things, underweight, excessive irritability, restlessness, excessive Crying, strong need to suckle, diarrhea and vomiting. Around a fifth of children show practically no withdrawal symptoms, despite their mother's heavy drug use. (...) "[49]

Poor material conditions (regular use of drugs, chaotic lifestyle, etc.) can lead to medical complications for the mother during pregnancy, such as: B. malnutrition, vitamin deficiency and chronic bronchitis. There may also be complications associated with intravenous drug use and sharing syringes: hepatitis, HIV / AIDS, phlebitis, gangrene, abscesses.[50]

3.4 Drugs and upbringing - effects of drug use on the child and the family

“The only thing that is reliable is unreliability. (...) ”- This is the headline of the keynote speech by Ingrid Arenz-Greiving at the symposium of the Federal Ministry for Health and Social Security in 2003 on the subject of“ Family secrets - when parents are addicted and their children suffer ”. In this paper Arenz-Greiving describes the situation of children in alcoholic families. The contents are summarized in the following.

Children of parents with addictions have numerous secrets to keep, as addiction is still a stigmatized disease. Nobody should notice what is really going on in the family.

A family with addiction often experiences crises: the dependent parent often loses their job, financial problems arise, social isolation increases, the relationship between the parents and the relationship within the entire family deteriorates.

As the dependent parent loses control of his or her life, he gains power and control over the family: He is the focus, receives care and attention, and sets rules that other family members obey and obey. The partnership and parent-child relationships or the interactions within the family structure are disturbed.

It is typical for an addict family to deny the addiction problem and the relationship problems. Conflicts are avoided and trivializing the situation and shifting the causes of the problem outward often seems to be the only solution to dealing with the situation. The family usually moves for years between hope on the one hand and disappointment on the other.

[...]



[1] Klein 2003, p. 1

[2] See Klein 2003, pp. 361, 366

[3] I have been able to gather this view from conversations with friends / acquaintances and family in the past since I started working in addiction care (author's note).

[4] See www.forum-recht-online.de/2003/203/203bammann.htm

[5] See Action Addiction Prevention 2001

[6] See Action Addiction Prevention 2001; see Schmidtbauer / vom Scheidt 1989, p. 493

[7] See Glöckl 2004, p. 1

[8] See Wittchen 1998, p. 32

[9] See Davison / Neal 2002, pp. 403f.

[10] Soyka 1998, p. 12

[11] See German headquarters against the dangers of addiction, brochure alcohol

[12] See Schmidtbauer / von Scheidt 2003, p. 246

[13] See Action Addiction Prevention 2001

[14] See Schmidtbauer / von Scheidt 2003, p. 343

[15] Addiction prevention campaign 2001

[16] See German headquarters against the dangers of addiction, brochure Heroin

[17] See German headquarters against the dangers of addiction, brochure cocaine

[18] See Wille 1994, p. 14ff

[19] See Laaser 2004, p. 1

[20] Laaser 2004, p. 1 [(sic!)]

[21] See Action Addiction Prevention 2001

[22] See Langfeldt 1996, p. 347

[23] German headquarters against the dangers of addiction, brochure "An offer to all, ..."

[24] See box 2005, p. 32ff.

[25] Box 2005, p. 34

[26] See box 2005, pp. 35ff.

[27] See Durkin 2002, p. 59

[28] Durkin 2002, p. 59

[29] See Durkin 2002, p. 60

[30] See Schmidt-Denter 2005, p. 13

[31] Further empirical findings on this thesis show that screaming and crying can have several functions (cf. Schmidt-Denter p. 14, 2005), which are not dealt with in detail in this elaboration.

[32] See Durkin 2002, p. 61

[33] Durkin 2002, p. 62

[34] See Schmidt-Denter 1996, p. 29f.

[35] See box 2005, pp. 65ff.

[36] Box 2005, p. 66

[37] See Klein 2002, pp. 20ff.

[38] Klein 2002, p. 20

[39] Klein 2002, p. 20; quoted in Werner 1999, 26

[40] Klein 2002, p. 21; based on: Laucht, Esser, Schmidt 1999

[41] Klein 2002, p. 21, quoted in Largo 1995, 17

[42] Klein 2002, p. 21f., Quoted in Neuhäuser 2000, 44

[43] Klein 2002 [(sic!)]

[44] See Klein 2003, pp. 359ff.

[45] See Rasenack 2003; Numbers are not known

[46] Numbers are not available.

[47] Exact numbers were not given.

[48] Numbers are not mentioned (author's note).

[49] Soer / Stratenwerth 1991, p. 53ff [(sic!)]

[50] Cf. Soer / Stratenwerth 1991, pp. 185f.

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