Psychological well-being and workability in child abuse investigators

Psychological well-being and workability in child abuse investigators Abstract Background Working with victims and offenders of child abuse can impact on the health and well-being of police officers and staff. Aims To identify the effects of tenure, work ability, gender and a personal experience of child abuse on symptoms of anxiety, depression and primary and secondary trauma in child abuse investigators (CAIs). Methods Screening questionnaires were sent to police officers and staff. The officers and staff worked in child protection in seven police forces. The surveillance was undertaken online and the data were encrypted and personal identifiers removed. The four clinical measures were Goldberg Anxiety/Depression Scale, Professional Quality of Life and Impact of Events (extended). Results Eighty-two per cent of 2798 CAIs returned questionnaires. There was a statistically significant relationship between all four clinical symptoms and workability (P < 0.001), between tenure and primary trauma (P < 0.01) and between anxiety, depression, primary trauma and workability and adverse childhood experience (ACE) scores (P < 0.001). Regression analysis showed that workability, tenure and ACE scores explained between 12 and 23% of the variance. There were gender differences with women having higher levels of symptoms; however, the effect size and clinical significance were negligible for all but the primary trauma scores. Conclusions Psychological surveillance can provide an important source of evidence for occupational health practitioners working with CAIs in informing them of the factors which could be considered in selecting, training, supporting and retaining officers and staff. Psychological surveillance can also help police management to identify ways to monitor the long-term effectiveness and well-being of CAIs. Adverse childhood experiences (ACE), child abuse investigators, gender, risk, tenure, workability Introduction The protection of children by the police is regionally organized in the UK. Within each force child abuse is investigated by specialist child abuse investigators (CAIs). The investigations include direct contact with children and offenders, historic child abuse, internet abuse and grooming. Occupational health (OH) professionals working within the police are aware of the adverse effects of exposure to child abuse images on CAIs [1] through increased sickness absence, requests for redeployment and medical retirements [2]. Psychological risk assessments of CAI roles which involve looking at several risk factors including the type, duration and seriousness of the abuse indicate that CAIs fall within a psychological high-risk group requiring regular screening and support [3]. It has been shown that early life trauma increases vulnerability to traumatic stress [4,5]. Surveys have indicated that CAIs are more likely to have experienced early life abuse than other occupational groups [6]. The use of tenure, the length of time an officer can remain in a role without a break, is applied to high-risk roles with the aim of reducing the potential impact of the role on health. Guidelines on tenure have been established which balance the needs of the force for retaining skilled investigators with the duty to protect their well-being. Many UK police officers are working longer, with some forces using the Work Ability Index (WAI) to monitor older officers deployed in high-risk roles. A workability scale [7] was developed to monitor the problems of an ageing workforce. A single-item question (What is your current ability to work compared to your highest ever ability to work?) has been taken from the scale and adopted as a workability measure [8] to test ongoing fitness for work. The measure has been shown to be effective in predicting future physical and psychological well-being. This is the first time that the workability measure has been used as an indicator of vulnerability to develop traumatic stress symptoms. The known psychological risks inherent in the CAI role create a responsibility for the employer to meet their duty of care under health and safety legislation [9]. While the use of physical health surveillance for ensuring physical ‘fitness for role’ with regular checks on eyesight, hearing and blood pressure is accepted in policing, it is less common to find screening for psychological conditions such as anxiety, depression and post-traumatic stress. This is despite the legal guidance requiring the surveillance of psychosocial hazards to be treated with the same importance as physical hazards [10]. An efficient way to measure psychological symptoms is through self-reported psychological screening. There are many questionnaires and screening tools which can be used to assess psychological conditions. However, not all are valid, reliable or appropriate for psychological surveillance [11]. The CAI surveillance programme monitors clinical symptoms [12], gender personality [13], coping [14] and other resilience factors [15]. Most police forces provide psychological screening for CAIs; these vary from an annual ‘welfare chat’ to a comprehensive psychological assessment using validated questionnaires and clinical assessments. Researchers have used screening to examine stress and trauma in CAIs [16,17]; however, reports on surveillance of workers in high-risk occupations are rare [18]. Where psychological surveillance is used, paper questionnaires are declining in favour of online screening as a means of ensuring data protection and confidentiality of personal material [19]; however, the benefits from online administration and data analysis also include the speed, accuracy of result generation and ease of providing management information on trends. Brewin and Copas [18] evaluated a CAI surveillance programme and found that almost 21% of workers had clinically significant trauma symptoms. The screening of three teams of CAIs [16] found high levels of anxiety, depression, burnout and primary and secondary trauma. A study of 294 CAI officers [14] found most coped well but some had significant reactions. A study of 562 child welfare workers [20] identified a high level of vicarious trauma with men having higher levels of symptoms than women. Craun et al. [17] used qualitative and quantitative measures in CAIs and found that many had become over involved in their work to the detriment of their own children. Brady [21] examined the levels of secondary traumatic stress, burnout and compassion satisfaction in CAIs and found that a quarter of the CAIs had low levels of compassion satisfaction and high levels of burnout and secondary trauma. The aim of this study was to address the following questions: What is the evidence that time in role (tenure) and workability are related to higher levels of primary and secondary traumatic stress? Does the number of early life traumas [adverse childhood experience (ACE) scores] increase the incidence of higher levels of traumatic stress symptoms? Are there gender differences in the levels of trauma responses? Methods The police forces involved in the study had adopted psychological surveillance for CAIs and had entered the surveillance programme over a 3-year period. In each of the CAI units, the investigators had been in post for different lengths of time. Some had just started working as a CAI and others had been in post for many years. The surveillance measures used in the study assessed levels of anxiety, depression and primary and secondary trauma. In addition, demographic information on gender, time in role (tenure), ACE and workability were gathered. The data were collected online as part of a regular surveillance programme that had been adopted by seven police forces. A link to the psychological screening questionnaires was sent to each of the CAIs. Those new to screening received an introductory letter to explain the purpose of the programme and contact names for queries or problems in completing the questionnaire. On the first page of the questionnaire, the participants ticked a box to confirm they had read the confidentiality statement and were aware that anonymized results would be combined to produce management information to improve the programme’s effectiveness. There was an option for participants to enter ‘preferred not to respond’ to questions regarding early life abuse or adversity. This study used data gathered in a surveillance programme with the purpose of reducing the incidence of primary trauma, compassion fatigue, anxiety and depression in CAIs. Anonymized data were aggregated for presentation to management in the form of dashboards showing mean scores for each of the clinical measures together with other information gathered in the screening including lifestyle, resilience and intention to leave. CAIs with significant or marginal scores were referred to an OH practitioner (OHP) or psychologist for well-being guidance, a referral for therapy or other support. Where there were concerns for safety or other red flag indicators, a direct referral was made to an OHP or psychologist. The dependent variables were four self-reported clinical measures. The cut-off levels for these measures had already been established [21]. The dependent variables were: Goldberg Anxiety and Depression Scale [22] which comprised of nine anxiety and nine depression symptoms experienced during the previous month. The range for this scale is 0–9 for each symptom. Secondary trauma was measured using the Professional Quality of Life Scale [23] and includes fear, sleep difficulties, intrusive images and avoidance. The participants indicate the frequency of their responses on a 5-point scale. This scale has been widely used and has high levels of reliability and validity. The range for secondary trauma is 0–50 on this scale. Traumatic stress was measured using the Impact of Events Scale-E [24]. This scale is made up of 23 items measuring the frequency of symptoms of avoidance, arousal and re-experience of trauma symptoms on a 5-point scale. In this study, global score which was the sum of the three symptoms was used to create a post traumatic stress disorder score with a range of 0–92 and the measure has been validated in a UK working population. The influence of four independent variables was examined in the study: (i) gender, (ii) years in post (tenure), (iii) the response to the workability questionnaire and (iv) the number of ACEs. As this study involved health and safety practice rather than research [25] and was undertaken under health and safety legislation, it did not require ethics approval. Nevertheless, the surveillance practice adopted meets the ethical standards required by the British Psychological Society [19]. The data were analysed using PSPP (GNU PSPP Statistical Analysis Software Release 0.9.0-g3a3d58). Results A total of 2798 CAIs were sent screening invitations and 2289 were completed. The overall response rate was 85% with most of the missing responses being due to CAIs being on sabbatical, moving role or on maternity leave. A small number of CAIs reported that they did not wish to participate in the programme. As the questions on workability and tenure were only added at the beginning of year 2 and year 3, the number of CAIs answering these questions was reduced to 732 and 658, respectively. The mean age of the group was 39 years, 56% were female and the mean number of years in the CAI post was 1.7 years. The first independent variable examined was gender. An independent samples t-test indicated that scores were significantly higher for anxiety: women (M = 2.92, SD = 2.63), men (M = 2.97, SD = 2.53), P < 0.001, d = 0.13; depression: women (M = 1.86, SD = 2.13), men (M = 1.65, SD = 2.00), P < 0.01, d = 0.1; secondary trauma: women (M = 9.94, SD = 6.72), men (M = 9.13, SD = 6.56), P < 0.01, d = 0.12; and primary trauma: woman (M = 31.46, SD = 18.03), P < 0.001, d = 0.38. Although all these gender differences were statistically significantly different, the effect size (Cohen d) was small. The magnitude of the clinical significance was negligible for anxiety, depression and secondary trauma (i.e. between 0.22 and 0.35 of a point on the 9-point scale). There was a moderate clinical difference (i.e. 6.83 points on a 92-point scale) between men and women for primary trauma (Table 1). Table 1. Gender differences in levels of anxiety, depression, secondary trauma and primary trauma in CAI Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 CI, confidence interval. View Large Table 1. Gender differences in levels of anxiety, depression, secondary trauma and primary trauma in CAI Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 CI, confidence interval. View Large A correlation was undertaken between the dependent and independent variables. It was found that tenure was positively correlated with primary trauma, r = 11, P < 0.01, but not with anxiety, depression or secondary trauma. These results suggest that a longer the time in role is associated with higher levels of trauma symptoms. Workability was negatively correlated with primary trauma, r = −0.31, P < 0.001; secondary trauma, r = −0.39, P < 0.001; anxiety, r = −0.48, P < 0.001; and depression, r = −0.42, P < 0.001. These results mean that the higher and more positive the workability score the lower the levels of symptoms. ACEs were positively correlated with primary trauma, r = 0.15, P < 0.001; anxiety, r = 12, P < 0.001; and depression, r = 14, P < 0.001. This suggests that a CAI with more ACEs had higher levels of symptoms. The analysis indicated no correlation between tenure and workability but an almost perfect correlation between workability and the ACE scores (Table 2) which suggests that there may be general factors for ACE and workability. Table 2. Correlations between tenure, ACE scores, workability and the four clinical scores Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 NS, non-significant. View Large Table 2. Correlations between tenure, ACE scores, workability and the four clinical scores Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 NS, non-significant. View Large A linear regression analysis was undertaken to test how much of the variance in primary trauma could be predicted by tenure and workability. The results showed that taken together tenure and workability accounted for 12% of the variance for primary trauma, R2 = 0.12, F(2,400) = 27.4, P < 0.001, and that workability significantly predicted primary trauma β = −0.31, P < 0.001 as did tenure β = −0.16, P < 0.001 (Table 3). Table 3. Tenure and workability as predictors of primary trauma Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 CI, confidence interval. View Large Table 3. Tenure and workability as predictors of primary trauma Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 CI, confidence interval. View Large A second linear regression analysis was then undertaken to test if workability predicted levels of anxiety, depression and secondary trauma. The results showed workability predicted 23% of the variance for anxiety, 18% of the variance in depression and 15% of the variance in secondary trauma (Table 4). Table 4. Workability as a predictor of anxiety, depression and secondary trauma Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 CI, confidence interval. View Large Table 4. Workability as a predictor of anxiety, depression and secondary trauma Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 CI, confidence interval. View Large Discussion This study demonstrated that all four independent variables impacted on mental health of CAIs with workability and ACE scores being the strongest predictors. This study involved the screening of a large group of CAI and achieved a high completion rate. The results were representative of this group of workers; however, it is not possible to say whether these results would be replicated in all police forces or in other occupational groups dealing with child abuse such as social workers, children’s charity workers and those in educational safeguarding. Other studies [16,17] have looked at smaller numbers of CAIs with lower completion rates; however, the results of this study confirm their findings demonstrating that working as a CAI poses a risk to mental health. One of the weaknesses of the study is its cross-sectional design; however, it is planned that the next stage of the screening programme will build on its database of results to undertake a longitudinal study on this group of workers. The findings from this study suggest that staying in role longer (tenure) caused CAIs to experience increased levels of primary trauma. This finding is important for police forces who may need to consider introducing psychological screening and role rotation of CAIs as a means of identifying and reducing the incidence of primary trauma in this group. The workability scale [8] was a recent introduction to the psychological screening programme and found to be a strong predictor of the four mental health measures. Workability is becoming established as a useful construct in OH [7] and the use of the workability measures in screening ageing and vulnerable workers is increasing. The study showed a lack of correlation between workability and tenure, suggesting that these variables may be affecting mental health via different pathways; however, this study did not explore this relationship and more work will be required to establish the underlying mechanisms. The study showed that low workability scores were strongly correlated with high ACE scores—these findings are consistent with earlier research which has shown that high ACE scores predict poorer well-being in later life [26]. The study also found that CAIs with more ACEs had higher levels of anxiety, depression and an increased incidence of primary but not secondary trauma. While the effects of ACE scores on anxiety, depression and primary trauma were in the anticipated direction, the discovery that there was no relationship between ACE and secondary trauma was a new and unexpected finding. A possible explanation could be that where a CAI has experienced early life trauma or adversity, working on investigations with children exposed to similar events could re-trigger responses to their own unresolved childhood traumas rather than create a secondary trauma response. This area needs further investigation but is likely to be complex as many early life traumas are stored out of conscious awareness until situationally activated through the actual exposure to stimuli mirroring their own childhood experiences [27]. Workability was a strong predictor of trauma symptoms, however, the information it provides fails to provide any indication of possible causal factors which could be used to inform counselling or therapeutic intervention to enhance well-being. An interesting follow-up to this study would be to investigate whether helping CAIs deal with their early life traumas through counselling or education would improve their workability and increase their overall resilience. There has been a lot of interest about whether men or women are more vulnerable to developing mental health conditions [4,13]. This study showed that while the statistical difference between the scores of men and women was significant, the effect size was tiny and the clinical difference is negligible apart from primary trauma where the results showed a slightly increased vulnerability in women. Women have always fulfilled an important role in child abuse investigations, so it is important for police forces to consider how they might respond to these findings. There is no evidence from this study to suggest that women should be prevented from working in a CAI role, but police forces need to ensure that CAIs are selected and psychologically assessed for ACEs that could increase their risk of developing mental health problems. The applicants should be informed of the potential risks of the role, educated in recognizing the early signs and symptoms of trauma and appraised of the support available should it be required. A follow-up longitudinal study which looks at the way in which tenure, workability, gender and ACE scores interact to cause increased psychological distress would be helpful in building the understanding of these variables [28]. It could be argued that in police forces, a small change in symptoms may be important in reducing sickness absence by protecting the well-being and effectiveness of teams. Some of the major determinants of the trauma symptoms are inherent in the CAI work and there are some aspects of the role that cannot be changed such as viewing child abuse images. However, leadership style, peer support, shift patterns and training may be more important factors. Even if it were possible to address the organizational issues finding ways to reduce tenure strain by rotating officers, having family friendly shift patterns or providing support for officers with early life adversity could make a substantial difference to sickness absence levels and worker efficiency. Although this study provides some insights into the way in which working with child abuse can cause increased levels of clinical symptoms, it also raises many additional questions that will need to be answered in future studies. Key points Child abuse investigators are at risk of developing symptoms of anxiety, depression and primary and secondary trauma. In this study there was a statistically significant relationship between clinical symptoms and workability, tenure and adverse childhood experience scores. The online delivery of psychological questionnaires makes surveillance easier and allows for valuable data to be gathered. Competing interests None declared. References 1. 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Psychological well-being and workability in child abuse investigators

Occupational Medicine , Volume Advance Article (3) – Mar 13, 2018

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Abstract

Abstract Background Working with victims and offenders of child abuse can impact on the health and well-being of police officers and staff. Aims To identify the effects of tenure, work ability, gender and a personal experience of child abuse on symptoms of anxiety, depression and primary and secondary trauma in child abuse investigators (CAIs). Methods Screening questionnaires were sent to police officers and staff. The officers and staff worked in child protection in seven police forces. The surveillance was undertaken online and the data were encrypted and personal identifiers removed. The four clinical measures were Goldberg Anxiety/Depression Scale, Professional Quality of Life and Impact of Events (extended). Results Eighty-two per cent of 2798 CAIs returned questionnaires. There was a statistically significant relationship between all four clinical symptoms and workability (P < 0.001), between tenure and primary trauma (P < 0.01) and between anxiety, depression, primary trauma and workability and adverse childhood experience (ACE) scores (P < 0.001). Regression analysis showed that workability, tenure and ACE scores explained between 12 and 23% of the variance. There were gender differences with women having higher levels of symptoms; however, the effect size and clinical significance were negligible for all but the primary trauma scores. Conclusions Psychological surveillance can provide an important source of evidence for occupational health practitioners working with CAIs in informing them of the factors which could be considered in selecting, training, supporting and retaining officers and staff. Psychological surveillance can also help police management to identify ways to monitor the long-term effectiveness and well-being of CAIs. Adverse childhood experiences (ACE), child abuse investigators, gender, risk, tenure, workability Introduction The protection of children by the police is regionally organized in the UK. Within each force child abuse is investigated by specialist child abuse investigators (CAIs). The investigations include direct contact with children and offenders, historic child abuse, internet abuse and grooming. Occupational health (OH) professionals working within the police are aware of the adverse effects of exposure to child abuse images on CAIs [1] through increased sickness absence, requests for redeployment and medical retirements [2]. Psychological risk assessments of CAI roles which involve looking at several risk factors including the type, duration and seriousness of the abuse indicate that CAIs fall within a psychological high-risk group requiring regular screening and support [3]. It has been shown that early life trauma increases vulnerability to traumatic stress [4,5]. Surveys have indicated that CAIs are more likely to have experienced early life abuse than other occupational groups [6]. The use of tenure, the length of time an officer can remain in a role without a break, is applied to high-risk roles with the aim of reducing the potential impact of the role on health. Guidelines on tenure have been established which balance the needs of the force for retaining skilled investigators with the duty to protect their well-being. Many UK police officers are working longer, with some forces using the Work Ability Index (WAI) to monitor older officers deployed in high-risk roles. A workability scale [7] was developed to monitor the problems of an ageing workforce. A single-item question (What is your current ability to work compared to your highest ever ability to work?) has been taken from the scale and adopted as a workability measure [8] to test ongoing fitness for work. The measure has been shown to be effective in predicting future physical and psychological well-being. This is the first time that the workability measure has been used as an indicator of vulnerability to develop traumatic stress symptoms. The known psychological risks inherent in the CAI role create a responsibility for the employer to meet their duty of care under health and safety legislation [9]. While the use of physical health surveillance for ensuring physical ‘fitness for role’ with regular checks on eyesight, hearing and blood pressure is accepted in policing, it is less common to find screening for psychological conditions such as anxiety, depression and post-traumatic stress. This is despite the legal guidance requiring the surveillance of psychosocial hazards to be treated with the same importance as physical hazards [10]. An efficient way to measure psychological symptoms is through self-reported psychological screening. There are many questionnaires and screening tools which can be used to assess psychological conditions. However, not all are valid, reliable or appropriate for psychological surveillance [11]. The CAI surveillance programme monitors clinical symptoms [12], gender personality [13], coping [14] and other resilience factors [15]. Most police forces provide psychological screening for CAIs; these vary from an annual ‘welfare chat’ to a comprehensive psychological assessment using validated questionnaires and clinical assessments. Researchers have used screening to examine stress and trauma in CAIs [16,17]; however, reports on surveillance of workers in high-risk occupations are rare [18]. Where psychological surveillance is used, paper questionnaires are declining in favour of online screening as a means of ensuring data protection and confidentiality of personal material [19]; however, the benefits from online administration and data analysis also include the speed, accuracy of result generation and ease of providing management information on trends. Brewin and Copas [18] evaluated a CAI surveillance programme and found that almost 21% of workers had clinically significant trauma symptoms. The screening of three teams of CAIs [16] found high levels of anxiety, depression, burnout and primary and secondary trauma. A study of 294 CAI officers [14] found most coped well but some had significant reactions. A study of 562 child welfare workers [20] identified a high level of vicarious trauma with men having higher levels of symptoms than women. Craun et al. [17] used qualitative and quantitative measures in CAIs and found that many had become over involved in their work to the detriment of their own children. Brady [21] examined the levels of secondary traumatic stress, burnout and compassion satisfaction in CAIs and found that a quarter of the CAIs had low levels of compassion satisfaction and high levels of burnout and secondary trauma. The aim of this study was to address the following questions: What is the evidence that time in role (tenure) and workability are related to higher levels of primary and secondary traumatic stress? Does the number of early life traumas [adverse childhood experience (ACE) scores] increase the incidence of higher levels of traumatic stress symptoms? Are there gender differences in the levels of trauma responses? Methods The police forces involved in the study had adopted psychological surveillance for CAIs and had entered the surveillance programme over a 3-year period. In each of the CAI units, the investigators had been in post for different lengths of time. Some had just started working as a CAI and others had been in post for many years. The surveillance measures used in the study assessed levels of anxiety, depression and primary and secondary trauma. In addition, demographic information on gender, time in role (tenure), ACE and workability were gathered. The data were collected online as part of a regular surveillance programme that had been adopted by seven police forces. A link to the psychological screening questionnaires was sent to each of the CAIs. Those new to screening received an introductory letter to explain the purpose of the programme and contact names for queries or problems in completing the questionnaire. On the first page of the questionnaire, the participants ticked a box to confirm they had read the confidentiality statement and were aware that anonymized results would be combined to produce management information to improve the programme’s effectiveness. There was an option for participants to enter ‘preferred not to respond’ to questions regarding early life abuse or adversity. This study used data gathered in a surveillance programme with the purpose of reducing the incidence of primary trauma, compassion fatigue, anxiety and depression in CAIs. Anonymized data were aggregated for presentation to management in the form of dashboards showing mean scores for each of the clinical measures together with other information gathered in the screening including lifestyle, resilience and intention to leave. CAIs with significant or marginal scores were referred to an OH practitioner (OHP) or psychologist for well-being guidance, a referral for therapy or other support. Where there were concerns for safety or other red flag indicators, a direct referral was made to an OHP or psychologist. The dependent variables were four self-reported clinical measures. The cut-off levels for these measures had already been established [21]. The dependent variables were: Goldberg Anxiety and Depression Scale [22] which comprised of nine anxiety and nine depression symptoms experienced during the previous month. The range for this scale is 0–9 for each symptom. Secondary trauma was measured using the Professional Quality of Life Scale [23] and includes fear, sleep difficulties, intrusive images and avoidance. The participants indicate the frequency of their responses on a 5-point scale. This scale has been widely used and has high levels of reliability and validity. The range for secondary trauma is 0–50 on this scale. Traumatic stress was measured using the Impact of Events Scale-E [24]. This scale is made up of 23 items measuring the frequency of symptoms of avoidance, arousal and re-experience of trauma symptoms on a 5-point scale. In this study, global score which was the sum of the three symptoms was used to create a post traumatic stress disorder score with a range of 0–92 and the measure has been validated in a UK working population. The influence of four independent variables was examined in the study: (i) gender, (ii) years in post (tenure), (iii) the response to the workability questionnaire and (iv) the number of ACEs. As this study involved health and safety practice rather than research [25] and was undertaken under health and safety legislation, it did not require ethics approval. Nevertheless, the surveillance practice adopted meets the ethical standards required by the British Psychological Society [19]. The data were analysed using PSPP (GNU PSPP Statistical Analysis Software Release 0.9.0-g3a3d58). Results A total of 2798 CAIs were sent screening invitations and 2289 were completed. The overall response rate was 85% with most of the missing responses being due to CAIs being on sabbatical, moving role or on maternity leave. A small number of CAIs reported that they did not wish to participate in the programme. As the questions on workability and tenure were only added at the beginning of year 2 and year 3, the number of CAIs answering these questions was reduced to 732 and 658, respectively. The mean age of the group was 39 years, 56% were female and the mean number of years in the CAI post was 1.7 years. The first independent variable examined was gender. An independent samples t-test indicated that scores were significantly higher for anxiety: women (M = 2.92, SD = 2.63), men (M = 2.97, SD = 2.53), P < 0.001, d = 0.13; depression: women (M = 1.86, SD = 2.13), men (M = 1.65, SD = 2.00), P < 0.01, d = 0.1; secondary trauma: women (M = 9.94, SD = 6.72), men (M = 9.13, SD = 6.56), P < 0.01, d = 0.12; and primary trauma: woman (M = 31.46, SD = 18.03), P < 0.001, d = 0.38. Although all these gender differences were statistically significantly different, the effect size (Cohen d) was small. The magnitude of the clinical significance was negligible for anxiety, depression and secondary trauma (i.e. between 0.22 and 0.35 of a point on the 9-point scale). There was a moderate clinical difference (i.e. 6.83 points on a 92-point scale) between men and women for primary trauma (Table 1). Table 1. Gender differences in levels of anxiety, depression, secondary trauma and primary trauma in CAI Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 CI, confidence interval. View Large Table 1. Gender differences in levels of anxiety, depression, secondary trauma and primary trauma in CAI Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 Gender Number Mean SD t Significance Mean difference SE 95% CI of the difference Lower Upper Anxiety Female 1279 2.92 2.63 3.22 p < 0.001 0.35 0.11 0.14 0.57 Male 1009 2.57 2.53 Depression Female 1279 1.86 2.13 2.47 p < 0.01 0.22 0.09 0.04 0.39 Male 1009 1.65 2.00 Secondary trauma Female 1279 9.94 6.72 2.90 p < 0.01 0.81 0.28 0.26 1.36 Male 1009 9.13 6.56 Primary trauma Female 1279 31.5 18.0 9.27 p < 0.001 6.83 0.73 5.40 8.26 Male 1009 24.6 16.8 CI, confidence interval. View Large A correlation was undertaken between the dependent and independent variables. It was found that tenure was positively correlated with primary trauma, r = 11, P < 0.01, but not with anxiety, depression or secondary trauma. These results suggest that a longer the time in role is associated with higher levels of trauma symptoms. Workability was negatively correlated with primary trauma, r = −0.31, P < 0.001; secondary trauma, r = −0.39, P < 0.001; anxiety, r = −0.48, P < 0.001; and depression, r = −0.42, P < 0.001. These results mean that the higher and more positive the workability score the lower the levels of symptoms. ACEs were positively correlated with primary trauma, r = 0.15, P < 0.001; anxiety, r = 12, P < 0.001; and depression, r = 14, P < 0.001. This suggests that a CAI with more ACEs had higher levels of symptoms. The analysis indicated no correlation between tenure and workability but an almost perfect correlation between workability and the ACE scores (Table 2) which suggests that there may be general factors for ACE and workability. Table 2. Correlations between tenure, ACE scores, workability and the four clinical scores Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 NS, non-significant. View Large Table 2. Correlations between tenure, ACE scores, workability and the four clinical scores Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 Primary trauma Secondary trauma Anxiety Depression Tenure Workability Tenure  Pearson correlation 0.11 0.02 0.02 0.02  Significance (two tail) 0.01 NS NS NS  Subjects 658 658 658 658 Workability  Pearson correlation −0.31 −0.39 −0.48 −0.42 0.00  Significance (two tail) 0.001 0.001 0.001 0.001 NS  Subjects 732 732 732 732 403 ACE  Pearson correlation 15 02 12 14 01 ∞  Significance (two tail) 0.001 NS 0.001 0.001 NS 0.001  Subjects 2288 2288 2288 2288 658 732 NS, non-significant. View Large A linear regression analysis was undertaken to test how much of the variance in primary trauma could be predicted by tenure and workability. The results showed that taken together tenure and workability accounted for 12% of the variance for primary trauma, R2 = 0.12, F(2,400) = 27.4, P < 0.001, and that workability significantly predicted primary trauma β = −0.31, P < 0.001 as did tenure β = −0.16, P < 0.001 (Table 3). Table 3. Tenure and workability as predictors of primary trauma Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 CI, confidence interval. View Large Table 3. Tenure and workability as predictors of primary trauma Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 Workability Tenure B CI SE r2 Significance B CI SE r2 Significance Primary trauma −6.22 −8.23 to −4.43 0.97 0.12 p < 0.001 −1.09 −1.71 to −1.19 0.32 0.12 p < 0.001 CI, confidence interval. View Large A second linear regression analysis was then undertaken to test if workability predicted levels of anxiety, depression and secondary trauma. The results showed workability predicted 23% of the variance for anxiety, 18% of the variance in depression and 15% of the variance in secondary trauma (Table 4). Table 4. Workability as a predictor of anxiety, depression and secondary trauma Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 CI, confidence interval. View Large Table 4. Workability as a predictor of anxiety, depression and secondary trauma Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 Workability B CI SE r2 Significance Anxiety −1.38 −1.57 to −1.19 0.09 0.23 p < 0.001 Depression −0.98 −1.14 to −0.83 0.08 0.18 p < 0.001 Secondary trauma −2.95 −3.45 to −2.45 0.25 0.15 p < 0.001 CI, confidence interval. View Large Discussion This study demonstrated that all four independent variables impacted on mental health of CAIs with workability and ACE scores being the strongest predictors. This study involved the screening of a large group of CAI and achieved a high completion rate. The results were representative of this group of workers; however, it is not possible to say whether these results would be replicated in all police forces or in other occupational groups dealing with child abuse such as social workers, children’s charity workers and those in educational safeguarding. Other studies [16,17] have looked at smaller numbers of CAIs with lower completion rates; however, the results of this study confirm their findings demonstrating that working as a CAI poses a risk to mental health. One of the weaknesses of the study is its cross-sectional design; however, it is planned that the next stage of the screening programme will build on its database of results to undertake a longitudinal study on this group of workers. The findings from this study suggest that staying in role longer (tenure) caused CAIs to experience increased levels of primary trauma. This finding is important for police forces who may need to consider introducing psychological screening and role rotation of CAIs as a means of identifying and reducing the incidence of primary trauma in this group. The workability scale [8] was a recent introduction to the psychological screening programme and found to be a strong predictor of the four mental health measures. Workability is becoming established as a useful construct in OH [7] and the use of the workability measures in screening ageing and vulnerable workers is increasing. The study showed a lack of correlation between workability and tenure, suggesting that these variables may be affecting mental health via different pathways; however, this study did not explore this relationship and more work will be required to establish the underlying mechanisms. The study showed that low workability scores were strongly correlated with high ACE scores—these findings are consistent with earlier research which has shown that high ACE scores predict poorer well-being in later life [26]. The study also found that CAIs with more ACEs had higher levels of anxiety, depression and an increased incidence of primary but not secondary trauma. While the effects of ACE scores on anxiety, depression and primary trauma were in the anticipated direction, the discovery that there was no relationship between ACE and secondary trauma was a new and unexpected finding. A possible explanation could be that where a CAI has experienced early life trauma or adversity, working on investigations with children exposed to similar events could re-trigger responses to their own unresolved childhood traumas rather than create a secondary trauma response. This area needs further investigation but is likely to be complex as many early life traumas are stored out of conscious awareness until situationally activated through the actual exposure to stimuli mirroring their own childhood experiences [27]. Workability was a strong predictor of trauma symptoms, however, the information it provides fails to provide any indication of possible causal factors which could be used to inform counselling or therapeutic intervention to enhance well-being. An interesting follow-up to this study would be to investigate whether helping CAIs deal with their early life traumas through counselling or education would improve their workability and increase their overall resilience. There has been a lot of interest about whether men or women are more vulnerable to developing mental health conditions [4,13]. This study showed that while the statistical difference between the scores of men and women was significant, the effect size was tiny and the clinical difference is negligible apart from primary trauma where the results showed a slightly increased vulnerability in women. Women have always fulfilled an important role in child abuse investigations, so it is important for police forces to consider how they might respond to these findings. There is no evidence from this study to suggest that women should be prevented from working in a CAI role, but police forces need to ensure that CAIs are selected and psychologically assessed for ACEs that could increase their risk of developing mental health problems. The applicants should be informed of the potential risks of the role, educated in recognizing the early signs and symptoms of trauma and appraised of the support available should it be required. A follow-up longitudinal study which looks at the way in which tenure, workability, gender and ACE scores interact to cause increased psychological distress would be helpful in building the understanding of these variables [28]. It could be argued that in police forces, a small change in symptoms may be important in reducing sickness absence by protecting the well-being and effectiveness of teams. Some of the major determinants of the trauma symptoms are inherent in the CAI work and there are some aspects of the role that cannot be changed such as viewing child abuse images. However, leadership style, peer support, shift patterns and training may be more important factors. Even if it were possible to address the organizational issues finding ways to reduce tenure strain by rotating officers, having family friendly shift patterns or providing support for officers with early life adversity could make a substantial difference to sickness absence levels and worker efficiency. Although this study provides some insights into the way in which working with child abuse can cause increased levels of clinical symptoms, it also raises many additional questions that will need to be answered in future studies. Key points Child abuse investigators are at risk of developing symptoms of anxiety, depression and primary and secondary trauma. In this study there was a statistically significant relationship between clinical symptoms and workability, tenure and adverse childhood experience scores. The online delivery of psychological questionnaires makes surveillance easier and allows for valuable data to be gathered. Competing interests None declared. References 1. 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For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Occupational MedicineOxford University Press

Published: Mar 13, 2018

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