Background: Childhood maltreatment such as abuse, neglect and family violence has a profound impact on children's psychological and relational functioning and their lifelong trajectory, with associated adverse physical and mental health outcomes, higher mortality rates and reduced socioeconomic opportunities. The aim of the study was to explore the impact of neurodevelopmentally- and trauma-informed interventions on the relational health of children who have experienced maltreatment.Context: The study was conducted at Berry Street Take Two, an Australian therapeutic service. Take Two provides services to Victorian children aged 0-18 years, to address the impact of the trauma they have experienced from maltreatment. Take Two clinicians use relational and ecological frameworks, neurodevelopmental research and evidence-informed approaches to repair family relationships and develop networks of caring adults that focus on meeting the child's needs. Take Two uses the NMT approach as a framework for clinical intervention-planning and is site-certified in the use of the NMT Clinical Practice tools.Method: The mixed methods study had two components. A cross sectional study of baseline and repeat clinical measure data (HoNOSCA and SDQ) with a cohort of children aged 2–11 years (n = 91), who were clients of Berry Street Take Two between 2014 and 2019, was conducted utilizing SPSS. The quantitative data analysis was supplemented by three case studies of Berry Street Take Two clients, which explored the process of intervention, including intervention type, timing and dosage. The case studies drew on the full case record for each child to illustrate the impact of NMT-informed interventions on the relational health, psychological and behavioral functioning of children.Results: The study found that Take Two intervention was associated with improved relational health, measured by the NMT metric and supported by significant positive changes on the SDQ and HoNOSCA with medium effect sizes (cohen's d). The case study analysis highlighted the importance of intervention addressing individual, family and systems elements to bring about positive change.Conclusions: This study illustrates the value of neurodevelopmental trauma-informed interventions in positively impacting on the relational health and current functioning of maltreated children and the potential to reduce the lifelong impact of maltreatment. Childhood maltreatment is a complex and challenging issue worldwide. There is a link between childhood maltreatment and adverse life outcomes, with a corresponding high cost to society, both in terms of economics and human suffering . MaltreaThe complexity of the issues related to childhood maltreatment, combined with the heterogeneity of maltreatment experiences and the complexity of their intersection with, and impact on, developmental trajectories, makes researching this area a formidable task . DespiteThe aim of the current study was to explore the impact of individually tailored neurodevelopmental and trauma-informed relational interventions on a cohort of Australian children who have experienced maltreatment.Tanaka et al.  noted thThe Australian Institute of Family Studies  conducteDetermining the prevalence rates of sexual abuse of Australian children is complicated by contested definitions and under-reporting. When broad definitions of abuse and neglect are applied prevalence rates can be up to 45% for females . When moIn the 2017–2018 year ~2.87%  of Australian children were subject to Child Protection interventions such as investigations and care/protective orders. Children who identify as Aboriginal and/or Torres Strait Islander were eight times more likely to be involved in Child Protection Services . This reChild maltreatment can have a pervasive neurophysiological impact on the developing child , 12. ChiSubsequently, children who have suffered maltreatment have a significantly higher risk than the general population of developing physical and mental health difficulties, such as mood, personality and anxiety disorders, schizophrenia, and post-traumatic stress disorder , 15–21. Additional to the neurobiological and psychological impacts, maltreated children are also more likely to have compromised social functioning due to impeded coping strategies and behavioral self-control , 24. As Maltreated children also frequently experience adverse impacts of family separation and negative experiences of the child protection system. These additional stressors, added to the already substantial trauma from the abuse and neglect, create a compounding effect for both the child and family , 31 withIt has been demonstrated that developmentally informed relationally focused intervention occurring following maltreatment can mitigate the negative impacts of maltreatment and developmental trauma for these children. Hambrick et al.  demonstrToth et al.  exploredd = 5.4  , 40, whiOther therapeutic approaches which demonstrate promising evidence include those which target foster parents. Foster parent training is generally based on the principle that foster parents are best placed to identify challenging behaviors and to encourage more adaptive coping strategies . LeadingAnother approach with a relational focus, Multi-Systemic Therapy (MST), was originally intended for children in the juvenile justice system who presented with oppositional defiant and conduct disorders , 50. MSTRelational health is also addressed in other interventions approaches including Filial Family Therapy . Child-fWhile there is a burgeoning of promising evidence in the literature on effective interventions for maltreated children, systematic reviews are yet to yield sufficiently strong evidence for any particular approach , 59. TheThere have been promising gains in the development of evidence-based frameworks for assessing the impact of maltreatment on a child's neurological and physiological development . Given tOne framework for understanding and assessing the impacts of childhood maltreatment is the Neurosequential Model of Therapeutics (NMT) developed by the ChildTrauma Academy . The NMTA key goal of the NMT is to assist clinicians to formulate individualized intervention plans that consider the specific relational and developmental needs of the client . InformaThe NMT approach recognizes that regulation and resilience building need to occur within a context of adequate relational health . Where aOne of the key tenets of the NMT approach is the centrality of safe, enduring relationships as a precursor to both healthy normative development and to the treatment of the impacts of abuse and neglect . A maltrThe NMT approach recognizes that regulation and resilience building need to occur within a context of adequate relational health . Where aFor the purpose of this study, relational health refers to the number of connections a child has in their life as well as the quality and the lived experience of these connections for the child. Wheeler et al.  examinedTwo predictors of a child's current level of functioning are their current relational health and the level of developmental risk they experienced in their first two months of life . It is hFurther, the finding that current relational health was a stronger predictor of current functioning than developmental risk, lends evidence to the position that children need to experience safe and positive relationships in order to thrive . For malBerry Street's Take Two service is an innovative Australian biopsychosocial therapeutic service for infants, children and young people who have experienced serious abuse and/or neglect and are at risk of developing, or already present with, emotional and/or behavioral challenges. Take Two provides active outreach working with children, caregivers and the service system to build a network of positive relationships around the child. Take Two is a clinical service with research and training capacity embedded within the model and the service represents a good practice treatment model for children who have experienced maltreatment .Take Two has operated since 2004 throughout Victoria, one of Australia's six states and its second most populated with about six million inhabitants. Berry Street, one of the largest independent child and family welfare organizations in Australia, is the lead agency for Take Two and partners with La Trobe University Discipline of Social Work and Social Policy, Mindful  and Victorian Aboriginal Child Care Agency (VACCA). The Take Two staff group is comprised of a multidisciplinary team of allied health clinicians, including but not limited to, psychologists, occupational therapists, family therapists, and social workers.The complex situations of infants, children and young people who have experienced severe maltreatment and childhood trauma experience particular challenges and needs that cannot always be addressed only by the more traditional clinical mental health services, or the social work based case management programs. Infants, children and young people who have experienced maltreatment, including neglect, during the developmental years are likely to have complex developmental disruptions which require multidisciplinary assessment and interventions beyond traditional individual therapy and psychiatric medication.Relational and ecological approaches form the cornerstone of Take Two practice. Take Two's approach to therapy utilizes developmentally informed and trauma-focused intervention methods to assist children to make sense of their experiences and to prevent their past traumas from manifesting either intrusively through flashbacks and nightmares, or by causing them to utilize antisocial or self-destructive coping responses. At a relational level, Take Two practice is informed by attachment theory , 73 and Take Two prioritizes the need for a culturally informed approach for all clients. This is especially important for Aboriginal and/or Torres Strait Islander children engaged in the service. The service has dedicated positions for Aboriginal staff members who provide cultural consultation and advice, as well as supporting clinicians to complete a cultural connectedness assessment and plan culturally sensitive intervention . The appFinally, at a broader system level, Take Two works with the education system, the child protection system and any available social network in which the child participates, including sporting clubs, interest groups and extended family. Systems work can include advocacy, education or dyadic work, but whatever the precise intervention, the goal is always to support those around the child to be empathic, reflective, purposeful and therapeutic in their everyday interactions with the child. In the local context, a care team is frequently established consisting of the young person, parents, caregivers and professionals that are engaged in providing coordinated care. Take Two are active members of these care teams.A suite of clinical measures has been implemented to canvass change across a depth and breadth of emotional and developmental functioning. Measures have been targeted toward age and stage, and include parent, caregiver, and teacher reports as well as self-reports for children over age eight and is aligned with the Take Two outcomes framework developed in 2004 .Take Two selected NMT as an assessment and intervention planning framework to support clinicians to take a developmental trauma lens when working with referred children in addition to the methods described earlier.Take Two is a flagship of the model in Australia and site-certified in the use of the NMT clinical practice tools, or “metrics” which provide a semi-structured assessment of important developmental experiences and a current “picture” of developmental functioning and the degree of positive connectedness to carers, family, peers and community  to guide intervention planning. The NMT Metrics assist Take Two clinical staff to select and sequence a range of evidence-informed clinical interventions including child psychotherapy, child-parent psychotherapy, family work, dyadic work, child-focused parent therapy, eye movement desensitization and reprocessing (EMDR), play therapy, art therapy, music therapy, somatosensory activities, case conferences, and psycho-education for parents or guardians.Take Two characterizes itself as a relationship-based service. It recognizes that as the referred infants, children and young people are harmed within the context of relationships, their subsequent healing must also occur within their relationship network , which wThe interventions are usually a combination of three empirically supported treatment methods with a combination of psychological and psychosocial interventions. The first of these is systems-level casework , aimed aThe aim of the current study was to explore the impact of individually tailored neurodevelopmental and trauma-informed relational interventions on a cohort of Australian children who have experienced maltreatment using a mixed methods study. Ethics approval was received from La Trobe University HREC (04-131).The study had two components. A cross sectional design which includes quantitative analysis of baseline and repeat clinical measure data with a cohort of children aged 2–11 years, who were clients of Berry Street Take Two between 2014–2019, was conducted utilizing SPSS.The purpose of the quantitative analysis was to explore the changes to the child's behavioral and psychological functioning following intervention using the standard clinical outcome measures which Take Two administers at initial assessment, review (3 months for clients <5 years of age and every 6 months for clients more than 5 years of age), and at case closure.The measures utilized in this study were:The Strengths and Difficulties Questionnaire (SDQ), for people aged from 2 years, is a brief measure of strengths and difficulties that has parent, teacher and self-report (from age eight) versions. It is comprised of the following scales: emotional symptoms; conduct problems; hyperactivity; peer problems; prosocial behavior, and a Total Difficulties Score .The Health of the Nations Outcomes Scale for Children and Adolescents (HoNOSCA) is a 15-item clinician rated measure of mental health functioning used in Australia, New Zealand, and the UK that measures the domains of behavior, impairment, symptoms, and social functioning. The HoNOSCA has been demonstrated to have good discriminative and concurrent validity, good face validity, and to be sensitive to change , 82.The NMT Metric facilitates examination of current developmental functioning and help identify a child's strengths and vulnerabilities in 32 brain-related areas . Four major functional domains are derived from these: sensory integration, self-regulation, relational, and cognitive. The results help identify the urgency of need for intervention and repair based upon how far the individual's functional capabilities are from neurotypical. This need is scored as essential, therapeutic, or enriching .The NMT current relational health (CRH) domain refers to the quality and availability of relationships to the child encompassing parents, caregivers, siblings, extended family, peers, school, clubs, therapists//support services and community/culture. Clinicians rate the quality of each of the child's current relational experiences from Poor (1–3), Episodic (4–6), Adequate (7–9) to Positive (10–12) with the sum of these items called the total Current RH score . The Curn = 91. January 2014 was selected as the earlier cutoff date as this aligned with all three measures being administered and December 2019 was the end of the last full year prior to data analysis.A process of data selection see  was undeNMT metric reports completed as fidelity exercises, practice, or training, or those that contained missing or errors or client identifiable information were excluded. NMT Metric reports completed by clinicians with low fidelity also were excluded.Descriptive data was obtained from referral documentation.SDQ Attribute Scales  and Total Difficulties) and HoNOSCA Scales  were selected for analysis. This was based on findings of significance in previous analysis of Take Two interventions  and aligt-test was utilized to ascertain if there was significant change over time. A priori calculations anticipated that a desired effect size of 0.4 will be obtained from a sample size of 52 with power of 0.8. An effect size of 0.2 is generally considered small; 0.5, medium; and 0.8, large  was drawn from this population. Of the sample, 35.2% were female and 25.3% identified as Aboriginal and/or Torres Strait Islander. The average age was 7.4 years at Time 1 and 8.3 years at Time 2. The age range was 2.6 years to 11.9 years. The average treatment length was 324 days with a range of 155 days to 654 days.The population for this study is a Take Two cohort of clients who received intervention between 2014 and 2019. The study sample (x = 2.2); Emotional and Related Symptoms (x = 2.5), Peer relationships (x = 2.0) and Family Life and Relationships (x = 2.7). The degree of symptomology in the study sample at baseline was generally higher than both a European and an Australian Child and Adolescent Mental Health Services (CAMHS) cohorts  in particular in relation to their Total Difficulties (p = < 0.01), disruptive, antisocial or aggressive behavior (p = < 0.01), over activity, attention and concentration (p = < 0.01), non-organic symptoms (p = 0.02); emotional and related symptoms (p = < 0.01); peer relationships (p = < 0.01), family life and relationships (p = < 0.01) as well as caregiver understanding of difficulties (p = 0.04). Effect sizes were calculated using Cohen's d with Hedges correction with small to medium effect sizes (0.2–0.6) found on all domains, except poor school attendance , carers (n = 39), teachers (n = 38), self (n = 1), and other (n = 1) and at Time Two by parents (n = 16), carers (n = 44), teachers (n = 26), self (n = 2), and others (n = 3). Analysis of all SDQ data found change in a positive direction on Total Difficulties (p = 0.08) and a statistically significant improvement in the domain of Peer Problems (p = 0.05). Small effect sizes (0.2) were found for Total Difficulties, Peer Problems and Conduct Problems (see The SDQ data set in this study consisted of measures completed at Time 1 by parents (lems see .n = 42). The data set of all matched respondent pairs was analyzed (see p = 0.05) and Total Difficulties domains (p = 0.03). Further analysis conducted on each respondent grouping found parents (n = 5) reported significant change on peer problems (p = 0.05) and Total Difficulties (p = 0.02) with carers (n = 24) also reporting significant change on peer problems (p = 0.05). Teacher completed SDQs (n = 12) did not reveal significant change over time on any domain.The SDQ repeated data set was recoded for matched respondent pairs , Self-Regulation (p = < 0.01), Relational (p = < 0.01), and Cognitive (p = 0.02). Small to medium effect sizes were found on all Current Functioning domains (see p = < 0.01) with an effect size of 0.4  and changes in all NMT current functioning domains were significant (cohen's d = 0.3–0. 6) as well as peer relationships  and family relationships , disruptive behavior  and emotional symptoms  as measured by HoNOSCA. Significant improvements were also reported by carers on the SDQ analysis in peer problems  and total difficulties (p = 0.03).In summary, the analysis showed changes in the strength of the child's relational health was significant , anxiety and withdrawn presentation and received an 11-month intervention.Following assessment Take Two recommended child-focussed psycho-education sessions with Ken's grandmother to support her understanding of his presenting issues and to develop strategies to manage them. Dyadic sessions with Ken and his grandmother were also recommended, with the aim of developing a shared narrative about Ken's removal from his grandmother's care and to repair the rupture that had occurred in their relationship as a result of the removal. As with all Take Two clients, regular meetings with K's care team was also a recommendation.Over an 11-month period Take Two provided a mixture of child-focussed psychoeducation sessions to Ken's grandmother alongside some dyadic sessions. During her sessions Ken's grandmother was able to acknowledge her feelings of guilt around the removal of Ken from her care, her fear that it would happen again and that these feelings were getting in the way of her being able to be an attentive and playful carer for Ken. This informed the dyadic work, with play being the focus as well as supporting the dyad to communicate about emotions and needs.The clinician maintained contact with those in Ken's therapeutic web which included the kindergarten, Child Protection staff, the care team and with the health service where Ken's grandmother was receiving treatment. This included advocating for an increased understanding of Ken's difficulties and the implementation of strategies to meet his needs.At the conclusion of the intervention Ken had made developmental gains in the areas of feeding, sleeping and emotional regulation though he was still below age typical. Ken's grandmother reported feeling more relaxed about her caring role and was enjoying the play activities suggested by the Take Two clinician. Although the intervention did not produce a coherent narrative about Ken's removal from his Grandmother's care there was an increase in the dyad's capacity to communicate about how they were feeling and what would help each other to feel better. Ken's grandmother's hoarding issues were still present, but she was seeking psychological support to manage these.The NMT Current Relational Health score reflects this improvement, changing from 40 at the beginning of the episode, to 59 at closure. Ken's overall self-regulation and relational functioning showed improvements also—the former from 82% age typical to 89%, the latter from 74 to 80%.These improvements in Ken's relational health are reflected in both his improvements in the NMT domains of Self-Regulation and Relational Functioning, controlled for age, and in Carer reported improvements in Ken's presentation in the home environment.On Total Difficulties and three of the domains  of the Carer completed SDQ, Ken moved from having his difficulties described as being in the Significant Difficulties category  to Minor Difficulties by the end of the intervention. On the domain, Hyperactivity, Ken changed from displaying Some Difficulties to Minor Difficulties see .Xavier is a 6-year-old Aboriginal boy referred to Take Two by Child Protection, due to concerns about the stability and safety of his current living situation. Xavier was displaying extremely dysregulated behaviors on an almost daily basis—head banging, pulling out his hair, kicking, punching others, and scratching himself. He had also harmed animals. He had poor sleep, poor academic performance, and hyperactivity.At the time of referral to Take Two he lived with a family friend , Anna's infant daughter and Anna's aunt Linda. Xavier had been removed from his parents' care at the age of 3 years due to concerns about his mother's deteriorating mental health and substance use. Xavier was placed with Anna who he had known since birth and who had often babysat and cared for him.The clinical formulation noted the profound impact of prolonged exposure to family violence and unpredictable caregiving on Xavier's functioning. In particular, he was reactive to unpredictability and change, and he struggled to rely on his primary caregiver who was unable to consistently respond to his underlying needs for co-regulation and developmentally-attuned care.Following the assessment, the clinician recommended Filial Therapy  for XaviThe primary goals of the carer psychoeducation were to:Address Xavier's poor sleep by developing a predictable, consistent and relationally rewarding night-time routine between Xavier and Anna.Address Xavier's sensitized stress neurobiology, manifested in his extreme behaviors, by developing a more predictable, structured household routine that allowed times for Xavier and Anna to connect, as well as opportunities for Xavier to experience consistent caregiving and attuned responses to co-regulate him in a developmentally-targeted way.Take Two provided a 9-month episode of care to Xavier. The direct therapeutic intervention involved six, one-hour sessions between clinician, Anna and sometimes, Linda. These psychoeducation sessions focussed on attachment-based concepts and models such as Circle of Security, including time in , relatioTake Two's participation in Xavier's care team (five meetings) was key to the intervention—ensuring that the key adults and decision-makers in Xavier's life shared a common understanding of his needs, and how to support Anna and Linda in their care of Xavier. This included the clinician's participation in Xavier's school Student Support Group meeting. The clinician also made monthly (six) phone calls to the Aboriginal Community Controlled Organization case manager to enable her to reinforce the psychoeducation in her own contact with Xavier, Anna and Linda.The Take Two engagement ceased when Xavier's primary presenting behaviors of concern had decreased (his head-banging had ceased) and were having less of an impact on his relationship with Anna and Linda. Anna and Linda had demonstrated capacity to respond to Xavier in more relationally-focussed ways, reducing the co-dysregulation that had previously been a feature of their interactions.Clinton is an 11-year-old girl referred to Take Two at the age of 9 years. At the time of referral Clinton was being reunited to live with her parents following a period of living in out of home care. Since her birth, Clinton had been placed in out of home care five times due to family violence between her parents and their substance use resulting in neglect of her and her brother. Prior to her current return to her parents, Clinton had taken responsibility for the care of her brother who was 3 years younger than her, preparing him for school and ensuring he had something to eat. When Clinton returned to her parents' care, the parents were separated, with the plan for her to spend half the week with each parent. However, Clinton's father became ill and was not able to care for her. Clinton's father only attended the first session with the Take Two clinician.Clinton was referred to Take Two to support her strengthening relationship with her parents. At time of referral she presented with complex behavioral problems including parentified behavior toward her younger brother and aggression to her mother, rejecting her parenting role.The assessment was undertaken with a developmental focus and included completion of the NMT, and other measures. On the NMT metric, Clinton's CRH was in the Adequate range. In the assessment of her current developmental functioning, her self-regulation score was 77% of age typical, as was her relational functioning.The objectives of the Take Two intervention included educating Clinton's parents on the impact of trauma, how to respond to her behavior, assisting her to self-expression in healthier ways and to feel secure and safe with her parents. To meet these objectives the intervention plan was as follows:Systems intervention: participating regularly in a combined parents and professionals care team to establish a safe respectful and non-blaming space to share information, discuss progression of supports and identify concerns over time. Take Two provided psychoeducation to the care team drawing on findings from the clinical assessment to promote a common understanding of and response to Clinton's needs and functioning.Child and Family Interventions. Child focused parent work, including psychoeducation.Individual therapeutic work for Clinton to address her experience of trauma and find a more adaptive means to address the impact of her past traumatic experiences.The three intervention strategies were integrated over a 12-month period. The focus of the systems intervention was sharing information between professionals ensuring a common understanding of the issues facing Clinton and the desired response of all professionals. The Care team meetings engaged Clinton's mother to join with the professionals in ensuring her understanding of Clinton's needs. The 15 individual sessions utilized EMDR  includinAt the conclusion of the intervention the clinician noted changes in the mother's engagement with Clinton and in her enjoyment playing with Clinton and her level of attainment was notably higher than when intervention began.Clinton's NMT self-regulation functioning was 87% age typical, and her relational functioning 91% and the family were coping as a family. This improvement in Relational Health is reflected in Clinton's improvement on the HoNOSCA Total Difficulties from 24 to 16 and on her Parent rated SDQ that describes her Emotional Symptoms as having moved from Significant Difficulties to Minor Difficulties and Hyperactivity from Significant Difficulties to Some Difficulties see .This study established that individually tailored neurodevelopmental and trauma-informed relational interventions contributed to significant improvements in children's relational health as well as behavioral and psychological wellbeing. This is consistent with Valentino  and TothThe case studies illustrated the role of integrated interventions delivered with the child and the therapeutic web. This is especially pertinent for children with maltreatment experiences as they are often experienced within the intersectionality of family violence, disability and reduced social supports . Thus, sIn the case studies the intervention plan was informed by the assessment and use of NMT and was influenced by the child's situation and their age. Each intervention utilized a trauma informed developmental lens, however, the type of intervention differed based on the child developmental stage and the family and system's understanding of the ecological system for the child. For Clinton, the oldest child in the vignettes, there was a focus on individual therapy integrated with dyadic treatment with her mother and systems intervention. For Ken in case vignette 1, the focus was upon child focused psychoeducation and dyadic work with the Grandmother, his primary carer. This assisted the Grandmother to address her own feelings of guilt of having the child removed from her care and to develop a more informed understanding of Ken's needs so that she could respond more appropriately. It was noted that during this time Ken made developmental gains although was still below age typical. Case vignette 2 highlighted the complexity of the impact of trauma and the often-slow progress of change. Moreover, as highlighted by the Aboriginal consultant more work could have occurred with the child's broader Aboriginal community and engaging in culturally informed interventions. The slight improvement in relational health demonstrates the importance of working with the therapeutic web to strengthen the supports available to the child. The case vignettes demonstrate the integration of individual, family and systems approaches which promote relational health.Strengths of this study include a robust sample size for the cross-sectional cohort study design allowing effect size to be determined. Review of similar studies examining relational health and NMT were significantly smaller , 91. TheThe use of multiple outcome measures  allows for gathering a comprehensive understanding of the child's presentation from multiple respondents who reflect on the child's presentation in different settings, including both the impact of adverse events as well as the impact of intervention. In this cohort the SDQ reflected parents and carers' assessment that their children made significant gains in the home environment, however, in the school environment teachers noted smaller degrees of change see .A limitation of the study is that frequently the respondent completing the measure at Time 1 was not the same individual who completed it at Time 2. Reasons included change of clinician, class teacher, or a change of home circumstances which could lead to a change of primary carer or school. This reflects the complexity of these children's lives and the high level of change which can occur for them whilst they are receiving Take Two intervention. This is a challenge in undertaking research in this area .In interpreting the changes between Time 1 and Time 2 in the clinical measures it is important to take into account that at Time 2 for the clinician, and perhaps other members of the therapeutic web, there is a deeper level of knowledge of the child and their environment. It is not known if this greater knowledge contributes to a changed interpretation of a situation. This may affect the scores reported in the clinical measures at Time 2.It is not possible to identify change in specific relationships the child has with others and within the therapeutic web, from the outcome measures. The clinical measures do not allow for specificity of information regarding the impact of an intervention targeting specific relationships. However, reviewing the findings from the three measures indicates the elements which have changed in the child's presentation.Another limitation is that only one of the measures includes self-report by the child and key members of the child's environment. The SDQ was the only measure that allowed for self-reports in this study, and it is noted that only three self-reports by children were completed. However, it is noted that the study cohort were all aged below 12 years and the Self report commences at age 11 years.A limitation of the study is that the data for the case studies in this research were based on case records and did not include interviews with the child, clinician or other members of the child's environment.The reduced stability in the living arrangements and household composition for the individuals in the study cohort limited the ability to determine if there were improvements in specific relationships contributing to the overall improvement in relational health. Refinement of data collection tools enabling recording of the specific relationship quality and availability being measured would achieve greater specificity in both intervention planning and outcome monitoring.A next step in research in relation to the impact of Take Two would be a comparison of Take Two intervention with an alternative intervention of comparable duration and intensity. Whilst the study findings report positive changes in the children's presentations, the methodology did not include a comparison with an alternative intervention or usual care thus it is not possible to determine the outcomes were a direct result of the intervention.Future research could compare the Take Two intervention with an alternative intervention and include in depth case studies including interviews with child, parents, carers, schools and clinicians and members of the therapeutic web. A qualitative study which included interviews with the child and key participants of the therapeutic web would provide more information of the process of the intervention which would supplement the quantitative analysis.The results of this study provide further evidence of the importance of relational health interventions to address developmental delay and trauma associated with experiences of maltreatment. Hambrick et al. , Ludy-Don = 120) of the ABC model, a brief relational intervention (d = 0.38) and reduced disorganized attachment .The study contributes to understanding the importance of addressing the pervasive impact of child maltreatment , 23, 24 The case studies in this research demonstrated the use of integrated interventions which engage with the child, family and professional service system. The purpose of intervention with care teams, as highlighted in case vignette 3, is to provide a space for parents and professionals to work toward a common understanding so they can better meet the needs of the child.As a relationship-based service, Take Two recognizes that as maltreated children and young people are harmed within the context of relationships, their healing must also occur within the context of relationships. The Take Two client group has complex, multiple and chronic needs. In many cases these children are not living in safe or stable circumstances, their needs are not about protection alone, nor are they therapeutic alone; they require an approach that responds to each child with their multiple needs. This study furthers the understanding of the manner in which the NMT tools can guide the selection of interventions contributing to improved relational health with associated positive behavioral, emotional, and developmental outcomes. This study further contributes to an increased understanding of the importance of relational health and its impact on social and emotional functioning as measures by the HoNOSCA and SDQ.The pervasive impact of child maltreatment  has presThis study provides evidence that a relational health intervention is associated with a positive change in the child's presentation across the three outcome measures utilized. Addressing the impact of the trauma of child maltreatment requires interventions which integrate attention to the individual child's presentation and to the system which surrounds the child which can become a therapeutic web . Each caThe NMT provides an analysis of the neurobiological impact on the child and their development and the level of relational health in the child's environment. This analysis assists the clinician to determine the type of intervention which is required to assist the child. The analysis provided by NMT addresses each level of the child's social ecological system environment  and highThe study also highlights that intervention with this population requires more than the implementation of one evidence-based intervention due to the severe symptomology, intersectionality and need for individuated interventions based on the individual needs of the child.The study has implications in relation to Child Protection Policy. It provides further support to the view that the concept of child wellbeing in child protection needs to be conceptualized broadly  and ensuIt is critical for children severely impacted by maltreatment that the intersectionality of their situation be addressed in intervention . Take TwIt is critical for children severely impacted by maltreatment that the intersectionality of their situation be addressed in intervention .This study illustrates the value of neurodevelopmental trauma-informed interventions in positively impacting on the relational health and current functioning of maltreated children and the potential to reduce the lifelong impact of maltreatment.The developmentally and trauma informed intervention approach utilized by Take Two requires attention to all aspects of the child's life and the NMT model provides a framework for assessing these elements.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by La Trobe University Human Research Ethics Committee- HEC 04-131. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor declared a past collaboration with several of the authors AC, MF, and CR.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study was aimed at describing our experience in congenital cataract surgery in a developing Country.  A retrospective study was conducted in Amman, Jordan. The patients who were diagnosed with congenital cataract and underwent the surgery were included in the study. It was decided to use an intraocular lens if the corneal diameter was more than 10 millimeters.  The findings revealed that around 13 of the patients did not have any visual axis opacification, indicating that they were aphakic. Visual axis opacification was seen in 8 out of the total sample of participants. Eleven patients with obvious opacification of the visual axis were found to be pseudophakic after at least two procedures and were thus cleared. It was necessary to do a second surgery to rectify the visual axis opacification induced by pseudophakia, which was putting the patient's ability to recuperate at danger. Three of them (or 12 percent) exhibited visual axis opacification, which is a rare occurrence. The intraocular lenses used in the remaining 24 patients were constructed of hydrophilic plastic.  Patients are less prone to have visual axis opacification while implanted by hydrophobic intraocular lenses is something they should consider. Possessing a congenital cataract in a kid has been associated with an elevated risk of juvenile blindness in studies conducted on this population –3. When In the case of congenital cataracts, issues emerge as a result of the creation of crucial proteins that are required to preserve the clarity of the native lens. Recently developed surgical techniques have had a substantial impact on the outcomes of cataract surgery in neonates, which has been shown to be significantly improved . HoweverThe most common complication of intraocular lens (IOL) implantation is secondary opacification of the visual axis, which occurs most often in newborns and is caused by cortical reproliferation. This is the most common complication of this procedure –8. The uCongenital cataracts have posed a significant challenge to the treatment of curable childhood blindness throughout the past few decades , 2. AlthA variety of surgical techniques have been developed to reduce the incidence of posterior capsular opacification. The surgical therapy for congenital cataracts is posterior chamber IOL implantation with anterior vitrectomy and posterior capsulotomy, which is usually acknowledged as the gold standard , 7. It iCataract surgery in children may have severe intraoperative and postoperative implications for children with a variety of medical conditions. Postoperative complications may include nystagmus and other vision problems such as glaucoma and strabismus. Due to a lack of equipment, money, methods, and health ministry strategic plans, effective and prompt treatment is also limited to developed areas , 11–13.Congenital cataract surgery is a demanding procedure that requires the use of advanced technology and close attention to detail. Congenital cataract surgery is fraught with controversy because of disagreements about the appropriate time and method to use. It is critical to have population-based information on surgical care and to conduct epidemiological research in order to improve management and preventative measures, particularly in developing nations , 2, 11.The Prince Hamza Hospital in Amman, Jordan, is the only pediatric ophthalmology referral hospital in the nation and the largest in the Middle East. It was founded in 1982. Data on the incidence and frequency of congenital cataracts in Jordan, on the other hand, are few in published research. Given that an infant's eye responds differently than an adult's eye, congenital cataract surgery should only be performed in institutions that are appropriately equipped to manage the complicated treatment. In order to get the greatest possible vision and limit the risk of acquiring glaucoma later on in life, congenital cataract surgery should be performed as soon as feasible after the patient's birth.Delaying cataract surgery may have significant repercussions for a person's ability to see well. Babies born with congenital cataracts have a decreased chance of regaining their vision if the cataract is not removed within the first few months of life. Consequently, the major objective of the research was to discuss our experience with congenital cataract surgery in a poor country. Furthermore, the various factors that impact anatomical and functional results following surgery for a congenital cataract were investigated in this study.The patients in this retrospective study were those who had been diagnosed with congenital cataract and had been operated on by the surgeon at Prince Hamza Hospital at the time of their diagnosis. All of these patients were seen by the same surgeon, who treated them all. In situations where the corneal diameter was more than 10 mm, an intraocular lens (IOL) was implanted that was about the same size as the diameter of the capsular bag, resulting in a clear vision. There has been a decision to employ intraocular lenses (IOLs) since they provide partial correction whereas other optical devices, such as contact lenses and aphakic glasses, need a larger degree of conformity. It was decided to enroll infants who had thick opacity over the whole lens and were older than 37 weeks of gestation as participants in the study.Individuals with persistent primary hyperplastic vitreous, ocular injuries, corneal problems, glaucoma, a history of Lower syndrome, or rubella, on the other hand, were excluded from the research. Either they were congenital, which means that they were there from birth, or they might have developed as a result of a trauma such as a car accident, according to the findings of the research. It was also agreed that patients who did not finish the follow-up and who did not have normal pupil dilation would be ruled out of consideration for future research. Before taking part in the research, all of the patients who were included in it were asked to sign an informed written permission form, which they did.Following the findings of this investigation, it was determined that the Prince Hamza Hospital is the only hospital in Jordan that delivers congenital cataract services under contract with the Ministry of Health.Children who took part in the research ranged in age from babies to eight-year-olds, with the youngest being eight months old. A PPC, an anterior vitrectomy, and an intraocular lens implant were among the treatments performed as part of their limbal surgery, which also included additional procedures (in the bag). Following surgery, the patients were given dexamethasone intracameral injections as well as gentamicin/dexamethasone subconjunctival injections in each of the four quadrants of their eyes. Information from patients' medical records, such as their age at the time of surgery, whether or not they had intraocular lenses implanted, how many surgeries they had, what sort of therapy they received, and whether or not they had any complications, was evaluated.The use of hydrophilic or hydrophobic acrylic IOLs as biocompatibility materials was made possible by the lengthy history of the material in clinical practice and its safety for intraocular implantation. The study identified which kind of intraocular lens (hydrophobic acrylic IOL or hydrophilic acrylic IOL) was used in the patient and then compared the effects of the two different therapies.As shown in Secondary membranes or an aberrant inflammatory response was not seen in any of the participants in the aphakic group. It was necessary to do a second procedure on two of the pseudophakic people to eliminate the obstruction in their visual axis. Pseudophakia afflicted 49 children, 25 of whom received a hydrophobic intraocular lens and 24 of whom had a hydrophilic IOL. There were three patients who developed VAO, which indicated the necessity for a second surgery in 33% of hydrophobic patients.It was found that eight hydrophilic patients (33 percent) developed VAO and needed a second surgery. This was removed from one patient in the hydrophilic group after three procedures, and IOL explantation was performed. One-third of the group (13 patients) was aphakic, and none of the patients had VAO. Eleven of the 49 pseudophakic patients needed two or more procedures to remove the VAO, which represents a large proportion of the population. Twenty-five pseudophakic patients were fitted with hydrophobic intraocular lenses, and three (12 percent) of them developed VAO.There were 24 patients in all, with 8 (33 percent) developing VAO, suggesting the need for a second procedure. Following the initial IOL, these eight patients received hydrophilic IOLs. In the course of the study, 22 patients were lost to follow-up; however, those who remained were investigated, and it was discovered that 8 of them were aphakic or pseudophakic in nature. 17 patients (27 percent) were found to be lost, with seven of those patients being aphakic. One of the patients had microphthalmia, while the other had a high intraocular pressure (IOP) before the cataract surgery. Both were treated successfully.Atypical inflammatory reactions or secondary membranes were not seen in any of the patients who participated in the study. Pseudophakia patients were treated with hydrophobic intraocular lenses in six instances and hydrophilic intraocular lenses in the other four cases. VAO has not been experienced by anybody in the aphakic group. In the pseudophakic group, VAO was found in just two patients out of every 10 patients. According to the findings of the study, the risk of VAO is decreased when using a hydrophobic IOL. Thirteen of the patients studied were aphakic, which means that they did not have visual axis opacification in their visual field. 49 patients were found to be pseudophakic, and 22 percent of them had severe VAO, requiring two or more procedures to clear the visual axis, delaying the start of their visual rehabilitation.Aphakic spectacles and contact lenses were used to visually rectify the condition of aphakia. They had to go through a period of visual rehabilitation once the procedure was completed. With the exception of endophthalmitis (1 case), dropped intraocular lenses (1 case), decentration (4 occurrences), and retinal detachment , the VAO-related issues found were the most prevalent. Among individuals who underwent cataract surgery, the researchers found no indication of glaucoma developing as a severe consequence. Some persons with bilateral cataracts vanished for two or three years after having an F/U procedure performed on one eye. They then reappeared.As a consequence of technical improvements, surgical procedures for congenital cataract surgery have advanced significantly in recent decades. Jordan's Ministry of Health facilities are home to just one pediatric ophthalmology service, which is situated at Prince Hamza Hospital in the country's capital, Amman, and serves children from birth to age 18.Early surgical intervention in microophthalmic eyes is associated with an acceptable incidence of postoperative complications, in addition to excellent visual results . FindingImproved microsurgical techniques, improved lens technology, and a better knowledge of refractive eye development have all contributed to the increased use of intraocular lenses in patients. The surgical method averted the development of the inflammatory membrane or posterior capsular opacification, resulting in a clean axis for the foreseeable future. Anesthesia was administered with the use of the proper equipment. We removed the posterior capsule with the use of a vitrectomy instrument. Following the results of recently completed clinical and laboratory tests, it has been determined that treatment protocols must be modified in order to give children with a decent binocular visual experience throughout their early years of life , 4.Additional factors that may have an impact on stereoacuity outcomes include the length of the operation, the severity of the postsurgical consequences, the treatment regimen, and the method used to test stereoacuity , 8. WhenDespite this, strabismus and myopia were seen in a lower proportion of the individuals. According to the research's postsurgical data, growing cataracts showed improved functional results when compared to congenital cataracts in the studied population. Drug exposure during pregnancy, ionizing radiation exposure during pregnancy, and gestational diabetes mellitus have all been linked to cataract development –3, 9.Despite the fact that glaucoma was not shown to be a serious issue in this study, one of the patients with bilateral cataracts was lost from the study following treatment in one eye, only to reappear 2 or 3 years after the first treatment [Visual loss caused by congenital cataracts causes dislocation of binocular cortex development during the acute period, resulting in impaired stereoacuity in the majority of cases . Lens foThe discoveries have assisted in the identification of original cataract-associated genes, which will aid in the development of a comprehensive understanding of the genetic basis of these abnormalities and remedies. A problematic aspect of congenital cataract surgery is the need for specialized tools, as well as a lengthy recuperation time after the procedure is completed , 8. PrimThere were also few or no postoperative complications in the cases presented, suggesting that there were no intraoperative issues. Primary intraocular lens (IOL) implantation may be performed within the first year of life if the necessary safeguards are taken. Previous research findings support the results reached in this study , 6, 10.Contrast sensitivity, stereopsis, and visual acuity were all shown to have an influence on patient satisfaction with their quality of life after cataract surgery, according to a recent study. The present inquiry is conducted in a similar way. It was advised to participants with infant aphakia who were enrolled in the Infant Aphasia Therapy Trial that they should not have a secondary intraocular lens placed for at least five years before , 2.Three patients under the age of five years had their intraocular lenses (IOLs) swapped because they had developed myopic refractive defects as a consequence of the axial length of the eye becoming longer. Neither the aphakic nor the pseudophakic groups showed statistically significant differences in visual outcomes.In the present study, a number of factors impacting morphological and functional outcomes after surgery for a congenital cataract were investigated. The results revealed that it is vital that bilateral surgery be promoted in poor countries in order to track down patients who have not shown up for further follow-up appointments. Pseudophakia was shown to be responsible for a higher percentage of patients not being followed up. As a result of the fact that it is a retrospective study, the information acquired is neither complete nor accurate. The research has a number of flaws, which are significant. As a consequence of scarcity of accurate data, the visual outcomes of cataract surgery were not included in the study. The study was a success despite its limitations since it brought attention to an important public health issue impacting the Jordanian people and one that has a direct impact on surgical results. Patients who had gone through the holes in the follow-up procedure had previously been identified as having a need for a service, according to the results of the investigation. When done successfully, bilateral surgery should be encouraged in the same operation.


Statistics on adult education and training (AET) are often considered as insufficient because they fail to deliver a comprehensive and consistent picture of this field of education. This study addresses a specific problem in AET statistics that is varying participation rates of adults in AET depending on underlying data sources. We elaborate potential causes for deviations in survey design and the measurement of participation in sample based AET statistics with reference to the Total Survey Error (TSE) approach. Our analysis compares AET participation rates and patterns from four representative German surveys and reveals substantial differences in participation rates and mixed results for patterns of participation in AET. We find similar relationships for the influence of employment and educational attainment. The relationship with region, gender, and age shows to some extent deviations that conclude in contradictory statements on probabilities of participation. The discussion addresses consequences for the interpretation of survey results on AET participations and draws conclusions for the further development of AET statistics. Evidence-based education policy making, nationally and internationally, heavily depends on statistics. Although the databases' quality are crucial, those for lifelong learning are lacking. The concept of lifelong learning expands the traditional focus on learning in the system of initial education to educational activities of adults within their employment, occupational career, and leisure time. Unlike the educational fields of schooling, vocational, and higher education, these lifelong learning activities take place in a plural and heterogeneous training sector for which official statistics are scarce. Instead, representative surveys provide research and monitoring of adult education and training (AET) with data on the context of adults organized learning , access and opportunity structures , characteristics of the learning activity  and individual and wider benefits of AET participation . Unequally distributed AET participation opportunities most notably in favor of those with high skills and favorable employment conditions are a dominant focus in participation research and education policy. AET participation levels is a key indicator and benchmark in educational monitoring  as a conceptual framework to systematize potential factors for deviations, related to either AET representation or measurement and work with four different representative surveys for Germany that include questions on AET participation. After harmonizing samples and variables, we apply descriptive statistics and multivariate models to illustrate residual variations between the four surveys in relation to AET participation rates and structures. The discussion considers consequences for educational research and monitoring and points out further needs for research as well as possible advancements in AET statistics.This chapter introduces the TSE approach in order to explore and systematize potential causes for varying AET participation rates between surveys as well as related empirical findings. It concludes with the elaboration of the research question.The TSE Approach provides a paradigm for the quality assessment of surveys in general . In addition to these error sources, we select error sources on which we have information either through the data source itself or via quality reports in the documentation. Further, we focus on bias-related errors, rather than variance-related errors. While the latter are a natural constituent in sample based estimations of population parameters, bias-related errors are not at random and systematically affect sampling or measurement  is likely to trigger memories on AET events and improve recall. However, this increases the complexity of the question and thereby the cognitive efforts to evaluate and report to it. If respondents report on AET participation by third parties in proxy-reports, e.g., for household members, this recall acting on behalf of another person may be less accurate than if this person had been interviewed him- or herself . Second with regard to measurement, they can influence respondents' answers in the course of the interview directly through the administration of the questionnaire or indirectly through their characteristics and behavior in the social situation of an interview  and the Labour Force Survey (LFS) are typically addressed as Europe-wide surveys as well as nationally specific surveys. The comparison of sample characteristics from voluntary surveys, e.g., the AES, to those of surveys with a huge sampling rate or a compulsory participation , shows deviations in the direction of an overrepresentation of high educational attainment and occupational positions in the voluntary surveys Lois, . This coVarying measurement of AET is often considered the most important cause for varying AET participation rates. A study on language use demonstrates that overall, respondents understanding of AET is rather narrow and the interpretation of the meaning varies with educational background and other characteristics  by means or averages. In addition to the extent of participation, other qualitative aspects are of interest. For example, the question of equal opportunities for participation in AET requires an analytical approach that sheds light on the associations of participation with different attributes. Generally, with regard to survey errors, the analytical use is prone to the same errors as is the descriptive use, but might affect analytical results differently. If, for example, AET participation is underreported in all qualification groups the descriptive results are not accurate. Nevertheless, the association between qualification and participation in AET is not affected, as far as underreporting is consistent over all qualification groups. However, if AET participation is underreported by specific qualification groups only, the association is biased  and serve as sources for educational monitoring as well as scientific research. The Adult Education Survey (AES) BMBF,  and the that leads to a recognized qualification in the national education system, often initial education, S.W.] within the process of lifelong learning of individuals […]. It caters to people of all ages but does not necessarily apply a continuous pathway structure; it may be short in duration and/or low-intensity; and it is typically provided in the form of short courses, workshops or seminars […]”  by Eurostat . The CLAApart from the questions, the surveys show distinct features that can affect the quality of measurement of AET: First, the panel design of NEPS and MC might facilitate a familiarity with the questionnaire that either promotes answers that are more accurate or it might provoke item non-response, in order to shorten interview duration by skipping questions. Second, compliance with the survey and cognitive ability to recall can also depend on the duration of the interview and the placement of the questions on AET within the questionnaire. Quality of recall and willingness to report correctly can decrease with the progress of the interview. A third feature that probably affects the assessment of AET are proxy interviews, which are only present in the MC (~26% of the interviews). Here, respondents also answer questions for other household members, which probably affects reported participation rates.Previous chapters described a range of characteristics of the surveys as potential error sources and causes for varying participation rates in AET from the perspective of the TSE paradigm. Unfortunately, we cannot disentangle the causes and effects in that respect with the available data. It is however possible to give a more comprehensive picture about diverging results on AET participation. Based on harmonized samples, we compare sample characteristics and participation rates in a descriptive analysis and use regression models to predict AET participation to compare analytical results of the four surveys.The data was prepared according to the highest common denominators. All surveys approximately refer to the reference period of 2011/2012. The period for which AET is reported, is the first and the last individual interview date during field work see  minus 12We analyze overall AET participation and vocational AET participation. Analyses of AET usually focus on vocational AET. These job-related participations account for by far the largest share of reported AET activities. The distinction between job-related and non-job-related participation makes sense, since specific motivations, characteristics and returns to participation are assumed in each case . X is a vector, which includes the following set of covariates:The dependent variable is participation in overall AET, respectively vocational AET , sex , age , educational attainment , and employment status Region  would indicate, that—everything else equal—women are on average five percentage points more likely to participate in AET than men. PMs are calculated for every value of a variable and give the absolute probability to participate in AET. For example, a PM of 0.2 for men indicates that—conditional on the other control variables in the model—men have a 20 percent probability of participating in AET. The relationship between AMEs and PMs is that AMEs express the difference of the PMs for the different values of a variable. In the example above, the PM for women would then be 0.25.We conduct the regression analyses for each of the four surveys separately and calculate average marginal effects (AMEs) and predictive margins (PM). AMEs give the average probability to participate in AET compared to a reference category. For example, an average marginal effect of 0.05 for the gender coefficient  decreases toward the share within the MC. This reflects previous findings from the literature that indicate an overrepresentation of high-qualified respondents in voluntary surveys .Although the sample distributions align, some differences between the surveys remain after the weighting adjustments. Whereas, in AES, PIAAC, and NEPS there are slightly more women than men, the opposite is the case in the MC. There are moderate deviations in the age distributions; the share of the population aged 45–64 years lies in between a range of 52.0 (PIAAC) and 53.4% (MC). Educational attainment varies between all four surveys, which is particularly evident in lower and upper qualification categories. The share of people with low educational attainment (levels 0–2) in AES and PIAAC is still smaller (with difference up to 3.7% points) than in the MC. Simultaneously, in PIAAC the share of academics (levels 5A and 6) is higher in comparison to the MC (4.0% points). The corresponding share in AES is only slightly below MC.The NEPS data is to some extent an outlier: its distributions differ more strikingly in terms of age (older), education , and employment status (less unemployed). As these differences are probably due to its cohort panel structure and the simulation of a cross-sectional sample for the purpose of our analysis, we do not make any further population-based comparisons with the cross-sectional studies. However, we need to keep in mind that these deviations might affect the aggregated chances of participating in AET .Whereas, the results for socio-demographic characteristics show some shifts in the distributions before and after weighting adjustments, the participation rates see  show onlIn order to meet the representative requirements of the surveys, the following results refer exclusively to the weighted data. We see substantial deviations in the levels of participation rates between the surveys. Between the MC with the lowest and PIAAC with the highest participation rates, there is a gap of 33.5% points in overall AET. In between this range, participation rates in AES (48.2%) are rather close to PIAAC, while the NEPS rate (40.77) lies below PIAAC and AES but still significantly above the MC rate. When focusing on vocational AET activities, the participation rate in the MC decreases by ~5.0%, in the AES by 13.2%, in PIAAC by 13.3%, and in the NEPS by 24.5% of the overall-AET-valueAfter the descriptive comparison of sample characteristics and AET participation rates, we extend the comparison toward participation patterns of AET in order to investigate the analytical use of the survey data.Whereas, the results of PIAAC, NEPS, and the MC suggest higher probabilities to participate in AET for people in West Germany, the AME based on the AES indicates a higher probability for people in the east. This also applies after excluding AET activities that are not vocational. Interestingly, while the probabilities for east and west in the other surveys converge, in the AES the gap between east and west is widening.With respect to gender, the results for overall AET based on AES and PIAAC do not show gender specific differences. In contrast, in the NEPS and the MC the probabilities for women are higher than for men. With focus on participation in vocational AET the proportions in the AES and PIAAC shift toward a disadvantage for women. The AMEs based on NEPS and the MC still indicate slightly higher probabilities for women.Based on estimates in AES, PIAAC and the MC the effects point to a significant under-representation of older people (ages 55–64) in AET compared to younger people. This result is also stable if only vocational AET activities are taken into account.Results regarding the relationship between education and AET participation reflect previous findings according to which the probability of participation increases with higher educational attainment. Within all surveys the results show a substantial gap between the groups of low-qualified (levels 0–2) and highly-qualified (levels 5A and 6). With focus on vocational AET this gap slightly reduces within the four surveys.Likewise, there are no substantial differences between the surveys in comparison of the impact of employment on participation in AET. Based on all of the four surveys the AMEs indicates much lower probabilities for people who are not employed. With vocational AET this gap becomes even wider.In summary, we determine different participation structures for  on the basis of harmonized representative samples and identical models. While education and employment show the same relationship over the surveys, we cannot make a clear statement for region, gender, and age about participation opportunities related to these characteristics.Lifelong learning has become ever more prominent, especially in light of digitalization, rapid changes in professional activities and work contexts, as well as the active adult life spans continuously being longer. Accordingly, there should be a high level of interest in the ability to reliably monitor and analyze AET backed by a solid database and valid indicators. However, there is large variation in AET participation rates across surveys. Our research was designed to identify reasons for the present shortcomings and to contribute to improving the use of AET statistics so that they might better serve as secondary data in educational research and monitoring. We drew on the TSE as an overall framework and applied it to four surveys.A first analysis showed that the four surveys  were comparable in key points in regards to representation and measurement of AET. More detailed analyses on their implementation, however, revealed several differences. As far as representation is concerned, we find the most noticeable differences in voluntary  or mandatory (MC) survey participation. They also vary depending on whether the units are determined by the use of population registers  or by random route procedures (AES). Our results on measurement show differences in how the questionnaires support the interpretation of AET and the recall of AET events with a relatively high support of recall in AES and PIAAC in comparison to MC and yet another approach in the NEPS with its episode-assisted measurement. Overall, our initial analysis shows that varying AET results cannot be traced back to just one decisive factor but a variety of details and potential interacting error sources.Our empirical comparisons addressed sample characteristics, participations rates, and participation patterns. After harmonizing the samples, their characteristics show similar distributions of key socio-demographic variables and only a slight educational bias in the voluntary surveys in comparison to the MC. A minor shift in participation rates can be detected before and after applying survey weights. After weighing and harmonizing the samples, the participation rates show a substantial gap of around 30 (±3) percentage points for overall AET and vocational AET participation rates.Beyond comparing participation rates, we studied the participation patterns for both types of AET by conducting a multivariate analysis. Both overall and vocational AET show similar patterns for employment status and educational qualification across the surveys. On the one hand, it is reassuring that our analysis of survey results confirms the core statements of empirical educational research, most prominently the Matthew effect that refers to higher participation chances for those who already attained higher initial education Boeren, . On the What do these results indicate for the use of AET statistics as secondary data in educational research and monitoring? For example, disparities in living conditions between East and West Germany have been the focus of reporting since reunification. Depending on the data basis, however, in the case of AET participation we arrive at different results regarding regionally specific participation chances. To be on the safe side, we could only communicate findings that can be replicated when analyzing various data bases. This approach considerably limits the analysis' potential due to the low level of standardization and risks not meeting the requirements placed on empirical educational research. Creating transparency about uncertainties would be desirable. While this is constitutive in the context of research, it is not always feasible in the context of policy and monitoring. Meaningful indicators and evidence-oriented education policy can only absorb a certain level of uncertainty. We see the solution in the further development of the survey-based measurement of AET and in our study we find starting points, which we explain further after having explained the limitations of our approach.The TSE approach was instrumental in conceptually decomposing the AET surveys as it allowed us to identify potential error sources, which can help explain variances in the surveys' AET statistics. The available data, however, neither allows us to quantify individual error components nor to consider their possible interactions. While our analysis contributes to assessing the quality of AET statistics, it does not allow us to assess the true value of AET participation. Even if this were possible, a comprehensive evaluation of AET statistics must go beyond the question of presence or absence of errors and account for different user perspectives and the purposes for which statistics were calculated  AET definition from the operationalization of the surveys, which to a large extent are based on the CLA. Our study was not concerned with the extent to which this classification and its implementation align to established, related, or contested concepts in this field, such as education, training, learning, adulthood, or vocation . This would not only considerably improve our knowledge on current AET levels and developments but also complement efforts in survey research to standardize  and harmonize  demographic and socio-economic variables : Starting Cohort Adults, doi: 10.5157/NEPS:SC6:9.0.1. From 2008 to 2013, NEPS data was collected as part of the Framework Program for the Promotion of Empirical Educational Research funded by the German Federal Ministry of Education and Research (BMBF). As of 2014, NEPS is carried out by the Leibniz Institute for Educational Trajectories (LIfBi) at the University of Bamberg in cooperation with a nationwide network.Publicly available datasets were analyzed in this study. This data can be found here: PIAAC Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.BG and SW contributed with the initial conceptualization of the study. Each author was responsible for information on and data preparation of a specific survey: SW for AES, BG and NM for PIAAC, MH for NEPS, and JC for MC. JC supervised the joint analysis of the data and contributed the data presentation. NM and BG contributed a draft to section Comparative analysis of adult education and training participation and participation patterns in four population-based surveys. JC contributed a draft to section Results. The remainder of the article was contributed by SW. All authors contributed to the revision of the final draft.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.