Klinik und Poliklinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters

In 2005, the Working Group for the Survey and Utilisation of Secondary Data (AGENS) of the German Society for Social Medicine and Prevention (DGSMP) and the German Society for Epidemiology (DGEpi) first published "Good Practice in Secondary Data Analysis (GPS)" formulating a standard for conducting secondary data analyses. GPS is intended as a guide for planning and conducting analyses and can provide a basis for contracts between data owners. The domain of these guidelines does not only include data routinely gathered by statutory health insurance funds and further statutory social insurance funds, but all forms of secondary data. The 11 guidelines range from ethical principles and study planning through quality assurance measures and data preparation to data privacy, contractual conditions and responsible communication of analytical results. They are complemented by explanations and practical assistance in the form of recommendations. GPS targets all persons directing their attention to secondary data, their analysis and interpretation from a scientific point of view and by employing scientific methods. This includes data owners. Furthermore, GPS is suitable to assess scientific publications regarding their quality by authors, referees and readers. In 2008, the first version of GPS was evaluated and revised by members of AGENS and the Epidemiological Methods Working Group of DGEpi, DGSMP and GMDS including other epidemiological experts and had then been accredited as implementation regulations of Good Epidemiological Practice (GEP). Since 2012, this third version of GPS is on hand and available for downloading from the DGEpi website at no charge. Especially linguistic specifications have been integrated into the current revision; its internal consistency was increased. With regards to contents, further recommendations concerning the guideline on data privacy have been added. On the basis of future developments in science and data privacy, further revisions will follow.

BACKGROUND: Adolescence is the phase of life between late childhood and adulthood. Typically, adolescents seek diversion, new experiences, and strong emotions, sometimes putting their health at serious risk. In Germany, for example, 62% of all deaths among persons aged 15 to 20 are due to traumatic injuries. Neuroscientific explanations have been proposed for typical adolescent behavior; with these explanations in mind, one can derive appropriate ways of dealing with adolescents. METHOD: We selectively review pertinent articles retrieved from the PubMed database about the structural and functional development of the brain in adolescence. RESULTS: New findings in developmental psychology and neuroscience reveal that a fundamental reorganization of the brain takes place in adolescence. In postnatal brain development, the maximum density of gray matter is reached first in the primary sensorimotor cortex, and the prefrontal cortex matures last. Subcortical brain areas, especially the limbic system and the reward system, develop earlier, so that there is an imbalance during adolescence between the more mature subcortical areas and less mature prefrontal areas. This may account for typical adolescent behavior patterns, including risk-taking. CONCLUSION: The high plasticity of the adolescent brain permits environmental influences to exert particularly strong effects on cortical circuitry. While this makes intellectual and emotional development possible, it also opens the door to potentially harmful influences.

BACKGROUND: Reaction time (RT) variability is one of the strongest findings to emerge in cognitive-experimental research of attention deficit hyperactivity disorder (ADHD). We set out to confirm the association between ADHD and slow and variable RTs and investigate the degree to which RT performance improves under fast event rate and incentives. Using a group familial correlation approach, we tested the hypothesis that there are shared familial effects on RT performance and ADHD. METHOD: A total of 144 ADHD combined-type probands, 125 siblings of the ADHD probands and 60 control participants, ages 6-18, performed a four-choice RT task with baseline and fast-incentive conditions. RESULTS: ADHD was associated with slow and variable RTs, and with greater improvement in speed and RT variability from baseline to fast-incentive condition. RT performance showed shared familial influences with ADHD. Under the assumption that the familial effects represent genetic influences, the proportion of the phenotypic correlation due to shared familial influences was estimated as 60-70%. CONCLUSIONS: The data are inconsistent with models that consider RT variability as reflecting a stable cognitive deficit in ADHD, but instead emphasize the extent to which energetic or motivational factors can have a greater effect on RT performance in ADHD. The findings support the role of RT variability as an endophenotype mediating the link between genes and ADHD.

OBJECTIVE: To examine the psychometric properties of the German version of the Autism Diagnostic Observation Schedule (ADOS). METHODS: Interrater and retest reliability, internal consistency, convergent and diagnostic validity were determined in a total sample of 137 subjects with autism, 23 with atypical autism or pervasive developmental disorder not otherwise specified, 16 with Asperger-syndrome and 13 with other psychiatric disorders. RESULTS: Interrater and retest reliability on the level of diagnosis (kappa w = 1.00 and .62) and raw-scores (ru = .84 and .79) were good. Likewise, the internal consistency of the algorithm scale communication and social interaction of modules 1 to 4 was fair (ru = .78 to .89). The categorical convergence for autism between the ADOS and the Autism Diagnostic Interview-Revised (ADI-R) reached 79% (kappa = .23), with their corresponding subscales correlating moderately (rtc = .31 to .45). The concordance of the ADOS judgment and the clinical consensus diagnosis was 77% (kappa w = .37), with a sensitivity of the ADOS of 90.4% and a specificity of 48.1% regarding the discrimination of autism and other autistic disorders. CONCLUSIONS: The ADOS is a reliable and sufficiently sensitive diagnostic tool in the assessment of autistic disorders. For ICD-10/DSM-IV classification and to ensure a high specificity of diagnosis additional information concerning repetitive, stereotyped behavior and early development (e.g. taken from the ADI-R) has to be collected.

Over the course of the last few decades, statutory health insurance data have become increasingly important for health services research. Of particular interest in this context are diagnoses. Since all health insurance data are originally collected for billing purposes, secondary analyses should examine the completeness, plausibility, and validity of the information provided. While an external validation through, for example, a comparison with the physician's records or a second independent medical examination can be seen as a gold standard, this is often not feasible. For this reason, internal validation approaches are recommended for studies based upon diagnoses drawn from routine data. For such approaches, no established standards are currently available. The aim of this contribution is to introduce a generic internal validation concept for chronic diseases. Data employed in the present contribution stem from the health insuree sample of the AOK health insurance fund Hesse. Criteria for assessing the validity of diagnoses (e.g., repetitions, codes assigned by various physicians, prescriptions) are presented for three chronic diseases - heart failure, dementia, and tuberculosis. Building upon these criteria, algorithms for the definition of epidemiologically certain cases are developed and prevalence estimates formed on the basis of these algorithms are compared with other data sources (registers and surveys). Internal confirmation of the diagnoses of heart failure and dementia was possible in 97% and 80% of cases, respectively. The difference between the two diagnoses is due to the low rate of treatment with specific pharmaceuticals in the case of dementia. Prevalence estimates are comparable with those based on other sources. Inpatient discharge diagnoses of tuberculosis were internally confirmed in 100% and outpatient diagnoses in 40% of cases. For this reason, outpatient diagnoses were not considered for the case definition of tuberculosis. A comparison with tuberculosis surveillance data reveals a somewhat higher incidence in the insuree sample. In selecting and weighting criteria as well as employing a case definition, the research aim of the respective investigation must be taken into account. The adopted procedure is to be presented in a transparent manner.

BACKGROUND: Obesity is associated with an increasing risk of morbidity and mortality. The World Health Organization (WHO) defines obesity as a body mass index (BMI) > or = 30.0 kg/m2. In contrast, percentiles depending on age and sex are used in adolescence. DATA AND METHODS: Using the LMS method, age and gender specific BMI percentiles for adulthood are estimated. Data basis is the Second Germany National Nutrition Survey (NVS II) which was surveyed in 2005 and 2006. This study is representative for the German population, and it is based on more than 13,000 adults. RESULTS: Percentiles increase in both sexes with age. It can be observed in females in nearly all age groups. In males, percentiles are saturated around the sixth decade. Only 9 % of 20 to 29 years old adults are obese using WHO criteria, while there are 29 % of 60 to 69 years old adults having a BMI > or = 30.0 kg/m2. CONCLUSIONS: Percentiles reflect age and sex dependencies of the BMI. They show that there is a larger part of the population in higher BMI intervals with increasing age. Thus, the adequacy of the WHO definition should be questioned. Based on the NVS II, current and representative BMI percentiles for adulthood are now available for Germany. These can be used as base for age and sex dependent evaluation of the BMI.

INTRODUCTION: The prevalence of treated diabetes in Germany and direct health care costs of individuals with diabetes were analysed for the 8-year period from 2000 to 2007, based on administrative data. Special interest was given to the incremental costs attributed to diabetes. MATERIAL AND METHODS: An 18.75% sample of all members of a large local German statutory health insurance provider, "AOK - Die Gesundheitskasse" in the federal state of Hesse was analysed with regard to cases of treated diabetes. To assess the incremental diabetes-related direct costs, the cost data of individuals with diabetes was compared to that of an age- and sex-matched group of persons without diabetes. Prevalence and costs were standardized according to the gender and age distribution of the German population. RESULTS: Between 2000 and 2007, the administrative prevalence of treated diabetes rose continuously in Germany, from 6.5 to 8.9% (+36.8%). The number of patients treated with 'insulin' or 'insulin & oral antidiabetic agents' increased by +54.7 and +61.7%, respectively. Direct costs per patient with diabetes, calculated using the unit costs reimbursed by statutory health and nursing care insurances, rose from € 5 197 to € 5 726 (+10.2%). Incremental per-capita costs were € 2 400 in 2000 and € 2 605 in 2007 (+8.5%). However, the total direct cost burden of diabetes in Germany grew from € 27.8 billion to € 42.0 billion (+51.1%). The incremental diabetes-related cost burden increased from € 12.9 billion to € 19.1 billion (+48.6%). CONCLUSIONS: There was a continuous increase in the prevalence of diabetes in Germany during the 8-year period. Although there was only a modest increase in annual diabetes-related per-capita costs, total healthcare expenditure rose substantially due to the growing number of patients being treated for diabetes.

The purpose of this study was to assess the reliability (internal consistency), the correlations of the scale scores and the factorial validity of the German version of the Child Behavior Checklist (CBCL). The analyses were performed in a sample of patients at two child and adolescent psychiatric facilities (N = 1653) and in a community sample (N = 1622). The analyses were based on the 1991 American version of the CBCL. The internal consistency of most of the scales was good to excellent (rtt > .80). The reliability of the scales "Withdrawn", "Somatic complaints" and "Social Problems" was not completely satisfactory (rtt > .70). The reliability of the syndrome scales "Thought Problems" and "Sex Problems" and the Competence Scales was unsatisfactory (rtt < .70). The internal consistency of the syndrome scales in the German and American samples was very similar. The correlations between the scales were predominantly in the lower range, with some in a medium range (rtt > .50). Factor analyses in the clinical sample confirmed that the syndrome scales had been well-designed. With the exception of the scales "Social Problems" and "Withdrawn", where the items have loadings on a common factor, the scales proved to be factorially valid.

Parental report Child Behavior Checklists (CBCL) of 77 male and female subjects aged 4-18 years were analyzed in this study. Individuals had been given diagnoses of autistic disorder using the Autism Diagnostic-Interview-Revised (ADI-R) within a research project on the genetics of autism. A feature of behavior problems independent of sex but influenced by age and IQ level could be identified for the autistic sample with highest relative scores on the scales measuring attention problems, social problems and thought problems and low scores on the scale for somatic complaints.

The feasibility and reliability of the German form of the revised parental interview to diagnose autism (Autism Diagnostic Interview-Revised, ADI-R) was investigated in this study. Brief examples of the description of formerly and currently used diagnostic guidelines are given and the outline of the interview algorithm which establishes thresholds for inclusion criteria. An excellent-to-good reliability could be demonstrated for the main symptoms according to the classification rules of the ICD-10 and DSM-IV for a sample of autistic subjects at different ages and intellectual levels. The results approve the use of this interview for research and clinical purposes.

OBJECTIVE: Excessive and addictive internet use and computer game playing is reported as an increasing problem in outpatient care. The aim of this paper is to give an overview about the current scientific discussion of the overuse and addiction of internet and computer game playing. METHODS: Pubmed was used for a systematic literature research considering original papers and review articles dealing with Internet/computer game addiction. RESULTS: Recent epidemiological data from Germany suggest that 1.5-3.5 % of adolescent computer and internet users show signs of an overuse or addictive use of computer and video games. Moreover there is evidence that the disorder is associated with higher rates of depression, anxiety, as well as lower achievements e. g. at school. Although the nosological assignment still remains unclear there is some evidence from neurobiological data that the disorder can be conceptualized as behavioral addiction. As treatment strategy CBT-techniques have been proposed, but there is still a lack of controlled clinical trials concerning their efficacy. CONCLUSIONS: Since the addicted persons often show little motivation for a behavioural change we consider it a promising approach to treat and train their relatives with the aim of increasing the motivation for a behavioural change of the addicted person.

Zusammenfassung. Fragestellung: Der Fremdbeurteilungsbogen für Hyperkinetische Störungen (FBB-HKS) ist Bestandteil des Diagnostik-Systems für Psychische Störungen im Kindes- und Jugendalter nach ICD-10 und DSM-IV (DISYPS-KJ). Er erfaßt in 20 Items die Symptomkriterien nach ICD-10 und DSM-IV. Die vorliegende Studie untersucht die Häufigkeit der einzelnen Symptome, sie überprüft die Reliabilität der Subskalen und der Gesamtskala, die Skalenkorrelationen sowie Alters- und Geschlechtseffekte. Stichprobe: Der Fragebogen wurde in einer Feldstichprobe von N = 165 Eltern von Kindern im Alter von sechs bis zehn Jahren beantwortet. Ergebnis: Bei Jungen schwanken die Symptomprävalenzen zwischen 31,4 % für “zappeln” und 8,1 % für “nicht beenden”, “schlecht organisieren” und “fühlt innere Unruhe”. Sie sind damit um das zwei- bis zwölffache gegenüber Mädchen erhöht. Bei 11 von 20 Items konnte das erhöhte relative Risiko gegen den Zufall abgesichert werden. Die Reliabilität der Subskalen Aufmerksamkeitsstörung, Hyperaktivität und Impulsivität sowie der Gesamtauffälligkeitsskala ist zufriedenstellend bis sehr gut. Auf allen Skalen konnten deutlich höhere Rohwerte bei Jungen im Vergleich zu Mädchen nachgewiesen werden. Es war jedoch kein signifikanter Alterseffekt feststellbar. Schlußfolgerung: Der Fremdbeurteilungsbogen für Hyperkinetische Störungen (FBB-HKS) ist für die untersuchte Altersgruppe als Elternfragebogen ein intern konsistentes Verfahren. Mit der Vorlage von Normen kann er in der Praxis gut eingesetzt werden.

Für das Neurofeedback (NF), ein verhaltenstherapeutisches Verfahren, das über die Modifikation von EEG-Parametern eine Verbesserung von ADHS-Kernsymptomen anstrebt, hat sich die Evidenzbasis in den vergangenen Jahren verbessert. Die Arbeit gibt einen Überblick über die vorliegenden Befunde. Die durch NF erreichten kurzfristigen Verbesserungen entsprachen in mehreren Studien denen einer pharmakotherapeutischen Stimulanzien-Behandlung. Untersuchungen zur Wirkdauer der Effekte sind ermutigend. In einer eigenen Pilotstudie wurden 34 Kinder mit ADHS zufällig einer Neurofeedback-Behandlung oder einem computergestützten Aufmerksamkeitstraining zugeteilt. Die Zahl der Impulsivitätsfehler in einem Stopp-Signal-Paradigma reduzierte sich durch Neurofeedback signifikant, während sich im Elternurteil keine differenziellen Effekte fanden. Eine weitgehende Normalisierung hirnelektrischer Korrelate von Hemmungskontrolle fand sich nur in der NF-Gruppe. Neurofeedback ist ein vielversprechender Ansatz in der ADHS-Behandlung. Gleichwohl besteht Bedarf an weiteren kontrollierten Studien mit einheitlichen diagnostischen Kriterien, ausreichend großen Stichproben, geeigneten Veränderungsmaßen und Katamnese-Untersuchungen.

Zusammenfassung. Der Begriff Resilienz beschreibt einen dynamischen oder kompensatorischen Prozess positiver Anpassung angesichts bedeutender Belastungen. Beide Aspekte, die positive Entwicklung und die aversiven Lebensumstände, erfordern eine genauere Betrachtung. Um das Resilienz-Konzept für die Entwicklungspsychopathologie und die Prävention fruchtbar machen zu können, müssen einige grundlegende konzeptuelle und methodische Probleme geklärt werden. So sollten nur solche Merkmale als resilienzerhöhend bezeichnet werden, die besonders oder ausschließlich wirksam sind, wenn auch eine risikoerhöhende Gefährdung vorliegt, die einen Puffereffekt ausüben und die bereits zeitlich vor dem risikoerhöhenden Ereignis bestanden haben, um dessen Auswirkungen moderieren zu können.

The peroxisome proliferator-activated receptor-gamma2 (PPARgamma2) is almost uniquely expressed in adipose tissue and is of major importance for fat cell differentiation and lipid metabolism. This study was undertaken to assess whether two missense variants in the PPARgamma2 gene are associated with early-onset obesity. A previously described polymorphism encoding for an amino acid exchange in codon 12 (Pro12Ala) was detected with allele frequencies of 0.13 in 296 markedly obese children and adolescents and 0.14 in 130 lean individuals. A Pro115Gln variant, which had been linked to obesity in Germans in a previous association study, was not detected in any of our obese or lean subjects, who are also of German origin. We conclude from our data that these two variants in the PPARgamma2 gene are unlikely to contribute to the high prevalence of early-onset obesity.

AIMS: The aim of this population-based study was to assess the prevalence of subjects with diabetes mellitus by retrospectively analysing routine health insurance data. METHODS: This analysis comprised a 18.75% random sample of all members of the largest regional statutory health insurance (Allgemeine Ortskrankenkasse, AOK) in Hesse. Patients with diabetes were identified by criteria such as ICD-10 diagnoses and regular prescriptions of insulin and oral antidiabetic agents. The data were corrected for the age and gender distribution of the German population. RESULTS: Over the 4-year observation period there was a continuous increase in the prevalence of subjects with known diabetes mellitus, from 7.24% in 1998 to 8.79% in 2001. After correction for the German population the last figure corresponded to a prevalence rate of 6.00% in 1998 and 6.91% in 2001. During this period, there was an overproportional increase in the percentage of subjects treated with insulin, from 1.49% in 1998 to 1.91% in 2001, while there was only a moderate increase in the percentage of subjects under oral medication and under dietary treatment, respectively. In the age group of 70 and above roughly 25% of all subjects had known diabetes. In this age group, more than 6% of all people were treated with insulin. CONCLUSIONS: This data suggests that there was a continuous increase in the prevalence of individuals treated for diabetes between 1998 and 2001 in Germany by approximately 5% per year. After correction for the total German population the pre-valence of diagnosed diabetes is nearly 7%.

METHOD: A study on behavioral and emotional problems and competence in children and adolescents in Germany (PAK-KID study) is described. It is the first nationwide representative survey of this kind of children and adolescents aged 4 to 18 years in Germany. For children aged 4 to 10 years the parents completed the German version of Achenbach's Child Behavior Checklist (CBCL 4-18) developed by the Arbeitsgruppe Deutsche Child Behavior Checklist. Children and adolescents aged 11 years and older filled out the German version of the Youth Self-Report that is part of Achenbach's CBCL in addition to the parents completing the German version of the CBCL. A total of 2856 parent questionnaires and 1798 self-report questionnaires completed by children and adolescents were analyzed. RESULTS: The sample was representative with respect to the main sociodemographic variables. On all problem scales children and adolescents aged 11 to 18 years reported significantly more problems than their parents did. The frequency of internalizing problems (social withdrawal, somatic complaints, anxiety/depression) and delinquent behavior of children and adolescents reported by parents increased with the children's age, whereas aggressive behavior and attention problems decreased with age. Girls reported significantly more problems than boys on all internalizing scales of the Youth Self-Report. The effect was not totally replicated in the parent reports. In the parent reports, boys had more attention problems and more aggressive and delinquent behavior than girls.

Zusammenfassung: Das ICD-10 fordert für die klinische Diagnose der Lese-Rechtschreibstörung die Verwendung von Tabellen, die die Korrelation von Rechtschreibung bzw. Lesen und Intelligenz berücksichtigen (Regressionsmodell). Im vorliegenden Beitrag werden die Konsequenzen für die Interpretation psychometrischer Tests zur Diagnostik der Lese-Rechtschreibstörung erörtert. Außerdem wird eine Tabelle vorgestellt, mit Hilfe derer diagnostische Entscheidungen unter Berücksichtigung des Regressionsmodells getroffen werden können. Darüber hinaus wird eine Abschätzung der zu erwartenden Prävalenz auf Grund einer Computer-Simulation mitgeteilt.

Up to now, the quality of life of children and adolescents with psychiatric disorders has rarely been investigated. Not many suitable instruments are available. A new one is the "Inventory for the Assessment of the Quality of Live in Children and Adolescents" presented here. Objectives and underlying conceptual assumptions are discussed, followed by an explanation of the instrument itself (questionnaires, rating scales, etc.). Finally, experiences with the application of the instrument are reported together with initial empirical results from a clinical sample and a sample of high school students. These indicate that the instrument usefully assesses clinically relevant information about the quality of life of the patients. A broader empirical analysis of this method is being prepared.

BACKGROUND: A considerable percentage of children and adolescents who avoid school have mental illnesses. This article reviews the typical manifestations, classification, development, course, and treatment of school-avoiding behavior. METHODS: Based on a selective review of recent literature, we present findings on the psychopathologically relevant features of school-avoiding children and adolescents, including psychiatric diagnoses, developmental, family-related, and psychological test variables. The emphasis is placed on our own studies of the subject. RESULTS: Although the evidence from the studies that have been performed to date is not definitive, the available findings show that school avoidance is associated with poor mental health and with unfavorable consequences onward into adulthood. Its causes include a number of individual and social stressors that place excessive demands on the affected children and adolescents and lead them to avoid school as a coping attempt. CONCLUSIONS: Many preventive and therapeutic interventions are now available, but the existing measures need to be better coordinated, and more effort needs to be directed to the early recognition and treatment of school-avoiding behavior. Physicians should consider the possibility of mental illness. Rather than writing sick notes or prescribing mother-child treatments at health resorts, which rather tend to sustain the problem, they should refer patients promptly to a child and adolescent psychiatrist.