Verordnungshäufigkeiten von Psychopharmaka bei Kindern und Jugendlichen mit psychischen Erkrankungen in Deutschland

Zusammenfassung. Psychopharmakotherapeutische Interventionen bei Kindern und Jugendlichen sind in der Öffentlichkeit immer wieder in der Diskussion. Steigende Verordnungszahlen werden teilweise als Überversorgung interpretiert. Mittels einer systematischen Analyse veröffentlichter Studien zur Psychopharmakoepidemiologie in Deutschland wurde die Entwicklung von Verordnungen von Psychostimulanzien, Antidepressiva und Antipsychotika an Kinder und Jugendliche zwischen 2000 und 2012 analysiert. Es zeigen sich steigende Verordnungshäufigkeiten insbesondere bei Psychostimulanzien und Antipsychotika, die sich jedoch im internationalen Vergleich meist unter dem Niveau anderer vergleichbarer Länder bewegen. Andererseits sind Entwicklungen wie z. B. ein Anstieg von Antipsychotikaverordnungen kritisch zu hinterfragen. Gleichzeitig ist aber aus einzelnen Untersuchungen ableitbar, dass die pharmakotherapeutischen Interventionen entgegen früherer Untersuchungen vermehrt nach Leitlinienempfehlungen und evidenzbasiert zu erfolgen scheinen. Kinderärzte zählen neben Kinder- und Jugendpsychiatern zu den hauptsächlichen Verordnenden.

Schlüsselwörter: Psychopharmakoepidemiologie, Psychopharmakotherapie, Psychoanaleptika, Psycholeptika, Antidepressiva

Experience by children and adolescents of more than one type of maltreatment: Association of different classes of maltreatment profiles with clinical outcome variables

Most victims of child abuse have experienced more than one type of maltreatment, yet there is a lack of understanding of the impact of specific combinations of types of maltreatment. This study aimed to identify meaningful classes of maltreatment profiles and to associate them with short-term clinical outcomes. A total of 358 German children and adolescents aged 4-17 with a known history of child maltreatment were included in the study. Through interviews and questionnaires, information was obtained from participants and their primary caregivers on history of maltreatment, sociodemographics, psychopathology, level of psychosocial functioning, and health-related quality of life. Types of abuse were categorized into six major groups: sexual abuse in general, sexual abuse with penetration, physical abuse, emotional abuse, neglect, and exposure to domestic violence. A latent class analysis (LCA) was performed to determine distinct multi-type maltreatment profiles, which were then assessed for their associations with the sociodemographic and clinical outcome variables. The LCA revealed that participants could be categorized into three meaningful classes according to history of maltreatment: (1) experience of multiple types of maltreatment excluding sexual abuse (63.1%), (2) experience of multiple types of maltreatment including sexual abuse (26.5%), and (3) experience of predominantly sexual abuse (10.3%). Members of Class 2 showed significantly worse short-term outcomes on psychopathology, level of functioning, and quality of life compared to the other classes. Three distinct profiles of multiple types of maltreatment were empirically identified in this sample. Exposure to multiple types of abuse was associated with poorer outcomes.

Professional caregiver's knowledge of self-reported delinquency in an adolescent sample in Swiss youth welfare and juvenile justice institutions

Since an important goal of the youth welfare system is to prevent troubled adolescents from committing acts of delinquency in future, professional caregivers need to possess accurate knowledge about past behaviors in order to implement appropriate interventions. As part of a comprehensive study on youth in state care, adolescents at 30 residential care facilities in Switzerland were surveyed about past acts of delinquency, and their responses were compared to those of their professional caregivers to see how well they correlated. A sample of 267 male and female adolescents aged 11-18years completed questionnaires about the frequency, nature, and seriousness of different types of offenses, while a designated caregiver for each resident completed a corresponding questionnaire. The majority of residents (86.1%) reported having committed at least one offense, which confirms the prevalence of problem behaviors in this population and the need for strategies to prevent it. The overall rate of agreement between the residents and their caregivers was 77.2%, with both parties reporting that the resident had committed at least one offense in 69.7% of cases, and both reporting that no offense had been committed in 7.5% of cases. Agreement was substantially higher for offenses that were serious than for those that were minor or moderate. Cohen's kappa reached slight to moderate values with regard to individual and categorized offenses. Seriousness scales of delinquency for self-reports and caregiver reports were moderately associated. While the overall rate of agreement between the residents and their caregivers was high, increasing it still further might lead to improvements in strategies for the prevention of recidivism.

On the incidence and prevalence of child maltreatment: a research agenda

Research on child maltreatment epidemiology has primarily been focused on population surveys with adult respondents. Far less attention has been paid to analyzing reported incidents of alleged child maltreatment and corresponding agency responses. This type of research is however indispensable to know how well a child protection system works and if the most vulnerable are identified and served. Notable findings of child maltreatment epidemiological research are summarized and directions for future studies discussed.

Psychosocial Risk Factors for Child Welfare among Postpartum Mothers with a History of Childhood Maltreatment and Neglect

Background: Childhood maltreatment (CM) can increase the risk of psychosocial risk factors in adulthood (e. g. intimate partner violence, financial problems, substance abuse or medical problems). The transition to parenthood presents those affected by CM with particular challenges, in addition to usual birth-related stressors. Methods: In this cross-sectional study a total of 240 women were interviewed in the puerperium with respect to CM experiences, using the German version of the Childhood Trauma Questionnaire (CTQ). Current psychosocial risk factors (e. g. financial concerns, maternal mental illness, single parent) were assessed using the Constance Index (KINDEX) for early childhood risk factors. Associations between CM experience and psychosocial risk factors were calculated using simple correlation. Results: The average age of participants was 33 years. On the CTQ 13.8 % of participants reported emotional abuse, 6.7 % physical abuse and 12.5 % sexual abuse, while 32.1 % reported emotional neglect and 7.5 % physical neglect during childhood. With rising severity of CM, more psychosocial risk factors (KINDEX) were present. Conclusions: This study shows a clear association between experiences of maltreatment during childhood and the presence of psychosocial stressors among women in the puerperium. Regular screening for a history of CM and parental psychosocial stressors should be conducted early, i.e. during pregnancy, to avoid negative consequences for the child.

Psychological Symptoms of Sexually Victimized Children and Adolescents Compared With Other Maltreatment Subtypes

The differential effects of sexual victimization and other forms of maltreatment on psychological functioning are not well understood. A sample of sexually victimized children and adolescents (N = 70; 6.3-17.9 years) and a group of youth with a history of nonsexual maltreatment (N = 108; 6.7-16.9 years) were compared using measures of mental health and psychosocial functioning. Assessments included standardized clinical interviews on individual maltreatment history and current psychopathology as well as questionnaires on behavioral and emotional symptoms, including posttraumatic stress symptoms. The results from this study suggest that the risk of experiencing any current mental disorders was independent of type of maltreatment. The risk of meeting the criteria for a current diagnosis of major depression, however, is greater among youth with a history of maltreatment that includes sexual victimization. The significant impact of sexual victimization on posttraumatic stress symptoms was found to be nonsignificant after controlling for age and gender effects. The results indicate that the outcomes of child maltreatment depend on type of maltreatment, but age and gender must be taken into account.

Variants of girls and boys with conduct disorder: anxiety symptoms and callous-unemotional traits

Recent research suggests that among the group of aggressive and antisocial adolescents, there are distinct variants who exhibit different levels of anxiety symptoms and callous-unemotional traits (CU traits). The purpose of the present study was to examine whether such variants are also present in male and female adolescents diagnosed with conduct disorder (CD). We used model-based cluster analysis to disaggregate data of 158 adolescents with CD (109 boys, 49 girls; mean age =15.61 years) living in child welfare and juvenile justice institutions. Three variants were identified: (1) CD only, (2) CD with moderate CU traits and anxiety symptoms, and (3) CD with severe CU traits. Variants differed in external validation measures assessing anger and irritability, externalizing behavior, traumatic experiences, and substance use. The CD variant with moderate CU traits and anxiety symptoms had the most severe pattern of psychopathology. Our results also indicated distinct profiles of personality development for all three variants. Gender-specific comparisons revealed differences between girls and boys with CD on clustering and external validation measures and a gender-specific cluster affiliation. The present results extend previously published findings on variants among aggressive and antisocial adolescents to male and female adolescents diagnosed with CD.

Please Tell! Barriers to Disclosing Sexual Victimization and Subsequent Social Support Perceived by Children and Adolescents

The present study examines barriers to disclosing sexual victimization and perceived social support after disclosure from the perspective of children and adolescents. Forty-two children and adolescents aged 6 to 17 years participated in semistructured interviews about their history of sexual victimization, the delay of disclosure, barriers to disclosure, informal and formal recipients of disclosure, as well as abuse-specific social support as perceived by the recipients. The participants disclosed their victimization with a delay of approximately 17 months, ranging from immediate reporting to 10 years of nondisclosure. The most frequent reasons to withhold the information were feelings of shame and threats by the perpetrator. A majority felt that people believed and supported them after disclosing, but a considerable proportion of study participants reported a lack of perceived protection against recurring victimization. The results underline the importance of educating children and adolescents about sexual victimization and of encouraging the immediate reporting of critical incidents. Possibilities to address the barriers identified in this study are discussed.

[Nonnative guidelines for allocating human resources in child and adolescent psychiatry using average values under convergence conditions instead of price determination - analysis of the data of university hospitals in Germany concerning the costs of calculating day and minute values according to Psych-PV and PEPP-System]

OBJECTIVE

Despite substantial opposition in the practical field, based on an amendment to the Hospital Financing Act (KHG). the so-called PEPP-System was introduced in child and adolescent psychiatry as a new calculation model. The 2-year moratorium, combined with the rescheduling of the repeal of the psychiatry personnel regulation (Psych-PV) and a convergence phase, provided the German Federal Ministry of Health with additional time to enter a structured dialogue with professional associations. Especially the perspective concerning the regulatory framework is presently unclear.

METHOD

In light of this debate, this article provides calculations to illustrate the transformation of the previous personnel regulation into the PEPP-System by means of the data of §21 KHEntgG stemming from the 22 university hospitals of child and adolescent psychiatry and psychotherapy in Germany. In 2013 there was a total of 7,712 cases and 263,694 calculation days. In order to identify a necessary basic reimbursement value th1\t would guarantee a constant quality of patient care, the authors utilize outcomes, cost structures, calculation days, and minute values for individual professional groups according to both systems (Psych-PV and PEPP) based on data from 2013 and the InEK' s analysis of the calculation datasets.

CONCLUSIONS

The authors propose a normative agreement on the basic reimbursement value between 270 and 285 EUR. This takes into account the concentration phenomenon and the expansion of services that has occurred since the introduction of the Psych-PV system. Such a normative agreement on structural quality could provide a verifiable framework for the allocation of human resources corresponding to the previous regulations of Psych-PV.

[Structural quality in inpatient and daycare child and adolescent psychiatry- indicators for planning future staff ratios for the era following the Psychiatry Personnel Act]

The German Psychiatry Personnel Act, which went into effect in 1990, has led to a decrease in the number of child and adolescent psychiatry inpatient beds, to a decrease in the length of stay, and to an increase in inpatient psychotherapy. Today, this act is outdated~ for a number of reasons, such as changes in the morbidity of the population, the rising number of emergencies, and new professional standards such as documentation. In addition, new legal provisions and conventions (like the UN Convention on the Rights of the Child) necessitate a complete reevaluation. Child and adolescent psychiatry needs a normative act to enable the necessary implementation. Many different rationales are available to support the debate.

Resilience in Survivors of Child Sexual Abuse: A Systematic Review of the Literature

OBJECTIVE

This review article summarizes empirical research on resilience in survivors of child sexual abuse (CSA) and discusses protective factors that are associated with adaptive functioning in spite of sexual victimization.

METHODS

A literature search to identify studies published up to November 2013 was performed within the databases PsycINFO, MEDLINE/PubMed, Web of Science, and PSYNDEXplus. Additional relevant studies were retrieved using a snowball technique. A total of 37 articles met the inclusion criteria and were included in the final sample.

RESULTS

In the studies included in this review, the percentage of CSA survivors who were found to have a normal level of functioning despite a history of sexual abuse ranged from 10% to 53%. The protective factors that had the best empirical support were found to be education, interpersonal and emotional competence, control beliefs, active coping, optimism, social attachment, external attribution of blame, and most importantly, support from the family and the wider social environment.

CONCLUSIONS

Preventive and clinical interventions for survivors of CSA should utilize psychoeducation and cognitive strategies that are adapted to the developmental level of the victim and that seek to enhance social support from significant others. Future research should focus on longitudinal research designs considering resilience rather as a dynamic process with multiple dimensions in a social and developmental context.

Resilience in Survivors of Child Sexual Abuse: A Systematic Review of the Literature

OBJECTIVE

This review article summarizes empirical research on resilience in survivors of child sexual abuse (CSA) and discusses protective factors that are associated with adaptive functioning in spite of sexual victimization.

METHODS

A literature search to identify studies published up to November 2013 was performed within the databases PsycINFO, MEDLINE/PubMed, Web of Science, and PSYNDEXplus. Additional relevant studies were retrieved using a snowball technique. A total of 37 articles met the inclusion criteria and were included in the final sample.

RESULTS

In the studies included in this review, the percentage of CSA survivors who were found to have a normal level of functioning despite a history of sexual abuse ranged from 10% to 53%. The protective factors that had the best empirical support were found to be education, interpersonal and emotional competence, control beliefs, active coping, optimism, social attachment, external attribution of blame, and most importantly, support from the family and the wider social environment.

CONCLUSIONS

Preventive and clinical interventions for survivors of CSA should utilize psychoeducation and cognitive strategies that are adapted to the developmental level of the victim and that seek to enhance social support from significant others. Future research should focus on longitudinal research designs considering resilience rather as a dynamic process with multiple dimensions in a social and developmental context.

Hilfebedarf und Hilfsangebote in der Versorgung von unbegleiteten minderjährigen Flüchtlingen

Zusammenfassung. In den letzten Jahren kommt es zu einer deutlichen Zunahme der Zahl unbegleiteter minderjähriger Flüchtlinge (UMF) in Deutschland. Dies stellt nicht zuletzt die klinische Versorgung vor neue Fragestellungen, da es sich um eine hoch vulnerable Gruppe handelt. In der vorliegenden Übersichtsarbeit sollen die psychischen Auffälligkeiten und deren längerfristiger Verlauf beschrieben werden, um den Hilfebedarf darzustellen. In einem weiteren Schritt werden die Hilfsangebote anhand der Rückmeldungen von UMF erfasst. Das klinische Bild wurde vorrangig von einer posttraumatischen Stresssymptomatik geprägt, wobei sich im Langzeitverlauf eine hohe Stabilität psychischer Belastungen zeigte. Daneben existiert jedoch auch ein erheblicher Anteil resilienter UMF. Mehrfach wurde von den UMF der Wunsch nach Schulbildung und rascher sprachlicher Integration geäußert.

Immigration as risk factor for non-suicidal self-injury and suicide attempts in adolescents in Germany

BACKGROUND

Whereas non-suicidal self-injury (NSSI) and suicide attempts (SA) are rather common among adolescents, the description of risk factors has often failed to take migration into perspective. Our study aimed to describe immigration status in adolescents with regards to their lifetime history of NSSI and SA.

METHODS

We carried out a population based study in a school community of ninth-graders (N = 452, mean age 14.85, SD 0.58) in southern Germany. Data were collected via adolescent self report on sociodemographic variables and on NSSI and SA using the Self Harm Behavior Questionnaire.

RESULTS

Adolescents born outside Germany showed an elevated rate of a lifetime history of NSSI and SA. When compared to German adolescents without a (family) history of migration (NSSI 19.16%, SA 3.24%), adolescents who were born in another country had an elevated risk for NSSI (42.86%, OR 3.36) and SA (17.86%, OR 6.78), which was higher than the risk of adolescents who had at least one parent who had emigrated from another country (NSSI 30.08%, OR 2.46 and SA 8.94%, OR 4.45).

CONCLUSION

Our findings should inform intervention services and prevention programs for NSSI and suicidality in youth. Adopting such programs to include culturally sensible modules could improve the outcome in ethnically diverse adolescents.

MICHI–eine Gruppen-Kurzzeitpsychotherapie zur Behandlung von Depressionen bei Jugendlichen

Kognitive Verhaltenstherapie (KVT) gilt als Mittel der Wahl bei der Behandlung von Depressionen im Jugendalter wobei bis dato noch kein deutsches Behandlungsmanual in einem randomisierten, kontrollierten Design untersucht wurde. 38 depressive Jugendliche (M=15,86, SD=±1,70 Jahre alt; 78,9 % weiblich) wurden randomisiert entweder der Kontrollgruppe (KG), die Behandlung wie üblich erhielt (TAU), oder Interventionsgruppe (IG), welche an einer ambulanten Gruppen-Kurzzeit-KVT (MICHI-Manual) teilnahm, zugeordnet. Als Effektivitätsmaße dienten die CDRS-R und das BDI-II. Die Interaktion aus Gruppe und Messzeitpunkt war sowohl für die CDRS-R (p=,02), mit einer mittleren Effektstärke (dkorr=,75), als auch für den BDI-II (p=,04), mit einer kleinen Effektstärke (dkorr=,39), signifikant. Die Gruppen-Kurzzeit-KVT entsprechend dem MICHI Manual ist verglichen mit TAU wirksam.

[School escorts in inclusive education- the current situation in the state of Baden-Wurttemberg]

In the context of inclusive education, so-called «Schulbegleiter» (school escorts) have been installed to assist children with special needs. However, adequate conceptions of their role are lacking, and no provisions exist describing the exact tasks and duties of these school escorts. This article presents data on a statewide empirical study and provides information on the professional background, qualifications, and assignments of such escorts as well as the nature of the assisted children in the German state of Baden-Württemberg. The data were collected in nearly 50 % of all schools providing general education in Baden-Württemberg, and a total of 526 school escorts completed a questionnaire on their work. Children with special needs who received such assistance were aged 6 to 19 years (M = 10.4) and had a mental disorder in nearly three-fourths of all cases, with autism spectrum disorders being most common (59.4 %). The most frequent assignments of the escorts were providing practical assistance during classes and mobilizing the child as well as providing direct support in emotionally challenging situations. Such escorts can make a significant contribution to the inclusive education of disabled children. They do, however, need an adequate qualification and practical competences to meet the diverse challenges of children with special needs. Child and adolescent psychiatrists are supposed to stay involved in the process, not only by planning interventions, but also during the course of inclusive education itself. Thus, the emotional situation and adjustment of included children with mental disorders over time must be monitored adequately.

Cost-effectiveness of intensive home treatment enhanced by inpatient treatment elements in child and adolescent psychiatry in Germany: A randomised trial

BACKGROUND

Admission rate to child and adolescent mental health inpatient units in Germany is high (54,467 admissions in 2013), resources for providing necessary beds are scarce. Alternative pathways to care are needed. Objective of this study was to assess the cost-effectiveness of inpatient treatment versus Hot-BITs-treatment (Hometreatment brings inpatient-treatment outside), a new supported discharge service offering an early discharge followed by 12 weeks of intensive support.

METHODS

Of 164 consecutively recruited children and adolescents, living within families and being in need of inpatient mental health care, 100 patients consented to participate and were randomised via a computer-list into intervention (n=54) and control groups (n=46). Follow-up data were available for 76 patients. Primary outcome was cost-effectiveness. Effectiveness was gathered by therapist-ratings on the Children's Global Assessment Scale (CGAS) at baseline (T1), treatment completion (T2) and an 8-month-follow-up (T3). Cost of service use (health care costs and non-health care costs) was calculated on an intention-to-treat basis at T2 and T3.

RESULTS

Significant treatment effects were observed for both groups between T1/T2 and T1/T3 (P<0.001). The Hot-BITs treatment, however, was associated with significantly lower costs at T2 (difference: -6900.47€, P=0.013) and T3 (difference: -8584.10€, P=0.007). Bootstrap cost-effectiveness ratio indicated that Hot-BITs was less costly and tended to be more effective at T2 and T3.

CONCLUSIONS

Hot-BITs may be a feasible cost-effective alternative to long inpatient stays in child and adolescent psychiatry. Further rigorous evaluations of the model are required. (

REGISTRATION NUMBER

ISRCTN02672532, part 1, Current Controlled Trials Ltd, URL: http://www.controlled-trials.com).

Child sexual abuse in the Roman Catholic Church in Germany: comparison of victim-impact data collected through church-sponsored and government-sponsored programs

At around the same time in 2010, the German government and the Roman Catholic Church in Germany each set up a critical incident reporting system (CIRS) to gather information on child sexual abuse that had taken place within the Church. The objective in both cases was to solicit stories from victims and former victims and allow them to have input into a review process. The existence of these two similar systems, one initiated by the institution involved in the abuse and the other by an independent entity, provided an opportunity to compare the background and motivation of victims who chose to communicate through one channel or the other. Data were obtained on a total of 927 individuals, 571 through the church CIRS and 356 through the government CIRS, who had reported that they had experienced childhood sexual abuse within the Roman Catholic Church. Some differences were found between the two groups in terms of gender, the reported frequency of abuse, and the desire for compensation. These differences highlight the need for an effective complaint management system to offer not just one but complementary channels of communication. In addition, the findings confirm the feasibility and value of a CIRS approach and the use of so-called 'citizen science' in politically driven review processes.

Inobhutnahme und Bindung

Inobhutnahmen sind zeitlich begrenzte Kriseninterventionen zum Schutz von Kindern meist in der Folge von vorhergehender Misshandlung und/oder Vernachlässigung. Die Dauer von Inobhutnahmen ist bei Säuglingen und Kleinkindern am längsten. Die mit einer längeren Trennung einhergehenden psychophysiologischen Belastungen der Kinder sowie das Vorgehen bei Inobhutnahmen werden vor dem Hintergrund der Bindungstheorie und bindungstheoretischer Forschung diskutiert. Es wird für die Entwicklung einer bindungstheoretisch begründeten Konzeption zu Verfahrensstandards und zur Gestaltung der Inobhutnahme bei Säuglingen und Kleinkindern plädiert.

Kinder- und Jugendpsychiatrie/Psychotherapie versus Kinder- und Jugendhilfe

Jugendhilfe und Kinder- und Jugendpsychiatrie/Psychotherapie besitzen eine unterschiedliche Tradition und werden durch unterschiedliche Berufsgruppen geprägt. Besonders deutlich zeigt sich dies im Verständnis und der Behandlungsbedürftigkeit von psychischen Störungen im Kindes- und Jugendalter. An dieser Unterschiedlichkeit der Professionen leidet die Kooperation zwischen beiden Bereichen erheblich. Zusätzlich unterscheiden sich beide Bereiche erheblich in ihren Forschungstraditionen und aktuellen Forschungsbemühungen. Die Bedeutung der Jugendhilfe wird durch die vielfältigen Vernetzungen mit den Bereichen „Schule”, „Justiz”, „Medizin” etc. unterstrichen.

Welche Faktoren beeinflussen Abbrüche in der Heimerziehung–welche Bedeutung haben limitierte prosoziale Fertigkeiten?

Über 20 % der stationären Jugendhilfemaßnahmen werden ungeplant beendet. Um Hilfe- und Beziehungsabbrüche vermeiden zu können, ist es wichtig, Jugendliche, welche die Jugendhilfe in besonderem Maße herausfordern, frühzeitig zu identifizieren, und besser zu verstehen, welche Faktoren das Risiko eines Abbruches erhöhen. Psychische Belastungen, Traumata, eine „Jugendhilfe-Karriere”, Delinquenz und psychopathische Persönlichkeitszüge gelten als Risikofaktoren für einen negativen Verlauf, weshalb sie in dieser Studie gezielt erfasst wurden. In einer Stichprobe von 497 Bewohnern Schweizer sozialpädagogischer Institutionen im Alter von 6 bis 26 Jahren wurden Teilnehmer mit und ohne irregulärem Maßnahmenende mittels uni- und multivariater Analyseverfahren miteinander verglichen. Sowohl univariate Analysen als auch eine binär logistische Regressionsanalyse ergaben, dass neben dem Alter vor allem psychopathische Persönlichkeitseigenschaften der zentrale Prädiktor für einen Abbruch der stationären Maßnahme sind. Das relative Risiko, die Maßnahme irregulär zu beenden, ist bei Teilnehmern mit auffällig hohen Werten auf Skalen, die psychopathische Eigenschaften erfassen, im Vergleich zu Teilnehmern mit durchweg unauffälligen Psychopathie-Werten um das Zwei- bis Dreifache erhöht. Aufgrund der Ergebnisse sollten spezifische pädagogische, milieu- und psychotherapeutische Konzepte für Jugendliche mit limitierten prosozialen Fertigkeiten entwickelt und evaluiert werden. Zudem sollten die Jugendlichen gezielt einem Screening unterzogen werden, um sicherzustellen, dass diese Persönlichkeitszüge im Rahmen der Hilfeplanung adäquat berücksichtigt werden können.

Mehrfachdiagnosen bei Schweizer Heimjugendlichen

Personen, die unter mehreren, insbesondere ätiologisch und symptomatologisch sehr unterschiedlichen psychischen Erkrankungen leiden, stellen eine besondere Herausforderung für die Behandelnden dar. Heimjugendliche akkumulieren biopsychosoziale Risikofaktoren, weshalb sie eine hohe Prävalenz an komorbiden psychischen Erkrankungen aufweisen. In der Schweiz mangelte es bisher an epidemiologischen Untersuchungen von Kindern und Jugendlichen in Heimeinrichtungen. Mit 483 in Schweizer sozialpädagogischen Einrichtungen platzierten Heranwachsenden im Alter von 6 bis 25 Jahren wurden klinische Interviews zur Diagnostik psychischer Störungen durchgeführt. Zur Verdeutlichung der Komplexität der vorliegenden komorbiden Störungen wurden Diagnosegruppen in Anlehnung an die von Andrews et al. (2009) vorgeschlagenen Symptomcluster gebildet. Die Prävalenz psychischer Störungen lag bei 74 %. Von den Betroffenen erfüllten 60 % die Kriterien für mehrere Diagnosen, etwa 25 % litten an komplexen psychischen Störungen mit emotionalen und externalisierenden Symptomen. Eine sorgfältige und individuell angepasste kinder-/jugendpsychiatrische/-psychotherapeutische Behandlungsplanung in enger Zusammenarbeit mit den sozialpädagogischen Fachkräften erscheint hier dringend indiziert. Demgegenüber fehlen bislang sowohl in der Grundlagen-, der Psychotherapie- als auch der Versorgungsforschung ätiologische Modelle und Interventionsansätze, die dieser Komplexität gerecht werden.

Vorläufige Schutzmaßnahmen für gefährdete Kinder und Jugendliche

Die Zahl der Inobhutnahmen ist in den letzten Jahren in Deutschland deutlich angestiegen. Es ist unklar, ob dieser Anstieg Ausdruck einer differenzierteren Wahrnehmung von Problemlagen oder eher Ausdruck einer Absicherungstendenz von Fachkräften darstellt. Es erfolgt einerseits ein Überblick über die internationale Faktenlage und andererseits werden öffentliche Datensätze zur Inobhutnahme in Bezug auf Altersverteilung, Geschlechtsverteilung, regionale Differenzen und Disparitäten anhand der Dortmunder Jugendhilfestatistik analysiert. Für die Zukunft wird eine differenzierte Auseinandersetzung mit dem Phänomen der Inobhutnahme gefordert. Wesentliche Fragestellungen, die einer gründlicheren Untersuchung harren, werden aufgezeigt.

Child sexual abuse in religiously affiliated and secular institutions: a retrospective descriptive analysis of data provided by victims in a government-sponsored reappraisal program in Germany

Background

The disclosure of widespread sexual abuse committed by professional educators and clergymen in institutions in Germany ignited a national political debate, in which special attention was paid to church-run institutions. We wanted to find out whether the nature of the abuse and its effect on victims differed depending on whether the abuse had been experienced in religiously affiliated versus secular institutions.

Methods

In 2010, the German government established a hotline that victims could contact anonymously to describe their experiences of sexual abuse. The information provided by callers was documented and categorized. Our analysis looked at a subset of the data collected, in order to compare the nature of the abuse experienced at three types of institutions: Roman Catholic, Protestant, and non–religiously affiliated. Non-parametric tests were used to compare frequency distributions, and qualitative data were analyzed descriptively.

Results

Of the 1050 victims in our sample, 404 had been in Roman Catholic, 130 in Protestant, and 516 in non-religious institutions. The overall mean age at the time of reporting was 52.2 years. Males (59.8%) outnumbered females. Victims who had been in religiously affiliated institutions were significantly older than those who had been in secular institutions. Almost half the victims had been abused physically as well as sexually, and most victims reported that the abuse had occurred repeatedly and that the assaults had been committed by males. Patterns of abuse (time, type, and extent), and the gender of the offenders did not differ between the three groups. Intercourse was more frequently reported by older victims and by females. Similar percentages of victims in all groups reported current psychiatric diagnoses (depression, anxiety disorders, PTSD). Significantly more victims from Protestant institutions reported having current psychosocial problems.

Conclusion

The results suggest that child sexual abuse in institutions is attributable to the nature of institutional structures and to societal assumptions about the rights of children more than to the attitudes towards sexuality of a specific religion. The exploratory data arising from this study may serve as a starting point for building hypotheses, and may point the way toward improvements in prevention and intervention strategies.

[Trauma history and posttraumatic stress symptoms among children and adolescents attending a mental health service]

OBJECTIVE

Systematic exploration of potentially traumatic events and posttraumatic stress symptoms of patients attending a hospital for child and adolescent psychiatry and psychotherapy.

METHODS

The UCLA PTSD Reaction Index for DSM-IV was filled in by 413 children and adolescents and 403 caregivers at their first attendance at the clinic.

RESULTS

At least one traumatic event was reported by 46.9% of the children and adolescents and/or caregivers. Clinically relevant post-traumatic stress symptoms were reported in 22.9%.

CONCLUSION

In the investigated sample routinely performed screening assessments can identify clinically relevant post-traumatic stress symptoms in almost one of four patients of child mental health services.

Prevention of sexual abuse: improved information is crucial

Sexual abuse can lead to long-lasting, even life-long, consequences and is a serious problem on an individual, familial and societal level. Therefore, prevention measures on different levels are a public health issue. Minors as well as adults should be involved in prevention work in order to prevent sexual abuse of minors in a sustainable way. Besides norms, structures and values in society, the respective laws as well as attitudes and structures should be changed and amended in such a way that abusers and the abuse are clearly confronted everywhere. In the last decades, numerous prevention programs for victims have been developed for various target groups (e.g. parenting education classes, home-visiting programs, public education, training sessions for teachers, E-Learning Programs of the German Federal Ministry for Education and Research and the Centre for Child Protection). Many of these programs have proven partially effective. Nevertheless, until now there is no consensus in the scientific community on what constitutes effectiveness in this context. Reasons for this are the discrepancies in definitions or the scarcity of attention which the evaluation of prevention measures has received.

[Sexual harassment among students - prevalence, developmental factors and potential ways of intervention]

Sexual harassment among adolescents has long been neglected in Germany though it is frequent and leads to significant strain for the victims. In international studies, the prevalence of sexual harassment ranges from 10 to 80 % among students. For the development of sexual harassment individual as well as school based factors play a role. Different pathways lead to this problematic behaviour. The effect of new media in the development of sexual harassment cannot be estimated so far. Frequent consequences of sexual harassment in addition to school associated difficulties are unspecific somatic complaints. General practitioners and pediatricians are frequently consulted tn the first place. Recommendations for consultation and interventions are presented.

Child sexual abuse in the context of the Roman Catholic Church: a review of literature from 1981-2013

Child sexual abuse in the Catholic Church has been increasingly recognized as a problem not limited to individual institutions. Recent inquiry commission reports provide substantial information on offense dynamics, but their conclusions have not been synthesized with empirical research to date. The aim of this systematic literature review was to bring together key findings and identify gaps in the evidence base. The three main focus points were (a) types of publications and methodology used, (b) frequency information on child sexual abuse in the Catholic Church, (c) individual factors in offending, and (d) institutional factors in offending. It was found that reports, legal assessments, and research on child sexual abuse within the Catholic Church provide extensive descriptive and qualitative information for five different countries. This includes individual psychological factors (static risk predictors, multiple trajectories) and institutional factors (opportunity, social dynamics) as well as prevalence rates illustrating a high "dark figure" of child sexual abuse.

[Temperament and character-traits as protective factors among adolescents in juvenile residential facilities]

Although adolescents in juvenile residential facilities are at high risk for mental disorders, not all of these adolescents develop psychiatric symptoms. The aim of our study was to define traits protecting these adolescents. A total of 314 adolescents of 20 juvenile residential facilities were examined using standardized assessment instruments (Child Behavior Checklist (CBCL), Junior Temperament and Character Inventory (JTCI)). Educators of the facilities filled out a sociodemographic questionnaire for each participant. Adolescents were divided into two groups (resilient vs. mental problems) by CBCL-Cut-off-Scores. Analyses were based on these two groups. Resilient youth differed from youth with psychiatric symptoms in temperament- and character-traits (e. g. self-directedness F = 28.4, p < .001, d = 0.64) with small to moderate effect sizes (d = 0.36 to 0.64). Resilient adolescents lived in larger facilities (U = 9080, p = .025). No associations were found between gender and resilience, as well as age at placement in the facility and duration of the stay in the facility and resilience. Significant differences in temperament- and character-traits between resilient adolescents and adolescents with mental problems were identified. Especially character-traits could be a basis for developing strategies for promoting mental health and further resilience factors, as social support.

Suicidality among medical students - a practical guide for staff members in medical schools

Although suicidality in medical students is important, few studies dealt with this issue regarding German universities. Our aims were to describe the epidemiology as well as factors leading to suicidality in medical students. Furthermore we wanted to raise awareness for this topic among university employees and show options for handling suicidal crises in students. This manuscript especially aims to address university employees working in direct contact with students (such as student counselors or teachers).

Assessing change in the behavior of children and adolescents in youth welfare institutions using goal attainment scaling

BACKGROUND

Evaluating youth welfare services is vital, both because of the considerable influence they have on the development of children and adolescents, as well as owing to the extensive financial costs involved, especially for child residential care. In this naturalistic study we have undertaken to evaluate changes in various behaviors of young people who are in youth welfare institutions, not only by using standardized questionnaires, but also specifically modified goal attainment scales (GAS). These scales were meant to represent the pedagogical objectives of youth welfare professionals as well as the individual goals of the young people in care.

METHODS

Goal attainment scales were used to ascertain behavioral changes in 433 children and adolescents (age 6 to 18 years) in 25 youth welfare institutions (day care and residential care) in Germany. Social and individual goals were rated by young people and caregivers together on at least two occasions. In addition, to examine potential problems of children and adolescents, quality of life as well as mental health and behavior problems were identified by the caregiver and also by the youth using a self-report inventory.

RESULTS

Many of the children and adolescents had experienced critical life events, problems in school, impaired quality of life, along with mental health and behavior problems (range: 41-87%). During their stay in day care or residential care institutions, children and adolescents showed some improvement in social goals (Cohen's d = 0.14-0.44), especially those young people with deficits at the beginning, and with regard to mental health and problem behavior (d = 0.10-0.31). For individual goals, progress was even more pronounced (d = 0.75). Improvements to social goals were more pronounced if mental health and behavior problems decreased. This link to changes in behavioral and emotional problems was only ascertained to a limited extent for individual goals.

CONCLUSIONS

Young people residing in youth welfare institutions achieved individual and social goals and improved with regard to behavior problems. The applied goal attainment scales are well suited for measuring individual change in children and adolescents and constitute a relevant addition to established instruments. Furthermore, their advantages include cooperative goal setting, the assessment of goals by caregivers and young people, and congruence with the pedagogical objectives of professionals.

Listening to victims: use of a Critical Incident Reporting System to enable adult victims of childhood sexual abuse to participate in a political reappraisal process in Germany

Recent revelations about the scope and severity of past child sexual abuse in German institutions set off a broad public debate on this issue, and led to the establishment of a politically appointed Round Table committee and an Independent Commissioner whose mandates were to reappraise the issue and develop recommendations for future policies. A media campaign was launched to publicize the establishment of a Critical Incident Reporting System (CIRS) whereby now-adult victims of past abuse could anonymously provide testimonials and let policy makers know what issues were important to them. Respondents could either call a hotline number or communicate by mail or email. The information collected was documented and analyzed by a research team, and the results of interim reports were included in the recommendations of the Independent Commissioner and the Round Table committee. Most of the respondents described severe and repeated occurrences of childhood sexual abuse. For many, priorities were improvements in therapy and counseling services, the abolishment of the statute of limitations on prosecuting offenders, and financial compensation. Based on the recommendations of the Round Table and the Independent Commissioner, two new laws were adopted as well as an action plan and some guidelines. In addition to rules for recompensation of victims in an institutional context a fund for victims of sexual abuse in intrafamilial context was established by the Federal Government. Another effect of this process was raising societal sensitivity to the problem of child sexual abuse. The use of a CIRS enabled those directly affected by childhood sexual abuse to have some input into a political process designed to address this issue. Such an approach could have applicability in other countries or in other domains of public health and other forms of societal conflict as well.

[Teaching child and adolescent psychiatry and psychotherapy in Germany-inventory and implications]

OBJECTIVE

Dissemination of knowledge concerning normal and deviant development as well as child and adolescent psychiatric (CAP) disorders with a focus on diagnosis and treatment should represent an integral part of medical training at every medical school. Furthermore, it is of utmost importance that medical students acquire skills in communication and basic psychiatric assessment of children and adolescents. The article summarizes the current state of affairs of teaching in CAP in German medical schools.

METHOD

All chairs of child and adolescent psychiatry were asked for detailed information on involvement in compulsory and noncompulsory medical training, scope of lectures in CAP, and courses for students of other disciplines.

RESULTS

In 25 out of 26 medical schools with a chair for CAP this medical specialty is already part of compulsory medical training. CAP is either taught in independent lectures or is integrated into lectures on psychiatry, pediatrics, and/or psychosomatics. The main lecture of 1.2 semester periods per week on average (range 0.1 to 2, the equivalent of 2 to 28 teaching units per semester) is complemented by numerous additional offers (internships, advanced courses, compulsory elective subjects). The CAP elective tertial of the "practical year" (final year of medical school in Germany) can be completed at all medical faculties with a CAP chair. CAP is often taught students of other disciplines as well, e.g., psychology or education.

CONCLUSIONS

Given the importance of CAP, the overall goal should be to anchor CAP as a required specialty in all 35 medical schools in Germany.