Culturally sensitive stepped care for adolescent refugees: efficacy and cost-utility of a multicentric randomized controlled trial

Adolescent refugees and asylum seekers (ARAS) are highly vulnerable to mental health problems. Stepped care models (SCM) and culturally sensitive therapies offer promising treatment approaches to effectively provide necessary medical and psychological support. To our knowledge, we were the first to investigate whether a culturally sensitive SCM will reduce symptoms of depression and PTSD in ARAS more effectively and efficiently than treatment as usual (TAU). We conducted a multicentric, randomized, controlled and rater-blinded trial across Germany with ARAS between the ages of 14 to 21 years. Participants (N = 158) were stratified by their level of depressive symptom severity and then equally randomized to either SCM or TAU. Depending on their severity level, SCM participants were allocated to tailored interventions. Symptom changes were assessed for depression (PHQ) and PTSD (CATS) at four time points, with the primary end point at post-intervention after 12 weeks. Based on an intention-to-treat sample, we used a linear mixed model approach for the main statistical analyses. Further evaluations included cost-utility analyses, sensitivity analyses, follow-up-analyses, response and remission rates and subgroup analysis. We found a significant reduction of PHQ (d = 0.52) and CATS (d = 0.27) scores in both groups. However, there was no significant difference between SCM and TAU. Cost-utility analyses indicated that SCM generated greater cost-utility when measured as quality-adjusted life years compared to TAU. Subgroup analysis revealed different effects for the SCM interventions depending on the outcome measure. Although culturally sensitive, SCMs did not prove to be more effective in symptom change and represent a more cost-effective treatment alternative for mentally burdened ARAS. Our research contributes to the optimization of clinical productivity and the improvement of therapeutic care for ARAS. Disorder-specific interventions should be further investigated.

Autism spectrum disorder in ICD-11-a critical reflection of its possible impact on clinical practice and research

This perspective article compares and contrasts the conceptualization of Autism Spectrum Disorder (ASD) in ICD-11 and DSM-5. By guiding the user through the ICD-11 text, it is argued that, in contrast to DSM-5, ICD-11 allows a high variety in symptom combinations, which results in an operationalization of ASD that is in favor of an extreme diverse picture, yet possibly at the expense of precision, including unforeseeable effects on clinical practice, care, and research. The clinical utility is questionable as this conceptualization can hardly be differentiated from other mental disorders and autism-like traits. It moves away from an observable, behavioral, and neurodevelopmental disorder to a disorder of inner experience that can hardly be measured objectively. It contains many vague and subjective concepts that lead to non-falsifiable diagnoses. This bears a large danger of false positive diagnoses, of further increased prevalence rates, limitations of access to ASD-specific services and of increasing the non-specificity of treatments. For research, the hypothesis is that the specificity of ASD will be reduced and this will additional increase the already high heterogeneity with the effect that replication of studies will be hampered. This could limit our understanding of etiology and biological pathways of ASD and bears the risk that precision medicine, i.e., a targeted approach for individual treatment strategies based on precise diagnostic markers, is more far from becoming reality. Thus, a more precise, quantitative description and more objective measurement of symptoms are suggested that define the clinical ASD phenotype. Identification of core ASD subtypes/endophenotypes and a precise description of symptoms is the necessary next step to advance diagnostic classification systems. Therefore, employing a more finely grained, objective, clinical symptom characterization which is more relatable to neurobehavioral concepts is of central significance.

Modeling face recognition in the predictive coding framework: A combined computational modeling and functional imaging study

The learning of new facial identities and the recognition of familiar faces are crucial processes for social interactions. Recently, a combined computational modeling and functional magnetic resonance imaging (fMRI) study used predictive coding as a biologically plausible framework to model face identity learning and to relate specific model parameters with brain activity (Apps and Tsakiris, Nat Commun 4, 2698, 2013). On the one hand, it was shown that behavioral responses on a two-option face recognition task could be predicted by the level of contextual and facial familiarity in a computational model derived from predictive-coding principles. On the other hand, brain activity in specific brain regions was associated with these parameters. More specifically, brain activity in the superior temporal sulcus (STS) varied with contextual familiarity, whereas activity in the fusiform face area (FFA) covaried with the prediction error parameter that updated facial familiarity. Literature combining fMRI assessments and computational modeling in humans still needs to be expanded. Furthermore, prior results are largely not replicated. The present study was, therefore, specifically set up to replicate these previous findings. Our results support the original findings in two critical aspects. First, on a group level, the behavioral responses were modeled best by the same computational model reported by the original authors. Second, we showed that estimates of these model parameters covary with brain activity in specific, face-sensitive brain regions. Our results thus provide further evidence that the functional properties of the face perception network conform to central principles of predictive coding. However, our study yielded diverging findings on specific computational model parameters reflected in brain activity. On the one hand, we did not find any evidence of a computational involvement of the STS. On the other hand, our results showed that activity in the right FFA was associated with multiple computational model parameters. Our data do not provide evidence for functional segregation between particular face-sensitive brain regions, as previously proposed.

Conceptualization of the latent structure of autism: further evidence and discussion of dimensional and hybrid models

Autism spectrum disorder (ASD) might be conceptualized as an essentially dimensional, categorical, or hybrid model. Yet, current empirical studies are inconclusive and the latent structure of ASD has explicitly been examined only in a few studies. The aim of our study was to identify and discuss the latent model structure of behavioral symptoms related to ASD and to address the question of whether categories and/or dimensions best represent ASD symptoms. We included data of 2920 participants (1-72 years of age), evaluated with the Autism Diagnostic Observation Schedule (Modules 1-4). We applied latent class analysis, confirmatory factor analysis, and factor mixture modeling and evaluated the model fit by a combination of criteria. Based on the model selection criteria, the model fits, the interpretability as well as the clinical utility we conclude that the hybrid model serves best for conceptualization and assessment of ASD symptoms. It is both grounded in empirical evidence and in clinical usefulness, is in line with the current classification system (DSM-5) and has the potential of being more specific than the dimensional approach (decreasing false positive diagnoses).

Empowerment group therapy for refugees with affective disorders: results of a multicenter randomized controlled trial

BACKGROUND

Against the background of missing culturally sensitive mental health care services for refugees, we developed a group intervention (Empowerment) for refugees at level 3 within the stratified Stepped and Collaborative Care Model of the project Mental Health in Refugees and Asylum Seekers (MEHIRA). We aim to evaluate the effectiveness of the Empowerment group intervention with its focus on psychoeducation, stress management, and emotion regulation strategies in a culturally sensitive context for refugees with affective disorders compared to treatment-as-usual (TAU).

METHOD

At level 3 of the MEHIRA project, 149 refugees and asylum seekers with clinically relevant depressive symptoms were randomized to the Empowerment group intervention or TAU. Treatment comprised 16 therapy sessions conducted over 12 weeks. Effects were measured with the Patient Health Questionnaire-9 (PHQ-9) and the Montgomery-Åsberg Depression Rating Scale (MÅDRS). Further scales included assessed emotional distress, self-efficacy, resilience, and quality of life.

RESULTS

Intention-to-treat analyses show significant cross-level interactions on both self-rated depressive symptoms (PHQ-9; F(1,147) = 13.32, p < 0.001) and clinician-rated depressive symptoms (MÅDRS; F(1,147) = 6.91, p = 0.01), indicating an improvement in depressive symptoms from baseline to post-intervention in the treatment group compared to the control group. The effect sizes for both scales were moderate (d = 0.68, 95% CI 0.21-1.15 for PHQ-9 and d = 0.51, 95% CI 0.04-0.99 for MÅDRS).

CONCLUSION

In the MEHIRA project comparing an SCCM approach versus TAU, the Empowerment group intervention at level 3 showed effectiveness for refugees with moderately severe depressive symptoms.

Shared sorrow, shared costs: cost-effectiveness analysis of the Empowerment group therapy approach to treat affective disorders in refugee populations

BACKGROUND

Refugees and asylum seekers (RAS) in Germany need tailored and resource-oriented mental healthcare interventions.

AIMS

To evaluate the cost-effectiveness of group psychotherapy for RAS with moderate depressive symptoms.

METHOD

This is a post hoc cost-effectiveness analysis of Empowerment group psychotherapy that was embedded in a stratified stepped and collaborative care model (SCCM) from the multicentre randomised controlled MEHIRA trial. One hundred and forty-nine participants were randomly assigned to SCCM or treatment as usual (TAU) and underwent Empowerment (i.e. level 3 of the SCCM for adults) or TAU. Effects were measured with the nine-item Patient Health Questionnaire (PHQ-9) and quality adjusted life-years (QALY) post-intervention. Health service and intervention costs were measured. Incremental cost-effectiveness ratios (ICER) were estimated and net monetary benefit (NMB) regressions with 95% confidence intervals were performed. Cost-effectiveness was ascertained for different values of willingness to pay (WTP) using cost-effectiveness acceptability curves for probable scenarios. Trial registration number: NCT03109028 on ClinicalTrials.gov.

RESULTS

Health service use costs were significantly lower for Empowerment than TAU after 1 year. Intervention costs were on average €409.6. Empowerment led to a significant change in PHQ-9 scores but not QALY. Bootstrapped mean ICER indicated cost-effectiveness according to PHQ-9 and varied considerably for QALY in the base case. NMB for a unit reduction in PHQ-9 score at WTP of €0 was €354.3 (€978.5 to -€269.9). Results were confirmed for different scenarios and varying WTP thresholds.

CONCLUSIONS

The Empowerment intervention was cost-effective in refugees with moderate depressive symptoms regarding the clinical outcome and led to a reduction in direct healthcare consumption. Concerning QALYs, there was a lack of confidence that Empowerment differed from TAU.

The associations of Positive and Negative Valence Systems, Cognitive Systems and Social Processes on disease severity in anxiety and depressive disorders

Background

Anxiety and depressive disorders share common features of mood dysfunctions. This has stimulated interest in transdiagnostic dimensional research as proposed by the Research Domain Criteria (RDoC) approach by the National Institute of Mental Health (NIMH) aiming to improve the understanding of underlying disease mechanisms. The purpose of this study was to investigate the processing of RDoC domains in relation to disease severity in order to identify latent disorder-specific as well as transdiagnostic indicators of disease severity in patients with anxiety and depressive disorders.

Methods

Within the German research network for mental disorders, 895 participants (n = 476 female, n = 602 anxiety disorder, n = 257 depressive disorder) were recruited for the Phenotypic, Diagnostic and Clinical Domain Assessment Network Germany (PD-CAN) and included in this cross-sectional study. We performed incremental regression models to investigate the association of four RDoC domains on disease severity in patients with affective disorders: Positive (PVS) and Negative Valance System (NVS), Cognitive Systems (CS) and Social Processes (SP).

Results

The results confirmed a transdiagnostic relationship for all four domains, as we found significant main effects on disease severity within domain-specific models (PVS: β = -0.35; NVS: β = 0.39; CS: β = -0.12; SP: β = -0.32). We also found three significant interaction effects with main diagnosis showing a disease-specific association.

Limitations

The cross-sectional study design prevents causal conclusions. Further limitations include possible outliers and heteroskedasticity in all regression models which we appropriately controlled for.

Conclusion

Our key results show that symptom burden in anxiety and depressive disorders is associated with latent RDoC indicators in transdiagnostic and disease-specific ways.

[Pathological Demand Avoidance: Current State of Research and Critical Discussion]

Pathological Demand Avoidance: Current State of Research and Critical Discussion Abstract: Pathological demand avoidance (PDA) describes children who obsessively avoid any demand to a clinically relevant extent and is presently the subject of controversial discussion. Their behavior may be interpreted as an attempt to reduce anxiety by establishing security and predictability through rigid control of the environment as well as the demands and expectations of others. The symptoms are described in the context of autism spectrum disorder. This article reviews the current state of research and discusses the questionable validity of pathological demand avoidance as an independent diagnostic entity. It also addresses the impact of the behavior profile on development and treatment. This paper concludes that PDA is not a diagnostic entity nor a subtype of autism; rather, it is a behavior profile that can be associated with adverse illness progression and unfavorable outcomes. PDA is one feature in a complex model. We must consider not only the patient's characteristics but also those of the caregiver and their psychopathology. The reactions of the interaction partners as well as the treatment decisions play a key role play for the affected individuals. Substantial research is needed concerning the occurrence of the behavior profile PDA in diverse disorders, treatment options, and treatment responses.

Review of neurodevelopmental disorders in patients with HNF1B gene variations

This review investigates the association between neurodevelopmental disorders (NDD) and variations of the gene HNF1B. Heterozygous intragenetic mutations or heterozygous gene deletions (17q12 microdeletion syndrome) of HNF1B are the cause of a multi-system developmental disorder, termed renal cysts and diabetes syndrome (RCAD). Several studies suggest that in general, patients with genetic variation of HNF1B have an elevated risk for additional neurodevelopmental disorders, especially autism spectrum disorder (ASD) but a comprehensive assessment is yet missing. This review provides an overview including all available studies of patients with HNF1B mutation or deletion with comorbid NDD with respect to the prevalence of NDDs and in how they differ between patients with an intragenic mutation or 17q12 microdeletion. A total of 31 studies was identified, comprising 695 patients with variations in HNF1B, (17q12 microdeletion N = 416, mutation N = 279). Main results include that NDDs are present in both groups (17q12 microdeletion 25.2% vs. mutation 6.8%, respectively) but that patients with 17q12 microdeletions presented more frequently with any NDDs and especially with learning difficulties compared to patients with a mutation of HNF1B. The observed prevalence of NDDs in patients with HNF1B variations seems to be higher than in the general population, but the validity of the estimated prevalence must be deemed insufficient. This review shows that systematical research of NDDs in patients with HNF1B mutations or deletions is lacking. Further studies regarding neuropsychological characteristics of both groups are needed. NDDs might be a concomitant of HFN1B-related disease and should be considered in clinical routine and scientific reports.

Predicting treatment outcomes of the Empowerment group intervention for refugees with affective disorders: Findings from the MEHIRA project

BACKGROUND

Research on outcome predictors in the field of transcultural treatment for refugees and asylum seekers (RAS) is scarce. We aimed to evaluate predictors of outcome of a group intervention (Empowerment) for RAS with affective disorders which was incorporated at level three of the stratified stepped-care model within the Mental Health in Refugees and Asylum Seekers (MEHIRA) project.

METHODS

A predictor analysis was performed at level three of the MEHIRA project, where 149 refugees with moderate depressive symptoms were treated either with Empowerment or Treatment-as-usual (TAU). Outcome measures were depression severity as assessed by patient-rated Patient Health Questionnaire 9 (PHQ-9) and clinician-rated Montgomery Asberg Depression Rating Scale (MADRS). Regression models with change scores (T1-T0) of PHQ-9 and MADRS as dependent variables were fit. Predictor selection was a mixed-method approach combining testing of literature-based hypotheses and explorative hypothesis-generating analyses of multiple baseline variables.

RESULTS

Intention-to-treat (ITT) analyses revealed significant linear relationships between change in PHQ-9 and baseline depression severity (β = -0.35, t = -3.27, p = .002) and perceived self-efficacy (β = -0.24, t = -2.26, p = .027) in the treatment (verum) condition. MADRS change scores were predicted by baseline depression severity (β = -0.71, t = -8.65, p < .001) in the treatment (verum) condition.

LIMITATIONS

Due to small cell numbers, single predictors could not be evaluated reliably.

CONCLUSIONS

Severity of depression and self-efficacy at baseline were predictors of symptom improvement at level three (Empowerment) of the MEHIRA project. Comorbidity and trauma indicators did not predict outcomes in the treatment (verum) condition, pointing towards broad applicability of the Empowerment intervention in refugee populations.

Social and Nonsocial Autism Symptom Domains in Children and Adolescents with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder: Insights into Their Symptomatological Interplay

INTRODUCTION

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) share overlapping symptomatology, particularly with regard to social impairments (including peer relationship difficulties), and they frequently co-occur. However, the nature of their co-occurrence remains unclear. Therefore, the current study aimed to examine the nature of the transdiagnostic link between ASD and ADHD from a symptomatological point of view measured with the Autism Diagnostic Observation Schedule (ADOS Module 3) and the Autism Diagnostic Interview-Revised (ADI-R).

METHODS

We analyzed the social and nonsocial ASD symptom domain scores from both diagnostic instruments in 4 clinically referred groups (i.e., ASD, ADHD, ASD + ADHD, and no psychiatric diagnosis) without other co-occurring mental disorders using a two-by-two full-factorial MANOVA design with the factors ASD (yes/no) and ADHD (yes/no).

RESULTS

We found no ASD by ADHD interaction effects across all symptom domain scores of ADOS and ADI-R, except for ADOS imagination/creativity. There were only main effects of the factor ASD but no main effects of ADHD. Follow-up contrasts showed that exclusively, ASD had an impact on the measured symptomatology in case of co-occurring ASD + ADHD.

CONCLUSION

Overall, the results support an additive model of the symptomatology across areas of communication, social interaction, and stereotyped behaviors and restricted interests in case of the co-occurrence of ASD and ADHD when assessed with ADOS/ADI-R. Thus, one can assume that the phenotypic overlap of ASD + ADHD may be less complicated than suspected - at least with regard to ASD symptomatology - and that in the presence of ADHD, ASD symptomatology is generally well measurable with best-practice diagnostic instruments.

Using machine learning to improve diagnostic assessment of ASD in the light of specific differential and co-occurring diagnoses

BACKGROUND

Diagnostic assessment of ASD requires substantial clinical experience and is particularly difficult in the context of other disorders with behavioral symptoms in the domain of social interaction and communication. Observation measures such as the Autism Diagnostic Observation Schedule (ADOS) do not take into account such co-occurring disorders.

METHOD

We used a well-characterized clinical sample of individuals (n = 1,251) that had received detailed outpatient evaluation for the presence of an ASD diagnosis (n = 481) and covered a range of additional overlapping diagnoses, including anxiety-related disorders (ANX, n = 122), ADHD (n = 439), and conduct disorder (CD, n = 194). We focused on ADOS module 3, covering the age range with particular high prevalence of such differential diagnoses. We used machine learning (ML) and trained random forest models on ADOS single item scores to predict a clinical best-estimate diagnosis of ASD in the context of these differential diagnoses (ASD vs. ANX, ASD vs. ADHD, ASD vs. CD), in the context of co-occurring ADHD, and an unspecific model using all available data. We employed nested cross-validation for an unbiased estimate of classification performance and made available a Webapp to showcase the results and feasibility for translation into clinical practice.

RESULTS

We obtained very good overall sensitivity (0.89-0.94) and specificity (0.87-0.89). In particular for individuals with less severe symptoms, our models showed increases of up to 35% in sensitivity or specificity. Furthermore, we analyzed item importance profiles of the ANX, ADHD, and CD models in comparison with the unspecific model revealing distinct patterns of importance for specific ADOS items with respect to differential diagnoses.

CONCLUSIONS

ML-based diagnostic classification may improve clinical decisions by utilizing the full range of information from detailed diagnostic observation instruments such as the ADOS. Importantly, this strategy might be of particular relevance for older children with less severe symptoms for whom the diagnostic decision is often particularly difficult.

A data driven machine learning approach to differentiate between autism spectrum disorder and attention-deficit/hyperactivity disorder based on the best-practice diagnostic instruments for autism

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are two frequently co-occurring neurodevelopmental conditions that share certain symptomatology, including social difficulties. This presents practitioners with challenging (differential) diagnostic considerations, particularly in clinically more complex cases with co-occurring ASD and ADHD. Therefore, the primary aim of the current study was to apply a data-driven machine learning approach (support vector machine) to determine whether and which items from the best-practice clinical instruments for diagnosing ASD (ADOS, ADI-R) would best differentiate between four groups of individuals referred to specialized ASD clinics (i.e., ASD, ADHD, ASD + ADHD, ND = no diagnosis). We found that a subset of five features from both ADOS (clinical observation) and ADI-R (parental interview) reliably differentiated between ASD groups (ASD & ASD + ADHD) and non-ASD groups (ADHD & ND), and these features corresponded to the social-communication but also restrictive and repetitive behavior domains. In conclusion, the results of the current study support the idea that detecting ASD in individuals with suspected signs of the diagnosis, including those with co-occurring ADHD, is possible with considerably fewer items relative to the original ADOS/2 and ADI-R algorithms (i.e., 92% item reduction) while preserving relatively high diagnostic accuracy. Clinical implications and study limitations are discussed.

Effectiveness and cost-effectiveness for the treatment of depressive symptoms in refugees and asylum seekers: A multi-centred randomized controlled trial

Background

Current evidence points towards a high prevalence of psychological distress in refugee populations, contrasting with a scarcity of resources and amplified by linguistic, institutional, financial, and cultural barriers. The objective of the study is to investigate the overall effectiveness and cost-effectiveness of a Stepped Care and Collaborative Model (SCCM) at reducing depressive symptoms in refugees, compared with the overall routine care practices within Germany's mental healthcare system (treatment-as-usual, TAU).

Methods

A multicentre, clinician-blinded, randomised, controlled trial was conducted across seven university sites in Germany. Asylum seekers and refugees with relevant depressive symptoms with a Patient Health Questionnaires score of ≥ 5 and a Refugee Health Screener score of ≥ 12. Participants were randomly allocated to one of two treatment arms (SCCM or TAU) for an intervention period of three months between April 2018 and March 2020. In the SCCM, participants were allocated to interventions tailored to their symptom severity, including watchful waiting, peer-to-peer- or smartphone intervention, psychological group therapies or mental health expert treatment. The primary endpoint was defined as the change in depressive symptoms (Patient Health Questionnaire-9, PHQ-9) after 12 weeks. The secondary outcome was the change in Montgomery Åsberg Depression Rating Scale (MADRS) from baseline to post-intervention.

Findings

The intention-to-treat sample included 584 participants who were randomized to the SCCM (n= 294) or TAU (n=290). Using a mixed-effects general linear model with time, and the interaction of time by randomisation group as fixed effects and study site as random effect, we found significant effects for time (p < .001) and time by group interaction (p < .05) for intention-to-treat and per-protocol analysis. Estimated marginal means of the PHQ-9 scores after 12 weeks were significantly lower in SCCM than in TAU (for intention-to-treat: PHQ-9 mean difference at T₁ 1.30, 95% CI 1.12 to 1.48, p < .001; Cohen's d=.23; baseline-adjusted PHQ-9 mean difference at T₁ 0.57, 95% CI 0.40 to 0.74, p < .001). Cost-effectiveness and net monetary benefit analyses provided evidence of cost-effectiveness for the primary outcome and quality-adjusted life years. Robustness of results were confirmed by sensitivity analyses.

Interpretation

The SSCM resulted in a more effective and cost-effective reduction of depressive symptoms compared with TAU. Findings suggest a suitable model to provide mental health services in circumstances where resources are limited, particularly in the context of forced migration and pandemics.

Funding

This project is funded by the Innovationsfond and German Ministry of Health [grant number 01VSF16061]. The present trial is registered under Clinical-Trials.gov under the registration number: NCT03109028. https://clinicaltrials.gov/ct2/show/NCT03109028

Mapping Research Domain Criteria using a transdiagnostic mini-RDoC assessment in mental disorders: a confirmatory factor analysis

This study aimed to build on the relationship of well-established self-report and behavioral assessments to the latent constructs positive (PVS) and negative valence systems (NVS), cognitive systems (CS), and social processes (SP) of the Research Domain Criteria (RDoC) framework in a large transnosological population which cuts across DSM/ICD-10 disorder criteria categories. One thousand four hundred and thirty one participants (42.1% suffering from anxiety/fear-related, 18.2% from depressive, 7.9% from schizophrenia spectrum, 7.5% from bipolar, 3.4% from autism spectrum, 2.2% from other disorders, 18.4% healthy controls, and 0.2% with no diagnosis specified) recruited in studies within the German research network for mental disorders for the Phenotypic, Diagnostic and Clinical Domain Assessment Network Germany (PD-CAN) were examined with a Mini-RDoC-Assessment including behavioral and self-report measures. The respective data was analyzed with confirmatory factor analysis (CFA) to delineate the underlying latent RDoC-structure. A revised four-factor model reflecting the core domains positive and negative valence systems as well as cognitive systems and social processes showed a good fit across this sample and showed significantly better fit compared to a one factor solution. The connections between the domains PVS, NVS and SP could be substantiated, indicating a universal latent structure spanning across known nosological entities. This study is the first to give an impression on the latent structure and intercorrelations between four core Research Domain Criteria in a transnosological sample. We emphasize the possibility of using already existing and well validated self-report and behavioral measurements to capture aspects of the latent structure informed by the RDoC matrix.

Health Services Use and Costs in Individuals with Autism Spectrum Disorder in Germany: Results from a Survey in ASD Outpatient Clinics

Introduction

Autism spectrum disorders (ASD) are associated with high services use, but European data on costs are scarce.

Objectives

Utilisation and annual costs of 385 individuals with ASD (aged 4-67 years; 18.2% females; 37.4% IQ < 85) from German outpatient clinics were assessed.

Methods

Client Service Receipt Inventory

Results

Average annual costs per person were 3287 EUR, with psychiatric inpatient care (19.8%), pharmacotherapy (11.1%), and occupational therapy (11.1%) being the largest cost components. Females incurred higher costs than males (4864 EUR vs. 2936 EUR). In a regression model, female sex (Cost Ratio: 1.65), lower IQ (1.90), and Asperger syndrome (1.54) were associated with higher costs.

Conclusions

In conclusion, ASD-related health costs are comparable to those of schizophrenia, thus underlining its public health relevance. Higher costs in females demand further research.

Disclosure

No significant relationships.

Phenotypic differences between female and male individuals with suspicion of autism spectrum disorder

Background

Although autism spectrum disorder (ASD) is a common developmental disorder, our knowledge about a behavioral and neurobiological female phenotype is still scarce. As the conceptualization and understanding of ASD are mainly based on the investigation of male individuals, females with ASD may not be adequately identified by routine clinical diagnostics. The present machine learning approach aimed to identify diagnostic information from the Autism Diagnostic Observation Schedule (ADOS) that discriminates best between ASD and non-ASD in females and males.

Methods

Random forests (RF) were used to discover patterns of symptoms in diagnostic data from the ADOS (modules 3 and 4) in 1057 participants with ASD (18.1% female) and 1230 participants with non-ASD (17.9% % female). Predictive performances of reduced feature models were explored and compared between females and males without intellectual disabilities.

Results

Reduced feature models relied on considerably fewer features from the ADOS in females compared to males, while still yielding similar classification performance (e.g., sensitivity, specificity).

Limitations

As in previous studies, the current sample of females with ASD is smaller than the male sample and thus, females may still be underrepresented, limiting the statistical power to detect small to moderate effects.

Conclusion

Our results do not suggest the need for new or altered diagnostic algorithms for females with ASD. Although we identified some phenotypic differences between females and males, the existing diagnostic tools seem to sufficiently capture the core autistic features in both groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13229-022-00491-9.

Abilities and Disabilities-Applying Machine Learning to Disentangle the Role of Intelligence in Diagnosing Autism Spectrum Disorders

Objective

Although autism spectrum disorder (ASD) is a relatively common, well-known but heterogeneous neuropsychiatric disorder, specific knowledge about characteristics of this heterogeneity is scarce. There is consensus that IQ contributes to this heterogeneity as well as complicates diagnostics and treatment planning. In this study, we assessed the accuracy of the Autism Diagnostic Observation Schedule (ADOS/2) in the whole and IQ-defined subsamples, and analyzed if the ADOS/2 accuracy may be increased by the application of machine learning (ML) algorithms that processed additional information including the IQ level.

Methods

The study included 1,084 individuals: 440 individuals with ASD (with a mean IQ level of 3.3 ± 1.5) and 644 individuals without ASD (with a mean IQ level of 3.2 ± 1.2). We applied and analyzed Random Forest (RF) and Decision Tree (DT) to the ADOS/2 data, compared their accuracy to ADOS/2 cutoff algorithms, and examined most relevant items to distinguish between ASD and Non-ASD. In sum, we included 49 individual features, independently of the applied ADOS module.

Results

In DT analyses, we observed that for the decision ASD/Non-ASD, solely one to four items are sufficient to differentiate between groups with high accuracy. In addition, in sub-cohorts of individuals with (a) below (IQ level ≥4)/ID and (b) above average intelligence (IQ level ≤ 2), the ADOS/2 cutoff showed reduced accuracy. This reduced accuracy results in (a) a three times higher risk of false-positive diagnoses or (b) a 1.7 higher risk for false-negative diagnoses; both errors could be significantly decreased by the application of the alternative ML algorithms.

Conclusions

Using ML algorithms showed that a small set of ADOS/2 items could help clinicians to more accurately detect ASD in clinical practice across all IQ levels and to increase diagnostic accuracy especially in individuals with below and above average IQ level.

A systematic review of risk and protective factors of mental health in unaccompanied minor refugees

In recent years, there has been a rising interest in the mental health of unaccompanied minor refugees (UMR), who are a high-risk group for mental disorders. Especially the investigation of predictive factors of the mental health of young refugees has received increasing attention. However, there has been no review on this current issue for the specific group of UMR so far. We aimed to summarize and evaluate the existing findings of specific risk and protective factors to identify the most verified influences on the mental health of UMR. Therefore, we conducted a systematic literature search. Study designs were limited to quantitative cross-sectional and longitudinal designs. Eight databases were searched in four different languages and article reference lists of relevant papers were screened. 27 studies were included (N = 4753). Qualitative synthesis revealed the number of stressful life events to be the most evaluated and verified risk factor for mental health of UMR. A stable environment and social support, on the other hand, can protect UMR from developing poor mental health. Besides that, several other influencing factors could be pointed out, such as type of accommodation, family contact, gender and cultural competences. Because of the large heterogeneity of outcome measures, quantitative synthesis was not possible. This review helps to improve our understanding of determinants of UMRs mental health and thus to provide more targeted treatment. Furthermore, it provides information on how to prevent the development of mental health problems by specifying factors that can be modified by different health and immigration sectors in advance. Further research is needed focusing on the interaction between the various predictive factors.

Corrigendum: Abilities and Disabilities-Applying Machine Learning to Disentangle the Role of Intelligence in Diagnosing Autism Spectrum Disorders

[This corrects the article DOI: 10.3389/fpsyt.2022.826043.].

Autism Spectrum Disorder and IQ - A Complex Interplay

Autism spectrum disorder (ASD) is characterized as a very heterogeneous child-onset disorder, whose heterogeneity is partly determined by differences in intelligence quotient (IQ). Older epidemiological studies suggested that the IQ-related spectrum tends to be skewed to the left, i.e., a larger proportion of individuals with ASD have below average intelligence, while only few individuals with ASD may have an IQ above average. This picture changed over time with broadening the spectrum view. Within the present perspective article, we discuss discrepancies in IQ profiles between epidemiological and clinical studies and identify potential underlying aspects, for example, the influence of external factors such as sample biases or differences in availability of autism health services. Additionally, we discuss the validity and reciprocal influences of ASD diagnostics and IQ measurement. We put the impact of these factors for diagnostic as well as care and support situations of patients into perspective and want to encourage further research to contribute to the conceptualization of "autism" more comprehensively including the IQ as well as to examine broader (life) circumstances, interacting factors and diagnostic requirements of given diagnoses in childhood as compared to adulthood.

Prevalences of mental distress and its associated factors in unaccompanied refugee minors in Germany

Prevalences for mental disorders within minor refugees are comparatively high and heterogeneous. To reduce heterogeneity and identify high-risk subgroups, we compared unaccompanied refugee minors (URM) to accompanied refugee minors (ARM) regarding depressive symptoms and mental distress. Furthermore, we examined associative factors of mental distress in URM on a broad scale. We conducted a survey with a cross-sectional design in four German University hospitals. The sample consisted of n = 172 URM and n = 52 ARM aged 14-21. Depressive symptoms were assessed via the Patient Health Questionnaire (PHQ-9). Mental distress was assessed by the Refugee Health Screener (RHS-15). Mann-Whitney test was used to examine differences between URM and ARM. Associated factors of mental distress were evaluated via a stepwise multiple regression analysis. URM showed significantly higher mean scores for PHQ-9 (p < .001) and RHS-15 (p < .001) compared to ARM indicating medium effect sizes. Furthermore, URM were significantly more likely to surpass the cut-off for depression (61.6% vs. 30.8%) and overall mental distress (81.4% vs. 53.8%) compared to ARM. The factors Number of stressful life events (SLE), Female gender, and Fear of deportation were found to be associated with an increased mental distress in URM, whereas Weekly contact to a family member, School attendance, and German language skills were accompanied with lower distress scores. All six factors accounted for 32% of the variance of mental distress in URM (p < .001). Within minor refugees, URM are a highly vulnerable subgroup, which should receive particular attention and more targeted measures by health authorities. Our results indicate that these measures should comprise a rapid promotion of family contact, school attendance, language acquisition, and the fast processing of asylum applications. However, the cross-sectional design limits the interpretability of the results.

Developmental changes within the extended face processing network: A cross-sectional functional magnetic resonance imaging study

In the field of face processing, the so-called "core network" has been intensively researched. Its neural activity can be reliably detected in children and adults using functional magnetic resonance imaging (fMRI). However, the core network's counterpart, the so-called "extended network," has been less researched. In the present study, we compared children's and adults' brain activity in the extended system, in particular in the amygdala, the insula, and the inferior frontal gyrus (IFG). Using fMRI, we compared the brain activation pattern between children aged 7-9 years and adults during an emotional face processing task. On the one hand, children showed increased activity in the extended face processing system in relation to adults, particularly in the left amygdala, the right insula, and the left IFG. On the other hand, lateralization indices revealed a "leftward bias" in children's IFG compared to adults. These results suggest that brain activity associated with face processing is characterized by a developmental decrease in activity. They further show that the development is associated with a rightward migration of face-related IFG activation, possibly due to the competition for neural space between several developing brain functions ("developmental competition hypothesis").

Assessment of Reward-Related Brain Function After a Single Dose of Oxytocin in Autism: A Randomized Controlled Trial

Background

Autism spectrum disorder (ASD) is characterized by difficulties in social communication and interaction, which have been related to atypical neural processing of rewards, especially in the social domain. As intranasal oxytocin has been shown to modulate activation of the brain’s reward circuit, oxytocin might ameliorate the processing of social rewards in ASD and thus improve social difficulties.

Methods

In this randomized, double-blind, placebo-controlled, crossover functional magnetic resonance imaging study, we examined effects of a 24-IU dose of intranasal oxytocin on reward-related brain function in 37 men with ASD without intellectual impairment and 37 age- and IQ-matched control participants. Participants performed an incentive delay task that allows the investigation of neural activity associated with the anticipation and receipt of monetary and social rewards.

Results

Nonsignificant tests suggested that oxytocin did not influence neural processes related to the anticipation of social or monetary rewards in either group. Complementary Bayesian analyses indicated moderate evidence for a null model, relative to an alternative model. Our results were inconclusive regarding possible oxytocin effects on amygdala responsiveness to social rewards during reward consumption. There were no significant differences in reward-related brain function between the two groups under placebo.

Conclusions

Our results do not support the hypothesis that intranasal oxytocin generally enhances activation of reward-related neural circuits in men with and without ASD.

Is the Combination of ADOS and ADI-R Necessary to Classify ASD? Rethinking the "Gold Standard" in Diagnosing ASD

Diagnosing autism spectrum disorder (ASD) requires extensive clinical expertise and training as well as a focus on differential diagnoses. The diagnostic process is particularly complex given symptom overlap with other mental disorders and high rates of co-occurring physical and mental health concerns. The aim of this study was to conduct a data-driven selection of the most relevant diagnostic information collected from a behavior observation and an anamnestic interview in two clinical samples of children/younger adolescents and adolescents/adults with suspected ASD. Via random forests, the present study discovered patterns of symptoms in the diagnostic data of 2310 participants (46% ASD, 54% non-ASD, age range 4-72 years) using data from the combined Autism Diagnostic Observation Schedule (ADOS) and Autism Diagnostic Interview-Revised (ADI-R) and ADOS data alone. Classifiers built on reduced subsets of diagnostic features yield satisfactory sensitivity and specificity values. For adolescents/adults specificity values were lower compared to those for children/younger adolescents. The models including ADOS and ADI-R data were mainly built on ADOS items and in the adolescent/adult sample the classifier including only ADOS items performed even better than the classifier including information from both instruments. Results suggest that reduced subsets of ADOS and ADI-R items may suffice to effectively differentiate ASD from other mental disorders. The imbalance of ADOS and ADI-R items included in the models leads to the assumption that, particularly in adolescents and adults, the ADI-R may play a lesser role than current behavior observations.

Differentiation of autism spectrum disorder and mood or anxiety disorder

Autism spectrum disorder shares many symptoms with other mental health disorders, and comorbid disorders such as mood and anxiety disorders are common, making the diagnostic process challenging. We aimed to explore the diagnostic accuracy of two standard autism spectrum disorder diagnostic instruments and to identify those behavioral items that best differentiate between autism spectrum disorder and mood and anxiety disorder in a naturalistic sample of patients utilizing autism spectrum disorder specialist services. The study included data of 847 participants (5–65 years of age, n = 586 with autism spectrum disorder, n = 261 with mood and anxiety disorder) all evaluated with the Autism Diagnostic Observation Schedule in the context of the diagnostic process. Data of the Autism Diagnostic Interview–Revised were available for 428 participants (5–51 years of age, n = 367 with autism spectrum disorder, n = 61 with mood and anxiety disorder). By means of binominal logistic regressions and an ensemble feature selection, we identified a subset of items that best differentiated between autism spectrum disorder and mood and anxiety disorder. Overall, the results indicate that a combination of communicational deficits and unusual and/or inappropriate social overtures differentiates autism spectrum disorder and mood and anxiety disorder. Aspects of social cognition are also relevant. Limitations of the current study and implications for research and practice are discussed.

Do German Children Differ? A Validation of Conners Early Childhood™

Objective: The present study aimed to validate the German version of the Conners Early Childhood (EC)™ among German-speaking children. Method: A total of 720 parental and 599 childcare provider ratings of 2- to 6-year-old children were surveyed throughout Germany. Validity was assessed by calculating exploratory factor analyses (EFAs) and confirmatory factor analyses (CFAs), and a series of multivariate analyses of variance (MANOVAs) to analyze associations between Conners EC™ symptom ratings and sociodemographic variables. In addition, parent and childcare provider ratings of Conners EC™ scales were correlated with a number of other well-validated German measures assessing preschoolers' behaviors. Results: Although the EFA yielded different factors than the original scales, CFA revealed acceptable to good model fits. Conclusion: Overall, we confirmed the factor structure of the Conners EC's™ American original within the German validation. The use of the American factor structure is justified and can be recommended to facilitate international research on psychopathology in early childhood.

Randomized clinical trial shows no substantial modulation of empathy-related neural activation by intranasal oxytocin in autism

Evidence suggests that intranasal application of oxytocin facilitates empathy and modulates its underlying neural processes, which are often impaired in individuals with autism spectrum disorders (ASD). Oxytocin has therefore been considered a promising candidate for the treatment of social difficulties in ASD. However, evidence linking oxytocin treatment to social behavior and brain function in ASD is limited and heterogeneous effects might depend on variations in the oxytocin-receptor gene (OXTR). We examined 25 male ASD patients without intellectual disability in a double-blind, cross-over, placebo-controlled fMRI-protocol, in which a single dose of oxytocin or placebo was applied intranasally. Patients performed three experiments in the MRI examining empathy for other's physical pain, basic emotions, and social pain. All participants were genotyped for the rs53576 single-nucleotide polymorphism of the OXTR. Oxytocin increased bilateral amygdala responsiveness during the physical pain task for both painful and neutral stimuli. Other than that, there were no effects of oxytocin treatment. OXTR genotype did not significantly interact with oxytocin treatment. Our results contribute to the growing body of empirical literature suggesting heterogenous effects of oxytocin administration in ASD. To draw clinically relevant conclusions regarding the usefulness of oxytocin treatment, however, empirical studies need to consider methods of delivery, dose, and moderating individual factors more carefully in larger samples.

Prevalence of depressive symptoms and symptoms of post-traumatic stress disorder among newly arrived refugees and asylum seekers in Germany: systematic review and meta-analysis

BACKGROUND

In total numbers, Germany has faced the largest number of refugees and asylum seekers (RAS) in Europe in the past decade. Although a considerable proportion have experienced traumatic and stressful life events, there is no systematic review to date examining the prevalence of depressive symptoms and post-traumatic stress disorder (PTSD) symptoms in RAS in Germany.

AIMS

To calculate the prevalence of depressive symptoms and PTSD symptoms in the general population of RAS living in Germany after the year 2000 and explore the impact of study- and participant-related characteristics on prevalence estimates.

METHOD

We systematically searched PubMed, CINAHL, PsycINFO, PSYNDEX, Academic Search Complete, Science Direct and Web of Science from January 2000 to May 2020 to identify articles reporting prevalence of depressive symptoms and PTSD in RAS in Germany (PROSPERO registration number: CRD42020182796).

RESULTS

In total, 31 different surveys met inclusion criteria with 20 surveys reporting prevalence estimates of depressive symptoms and 25 surveys symptoms of PTSD. Based on screening tools, the pooled prevalence estimate of PTSD symptoms was 29.9% (95% CI 20.8-38.7%) and of depressive symptoms 39.8% (95% CI 29.8-50.1%). Heterogeneity was large within and between subgroups. In multivariate meta-regressions on depressive symptoms, heterogeneity was largely explained by survey period, length of field period and study quality.

CONCLUSIONS

Prevalence rates of depressive symptoms and PTSD symptoms in RAS are notably large. They exceed the prevalence in the general German population. As a result of high heterogeneity, however, pooled prevalence rates should be interpreted with caution.

Special educational support in children and adolescents with Autism Spectrum Disorder in Germany: Results from a parent survey

OBJECTIVE

Children and adolescents with Autism Spectrum Disorder (ASD) often receive special educational support (SES). This study aimed to evaluate SES prevalence in children and adolescents with ASD in Germany.

METHODS

A mail survey was distributed to the caregivers of 637 children and adolescents recruited at three German ASD outpatient clinics.

RESULTS

Among the 211 respondents (response: 33.1 %), 82.5 % were provided with a special educational needs statement, and 63.9 % received special education, most of them attending a public special school (57.9 %). The most frequently indicated additional support was a classroom assistant (69.0 %), followed by smaller learning groups (31.7 %). Special education was less frequently provided to individuals with Asperger syndrome than to those with childhood or atypical autism (36.0 %, 76.1 %, and 63.4 %, respectively). Using logistic regression analysis, receiving special education was significantly associated with lower IQ (<85) (Odds Ratio (OR): 8.72; 95 % confidence interval (CI): 3.41-22.32) and younger age (≤11 years, OR: 2.87; 95 % CI: 1.11-7.38), but not with ASD symptom severity.

CONCLUSIONS

The majority of children and adolescents with ASD received SES, indicating a satisfactory supply of such services in Germany. The finding that lower IQ but not ASD symptom severity predicted access to SES raises questions about the specificity of the used selection criteria.

Associations of subclinical autistic-like traits with brain structural variation using diffusion tensor imaging and voxel-based morphometry

Background

Previous case–control studies of autistic spectrum disorder (ASD) have identified altered brain structure such as altered frontal and temporal cortex volumes, or decreased fractional anisotropy (FA) within the inferior fronto-occipital fasciculus in patients. It remains unclear whether subclinical autistic-like traits might also be related to variation in these brain structures.

Methods

In this study, we analyzed magnetic resonance imaging (MRI) data of 250 psychiatrically healthy subjects phenotyped for subclinical autistic-like traits using the Autism Spectrum Quotient (AQ). For data analysis, we used voxel-based morphometry of T1-MRIs (Computational Anatomy Toolbox) and tract-based spatial statistics for diffusion tensor imaging data.

Results

AQ attention switching subscale correlated negatively with FA values in the bilateral uncinate fasciculus as well as the bilateral inferior fronto-occipital fasciculus. Higher AQ attention switching subscale scores were associated with increased mean diffusivity and radial diffusivity values in the uncinate fasciculus, while axial diffusivity values within this tract show a negative correlation. AQ attention to detail subscale correlated positively with gray matter volume in the right pre- and postcentral gyrus.

Conclusions

We demonstrate that individuals with higher levels of autism-spectrum-like features show decreased white matter integrity in tracts associated with higher-level visual processing and increased cortical volume in areas linked to movement sequencing and working memory. Our results resemble regional brain structure alterations found in individuals with ASD. This offers opportunities to further understand the etiology and pathogenesis of the disorder and shows a subclinical continuum perspective.

The Trajectory of Hemispheric Lateralization in the Core System of Face Processing: A Cross-Sectional Functional Magnetic Resonance Imaging Pilot Study

Face processing is mediated by a distributed neural network commonly divided into a “core system” and an “extended system.” The core system consists of several, typically right-lateralized brain regions in the occipito-temporal cortex, including the occipital face area (OFA), the fusiform face area (FFA) and the posterior superior temporal sulcus (pSTS). It was recently proposed that the face processing network is initially bilateral and becomes right-specialized in the course of the development of reading abilities due to the competition between language-related regions in the left occipito-temporal cortex (e.g., the visual word form area, VWFA) and the FFA for common neural resources. In the present pilot study, we assessed the neural face processing network in 12 children (aged 7–9 years) and 10 adults with functional magnetic resonance imaging (fMRI). The hemispheric lateralization of the core face regions was compared between both groups. The study had two goals: First, we aimed to establish an fMRI paradigm suitable for assessing activation in the core system of face processing in young children at the single subject level. Second, we planned to collect data for a power analysis to calculate the necessary group size for a large-scale cross-sectional imaging study assessing the ontogenetic development of the lateralization of the face processing network, with focus on the FFA. It was possible to detect brain activity in the core system of 75% of children at the single subject level. The average scan-to-scan motion of the included children was comparable to adults, ruling out that potential activation differences between groups are caused by unequal motion artifacts. Hemispheric lateralization of the FFA was 0.07 ± 0.48 in children (indicating bilateral activation) and −0.32 ± 0.52 in adults (indicating right-hemispheric dominance). These results thus showed, as expected, a trend for increased lateralization in adults. The estimated effect size for the FFA lateralization difference was d = 0.78 (indicating medium to large effects). An adequately powered follow-up study (sensitivity 0.8) testing developmental changes of FFA lateralization would therefore require the inclusion of 18 children and 26 adults.

[Autism spectrum disorder in childhood and adults: diagnosis and differential diagnoses]

Autistic disorders are summarized in DSM‑5 under the term autism spectrum disorder (ASD) and are severe, lifelong, pervasive neurodevelopmental disorders. Core features manifested even in childhood are impairments in social interaction and communication as well as restricted and repetitive behavior. The intensity of symptoms, language and cognitive impairments vary but the majority of affected individuals have below average intelligence and 80% have at least one comorbid disorder. The diverse pathology and heterogeneity in phenotypes are caused by a complex genetic etiology, which is associated with a reduced synaptic plasticity of neural networks. The disorder is associated with a clearly reduced quality of life as well as a high familial burden. The differential diagnostics have a high relevance and the diagnosis should be carried out by specialized institutions. Behavioral therapeutic interventions are indicated.

Identifying predictive features of autism spectrum disorders in a clinical sample of adolescents and adults using machine learning

Diagnosing autism spectrum disorders (ASD) is a complicated, time-consuming process which is particularly challenging in older individuals. One of the most widely used behavioral diagnostic tools is the Autism Diagnostic Observation Schedule (ADOS). Previous work using machine learning techniques suggested that ASD detection in children can be achieved with substantially fewer items than the original ADOS. Here, we expand on this work with a specific focus on adolescents and adults as assessed with the ADOS Module 4. We used a machine learning algorithm (support vector machine) to examine whether ASD detection can be improved by identifying a subset of behavioral features from the ADOS Module 4 in a routine clinical sample of N = 673 high-functioning adolescents and adults with ASD (n = 385) and individuals with suspected ASD but other best-estimate or no psychiatric diagnoses (n = 288). We identified reduced subsets of 5 behavioral features for the whole sample as well as age subgroups (adolescents vs. adults) that showed good specificity and sensitivity and reached performance close to that of the existing ADOS algorithm and the full ADOS, with no significant differences in overall performance. These results may help to improve the complicated diagnostic process of ASD by encouraging future efforts to develop novel diagnostic instruments for ASD detection based on the identified constructs as well as aiding clinicians in the difficult question of differential diagnosis.

[Transition in autism spectrum disorders]

Transition in autism spectrum disorders Abstract. Children and adolescents with autism spectrum disorder (ASD) are regularly seen by child and adolescent psychiatrists. Many diagnostic and therapeutic interventions are available for this age group. However, ASD is a rather unknown disorder in adult services, including psychiatry - despite the chronic course and the individual need for diagnosis, intervention, and support also in adulthood. Transition from childhood into adulthood is a rather complex topic that includes the challenge of mastering education and employment. This article presents these transition-related aspects and recommendations to improve healthcare in Germany.

Segen oder Fluch? Das Internet als Informationsquelle über Autismus und Asperger-Syndrom

Zusammenfassung. Fragestellung: Sehr viele Menschen informieren sich heutzutage über gesundheitsrelevante Themen im Internet, wobei die Qualität dieser Informationen fraglich ist. In der vorliegenden Studie soll beispielhaft für ein psychisches Störungsbild (Autismus-Spektrum-Störung) die Qualität der Informationsquelle Internet sowie die sich daraus ergebenden Implikationen diskutiert werden. Methodik: Es wurde eine systematische Auswertung von 96 deutschsprachigen Internetseiten durchgeführt mit dem Ziel, neben konkreten Charakteristika der Internetseiten auch die Zuverlässigkeit der Publikationen, die Informationsdarstellung sowie die Gesamtqualität der Internetseiten zu bewerten und die sich aus der Darstellung ergebenden klinischen Implikationen zu analysieren. Ergebnisse: Nur bei 39 % der Internetseiten ließen sich Referenzen für wissenschaftlich fundierte Informationen feststellen, Werbung war hingegen auf 53 % der Internetseiten vorhanden. Die meisten falschen Informationen wurden im Bereich der „Behandlung“ (17 %) verbreitet. Bei 75 % der Internetseiten traf die Vollständigkeit nicht zu. Lediglich 10 % der Internetseiten thematisierte die Beeinträchtigung bzw. Belastung der Familien. Die Qualität der Seiten wurde bei 30 % als ungenügend, bei 41 % als mangelhaft und nur bei 6 % als gut beurteilt. Schlussfolgerungen: Ähnlich wie durch die bereits vorliegenden Analysen zu englischsprachigen Internetseiten festgestellt, können für viele der deutschsprachigen Seiten deutliche Qualitätsmängel konstatiert werden. Die Implikationen in Bezug auf Bestätigungsfehler, Stigmatisierung, Überidentifikation, Ingroup-Outgroup-Effekte, Kontrast- und Schneeballeffekte werden diskutiert.

Mental health in refugees and asylum seekers (MEHIRA): study design and methodology of a prospective multicentre randomized controlled trail investigating the effects of a stepped and collaborative care model

The sudden arrival of culturally diverse asylum seekers and refugees into Germany has created a strong demand for recognizing and appropriately treating those suffering from mental health issues. Due to many systemic, organizational, cultural and socio-linguistic barriers, psychiatric treatment of refugees is posing a major challenge to Germany's mental health care system. Thus, there is a need for alternative models that allow for increased access to adequate, effective and efficient culturally sensitive mental health care services. Here, we describe the Mental Health in Refugees and Asylum Seekers (MEHIRA) project, a multicentre randomized controlled trial investigating a stepped collaborative care model (SCCM) for providing mental health treatment in this vulnerable population. The proposed SCCM aims to decrease the aforementioned barriers. Adult and adolescent participants will be screened for depressive symptoms and matched to appropriate psychological interventions, including group-level interventions (START intervention, Empowerment/Gender-sensitive/Peer to peer), and other innovative, digital treatment approaches (Smartphone application). The therapeutic effect of the SCCM will be compared to TAU (treatment-as-usual). All interventions have been designed to be culturally sensitive, and offered in two different languages: Arabic and Farsi. The outcome of this study may contribute significantly to future clinical and legal guidelines in developing parallel and efficient new structures of treatment. Collected data will inform primary and secondary mental health care providers with recommendations concerning the design and implementation of effective treatment models and programmes. Guidelines and recommendations may also potentially be adopted by other host countries, developing countries and also in humanitarian aid programmes.

Effectiveness of the Stepping Stones Triple P group parenting program in reducing comorbid behavioral problems in children with autism

Children with autism spectrum disorders often exhibit comorbid behavioral problems. These problems have an impact on the severity of the core symptoms, the progression of the disorder as well as on the families’ quality of life. We evaluated the effectiveness of the Stepping Stones Triple P group parent training program as a supplementary intervention in the treatment of children with autism spectrum disorder. Therefore, we employed a single group repeated measures design and assessed child variables via parents’ and teachers’ judgments at four successive time points. The participants were parents of 24 children with autism spectrum disorder aged between 3.6 and 12 years. We found a significant reduction of comorbid behavioral problems in the children, primarily in the parents’ judgment at follow-up. Furthermore, a reduction of the autism spectrum disorder core symptoms emerged. The teachers’ judgment particularly revealed an improvement in children’s social relationships. Effect sizes were large ( ƞ2 ranging from 0.14 to 0.23). The findings demonstrate the effectiveness of the Stepping Stones Triple P as a supplementary intervention for reducing comorbid behavioral problems in the treatment of children with autism spectrum disorder. Higher parental self-efficacy and parental attributions, including parents’ ability to influence child problem behaviors, are discussed as important factors for the effectiveness of Stepping Stones Triple P.

Diagnostik von Autismus- Spektrum-Störungen im Kindes-, Jugend- und Erwachsenenalter: Überblick zu den wesentlichen Fragestellungen und Ergebnissen des ersten Teils der S3-Leitlinie

Zusammenfassung. Hintergrund: Autismus-Spektrum-Störungen (ASS) umfassen die ICD-10-Diagnosen (International Statistical Classification of Diseases and Related Health Problems) frühkindlicher Autismus, Asperger-Syndrom und atypischer Autismus und zeigen eine Lebenszeitprävalenz von bis zu 1 %. Die S3-Leitlinie der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. hat zum Ziel, evidenzbasierte Diagnostik und Therapie für professionelle Akteure im Gesundheits- und Sozialsystem systematisch zusammenzufassen und klinische Empfehlungen zu konsentieren. Der vorliegende Artikel fasst die wesentlichen Ergebnisse zum Teil Diagnostik zusammen. Methodik: Die Leitliniengruppe besteht aus 14 klinischen und wissenschaftlichen Fachgesellschaften sowie Patienten-/Angehörigen-Vertretern. Die Empfehlungen basieren dabei auf den Ergebnissen systematischer Literatursuche, Datenextraktion, Studienqualitäts-Bewertung sowie metaanalytischer Datenaggregation in Kombination mit der klinischen Expertise der jeweiligen Vertreter. Die Empfehlungen wurden anhand eines nominalen Gruppenprozesses abgestimmt. Ergebnisse: Der aktuelle Forschungsstand zur Diagnostik wird zusammengefasst. Dabei liegt ein besonderer Schwerpunkt auf der Frage der Notwendigkeit und Entbehrlichkeit verschiedener Bestandteile des diagnostischen Prozesses. Nach einer allgemeinen Einführung zum Krankheitsbild werden insbesondere die wesentlichen Aspekte der Anamnese, die sinnvolle Verwendung von Screening- und Diagnostikinstrumenten, die internistisch-neurologische Untersuchung, apparative Diagnostik, testpsychologische Untersuchung, Aufklärung und Beratung sowie sinnvolle Verlaufsdiagnostik detailliert dargestellt. Schlussfolgerung: Die ASS-Leitlinie gibt evidenzbasierte, klinisch konsentierte Empfehlungen zum Prozess der Diagnostik von ASS im Kindes-, Jugend- und Erwachsenenalter. Sie bietet Anwendern zudem die Möglichkeit, sich in kurzer Zeit über die Hintergründe der Störung sowie verschiedene diagnostische Instrumente zu informieren.

Internalised stigma in adults with autism: A German multi-center survey

The aim of this study was to evaluate the extent of internalised stigma and possible predictors in adults with a diagnosis of autism spectrum disorder (ASD). We measured internalised stigma in a sample of 149 adults with ASD and an IQ ≥70 (79.2% male, mean age 31.8 years), using the Brief Version of the Internalized Stigma of Mental Illness Scale (ISMI-10). The mean ISMI-10 score was 1.93 (SD=0.57), with 15.4% of participants reporting moderate or severe internalised stigma. Moderate or severe stigma was more frequent in persons aged ≥35 years (OR: 4.36), and in individuals with low educational level (OR: 6.00). IQ, sex and ASD diagnostic subtype (ICD-10) did not influence stigma severity. Compared to other mental disorders, the level of internalised stigma in adults with ASD without intellectual disability appears to be lower.

Pathways to a diagnosis of autism spectrum disorder in Germany: a survey of parents

BACKGROUND

Early identification of autism spectrum disorders (ASD) is a prerequisite for access to early interventions. Although parents often note developmental atypicalities during the first 2 years of life, many children with ASD are not diagnosed until school age. For parents, the long period between first parental concerns and diagnosis is often frustrating and accompanied by uncertainty and worry.

METHODS

This study retrospectively explored the trajectories of children with a confirmed ASD diagnosis during the diagnostic process, from first parental concerns about their child's development until the definite diagnosis. A survey concerning the diagnostic process was distributed to parents or legal guardians of children with ASD from three specialized ASD outpatient clinics in Germany.

RESULTS

The response rate was 36.9%, and the final sample consisted of carers of 207 affected children (83.6% male, mean age 12.9 years). The children had been diagnosed with childhood autism (55.6%), Asperger syndrome (24.2%), or atypical autism (20.3%). On average, parents had first concerns when their child was 23.4 months old, and an ASD diagnosis was established at a mean age of 78.5 months. Children with atypical autism or Asperger syndrome were diagnosed significantly later (83.9 and 98.1 months, respectively) than children with childhood autism (68.1 months). Children with an IQ < 85 were diagnosed much earlier than those with an IQ ≥ 85. On average, parents visited 3.4 different health professionals (SD = 2.4, range 1-20, median: 3.0) until their child received a definite ASD diagnosis. Overall, 38.5% of carers were satisfied with the diagnostic process.

CONCLUSIONS

In this sample of children with ASD in Germany, the time to diagnosis was higher than in the majority of other comparable studies. These results flag the need for improved forms of service provision and delivery for suspected cases of ASD in Germany.

Complementary and alternative medicine use in adults with autism spectrum disorder in Germany: results from a multi-center survey

BACKGROUND

Complementary and Alternative Medicine (CAM) is widely used both in the general population and for the treatment of somatic and psychiatric disorders. Studies on CAM use among patients with autism spectrum disorder (ASD) have so far only focused on children and adolescents. The aim of this study was to investigate patterns of CAM use among adults with ASD.

METHODS

A questionnaire survey concerning current and lifetime use of CAM was distributed to adults with ASD between November 2015 and June 2016. Participants diagnosed by experienced clinicians using the current diagnostic gold standard were recruited from four ASD outpatient clinics in Germany. Questionnaire data was then linked to supplementary clinical data.

RESULTS

The final sample consisted of 192 adults (response: 26.8%) with a mean age of 31.5 years (80% male; diagnoses: Asperger's syndrome (58%), childhood autism (27%), atypical autism (12%)). 45% of the respondents stated that they were currently using or had used at least one CAM modality in their life. Among the participants with lifetime CAM use, almost half had used two or more different types of CAM. Alternative medical systems (e.g. homeopathy, acupuncture) were most frequently used, followed by mind-body interventions (e.g. yoga, biofeedback, animal assisted therapy). Overall, 20% of respondents stated that they would like to try at least one listed CAM modality in the future.

CONCLUSIONS

This is the first study on CAM use in adults with ASD, demonstrating considerable CAM use in this population. Given the popularity of CAM, patients should be informed about the effectiveness and potentially dangerous side effects of CAM treatments, as evidence for the majority of CAM methods in ASD is still limited.

Willingness to try and lifetime use of complementary and alternative medicine in children and adolescents with autism spectrum disorder in Germany: A survey of parents

Regardless of their limited evidence and potential adverse effects, use of complementary and alternative medicine is common in children with autism spectrum disorder. Nevertheless, data on complementary and alternative medicine use in children with autism spectrum disorder in Germany are lacking. Therefore, a questionnaire survey on the use of complementary and alternative medicine was distributed to parents of children with autism spectrum disorder from three academic autism spectrum disorder outpatient clinics in Germany. Of 211 respondents, 46% stated that their child currently used or had ever used some form of complementary and alternative medicine in their life. The complementary and alternative medicine modalities most frequently used were manipulative and body-based methods (e.g. craniosacral therapy). And 18% of caregivers expressed willingness to try complementary and alternative medicine treatments for their child with autism spectrum disorder in the future, with mind–body interventions predominating. Health professionals should be aware of the considerable complementary and alternative medicine use prevalence among children with autism spectrum disorder and offer parents information about its effectiveness and potential side effects.

Empathy in Females With Autism Spectrum Disorder

Objective: Despite the fact that autism spectrum disorder (ASD) is a common psychiatric diagnosis, knowledge about the special behavioral and neurobiological female phenotype is still scarce. The present study aimed to investigate neural correlates of empathy for physical and social pain and to assess the impact of egocentric perspective taking on social pain empathy in complex social situations in women and girls with ASD. Methods: Nine female individuals with high functioning ASD were compared to nine matched peers without ASD during two functional magnetic resonance imaging (fMRI) experiments, examining empathy for physical and social pain using well-established paradigms. Participants viewed multiple pictorial stimuli depicting a social target in either physically painful or socially unpleasant situations. In the social situations, the participant either shared the social target's knowledge about the inappropriateness of the situation (observed social target is aware about the embarrassment of the situation; e.g., tripping in public) or not (observed social target is unaware about the embarrassment of the situation; e.g., open zipper). Results: Females with ASD did not rate the physical pain stimuli differently from non-clinical controls. Social pain situations, however, posed a greater challenge to females with ASD: For non-shared knowledge situations, females with ASD rated the social target's embarrassment as more intense. Thus, compared to non-clinical controls, females with ASD had a stronger egocentric perspective of the situation rather than sharing the social target's perspective. On the neural systems level, both groups showed activation of areas of the so-called empathy network that was attenuated in females with ASD during empathy for physical and social pain with a particular reduction in insula activation. Conclusion: Females with high functioning ASD are able to share another person's physical or social pain on the neural systems level. However, hypoactivation of the anterior insula in contrast to individuals without ASD suggests that they are less able to rely on their shared representations of emotions along with difficulties to take over a person's perspective and to make a clear distinction between their own and someone else's experience of embarrassment.

Disruptive Behaviors across Different Disorders: Evaluation of a Clinical Sample Using the Eyberg Child Behavior Inventory

OBJECTIVE

The study reports the prevalence of disruptive behaviors in a help-seeking sample of young children across a diverse range of clinical diagnoses (based on ICD-10).

METHOD

The Eyberg Child Behavior Inventory (ECBI), a parent rating scale of disruptive behaviors, was completed on 310 children (2-11 years) at three child and adolescent psychiatry clinics in three German states (Bavaria, Hesse, Lower Saxony); the majority of children were outpatients.

RESULTS

Mean intensity scores of disruptive behaviors differed significantly by diagnostic group, with the lowest ratings within a community sample, and increasingly higher scores in children with a diagnosis from the internalizing spectrum, those with pervasive developmental disorders, and finally, those with externalizing disorders (e. g. hyperkinetic disorder, conduct disorders). Seventy percent of the clinical sample, compared to only 17 % of the community sample, exceeded the normative cut-off score of 111, indicating that disruptive behaviors are common in young German children seeking help for different mental health problems.

CONCLUSIONS

These findings support the Research Domain Criteria approach by showing that disruptive behaviors cross our current diagnostic labels and may need to be assessed and conceptualized in treatment planning, even in children without a primary diagnosis from the externalizing spectrum.