Recognition and management of children and adolescents with conduct disorder: a real-world data study from four western countries

BACKGROUND

Conduct disorders (CD) are among the most frequent psychiatric disorders in children and adolescents, with an estimated worldwide prevalence in the community of 2-4%. Evidence-based psychological outpatient treatment leads to significant improvement in about two-thirds of cases. However, there seems to be considerable variation in rates of CD diagnoses and implementation of evidence-based interventions between nations. The aim of this study was to compare administrative prevalence and treatment patterns for CD in children and adolescents seen in health care systems across four Western countries (Denmark, Germany, Norway, and the USA).

METHODS

Cross-sectional observational study using healthcare data to identify children and adolescents (aged 0-19 years) with an ICD-10 code for CD within the calendar year 2018. Within each country's study population, the prevalence of CD, psychiatric comorbidity, psychopharmacological treatment, and psychiatric hospitalisation was calculated.

RESULTS

The prevalence of diagnosed CD differed 31-fold between countries: 0.1% (Denmark), 0.3% (Norway), 1.1% (USA) and 3.1% (Germany), with a male/female ratio of 2.0-2.5:1. The rate of psychiatric comorbidity ranged from 69.7 to 86.1%, with attention-deficit/hyperactivity disorder being most common. Between 4.0% (Germany) and 12.2% (USA) of youths with a CD diagnosis were prescribed antipsychotic medication, and 1.2% (Norway) to 12.5% (Germany) underwent psychiatric hospitalisation.

CONCLUSION

Recognition and characteristics of youths diagnosed with CD varied greatly by country. In some countries, the administrative prevalence of diagnosed CD was markedly lower than the average estimated worldwide prevalence. This variation might reflect country-specific differences in CD prevalence, referral thresholds for mental health care, diagnostic tradition, and international variation in service organisation, CD recognition, and availability of treatment offers for youths with CD. The rather high rates of antipsychotic prescription and hospitalisation in some countries are remarkable, due to the lack of evidence for these therapeutic approaches. These findings stress the need of prioritising evidence-based treatment options in CD. Future research should focus on possible reasons for inter-country variation in recognition and management of CD, and also address possible differences in patient-level outcomes.

Trends in antipsychotic use among children and adolescents in Germany: a study using 2011-2020 nationwide outpatient claims data

Introduction

We aimed to provide an update on trends in antipsychotic (AP) use among children and adolescents in Germany.

Materials and methods

Based on nationwide outpatient claims data from Germany, we conducted a cross-sectional study. For each year from 2011 to 2020, we determined the prevalence of AP use, defined as the proportion of children and adolescents with at least one AP dispensation. We evaluated trends in AP use by age, sex, and AP class (typical vs. atypical). Additionally, we assessed trends in the specialty of AP prescribers and the frequency of psychiatric diagnoses among AP users.

Results

Overall, data from more than 12 million children and adolescents were included for each calendar year (2011: 12,488,827; 2020: 13,330,836). From 2011 to 2020, the overall prevalence of pediatric AP use increased from 3.16 to 3.65 per 1,000, due to an increase in use of both typical APs (from 1.16 to 1.35 per 1,000) and atypical APs (from 2.35 to 2.75 per 1,000). The largest increase in AP use was found among 15- to 19-year-old females, with an increase from 3.88 per 1,000 in 2011 to 7.86 per 1,000 in 2020 (+103%), mainly due to rising quetiapine use (from 1.17 to 3.46 per 1,000). Regarding prescribers' specialty, the proportion of APs prescribed by child and adolescent psychiatrists increased during the studied period (2011: 24.8%; 2020: 36.4%), whereas prescriptions by pediatricians (2011: 26.0%; 2020: 19.9%) and general practitioners (2011: 18.0%; 2020: 12.4%) decreased. Risperidone was the most commonly used AP in males, and quetiapine was the leading AP in females, each with the highest prevalence in 15- to 19-year-olds. In male risperidone users in this age group, the most frequent diagnosis was attention-deficit/hyperactivity disorder (50.4%), while in female quetiapine users it was depression (82.0%).

Discussion

Use of APs among children and adolescents in Germany has continued to increase over the last decade. The sharp increase in AP use among 15- to 19-year-old females, which is largely due to an increased use of quetiapine, is remarkable. Potential reasons for this increase-e.g., limited access to psychosocial treatments-should be carefully analyzed. Also, the introduction of more restrictive prescribing guidelines might be considered.

Secure attachment predicts lower societal cost amongst severely antisocial adolescents

BACKGROUND

Social and economic costs associated with antisocial behaviour are well-established, but little is known about the potential costs savings/benefits of secure attachment in this high-risk group. We aimed to provide the first test of attachment quality as a distinct predictor of economic costs.

METHODS

111 adolescents (10-17 years of age, M = 15.0, SD = 1.6; 71% male) referred to young offender services due to high levels of antisocial behaviour were included. Costs were measured by detailed service-use interview, and attachment security to mother and father elicited through the Child Attachment Interview. The level of antisocial behaviour and callous-unemotional traits were assessed. Cost predictors were calculated using generalised linear models.

RESULTS

Mean 12-months service costs were £5,368 (sd 5,769) per adolescent, with justice system and educational service costs being the main components. After adjusting for covariates, economic costs were predicted by attachment quality to fathers, with a difference of £2,655 per year between those with secure (£3,338) versus insecure attachment (£5,993); significant cost effects were not found for attachment quality to mothers. Higher levels of callous-unemotional traits, lower verbal IQ, higher levels of antisocial behaviour, and older age were also significant cost predictors.

CONCLUSIONS

Secure attachment to fathers is a predictor of reduced public cost in adolescents with severe antisocial behaviour. This novel finding for severely antisocial youth extends previous findings in less antisocial children and underscores the public health and policy benefits of good caregiving quality and the value of population-level dissemination of evidence-based interventions that improve caregiving quality.

Characteristics and outcomes of cases with methylphenidate abuse, dependence or withdrawal: an analysis of spontaneous reports in EudraVigilance

Methylphenidate (MPH) is a central nervous stimulant, which is mainly used in attention deficit hyperactivity disorder (ADHD) and narcolepsy. In recent years, rising MPH prescription volumes have drawn attention to possible misuse. We analyzed data on suspected MPH abuse, dependence or withdrawal reported to the EudraVigilance database (1996-2019), comparing case characteristics (e.g. age, indications and outcome). In 1531 cases from 35 countries (median: 29 years, 57.6% male), 42.3% had been diagnosed with ADHD and 8.0% with narcolepsy. Narcolepsy cases were older than ADHD cases (mean age: 47 vs. 22 years), and used co-medications more frequently (79.4 vs. 47.8%). Intravenous MPH administration was most common among individuals not diagnosed with ADHD or narcolepsy. A history of abuse, dependence or withdrawal of any substance was more often documented in fatal than in nonfatal cases (49.0 vs. 22.5%), whereas differences regarding the route of administration were less pronounced. Minors, who presumably received MPH for ADHD treatment, presented less frequently with serious outcomes than older cases or those without an approved indication. Prescribers should exercise caution in adult MPH users and should make a thorough co-medication assessment. Finally, more research on substance abuse in narcolepsy patients is required, which should include comorbidities and co-medication.

[Maintaining a comprehensive provision of inpatient child and adolescent mental health services in the years to come-a German perspective]

BACKGROUND

A considerable number of child and adolescent psychiatry inpatient units in Germany suffer from a significant shortage of doctors, which endangers the current system of nation-wide availability of high-quality child and adolescent inpatient services.

METHODS

Drawing on recent data, this article pictures the status quo of child and adolescent psychiatry inpatient services in Germany. The authors then discuss the pros and cons of different suggestions of how to cope with the doctor shortage crisis in child and adolescent psychiatry.

RESULTS

The following options for action are suggested: reduction of service provision across the board, shift from personnel-intensive inpatient towards home-based treatment, trans-sectoral cooperation by means of tele-psychiatry, delegation of clinical responsibilities to psychologists, limiting ward physicians' tasks to mere medical care of patients, improvement of working conditions in inpatient units, recruitment of doctors from abroad, and increased recruiting efforts at medical school level. From the authors' viewpoint, the latter option offers the best chance of lasting success; however, this requires a long-term, nationwide approach and considerable efforts of all departments involved.

A good investment: longer-term cost savings of sensitive parenting in childhood

BACKGROUND

Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan. The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested.

METHODS

Design: Longitudinal study with follow-up from 2012 to 2016.

SETTING

UK multicentre study cohort (London, South-East England).

PARTICIPANTS

174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4-6 years then followed up in early adolescence (mean age 12.1 years).

MEASURES

The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent-child interaction.

RESULTS

Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security.

CONCLUSIONS

This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. Savings are likely to increase as individuals grow older since early parenting quality predicts health, behavioural and occupational outcomes in adulthood. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

Assessment of the quality of routine ambulatory healthcare for common disorders in children and adolescents in Germany: study protocol for a retrospective medical record review (QualiPäd)

INTRODUCTION

The quality of healthcare in childhood and adolescence is of key importance, in order to foster a healthy development and to avoid chronic health problems. Yet, data for Germany regarding the quality of healthcare for this patient group are lacking. The QualiPäd research project aims to estimate the quality of outpatient healthcare for children and adolescents in Germany, focusing on common psychiatric and physical disorders.

METHODS AND ANALYSIS

Quality indicators for seven common physical and mental childhood and adolescent clinical conditions (attention deficit/hyperactivity disorder, asthma, atopic dermatitis, depression, otitis media, conduct disorder/oppositional defiant disorder, tonsillitis) will be developed and ratified by experts, using the RAND/UCLA Appropriateness Method.Initially, 1400 medical records of children and adolescents with one of the aforementioned clinical conditions will then be randomly drawn from 40 outpatient practices in the German federal state of Hessen. The records will then be assessed regarding their adherence to the respective quality indicators. Based on this, the percentage of appropriate and inappropriate (eg, wasteful) healthcare of all clinical conditions (primary endpoint) will be estimated. Additionally, possible factors influencing the quality of care (eg, patient characteristics, type of condition, type of practice) will be identified using generalised estimation equation models.

ETHICS AND DISSEMINATION

This study will show for which of the studied clinical conditions and/or patients improvement of quality of care is necessary within the German health system. Also, the quality indicators designed for the study can afterwards be implemented in regular care and thus enable regular reporting of the outpatient care of this target group. The authors plan to disseminate their findings through international, peer-reviewed scientific publications, and through presentations at national and international paediatric and child psychiatric conferences.

TRIAL REGISTRATION NUMBER

DRKS00022408.

Prävalenz und Versorgung der Posttraumatischen Belastungsstörung in Deutschland: Eine bundesweite Auswertung von Krankenkassendaten aus den Jahren 2008 und 2017

Ziel der Studie Gewinnung von Daten zur Prävalenz sowie medizinischen und psychotherapeutischen Versorgung von Menschen mit PTBS in Deutschland.

Methodik Aus Sekundärdaten der BARMER wurde die Prävalenz von PTBS-Diagnosen (ICD-10: F43.1) sowie psychiatrischen Komorbiditäten, Psychotherapie und Pharmakotherapie für diese Versichertengruppe abgeleitet. Ergänzend wurden Prävalenztrends (2008 vs. 2017) berechnet.

Ergebnisse Im Jahr 2017 lag die PTBS-Diagnoseprävalenz bei 0,7 % (Frauen: 0,9 %; Männer: 0,4 %); gegenüber 0,3 % in 2008. 74,4 % aller Versicherten mit PTBS-Diagnose erhielten ambulante Psychotherapie, 43,6 % erhielten Antidepressiva (meistverordnet: Venlafaxin) und 14,4 % Antipsychotika (häufigste Substanz: Quetiapin).

Schlussfolgerung Im untersuchten Zeitraum hat sich die Diagnosehäufigkeit von PTBS mehr als verdoppelt. Sie liegt jedoch weiterhin unter der in epidemiologischen Studien ermittelten Prävalenz, was auf Potenzial für eine verbesserte diagnostische Erkennung von PTBS hindeutet.

First-Time Users of ADHD Medication Among Children and Adolescents in Germany: An Evaluation of Adherence to Prescribing Guidelines Based on Claims Data

Background: Drug utilization studies based on real-world data are vital for the identification of potentially needed improvements to rational prescribing. This is particularly important for the pharmacological treatment of children and adolescents with attention-deficit hyperactivity disorder (ADHD) due to the associated potential side effects and the frequent use. Whereas prevalent use is well-characterized, studies on first-time use of ADHD medication are scarce. This study aimed to evaluate off-label prescribing in first-time users of ADHD medication among children and adolescents in Germany based on three criteria: (i) lack of a documented ADHD diagnosis; (ii) first-time pharmacological treatment with a second-line drug; and (iii) patient age below 6 years. Methods: Based on German claims data, we included children and adolescents aged 0-17 years with a first-time dispensation of any ADHD medication in the period 2015-2017. These first-time users were characterized with regard to sex, age, specialty of the prescribing physician, documentation of an ADHD diagnosis, psychiatric hospitalization, psychiatric comorbidities, and history of other psychopharmacological drugs at first-time use. Results: The study population comprised 18,703 pediatric first-time users of ADHD medication. Of these, 9.8% had no documented ADHD diagnosis. Most of the ADHD drug users received first-line ADHD pharmacotherapy (methylphenidate, atomoxetine), whereas 2.6% were prescribed second-line ADHD medication (lisdexamfetamine, guanfacine, dexamfetamine, multiple ADHD drugs) as first drug. Overall, 1.2% of first-time users were aged below 6 years. A total of 12.7% of the study population met any off-label criterion. Conclusions: About 13% of pediatric first-time users of ADHD medication in Germany received an off-label pharmacotherapy at first-time use. Prescribing ADHD medication without a confirmed ADHD diagnosis was the most common of the three assessed off-label criteria. Off-label prescribing regarding drug choice and age of patients only occurred in a small percentage of initial pharmacological ADHD treatment. Our results suggest the need for improvement in rational prescribing, especially with regard to diagnostic requirements.

The cost of love: financial consequences of insecure attachment in antisocial youth

BACKGROUND

Knowing that your parent or caregiver will be there for you in times of emotional need and distress is a core aspect of the human experience of feeling loved and being securely attached. In contrast, an insecure attachment pattern is found in many antisocial youth and is related to less sensitive caregiving. Such youth are often distrustful of adults and authority figures, and are at high risk of poor outcomes. As they become adults, they require extensive health, social and economic support, costing society ten times more than their well-adjusted peers. However, it is not known whether insecure attachment itself is associated with higher costs in at-risk youth, independently of potential confounders, nor whether cost differences are already beginning to emerge early in adolescence.

METHODS

Sample: A total of 174 young people followed up aged 9-17 years (mean 12.1, SD 1.8): 85 recruited with moderate antisocial behaviour (80th percentile) from a school screen aged 4-6 years; 89 clinically referred with very high antisocial behaviour (98th percentile) aged 3-7 years.

MEASURES

Costs by detailed health economic and service-use interview; attachment security to mother and father from interview; diagnostic interviews for oppositional and conduct problems; self-reported delinquent behaviour.

RESULTS

Costs were greater for youth insecurely attached to their mothers (secure £6,743, insecure £10,199, p = .001) and more so to fathers (secure £1,353, insecure £13,978, p < .001). These differences remained significant (mother p = .019, father p < .001) after adjusting for confounders, notably family income and education, intelligence and antisocial behaviour severity.

CONCLUSIONS

Attachment insecurity is a significant predictor of public cost in at-risk youth, even after accounting for covariates. Since adolescent attachment security is influenced by caregiving quality earlier in childhood, these findings add support to the public health case for early parenting interventions to improve child outcomes and reduce the financial burden on society.

[Socioeconomic status and health insurance expenditures for children and adolescents with conduct disorder : An analysis of statutory health insurance data]

BACKGROUND

For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking.

OBJECTIVES

To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES.

MATERIALS AND METHODS

The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication.

RESULTS

There was no significant functional association between SES and healthcare costs for any of the analysed cost types.

CONCLUSIONS

In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

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.

A comparison study of anxiety in children undergoing brain MRI vs adults undergoing brain MRI vs children undergoing an electroencephalogram

Background

Magnetic resonance imaging (MRI) of the brain in children and adolescents is a well-established method in both clinical practice and in neuroscientific research. This practice is sometimes viewed critically, as MRI scans might expose minors (e.g. through scan-associated fears) to more than the legally permissible “minimal burden”. While there is evidence that a significant portion of adults undergoing brain MRI scans experience anxiety, data on anxiety in children and adolescents undergoing brain MRI scans is rare. This study therefore aimed to examine the prevalence and level of anxiety in children and adolescents who had MRI scans of the brain, and to compare the results to adults undergoing brain MRI scans, and to children and adolescents undergoing electroencephalography (EEG; which is usually regarded a “minimal burden”).

Method

Participants were 57 children and adolescents who had a brain MRI scan (MRI-C; mean age 12.9 years), 28 adults who had a brain MRI scan (MRI-A; mean age 43.7 years), and 66 children and adolescents undergoing EEG (EEG-C; mean age 12.9 years). Anxiety was assessed on the subjective (situational anxiety) and on the physiological level (arousal), before and after the respective examination.

Results

More than 98% of children and adolescents reported no or only minimal fear during the MRI scan. Both pre- and post-examination, the MRI-C and the MRI-A groups did not differ significantly with respect to situational anxiety (p = 0.262 and p = 0.374, respectively), and to physiological arousal (p = 0.050, p = 0.472). Between the MRI-C and the EEG-C group, there were also no significant differences in terms of situational anxiety (p = 0.525, p = 0.875), or physiological arousal (p = 0.535, p = 0.189). Prior MRI experience did not significantly influence subjective or physiological anxiety parameters.

Conclusions

In this study, children and adolescents undergoing a brain MRI scan did not experience significantly more anxiety than those undergoing an EEG, or adults undergoing MRI scanning. Therefore, a general exclusion of minors from MRI research studies does not appear reasonable.

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.

ADHD in Germany: Trends in Diagnosis and Pharmacotherapy

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) sometimes persists into adulthood. There have been no studies from Germany until the present time on the diagnosis and treatment of ADHD over the course of patients' lives, in particular during the transition from adolescence to early adulthood.

METHODS

We used nationwide routine data of the AOK statutory healthinsurance fund to determine the frequency of ADHD diagnoses and prescriptions of medication for ADHD. We additionally analyzed the care of a transition cohort of initially 15-year-old ADHD patients over a period of six years.

RESULTS

From 2009 to 2014, the prevalence of a diagnosis of ADHD rose from 5.0% to 6.1% in persons aged 0 to 17 years (with a maximum of 13.9% in 9-year-old boys) and from 0.2% to 0.4% in persons aged 18 to 69 years. The amount of ADHD medication prescribed to adults with ADHD increased over time, while the amount prescribed to children and adolescents fell. Methylphenidate was the most commonly prescribed drug, followed by atomoxetine and lisdexamfetamine. Only 31.2% of the patients in the transition cohort still carried the diagnosis of ADHD at the end of the six-year period, at age 21. The percentage of patients taking ADHD medication in this group fell from 51.8% at age 15 to 6.6% at age 21.

CONCLUSION

The administrative prevalence of a diagnosis of ADHD among adults and the degree of medication use for ADHD by adults have risen in recent years. This can be interpreted as an indication of the sensitization of physicians and patients to the possibility of adult ADHD. Nonetheless, the prevalence of diagnosed ADHD remains less than the prevalence revealed by epidemiologic studies. This may indicate that adults with ADHD are currently underdiagnosed and undertreated. The low rate of use of ADHD medications among adolescents with ADHD who are on the verge of adulthood leads us to the question of whether specific transitional concepts need to be developed for this age group.

Prescriber and institutional barriers and facilitators of clozapine use: A systematic review

BACKGROUND

As clozapine is under-prescribed in persons with treatment-resistant schizophrenia (TRS), it is necessary to better identify the determinants of health inequalities in access to clozapine use.

OBJECTIVE

To identify mental health professionals' characteristics or attitudes and institutional characteristics facilitating or limiting clozapine prescribing.

METHOD

We systematically searched multiple electronic databases for articles reporting: (i) mental health professionals' attitudes and characteristics favoring or limiting clozapine prescribing; (ii) institutional characteristics associated with variations in clozapine prescribing; (iii) interventions aimed at enhancing clozapine prescribing. Data were synthesized narratively.

RESULTS

A total of 31 articles reporting findings of 29 studies published from 1993 to 2017 in 11 countries fulfilled our inclusion criteria. The main prescriber-related barriers to clozapine prescribing are lack of personal prescribing experience and concern with pharmacological characteristics of clozapine (blood monitoring and adverse effects). Lack of knowledge about the effectiveness of clozapine does not appear as a major determinant of under-prescription. Institutional-related characteristics favoring clozapine prescribing are prescribers' adherence to evidence-based medicine principles and learning by modelling from experienced clozapine prescribers.

CONCLUSION

Effective strategies to increase access to clozapine in persons with TRS include implementation of integrated clozapine clinics, simplification of blood monitoring, education for prescribers and contact with experienced prescribers. Programs addressing barriers in clozapine prescription need to be disseminated more broadly to ensure persons with TRS have access to evidenced based treatments such as clozapine. Inequality in access to clozapine care should be more systematically handled by mental health facilities and health regulatory agencies.

Differences in healthcare costs in youths with conduct disorders in rural vs. urban regions: an analysis of German health insurance data

Background

For children and adolescents with mental health problems, there is a lack of data as to whether the type of residential area (urban vs. rural) influences healthcare costs for affected individuals. The aim of this study was therefore to explore potential urban vs. rural healthcare cost differences in children and adolescents with conduct disorder (CD), one of the most frequent and cost-intensive child and adolescent psychiatric disorders. Additionally, we aimed to compare healthcare costs of youths with CD, and of youths without this diagnosis.

Methods

We analysed data from a German health insurance company, extracting all youths with a CD diagnosis in 2011 (CD group; N = 6337), and an age- and sex-matched group without this diagnosis (control group). For both groups, annual costs per person for outpatient and inpatient healthcare were aggregated, stratified by area of residence (urban vs. rural).

Results

While mean annual overall costs in the CD group did not differ significantly between urban and rural areas of residence (2785 EUR vs. 3557 EUR, p = 0.253), inpatient treatment costs were significantly higher in rural areas (2166 EUR (60.9% of overall costs) vs. 1199 EUR (43.1% of overall costs), p < 0.0005). For outpatient healthcare costs, the reverse effect was found, with significantly higher costs in individuals from urban areas of residence (901 EUR (32.3% of overall costs) vs. 581 EUR (16.3% of overall costs), p < 0.0005).

In the control group, no significant rural vs. urban difference was found for either overall health costs, inpatient or outpatient costs. Mean overall costs in the CD group were four times higher than in the control group (3162 (±5934) EUR vs. 795 (±4425) EUR).

Conclusions

This study is the first to demonstrate urban vs. rural differences in healthcare costs among youths with CD. The higher costs of inpatient treatment in rural regions may indicate a need for alternative forms of service provision and delivery in rural settings.

A multi-national comparison of antipsychotic drug use in children and adolescents, 2005-2012

Over the last decades, an increase in antipsychotic (AP) prescribing and a shift from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA) among youth have been reported. However, most AP prescriptions for youth are off-label, and there are worrying long-term safety data in youth. The objective of this study was to assess multinational trends in AP use among children and adolescents. A repeated cross-sectional design was applied to cohorts from varied sources from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The annual prevalence of AP use was assessed, stratified by age group, sex and subclass (FGA/SGA). The prevalence of AP use increased from 0.78 to 1.03% in the Netherlands' data, from 0.26 to 0.48% in the Danish cohort, from 0.23 to 0.32% in the German cohort, and from 0.1 to 0.14% in the UK cohort. In the US cohort, AP use decreased from 0.94 to 0.79%. In the US cohort, nearly all ATP dispensings were for SGA, while among the European cohorts the proportion of SGA dispensings grew to nearly 75% of all AP dispensings. With the exception of the Netherlands, AP use prevalence was highest in 15-19 year-olds. So, from 2005/6 to 2012, AP use prevalence increased in all youth cohorts from European countries and decreased in the US cohort. SGA were favoured in all countries' cohorts.

International trends in clozapine use: a study in 17 countries

OBJECTIVE

There is some evidence that clozapine is significantly underutilised. Also, clozapine use is thought to vary by country, but so far no international study has assessed trends in clozapine prescribing. Therefore, this study aimed to assess clozapine use trends on an international scale, using standardised criteria for data analysis.

METHOD

A repeated cross-sectional design was applied to data extracts (2005-2014) from 17 countries worldwide.

RESULTS

In 2014, overall clozapine use prevalence was greatest in Finland (189.2/100 000 persons) and in New Zealand (116.3/100 000), and lowest in the Japanese cohort (0.6/100 000), and in the privately insured US cohort (14.0/100 000). From 2005 to 2014, clozapine use increased in almost all studied countries (relative increase: 7.8-197.2%). In most countries, clozapine use was highest in 40-59-year-olds (range: 0.6/100 000 (Japan) to 344.8/100 000 (Finland)). In youths (10-19 years), clozapine use was highest in Finland (24.7/100 000) and in the publicly insured US cohort (15.5/100 000).

CONCLUSION

While clozapine use has increased in most studied countries over recent years, clozapine is still underutilised in many countries, with clozapine utilisation patterns differing significantly between countries. Future research should address the implementation of interventions designed to facilitate increased clozapine utilisation.

Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012

Over the last two decades, the use of ADHD medication in US youth has markedly increased. However, less is known about ADHD medication use among European children and adolescents. A repeated cross-sectional design was applied to national or regional data extracts from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The prevalence of ADHD medication use was assessed, stratified by age and sex. Furthermore, the most commonly prescribed ADHD medications were assessed. ADHD medication use prevalence increased from 1.8% to 3.9% in the Netherlands cohort (relative increase: +111.9%), from 3.3% to 3.7% in the US cohort (+10.7%), from 1.3% to 2.2% in the German cohort (+62.4%), from 0.4% to 1.5% in the Danish cohort (+302.7%), and from 0.3% to 0.5% in the UK cohort (+56.6%). ADHD medication use was highest in 10-14-year olds, peaking in the Netherlands (7.1%) and the US (8.8%). Methylphenidate use predominated in Europe, whereas in the US amphetamines were nearly as common as methylphenidate. Although there was a substantially greater use of ADHD medications in the US cohort, there was a relatively greater increase in ADHD medication use in youth in the four European countries. ADHD medication use patterns in the US differed markedly from those in western European countries.

Diagnoses of autism spectrum disorders in Germany: Time trends in administrative prevalence and diagnostic stability

For Germany, no data on trends in autism spectrum disorder diagnoses are available. The primary aim of this study was to establish the time trends in the administrative prevalence of autism spectrum disorder diagnoses. The second aim was to assess the stability of autism spectrum disorder diagnoses over time. We analysed administrative outpatient data (2006-2012) from a nationwide health insurance fund and calculated the prevalence of autism spectrum disorder diagnoses for each year, stratified by age and sex. Additionally, we studied a cohort with a first-time diagnosis of autism spectrum disorder in 2007 through 2012, investigating the percentage of retained autism spectrum disorder diagnoses. From 2006 to 2012, the prevalence of autism spectrum disorder diagnoses in 0- to 24-year-olds increased from 0.22% to 0.38%. In insurees with a first-time autism spectrum disorder diagnosis in 2007, this diagnosis was carried on in all years through 2012 in 33.0% (The International Classification of Diseases, Tenth Revision diagnoses: F84.0/F84.1/F84.5) and 11.2% (F84.8/F84.9), respectively. In Germany, like in other countries, there has been an increase in the administrative prevalence of autism spectrum disorder diagnoses. Yet, prevalences are still lower than in some other Western countries. The marked percentage of autism spectrum disorder diagnoses which were not retained could indicate a significant portion of autism spectrum disorder misdiagnoses, which might contribute to rising autism spectrum disorder prevalences.

Anti-NMDA receptor encephalitis presenting as atypical anorexia nervosa: an adolescent case report

Since 2007, more than 600 patients have been diagnosed with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, with almost 40 % of those affected being children or adolescents. In early phases of the illness, this life-threatening disease is characterized by psychiatric symptoms, such as depression, anxiety, obsessions, hallucinations or delusions. Consequently, a high percentage of patients receive psychiatric diagnoses at first, hindering the crucial early diagnosis and treatment of the anti-NMDA receptor encephalitis. We report on a 15-year-old girl initially presenting with pathological eating behaviour and significant weight loss resulting in an (atypical) anorexia nervosa (AN) diagnosis. Her early course of illness, diagnostic process, treatment and short-term outcome are described. This case report aims to raise awareness about the association between anorectic behaviour and anti-NMDA receptor encephalitis and highlight the importance of multidisciplinary teams in child and adolescent services.

[Sex-specific differences in drug utilisation in different phases of life]

The aim of the present study is to analyse sex-specific differences in drug utilisation during different phases of life using relevant diseases as examples. We used a cohort of 1.7 million subjects who were insured with the Gmünder ErsatzKasse (GEK), a German health insurance fund, for at least one day in all four quarters of 2009. We analysed subjects with outpatient diagnoses of the following diseases: attention-deficit/hyperactivity disorder (ADHD) (0-17 years), hypothyroidism (18-49 years), osteoporosis (50-79 years) and coronary heart disease (80 + years). Analysis was performed on an active-substance level. A number of differences were observed in drug treatment for the selected diseases (for example, substances for ADHD were prescribed more often in males and for hypothyroidism more often in females), as well as in prescribing practices relating to other drugs used in these groups. However, clear explanations for these differences, such as drug approval status, were not always apparent.

[Differences in sociodemographic characteristics, health, and health service use of children and adolescents according to their health insurance funds]

Differences in the socioeconomic characteristics and morbidity between members of German private and statutory health insurance funds and also between several statutory health insurances have been shown for adults. We used data from the National Health Survey for Children and Adolescents (KiGGS) to study differences in sociodemographic characteristics, health risks, morbidity, and health service use in child and adolescent insurants of different types of health insurance funds (Ersatzkasse, Allgemeine Ortskrankenkasse, Betriebskrankenkasse , Innungskrankenkasse, other statutory health insurance funds, private health insurance). Differences in the proportion of respondents with a migration background, somatic diseases, psychopathological problems, and contact with a dentist between the different health insurance fund types were found. These results should be considered in studies on health inequalities, which often focus solely on differences between statutory and private health insurance. Our results are also of relevance for health services research using the claims data of health insurance funds.

Antipsychotic prescription in children and adolescents: an analysis of data from a German statutory health insurance company from 2005 to 2012

BACKGROUND

Despite sparse documentation of their long-term therapeutic effects and side effects, antipsychotic drugs have come to be prescribed more frequently for children and adolescents in recent years, both in the USA and in Europe. No current data are available about antipsychotic prescriptions for this age group in Germany.

METHODS

Data from the largest statutory health insurance fund in Germany (BARMER GEK) were studied to identify antipsychotic prescriptions for children and adolescents (age 0-19 years) from 2005 to 2012 and analyze them with respect to age, sex, drug prescribed, prescribing medical specialty, and any observable secular trends.

RESULTS

The percentage of children and adolescents receiving a prescription for an antipsychotic drug rose from 0.23% in 2005 to 0.32% in 2012. In particular, atypical antipsychotic drugs were prescribed more frequently over time (from 0.10% in 2005 to 0.24% in 2012). The rise in antipsychotic prescriptions was particularly marked among 10- to 14-year-olds (from 0.24% to 0.43%) and among 15- to 19-year-olds (from 0.34% to 0.54%). The prescribing physicians were mostly either child and adolescent psychiatrists or pediatricians; the most commonly prescribed drugs were risperidone and pipamperone. Risperidone was most commonly prescribed for patients with hyperkinetic disorders and conduct disorders.

CONCLUSION

In Germany as in other industrialized countries, antipsychotic drugs have come to be prescribed more frequently for children and adolescents in ecent years. The German figures, while still lower than those from North America, are in the middle range of figures from European countries. The causes of the increase should be critically examined; if appropriate, the introduction of prescribing guidelines of a more restrictive nature could be considered.

Trends in psychopharmacologic treatment of tic disorders in children and adolescents in Germany

Data on medical treatment of children and adolescents with tic disorders are scarce. This study examined the administrative prevalence of psychopharmacological prescriptions in this patient group in Germany. Data of the largest German health insurance fund were analysed. In outpatients aged 0-19 years with diagnosed tic disorder, psychotropic prescriptions were evaluated for the years 2006 and 2011. In 2011, the percentage of psychotropic prescriptions was slightly higher than in 2006 (21.2 vs. 18.6%). The highest prescription prevalence was found in Tourette syndrome (51.5 and 53.0%, respectively). ADHD drugs were most frequently prescribed, followed by antipsychotics. In 2011, prescriptions of second generation antipsychotics (SGA) were higher and prescriptions of first generation antipsychotics (FGA) lower than in 2006. Concerning prescribed antipsychotic substances, in 2011 risperidone prescriptions were higher and tiapride prescriptions lower. Paediatricians issued 37.4%, and child and adolescent psychiatrists issued 37.1% of psychotropic prescriptions. The FGA/SGA ratio was highest in GPs (1.25) and lowest in child and adolescent psychiatrists (0.96). From 2006 to 2011, there was only a slight increase in psychotropic prescriptions for children and adolescents with a diagnosis of tic disorder in Germany, which stands in contrast towards the significant increase in psychotropic prescriptions in other child and adolescent psychiatric disorders (e.g. ADHD). There were marked differences in treatment patterns by tic disorder subgroups, with Tourette syndrome patients receiving most frequently psychopharmacotherapy. Risperidone prescriptions increased, probably reflecting a switch in prescribing practice towards up-to-date treatment guidelines. In primary care physicians, dissemination of current tic disorder treatment guidelines might constitute an important educational goal.

Psychopharmacological treatment in children and adolescents with autism spectrum disorders in Germany

Data on psychopharmacological treatment of individuals with autism spectrum disorder (ASD) are scarce, especially for European countries. This study evaluated psychopharmacotherapy utilisation in children and adolescents with a diagnosis of ASD in Germany. Data of a large statutory health insurance company were analysed and outpatients aged 0-24 years with a diagnosis of ASD during a 1-year-period (2009) were identified. For this cohort, the prescription of psychopharmacotherapy was evaluated. Aditionally, we analysed time trends in prescriptions from 2004 to 2009. One thousand one hundred twenty-four patients (75.4% male; mean age: 11.1 years) matched the inclusion criteria. The prevalence of ASD was 0.37% in males and 0.12% in females, respectively. Of all ASD patients, 33.0% were prescribed psychotropic drugs in 2009. 12.5% of ASD patients were treated with stimulants or atomoxetine, 11.7% with antipsychotics, 9.1% with antiepileptics, 6.8% with benzodiazepines, and 3.8% with antidepressants/SSRI. Regarding substances, methylphenidate (24.4% of all psychotropic prescriptions), risperidone (13.3%) and valproate (9.1%) were most frequently prescribed. Psychopharmacologic treatment prevalence was age-related and increased from 16.3% in individuals aged 0-4 years to 55.1% in 20-24 year olds. From 2004 to 2009, the proportion of ASD patients treated with psychotropic drugs rose from 25.9% to 33.0%. This naturalistic study furnishes evidence that the proportion of ASD patients treated with psychotropic drugs has grown considerably in Germany over the least years, with methylphenidate and risperidone being the most frequently prescribed substances. Compared with data from the USA, the proportion of ASD patients with psychopharmacological treatment is noticeably lower in Germany.

Prevalence and comorbidities of adolescent depression in Germany. An analysis of Health Insurance Data

OBJECTIVE

Data on the prevalence of depressive disorders in adolescents are scarce. We aimed to examine the administrative prevalence of depressive disorders and related comorbidities in German adolescents. A second objective of was to assess potential regional (East vs. West Germany) differences in depression prevalence.

METHOD

Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years of age with diagnosed depression during a one-year-period (2009) were identified.

RESULTS

The population at risk consisted of 140,563 adolescents. Of these, 4,295 (41.2% male; mean age: 15.5 years) had a diagnosis of depression. This equates to a prevalence of 3.1% (females: 3.7%, males: 2.5%). There were no significant differences between East and West Germany. Of all adolescents with depression, 62.5% had at least one comorbid psychiatric diagnosis, with anxiety and emotional disorders (23.7%), somatoform disorders (16.8%), hyperkinetic disorders (16.2%) and posttraumatic stress disorder (10.0%) being most frequently diagnosed.

CONCLUSIONS

The depression prevalence in this sample was lower than that in studies of clinical samples. There was a marked prevalence of psychiatric comorbidities, especially of internalizing disorders. In adolescents, the risk of depression seems to be comparable in both East and West Germany.

Durch Jugendliche mit Störungen des Sozialverhaltens ausgelöste Krankenkassenausgaben

Die Studie basiert auf Abrechnungsdaten einer großen gesetzlichen Krankenkasse (AOK Nordost). Es wurden Patienten im Alter von 13 bis 18 Jahren mit dokumentierter ICD-10-Diagnose einer Störung des Sozialverhaltens eingeschlossen (Indexgruppe, IG, N=665) und mit einer nach Alter und Geschlecht parallelisierten Kontrollgruppe (KG, N=16.625) verglichen. Während in der KG mittlere Jahreskosten von 687 € zu verzeichnen waren, beliefen sich diese bei der IG mit 2.632 € auf das 3,83fache (p<0,001). In beiden Gruppen verursachten weibliche Versicherte höhere Kosten als männliche (IG: 2.883 € vs. 2.501 €, p=0,41; KG: 758 € vs. 649 €, p=0,22). Jugendliche mit Störungen des Sozialverhaltens lösten deutlich höhere Krankenkassenausgaben aus als Jugendliche ohne diese Diagnose. Dieses Ergebnis weist auf die gesundheitsökonomische Bedeutung des Störungsbildes hin.

Outpatient treatment in German adolescents with depression: an analysis of nationwide health insurance data

PURPOSE

Data on medical treatment of adolescents with depression are scarce. This study aimed to examine outpatient health services utilisation of depressive disorders in adolescents.

METHODS

Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years old with diagnosed depression during a 1-year period (2009) were identified. For this cohort, the prescription of antidepressants and psychotherapy was evaluated with respect to age and sex.

RESULTS

A total of 4295 patients (41.2% males; mean age, 15.5 years) matched the inclusion criteria. Of the patients, 29.7% consulted a child and adolescent psychiatrist. A total of 59.6% were treated with psychotherapy only, 9.6% were treated with a combination of psychotherapy and antidepressants, and 1.9% received only antidepressants. For 28.8% of patients, no specific depression-related treatment was prescribed. A total of 1357 packages of antidepressants were analysed, of which fluoxetine (24.4% of prescriptions), citalopram (14.0%), and mirtazapine (9.7%) were the most frequently prescribed substances. Regarding substance classes, selective serotonin reuptake inhibitors (SSRIs; 55.6%), tricyclic antidepressants (TCAs; 17.9%), and hypericum (St. John's wort; 8.5%) were most common.

CONCLUSIONS

Although the underlying data were coded for insurance purposes, which might result in some data impreciseness, this naturalistic study furnishes evidence that outpatient treatment of adolescents with depressive disorders in Germany only partly complies with guideline recommendations for first-line treatment: Although the prescriptions of SSRI for adolescent depression have risen over recent years, still, a quarter of antidepressant prescriptions for adolescents with depression were TCA or hypericum. Therefore, dissemination of knowledge on state-of-the-art treatment for adolescent depression remains a major educational goal.

Subjective and Biological Weight-Related Parameters

Objective: Administration of atypical antipsychotics often induces significant weight gain and metabolic changes. Little is known about subjective weight-related parameters in adolescent patients. Therefore, this cross-sectional, explorative study aimed to assess these parameters and their relationship with biological weight-related parameters. Method: 74 patients (mean age: 19.9 [SD ± 2.3] years; 66.2% male) with schizophrenia under clozapine or olanzapine treatment were examined. Subjective well-being, eating behavior, body perception and social functioning were assessed, using the Three-Factor-Eating-Questionnaire, FKB-20 Body Perception Questionnaire, Subjective Well-being under Neuroleptics, Short Form and Global Assessment of Functioning. Patients’ biological weight-related parameters were measured as well. Gender differences as well as associations between subjective and biological weight-related parameters were evaluated. Results: Female patients reported significantly worse negative body appraisal and physical functioning than males. An elevated BMI was associated with impaired physical functioning in females and with negative body appraisal and hunger in males. Conclusions: In our sample of young patients with schizophrenia unter treatment with atypical antipsychotics, an elevated BMI was associated with impaired physical functioning and negative body appraisal, respectively. Bearing in mind the high risk of obesity in this population, the mentioned impairments should be accounted for, especially in terms of compliance and quality of life.

[What do medical students expect of lectures in child and adolescent psychiatry?]

OBJECTIVE

In child and adolescent psychiatry (CAP) lectures are the most common teaching format for medical students. Besides conveying basic knowledge and skills related to the medical management of children and adolescents with mental health problems, lectures also play a decisive role in the recruitment of future residents for this discipline. Thus, knowledge of the expectations of medical students of lectures is a crucial factor.

METHOD

1,029 medical students at ten German medical schools were surveyed with a questionnaire in a cross-sectional design.

RESULTS

Items perceived as most important were knowledge of disorders (73 %), medical skills in handling children and adolescents (61 %), and differential diagnosis of normal and abnormal child behaviour in children and adolescents (59 %). 71 % set a high value on patient presentation, while 41 % expressed ethical concerns about presenting mentally ill minors in lectures.

CONCLUSIONS

The expectations of medical students toward CAP lectures are mainly related to the transfer of specialty-related knowledge and generic skills. The important area of teaching attitudes could best be covered via patient presentations, which are desired by most students. However, ethical concerns over patient presentation also need to be discussed with students.

Urinary incontinence in children

BACKGROUND

Urinary incontinence (bedwetting, enuresis) is the commonest urinary symptom in children and adolescents and can lead to major distress for the affected children and their parents. Physiological and non-physiological types of urinary incontinence are sometimes hard to tell apart in this age group.

METHODS

This article is based on selected literature retrieved by a PubMed search and on an interdisciplinary expert consensus.

RESULTS AND CONCLUSION

Nocturnal enuresis has a variety of causes. The main causative factors in monosymptomatic enuresis nocturna (MEN) are an impaired ability to wake up when the bladder is full, due to impaired or absent perception of fullness during sleep, and an imbalance between bladder capacity and nocturnal urine production. On the other hand, non-monosymptomatic enuresis nocturna (non-MEN) is usually traceable to bladder dysfunction, which is also the main cause of diurnal incontinence. A basic battery of non-invasive diagnostic tests usually suffices to determine which type of incontinence is present. Further and more specific testing is indicated if an organic cause is suspected or if the treatment fails. The mainstay of treatment is urotherapy (all non-surgical and non-pharmacological therapeutic modalities). Some patients, however, will need supportive medication in addition. Urinary incontinence has different causes in children and adults and must therefore be diagnosed and treated differently as well. All physicians who treat the affected children (not just pediatricians and family doctors, but also pediatric nephrologists, urologists, pediatric surgeons, and child psychiatrists) must be aware of the specific features of urinary incontinence in childhood.

Which treatments do children with newly diagnosed non-organic urinary incontinence receive? An analysis of 3,188 outpatient cases from Germany

AIMS

Objectives of this study were to examine the administrative incidence of urinary incontinence in children and to assess related outpatient health services utilization in this cohort.

METHODS

Data of a statutory health insurance company were analyzed and outpatients from 1 to 18 years of age with a first recorded ICD-10 code for non-organic urinary incontinence during a 1-year-period (2007) were identified. For this cohort, the prescription of desmopressin, antispasmodics, non-selective monoamine reuptake inhibitors, alarm devices, and incontinence pads in the quarter of the first diagnosis and in the following one (i.e., 6 months) was evaluated with respect to age and gender.

RESULTS

3,188 patients (59.4% male; mean age 6.8 years) matched the inclusion criteria, of whom 25.4% were under 5 years old. 7.9% were prescribed desmopressin, 7.4% received urinary antispasmodics, and 7.0% were treated with alarm devices. For 77.9% of patients, no specific incontinence-related treatments were prescribed. We found considerable differences in treatment patterns between age groups, with patients ≥ 7 years receiving desmopressin more frequently than alarm devices. Regarding gender differences, the proportion of males treated with alarm devices (prevalence ratio [PR] 1.46; 95% confidence interval [95%CI] 1.11-1.92) and at least one specific treatment (PR 1.19; 95%CI 1.04-1.35) remained statistically significantly higher, even after adjusting for age.

CONCLUSIONS

In our study, we found evidence that treatment modalities only partly comply with the current guidelines for treatment of children and adolescents with non-organic urinary incontinence. Therefore, the dissemination of current guidelines remains a major educational goal.

Health-related quality of life in children and adolescents with autism spectrum disorder

OBJECTIVE

This study evaluates self- and proxy-reported health-related quality of life (HRQOL) in children and adolescents with autism spectrum disorders (ASD). The study also compares HRQOL in ASD patients with a healthy control sample and a psychiatric reference sample.

METHOD

42 children and adolescents (39 male, mean age: 12.7 ± 2.6 years, mean IQ: 100.5 ± 20.7) with the diagnosis of autism spectrum disorder (ASD) and their parents completed the Inventory for the Assessment of Quality of Life in Children and Adolescents (ILK).

RESULTS

Mean ILK LQ 0-28 scores were 20.6 (± 4.6) (self-report version) and 18.2 (± 4.0) (proxy version). Compared to a reference sample, mean ILK scores from the ASD sample were at the 47th percentile (self-report) and the 33rd percentile (proxy). Compared to children and adolescents with psychiatric disorders, self-reported ILK scores correlated with the 69th percentile, and proxy-reported ILK scores correlated with the 67th percentile. Self-reported HRQOL was significantly higher than proxy-reported HRQOL. No significant correlation was found between HRQOL and age, IQ, or autistic symptoms.

CONCLUSIONS

HRQOL in children and adolescents with ASD seems to be better than in other psychiatric disorders, but lower than in healthy controls.

Evidenzbasierte psychotherapeutische Interventionen für Kinder und Jugendliche mit aggressivem Verhalten

Bei der Behandlung von Kindern und Jugendlichen mit aggressivem Verhalten ist in den vergangenen Jahren vor allem im englischsprachigen Ausland ein Trend zum Einsatz evidenzbasierter psychotherapeutischer Interventionen zu verzeichnen. In diesem Beitrag werden–getrennt für Kindes- und Jugendalter–die am besten evaluierten Therapieprogramme (u. a. Multisystemic Therapy, Functional Family Therapy, The Incredible Years) für diese Indikation dargestellt. Es werden aktuelle Fragen der Implementation und Disseminierung evidenzbasierter Interventionen für aggressive Kinder und Jugendliche diskutiert (z. B. Qualitätssicherung, Therapietreue). Abschließend werden Perspektiven für eine Implementation evidenzbasierter Interventionen in Deutschland aufgezeigt.

Health-related quality of life in adolescents and young adults with high functioning autism-spectrum disorder

AIM

Over the last years, health-related quality of life (HRQOL) has emerged as an important measure not only in somatic medicine but also in psychiatry. To date, there are only few reports on HRQOL in patients with autism-spectrum disorder (ASD). This study aimed at studying HRQOL in ASD patients with an IQ >70, using a self-report HRQOL questionnaire with cross-cultural validity.

METHODS

In this cross-sectional study, twenty-six male adolescents and young adults with the diagnosis of Asperger Syndrome, high functioning autism and atypical autism were evaluated, using the German version of the WHOQOL-BREF HRQOL questionnaire.

RESULTS

Mean WHOQOL-BREF global scores were 60.6 (SD ±26.1), mean WHOQOL-BREF subscale scores were 70.1 (SD ±19.1) for the domain "physical health", 61.5 (SD ±21.9) for the domain "psychological health", 53.8 (SD ±23.5) for the domain "social relationships" and 67.9 (SD ±17.4) for the domain "environment". Compared to a reference population of healthy controls, our sample scored significantly lower in three of four WHOQOL-BREF domains. In comparison to a reference sample of individuals with schizophrenia spectrum disorder (SSD), HRQOL of our sample was significantly better in all domains except for the "social relations" domain. There was a significant association between HRQOL and the Vineland Adaptive Behavior Scales domain "daily living skills", but not with age, IQ, or ADOS-G summary scores.

CONCLUSION

Overall self-reported HRQOL in patients with high functioning ASD seems to be lower than in healthy individuals, but better than in patients with SSD. Also, higher HRQOL was associated with better daily living skills. This interrelationship should especially be accounted for in the design and application of treatment programmes for individuals with ASD, as it is of importance for the level of self-perceived HRQOL.

Frühsymptome des Asperger-Syndroms im Kindesalter

Obwohl sich Eltern autistischer Kinder bereits in den ersten Lebensjahren Sorgen über die Entwicklung ihres Kindes machen, wird die Diagnose, insbesondere die des Asperger-Syndroms (AS), auch heute noch relativ spät gestellt. Vorhandene Studienergebnisse zu Frühsymptomen beziehen sich zumeist auf den frühkindlichen Autismus und zu ersten Symptomen bei AS liegen bisher nur wenige Studien vor. In der vorliegenden Untersuchung wird der Frage nachgegangen, welche spezifischen Frühsymptome beim AS auftreten, die eine frühe Diagnosestellung und differentialdiagnostische Unterscheidung zwischen AS und AHDS ermöglichen. Die Eltern von 117 Kindern im Alter von fünf bis 18 Jahren (74 mit Diagnose AS, 43 mit ADHS) wurden retrospektiv hinsichtlich früher Auffälligkeiten in der Entwicklung ihrer Kinder befragt. Es wurden zehn früh auftretende Symptome bei AS ermittelt, die eine gute Differenzierung zwischen den Diagnosen ermöglichen: Früh beginnende Kontakt- und Kommunikationsprobleme in Kombination mit im Entwicklungsverlauf zunehmenden stereotypen Verhaltensweisen stellen Symptome dar, die einer weiteren, differenzierten Diagnostik bedürfen.