Christian J. Bachmann

Psychological and psychiatric issues in urinary and fecal incontinence

PURPOSE We provide an overview of the psychological and psychiatric aspects of nocturnal enuresis, urinary and fecal incontinence. Clinical behavioral disorders and subclinical psychological symptoms are reviewed. Aspects of screening, assessment, counseling and in severe cases treatment are outlined, and recommendations are formulated. MATERIALS AND METHODS Relevant publications on psychological and psychiatric aspects are reviewed. The recommendations passed several rounds of consensus finding, and were circulated among International Childrens Continence Society members and external experts. RESULTS In addition to subclinical effects on self-esteem, quality of life and distress, the rate of comorbid clinical behavioral disorders is increased. In fact, 20% to 30% of children with nocturnal enuresis, 20% to 40% with daytime urinary incontinence and 30% to 50% with fecal incontinence fulfill the criteria for ICD-10 or Diagnostic and Statistical Manual of Mental Disorders IV psychiatric disorders. These concomitant disturbances require assessment and counseling, and in severe cases treatment. They have a negative effect on compliance and outcome if not addressed and left untreated. CONCLUSIONS Because the comorbidity rate is high, screening for psychological symptoms is recommended for all children in all settings with enuresis and/or daytime urinary and/or fecal incontinence. Standardized, validated questionnaires are recommended. In addition to clinical observation and history, a short screening questionnaire can be used as a first step. If problem behaviors are present a longer broadband questionnaire is recommended. If problem items in the clinical range are noted, a full child psychiatric or psychological assessment is recommended.

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.

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.

Wirksamkeit psychiatrischer und psychotherapeutischer Behandlungen bei psychischen Störungen von Kindern und Jugendlichen

OBJECTIVE In recent years, a large and growing body of research on the effectiveness of treatments for psychiatric disorders in childhood and adolescence has been published; however the large number makes it difficult to get an overview on the current status of research. The aim of this article is to systematically review the existing meta-analyses and reviews disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder) and to present an up-to-date summary on the effects of treatment for those disorders. METHODS This article is based on a systematic literature search, which produced 112 meta-analyses and reviews on the efficacy of psychological and psychiatric interventions in childhood and adolescence published between 2000 and 2007. The articles resulting from the literature search were evaluated according to clearly defined criteria. Presentation of the results follows a dichotomous classification (internalizing vs. externalizing disorders), with Part II of this article reporting the results on ADHD and conduct disorders. RESULTS The majority of reviews published between 2000 and 2007 focuses on the treatment of depressive disorders and ADHD. Only for ADHD is the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Considering the efficacy, treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders. For all disorders, there are several desiderata (content and methodological aspects) to be incorporated into future research. CONCLUSIONS Empirically supported treatment recommendations can be derived for anxiety disorders, depressive disorders, ADHD and conduct disorders. Finally, important implications for research and practice are discussed.Zusammenfassung: Fragestellung: In den letzten Jahren hat die Forschung zur Wirksamkeit von Therapien bei psychisch gestorten Kindern und Jugendlichen erfreulicherweise einen starken Aufschwung genommen. Mittlerweile liegen sehr viele Reviews und Metaanalysen zu den Forschungsergebnissen vor, so dass es schwer ist, einen Uberblick uber den aktuellen Forschungsstand zu gewinnen. Ziel der vorliegenden Arbeit war es, die vorliegenden Reviews und Metaanalysen in systematischer Weise auszuwerten, um den aktuellen Ergebnisstand der Therapie-Wirksamkeitsforschung bei den vier haufigsten psychischen Storungen von Kindern und Jugendlichen (Angststorungen, depressive Storungen, ADHS, Storungen des Sozialverhaltens) zusammenfassend zu charakterisieren. Methodik: Grundlage der vorliegenden Arbeit war eine systematische Literaturrecherche; in die Auswertung wurden 112 Metaanalysen bzw. Reviews zur Wirksamkeit psychotherapeutischer und psychiatrischer Behandlungsansatze im Kindes- und Jugendalter eingeschlossen, die zw...

Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005-2012

Following the FDA black box warning in 2004, substantial reductions in antidepressant (ATD) use were observed within 2 years in children and adolescents in several countries. However, whether these reductions were sustained is not known. The objective of this study was to assess more recent trends in ATD use in youth (0-19 years) for the calendar years 2005/6-2012 using data extracted from regional or national databases of Denmark, Germany, the Netherlands, the United Kingdom (UK), and the United States (US). In a repeated cross-sectional design, the annual prevalence of ATD use was calculated and stratified by age, sex, and according to subclass and specific drug. Across the years, the prevalence of ATD use increased from 1.3% to 1.6% in the US data (+26.1%); 0.7% to 1.1% in the UK data (+54.4%); 0.6% to 1.0% in Denmark data (+60.5%); 0.5% to 0.6% in the Netherlands data (+17.6%); and 0.3% to 0.5% in Germany data (+49.2%). The relative growth was greatest for 15-19 year olds in Denmark, Germany and UK cohorts, and for 10-14 year olds in Netherlands and US cohorts. While SSRIs were the most commonly used ATDs, particularly in Denmark (81.8% of all ATDs), Germany and the UK still displayed notable proportions of tricyclic antidepressant use (23.0% and 19.5%, respectively). Despite the sudden decline in ATD use in the wake of government warnings, this trend did not persist, and by contrast, in recent years, ATD use in children and adolescents has increased substantially in youth cohorts from five Western countries.

[Efficacy of psychiatric and psychotherapeutic interventions in children and adolescents with psychiatric disorders--a systematic evaluation of meta-analyses and reviews. Part I: Anxiety disorders and depressive disorders].

OBJECTIVE In recent years, a large and growing body of research on the effectiveness of treatments for psychiatric disorders in childhood and adolescence has been published; however, the large number makes it difficult to get an overview on the current status of research. The aim of this article is to systematically review the existing meta-analyses and reviews on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder) and to present an up-to-date summary on the effects of treatment for those disorders. METHODS This article is based on a systematic literature search, which produced 112 meta-analyses and reviews on efficacy of psychological and psychiatric interventions in childhood and adolescence published between 2000 and 2007. The articles resulting from the literature search were evaluated according to clearly defined criteria. Presentation of the results follows a dichotomous classification (internalizing vs. externalizing disorders), with Part I of this article reporting the results on anxiety disorders and depressive disorders. RESULTS The majority of reviews published between 2000 and 2007 focuses on the treatment of depressive disorders and ADHD. Only for ADHD is the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Considering the efficacy, treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders. For all disorders, there are several desiderata (content and methodological aspects) to be incorporated into future research. DISCUSSION Empirically supported treatment recommendations can be derived for anxiety disorders, depressive disorders, ADHD and conduct disorders. Finally, important implications for research and practice are discussed.

[Efficacy of psychiatric and psychotherapeutic interventions in children and adolescents with psychiatric disorders--a systematic evaluation of meta-analyses and reviews. Part II: ADHD and conduct disorders].

OBJECTIVE In recent years, a large and growing body of research on the effectiveness of treatments for psychiatric disorders in childhood and adolescence has been published; however the large number makes it difficult to get an overview on the current status of research. The aim of this article is to systematically review the existing meta-analyses and reviews disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder) and to present an up-to-date summary on the effects of treatment for those disorders. METHODS This article is based on a systematic literature search, which produced 112 meta-analyses and reviews on the efficacy of psychological and psychiatric interventions in childhood and adolescence published between 2000 and 2007. The articles resulting from the literature search were evaluated according to clearly defined criteria. Presentation of the results follows a dichotomous classification (internalizing vs. externalizing disorders), with Part II of this article reporting the results on ADHD and conduct disorders. RESULTS The majority of reviews published between 2000 and 2007 focuses on the treatment of depressive disorders and ADHD. Only for ADHD is the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Considering the efficacy, treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders. For all disorders, there are several desiderata (content and methodological aspects) to be incorporated into future research. CONCLUSIONS Empirically supported treatment recommendations can be derived for anxiety disorders, depressive disorders, ADHD and conduct disorders. Finally, important implications for research and practice are discussed.Zusammenfassung: Fragestellung: In den letzten Jahren hat die Forschung zur Wirksamkeit von Therapien bei psychisch gestorten Kindern und Jugendlichen erfreulicherweise einen starken Aufschwung genommen. Mittlerweile liegen sehr viele Reviews und Metaanalysen zu den Forschungsergebnissen vor, so dass es schwer ist, einen Uberblick uber den aktuellen Forschungsstand zu gewinnen. Ziel der vorliegenden Arbeit war es, die vorliegenden Reviews und Metaanalysen in systematischer Weise auszuwerten, um den aktuellen Ergebnisstand der Therapie-Wirksamkeitsforschung bei den vier haufigsten psychischen Storungen von Kindern und Jugendlichen (Angststorungen, depressive Storungen, ADHS, Storungen des Sozialverhaltens) zusammenfassend zu charakterisieren. Methodik: Grundlage der vorliegenden Arbeit war eine systematische Literaturrecherche; in die Auswertung wurden 112 Metaanalysen bzw. Reviews zur Wirksamkeit psychotherapeutischer und psychiatrischer Behandlungsansatze im Kindes- und Jugendalter eingeschlossen, die zw...

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.

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

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

Impact of ADHD symptoms on autism spectrum disorder symptom severity

Despite the official exclusion criteria for autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) in the DSM-IV and ICD-10, patients with ASD often show ADHD symptoms. We aimed to examine the potential influence of ADHD symptoms on autistic psychopathology in a large sample of patients with ASD. We tested the hypothesis that patients with ASD and an additional ADHD (ASD+) would show a higher severity of autistic symptoms than those with ASD only (ASD-). We measured autistic symptoms using the autism diagnostic observation schedule (ADOS-G), the autism diagnostic interview (ADI-R), and the social responsiveness scale (SRS). To measure overall psychopathology and ADHD symptoms, we used the child behavior checklist (CBCL) and the ADHD rating scale (FBB-ADHS), respectively. Group differences between the ASD+ and the ASD- group (group division was conducted according to the results of the FBB-ADHS) were calculated using a univariate analysis of variance (ANOVA). The ASD+ group showed a greater severity of autistic symptoms than the ASD- group, measured by the SRS and the ADI-R. Especially in the social interaction subscale (ADI-R), a significantly higher symptom severity was found in the ASD+ group. No significant group differences were found regarding autistic symptoms measured by the ADOS-G. Patients with ASD and an additional ADHD expressed a stronger severity of autistic symptoms than patients with ASD only. According to our results, the possibility of a co-diagnosis of ADS and ADHD, as is being planned in the DSM-5, is in line with earlier studies, is highly reasonable, will simplify research, and have therapeutic implications.