Jan Frölich

Computerspiele im Kindes- und Jugendalter unter besonderer Betrachtung von Suchtverhalten, ADHS und Aggressivität

UNLABELLED Playing computer games has become one of the main leisure activities in children and adolescents and increasingly replaces traditional playing and interactional activities. There might exist developmental benefits or positive effects of computer games that can be used for educational or therapeutic purposes. More important several studies have well demonstrated that excessive computer game playing is associated with behavior that features all components of non-chemical addiction and the prevalences across all age groups seem to be impressingly high. OBJECTIVE This overview relies on a Medline research. Its objective is to describe motivational and developmental characteristics attributed to computer games as well as the prevalences of computer playing in children and adolescents to better understand the risks for addictive use. We especially focus on the relations of excessive computer playing with attention-deficit hyperactivity disorder (ADHD) and aggressive behavior. RESULTS The results demonstrate that children with ADHD are especially vulnerable to addictive use of computer games due to their neuropsychological profile. Moreover excessive violent computer game playing might be a significant risk variable for aggressive behavior in the presence of personality traits with aggressive cognitions and behavior scripts in the consumers. CONCLUSIONS The increasing clinical meaning of addictive computer games playing urgently necessitates the development of diagnostic and therapeutic tools for clinical practice as well as the cooperation with allied disciplines.

Prevalence of Sleep Problems and Relationship between Sleep Problems and School Refusal Behavior in School-Aged Children in Children's and Parents' Ratings

Objective: This cross-section study investigated the prevalence of sleep disorders and the relationship between sleep problems (insomnias, parasomnias, and daytime sleepiness) and school refusal behavior in school-age children (fourth grade elementary school in Cologne, Germany). Method: A sample of 1,490 children (age range: 8-11 years) and their parents each completed a sleep questionnaire and the School Refusal Assessment Scale. Results: The results indicate that sleep problems in childhood are frequent. Furthermore, the results of the study clearly indicate that there is a relationship between sleep problems and school refusal behavior. Children suffering from insomnias (sleep onset problems, difficulties maintaining sleep), parasomnias (nightmares, night terrors), and daytime sleepiness showed without exception significantly higher scores in 3 out of 4 school refusal behavior maintaining conditions compared to children without sleep problems. These three conditions are all associated with anxiety disorders (anxiety or depressive disorder, as well as separation anxiety disorder). Only in the fourth condition, which is associated with oppositional defiant or conduct disorders, truancy, or no disorder at all, were there no significant differences between children with and children without sleep problems. Conclusions: For research and clinical practice, it is important to view sleep problems and school refusal behavior in relation to each other rather than as isolated phenomena.

Schlafstörungen bei hyperkinetischen Kindern - polysomnografische Untersuchungen zur Schlafstruktur und -architektur

Zusammenfassung: Fragestellung: In der vorliegenden Untersuchung wurde der Frage nachgegangen, ob bei hyperkinetischen Kindern spezifische Auffalligkeiten in der Schlafstruktur und -architektur gefunden werden konnen und ob sie ein erhohtes Risiko fur das Auftreten einer schlafbezogenen Atmungsstorung vorweisen. Methoden: In einer Schlaflaboruntersuchung bei hyperkinetischen Kindern und schlafgestorten Kindern im Alter zwischen 6 und 12 Jahren wurde die polysomnografisch gemessene Schlafstruktur von hyperkinetischen Kindern (n = 36) verglichen mit den Ergebnissen nicht schlafgestorter Kinder (n = 87) sowie von Kindern mit Schlafstorungen (n = 15). Des Weiteren erfolgten gruppenvergleichende kardiorespirografische Analysen. Ergebnisse: Die Ergebnisse der Studie weisen aus, dass die Schlafstruktur nicht-schlafgestorter Kinder mit hyperkinetischen Storungen gegenuber unauffalligen Kindern nur geringe Abweichungen aufweist. Die festgestellten Auffalligkeiten schlafgestorter Kinder mit hyperkinetischen Storung...

Evaluation of a computer-based neuropsychological training in children with attention-deficit hyperactivity disorder (ADHD).

BACKGROUND We report the effects of a computer-based neuropsychological training in children with Attention-Deficit Hyperactivity Disorder (ADHD). We hypothesized that a specific training focusing on attentional dysfunction would result in an improvement of inattention, observable in test performance, behavior and performance during experimental school lessons and in parent and teacher ratings of the related core symptom. METHOD We chose a within-subject-control-design with a 4 week baseline period and subsequent 12 to 15 weekly training-sessions. 30 children (6 to 13 years old) with a diagnosis of ADHD (ICD 10: F 90.0) and no other comorbidities participated in the study. RESULTS The training revealed significant improvement in training parameters of the neuropsychological training and in the symptoms of inattention and deportment as rated during experimental school lessons. However, generalization of training effects as measured by parent and teacher ratings was not detected. CONCLUSIONS We conclude that neuropsychological training could be helpful as one adjunct module in the complex treatment of ADHD but to prove clinical value, similar training programs must focus more strongly on individually existing neuropsychological deficits. Training programs should be more intensive and should eventually be combined with home based training access.

Die medikamentöse Behandlung der Aufmerksamkeitsdefizit- Hyperaktivitätsstörung im Kindes- und Jugendalter mit Amphetaminpräparaten

INTRODUCTION Psychostimulants (methylphenidate and amphetamines) are the drugs of first choice in the pharmacological treatment of children and adolescents with attention deficit hyperactivity disorder (ADHD). OBJECTIVE We summarize the pharmacological characteristics of amphetamines and compare them with methylphenidate, special emphasis being given to a comparison of effects and side effects of the two substances. Finally, we analyze the abuse and addiction risks. METHODS Publications were chosen based on a Medline analysis for controlled studies and meta-analyses published between 1980 and 2011; keywords were amphetamine, amphetamine salts, lisdexamphetamine, controlled studies, and metaanalyses. RESULTS AND DISCUSSION Amphetamines generally exhibit some pharmacologic similarities with methylphenidate. However, besides inhibiting dopamine reuptake amphetamines also cause the release of monoamines. Moreover, plasma half-life is significantly prolonged. The clinical efficacy and tolerability of amphetamines is comparable to methylphenidate. Amphetamines can therefore be used if the individual response to methylphenidate or tolerability is insufficient before switching to a nonstimulant substance, thus improving the total response rate to psychostimulant treatment. Because of the high abuse potential of amphetamines, especially in adults, the prodrug lisdexamphetamine (Vyvanse) could become an effective treatment alternative. Available study data suggest a combination of high clinical effect size with a beneficial pharmacokinetic profile and a reduced abuse risk. CONCLUSIONS In addition to methylphenidate, amphetamines serve as important complements in the psychostimulant treatment of ADHD. Future studies should focus on a differential comparison of the two substances with regard to their effects on different core symptom constellations and the presence of various comorbidities.

Schlafstörungen bei hyperkinetischen Kindern - Zusammenhänge zu Arousalstörungen, differentialdiagnostische Abgrenzungen und Komorbiditäten

OBJECTIVES Sleep disorders are frequently observed in Attention Deficit-Hyperactivity Disorder (ADHD). At the same time, however, there is little evidence of their prevalence and their specific characteristics. Also unclear is a possible pathogenetic relationship between disturbed sleep and the core symptoms of ADHD. There are still very few findings on the role of comorbid internal and neurological disorders like sleep apnea and restless legs syndrome in the differential diagnosis of ADHD. METHODS We present an overview of the current literature, describing the most important results concerning sleep disorders in ADHD. RESULTS A principal goal of future assessments is to ascertain whether sleep problems in children with ADHD represent unspecific concurrent symptoms or whether they play a substantial role in the pathogenesis of ADHD. CONCLUSIONS Moreover a possibly increased risk of comorbid sleep-disordered breathing disorder might be an important issue in the differential diagnostic considerations with regard to ADHD.

[Aripiprazole - a medical treatment alternative for Tourette Syndrome in childhood and adolescence].

OBJECTIVE We report a case-series of seven patients with a medical history of at least two years of tic disorder treated with the partial dopamine agonist aripiprazole to illustrate its efficacy as a treatment alternative for motor and vocal tics in children and adolescents. METHOD A case series of five patients with Tourette Syndrome (TS) and two with chronic motor tic disorder (age range 8; 7-18; 1 year), the majority of whom had been refractory to treatment with other neuroleptics or had ceased treatment due to intolerable side effects, were treated for eight weeks with aripiprazole. Before and after treatment, parents rated the severity of motor and vocal tic symptoms on the Yale Tourette Syndrome Checklist. RESULTS Within eight weeks mean motor tic symptoms decreased by 66% and mean vocal tic symptoms decreased by 26%. Mean effective dosage was 14.3 mg/day (min. 5 mg, max. 30 mg). Symptoms of comorbid ADHD or Obsessive Compulsive Disorder were not significantly influenced. During medication only mild side effects were observed, e.g., abdominal pain, fatigue and increased emotional sensitivity. No patient dropped out of treatment due to side effects. CONCLUSIONS Aripiprazole may be an effective pharmacologic treatment alternative for individuals with chronic motor tic disorder and TS. It induces quick, significant and sustained effects with few generally mild and transient side effects, if anything. Its effectiveness, especially relative to comorbidities, should be verified in double-blind, placebo-controlled studies.

Medikamentöse Behandlungsalgorithmen bei Aufmerksamkeitsdefizit-Hyperaktivitätsstörungen unter Berücksichtigung spezifischer Komorbiditäten

BACKGROUND In clinical practice Attention Deficit Hyperactivity Disorder (ADHD) is a challenge for diagnostic and therapeutic effort due to a number of co-morbidities, e.g., depression, anxiety disorders, Tourette Syndrome and impulsive aggression that can be a complication or a result of the core symptoms or evolve parallel to the basic disorder. The therapeutic strategies incorporate a multimodal access with a combination of psychosocial, psychotherapeutic and medical measures. The combination of various medical substances for an effective treatment of these co-morbidities, especially Serotonin-Reuptake Inhibitors (SSRIs) and atypical neuroleptics with psychostimulants has substantially reduced the occurrence of the main symptoms of the disorder in many cases and thus can also lead to a decrease in the occurrence of co-morbidities. Where this strategy fails to suffice, it is recommended to consider medical treatment strategies in combination with other substances that alternatively or in combination with psychostimulants increasingly positively influence co-morbid symptoms. OBJECTIVE AND METHOD Based on a Medline literature search we report the results of combined medical approaches for an effective medical treatment of the ADHD core symptoms accompanied by serious co-morbid symptoms. Hereby we focused on the above cited disorders. Combined treatment options that include psychostimulants are considered in particular. Moreover, recommendations for medical treatment strategies oriented to the clinical cardinal symptoms are presented in the form of algorithms. Evidence-based literature and practical experience are critically reviewed. RESULTS In most cases it will be sufficient to begin the treatment with a psychostimulant because co-morbid symptoms also will be significantly reduced. However, if the latter are in the foreground of the clinical picture, antidepressants or neuroleptics are to be considered as primary or equivalent treatment options. CONCLUSIONS Since in Germany most of the substances discussed are not licensed for use in paediatric treatment, proofs of efficacy in children are lacking. One also must reckon with the frequent occurrence of side effects. Finally, little data exist on treatments that include the use of psychostimulants.

Die Behandlung von Aufmerksamkeitsdefizit-/Hyperaktivitätsstörungen mit mehrfach ungesättigten Fettsäuren - eine wirksame Behandlungsoption?

OBJECTIVES Both omega-3 and omega-6 long-chain polyunsaturated fatty acids (PUFA) have a substantial impact on human brain development and function. However, in western industrial countries omega-3 LC-PUFA in particular are often lacking in diets. Increasing evidence indicates that LC-PUFA imbalance or deficiencies may be associated with Attention Deficit/Hyperactivity Disorder (ADHD) through involvement in the dopaminergic corico-striatal metabolism. Preliminary study result suggest that dietary supplementation with LC-PUFA might be effective in the treatment of ADHD. METHODS This review summarizes the knowledge in terms of a hypothesized pathogenetic relationship between fatty acid metabolism and ADHD and discusses the possible clinical benefit of a primary or combined treatment with LC-PUFA. RESULTS Actually it is unclear whether a deficit in intake or metabolism of LC-PUFA may play a major role in the pathogenesis of ADHD. Moreover treatment studies yielded conflicting results. A combination of Omega-3 and Omega-6 - fatty acids might attenuate the symptoms of ADHD significantly, thus making this dietary intake useful. CONCLUSIONS Considerable research has to be done in the future to identify ideal therapeutic combinations and dosages of various fatty acids, and to develop reliable ways of defining those individuals to benefit from this treatment access.

Successful treatment of severe parasomnias with paroxetine in a 12-year-old boy

Night terrors and somnambulism are parasomnias associated with non-REM sleep. Medical treatment is only considered in severe cases with persistent and extended symptoms where there is a high risk of self-injury. We report the case of a 12-year-old boy with severe night terrors and somnambulism whose symptoms completely remitted under medication with the selective serotonin re-uptake inhibitor paroxetine. Its impact on sleep remains unclear as we were not able to show any significant changes in the polysomnographic sleep macroarchitecture. Paroxetine might be an alternative to benzodiazepines or tricyclic antidepressants because it permits subchronic medication, necessitates little dose titration and is well tolerated, with few side-effects, and, in particular, has low sedating properties.Night terrors and somnambulism are parasomnias associated with non-REM sleep. Medical treatment is only considered in severe cases with persistent and extended symptoms where there is a high risk of self-injury. We report the case of a 12-year-old boy with severe night terrors and somnambulism whose symptoms completely remitted under medication with the selective serotonin re-uptake inhibitor paroxetine. Its impact on sleep remains unclear as we were not able to show any significant changes in the polysomnographic sleep macroarchitecture. Paroxetine might be an alternative to benzodiazepines or tricyclic antidepressants because it permits subchronic medication, necessitates little dose titration and is well tolerated, with few side-effects, and, in particular, has low sedating properties.