Michael Erhart

Generic Health-Related Quality-of-Life Assessment in Children and Adolescents

The health-related quality of life (HR-QOL) of children and adolescents is increasingly considered a relevant topic for research. Instruments to assess quality of life in children and adolescents of a generic as well as disease- or condition-specific nature are being developed and applied in epidemiological surveys, clinical studies, quality assurance and health economics. This paper attempts to give an overview on the state of the art of HR-QOL assessment in children as it relates to methodological and conceptual challenges. Instruments available in international or cross-cultural research to assess HR-QOL in generic terms were identified and described according to psychometric data provided and the width of application.In an initial literature search, several challenges in the assessment of child and adolescent HR-QOL were identified, ranging from conceptual and methodological to practical aspects. Seven specific major issues were considered: (i) What are the dimensions of HR-QOL relevant for children and adolescents, and do suitable instruments for their measurement exist? (ii) Can these dimensions be collected in a cross-culturally comparable way? (iii) What advantages and disadvantages do self-rated versus externally evaluated HR-QOL measurements of children and adolescents have? (iv) How can HR-QOL be assessed in an age-appropriate way? (v) What are the advantages and disadvantages of disease-specific and generic data collection? (vi) What advantages and disadvantages do profile and index instruments have? (vii) How can HR-QOL be connected with utility- preference values? In a second literature search we identified nine generic HR-QOL instruments and four utility health state classification systems that complied with the prespecified inclusion criteria.It was concluded that (i) HR-QOL instruments are available to assess the dimensions of the construct relevant to children and adolescents; (ii) provided that an instrument was constructed in an appropriate way, the dimensions of HR-QOL can be measured in an interculturally comparable manner; (iii) the HR-QOL of children and adolescents can and should be ascertained by self-rating; (iv) the measurement instruments used have to consider maturity and cognitive development; (v) only generic quality-of-life instruments allow for an assessment of HRQOL in both healthy and chronically ill children and adolescents; (vi) the representation of HR-QOL achieved through a singular index value is connected to strict psychometric conditions: the index instrument has to be tailored to these psychometric conditions; (vii) how far utility measures are employable with children and adolescents has to be investigated in further studies.The problem aspects identified indicate the necessity for further research. Nevertheless, instruments for assessing the HR-QOL of children and adolescents can be identified that meet the requirements mentioned above.

Reliability, construct and criterion validity of the KIDSCREEN-10 score: A short measure for children and adolescents' well-being and health-related quality of life

BackgroundTo assess the criterion and construct validity of the KIDSCREEN-10 well-being and health-related quality of life (HRQoL) score, a short version of the KIDSCREEN-52 and KIDSCREEN-27 instruments.MethodsThe child self-report and parent report versions of the KIDSCREEN-10 were tested in a sample of 22,830 European children and adolescents aged 8–18 and their parents (nxa0=xa016,237). Correlation with the KIDSCREEN-52 and associations with other generic HRQoL measures, physical and mental health, and socioeconomic status were examined. Score differences by age, gender, and country were investigated.ResultsCorrelations between the 10-item KIDSCREEN score and KIDSCREEN-52 scales ranged from rxa0=xa00.24 to 0.72 (rxa0=xa00.27–0.72) for the self-report version (proxy-report version). Coefficients below rxa0=xa00.5 were observed for the KIDSCREEN-52 dimensions Financial Resources and Being Bullied only. Cronbach alpha was 0.82 (0.78), test–retest reliability was ICCxa0=xa00.70 (0.67) for the self- (proxy-)report version. Correlations between other children self-completed HRQoL questionnaires and KIDSCREEN-10 ranged from rxa0=xa00.43 to rxa0=xa00.63 for the KIDSCREEN children self-report and rxa0=xa00.22–0.40 for the KIDSCREEN parent proxy report. Known group differences in HRQoL between physically/mentally healthy and ill children were observed in the KIDSCREEN-10 self and proxy scores. Associations with self-reported psychosomatic complaints were rxa0=xa0−0.52 (−0.36) for the KIDSCREEN-10 self-report (proxy-report). Statistically significant differences in KIDSCREEN-10 self and proxy scores were found by socioeconomic status, age, and gender.ConclusionsOur results indicate that the KIDSCREEN-10 provides a valid measure of a general HRQoL factor in children and adolescents, but the instrument does not represent well most of the single dimensions of the original KIDSCREEN-52. Test–retest reliability was slightly below a priori defined thresholds.

Subjective health, symptom load and quality of life of children and adolescents in Europe.

Objectives:To examine cross-cultural differences in the prevalence of school childrens subjective health types and the pattern of socio-demographic and socio-economic differences.Methods:Within the cross-sectional Health Behaviour in Schoolaged Children 2005/2006 Survey 200,000 school children aged 11, 13 and 15 answered a general health item, the Cantrill life satisfaction ladder and a subjective health complaints checklist. ANOVA and multilevel logistic regression models were conducted.Results:Overall, 44% of the respondents reported multiple recurrent health complaints, only poor to fair general health, low life satisfaction or a combination of these. Older adolescents (OR: 1.1–1.6) and girls (OR: 1.2–1.4) reported more health problems, the gender difference increased with age (OR: 1.3–1.6). Low socio-economic status was also associated with health problems (OR: 1.4–2.3). Sizeable cross-national variation in the prevalence of health types and the impact of the above mentioned factors were observed, yet the main pattern of impact could be confirmed cross-culturally.Conclusions:Increasing social and gender role pressure with growing age, as well as restricted access to material resources and psychosocial strains are discussed as potential explanations for the observed health inequalities.

Verhaltensauffälligkeiten bei Kindern und Jugendlichen - Erste Ergebnisse aus dem Kinder- und Jugendgesundheitssurvey (KiGGS)

ZusammenfassungPsychische Probleme im Kindes- und Jugendalter stellen gesundheitliche Beeinträchtigungen mit zum Teil schwerwiegenden Konsequenzen für das individuelle Wohlbefinden sowie die alltägliche und soziale Funktionsfähigkeit dar. Häufig sind diese Probleme auch mit starken Belastungen für das soziale Umfeld verbunden. Im Rahmen des Kinder- und Jugendgesundheitssurvey (KiGGS) beantworteten die Eltern von 14.478 Kindern und Jugendlichen im Alter von 3–17 Jahren den Strengths and Difficulties Questionnaire (SDQ), der Verhaltensauffälligkeiten und Stärken in den Bereichen emotionale Probleme, Hyperaktivität, Verhaltensprobleme, Probleme mit Gleichaltrigen und prosoziales Verhalten erfasst. Nach dem SDQ-Gesamtproblemwert sind 11,5 % der Mädchen (M) und 17,8 % der Jungen (J) verhaltensauffällig bzw. grenzwertig auffällig. 92,5 % der Mädchen bzw. 86,3 % der Jungen verfügen über ein adäquates prosoziales Verhalten. Die häufigsten Problembereiche sind Verhaltensprobleme (M = 11,9 %, J = 17,6 %) emotionale Probleme (M = 9,7 %, J = 8,6 %) und Hyperaktivitätsprobleme (M = 4,8 %, J = 10,8 %). Etwa 8,1 % der Befragten mit hohem sozioökonomischem Status, 13,4 % der mit mittlerem und 23,2 % der mit niedrigem Sozialstatus zeigen Hinweise auf psychische Probleme. Kinder mit Migrationshintergrund sind häufiger betroffen als Kinder von Nicht-Migranten. Die Resultate betonen die Notwendigkeit, beginnende psychische Probleme frühzeitig zu erkennen und ihnen präventiv zu begegnen. Insbesondere nur schwer erreichbare Gruppen wie z. B. sozial Benachteiligte oder Kinder mit Migrationshintergrund müssen hierbei berücksichtigt werden.AbstractMental health problems in children and adolescents constitute health impairments with major implications regarding individual wellbeing as well as daily and social functioning. In addition, these problems often burden the social partners of the individual. Within the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), the parents of 14478 children and adolescents aged 3–17 answered the Strengths and Difficulties Questionnaire (SDQ) which assesses behavioral problems and strengths in the areas emotional problems, hyperactivity, behavioral problems, peer problems and prosocial behavior. According to the results of the Total Difficulties Score (SDQ) 11,5 % girls (G) and 17,8 % boys (B) are classified borderline or abnormal, respectively. 92,5 % (G) and 86,3 % (B) display an adequate pro social behavior. Most prevalent problem areas are behavioral problems (G = 11,9 %, B = 17,9 %), emotional problems (G = 9,7 %, B = 8,6 %) and hyperactivity problems (G = 4,8 %, B = 10,8 %). The test-data of approximately 8,1 % of the respondents with high socio-economic status (SES), 13,4 % of those with middle SES and 23,2 % of those with low SES hinted at mental health problems. Migrants are more frequently affected than non-migrants. Results point at the need for early detection and prevention of commencing mental health problems. Especially the noneasily accessible groups like those with low socioeconomic status or migrants have to be considered.

Examining the relationship between Attention-Deficit/Hyperactivity Disorder and overweight in children and adolescents

Although a higher prevalence of overweight/obesity was reported in clinical samples of patients with Attention-Deficit/Hyperactivity Disorder (ADHD), an association between overweight and ADHD has yet not been established in the general population in childhood. As both disorders are common and significantly affect psychosocial functioning, we investigated the prevalence of ADHD in overweight/obese youth and vice versa. In a cross-sectional nationally representative and community based survey 2,863 parents and their children aged 11–17xa0years rated symptoms on the Diagnostic and Statistical Manual of Mental Disorders-based German ADHD Rating scale. Weight and height were assessed by professionals. Body mass index was categorized according to national age and sex specific reference values. Overall, 4.2% of the respondents met criteria for ADHD. The prevalence of ADHD was significantly higher for overweight/obese (7%) than for normal weight (3.5%) and underweight (4.9%) children. In a logistic regression analysis controlling for age, gender, and socio-economic status, overweight/obese children were twice as likely to have an ADHD diagnosis (ORxa0=xa02.0). Vice versa, adjusting for all covariates, children with ADHD had an OR of 1.9 for overweight/obesity status. For all weight-status groups, children with ADHD more frequently reported eating problems as compared to their non-clinical counterparts. Overweight/obese respondents with ADHD displayed the highest level of health services utilization. A clinician should be aware of the significant risk for a child with ADHD to become overweight and for an overweight child to have ADHD. Longitudinal studies are needed to better understand the mechanisms underlying the association between ADHD and overweight/obesity.

Overweight and its impact on the health-related quality of life in children and adolescents: results from the European KIDSCREEN survey

PurposeTo analyse the impact of overweight on HRQoL in a European sample of children and adolescents.MethodsAnalyses were conducted using data on 17,159 children and adolescents aged 8–18 from 10 European countries (Germany, Spain, France, Netherlands, Austria, United Kingdom, Switzerland, Hungary, Czech Republic and Poland) participating in the KIDSCREEN Health Interview Survey. In the studied sample (Nxa0=xa013,041), there were slightly more girls (52.6%) than boys (47.4%). Gender- and age-specific cut-offs of Cole et al. (BMJ 320:1240, 2000) were used to define overweight and obesity. The two groups were collapsed into one ‘overweight’ category. HRQoL was assessed on 10 dimensions using the KIDSCREEN-52. Univariate analysis of covariance (ANCOVA) was performed for group comparisons (normal weight vs. overweight). Partial eta squared (ηp2) was used as a measure of effect strength.ResultsOverall, 14.2% (Nxa0=xa01,849) of the sample was overweight, with prevalence rates ranging between 9.4% in France and 17.6% in Spain. Across all countries, overweight children and adolescents had lower mean HRQoL scores than normal weight children and adolescents. The strongest HRQoL impairments emerged on the physical well-being (ηp2xa0=xa00.012) and self-perception dimensions (ηp2xa0=xa00.021), both Pxa0<xa00.001.ConclusionsThis is one of the first studies comparing the impact of HRQoL at European level using a generic and internationally valid HRQoL instrument, and the results show that, irrespective of national background, overweight children and adolescents are significantly impaired on their HRQoL, in particular on the physical well-being and the self-perception domain.

Measuring mental health and well-being of school-children in 15 European countries using the KIDSCREEN-10 index

Objectives:To test the psychometric properties and measurement results of the KIDSCREEN-10 Mental Health Index in school children from 15 European countries.Methods:Within the cross-sectional Health Behaviour in School-aged Children 2005/2006 Survey, 78,000 pupils aged 11, 13, 15 answered the KIDSCREEN and additional measures. Cronbach’s alpha, Rasch partial credit model itemfit and ANOVAs were conducted.Results:Cronbach’s alpha was 0.81, Rasch infit mean square residuals were 0.7–1.3. Mean scores varied 0.8 standard deviation across countries. Older pupils (effect size [ES] = 0.6), girls (ES = 0.2), pupils with low socio-economic status (ES = 0.5) or frequent health complaints (r = 0.5) reported decreased mental health.Conclusions:The KIDSCREEN-10 displayed good psychometric properties. Measured differences between countries, age, gender, SES, and health complaints comply with theoretical considerations.

Measuring adolescents' HRQoL via self reports and parent proxy reports: an evaluation of the psychometric properties of both versions of the KINDL-R instrument.

BackgroundSeveral instruments are available to assess childrens health-related quality of life (HRQoL) based on self reports as well as proxy reports from parents. Previous studies have found only low-to-moderate agreement between self and proxy reports, but few studies have explicitly compared the psychometric qualities of both. This study compares the reliability, factorial validity and convergent and known group validity of the self-report and parent-report versions of the HRQoL KINDL-R questionnaire for children and adolescents.MethodsWithin the nationally representative cross-sectional German Health Interview and Examination Survey for Children and Adolescents (KiGGS), 6,813 children and adolescents aged 11 to 17 years completed the KINDL-R generic HRQoL instrument while their parents answered the KINDL proxy version (both in paper-and-pencil versions). Cronbachs alpha and confirmatory factor-analysis models (linear structural equation model) were obtained. Convergent and discriminant validity were assessed by calculating the Pearsons correlation coefficient for the Strengths and Difficulties Questionnaire. Known-groups differences were examined (ANOVA) for obese children and children with a lower familial socio-economic status.ResultsThe parent reports achieved slightly higher Cronbachs alpha values for the total score (0.86 vs. 0.83) and most sub-scores. Confirmatory factor analysis revealed an acceptable fit of the six-dimensional measurement model of the KINDL for the parent (RMSEA = 0.07) and child reports (RMSEA = 0.06). Factorial invariance across the two versions did not hold with regards to the pattern of loadings, the item errors and the covariation between latent concepts. However the magnitude of the differences was rather small. The parent report version achieved slightly higher convergent validity (r = 0.44 – 0.63 vs. r = 0.33 – 0.59) in the Strengths and Difficulties Questionnaire. No clear differences were observed for known-groups validity.ConclusionOur study showed that parent proxy reports and child self reports on the childs HRQoL slightly differ with regards to how the perceptions, evaluations and possibly the affective resonance of each group are structured and internally consistent. Overall, the parent reports achieved slightly higher reliability and thus are favoured for the examination of small samples. No version was universally superior with regards to the validity of the measurements. Whenever possible, childrens HRQoL should be measured via both sources of information.

The Role of Individual- and Macro-Level Social Determinants on Young Adolescents’ Psychosomatic Complaints:

This study examines the social determinants of psychosomatic complaints in young adolescents. Using data from the Health Behaviour in School-aged Children (HBSC) study, psychosomatic complaints are studied in 98,773 adolescents (11- and 13-year-olds; 48% 11-year-olds, 52% 13-year-olds; 52% females, 48% males) from 34 European countries. Individual-level determinants, including family-, peer- and school-related factors as well as country-level determinants (Human Development Index [HDI]) are considered. In line with existing evidence, results revealed more psychosomatic complaints in young adolescents experiencing stress inducing familial-, peer- and school-related factors. Negative effects of poor friendships, negative class climate, school pressure, and high media use were more pronounced for girls. After controlling for these factors, a higher HDI was related to a lower risk for psychosomatic complaints. Gender-specific intervention programs should aim at improving the quality of relationships, especially among peers, to prevent psychosomatic complaints among young adolescents.

Rasch Measurement Properties of the KIDSCREEN Quality of Life Instrument in Children with Cerebral Palsy and Differential Item Functioning between Children with and without Cerebral Palsy

OBJECTIVEnTo assess if the Rasch-scaled KIDSCREEN-52 generic health-related quality of life measure was valid in children with cerebral palsy (CP).nnnMETHODSnThe Rasch measurement properties and differential item functioning (DIF) of the KIDSCREEN-52 were examined in children with CP. Data were available from the KIDSCREEN project from 3219 children aged 8 to 12 years and 2126 parents in the general population; and from the SPARCLE project from 501 children aged 8 to 12 years with CP and 823 parents. Analysis used Zumbos logistic regression DIF approach. Partial credit model analyses were conducted.nnnRESULTSnAll items of the KIDSCREEN self-report version fitted the partial credit model (smallest P-value: 0.256). Only one item of the parent version did not fit the data well (smallest P-value 0.001). Statistically significant DIF was observed in some items, but was of substantial magnitude (ΔR2 = 0.046, 0.049) for only two items in two dimensions of the parent version. The practical impact of DIF was small. DIF-adjusted standardized mean differences between children with and without CP being 1.07 and 0.34 for the physical and school dimensions, respectively (unadjusted: 1.09 and 0.16).nnnCONCLUSIONnThe KIDSCREEN-52 functions in a similar way in children with CP and in the general population. Comparisons of quality of life between such children are therefore likely to be valid.