Ulrike M. E. Schulze

The association of non-suicidal self-injury and suicidal behavior according to DSM-5 in adolescent psychiatric inpatients

Non-suicidal self-injury (NSSI) and suicidal behaviors frequently occur among adolescent psychiatric patients. Although those behaviors are distinct with regards to intent, NSSI has been shown to be an important risk-factor for suicide attempts. However, the association of NSSI and Suicidal Behavior Disorder (SBD) according to DSM-5 criteria has not yet been investigated. For investigating distinctive features and mutual risk-factors of NSSI-disorder and SBD, adolescent psychiatric inpatients (N=111, aged 12-19 years; 65.8% females) were interviewed using the Self-Injurious-Thoughts-And-Behaviors-Interview-German (SITBI-G). NSSI started significantly earlier in life (M=12.5 years, SD=2.2) than first suicide attempts (M=14.1 years, SD=2.0). Patients meeting NSSI-disorder and/or SBD were significantly more likely to be female and to be diagnosed with an affective disorder. NSSI-disorder and SBD seem to have several distinctive features (i.e. age of onset or frequency), but also seem to share certain mutual risk-factors (i.e. affective disorders, female gender). While both NSSI and SBD seem to be maintained by mainly automatic negative reinforcement, positive automatic and social functions were rated significantly higher for NSSI. Most importantly, NSSI seems to be a strong risk factor for the occurrence of SBD (even when controlling for suicidal ideation) and should therefore always be assessed when dealing with psychiatric adolescent patients.

Architecture and functioning of child and adolescent mental health services: a 28-country survey in Europe

The WHO Child and Adolescent Mental Health Atlas, published in 2005, reported that child and adolescent mental health services (CAMHS) in Europe differed substantially in their architecture and functioning. We assessed the characteristics of national CAMHS across the European Union (EU), including legal aspects of adolescent care. Using an online mapping survey aimed at expert(s) in each country, we obtained data for all 28 countries in the EU. The characteristics and activities of CAMHS (ie, availability of services, inpatient beds, and clinicians and organisations, and delivery of specific CAMHS services and treatments) varied considerably between countries, as did funding sources and user access. Neurodevelopmental disorders were the most frequent diagnostic group (up to 81%) for people seen at CAMHS (data available from only 13 [46%] countries). 20 (70%) countries reported having an official national child and adolescent mental health policy, covering young people until their official age of transition to adulthood. The heterogeneity in resource allocation did not seem to match epidemiological burden. Substantial improvements in the planning, monitoring, and delivery of mental health services for children and adolescents are needed.

Paediatric European Risperidone Studies (PERS): context, rationale, objectives, strategy, and challenges

Abstract In children and adolescents with conduct disorder (CD), pharmacotherapy is considered when non-pharmacological interventions do not improve symptoms and functional impairment. Risperidone, a second-generation antipsychotic is increasingly prescribed off-label in this indication, but its efficacy and tolerability is poorly studied in CD, especially in young people with normal intelligence. The Paediatric European Risperidone Studies (PERS) include a series of trials to assess short-term efficacy, tolerability and maintenance effects of risperidone in children and adolescents with CD and normal intelligence as well as long-term tolerability in a 2-year pharmacovigilance. In addition to its core studies, secondary PERS analyses will examine moderators of drug effects. As PERS is a large-scale academic project involving a collaborative network of expert centres from different countries, it is expected that results will lead to strengthen the evidence base for the use of risperidone in CD and improve standards of care. Challenging issues faced by the PERS consortium are described to facilitate future developments in paediatric neuropsychopharmacology.

Bone mineral density in partially recovered early onset anorexic patients - a follow-up investigation

Background and aimsThere still is a lack of prospective studies on bone mineral development in patients with a history of early onset Anorexia nervosa (AN). Therefore we assessed associations between bone mass accrual and clinical outcomes in a former clinical sample. In addition to an expected influence of regular physical activity and hormone replacement therapy, we explored correlations with nutritionally dependent hormones.Methods3-9 years (mean 5.2 ± 1.7) after hospital discharge, we re-investigated 52 female subjects with a history of early onset AN. By means of a standardized approach, we evaluated the general outcome of AN. Moreover, bone mineral content (BMC) and bone mineral density (BMD) as well as lean and fat mass were measured by dual-energy x-ray absorptiometry (DXA). In a substudy, we measured the serum concentrations of leptin and insulin-like growth factor-I (IGF-I).ResultsThe general outcome of anorexia nervosa was good in 50% of the subjects (BMI ≥ 17.5 kg/m2, resumption of menses). Clinical improvement was correlated with BMC and BMD accrual (χ2 = 5.62/χ2 = 6.65, p = 0.06 / p = 0.036). The duration of amenorrhea had a negative correlation with BMD (r = -.362; p < 0.01), but not with BMC. Regular physical activity tended to show a positive effect on bone recovery, but the effect of hormone replacement therapy was not significant. Using age-related standards, the post-discharge sample for the substudy presented IGF-I levels below the 5th percentile. IGF-I serum concentrations corresponded to the general outcome of AN. By contrast, leptin serum concentrations showed great variability. They correlated with BMC and current body composition parameters.ConclusionsOur results from the main study indicate a certain adaptability of bone mineral accrual which is dependent on a speedy and ongoing recovery. While leptin levels in the substudy tended to respond immediately to current nutritional status, IGF-I serum concentrations corresponded to the individuals age and general outcome of AN.

Attention Deficit Hyperactivity Disorder (ADHD) and road traffic - special considerations for the treatment of adolescents with ADHD

Die Aufmerksamkeitsdefizit-Hyperaktivitatsstorung (ADHS) besteht bei ca. einem Drittel der Betroffenen auch noch in der Adoleszenz und im jungen Erwachsenenalter fort. Relevante Auswirkungen der Storung konnen die weiterhin bestehende Unaufmerksamkeit, Konzentrationsschwache und auch gesteigertes impulsives Verhalten im Strasenverkehr sein: Jugendliche und junge Erwachsene mit ADHS verursachen im Vergleich zu Gleichaltrigen insgesamt mehr als doppelt so haufig Verkehrsunfalle mit Kraftfahrzeugen. In dieser Ubersichtsarbeit soll ein kurzer Abriss der rechtlichen Situation und der aktuellen Studienlage zum Fahrverhalten von jungen Menschen mit ADHS gegeben werden. Stimulanzien gehoren nach der Strasenverkehrsordnung (StVO) zu den verbotenen Rauschmitteln, verbessern aber nach heutiger Studienlage die Fahrleistung von ADHS-Patienten signifikant. Fur Atomoxetin, das als nicht BtM-rezeptpflichtiges Arzneimittel problemlos gegeben werden kann, da es nicht in der StVO aufgefuhrt ist, sind die Forschungsergebniss...Attention Deficit Hyperactivity Disorder (ADHD) is not only a childhood disorder but symptoms persist into adolescence and adulthood in approximately one third of the patients. Especially inattention and poor concentration impair driving performance in road traffic. Adolescents and young adults with ADHD are twice as likely to be involved in traffic accidents as people of the same age. This review sums up the legal situation in Germany and provides an overview of the current existing experimental studies on driving performance of adolescents and young adults with ADHD. Psychostimulant therapy seems to improve driving performance in ADHD patients. At the same time psychostimulants are prohibited, according to the road traffic act. Atomoxetine as a non-stimulant is not mentioned there. Therefore it could be unproblematically prescribed, however, the evidence for improved driving is not as unequivocal as for methylphenidate. The psychoeducation of adolescents and young adults with ADHD concerning their increased risk in road traffic often seems to be insufficient in clinical practice. Given the high number of traffic deaths in these young age groups consulting regarding this matter should be of high priority.

Aufmerksamkeitsdefizit-Hyperaktivitätsstörung (ADHS) und Straßenverkehr

Die Aufmerksamkeitsdefizit-Hyperaktivitatsstorung (ADHS) besteht bei ca. einem Drittel der Betroffenen auch noch in der Adoleszenz und im jungen Erwachsenenalter fort. Relevante Auswirkungen der Storung konnen die weiterhin bestehende Unaufmerksamkeit, Konzentrationsschwache und auch gesteigertes impulsives Verhalten im Strasenverkehr sein: Jugendliche und junge Erwachsene mit ADHS verursachen im Vergleich zu Gleichaltrigen insgesamt mehr als doppelt so haufig Verkehrsunfalle mit Kraftfahrzeugen. In dieser Ubersichtsarbeit soll ein kurzer Abriss der rechtlichen Situation und der aktuellen Studienlage zum Fahrverhalten von jungen Menschen mit ADHS gegeben werden. Stimulanzien gehoren nach der Strasenverkehrsordnung (StVO) zu den verbotenen Rauschmitteln, verbessern aber nach heutiger Studienlage die Fahrleistung von ADHS-Patienten signifikant. Fur Atomoxetin, das als nicht BtM-rezeptpflichtiges Arzneimittel problemlos gegeben werden kann, da es nicht in der StVO aufgefuhrt ist, sind die Forschungsergebniss...Attention Deficit Hyperactivity Disorder (ADHD) is not only a childhood disorder but symptoms persist into adolescence and adulthood in approximately one third of the patients. Especially inattention and poor concentration impair driving performance in road traffic. Adolescents and young adults with ADHD are twice as likely to be involved in traffic accidents as people of the same age. This review sums up the legal situation in Germany and provides an overview of the current existing experimental studies on driving performance of adolescents and young adults with ADHD. Psychostimulant therapy seems to improve driving performance in ADHD patients. At the same time psychostimulants are prohibited, according to the road traffic act. Atomoxetine as a non-stimulant is not mentioned there. Therefore it could be unproblematically prescribed, however, the evidence for improved driving is not as unequivocal as for methylphenidate. The psychoeducation of adolescents and young adults with ADHD concerning their increased risk in road traffic often seems to be insufficient in clinical practice. Given the high number of traffic deaths in these young age groups consulting regarding this matter should be of high priority.

Trait anxiety in children and adolescents with anorexia nervosa

In this study of trait anxiety in children and adolescents with anorexia nervosa, a consecutive series of 23 newly admitted children and adolescents with anorexia nervosa was studied by use of the State-Trait-Anxiety-Inventory, the Eating Disorders Inventory (EDI), the Social Phobia and Anxiety Inventory for Children (SPAI-C), and a structured psychiatric interview (DIPS: Diagnostisches Interview bei psychischen StÖrungen). In addition, clinical diagnoses were taken from the files. Trait anxiety was significantly increased at the time of admission and social phobia was present in a large proportion of the patients. Specific eating disorder psychopathology as measured by the EDI was significantly associated with trait anxiety. There were no clinical diagnoses (according to the International Classification of Diseases — Tenth Revision) of anxiety disorders. Features of anxiety are very common in young patients with anorexia nervosa and closely linked to specific psychopathology. Anxiety disorders need careful evaluation in these patients.

Psychopharmakotherapie mit Clomipramin und Paroxetin bei jugendlichen Patientinnen mit «Anorexia nervosa» und «Depressiver Episode» - eine Pilotstudie zu Verträglichkeit, Absetzquote und therapeutischen Verlaufskriterien

Zusammenfassung: Fragestellung: Die Frage der Indikation und Wirkung antidepressiver Medikation bei Anorexia nervosa mit Beginn im Kindes- und Jugendalter im Verlauf stationarer Behandlung wurde bislang nur wenig untersucht. Auch mangelt es an vergleichenden Studien zu Vertraglichkeit und Wirkung unterschiedlicher Thymoleptika an anorektischen Patienten dieses Altersspektrums. Gegenstand der vorliegenden Studie war ein Vergleich der Behandlungsverlaufe unter Paroxetin, einem SSRI, und Clomipramin, einem trizyklischen Antidepressivum mit serotonerger Wirkkomponente. Neben Qualitat und Auftretenshaufigkeit unerwunschter Wirkungen sowie Haufigkeit und Ursachen des Absetzens der Medikation galt das Interesse verschiedenen therapeutischen Verlaufskriterien. Methodik: In die retrospektive Untersuchung wurden 83 Patientinnen einbezogen, die im Zeitraum von 1988 bis 1998 erstmalig stationar in der Klinik und Poliklinik fur Kinder- und Jugendpsychiatrie und Psychotherapie der Universitat Wurzburg behandelt wurden....

Development and psychometric properties of the Suicidality: Treatment Occurring in Paediatrics (STOP) Suicidality Assessment Scale (STOP-SAS) in children and adolescents

BackgroundTo create a self-reported, internet-based questionnaire for the assessment of suicide risk in children and adolescents.MethodsAs part of the EU project ‘Suicidality: Treatment Occurring in Paediatrics’ (STOP project), we developed web-based Patient Reported Outcome Measures (PROMs) for children and adolescents and for proxy reports by parents and clinicians in order to assess suicidality. Based on a literature review, expert panels and focus groups of patients, we developed the items of the STOP Suicidality Assessment Scale (STOP-SAS) in Spanish and English, translated it into four more languages, and optimized it for web-based presentation using the HealthTrackerTM platform. Of the total 19 questions developed for the STOP-SAS, four questions that assess low-level suicidality were identified as screening questions (three of them for use with children, and all four for use with adolescents, parents and clinicians). A total of 395 adolescents, 110 children, 637 parents and 716 clinicians completed the questionnaire using the HealthTrackerTM, allowing us to evaluate the internal consistency and convergent validity of the STOP-SAS with the clinician-rated Columbia Suicide Severity Rating Scale (C-SSRS). Validity was also assessed with the receiver operating characteristic (ROC) area of the STOP-SAS with the C-SSRS.ResultsThe STOP-SAS comprises 19 items in its adolescent, parent, and clinician versions, and 14 items in its children’s version. Good internal consistency was found for adolescents (Cronbach’s alpha: 0.965), children (Cronbach’s alpha: 0.922), parents (Cronbach’s alpha: 0.951) and clinicians (Cronbach’s alpha: 0.955) versions. A strong correlation was found between the STOP-SAS and the C-SSRS for adolescents (r:0.670), parents (r:0.548), clinicians (r:0.863) and children (r:0.654). The ROC area was good for clinicians’ (0.917), adolescents’ (0.834) and parents’ (0.756) versions but only fair (0.683) for children’s version.ConclusionsThe STOP-SAS is a comprehensive, web-based PROM developed on the HealthTrackerTM platform, and co-designed for use by adolescents, children, parents and clinicians. It allows the evaluation of aspects of suicidality and shows good reliability and validity.

Protocol for a cohort study of adolescent mental health service users with a nested cluster randomised controlled trial to assess the clinical and cost-effectiveness of managed transition in improving transitions from child to adult mental health services (the MILESTONE study)

Introduction Disruption of care during transition from child and adolescent mental health services (CAMHS) to adult mental health services may adversely affect the health and well-being of service users. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Healthcare) study evaluates the longitudinal course and outcomes of adolescents approaching the transition boundary (TB) of their CAMHS and determines the effectiveness of the model of managed transition in improving outcomes, compared with usual care. Methods and analysis This is a cohort study with a nested cluster randomised controlled trial. Recruited CAMHS have been randomised to provide either (1) managed transition using the Transition Readiness and Appropriateness Measure score summary as a decision aid, or (2) usual care for young people reaching the TB. Participants are young people within 1 year of reaching the TB of their CAMHS in eight European countries; one parent/carer and a CAMHS clinician for each recruited young person; and adult mental health clinician or other community-based care provider, if young person transitions. The primary outcome is Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) measuring health and social functioning at 15 months postintervention. The secondary outcomes include mental health, quality of life, transition experience and healthcare usage assessed at 9, 15 and 24 months postintervention. With a mean cluster size of 21, a total of 840 participants randomised in a 1:2 intervention to control are required, providing 89% power to detect a difference in HoNOSCA score of 0.30 SD. The addition of 210 recruits for the cohort study ensures sufficient power for studying predictors, resulting in 1050 participants and an approximate 1:3 randomisation. Ethics and dissemination The study protocol was approved by the UK National Research Ethics Service (15/WM/0052) and equivalent ethics boards in participating countries. Results will be reported at conferences, in peer-reviewed publications and to all relevant stakeholder groups. Trial registration number ISRCTN83240263; NCT03013595 (pre-results).