Process evaluation of a kindergarten-based intervention for obesity prevention in early childhood: the Toybox study Malaysia.

BACKGROUND: Toybox is a kindergarten-based intervention program that targets sedentary behavior, snacking and drinking habits, as well as promoting physical activity in an effort to improve healthy energy balance-related behaviors among children attending kindergartens in Malaysia. The pilot of this program was conducted as a randomized controlled trial (RCT) involving 837 children from 22 intervention kindergartens and 26 control kindergartens respectively. This paper outlines the process evaluation of this intervention. METHODS: We assessed five process indicators: recruitment, retention, dosage, fidelity, and satisfaction for the Toybox program. Data collection was conducted via teachers' monthly logbooks, post-intervention feedback through questionnaires, and focus group discussions (FGD) with teachers, parents, and children. Data were analyzed using quantitative and qualitative data analysis methods. RESULTS: A total of 1072 children were invited. Out of the 1001 children whose parents consented to join, only 837 completed the program (Retention rate: 88.4%). As high as 91% of the 44 teachers and their assistants engaged positively in one or more of the process evaluation data collection methods. In terms of dosage and fidelity, 76% of parents had received newsletters, tip cards, and posters at the appropriate times. All teachers and their assistants felt satisfied with the intervention program. However, they also mentioned some barriers to its implementation, including the lack of suitable indoor environments to conduct activities and the need to make kangaroo stories more interesting to captivate the children's attention. As for parents, 88% of them were satisfied with the family-based activities and enjoyed them. They also felt that the materials provided were easy to understand and managed to improve their knowledge. Lastly, the children showed positive behaviors in consuming more water, fruits, and vegetables. CONCLUSIONS: The Toybox program was deemed acceptable and feasible to implement by the parents and teachers. However, several factors need to be improved before it can be expanded and embedded as a routine practice across Malaysia.

[Depression, anxiety and stress scales: DASS--A screening procedure not only for pain patients]. / Die Depressions-Angst-Stress-Skalen: Der DASS--ein Screeningverfahren nicht nur für Schmerzpatienten.

BACKGROUND: The assessment of mental distress is a central aspect in pain research and treatment. Particularly for depression the comorbidity with pain poses methodological and conceptual challenges. This study examined the psychometric properties of the short version of the depression, anxiety and stress scale (DASS), used in both pain research and treatment and constructed to overcome the particular problems by omitting somatic items and concentrating on the psychological core aspects of depression, anxiety and stress. METHOD: The psychometric properties of the DASS-21 were compared between patients with pain and various people without any pain problems (N = 950). The DASS has three subscales, depression, anxiety and stress, each with seven items. The construct validity of the DASS was examined using the hospital anxiety and depression scale (HADS) for anxiety and depression and the general depression scale (Allgemeine Depressionsskala, ADS) for depression. The sensitivity and specificity for depression were determined against a structured interview for diagnostic and statistical manual of mental disorders (DSM-IV) and compared with the Center for Epidemiological Studies depression scale (CESD) and HADS in pain patients. RESULTS: Cronbach's alpha of the DASS for the depression subscale was at least 0.91, while the anxiety and stress subscales had Cronbach alphas of 0.78-0.82 and 0.81-0.89, respectively. Although the depression subscale has only 7 items, it is just as reliable as the ADS with 21 items. It also has a better sensitivity and specificity than the HADS in identifying clinical patients with depression. DISCUSSION: The DASS is a reliable questionnaire, free to use and brief to administer; therefore, it is an alternative to the previously used instruments for the screening of depression. Furthermore, the subscale stress measures irritability and tension, which are important aspects of pain experience but underused in assessment procedures for the diagnosis and treatment evaluation of patients with pain.

[Anxiety prevention among schoolchildren]. / Angstprävention bei Schulkindern.

The FRIENDS programme is a prevention and early intervention programme, which teaches children strategies to cope with anxiety and challenging situations. This paper examines the social validity of the German version of the FRIENDS programme using data from a large-scale study on the prevention of anxiety disorders in schoolchildren, which is funded by the Dr. Karl-Wilder Stiftung. In this paper, data of 208 schoolchildren (aged 9 to 12 years) are used. Results show that the children and their parents were highly satisfied with the FRIENDS programme. Childrens attendance and completion of their homework assignments were very high. Both the children and their parents rated relaxation exercises and thinking helpful thoughts as being more useful for the children than other skills. Treatment acceptability correlated significantly with the childrens clinical outcome. The implications of our findings for future research are discussed.

Anxiety symptoms in Japanese and in German children.

The purpose of this study was to compare the frequency of anxiety symptoms and their association with gender and age in Japanese and German children using the Spence Children's Anxiety Scale (SCAS). A total of 1837 children (862 from Germany and 975 from Japan) between the age of 8 and 12 years were investigated. Results revealed that German children reported significantly higher symptoms of separation anxiety, social phobia, obsessive compulsive disorder, and generalized anxiety disorder than Japanese children. Conversely, Japanese children reported significantly higher scores on symptoms related to physical injury fear. In both countries, girls scored higher than boys on all the scales of the SCAS. Symptoms of separation anxiety and panic decreased with age, whereas social phobia increased with age. The findings underscore the impact of culture on children's anxiety.

Frequency, comorbidity, and psychosocial impairment of anxiety disorders in German adolescents.

The frequency, comorbidity, and psychosocial impairment of anxiety disorders among German adolescents was estimated from a survey of 1,035 students aged 12-17 years. The adolescents were randomly selected from 36 schools in the province of Bremen, Germany. Anxiety disorders and other psychiatric disorders were coded based on criteria from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, using the computerized Munich version of the Composite International Diagnostic Interview. Anxiety disorders occurred frequently in our sample of adolescents, with a rate of 18.6%. When considering the subtypes of anxiety disorders, phobia was the most common. Posttraumatic stress disorder and obsessive-compulsive disorder occurred less frequently with rates below 2%. Panic disorder and generalized anxiety disorder were the least common, with rates well below 1%. Anxiety disorders were significantly higher in girls than in boys, and that the rates increased with age. Comorbidity occurs quite frequently, both within the anxiety disorders and also with other psychiatric disorders. The most common pattern of comorbidity was that of anxiety and depressive disorders. Although a high number of anxiety cases were psychosocially impaired, at least during the worst episode of their disorders, only a few of them sought treatment for their problems. We conclude by discussing some research priorities in the area of anxiety disorders in children and adolescents.

[Increasing depression in children and adolescents. Only early intervention can prevent dire outcome]. / Immer mehr Depressionen bei Kindern und Jugendlichen. Nur frühe Intervention kann schlimme Schicksale verhindern.

Numerous recent epidemiological studies indicate that depressive disorders in children and adolescents are quite common. Roughly 15% of adolescents admit to having suffered from such a disorder at some time or other. Depressive disorders increase with age with a preponderance of girls over boys. Risk factors that have been found to be associated with depressive disorders include parental psychopathology, familial dysfunction, and negative life events. Depression frequently occurs together with other disorders, and shows a tendency to become chronic. Finally the article discusses the implications of the latest findings for preventive and interventional strategies.

Frequency, comorbidity, and psychosocial impairment of specific phobia in adolescents.

Investigated the frequency, comorbidity, and psychosocial impairment of specific phobia and specific fears among 1,035 adolescents 12 to 17 years old. The adolescents were recruited from 36 schools in the province of Bremen, Germany. Specific phobia and other psychiatric disorders were coded based on Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) criteria using the computerized Munich version of the Composite International Diagnostic Interview (Wittchen & Pfister, 1996). Thirty-six (3.5%) of the adolescents met DSM-IV criteria for specific phobia sometime in their life. Of all the subtypes of specific phobia, animal and natural environment phobia were the most common. More girls than boys received the diagnosis of specific phobia. One third of the adolescents with specific phobia also had depressive and somatoform disorders. Despite the high level of psychosocial impairment experienced by individuals with specific phobia both during the worst episode of their disorder and in the last 4 weeks, only a small portion of them sought professional help.

[Frequency, comorbidity and psychosocial correlates of attention-deficit/hyperactivity disorder. Results of a Bremen adolescent study]. / Häufigkeit, Komorbidität und psychosoziale Korrelate der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung. Ergebnisse der Bremer Jugendstudie.

Using data from the first wave of the Bremen Adolescent Study, this article presents findings on the frequency, comorbidity and correlates of Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD ist the least common disorder examined in our study, with only two out of 1009 adolescents (0.2%) meeting the full DSM-IV criteria for ADHD. On the symptom level, our data show that 159 adolescents (15.8%) report at least six symptoms of inattention and/or six symptoms of hyperactivity-impulsivity. When considering those with this ADHD syndrome, our data show that about half of them have problems in school and at home, and 69.8% of them have at least one comorbid disorder. Compared to adolescents without any disorder and to those with other disorders, adolescents with only ADHD syndrome score significantly lower on control orientation (behavior conduct), perceived competence (academic, behavior, friendship subscales), and show lower emotional attachment to parents and peers. The results are discussed in terms of their implication for classification and intervention.

Frequency and comorbidity of social phobia and social fears in adolescents.

This report presents findings on the frequency, comorbidity and psychosocial impairment of social phobia and social fears among 1035 adolescents, aged 12-17 years. The adolescents were randomly selected from 36 schools in the province of Bremen, Germany. Social phobia and other psychiatric disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. Seventeen (1.6%) of the adolescents met the DSM-IV criteria for social phobia sometimes in their life. More girls than boys received the diagnosis of social phobia and the frequency of the disorder increased with age. The lifetime frequency of social fears were much higher than that of social phobia. The most common types of feared social situations were fear of doing something in front of other people, followed by public speaking. Social phobia comorbid highly with depressive disorders, somatoform disorders and substance use disorders. Despite the high level of psychosocial impairment experienced by cases with social phobia and those with any social fears, only a small portion of them did receive professional help.

[Incidence of post-traumatic stress disorder in adolescents: results of the Bremen Adolescent Study]. / Häufigkeit der Posttraumatischen Belastungsstörung bei Jugendlichen: Ergebnisse der Bremer Jugendstudie.

The frequency and comorbidity of posttraumatic stress disorders (PTSD) were assessed together with the resultant psychosocial impairment in 1035 adolescents between the ages of 12 and 17 years. Posttraumatic stress disorder and other psychiatric disorders were coded on the basis of the DSM-IV criteria using the computerized personal interview of the Munich version of the Composite International Diagnostic Interview (CIDI). A total of 17 (1.6%) adolescents met the DSM-IV criteria for PTSD at some point in their life. Slightly more girls than boys met the criteria for the disorder, whose frequency increased with age. The lifetime prevalence of traumatic events is much higher still: 233 (22.5%) adolescents reported one or more traumatic events in their life. The types of traumatic events experienced by the greatest number of adolescents were: physical attack, injury, and serious accident. Boys experienced significantly more traumatic events than did girls. The occurrence of a traumatic event was mostly associated with hypervigilance and recurrent and intrusive psychological distress upon exposure to cues which symbolized the event itself or resembled an aspect thereof. PTSD occurred in highly frequent comorbidity with depressive disorders, somatoform disorders, and substance abuse. Over 90% of those with posttraumatic stress disorder were severely impaired in their daily life and activities. Despite the high-grade psychosocial impairment, only a small number sought professional help.

Frequency of panic attacks and panic disorder in adolescents.

By using data from the Bremer Adolescent Study, this report presents findings on the frequency, comorbidity, and psychosocial impairment of panic disorder and panic attacks among 1,035 adolescents. The adolescents were randomly selected from 36 schools in the province of Bremen, Germany. Panic disorder and other psychiatric disorders were coded based on DSM-IV criteria using the computerized-assisted personal interview of the Munich version of the Composite International Diagnostic Interview. Panic disorder occurred rather rare, with only 0.5% of all the adolescents met the DSM-IV criteria for this disorder sometimes in their live. Panic attack occurred more frequently, with 18% of the adolescents reported having had at least one panic attack. Slightly more girls than boys had panic attack and panic disorder. The occurrence of panic attack and panic disorder were the greatest among the 14-15 year olds. The experience of having a panic attack was associated with a number of problems, the most frequent being avoiding the situation for fear of having another attack. Four most common symptoms associated with a panic attack were that of palpitations, trembling/shaking, nausea or abdominal distress, and chills or hot flushes. Panic disorder comorbid highly with other psychiatric disorder covered in our study, especially with that of major depression. Among those with a panic disorder, about 40% of them were severely impaired during the worst episode of their illness. Only one out of five adolescents with panic disorder sought professional help for emotional and psychiatric problems. The implication of our findings for research and clinical practice are discussed.

[Anxiety disorders in children and adolescents. Epidemiology, risk factors and intervention]. / Angststörungen bei Kindern und Jugendlichen. Epidemiologie, Risikofaktoren und Intervention.

The article reviews the literature on anxiety disorders in children and adolescents. Anxiety disorders represent one of the most common disorders in children and adolescents, with a life-time prevalence of about 10%. In most studies, significantly more females than males met the diagnosis of anxiety disorders. Some factors that have been commonly found to be associated with anxiety disorders include parental psychopathology, familial dysfunction, negative life events, and behavioral inhibition. Anxiety co-occurs frequently with other disorders; it has a chronic course and most of the anxiety cases are psychosocially impaired in various areas of life. The article ends by giving an overview of various types of intervention strategies commonly used to treat children and adolescents with anxiety disorders.

[Frequency and comorbidity of social anxiety and social phobia in adolescents. Results of a Bremen adolescent study]. / Häufigkeit und Komorbidität sozialer Angste und sozialer Phobie bei Jugendlichen. Ergebnisse der Bremer Jugendstudie.

Using data from the Bremen Adolescent Study, this report presents findings on the frequency, comorbidity and psychosocial impairment of social phobia and social fears among 1035 German adolescents of 12-17 years of age. The adolescents were randomly selected from 36 schools in the city and provincial government area of Bremen, Germany. Social phobia and other psychiatric disorders were coded based on DSM-IV criteria using the computerized personal interview of the Munich version of the Composite International Diagnostic Interview. Seventeen (1.6%) of the adolescents had met the DSM-IV criteria for social phobia at some time in their life. More girls than boys were diagnosed as suffering from social phobia. The incidence of the disorder increased with age. The lifetime frequency of social fears is much higher. The most common types of feared social situations were fear of doing something in front of other people, followed by public speaking. Social phobia very often co-occurred with depressive disorders, somatoform disorders and disorders caused by excessive or inappropriate consumption of substances. Over 94% of those with social phobia and 54.4% with any social fears were severely impaired in their daily life during the worst episode. Despite the high level of psychosocial impairment, only a small portion of the cases received professional help.

[Substance abuse and dependence in adolescents]. / Substanzmissbrauch und -abhängigkeit bei Jugendlichen.

This manuscript reviews literature on the prevalence/frequency, risk factors, course and outcome of substance use disorders in adolescents. Recent epidemiological studies conducted in various parts of the world have indicated a high frequency of substance use disorders in adolescents, with values ranging from 5 to 8%; the rate for alcohol abuse and dependence range from 2 to 32%, and for drugs from 5 to 10%. Substance use disorders were significantly higher in males than in females, and that they increased with age. Other risk factors commonly reported for substance use disorders include biological, familial, and social factors. Several intervention and prevention programs are presented and discussed.

Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse: results of an international task force.

Associations between affective disorders, anxiety disorders, and substance use disorders were examined in epidemiological studies conducted in Germany, Switzerland, Puerto Rico, and the mainland US. There was a remarkable degree of similarity across studies in the magnitude and type of specific disorders associated with the affective disorders. Comorbidity with affective disorders was greater for the anxiety disorders than for substance misuse. Panic disorder was the subtype of anxiety that was most highly comorbid with depression. Social phobia was the specific phobic type with the strongest association with the affective disorders. The magnitude of associations between substance misuse and affective disorders generally was quite low and less consistent across sites. No major differences were found in the patterns of comorbidity by gender or age group, affective subtype or prevalence period. The onset of anxiety disorders generally preceded that of depression, whereas alcohol misuse was equally likely to pre-or post-date the onset of affective disorders. Finally, comorbidity was associated with an elevation in treatment rates across all sites, confirming Berkson's paradox on an international level.

[Depressive symptoms and syndromes in adolescents]. / Depressive Symptome und Syndrome bei Jugendlichen.

The present study examined the frequency of self-reported depressive symptoms in high school students aged 11 to 19 years using the Revised Ontario Child Health Study Scales. A high percentage of subjects occasionally experienced some types of depressive symptoms in the last six months. Three levels of diagnostic certainty were generated by varying the severity of depressive symptoms. The frequency of depression for the 'low diagnostic certainty' was 51.6%, the "medium diagnostic certainty' 5.6%, and for the 'high diagnostic certainty' 0%. Depressive symptoms correlated significantly with doctor's visit and life events. The implication of the results for clinical practice and research was discussed.

[Symptoms of anxiety and depression in adolescents]. / Symptome von Angst und Depression bei Jugendlichen.

The main aim of the present study was to examine the frequency and correlates of anxiety and depressive symptoms. Anxiety and depressive symptoms were evaluated by means of the Revised Ontario Health Study Scales. The probands were 215 adolescents aged 11 to 19 years. An important finding was the high rates of suicidal thought in the 11-12 year old boys (23.1%) and the 17-19 year girls (26.7%). Our result also showed a significant correlation between depressive symptoms and doctor's visit and critical life events. The implication of the results for clinical practice and research were discussed.

[Depression in children and adolescents]. / Depression bei Kindern und Jugendlichen.

The prevalence of major depression in preschool is less than 1 procent, in school-age children about 2 percent, and in adolescents about 4.7 percent. While as no significant sex differences have been reported among preadolescents, studies of adolescents have reported 2 to 3 times higher rates of depression. The most frequent course of depression is chronic and persistent, the mean length of depressive episode being 30 weeks. Depressed children and adolescents have impaired psychosocial functioning and school problems. Relapse occurs at a high frequency for depressed patients. The high recurrence of depression in children and adolescents calls for a long-term management in these age-groups.

Epidemiology of panic disorder: progress and unresolved issues.

Recent epidemiological studies have consistently shown that panic disorder, according to DSM-III, occurs in adults with a lifetime prevalence of about 2% and a 6-month prevalence of about 1.2%. Panic attacks are relatively common, with a lifetime rate of about 9%. Being female and divorced and separated is associated with higher prevalence of panic disorder. The hazard rates for panic disorder were highest between the ages of 25 and 34 years for females and between the ages of 30 and 44 years for males. Panic disorder frequently co-occurs with other anxiety disorders as well as with a wide range of mental disorders such as depression and substance use disorder. Based on few epidemiological studies, panic disorder has been found to have a chronic course with rare complete remission. Subjects with panic disorder were at an increased risk of social impairment, not getting along with their partners, as well as being financially dependent, and were likely to report fair or poor global physical health, and emotional health. Cases with panic disorder had the most severe psychosocial impairment and the worst outcome as compared to other anxiety disorders. Moreover, they are high users of all types of medical services, including mental health and general medical providers. Although recent epidemiological data, with its improved methodology, have considerably increased our knowledge concerning panic attack, panic disorder and agoraphobia, there are still major questions concerning the etiology, natural history, prevention, or control of panic disorder that need to be answered. Furthermore, since panic disorder has been considered as developing in stages, our current epidemiological knowledge cannot tell us in sufficient detail about the specific role of suggested risk factors in the development of panic disorder through its various stages.