[The health economics of attention deficit hyperactivity disorder in Germany. Part 1: Health care utilization and cost of illness]. / Gesundheitsökonomie der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung in Deutschland Teil 1: Versorgungsepidemiologie und Krankheitskosten.

In the German region of Nordbaden, 5% of children (aged 7-12 years) and 1.3% of adolescents (aged 13-19 years) were diagnosed with attention deficit hyperactivity disorder (ADHD) in 2003. About two thirds of these patients were not seen by a physician specialized in psychiatry. Now the National Association of Statutory Health Insurance Physicians in Germany (Kassenaerztliche Bundesvereinigung, KBV) has developed a proposal for the integrated provision of care for these patients, combining a guidelines-oriented multidisciplinary approach with a system of quality assurance. Against this background, currently available ADHD-related data are presented, covering epidemiology, comorbidity and differential diagnosis, health care utilization, and cost of illness. According to administrative data analyses from Nordbaden, direct medical costs for patients with ADHD, from the perspective of statutory health insurance (SHI), exceed those of matched controls by a factor of >2.5. On this basis, ADHD-related expenditures of the German SHI may be estimated at around EUR 260 million in 2003, and almost certainly will have continued to grow further since. In addition to this, a diagnosis of ADHD is associated with substantial indirect cost. Although the literature on the burden of ADHD is incomplete, it seems plausible that the cost of illness might be comparable to that reported for alcohol and addiction disorders. Thus we anticipate an increasing relevance of formal health economic evaluations of health care programs offered to patients with ADHD.

[The health economics of attention deficit hyperactivity disorder in Germany. Part 2: Therapeutic options and their cost-effectiveness]. / Gesundheitsökonomie der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung in Deutschland. Teil 2: Therapeutische Optionen und ihre Kosteneffektivität.

Attention deficit hyperactivity disorder (ADHD) has been associated with a continuous increase of health care utilization and thus expenditures. This raises the issue of cost-effectiveness of health care provided for patients with ADHD. Comparative health economic evaluations generate relevant insights and typically report incremental cost-effectiveness ratios (ICERs) of alternatives versus an established standard. Typically, results of cost-effectiveness analyses (CEAs) are reported in terms of incremental cost-effectiveness ratios (ICERs). International evaluations, as well specific adaptations to Germany, indicate an acceptable to attractive cost-effectiveness--according to currently used international benchmarks--of an intense medication management strategy based on stimulants, primarily methylphenidate, with ICERs ranging from 20,000 EUR to 37,000 EUR per quality-adjusted life year (QALY) gained. Economic modeling studies also suggest cost-effectiveness of long-acting modified-release preparations of methylphenidate, owing to improved treatment compliance associated with simplified once daily administration schemes. Atomoxetine, in contrast, appears economically inferior compared to long-acting stimulants, given its higher acquisition costs and at best equal clinical effectiveness. There are currently no data supporting the cost-effectiveness of psychotherapeutic or behavioral interventions. Economic evaluations, which have been published to date, are generally limited by time horizons of up to 1 year and by their prevailing focus on ADHD core symptom improvement only. Therefore, further research into the cost-effectiveness of ADHD treatment strategies seems warranted.

Symptom control in children and adolescents with attention-deficit/hyperactivity disorder on switching from immediate-release MPH to OROS MPH Results of a 3-week open-label study.

AIM: The aim of this study was to assess the impact of switching from immediate-release (IR) methylphenidate (MPH) to OROS MPH (CONCERTA, a once-daily long-acting MPH formulation, in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). METHODS: Subjects with ADHD aged 6-16 (n=105),who were stably maintained on their current IR MPH regimen (10-60 mg/day), were switched to 18, 36 or 54 mg OROS MPH once daily for 21 days, depending on pre-study daily MPH dose. ADHD symptoms were assessed by parents, teachers and investigators. RESULTS: By Day 21, parent/caregiver IOWA Conners ratings had decreased from baseline by 2.7 points to 5.2 (I/O), and by 1.8 points to 5.0 (O/D). Teacher IOWA Conners ratings were maintained. Decreases in IOWA Conners ratings are indicative of ADHD symptom improvement. Approximately 75% of parents and investigators rated therapy as good or excellent. OROS MPH therapy was well tolerated. CONCLUSIONS: Switching from IR MPH to OROS MPH maintained and may have improved symptom control in children and adolescents with ADHD, during the course of this study. The changes in parent/caregiver IOWA Conners ratings suggest that OROS MPH improves symptom control in the after-school period. This is consistent with the 12-h duration of action previously demonstrated for OROS MPH.

12-month efficacy and safety of OROS MPH in children and adolescents with attention-deficit/hyperactivity disorder switched from MPH.

PURPOSE: The aim of this study was to evaluate long-term clinical treatment with OROS methylphenidate (MPH) (Concerta) in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) who had been previously treated with immediate release (IR) MPH. METHODS: Subjects aged 6-16 years (n=105) who were stable on IR MPH (10-60 mg/day) were switched to 18, 36 or 54 mg OROS MPH once daily for 21 days, depending on prestudy MPH dose. Subjects who benefited from OROS MPH could continue in a 12-month extension period. ADHD symptoms and treatment response were assessed by parents/caregivers and investigators. RESULTS: Out of 105 enrolled children, 101 completed the 21-day treatment phase. In all, 89 parents/caregivers (88.1%) wanted their child to continue with the study treatment into the extension phase, and 56 children (63 %) completed the 1-year trial. The parent/caregiver global assessment of satisfaction ranged from 49 to 69% during the extension phase, and 49 to 71% of investigators rated the treatment as adequate. Efficacy and satisfaction were found more commonly in patients in the older age group (10-16 years), those on a higher dose (36 mg or 54 mg) and with the predominantly inattentive ADHD subtype. OROS MPH was well tolerated. CONCLUSIONS: Children and adolescents can effectively and safely be switched from IR MPH to OROS MPH with improved symptom control and compliance.

[Tools for the diagnosis of attention-deficit/hyperactivity disorder in adults. Self-rating behaviour questionnaire and diagnostic checklist]. / Instrumente zur Diagnostik der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im ErwachsenenalterSelbstbeurteilungsskala (ADHS-SB) und Diagnosecheckliste (ADHS-DC).

We report on the development of a German self-rating behaviour questionnaire (ADHD-SR) and diagnostic checklist (ADHD-DC) for the diagnosis of attention-deficit/hyperactivity disorder in adults according to DSM IV and ICD 10 research criteria. When comparing self-rating with expert rating, we found good concordance measured by intraclass coefficients on the level of single symptoms and syndrome scores. High retest reliability of the ADHD-SR demonstrated the ability to assess time-stable behaviour traits. Evaluation of the psychometric properties revealed good internal consistency and adequate convergent and divergent validity measured by the "big five" derived from the NEO-FFI and the constructs impulsivity, venturesomeness, and empathy of Eysenck's impulsiveness questionnaire. We detected a remarkable correlation with the Wender Utah Rating Scale, which targets the detection of childhood ADHD symptoms. Diagnostic sensitivity for different cutoff points was calculated by ROC analysis at 65--88%. Specificity was 67% to 92%.

[Wender Utah rating scale. The short-version for the assessment of the attention-deficit hyperactivity disorder in adults]. / Wender Utah Rating Scale (WURS-k) Die deutsche Kurzform zur retrospektiven Erfassung des hyperkinetischen Syndroms bei Erwachsenen.

This work presents a statistical analysis of the German version of the Wender Utah rating scale (WURS) for the retrospective diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults. Data were obtained from 703 subjects. Item selection according to item-total correlation scores, frequency, and plausibility led to a short version of the scale that includes 21 items with item-total correlations from 0.19 to 0.61. Retest reliability of the WURS-k was r=0.9.

Children with comorbid attention-deficit-hyperactivity disorder and tic disorder: evidence for additive inhibitory deficits within the motor system.

For children with attention-deficit-hyperactivity disorder (ADHD) or tic disorder (TD), we recently reported deficient inhibitory mechanisms within the motor system by using transcranial magnetic stimulation. These deficits--stated as reduced intracortical inhibition in ADHD and shortened cortical silent period in TD--could be seen as neurophysiological correlates of motor hyperactivity and tics, respectively. To investigate neurophysiological aspects of comorbidity, we measured motor system excitability for the first time also in children with combined ADHD and TD. The findings of a reduced intracortical inhibition as well as a shortened cortical silent period in these comorbid children provide evidence for additive effects at the level of motor system excitability.

[Attention and hyperactivity disorder in children. Early detection--preventing social consequences]. / Aufmerksamkeits- und Aktivitätsstörung bei Kindern. Früh erkennen--soziales Abrutschen verhindern.

Attention deficit and activity disorder is characterized by impaired concentration, increased impulsiveness and motor restlessness. In a high percentage of cases, the symptoms persist into adulthood. Untreated victims have an increased risk of: failing to realize their full potential with regard to school-leaving performance, of developing substance dependence, of dissocial development, and of becoming more prone to accidents during leisure activity, in traffic and at work. The treatment strategies recommended in guidelines issued by the German societies of child and adolescent psychiatry are evidence-based and reliably effective.

A study of cranial computer tomograms in very early and early onset schizophrenia.

The cranial computer-assisted tomograms of 19 patients suffering from schizophrenic psychoses with onset by age of 14 were examined. The emphasis was on the extent of the inner liquor spaces. Compared to healthy controls, at the beginning of illness a significant enlargement was revealed only in the patient group with very early onset schizophrenia (VEOS, onset prior to the age of 12), whereas children with early onset (EOS, 12 to 14 years of age) showed no significant brain pathology. As a second result, an increase in the extent of the inner liquor spaces seems to correlate with the duration of illness. It is therefore concluded that psychoses interfere with neurodevelopmental processes and cause more severe brain pathology in very young children, already detectable at the onset of the illness. EOS, on the other hand, induces progressive morphological abnormalities over the course of the illness.

Dermatologic findings in anorexia and bulimia nervosa of childhood and adolescence.

The cutaneous signs of anorexia nervosa (AN) and bulimia nervosa (BN) have been described previously in adult patients. For the first time, we present here dermatologic findings in children and adolescents suffering from eating disorders. Thirty consecutive young anorexic and bulimic inpatients (8 to 17 years of age, mean 15.1 years) underwent a standardized dermatologic examination. Patients were checked for abnormalities of the skin including atopic stigmata, dermographism, hair, nails, and oral cavity. Serum was obtained for hemoglobin, iron, zinc, GPT, thyroid, and sex-hormone levels. In 13 patients, the total serum IgE was determined, and a prick test was carried out with defined type I allergens. Findings in order of frequency included xerosis of the skin, white dermographism, diffuse hypertrichosis, acrocyanosis, scars, diffuse effluvium, artifacts, brittle nails, and onychophagia. Significant co-relations were found between the presence of hypertrichosis and the existence of amenorrhea or a body mass index of less than 16. In 22 patients a low T3 level was found. In summary, children and adolescents suffering from AN or BN show dermatologic features similar to those reported in older patients. Special findings in this age group are extensive lanugo hair and signs of autoaggressive behavior.

[Assessment of the attention-deficit hyperactivity disorder in adults]. / Erfassung des hyperkinetischen Syndroms bei Erwachsenen.

The attention-deficit hyperactivity disorder (ADHD) is one of the most common disorders in childhood and adolescence with a prevalence of app. 5%. The importance of ADHD in childhood as a factor of vulnerability for psychiatric disorders in adults is becoming a focus of discussion. It was shown that there is a comorbidity in adults with substance abuse, delinquency and personality disorders. There is a growing evidence that ADHD will persist in a significant number of patients during adulthood. This is the first german study to evaluate this interdependence. We examined 164 adult inpatients and 48 healthy volunteers with the Wender Utah Rating Scale (WURS), a retrospective self-evaluation scale for the diagnosis of ADHD in childhood, and the Eysenck impulsiveness questionnaire I7. It could be shown that the WURS and the I7 are suitable instruments for the evaluation of the ADHD in adults especially concerning the aspects of attention deficits and impulsiveness.

[Hyperkinetic syndrome (attention deficit-/hyperactivity disorder) in adulthood]. / Das hyperkinetische Syndrom (Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung) des Erwachsenenalters.

The clinical picture of adult hyperkinetic syndrome (HKS) or attention deficit/hyperactivity disorder is nearly unknown in Germany. It can be estimated, that approximately one third of affected children also show symptoms as adults. In the combined type of the syndrome symptoms of inattention as well as of hyperactivity and impulsivity are present, a predominantly inattentive or hyperactive-impulsive type is possible. Retrospective diagnosis of HKS in childhood can be difficult. Disorganization, emotional disturbances and stress intolerance are common in adults with HKS as well as residual symptoms of learning disorders like dyslexia, dyscalculia and dysgraphia. In differential diagnosis especially affective, anxiety and antisocial personality disorders have to be considered, for which on the other side a frequent comorbidity with HKS is known. There is strong evidence for genetic transmission. Neurobiological findings revealed dysregulation of neurotransmitters. For treatment stimulants as pemoline and methamphetamin are effective, in addition tricyclic antidepressants or beta blockers; positive effects are probable for moclobemide, bupropion, fluoxetine and venlafaxine.

Comparison of total and regional body composition in adolescent patients with anorexia nervosa and pair-matched controls.

Body composition in 31 adolescent girls suffering from anorexia nervosa (AN) was measured at the time of hospitalization in order to assess the muscle/bone relationship as a potential source of the development of osteopenia. Differences in lean tissue, fat and bone mass in total body, weight bearing and non weight bearing limbs were estimated in AN and pair-matched controls aged 14.2 +/- 1.8 years (range: 9-17 years). Further, it was investigated if bone mineral density (BMD) better reflects the muscle/bone relationship than bone mineral content (BMC). At the distal radius parameters measured by peripheral quantitative computed tomography (pQCT) were used to estimate the association of volumetric bone density to bone strength and lean body mass. The correspondence to the same and different body regions was assessed. Total lean mass in the controls was closely related to total body bone mineral content (TBBMC), as was lean tissue and bone mass of the limb subregions (r = 0.82 to 0.93). In contrast, the correlation was significantly lower in AN (r = 0.33 to 0.77). In the controls, the pQCT-derived bone strength was correlated with muscle mass of the forearm (r = 0.78, p < 0.001), but only moderately in AN (r = 0.47, n.s.). Regional lean tissue was 11-20% and fat mass was 56-66% lower in AN (p < 0.01). After adjustment for height, TBBMC was different at p = 0.01. Within the limbs subregions, BMC (but not BMD) was different in both groups only in the upper arm and the thigh. BMC reflected the bone/muscle relationship better than BMD. Intra- and between group regressions gave no significant differences between weight bearing and non weight bearing limbs. In conclusion, the assessment of musculoskeletal factors may be a useful tool to develop individual preventive measures for therapy after recovery of our patients.

[Self-assessment of prescribing behavior of psychotropic drugs for children and adolescence. Results of a survey of established physicians]. / Selbsteinschätzung des Verordnungsverhaltens bei Psychopharmaka an Kindern und Jugendlichen. Ergebnisse einer Befragung von niedergelassenen Arzten.

All registered general practitioners, pediatricians, and neuropsychiatrists of lower franconia were asked to fill out a questionnaire regarding the ratio of 0-20 year old patients with psychiatric symptoms and their prescribing methods of psychopharmaca. Neuropsychiatrists treated less children and adolescents with psychiatric symptoms than pediatricians or general practitioners. Approximately 50% of the patients with psychiatric symptoms received psychopharmaca. The most frequently prescribed psychopharmaca were neuroleptics and antidepressants, followed by phytopharmaca with various ingredients, which were most frequently prescribed by general practitioners. The average duration of a psychopharmacotherapy was 9 weeks. A great deal of uncertainty regarding the prescription of psychopharmaca to children and adolescents has become evident. Despite the fact that an enuresis can not be diagnosed before the end of the 5th year, it was one of the most frequently treated symptom of the 2-5 year old children. On the other hand, approximately one third of all physicians principally do not treat children and adolescents with psychopharmaca.

[Children as witnesses of violence: consequences for determining reliability]. / Kinder als Zeugen von Gewalttaten: Konsequenzen für die Aussagefähigkeit.

For many years testimony by children was considered to be of little value. The authors of the present article do not share the view that the credibility of children should generally be questioned. Different investigations show that even young children are able to make forensically relevant depositions. The roles of developmental stage, memory and suggestibility of children are discussed in detail. A case report of a child who witnessed the murder of both parents demonstrates the importance of age-related aspects of emotional experience, development of memory and the ability of children to recall memories. Even at the first hearings it is important to establish a nonthreatening atmosphere in which the child can feel safe and protected. An experienced child and adolescent psychiatrist should be consulted early on.