Predictors of length of stay in inpatient child and adolescent psychiatry: failure to validate an evidence-based model.

OBJECTIVE: To test if predictors of length of stay are based on empirical evidence. METHOD: 1001 regularly terminated treatment episodes from 13 child and adolescent psychiatric hospitals were analysed. In order to cross- validate the results, the sample was randomly divided into a definition sample (n = 500) and a validation sample (n = 501). The variables in the definition sample were screened statistically for their suitability as predictors of logarithmic length of stay (logLOS). Variables shown to be significant and uncorrelated were entered into multifactor analyses of variance in order to generate the model with the largest amount of explained variance of logLOS. Subsequently the results were tested against the validation sample. RESULTS: In the definition sample we found the three predictor variables admission as crisis intervention, out of home dispositions and psychoanalytic therapy which could explain 23.7 % of the variance of logLOS. Unfortunately, this could not be replicated in the validation sample as a model. CONCLUSION: Simple models of prediction of LOS in the field of child and adolescent psychiatry cannot be reliably based on empirical evidence. The main consequence is that fixed disorder-related reimbursement systems do not seem justified.

[Repeated suicide attempts by children and adolescents--results of a retrospective study]. / Wiederholungen von Suizidversuchen durch Kinder und Jugendliche--Ergebnisse einer retrospektiven Studie.

Children and adolescents who had attempted suicide once are at higher risk for further suicide attempts. In order to better identify those likely to make a further suicide attempt, they were compared at the time of their first suicide attempt with those who had only attempted suicide once. The details of all children and adolescents who had attempted suicide and been treated as inpatients or outpatients in the University Hospital in Göttingen, Germany, over a 10-year period were collected by file-analysis. Sociodemographic characteristics, stresses that preceded the suicide attempts and the chosen methods of attempted suicide were ascertained. 55 male und 116 female subjects had attempted suicide once, 17 male and 79 female subjects had attempted suicide more than once. Those with repeated suicide attempts were younger at the time of their first suicide attempt at 14 years and eight months, than those who did not make a repeat attempt, at 15 years and 7 months. Male repeaters more often experienced conflicts with their parents. Female repeaters were suffering more from emotional or chronic physical diseases and more often drank alcohol in connection with their first suicide attempt. Paediatricians, who are often the first to be confronted with suicide attempts by young people, should work towards providing psychotherapeutic support especially for children and younger adolescents with the particular stresses described.

Male adolescent sex offenders against children: similarities and differences between those offenders with and those without a history of sexual abuse.

This study compares a defined sample of male adolescents (n = 36) with regard to their personal development, family characteristics and the types of offence they committed. Adolescent sex offenders with (n = 16) and without (n = 20) a history of sexual abuse who had offended against children were investigated during ongoing criminal proceedings by means of questionnaires and intelligence tests. The most important characteristic that distinguishes the two groups from each other is the more frequent absence of the parents of adolescents who committed sexual offences against children and had a history of sexual abuse. The consequences to be drawn from these results with regard to aggressive sexual delinquency in adolescence are discussed and suggestions are made with regard to further avenues of investigation.

[Comparison of suicide attempts by male and female adolescents. Results of a 10-year patient population of a child and adolescent psychiatry clinic]. / Suizidversuche durch männliche und weibliche Jugendliche im Vergleich. Ergebnisse einer 10-Jahres-Inanspruchnahmepopulation einer Klinik für Kinder- und Jugendpsychiatrie.

OBJECTIVE: This study examines the way in which suicide attempts differ between male and female adolescents. METHODS: The characteristics of 173 female and 62 male adolescents who were treated at a clinic for child and adolescent psychiatry over a period of 10 years were investigated. RESULTS: Suicide attempts by adolescents in the patient population did not decrease in accordance with suicides in the same age-group among the general population. Male adolescents more often attempted suicide in a place where they were less likely to be discovered, but did not use a "harsher" method than female adolescents. The diagnosis rendered according to ICD-10 in 36% of cases was not always typical for the respective sex. CONCLUSIONS: The ways in which adolescents attempt suicide have clearly changed over the past years. Diagnoses that are untypical for the respective sex may represent a risk factor.

[Development of child guidance clinics in Germany--an overview]. / Entwicklung der Erziehungsberatungsstellen in der Bundesrepublik Deutschland--ein Uberblick.

The development of child guidance centres began before 1910 with single institutions characterized by various subject areas (medicine, pedagogy, psychology) as well as by the connection of counselling and therapeutic treatments. Since about 1920 it has become customary to call such institutions child guidance centres. A consistent development lead to the fact that in the Child and Adolescent Aid Law of 1990 child guidance centres are called institutions which are capable of handling different problems with a multi-professional staff and various methods, and offering counselling and treatments as required. People seeking advice shall be able to contact child guidance centres directly of their own free will.

[Variability of inpatient child and adolescent psychiatry--results of a multicenter documentation]. / Variationsbreite stationärer Kinder- und Jugendpsychiatrie--Ergebnisse einer multizentrischen Dokumentation.

OBJECTIVE: For the first time in the German-speaking countries a complete evaluation of all 1236 inpatient treatment episodes within one year of investigation was carried out. METHOD: Case-related patient documentation at all of the 13 clinics for child and adolescent psychiatry in Lower Saxony and Bremen were evaluated. RESULTS: Data from all clinics agreed widely on the following: 1. the divergent family structures of the young patients compared to those of the general public, 2. a high degree of individual psychotherapy, and 3. the inclusion of the patient's social circumstances in the individual psychotherapy. Nonetheless, results for most of the variables assessed differed strongly. Inpatient child and adolescent psychiatric care thus seems to vary highly among clinics within the same epidemiological area. CONCLUSIONS: Hence, even when the reported number of episodes is high, no general conclusions on inpatient child and juvenile psychiatric treatment can be drawn on the basis of admissions data for individual clinics. Interinstitutional comparisons must be made on the assumption that there is no prototype clinic for child and adolescent psychiatry. Additional general conclusions include the lack of a disorder-specific approach to treatment. The entry of a large number of patients into foster or state homes following inpatient treatment reflects the impact upon them of abnormal psychosocial circumstances, as well as their decreased psychosocial adaption.

[Modification of rehabilitation possibilities by psychiatric disorders. Concepts and explanations in implementing section 35 of the child and adolescent welfare regulation]. / Beeinträchtigungen der Eingliederungsmöglichkeiten durch psychische Störungen. Begrifflichkeiten und Klärungserfordernisse bei der Umsetzung von section 35 a des Kinder- und Jugendhilfegesetzes.

Giving integration assistance to children and youths whose chances of integration are longterm impaired due to the effects of mental disturbances require that the helping systems involved--especially the youth aid of children and youth psychiatrics (as a part of the health services)--cooperate. This presupposes that the terms and procedures have been clarified as discussed in this article.

[Rules of specialty skills in psychosocial counseling of children, adolescence and parents]. / Zu den Regeln des fachlichen Könnens in der psychosozialen Beratung von Kindern, Jugendlichen und Eltern.

This article is a revised version of a short expert opinion of the Ministry of Work, Health and Social Matters of the state of North Rhine-Westphalia (West Germany) dealing with the rules of expert skills in educational counselling. After the attempt of clarifying terms (consultation, therapy, medicine) the processes of consultation and treatment are described in general as influencing in a communicative way, whereby common qualitative characteristics are pointed out. The author also goes into taking ethical principles into consideration, possibilities of preventive effectiveness and consequences for education and further training of experts working in educational counselling facilities.

[Inpatient and partial hospitalization facilities for child and adolescent psychiatry in the unified Germany, 1991]. / Stationäre und teilstationäre Einrichtungen für Kinder- und Jugendpsychiatrie im vereinten Deutschland 1991.

First results of the project "Surveys regarding the structure of psychiatric institutions for children and adolescents in the Federal Republic of Germany" are described. On July 1, 1991 there were 111 in-patient institutions with a total capacity for 6363 children and youths. The contributing shares of each state (Bundesland) vary enormously. The number of accommodations per 100,000 residents is between 2.1 and 19. One reason for this discrepancy lies in the fact that the services of the institutions are called upon without regard to the state borders. More important though is the fact that in the new states the psychiatric institutions for children and youths also treat young patients who are psychologically or mentally handicapped with neuropsychiatric complications to a greater extent than comparable institutions in the old states.

[Child and adolescent psychiatry--how, where, for whom? Questions on medical care and medical care research]. / Kinder- und Jugendpsychiatrie--wie, wo, für wen?--Fragen der Versorgung und Versorgungsforschung.

Regarding the question of child psychiatry--how, where, for whom? research of medical care can provide some answers, which are referred to here. However, many questions regarding epidemiology and research of structure, use and development remain open. Because of constant urgency to take action provisional situations have to be accepted, processes have to be attended to, statements have to be examined concerning their validity and theories concerning their range.

[Collaboration of the involved psychosocial systems in the management of children and adolescents with psychiatric disorders]. / Die Zusammenarbeit der beteiligten psychosozialen Systeme bei der Versorgung psychisch gestörter Kinder und Jugendlicher.

Described and discussed here are the concrete need for professional help for children and juveniles with psychological problems as well as support systems and their institutions. The necessity of cooperation between systems and institutions is explained, and the obstacles to and problems involved in such cooperation are outlined. The attitudes toward cooperation held by professionals and the expectations and views of those in need of help are compared.

[Anorexia nervosa and Down syndrome]. / Anorexia nervosa und Down Syndrom.

This article reports on a 24-year-old woman patient with anorexia nervosa and Down's syndrome. Following examination of previous case studies on the simultaneous occurrence of these illnesses, the authors make a further contribution to the controversial discussion of whether primary anorexia can occur at all in the mentally retarded or whether it should not rather be considered an anorectic reaction related to other disorders, e.g. depressive disturbances.

[Foster care placement and self determination]. / "Fremdplazierung" und Selbstbestimmung.

Tension exists between the reality of outside placement and the tendency toward self-determination. The importance of this tension is examined by way of the history of outside placement, the current practice of outside placement, and the experience of the children involved; the relationship to protective conditions is also examined.

[Effects of pentoxifylline on diastolic heart function in patients with angina pectoris and an increased left ventricular wall mass]. / Die Wirkung von Pentoxifyllin auf die diastolische Herzfunktion bei Patienten mit Angina pectoris und linksventrikulärer Wandmassenvermehrung.

The combination of coronary heart disease (CHD) with increased left ventricular wall mass (LVWM) appears associated with prolonged isovolumetric relaxation (IVR) and consequently, alterations in the rapid filling phase. Methylxanthine-substances may improve relaxation through inhibition of phosphodiesterase activity. Accordingly we examined multiple indexes of left ventricular diastolic function before and after administration of 200 mg pentoxifylline (Trental) intravenously to 18 patients (51.3 +/- 9.0 years, 15 males, three females) with stable angina pectoris and positive exercise-ECG in NYHA class I or II and LVWM greater than 160 g (n = 9) and less than or equal to 160 g (n = 9). Left ventricular pressure (P) and volume (V) measurements were made with a high-fidelity-micromanometer before and twelve minutes after administration of pentoxifylline. The time constant of left ventricular isovolumic relaxation (T), usual global left ventricular volumes and derived indexes such as peak filling rate (PFR), time to peak filling rate (TPFR), segmental (relaxation and rapid filling phases) and total pressure-volume relationship before and after pentoxifylline were calculated. Significant differences between these two groups (greater than/less than or equal to 160 g LVWM) were found for end-diastolic volume (68.7 +/- 19.0 to 90.8 +/- 22.6 ml/sqm), end-systolic volume (21.7 +/- 16.0 to 36.1 +/- 14.7 ml/sqm), end-diastolic pressure (15.0 +/- 4.8 to 15.7 +/- 5.1 mm Hg), PFR (3.25 +/- 1.18 to 2.66 +/- 0.71 s-1), T (46.0 +/- 5.7 to 52.7 +/- 7.2 ms), the linear regression of lnP-V (lny = -0.117 x + 4.59 to lny = -0.091 x + 4.75) in the IVR-phase (dp/dtmin less than or equal to x less than or equal to 80 ms) (leftward shift in p-V-relationship when less than or equal to 160 g) and the complet p-V-areas. After pentoxifyl-line-administration there were significant decreases in T in patients with increased LVWM (52.7 +/- 7.2 to 47.7 +/- 5.9 ms) and the P-V-product over the time in the rapid filling phase in patients with LVWM less than or equal to 160 g. Total peripheral resistance and heart rate did not change. These changes in parameters of left ventricular diastolic function in combination with significant improvement of pump function especially in patients with LVWM greater than 160 g after administration of pentoxifylline suggest that improved diastolic function is the result of a direct myocardial effect of pentoxifylline.