Electroconvulsive therapy in children and adolescents in Europe-a systematic review of the literature complemented by expert information and guideline recommendations.

The first documented pediatric use of Electroconvulsive therapy (ECT) occurred in Europe in 1941. Since then, predominantly successful treatments and reasonable side effects have been reported in severely ill minors. Nevertheless, a shy reluctance determines the controversy about ECT in young patients. This study describes the use of ECT in children and adolescents in Europe. We systematically searched the literature concerning the practice of ECT in minors in all 53 European countries. In addition, we surveyed European experts about national practices and compared guidelines for ECT in minors. The search yielded 79 publications from 18 European countries, mainly from Western Europe, Israel, and Turkey. National data were available from eight countries. These showed an interestingly high relationship between the number of minors treated with ECT and the general use of ECT. No persistent deficits or deaths were reported. On the other hand, no randomized clinical trial was found, and many publications lacked relevant information. Accordingly, the appraisal of the evidence in the guidelines varies considerably. Experts from 13 European countries consistently reported infrequent and unsystematic use of ECT in minors. ECT has been used successfully in minors in Europe with reasonable complications and side effects. Adverse effects on the developing brain, as often suspected, have not been scientifically supported in eight decades. Nevertheless, the use of ECT in Europe is sparse and dependent on accidental circumstances. High-quality evidence is needed, as well as improved knowledge and training of child and adolescent psychiatrists.

Electroconvulsive Therapy in Children and Adolescents in Germany-A Case Series From 3 University Hospitals.

OBJECTIVE: Electroconvulsive therapy (ECT) is a well-established, safe, and efficacious treatment for severe psychiatric disorders. In children and adolescents, it is used much less frequently than in adults, likely because of a lack of knowledge. METHODS: We retrospectively analyzed all patients aged 12 to 17 years who completed a course of ECT at 3 psychiatric university hospitals in Germany between 2010 and 2020. Clinical Global Impression Severity (CGI-S) scores were assessed based on electronic medical records. Changes in CGI-S scores were assessed using a paired samples t test. Predictors for response and remission were assessed using binomial logistic regression. RESULTS: We included 32 patients. The CGI-S scores improved significantly from before to after ECT treatment (6.9 vs 3.9, t = 10.0, P < 0.01). A total of 40.6% of patients responded (CGI ≤ 3) and 21.9% remitted (CGI ≤ 2). The number of ineffective medication trials in the 6 months before ECT treatment was significantly associated with response (odds ratio, 0.54; P = 0.028) and remission (odds ratio, 0.31; P = 0.048). Five patients reported subjective cognitive adverse effects, 2 patients exhibited a prolonged seizure, 1 patient reported headaches, and 1 patient experienced a mild allergic reaction after anesthesia with etomidate. A total of 65.6% of patients experienced no adverse effects at all. CONCLUSIONS: This retrospective analysis found ECT to be effective and safe in children and adolescents irrespective of their main diagnosis. The reported data point to the importance of an early use of ECT for severe psychiatric diseases in child and adolescent psychiatry.

[Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany]. / Elektrokonvulsionstherapie im Kindes- und Jugendalter.

Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany Abstract. Abstract. Background: Electroconvulsive therapy (ECT) is a highly effective and well-researched therapy in adult psychiatry and has been successfully used especially as a treatment for severe depressive, catatonic, and psychotic disorders. Although severe disease progressions also occur in child and adolescent psychiatry, ECT is used much less frequently there. This may be because hardly any data have been collected on the use, effectiveness, and tolerability of ECT in child and adolescent psychiatric patients. This article outlines the application, effectiveness, and tolerability of ECT when applied to young adolescents in Germany. Methods: A retrospective survey on ECT in 29 patients under 18 years of age was conducted at three German university centers. All documented cases were recorded and evaluated for effectiveness and tolerability. In addition, a comprehensive PubMed-based database search was carried out. Results and conclusions: Internationally, there are no meta-analyses or randomized controlled studies and hardly any published cases on electroconvulsive therapy in German child and adolescent psychiatry. Our data on ECT show high efficacy in previously treatment-resistant and severely ill patients. Side effects occurred rarely. There was no evidence of differences between adults and adolescents in indication (depression, catatonia, schizophrenia), effectiveness, tolerability, and negative predictors of response to ECT. The results also suggest that the use of ECT in adolescents should be considered earlier in the treatment course.

[Comparison of Inpatients in Child Psychiatry in Rostock Between 1960 and 2015]. / Vergleich der stationären Kinderpsychiatrie 1960 und 2015 in Rostock.

Comparison of Inpatients in Child Psychiatry in Rostock Between 1960 and 2015 Since its beginnings, child psychiatry has been subject to permanent change due to social changes and thus different expectations of the field, developments in diagnostics, therapy and the respective classification systems. After 1949 Child and Adolescent Psychiatry in the German Democratic Republic (GDR) underwent an independent and somatically oriented development. Although assumed that there was systematic injustice in inpatient facilities of child psychiatry in the GDR, no study from this period has been published to our knowledge up to now. The work presented here begins to close this gap by comparing data from 1960 with current data (2015) of the Child and Adolescent Psychiatry Department at the Rostock Medical Center. Significant differences between results from 1960 and 2015 indicate a currently higher number of admissions, only half the length of stay, an alignment in the gender ratio, a trend towards adolescent patients, a shift away from the 1960 dominant intelligence impairment towards behavioural and emotional disorders, a higher proportion of children and adolescents treated with drugs, and more specialist follow-up treatments after the inpatient stay in 2015. We found no evidence of forced medication in 1960. The discussion also addresses the danger of a solitary development of child psychiatry away from a medical to a more social psychiatric, educational and therapeutic subject.

Feasibility of a Complex Setting for Assessing Sleep and Circadian Rhythmicity in a Fragile X Cohort.

INTRODUCTION: Sleep, circadian rhythms, (mental) health, and development are assumed to be intertwined. However, differentiated and reliable parameters of sleep and circadian rhythms are particularly difficult to assess for Fragile X (FXS) individuals. As those parameters need to be observed in complex settings, the feasibility of measurements for people with FXS was to be proven. Findings from this pilot study can inform further research and help to estimate sample sizes for future studies on FXS patients. METHODS AND SAMPLE: Nine individuals (male and female) with full mutation of the FMR1 gene were integrated in the study and underwent a complex measurement including actigraphy, sleep log, and 24-h saliva sampling in order to examine profiles of melatonin and cortisol, and a polysomnography. RESULTS: Seven actigraphy profiles, eight sleep logs, eight saliva profiles and seven polysomnographic data sets were collected. Complete data were analyzed for six individuals [mean age 14.87 years (SD 4.12), mean BMI 25.90 (SD 4.44)] were collected. No drop outs due to the constraints of the assessment were registered. DISCUSSION: All assessments and the setting in total were tolerated well by participants and caregivers. Procedures were adapted to individual needs of the participants. CONCLUSION: All its components and the setting in total are absolutely feasible in the specific population of FXS individuals. Losses during consenting and recruiting have to be planned as well as high amounts of interindividual variances have to be taken into account.

[Electroconvulsive Therapy - A beneficial and well tolerated therapy in children and adolescents with schizophrenia]. / Elektrokonvulsionstherapie ­ bei Kindern und Jugendlichen mit Schizophrenie wirksam und gut verträglich.

We report four cases of 12- to 17-year-old patients with schizophrenia, two of them suffering from catatonia, which were treated by ECT. Under a combined treatment with either ziprasidone or clozapine, and electroconvulsive therapy (ECT), they improved markedly. Severity and course of acute schizophrenia were evaluated by the Brief Psychiatric rating Scale (BPRS), severity and course of catatonia were evaluated with the Bush-Francis Catatonia Rating Scale (BFCRS). This article underlines the benefit, the safety and the tolerability of ECT in younger patients with schizophrenic disorders.

[Opioid maintenance treatment and Cannabis use]. / Opioidsubstitutionsbehandlung und Cannabiskonsum.

OBJECTIVES: More than 30 % of patients participating in an opioid maintenance program consume cannabis. This article describes the effects of additional cannabis use during an opioid maintenance treatment program. METHODS: Narrative literature research using online publication databases (MedLine, PubMed) RESULTS: The additional use of cannabis during an opioid maintenance treatment program may have negative side effects. CONCLUSION: Cannabis use should be discussed with the patient. It is in principle not a reason for discontinuing an opioid maintenance treatment program.

Differential relationships of PTSD and childhood trauma with the course of substance use disorders.

A large body of research documents the link between Posttraumatic Stress Disorder (PTSD) and the course of Substance Use Disorders (SUD). Similar relationships have been reported between Childhood Trauma (CT) and the course of illness in patients with SUD even in the absence of PTSD, but few studies have examined differential effects of PTSD and CT (independent of PTSD) in this population. We used the International Diagnostic Checklist (IDCL) and the Posttraumatic Diagnostic Scale (PDS) to diagnose PTSD in a sample of patients with SUD (N = 459). The Childhood Trauma Questionnaire (CTQ) and the European Addiction Severity Index (EuropASI) were administered to assess childhood trauma and addiction related problems including comorbid psychopathological symptoms. The sample was divided into three groups: patients with experiences of CT and PTSD (CT-PTSD), experiences of CT without PTSD (CT-only), and neither experiences of CT nor PTSD (No trauma) to examine their differential associations with the course and severity of SUD. Patients of both the CT-PTSD (n = 95) and the CT-only group (n = 134) reported significantly higher levels of anxiety and depression as well as more suicidal thoughts and suicide attempts during their lifetime than the No trauma group (n = 209). Regarding most variables a graded association became apparent, with the highest level of symptoms in the CT-PTSD group, an intermediate level in the CT-only group and the lowest level in the No trauma group. The CT-PTSD group also differed in almost all substance use variables significantly from the No trauma group, including a younger age at first use of alcohol and cannabis, more cannabis use in the last month, and more lifetime drug overdoses. Our results confirm the relationships of both CT and PTSD with psychiatric symptoms in patients with SUD. Thus, it seems important to include both domains into the routine assessment of SUD patients. Specific treatments for comorbid PTSD but also for other consequences of childhood trauma should be integrated into SUD treatment programs.

[Electroconvulsive Therapy (ECT) of a 15-year-old female patient suffering from a severe delusional depression: a case report]. / Fallbericht einer 15-jährigen Patientin mit einer schweren wahnhaften Depression, behandelt mit Elektrokonvulsionstherapie.

Electroconvulsive Therapy (ECT) of a 15-year-old female patient suffering from a severe delusional depression: a case report Abstract. OBJECTIVE: Electroconvulsive Therapy (ECT) is a modern therapy of severe psychiatric disorders. However, ECT is rarely used in treating children and adolescents with psychiatric disorders. This case report refers about a 15-year-old female patient suffering from severe depressive episodes with psychotic symptoms treated with ECT. METHOD: After unsuccessful combined behavioral therapy and medication, the patient received a total of 11 ECT treatments with right unilateral electrode placement. The severity of depressive symptoms was assessed by self (BDI-II) and external (HDRS21) scores before, during and after treatment. RESULTS: A rapid decline of depressive symptoms was observed. CONCLUSION: ECT provides a safe and effective method for the treatment of severe depressive disorders in childhood and adolescence and should be included earlier than usual into the standard therapeutic concepts.

Living in the Fast Lane: Evidence for a Global Perceptual Timing Deficit in Childhood ADHD Caused by Distinct but Partially Overlapping Task-Dependent Cognitive Mechanisms.

Dysfunctions in perceptual timing have been reported in children with ADHD, but so far only from studies that have not used the whole set of timing paradigms available from the literature, with the diversity of findings complicating the development of a unified model of timing dysfunctions and its determinants in ADHD. Therefore, we employed a comprehensive set of paradigms (time discrimination, time estimation, time production, and time reproduction) in order to explore the perceptual timing deficit profile in our ADHD sample. Moreover, we aimed to detect predictors responsible for timing task performance deficits in children with ADHD and how the timing deficits might be positively affected by methylphenidate. Male children with ADHD and healthy control children, all aged between 8 and 13 years, participated in this longitudinal study with three experimental sessions, where children with ADHD were medicated with methylphenidate at the second session but discontinued their medication at the remaining sessions. The results of our study reveal that children with ADHD were impaired in all timing tasks, arguing for a general perceptual timing deficit in ADHD. In doing so, our predictor analyses support the notion that distinct but partially overlapping cognitive mechanisms might exist for discriminating, estimating/producing, and reproducing time intervals. In this sense, working memory deficits in terms of an abnormally fast internal counting process might be common to dysfunctions in the time estimation/time production tasks and in the time reproduction task, with attention deficits (e.g., in terms of disruptions of the counting process) additionally contributing to time estimation/time production deficits and motivational alterations additionally contributing to time reproduction deficits. Methylphenidate did not significantly alter performance of the ADHD sample, presumably due to limited statistical power of our study. The findings of our study demonstrate a pivotal role of disturbed working memory processes in perceptual timing task performance in childhood ADHD, at the same time broadening the view for additional attentional and motivational determinants of impaired task performance.

[Pilot study of psychiatric and social aspects of children and adolescents with fragile X syndrome]. / Pilotstudie zu psychiatrischen und sozialen Aspekten bei Kindern und Jugendlichen mit Fragilem-X-Syndrom (FRX).

Objective: The study describes the burden of psychosocial risks of mental illnesses and the ways in which children and adolescents with fragile X syndrome (FRX) can be treated. Method: Data from a sample of 34 patients with FRX younger than 18 years stemming from a prospective multicenter (n = 11) registry study (EXPLAIN) were analyzed with regard to psychosocial burden and Treatment. Results: One third of all participants reported having relatives who suffer from FRX. The majority of participants were suffering themselves from one kind or another mental or neurological problems. Younger participants (< 14 years) tended to suffer from atactic disorders, epileptic seizures, and autistic symptoms. These disorders were usually treated by psychotropic drugs supplemented by logopedic therapies and occupational therapies (more than once a month). In our sample, 96.3 % of the younger patients and more than 57.1 % of the older patients were still living with their parents. Conclusions: Patients with FRX often suffer from additional neurological and mental disorders. For that reason, they should be diagnosed and treated early on.

Relationships between a Dissociative Subtype of PTSD and Clinical Characteristics in Patients with Substance Use Disorders.

The increasing support for a dissociative subtype of post-traumatic stress disorder (PTSD-D) has led to its inclusion in DSM-5. We examined relationships between PTSD-D and relevant variables in patients with substance use disorders (SUD). The sample comprised N = 459 patients with SUD. The International Diagnostic Checklist and the Posttraumatic Diagnostic Scale were used to diagnose PTSD. In addition, participants completed the Childhood Trauma Questionnaire and the Dissociative Experiences Scale. The course of SUD was assessed by means of the European Addiction Severity Index. One-fourth of participants fulfilled a diagnosis of PTSD (25.3%). Patients with PTSD-D (N = 32, 27.6% of all patients with PTSD) reported significantly more current depressive symptoms, more current suicidal thoughts, more lifetime anxiety/tension, and more suicide attempts. The PTSD-D group also showed a significantly higher need for treatment due to drug problems, higher current use of opiates/analgesics, and a higher number of lifetime drug overdoses. In a regression model, symptoms of depression in the last month and lifetime suicide attempts significantly predicted PTSD-D. These findings suggest that PTSD-D is related to additional psychopathology and to a more severe course of substance-related problems in patients with SUD, indicating that this group also has additional treatment needs.

[A Multi-arm Placebo-controlled Study with Glutamic Acid Conducted in Rostock in 1953/1954]. / Eine Rostocker Placebo-kontrollierte mehrarmige Studie mit Glutaminsäure bei Kindern und Jugendlichen 1953/54.

A Multi-arm Placebo-controlled Study with Glutamic Acid Conducted in Rostock in 1953/1954 Glutamic acid was commonly used in the treatment of intellectually disabled children in the 50s. Koch reported first results of an observation of 140 children treated with glutamic acid in 1952. In this line is the multi-arm placebo-controlled study reported here. The original study protocols were available. 58 children with speech problems who attending a school of special needs received glutamic acid, or vitamin B, or St.-John's-wort. The effect of glutamic acid was in few cases an improvement of attention. On the other hand restlessness and stutter increased. The majority of all reported a weight loss. The treatment with vitamin B showed a positive effect concerning concentration. The treatment with St.-John's wort was stopped caused by headache and vomiting in eight of nine cases. The results of the study reported here are unpublished. The reason may be that until the 60s the effects of glutamic acid in the treatment of intellectually disabled children were in generally overestimated.

[Psychiatric and Social Aspects of Patients with Fragile X Syndrome]. / Psychiatrische und soziale Aspekte bei Patienten mit fragilem X-Syndrom (FRX).

OBJECTIVE: The goal of the study was to describe the burden of psychosocial risks, of mental illnesses and the ways of treatment of patients with fragile X syndrome (FRX). METHOD: Data from a sample of 46 FRX-patients stemming from a prospective multicenter (N = 12) registry study (EXPLAIN) were analyzed with regard to psychosocial burden and treatment. RESULTS: More than 50 % of all participants reported about relatives suffering from FRX, too. The majority of participants did not finish school and was suffering from one or another kind of mental problems. Younger participants (< 18 yrs.) tended to suffer from expansive disorders. Older participants were rather burdened by internalizing symptoms and disorders. Disorders were usually treated by psychotropic drugs added by logopedic therapies and occupational therapies (more than once a month). In our sample 90.6 % of younger and more than 64.3 % of older patients were still living with their parents. CONCLUSIONS: Patients with FRX often suffer from additional mental disorders and should be diagnosed and treated early.

A case of catatonia in a 14-year-old girl with schizophrenia treated with electroconvulsive therapy.

This article presents a case of a 14-year-old female twin with schizophrenia who developed severe catatonia following treatment with olanzapine. Under a combined treatment with amantadine, electroconvulsive therapy (ECT), and (currently) ziprasidone alone she improved markedly. Severity and course of catatonia including treatment response were evaluated with the Bush-Francis Catatonia Rating Scale (BFCRS). This case report emphasizes the benefit of ECT in the treatment of catatonic symptoms in an adolescent patient with schizophrenic illness.

Modified magnesium and lipoproteins in children with attention deficit hyperactivity disorder (ADHD).

OBJECTIVE: Polyunsaturated fatty acids (PUFAs) have shown to be helpful in the therapy of ADHD. Various stabilizing co-factors may contribute to this effect, as like magnesium (Mg). Mg supports fatty acid enzyme activity and is essential for the neuronal activity. However, the way of Mg to influence psychic processes, particularly in ADHS, is not yet known precisely. Therefore, in this study the concentrations of further lipid parameters were assessed. We intended to prove, if there is a lack of Mg and someone different lipoprotein concentration in ADHD patients compared to controls. METHODS: In nine boys with ADHD (8.2 ± 0.6 years) and 11 controls (7.9 ± 0.87 years), blood serum Mg, total cholesterol, triglycerides, Lipoprotein Lipase, total Phospholipids, Apolipoproteins a and b, HDL- and LDL-cholesterol were measured, under two different stressful conditions. RESULTS: In ADHD, Mg and HDL concentrations were significantly higher and Apob lower than in controls. CONCLUSIONS: Contrary to our supposition, in ADHD was no lack, but an excess of Mg. HDL was hightened and Apob lowered. Lipoprotein metabolism seems to be modified in ADHD.

Childhood trauma and dissociation in patients with alcohol dependence, drug dependence, or both-A multi-center study.

BACKGROUND: The aims of this study were to examine the level of dissociative symptoms in patients with different substance related disorders (alcohol dependence, drug dependence, and combined alcohol and drug dependence), and to investigate the influence of potentially traumatic events in childhood, age, gender, and posttraumatic stress disorder on the relationship between dissociative symptoms and type of substance abuse. METHODS: Of the 459 participants (59.7% male) 182 (39.7%) were alcohol-dependent (A), 154 (33.6%) were drug-dependent (D), and 123 (26.8%) were dependent on both, alcohol and drugs (AD) based on the DSM-IV criteria for a current diagnosis. Participants completed the Childhood Trauma Questionnaire (CTQ) and the Dissociative Experiences Scale (DES). The International Diagnostics Checklist (IDCL) was administered to diagnose PTSD. RESULTS: Higher levels of dissociation were observed in patients with drug dependence as compared to patients with mere alcohol dependence (mean DES group A: 9.9+/-8.8; group D: 12.9+/-11.7; group AD: 15.1+/-11.3). However, when severity of potentially traumatic events in childhood, PTSD, age and gender were included in the analysis, the influence of the type of substance abuse did not prove to be statistically significant. The variable most strongly related to dissociative symptoms was severity of potentially traumatic events in childhood, in particular emotional abuse, even after controlling for PTSD and other potential confounders. CONCLUSIONS: It seems appropriate to screen SUD patients for dissociative symptoms, especially those with a more complex risk profile including (additional) drug abuse, female gender, younger age and most importantly a history of childhood trauma.

[The problem of differentiating between sudden infant death syndrome, fatal Munchausen's syndrome by proxy, and infanticide]. / Unterscfliede und Gemeinsamkeiten zwischen plötzlichem SäugIingstod (SIDS), Münchhausen-Syndrom by proxy (MSBP) mit tödlichem Ausgang und Infantizid.

INTRODUCTION: Sudden infant death syndrome (SIDS) is the most common type of post-neonatal death in infants under 1 year of age. It is defined as the sudden death of an infant that is unexpected on the basis of the child's history and unexplained by a thorough post-mortem examination. The incidence of SIDS in Germany has fallen from 1.7 per 1000 live births in 1990 to 0.62 in 2000. In the U.K. the incidence was 0.56 in 1998. According to the literature, 5 to 11 percent of deaths recorded as SIDS may be disguised homicides. These homicides can be caused by a Munchausen's syndrome by proxy (MSBP). Munchausen's syndrome by proxy is defined as an extreme form of abuse wherein the caregivers produce symptoms of illness in a child by means of internal or by external manipulation. Using case reports, this paper examines some difficulties in differentiating between SIDS, MSBP, and homicide. CASE REPORT: In a family with three children, the youngest daughter died suddenly of suffocation at the age of 17 months. Before her death, the child had been admitted 11 times to different hospitals for various reasons. The mother reported that her daughter was admitted for epileptic seizures, suffocation attacks, and diarrhoea. No noticeable organic signs or symptoms were found during the child's stays in a hospital. The girl was discharged each time without symptoms and without a clear-cut diagnosis. Toxicological analysis of the blood revealed the presence of caffeine. Clinically, an accidental death appeared to be unlikely. CONCLUSIONS: When assessing cases of SIDS, a MSBP, or homicide, practitioners should be on the lookout for recurrent symptoms of illness, repeated hospitalisation and/or consultation of physicians, multiple diagnostic procedures without establishment of a clear-cut diagnosis, a certain resistance to therapy, illness or unnatural death of siblings, and repeated signs of poisoning or suffocation. Differentiation between SIDS, MSBP, and homicide should be extensive and done with great care since the legal consequences differ vastly according to the facts of the matter.