[Recommendations for the Strategic Development of Health Care for People with Autism Spectrum Disorder (ASD) in Bavaria]. / Empfehlungen zur strategischen Entwicklung der gesundheitlichen Versorgung für Menschen mit Autismus-Spektrum-Störung (ASS) in Bayern.

As mental illnesses Autism spectrum disorders (ASD) in DSM-V and ICD - 11 are classified under the category of neuronal and mental disorders. ASD manifests itself them selves in early childhood. A valid, early diagnosis is a basic prerequisite for the provision of appropriate treatment and support services as well as any care planning in all relevant areas such as therapy and early intervention. On the basis of a participatory, scientific developmental process for the formulation of recommendations for the first Bavarian ASD strategy from 2018 to 2021, principles, goals, fields of action and measures for optimizing the care for people with ASD and their relatives were defined. It became clear that there is a need, in particular, to raise awareness of ASD, further generation and provision of knowledge about ASD, expansion of specialized services for early detection, counseling and diagnostics, as well as comprehensive access to early support and therapy.

Honest, Open, Proud for adolescents with mental illness: pilot randomized controlled trial.

BACKGROUND: Due to public stigma or self-stigma and shame, many adolescents with mental illness (MI) struggle with the decision whether to disclose their MI to others. Both disclosure and nondisclosure are associated with risks and benefits. Honest, Open, Proud (HOP) is a peer-led group program that supports participants with disclosure decisions in order to reduce stigma's impact. Previously, HOP had only been evaluated among adults with MI. METHODS: This two-arm pilot randomized controlled trial included 98 adolescents with MI. Participants were randomly assigned to HOP and treatment as usual (TAU) or to TAU alone. Outcomes were assessed pre (T0/baseline), post (T1/after the HOP program), and at 3-week follow-up (T2/6 weeks after T0). Primary endpoints were stigma stress at T1 and quality of life at T2. Secondary outcomes included self-stigma, disclosure-related distress, empowerment, help-seeking intentions, recovery, and depressive symptoms. The trial is registered on ClinicalTrials (NCT02751229; http://www.clinicaltrials.gov). RESULTS: Compared to TAU, adolescents in the HOP program showed significantly reduced stigma stress at T1 (d = .92, p < .001) and increased quality of life at T2 (d = .60, p = .004). In a longitudinal mediation model, the latter effect was fully mediated by stigma stress reduction at T1. HOP further showed significant positive effects on self-stigma, disclosure-related distress, secrecy, help-seeking intentions, attitudes to disclosure, recovery, and depressive symptoms. Effects at T1 remained stable or improved further at follow-up. In a limited economic evaluation HOP was cost-efficient in relation to gains in quality of life. CONCLUSIONS: As HOP is a compact three-session program and showed positive effects on stigma and disclosure variables as well as on symptoms and quality of life, it could help to reduce stigma's negative impact among adolescents with MI.

Fostering socio-emotional competencies in children on the autism spectrum using a parent-assisted serious game: A multicenter randomized controlled trial.

OBJECTIVE: Serious games are a promising means of fostering socio-emotional skills in children on the autism spectrum (AS). However, empathy and related constructs have not yet been addressed comprehensively and together with emotion recognition, and there is a lack of randomized controlled trials (RCT) to investigate skill maintenance and the transfer to functional behavior. METHOD: The manualized, parent-assisted serious game Zirkus Empathico (ZE) was tested against an active control group, in a six-week multicenter RCT. Eighty-two children aged 5-10 years on the AS were assessed at baseline, post-treatment, and three-month follow-up. Empathy and emotion recognition skills were defined as the primary outcomes. The secondary outcomes included measures of emotional awareness, emotion regulation, autism social symptomatology (Social Responsiveness Scale), and subjective therapy goals. RESULTS: Training effects were observed after the intervention for empathy (d = 0.71) and emotion recognition (d = 0.50), but not at follow-up. Moderate effects on emotional awareness, emotion regulation, and autism social symptomatology were indicated by the short and mid-term assessments. Parents reported treatment goal attainment and positive training transfer. CONCLUSION: While a six-week training with ZE failed to induce lasting changes in empathy and emotion recognition, it may be effective for improving emotional awareness and emotion regulation, and mitigate general autism symptomatology. CLINICAL TRIAL REGISTRATION INFORMATION: Zirkus Empathico - Promoting socioemotional competencies in 5- to 10-year-old children with autism spectrum conditions using a computer-based training program; https://www.drks.de/; DRKS-ID: DRKS00009337; Universal Trial Number (UTN): U1111-1175-5451.

Asperger's syndrome and high-functioning autism: language, motor and cognitive profiles.

The objective of this study is to compare the cognitive profile, the motor and language functioning and the psychosocial adaptation of children with Asperger syndrome (AS) and with high-functioning autism (HFA). Subjects were recruited through the department Autism and Developmental Disorders of the Heckscher-Klinikum. To be included in the study, the full-scale-IQ had to be at least 80. Subjects with AS had to have a normal early language development and subjects with HFA a clear delay in language development, as reported by their parents. The sample consisted of 57 children with Asperger syndrome and 55 children with high-functioning autism. The mean age of the children was 10 years. All subjects were examined with a standardised test battery. Children with AS had a higher full-scale-IQ than children with HFA. This was due to a higher verbal-IQ. There were no significant differences in the performance-IQ. At a mean age of 10 years, subjects with AS had better language skills than subjects with HFA, but at least 30% showed clear receptive language problems. Motor problems were present in about 50% of the children with AS and HFA. The level of psychosocial adaptation was clearly reduced, but was comparable for the two groups. The differences in verbal-IQ and language skills between the two groups could be explained through the definition of the syndromes. The presence of language problems in the subjects with AS at age 10, the comparable degree of motor impairment and level of psychosocial adaptation question the validity of the distinction between AS and HFA within the category of pervasive developmental disorders.

[Comorbidity in autism spectrum disorders - I. Mental retardation and psychiatric comorbidity]. / Begleitsymptomatik bei tief greifenden Entwicklungsstörungen.

OBJECTIVE: Recent epidemiological surveys show a higher prevalence of autism spectrum disorders than was to be expected based on the first studies in this field. The objective of our study is to analyse the frequency of mental retardation and co-morbid psychiatric disorders and symptoms in a large clinical sample of patients with pervasive developmental disorders. METHOD: The sample consists of all patients (N = 601) with a pervasive developmental disorder diagnosed at the Department of Developmental Disorders at the Heckscher-Klinikum. For all patients the level of intellectual functioning was measured. In addition to psychiatric diagnoses, we also recorded intervention-relevant symptoms such as eating and sleeping problems, and auto-aggressive behavior on Axis I, as well as psychosocial impairments and level of psychosocial functioning on Axes V and VI. RESULTS: 26% of the patients functioned on a normal intellectual level (N = 58). 54% of the patients (N = 325) had at least one additional psychiatric diagnosis, and 19% (N = 110) had two additional diagnoses. The most frequent diagnoses were externalizing disorders (N = 221). Internalizing disorders (N = 96), as well as other disorders (N = 114) were about equally frequent. Auto-aggressive behavior occurred more often among children with severe mental retardation than in children of normal intelligence. There was a significant association between the presence of (auto-)aggressive behavior as well as externalizing diagnoses and the level of psychosocial functioning. CONCLUSIONS: Children with pervasive developmental disorders show a wide variety of co-morbid problems, which are relevant for the treatment and the course of the disorder. The presence of externalizing behaviors is an additional burden on the development of these children.

[Comorbidity in autism spectrum disorders - II. Genetic syndromes and neurological problems]. / Begleitsymptomatik bei tief greifenden Entwicklungsstörungen.

OBJECTIVE: Children with a pervasive developmental disorder show in addition to core symptoms a variety of genetic syndromes as well as neurological problems, which are relevant for the treatment and the course of the disorder. The objective of our study is to analyse the nature and the frequency of these co-morbid somatic disorders in relation to the level of intellectual functioning of the patients. METHOD: The sample consists of 601 patients with a pervasive developmental disorder diagnosed at the Department of Developmental Disorders at the Heckscher-Klinikum between 1997 and 2007. In addition to genetic syndromes, we also recorded a variety of neurological disorders. RESULTS: 373 of the patients (62%) had at least one additional diagnosis and 121 (20%) had at least two additional diagnoses on Axis IV of the multi-axial classification scheme. Genetic syndromes were found in 6% of the patients (N = 37). Movement disorders (N = 214; 35.6%) and epilepsy (N = 98; 16.3%) were the most frequent neurological disorders. Children with mental retardation showed significantly more somatic diagnoses than children without mental retardation. CONCLUSIONS: Children with pervasive developmental disorders show a wide variety of co-morbid somatic problems, which are relevant for the treatment and the course of the disorder. Children with autism and mental retardation show more co-morbid conditions and are more impaired in their psychosocial adaptation than children with autism without mental retardation.

[Psychiatric disorders and neurological comorbidity in children with intellectual disability]. / Psychiatrische Störungen und neurologische Komorbiditäten bei Kindern und Jugendlichen mit Intelligenzminderung.

INTRODUCTION: This article gives an overview of the consultant child and adolescent psychiatric services in the region of Upper Bavaria (Germany). METHOD: The data of 257 children and adolescents with intellectual disability and psychiatric disorders were evaluated. RESULTS: About 14% of the children with ID in special schools or day care centers, and 40% of the children with ID in residential care showed a definite psychiatric disorder. The most frequently diagnosed disorders were adjustment disorders, hyperkinetic disorders and conduct disorders, as well as emotional problems and pervasive developmental disorders. Children with severe intellectual disability had more additional somatic disorders and were more impaired in their psychosocial functions. CONCLUSIONS: The results show the need for psychiatric services for children and adolescents with intellectual disability and psychiatric disorders. The development and implementation of integrative and interdisciplinary models is necessary to allow for adequate medical care for these patients.

Study protocol of the multi-centre, randomised controlled trial of the Frankfurt Early Intervention Programme A-FFIP versus early intervention as usual for toddlers and preschool children with Autism Spectrum Disorder (A-FFIP study).

BACKGROUND: Naturalistic developmental behavioural interventions (NDBI) have been shown to improve autism-specific symptoms in young children with Autism Spectrum Disorder (ASD). NDBI approaches, such as the ASD-specific Frankfurt Early Intervention Programme for ASD (A-FFIP), are based on ASD-specific developmental and learning aspects. A-FFIP is a low-intensity intervention which can easily be implemented in the local health care/social welfare system. The aim of the present study is to establish 1-year efficacy of the manualised early intervention programme A-FFIP in toddlers and preschool children with ASD. It is hypothesised that A-FFIP will result in improved ASD-specific symptoms compared to early intervention as usual (EIAU). Child- and family-specific secondary outcomes, as well as moderators and mediators of outcome, will be explored. METHODS/DESIGN: A prospective, multi-centre, parallel-group, randomised controlled, phase-III trial comparing A-FFIP versus EIAU. A total of 134 children (A-FFIP: 67, EIAU: 67) aged 24-66 months at baseline assessment meeting the criteria for ASD (DSM-5) will be included. The primary outcome is the absolute change of the total score of the Brief Observation of Social Communication Change (BOSCC-AT) between baseline (T2) and 1-year follow-up (T6). The treatment effect will be tested, adjusted for relevant covariates applying a mixed model for repeated measures. Secondary outcomes are BOSCC social communication and repetitive-behaviour scores, single ASD symptoms, language, cognition, psychopathology, parental well-being and family quality of life. Predictors, moderators and mediating mechanisms will be explored. DISCUSSION: If efficacy of the manualised A-FFIP early intervention is established, the current study has the potential to change clinical practice strongly towards the implementation of a low-intensity, evidence-based, natural early intervention in ASD. Early intervention in ASD requires specialist training, which subsequently needs to be developed or included into current training curricula. TRIAL REGISTRATION: German Registry for Clinical Trials (Deutscher Register Klinischer Studien, DRKS); ID: 00016330. Retrospectively registered on 4 January 2019. URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00016330.

[What do medical students learn in the elective course in Child and Adolescent Psychiatry?]. / Was lernen Medizinstudenten im Wahlfach Kinder- und Jugendpsychiatrie?

OBJECTIVE: A course in child and adolescent psychiatry and psychotherapy is optional for medical students within the Medical Curriculum Munich (MeCuMLMU). Aims of the course are to give insight into the specialty of child and adolescent psychiatry and to help students acquire basic skills. The focus is on psychopathology and on communication skills. METHOD: A course comprising 23 teaching units and limited to twelve students is taught over four days within one week twice per semester. Child and Adolescent Psychiatry is introduced by means of case presentations of children in different age groups, each with externalizing, and internalizing disorders and with developmental delay, and by a clinical round in the teaching hospital affiliated to the University. Case examples of children are presented by video. In group discussions guided by a teacher students learn to formulate a psychopathological status. Role-plays derived from the clinical examples and video-based feed-back provides students with the opportunity to improve their communication skills. RESULTS: The course is evaluated by means of a written examination, in which a psychopathological status must be written down independently. Students and teachers evaluate the seminar in a structured way. Videotapes of the role-plays are analyzed by the teachers after the course. In a sub-sample, a follow-up evaluation was carried out six months later. CONCLUSIONS: The seminar offers an excellent opportunity to introduce medical students to child and adolescent psychiatry and to recruit and inspire a future generation of child and adolescent psychiatrists.

[Usefulness of the Child Behavior Checklist in the assessment of preschool children with developmental problems]. / Anwendbarkeit der Child Behavior Checklist 11/2-5 als orientierendes Untersuchungsinstrument bei Vorschulkindern mit Entwicklungsproblemen.

The diagnostic evaluation of developmental problems and behavior problems in early childhood is difficult and time consuming. This study analyses the usefulness of the Child Behavior Checklist (CBCL) as a screening instrument in a special clinic for children with pervasive and specific developmental disorders. 106 children under the age of 6 years were enrolled in the study. All children were individually assessed. Psychiatric diagnoses were based on parent interview, observation of the child, speech and language assessment as well as cognitive assessment and extensive neurological examination. In addition, behavior and emotional problems were recorded with the CBCL. The results show that less than half of the children with a psychiatric diagnosis had a total score (CBCL) above the cut-off value. However, all children with a total score in the clinical range had a psychiatric diagnosis. The syndrome scales and diagnostic scales are not sensitive. The diagnostic scale "pervasive developmental disorder" is not specific enough to be used as a reliable instrument. In order to improve the usefulness of the checklist, a adjustment of the cut-off values should be considered.

The German version of the Child Behavior Checklist 1.5-5 to identify children with a risk of autism spectrum disorder.

A long delay between the first registered symptoms of autism spectrum disorder and a final diagnosis has been reported. The reasons for this are the spare use of specialized autism instruments, missing clinical expertise, and the late referral to specialized centers in primary care. Previous studies recommending the Child Behavior Checklist 1.5-5 for screening have requested additional research. A total of 183 children aged 25-71 months participated in this study. The Child Behavior Checklist scales of 80 children with autism spectrum disorder were compared with 103 children diagnosed with other psychiatric disorders. In the logistic regression analysis, the Withdrawn and Pervasive Developmental Problems Child Behavior Checklist scales with a significant predictive value of risk for an autism spectrum disorder diagnosis were identified. The optimal cutoff points T = 64.5 on the Pervasive Developmental Problems scale (area under the curve = 0.781, sensitivity = 0.83, specificity = 0.60, positive predictive value = 0.62, negative predictive value = 0.82, odds ratio = 7) and T = 60.5 on the Withdrawn scale (area under the curve = 0.809, sensitivity = 0.88, specificity = 0.63, positive predictive value = 0.65, negative predictive value = 0.87, odds ratio = 12) were evaluated in the receiver operating characteristics analysis. The present study confirms the utility of the German version of the Child Behavior Checklist 1.5-5 as a level 1 screening tool to identify children with a risk of autism spectrum disorder; however, a risk of over-identifying should be considered. The Child Behavior Checklist 1.5-5 can complement the pediatric examination as a quick and cost-effective questionnaire.

Use of early intervention for young children with autism spectrum disorder across Europe.

Little is known about use of early interventions for autism spectrum disorder in Europe. Parents of children with autism spectrum disorder aged 7 years or younger (N = 1680) were recruited through parent organisations in 18 European countries and completed an online survey about the interventions their child received. There was considerable variation in use of interventions, and in some countries more than 20% of children received no intervention at all. The most frequently reported interventions were speech and language therapy (64%) and behavioural, developmental and relationship-based interventions (55%). In some parts of Europe, use of behavioural, developmental and relationship-based interventions was associated with higher parental educational level and time passed since diagnosis, rather than with child characteristics. These findings highlight the need to monitor use of intervention for children with autism spectrum disorder in Europe in order to contrast inequalities.

Parent information and direct observation in the diagnosis of pervasive and specific developmental disorders.

Children with autism and children with a severe specific receptive language disorder show clear deficits in communicative language skills and social relationships. In this study the usefulness of a standardized parent interview (ADI-R) and a standardized observation schedule (ADOS-G) for the differential diagnosis of these two groups was assessed. Eleven children with early infantile autism and 16 children with a specific receptive language disorder participated. The parent interview was conducted with all parents and the observation schedule was administered to all children. Ten out of 11 children with autism were correctly classified as having autism on the ADI-R and the ADOS-G. One child with a receptive language disorder was falsely classified as having autism on the ADI-R, and none on the ADOS-G. Parent interview provides extensive information on the developmental course of the child. Direct observation gives an overview of actual relevant behavioural problems. The two instruments are complementary in the diagnosis of developmental disorders.

Early symptoms and recognition of pervasive developmental disorders in Germany.

Pervasive developmental disorders are characterised by the presence of abnormalities in social interaction and communication as well as repetitive patterns of behaviours. Although early symptoms of the disorder often appear during the first two years of life, its diagnosis is often delayed. The purpose of this study is to analyse the delay between age at first symptoms and age at diagnosis as well as the characteristics of the first symptoms for the different subcategories of pervasive developmental disorders. The sample consists of 601 children with a diagnosis of a pervasive developmental disorder. Age at first symptoms, age at diagnosis and the type of the first problems are registered. The results show that children with autism show first symptoms at a mean age of 15 months whereas diagnosis is made at a mean age of 76 months. Children with Asperger's syndrome show first symptoms at a mean age of 26 months, while diagnosis is made at the mean age of 110 months. There is still a large delay between the age at which parents first report first symptoms and age at diagnosis. To improve early detection, systematic screening and training of primary care paediatricians should be implemented.

Evaluation of neuromotor deficits in children with autism and children with a specific speech and language disorder.

Several studies have described problems in motor functions in children with autism and children with a specific speech and language disorder. The purpose of this study was to identify neuromotor deficits in these neurodevelopmentally impaired children. A standardised neurological examination was performed in 11 children with childhood autism, 11 children with an expressive language disorder, 11 children with a receptive language disorder and 11 control children. The children were matched for age and non-verbal IQ, not for gender. All children had a non-verbal IQ above 85. The neurological examination procedure allowed for a qualitative and quantitative assessment of five specific neurological subsystems: fine and gross motor functions, balance, coordination and oral motor functions. The high-functioning children with autism and the children with a specific language disorder (expressive or receptive) had more motor problems than the control children on most neurological subsystems. There were few statistically significant differences between the three groups of developmentally impaired children. The frequent co-occurrence of verbal and non-verbal, in particular neuromotor, deficits in developmentally impaired children put an additional burden on the development of these children and should be diagnosed as early as possible.

[Analysis of comorbid psychiatric disorders in child and adolescent psychiatry using the standardised basic documentation]. / Analyse der komorbiden psychiatrischen Diagnosen anhand der Basisdokumentation der Kinder- und Jugendpsychiatrie.

A slightly modified version of the basic documentation of the Child and Adolescent Psychiatric Associations is used to record in a standardised way important characteristics of the patients consulting clinics in Munich and Regensburg. The focus of the instrument is on the diagnostic classification of the symptoms according to the multiaxial classification scheme. The data of 5166 patients were analysed for frequency and type of combined psychiatric disorder. The results showed, that more than 60 % of the patients had more than one psychiatric diagnosis. The type of the comorbid disorders are discussed.

[Basic Documentation in Child and Adolescent Psychiatry: Preliminary Data Analysis and Practicability] / Die Basisdokumentation in der Kinder- und Jugendpsychiatrie: Erste Auswertungen und Erfahrungen.

A lightly modified version of the basic documentation of the Child and Adolescent Psychiatric Associations was introduced in three different clinics. Relevant items were analysed for about 5300 patients. The data of the 3 clinics were compared. There was a fair amount of agreement in the age structure and the distribution of the diagnoses between the clinics. A regular and detailed comparative analysis of the data will be developed as a measure of quality. The results of these analyses will be discussed in the 3 clinics and implemented in the daily routines.

[Basic documentation in child and adolescent psychiatry: first evaluations and experiences]. / Die Basisdokumentation in der Kinder- und Jugendpsychiatrie: Erste Auswertungen und Erfahrungen.

A lightly modified version of the basic documentation of the Child and Adolescent Psychiatric Associations was introduced in three different clinics. Relevant items were analysed for about 5300 patients. The data of the 3 clinics were compared. There was a fair amount of agreement in the age structure and the distribution of the diagnoses between the clinics. A regular and detailed comparative analysis of the data will be developed as a measure of quality. The results of these analyses will be discussed in the 3 clinics and implemented in the daily routines.