Secure attachment predicts lower societal cost amongst severely antisocial adolescents.

BACKGROUND: Social and economic costs associated with antisocial behaviour are well-established, but little is known about the potential costs savings/benefits of secure attachment in this high-risk group. We aimed to provide the first test of attachment quality as a distinct predictor of economic costs. METHODS: 111 adolescents (10-17 years of age, M = 15.0, SD = 1.6; 71% male) referred to young offender services due to high levels of antisocial behaviour were included. Costs were measured by detailed service-use interview, and attachment security to mother and father elicited through the Child Attachment Interview. The level of antisocial behaviour and callous-unemotional traits were assessed. Cost predictors were calculated using generalised linear models. RESULTS: Mean 12-months service costs were £5,368 (sd 5,769) per adolescent, with justice system and educational service costs being the main components. After adjusting for covariates, economic costs were predicted by attachment quality to fathers, with a difference of £2,655 per year between those with secure (£3,338) versus insecure attachment (£5,993); significant cost effects were not found for attachment quality to mothers. Higher levels of callous-unemotional traits, lower verbal IQ, higher levels of antisocial behaviour, and older age were also significant cost predictors. CONCLUSIONS: Secure attachment to fathers is a predictor of reduced public cost in adolescents with severe antisocial behaviour. This novel finding for severely antisocial youth extends previous findings in less antisocial children and underscores the public health and policy benefits of good caregiving quality and the value of population-level dissemination of evidence-based interventions that improve caregiving quality.

Health Services Use and Costs in Individuals with Autism Spectrum Disorder in Germany: Results from a Survey in ASD Outpatient Clinics.

Autism spectrum disorders (ASD) are associated with high services use, but European data on costs are scarce. Utilisation and annual costs of 385 individuals with ASD (aged 4-67 years; 18.2% females; 37.4% IQ < 85) from German outpatient clinics were assessed. Average annual costs per person were 3287 EUR, with psychiatric inpatient care (19.8%), pharmacotherapy (11.1%), and occupational therapy (11.1%) being the largest cost components. Females incurred higher costs than males (4864 EUR vs. 2936 EUR). In a regression model, female sex (Cost Ratio: 1.65), lower IQ (1.90), and Asperger syndrome (1.54) were associated with higher costs. In conclusion, ASD-related health costs are comparable to those of schizophrenia, thus underlining its public health relevance. Higher costs in females demand further research.

A good investment: longer-term cost savings of sensitive parenting in childhood.

BACKGROUND: Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan. The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested. METHODS: Design: Longitudinal study with follow-up from 2012 to 2016. SETTING: UK multicentre study cohort (London, South-East England). PARTICIPANTS: 174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4-6 years then followed up in early adolescence (mean age 12.1 years). MEASURES: The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent-child interaction. RESULTS: Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p < .001). Costs were spread across personal family expenditure and education, health, social and justice services. The cost difference remained significant after controlling for several potential confounders. These included demographic variables (family poverty, parental education); exposure to child abuse; and child/young person variables including level of antisocial behaviour in both childhood and adolescence, IQ and attachment security. CONCLUSIONS: This study is the first showing that more sensitive early parental care predicts lower costs to society many years later, independent of poverty, child and youth antisocial behaviour levels and IQ. Savings are likely to increase as individuals grow older since early parenting quality predicts health, behavioural and occupational outcomes in adulthood. The findings provide novel evidence for the public health impact of early caregiving quality and likely financial benefits of improving it.

Assessment of the quality of routine ambulatory healthcare for common disorders in children and adolescents in Germany: study protocol for a retrospective medical record review (QualiPäd).

INTRODUCTION: The quality of healthcare in childhood and adolescence is of key importance, in order to foster a healthy development and to avoid chronic health problems. Yet, data for Germany regarding the quality of healthcare for this patient group are lacking. The QualiPäd research project aims to estimate the quality of outpatient healthcare for children and adolescents in Germany, focusing on common psychiatric and physical disorders. METHODS AND ANALYSIS: Quality indicators for seven common physical and mental childhood and adolescent clinical conditions (attention deficit/hyperactivity disorder, asthma, atopic dermatitis, depression, otitis media, conduct disorder/oppositional defiant disorder, tonsillitis) will be developed and ratified by experts, using the RAND/UCLA Appropriateness Method.Initially, 1400 medical records of children and adolescents with one of the aforementioned clinical conditions will then be randomly drawn from 40 outpatient practices in the German federal state of Hessen. The records will then be assessed regarding their adherence to the respective quality indicators. Based on this, the percentage of appropriate and inappropriate (eg, wasteful) healthcare of all clinical conditions (primary endpoint) will be estimated. Additionally, possible factors influencing the quality of care (eg, patient characteristics, type of condition, type of practice) will be identified using generalised estimation equation models. ETHICS AND DISSEMINATION: This study will show for which of the studied clinical conditions and/or patients improvement of quality of care is necessary within the German health system. Also, the quality indicators designed for the study can afterwards be implemented in regular care and thus enable regular reporting of the outpatient care of this target group. The authors plan to disseminate their findings through international, peer-reviewed scientific publications, and through presentations at national and international paediatric and child psychiatric conferences. TRIAL REGISTRATION NUMBER: DRKS00022408.

[Prevalence and Treatment of Posttraumatic Stress Disorder in Germany: An Analysis of Nationwide Health Insurance Data, 2008 vs 2017]. / Prävalenz und Versorgung der Posttraumatischen Belastungsstörung in Deutschland: Eine bundesweite Auswertung von Krankenkassendaten aus den Jahren 2008 und 2017.

OBJECTIVE: To provide German data regarding prevalence and treatment (pharmacotherapy, psychotherapy) for individuals with PTSD. METHODS: Based on BARMER health insurance data, the administrative prevalence of PTSD (ICD-10: F43.1), psychiatric comorbidity, psychotherapy and pharmacotherapy were estimated. Additionally, prevalence trends for years 2008 vs. 2017 were computed. RESULTS: In 2017, the overall PTSD prevalence was 0.7 % (females: 0.9 %, males: 0.4 %), whereas in 2008 it was 0.3 %. 74.4 % of all PTSD cases received psychotherapy, 43.6 % were prescribed an antidepressant (first choice: venlafaxine), and 14.4 % were prescribed an antipsychotic (first choice: quetiapine). CONCLUSION: Within the studied period, the administrative prevalence of PTSD has more than doubled. Still, the prevalence rate found in our study is lower than figures from epidemiological studies, thus indicating room for improvement in diagnosing PTSD.

The cost of love: financial consequences of insecure attachment in antisocial youth.

BACKGROUND: Knowing that your parent or caregiver will be there for you in times of emotional need and distress is a core aspect of the human experience of feeling loved and being securely attached. In contrast, an insecure attachment pattern is found in many antisocial youth and is related to less sensitive caregiving. Such youth are often distrustful of adults and authority figures, and are at high risk of poor outcomes. As they become adults, they require extensive health, social and economic support, costing society ten times more than their well-adjusted peers. However, it is not known whether insecure attachment itself is associated with higher costs in at-risk youth, independently of potential confounders, nor whether cost differences are already beginning to emerge early in adolescence. METHODS: Sample: A total of 174 young people followed up aged 9-17 years (mean 12.1, SD 1.8): 85 recruited with moderate antisocial behaviour (80th percentile) from a school screen aged 4-6 years; 89 clinically referred with very high antisocial behaviour (98th percentile) aged 3-7 years. MEASURES: Costs by detailed health economic and service-use interview; attachment security to mother and father from interview; diagnostic interviews for oppositional and conduct problems; self-reported delinquent behaviour. RESULTS: Costs were greater for youth insecurely attached to their mothers (secure £6,743, insecure £10,199, p = .001) and more so to fathers (secure £1,353, insecure £13,978, p < .001). These differences remained significant (mother p = .019, father p < .001) after adjusting for confounders, notably family income and education, intelligence and antisocial behaviour severity. CONCLUSIONS: Attachment insecurity is a significant predictor of public cost in at-risk youth, even after accounting for covariates. Since adolescent attachment security is influenced by caregiving quality earlier in childhood, these findings add support to the public health case for early parenting interventions to improve child outcomes and reduce the financial burden on society.

[Socioeconomic status and health insurance expenditures for children and adolescents with conduct disorder : An analysis of statutory health insurance data]. / Einfluss des sozioökonomischen Status auf Gesundheitskosten für Kinder und Jugendliche mit Störungen des Sozialverhaltens : Eine Analyse von Routinedaten einer gesetzlichen Krankenversicherung.

BACKGROUND: For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking. OBJECTIVES: To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES. MATERIALS AND METHODS: The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication. RESULTS: There was no significant functional association between SES and healthcare costs for any of the analysed cost types. CONCLUSIONS: In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

Differences in healthcare costs in youths with conduct disorders in rural vs. urban regions: an analysis of German health insurance data.

BACKGROUND: For children and adolescents with mental health problems, there is a lack of data as to whether the type of residential area (urban vs. rural) influences healthcare costs for affected individuals. The aim of this study was therefore to explore potential urban vs. rural healthcare cost differences in children and adolescents with conduct disorder (CD), one of the most frequent and cost-intensive child and adolescent psychiatric disorders. Additionally, we aimed to compare healthcare costs of youths with CD, and of youths without this diagnosis. METHODS: We analysed data from a German health insurance company, extracting all youths with a CD diagnosis in 2011 (CD group; N = 6337), and an age- and sex-matched group without this diagnosis (control group). For both groups, annual costs per person for outpatient and inpatient healthcare were aggregated, stratified by area of residence (urban vs. rural). RESULTS: While mean annual overall costs in the CD group did not differ significantly between urban and rural areas of residence (2785 EUR vs. 3557 EUR, p = 0.253), inpatient treatment costs were significantly higher in rural areas (2166 EUR (60.9% of overall costs) vs. 1199 EUR (43.1% of overall costs), p < 0.0005). For outpatient healthcare costs, the reverse effect was found, with significantly higher costs in individuals from urban areas of residence (901 EUR (32.3% of overall costs) vs. 581 EUR (16.3% of overall costs), p < 0.0005). In the control group, no significant rural vs. urban difference was found for either overall health costs, inpatient or outpatient costs. Mean overall costs in the CD group were four times higher than in the control group (3162 (±5934) EUR vs. 795 (±4425) EUR). CONCLUSIONS: This study is the first to demonstrate urban vs. rural differences in healthcare costs among youths with CD. The higher costs of inpatient treatment in rural regions may indicate a need for alternative forms of service provision and delivery in rural settings.

Prescriber and institutional barriers and facilitators of clozapine use: A systematic review.

BACKGROUND: As clozapine is under-prescribed in persons with treatment-resistant schizophrenia (TRS), it is necessary to better identify the determinants of health inequalities in access to clozapine use. OBJECTIVE: To identify mental health professionals' characteristics or attitudes and institutional characteristics facilitating or limiting clozapine prescribing. METHOD: We systematically searched multiple electronic databases for articles reporting: (i) mental health professionals' attitudes and characteristics favoring or limiting clozapine prescribing; (ii) institutional characteristics associated with variations in clozapine prescribing; (iii) interventions aimed at enhancing clozapine prescribing. Data were synthesized narratively. RESULTS: A total of 31 articles reporting findings of 29 studies published from 1993 to 2017 in 11 countries fulfilled our inclusion criteria. The main prescriber-related barriers to clozapine prescribing are lack of personal prescribing experience and concern with pharmacological characteristics of clozapine (blood monitoring and adverse effects). Lack of knowledge about the effectiveness of clozapine does not appear as a major determinant of under-prescription. Institutional-related characteristics favoring clozapine prescribing are prescribers' adherence to evidence-based medicine principles and learning by modelling from experienced clozapine prescribers. CONCLUSION: Effective strategies to increase access to clozapine in persons with TRS include implementation of integrated clozapine clinics, simplification of blood monitoring, education for prescribers and contact with experienced prescribers. Programs addressing barriers in clozapine prescription need to be disseminated more broadly to ensure persons with TRS have access to evidenced based treatments such as clozapine. Inequality in access to clozapine care should be more systematically handled by mental health facilities and health regulatory agencies.

Trends in psychopharmacologic treatment of tic disorders in children and adolescents in Germany.

Data on medical treatment of children and adolescents with tic disorders are scarce. This study examined the administrative prevalence of psychopharmacological prescriptions in this patient group in Germany. Data of the largest German health insurance fund were analysed. In outpatients aged 0-19 years with diagnosed tic disorder, psychotropic prescriptions were evaluated for the years 2006 and 2011. In 2011, the percentage of psychotropic prescriptions was slightly higher than in 2006 (21.2 vs. 18.6%). The highest prescription prevalence was found in Tourette syndrome (51.5 and 53.0%, respectively). ADHD drugs were most frequently prescribed, followed by antipsychotics. In 2011, prescriptions of second generation antipsychotics (SGA) were higher and prescriptions of first generation antipsychotics (FGA) lower than in 2006. Concerning prescribed antipsychotic substances, in 2011 risperidone prescriptions were higher and tiapride prescriptions lower. Paediatricians issued 37.4%, and child and adolescent psychiatrists issued 37.1% of psychotropic prescriptions. The FGA/SGA ratio was highest in GPs (1.25) and lowest in child and adolescent psychiatrists (0.96). From 2006 to 2011, there was only a slight increase in psychotropic prescriptions for children and adolescents with a diagnosis of tic disorder in Germany, which stands in contrast towards the significant increase in psychotropic prescriptions in other child and adolescent psychiatric disorders (e.g. ADHD). There were marked differences in treatment patterns by tic disorder subgroups, with Tourette syndrome patients receiving most frequently psychopharmacotherapy. Risperidone prescriptions increased, probably reflecting a switch in prescribing practice towards up-to-date treatment guidelines. In primary care physicians, dissemination of current tic disorder treatment guidelines might constitute an important educational goal.