[Establishing ward-independent, intensive treatment concept in a psychiatric hospital : A model project within the new German remuneration system]. / Implementierung stationsungebundener Leistungen in der Psychiatrie : Modellvorhaben zum neuen Entgeltsystem.

Model projects according to § 64b of the Social Code V in the context of the new remuneration system in psychiatry and psychosomatics, offer great possibilities to improve the treatment of people with mental illnesses. This article presents the model project of the University Hospital Bochum, which is essentially characterized by improved transition through the internal hospital sections so that patients can be quickly transferred from inpatient and daycare sections to high frequency outpatient sections with ward-independent therapies (SUL), including outreach home treatment. The SUL is also intended to facilitate preadmission crises, to significantly reduce duration of inpatient treatment and to maximize post-inpatient continuity of treatment.

[Survivors of pediatric cancer. Developmental paths and outcomes between trauma and resilience]. / Überlebende von Krebserkrankungen des Kindes- und Jugendalters. Entwicklungsverläufe zwischen Traumatisierung und Resilienz.

In Europe and North America, about 80% of all patients with cancer in childhood and adolescence survive their leukemia, lymphomas or tumors. Therefore, neuropsychological impairments, psychopathological comorbidity and health-related quality of life become relevant parameters for treatment evaluation and conceptualization of future therapy protocols. During the last decade, a number of patient registries, multicenter studies and meta-analyses have analyzed the interaction of disease- and treatment-associated risk factors with pre-existing socio-demographic and psychosocial vulnerability factors. Brain tumors and treatment strategies including CNS surgery, cranial radiotherapy and intrathecal chemotherapy carry an increased risk for neurological and neuropsychological long-term outcomes, which in turn also threatens the patients' psychosocial and vocational participation. In the area of psychosocial adaptation, a wide range of developmental paths results, ranging from increased psychological comorbidity, to subclinical impairments in quality of life, to normal courses to resilient outcomes, even with a developmental benefit. A hypothetical model is presented to explain this enormous variance in outcomes. Protective cognitive-emotional schemata already established at the premorbid stage predispose patients to be able to cope successfully with cancer-related challenges and thus further enhance the patients' future adaptability. In contrast, dysfunctional schemata at the premorbid level increase risks of coping failure and thus intensify the long-term risk for psychopathological comorbidity in terms of post-traumatic stress disorder, anxiety disorder or depression.

Child abuse - some aspects for neurosurgeons.

Neurosurgeons are mainly concerned with child abuse in cases of severe cranio-cerebral trauma. Aim of the present paper is to highlight the clinical picture and symptoms in cases of child abuse and our multidisciplinary approach to reveal a solid diagnosis. The detection of child abuse requires a high index of suspicion, especially in cases of subtle injuries. Besides reporting to the appropriate agencies primary goals are to terminate suspected abuse and to prevent further harm to the child. All this requires a confirmed diagnosis.

[Neurocognitive and psychosocial development in SGA and the indication for growth hormone therapy]. / Neurokognitive und psychosoziale Entwicklung bei SGA im Kontext der Indikation zur Wachstumshormontherapie.

After recent approval of treatment indication for growth hormone therapy (GHT) in SGA (small for gestational age) treatment expectations do not only refer to improvement of growth parameters but also to enhancement of suspected impairments of neurocognitive, behavioural and educational development. Clinical prognosis, however, is difficult which specific developmental risks are to be expected in the individual case and if their course may response to GHT. The paper reviews recent findings of clinical and population-based studies on neurocognitive and psychosocial outcome in SGA and delineates an integrative framework on the emergence and course of potential developmental risk comprising three major causes: Conclusions are drawn for the clinical differentiation of specific adaptation difficulties towards short stature versus global, short stature independent behavioral disorders. Psychosocial outcome parameters can be expected to respond best to endocrinological growth stimulation in conditions with a high specific short stature related maladjustment; in turn, the relevance of child psychology interventions increases in conditions with global disturbance and short stature independent origin.

[Subjective developmental outcome in bladder exstrophy and epispadias. A pilot study]. / Entwicklungsergebnis bei Blasenekstrophie und Epispadie aus Patientensicht Eine Pilotstudie.

The bladder exstrophy-epispadias complex (BEEC) belongs to one of the most devastating urological malformations affecting the complete urinary tract including the genitalia. A semi-standardized questionnaire was used to evaluate the functional and psychosocial developmental outcome in 122 affected patients recruited from German-speaking self-referral support groups. The questionnaire covered mode of reconstruction, subjective assessment of continence, milestones of child development, education, school performance, level of life satisfaction, anxieties, and in patients older than 16 years partnership experience. The results showed a mean of one surgery in the age group 0-4, of four surgeries in both age groups 5-13 and 14-20, and seven surgeries in patients aged 20 and over. The continence rates for the latter three age groups were 36, 64, and 80%, respectively. We found that the neurocognitive development was unremarkable. Most patients showed above average performance in school and in their profession. On the other hand, they exhibited psychological anxieties and worries in their experience with sexuality and partnerships. Future studies will be necessary to clarify the association of urological status, functional impairments, and psychosocial adaptation as a basis for improved approaches to comprehensive care and support.

Successful cognitive-behavioral habituation training toward photophobia in photogenic partial seizures.

We report on the cognitive-behavioral treatment of a 12-year-old boy with photogenic partial seizures with secondary generalization who had developed phobic avoidant behavior toward all kinds of situations with potential photostimulation, leading to serious impairments of life quality. Based on a behavioral analysis of seizure and anxiety reaction, a habituation training (systematic desensitization procedure) was developed and performed, while maintaining protection against seizures with antiepileptic pharmacotherapy. The treatment was to gradually increase exposure to computer monitor and television screen photostimulation, closely adjusted to the level of subjective distress and tolerance. In addition to exercising control of photogenic input by regulating the monitor control button, rapid relaxation and imagery techniques were taught and applied as countermeasures at the onset of seizure precipitants. The treatment resulted in complete remission of phobic anxieties and responses and may also have facilitated ongoing seizure control after termination of antiepileptic medication.

[Psychosocial adaptation and compliance in chronic diseases in childhood]. / Psychosoziale Adaptation und Compliance bei chronischen Erkrankungen im Kindesalter.

A chronic disease in childhood often entails multidimensional, medical, psychosocial and financial risks which empede efficient adaptation to the disease for the whole family. Aim of this review is to describe possible strategies for effective coping with the chronic disease with the main focus on self-help-competence for the affected child and his family. Furthermore, there are proposals regarding practical handling of therapeutical noncompliance in the chronically ill infant. The family of a child with a chronic disease often contacts nurses for further, non-medical information. Therefore the aim of the review is to inform nurses of the biopsychosocial risks and consequences for every day life as well as to provide them with supportive self-help-strategies of the affected family.

Evidence of a specific vulnerability for deficient sequential cognitive information processing in epilepsy.

The aim was to study sequential versus simultaneous cognitive information processing and their relation to acquired intellectual abilities in children with epilepsy. A total of 175 children with epilepsy (mean age 8.7 years; SD 2.9) were neuropsychologically examined on the basis of the Kaufman Assessment Battery for Children (K-ABC). To avoid confoundation with factors other than epilepsy, patients with underlying metabolic disorders or patients who were incapable of neuropsychologic testing because of severe mental retardation were excluded. We found significantly reduced cognitive processing, especially in sequential information processing compared with simultaneous information processing (mean score 85.9 versus 91.0). This selective impairment in sequential cognitive processing turned out to be a good statistical predictor for acquired abilities in the group of idiopathic epilepsy (beta = 0.53; P < .01), indicating a specific epileptic neuropsychologic association. Our findings provide evidence of a specific vulnerability for deficient sequential information processing presumably impairing academic achievement in childhood epilepsy.

[Processes of body perception and their therapeutic use in pediatrics. From nonspecific relaxation therapy to training to recognize disease-specific symptoms]. / Prozesse der Körperwahrnehmung und deren therapeutische Nutzung in der Pädiatrie: Die Weiterentwicklung unspezifischer Entspannungsverfahren zum Training krankheitsspezifischer Beschwerde- und Symptomwahrnehmung.

Focussing on processes of body perception is a major pathway of relaxation therapies (progressive relaxation, autogenic training, guided imagery, hypnotherapy, biofeedback). Traditionally its application has been related to psychosomatic and psychotherapeutic indications. Beyond this classical approach, recent behavioral medicine has emphasized the relevance of interoception processes and adequate attribution patterns concerning bodily sensations as a major source of adequate coping and self-management with somatic illness. Clinical application may refer to an improved cognitive-behavioral pain management in disease and treatment related conditions. Especially children and adolescents suffering from chronic conditions that may exacerbate rapidly may benefit from an education approach that teaches them to perceive their disease-related complaints and symptoms accurately and to attribute them correctly. A precise, panic-free and immediate symptom recognition of sudden airway obstruction is an important precondition of adequate coping with acute asthma crisis and starting risk orientated antiasthmatic treatment. In a similar way, the child with diabetes mellitus may identify early signs of hypoglycemia by self-observation, recognition and discrimination of physical, vegetative and psychological indicators of blood glucose decline that enable the child to take appropriate countermeasures. Other childhood disorders that offer chances for symptomatic self-monitoring and self-control comprise atopic dermatitis or epileptic seizures. Training young patients in precise symptom recognition may not only empower them in handling acute crisis but also strengthen global development of autonomy, control beliefs, self-responsibility and self-esteem.

Interstitial deletion in Xp22.3 is associated with X linked ichthyosis, mental retardation, and epilepsy.

We describe monozygotic male twins with an interstitial deletion of Xp22.3 including the steroid sulphatase gene (STS). The twins had X linked ichthyosis, X linked mental retardation, and epilepsy. A locus for X linked mental retardation has been assigned to a region between STS and DXS31 spanning approximately 3 Mb. Recently the locus was further refined to an approximately 1 Mb region between DXS1060 and GS1. By PCR analysis of flanking STS gene markers in our patients we succeeded in narrowing down the locus to between DXS6837 and GS1.

Symptomatic versus substitution growth hormone therapy in short children: from auxology towards a comprehensive multidimensional assessment of short stature and related interventions.

There is an ongoing debate as to whether symptomatic growth hormone treatment (GHT) in short children without growth hormone deficiency (GHD) is justified, since there is no substitutional indication. The increasing evidence that final height cannot be normalized in these patients (e.g. in Ullrich-Turner syndrome) reinforces this controversy. We have focused on the empirical evidence on the psychosocial and physical meaning of being short in childhood as well as on the underlying assumptions of the different GHT indications. The indication for GHT in patients with non-GHD may be seen as a pharmacotherapeutic intervention in order to prevent the developmental, physical and psychosocial risks associated with short stature. This requires a qualitative shift in methodological assessment with respect to the psychosocial and physical impact of being short as well as of the potential benefit of new treatment indications in terms of a more comprehensive evaluation including health-related quality of life for these patients.

Good prognosis for psychomotor development in survivors with nonimmune hydrops fetalis.

We examined the psychomotor development of 33 of 61 surviving children, from a series of 107 consecutive live-born cases with nonimmune hydrops fetalis. The majority had a normal outcome. Three had a (simultaneous) serious underlying disease (e.g. fetal herpes infection) and had either severe psychomotor retardation or blindness. Two showed clumsiness and were considered to have minor neurological dysfunction. We conclude that survivors, especially those with transient benign intrauterine conditions, such as lymphatic aetiology have no additional risk to their psychomotor development.

Adjustment in conditions with short stature: a conceptual framework.

A major justification of extended indications for GH therapy in conditions with short stature is based on the objective of preventing or alleviating suspected psychosocial maladjustment. Despite more sophisticated research, results are still controversial concerning the actual seriousness of adjustment difficulties in various conditions with short stature, thus making it difficult to determine a patient's need for treatment. This paper discusses different concepts and assessment strategies of "adjustment" as a major source of the apparent heterogeneity among study findings, conclusions and treatment recommendations. A concise framework is developed that identifies and differentiates three hierarchical levels of research on adjustment in conditions with growth retardation: (1) stress exposure due to short stature, (2) quality of coping responses, and (3) occurrence of psychopathology. Choosing a particular research level and its corresponding measures may imply whether a high, medium or very low impact of short stature on adjustment is found, and the need for treatment that is inferred. The integration of these different research approaches within an integrative model may help to resolve apparent inconsistencies among empirical studies and reveal sources of confoundation due to other, short stature independent risk factors associated with the particular underlying growth disorder. The key terms of the suggested model are transformed into a clinical guideline for psychological assessment in patients with growth retardation and into three key criteria for the decision making process on extended indications for GH treatment with respect to the improvement of psychosocial adjustment.

'Short stature in children--a questionnaire for parents': a new instrument for growth disorder-specific psychosocial adaptation in children.

Recent studies report comparable psychosocial adaptation in children with or without a growth disorder. These findings may be due to a general lack of sensitive and specific techniques for analysing and comparing their respective qualities of life. In this study we present a new questionnaire for parents of short-statured children. We suggest both a qualitative and quantitative approach providing specific information about the relative extent of individual stress factors and sources of help. The parents of 442 children with growth retardation resulting from different aetiologies completed the questionnaire. A principal component analysis of the scaled items revealed four dimensions of psychosocial adaptation; suffering, future anxieties, behavioural problems and coping efforts. The index of internal consistency reliability was sufficient for all scales. The comparison of two selected growth disorder groups (achondroplasia versus growth hormone deficiency) demonstrated growth disorder-specific but not very different profiles of psychosocial adaptation. The qualitative analysis revealed a shift in the stress factor patterns (achondroplasia, more physical restrictions). These findings give evidence for both the specificity and construct validity of the new instrument. Therefore, we may conclude that this questionnaire is a helpful method in attaining growth disorder-specific information about individual stress factors, resources and psychosocial adaptation.

Children's and adolescents' perception of their asthma bronchiale.

The present study examines the perception of asthma bronchiale in a large sample of 382 children and adolescents (mean age = 12.5 years) across three different treatment settings (outpatient, short-term rehabilitation, residential treatment) by using a revised child version of the 'Asthma Problem Behavior Checklist.' A PCA reveals two factors (eigenvalues: 26.3; 4.2; 0.9 ..) with a complementary structure: 'appraisal of asthma-related distress' (explained variance: 48.5%) and 'appraisal of resources in coping with asthma-related distress' (explained variance: 20.9%). Implications for clinical psychological assessment of young patients with asthma and the congruence with the LAZARUS transactional conceptualization of stress and coping are discussed.

[Conditioning of affect-induced breath-holding spells]. / Zur Konditionierbarkeit respiratorischer Affektkrämpfe.

Breath holding spells often arise in the context of affectively dramatic conflict situations between mother and child. Assessment by psychopathological screening instruments, however, has not given empirical evidence of an increased psychiatric morbidity in these children. Therefore, in our study we did not concentrate on basic psychopathology but on behavioral variables that might be effective during the ongoing attack episode and, hereby, exert an influence on the risk of chronification (relapse rate). The main goal of this approach is to examine secondary reinforcement effects on the attack behavior according to the learning principle of operant conditioning. Our sample consisted of 28 children and ten siblings as control group. To control for effects of behavioral disorders in the sample, we applied the Marburger Verhaltensliste (MVL) on the level of the child, and the Familienfragebogen (FFBO-III) on the level of family adaptation. The main assessment instrument, however, was the Functional Behavior Analysis (FBA) in order to measure the trigger, reaction and consequence conditions in the course of given attack episodes. MVL and FFBO-III results confirm the lack of basic psychopathology in the patients and their families. The individualized FBA's can be transformed in a taxonomy of five distinct types. All the first three types are triggered by intensive conflict situations and show a high relapse rate (type 1) if the mother reacts in a rewarding manner with positive consequences for the child (reinforcement condition), a dramatically reduced rate (type 2) if the mother reacts neutral (extinction condition), or a heterogeneous pattern (type 3) if the mother reacts punishing (punishment condition). In type 4 (pallid type) and type 5 (triggered spontaneously), respectively, no responsiveness to conditioning effects can be recognized. With respect to parent counselling, a recommendation for a quiet and consequent reaction can be concluded, especially in the case of a preceding conflict situation. The empirical results are integrated into a hypothetical model on pathogenesis that delineates the interaction of neurophysiological and behavioral factors in the maintenance of breath-holding spells.

[Bronchial asthma in childhood and adolescence. Burden of illness and coping with the disease]. / Asthma bronchiale im Kindes- und Jugendalter. Krankheitsbelastung und Krankheitsbewältigung.

We report an empirical study in which the subjective complaints and stress experiences of children with bronchial asthma (outpatient, short- and long-term rehabilitation) are analyzed. The data were taken from a specifically developed questionnaire. The results should contribute to the conceptualization of programs for patient education and asthma training in order to meet the exact requirements and needs of the children to be instructed. The role of emotional asthma triggers is specified. Hierarchical cluster analysis is applied in order to analyze, first, the perception patterns of attack precursors and, second, the array of stressors that a child has to face as a consequence of suffering chronic asthma. Based on the social learning theory approach, the child's various expectations about the controllability of an asthma attack are differentiated. A factor analysis reveals that the coping process can be described by two basic coping dimensions.