[Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders]. / Minderjährige in klinischen Prüfungen: Ethische Abwägungen ihres Einbezugs am Beispiel der indizierten Prävention psychotischer Erkrankungen.

Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders Abstract: As a vulnerable group, minors require special protection in studies. For this reason, researchers are often reluctant to initiate studies, and ethics committees are reluctant to authorize such studies. This often excludes minors from participating in clinical studies. This exclusion can lead to researchers and clinicians receiving only incomplete data or having to rely on adult-based findings in the treatment of minors. Using the example of the study "Computer-Assisted Risk Evaluation in the Early Detection of Psychotic Disorders" (CARE), which was conducted as an 'other clinical investigation' according to the Medical Device Regulation, we present a line of argumentation for the inclusion of minors which weighs the ethical principles of nonmaleficence (especially regarding possible stigmatization), beneficence, autonomy, and fairness. We show the necessity of including minors based on the development-specific differences in diagnostics and early intervention. Further, we present specific protective measures. This argumentation can also be transferred to other disorders with the onset in childhood and adolescence and thus help to avoid excluding minors from appropriate evidence-based care because of insufficient studies.

Effects of Posttraumatic Stress Disorder and Mental Disorders on the Labor Market Integration of Young Syrian Refugees.

Civil war experience in the Syrian home country, insecurity and critical life events during migration, or adverse events in the receiving country might affect refugees' mental health. This paper addresses the effects of psychological distress and mental disorders on refugees' labor market integration in Germany between 2016 and 2021. We employ survey data from about 2700 young Syrians, delivering information on individuals' experience of migration and arrival in Germany in 2016. The survey data were successfully merged with register data, delivering detailed information regarding individuals' process of labor market integration and employment status from 2016 to 2021. Overall, the labor market integration of young refugees improved remarkably over time. In 2021, about 69% of the study population was integrated in a wider sense, and 30% was employed in fulltime contracts in 2021. However, the results indicate long-lasting effects of PTSD and mental disorders on individuals' labor market integration, whilst individuals' characteristics related to migration and arrival lose relevance over time and hardly affect labor market integration around five years after arrival. High PTSD scores in 2016 indicate a significantly reduced full-time employment probability in 2021. Anxiety and depression show significant negative effects on individuals' labor market integration, but with a less severe impact compared to a PTSD diagnosis.

[Course of School Absenteeism 1.5-3 Years After Initial Evaluation: Symptoms, Psychosocial Functioning, and Help-Seeking Behavior]. / Verlauf von Schulabsentismus 1.5 bis 3 Jahre nach Erstvorstellung: Prädiktoren, psychosoziales Funktionsniveau und Inanspruchnahme von Hilfen.

Course of School Absenteeism 1.5-3 Years After Initial Evaluation: Symptoms, Psychosocial Functioning, and Help-Seeking Behavior Abstract. Objective: To explore the course of patients with school absenteeism 1.5-3 years after their initial evaluation, including symptoms, school attendance, psychosocial functioning, and help-seeking behavior. Method: Of the 237 patients from specialized psychiatric units for youths displaying school absenteeism, we successfully contacted 108 of them 1.5-3 years after initial admission. We conducted a telephone interview with their parents (SDQ, school situation, help-seeking behavior). Among others, we analyzed the extent of school absenteeism, the scales of the Inventory of School Attendance Problems (ISAP; Knollmann et al., 2019), and the quality of school absenteeism (school refusal vs. truancy vs. mixed group) at admission as possible predictors. Results: The patients had received an extensive amount of youth-welfare measures and inpatient, daycare, and outpatient therapy. 46.3 % had elevated values in the SDQ total score at follow-up, mostly because of emotional problems or problems with peers. Psychosocial functioning, including school attendance, was described as poor for only about 30 %. School attendance problems were significantly predicted by having a conduct disorder and elevated scores on the ISAP-scales Aggression, Teacher Problems, and Peer Problems, though the effect sizes were weak. Conclusions: Externalizing symptoms and associated psychosocial problems seem to be predictive of a negative course of school absenteeism. Implications for prospective longitudinal studies are discussed.

The bidirectional relationship of obesity and labor market status - Findings from a German prospective panel study.

BACKGROUND: Given the inconsistent findings regarding associations between obesity and unemployment, our analysis is one of the few that explores bidirectional changes in obesity and unemployment. In our prospective study, we address factors associated with the a. transition into and transition out of obesity, including unemployment, and b. transition into and out of unemployment, including obesity. SUBJECTS AND METHODS: The Labor Market and Social Security-Panel (PASS) consists of two independent, nationally representative German subsamples: residents receiving unemployment benefits (50%) and a representative sample of residents (50%). The sample contains N = 11 361 observations between two measurement points three years apart of N = 8440 individuals participating in two or three waves between 2009 and 2015. We analyzed potential predictors of the transition in and out of obesity and unemployment, including health-related quality of life (HrQoL) and physical activity, using logistic regression models. RESULTS: 1. Transition into obesity: Unemployed participants had a higher probability of exhibiting a body mass index (BMI) ≥ 35 kg/m2 three years later (transition into obesity classes II and III; Exp(B) = 1.5). 2. Transition out of obesity: Unemployment did not predict transition out of obesity. Physical activity at least once weekly increased the probability of no longer having a BMI ≥ 35 kg/m2 three years later (Exp(B) = 2.0). 3. Transition into unemployment: Obesity was not associated with becoming unemployed three years later. Participants with a lower mental HrQoL were more likely to become unemployed (Exp(B) = 0.98). 4. Transition out of unemployment: Unemployed individuals reporting a BMI of 30-34.9 kg/m2 were less likely to leave unemployment (Exp(B) = 0.67). A better physical HrQoL was associated with a higher probability of leaving unemployment (Exp(B) = 1.01). CONCLUSIONS: Obesity does not predict future unemployment, but unemployed individuals with obesity have a lower probability of labor market re-entry. Unemployment increases obesity risk. Interactions between obesity and possible confounding variables and their effect on unemployment warrants further examination.

School-to-work transition and subjective well-being in Australia.

The school-to-work transition is a demanding period during an individual's life course in all societies particularly because the educational decisions made during this period have long-lasting consequences in multiple life domains. Moreover, adverse starting points after secondary school are likely to lead to adverse outcomes that might cumulate over the life course. This study analyses subjective well-being during this sensitive period and examines the following two questions. First, how do different school-to-work transitions relate to subjective well-being changes? Second, how does subjective well-being develop during and after secondary schooling? As the school-to-work transition period is structured by gender, each analytical step aims to identify gender differences. Furthermore, based on life course theories, this study investigates whether adverse starting points after secondary school lead to cumulative effects in the development of subjective well-being. Based on data from the Household, Income and Labour Dynamics in Australia (HILDA) survey and fixed effects regressions, our results reveal that transitions to employment increase subjective well-being, while transitions to unemployment decrease subjective well-being. Furthermore, transitions to study increase subjective well-being only among men, while such transitions appear to decrease subjective well-being among women. The results related to the development of subjective well-being indicate that subjective well-being decreases during secondary schooling and continues to decrease after individuals leave school. This decrease is stronger among men. Finally, our results reveal the negative cumulative effects of adverse starting points on the development of subjective well-being. Overall, the results reveal great intra-individual variation in subjective well-being during the school-to-work transition period in Australia.

Screening for posttraumatic stress disorder in young adult refugees from Syria and Iraq.

INTRODUCTION: In January 2016, 2057 refugees from civil war-torn Syria and Iraq, aged 18.0 to 24.9 years, were first-time entrants into the German unemployment register and thus potentially eligible for the labor market. Civil war and forced migration may affect individuals' mental health. Traumatic experiences in particular are assumed to represent a major barrier, e.g., to labor-market integration. This study aimed to screen the rates of posttraumatic stress disorder (PTSD). Former refugee studies have reported PTSD screening rates between 3% and 44%. METHOD: A total of 8.5% (N = 175 of 2057) of respondents were randomly interviewed either by telephone or web-based interviews. A total of 84 respondents (48% out of 175 respondents) were screened using the Essen Trauma Inventory (ETI) based on the DSM-IV, and 91 (52%) respondents used the Short Screening Scale for Posttraumatic Stress Disorder (SSS-PSD). All respondents were additionally questioned regarding psychological impairment (Symptom Checklist 10) and health status (Short Form 12). RESULTS: Of the respondents, 59.4% reported at least one traumatic experience. The percentage of positive PTSD screenings obtained using the ETI was 9.5% (N = 84) and 6.6% (N = 91) using the SSS-PSD. The percentage of positive PTSD screenings obtained with both screening instruments was 8% (N = 175; 95%-CI: 3.9% to 12.1%). A total of 19.4% of the subjects were above the SCL-10 cut-off for psychiatric caseness. DISCUSSION: The PTSD rate in this sample was in the average range compared to previous estimates from large samples of refugees. Psychiatric caseness was high. The results should be considered for planning labor-market integration programs and the design of supportive schemes.

Towards a comprehensive assessment of school absenteeism: development and initial validation of the inventory of school attendance problems.

School attendance problems (SAPs) become manifest in many ways and are associated with multiple risk factors, calling for comprehensive assessment methods. This study documents the development of the inventory of school attendance problems (ISAP), which assesses both the quality and the function of a broad spectrum of SAPs by first asking students with SAPs to rate the intensity of symptoms prior to or at school and then to rate their impact on school attendance. An empirically generated pool of 124 items was analyzed (explorative factor analysis) using a clinical sample of N = 245 students with SAPs (53.5% male; Mage: 14.4). The Youth Self Report (YSR), a German version of the School Refusal Assessment Scale (SRAS), and the extent of school absenteeism were used to determine construct validity. The resulting 48 items loaded on 13 factors. The 13 scales assess internalizing and externalizing symptoms (Depression, Social Anxiety, Performance Anxiety, Agoraphobia/Panic, Separation Anxiety, Somatic Complaints, Aggression, School Aversion/Attractive Alternatives) as well as emotional distress due to problems in the school or family context (Problems with Teachers, Dislike of the Specific School, Problems with Peers, Problems Within the Family, Problems with Parents). All scales showed good internal consistencies. Their correlations with the YSR and the SRAS indicated convergent and discriminant validity. Positive associations between most of the scales and the extent of school absenteeism were obtained. Although preliminary, these results support the usefulness of the ISAP for a comprehensive assessment of SAPs in clinical settings.

[Economic evaluation of a manual-based, multimodal cognitive behavioural therapy for school avoiding children with psychiatric disorder]. / Ökonomische Evaluation eines manualbasierten Therapiekonzeptes für psychisch kranke Kinder und Jugendliche mit schulvermeidendem Verhalten.

Objective: Untreated school refusal increases the risk of a premature discontinuation of the educational career. The aim of this study is the economic evaluation of a manual-based treatment for school refusal in comparison to the standard treatment. Method: Within the cost-minimisation analysis, resource use is measured retrospectively for six months using the CSSRI questionnaire. Unit costs for most health care services are derived from published standard prices. Costs are calculated from the societal perspective based on prices compiled in 2011. The cost comparison during the one-year intervention period applies a difference in differences Approach. Results: The most common diagnoses among the 112 participants are phobic and emotional disorders. The average cost per patient during the intervention period amounts to 7197 € (95 %-CI: 4746 € ­ 10 079 €) for the manual group and 9294 € (95 %-CI: 6313 € ­ 12 878 €) for the control group. The difference in adjusted costs of 1453 € in favour of the manual group is not statistically relevant. Conclusions: The manual-based treatment is equivalent if not slightly advantageous compared to the standard treatment considering the clinical outcomes and cost of illness.

Low 25(OH)-vitamin D concentrations are associated with emotional and behavioral problems in German children and adolescents.

BACKGROUND: Evidence has accumulated for the association between low vitamin D serum concentrations and mental health disorders in both children and adults. We performed a cross-sectional analysis in a population-based sample of children and adolescents to detect associations between 25(OH)-vitamin D serum [25(OH)D] concentrations and scores of the five Strengths and Difficulties Questionnaire (SDQ) subscales and the total difficulties score in different age groups (age ≥3-<12 years and ≥12-<18 years). METHODS: 9068 participants of the population-based, nation-wide German Health Interview and Examination Survey for Children and Adolescents (KIGGS) with information on mental health status assessed by the SDQ and 25(OH)D levels were included in the analysis. For statistical analysis we used linear regression models stratified by gender based on different adjustment sets. For the younger subsample the analysis was additionally adjusted for the frequency of playing outside. We compared the associations based on parent- and self-ratings of the SDQ for children and adolescents aged ≥12-<18 years. RESULTS: We found inverse associations between 25(OH)D concentrations and the subscales emotional problems, peer relationship problems and the total difficulties score in both genders after adjustment for potential confounders. The strongest associations were observed in the older subsample for parent-ratings in boys and self-ratings in girls. In the younger subsample the associations were less strong and no longer evident after adjustment for potential confounders such as migration background, socioeconomic status and frequency of playing outside. CONCLUSION: Based on the large-scale cross-sectional study in a German population-based sample of children and adolescents we detected inverse associations between 25(OH)D concentrations and both parent- and self-rated SDQ scores of the total difficulties scale and different subscales with the strongest association in the subsample aged ≥12-<18 years for both genders. Migration background and socioeconomic status were detected as relevant confounders. Further studies-particularly in countries with comparatively low mean 25(OH)D concentrations-in childhood and adolescence are warranted. Longitudinal studies are also necessary to infer direction of effects. Finally, RCTs in children and adolescents are required to determine whether Vitamin D is beneficial for mental health.

[The School Refusal Assessment Scale: Psychometric properties and validation of a modified version]. / Die Einschätzungsskala der Schulverweigerung: Psychometrische Gütekriterien und Validierung einer modifizierten Version.

Objective: Psychometric properties of the original and a modified version of the «Einschätzungsskala der Schulverweigerung¼ (German version of the School Refusal Assessment Scale, SRAS; Kearney & Silverman, 1993; Overmeyer et al., 1994) were analyzed in order to identify alternative ways to revise the SRAS/ESV compared to the existing revision SRAS-R (Kearney, 2002). The SRAS/ESV consists of a parent and a child version and measures four functions of school refusal (avoidance of negative affect related to school settings, escape from aversive social or evaluative situations, attention-getting behavior, positive tangible reinforcement). Method: Data from N = 124 (parent version) respectively N = 156 (child version) patients of a specialized psychiatric outpatient unit for children and adolescents with school-avoiding behavior were obtained. Analyzes included characteristics of items and scales, face-, factorial-, and construct-validity (correlations with other questionnaires, e. g., YSR, CBCL were analyzed). Results: Many items seem to measure overall anxiety instead of the functional aspects of school refusal, one item measures expansive behavior. Four factors were obtained, but they did not reflect the assumed structure of the ESV (e. g., overlap of the two avoidance-related scales). Post-hoc-analyzes with a modified version (elimination of several items with problematic content validity) suggested three factors, convergent and discriminative validity of the modified version was confirmed. Because only some of the afore-mentioned problems have been addressed in the revised version (SRAS-R; Kearney, 2002), a new revision and extension of the German version of the questionnaire covering more aspects of school avoidance behavior (e. g., bullying, depression, somatic complaints, psychosocial factors) is discussed.

The Treatment of School Avoidance in Children and Adolescents With Psychiatric Illness.

BACKGROUND: 5-10% of schoolchildren in Germany are absent from school without an excuse more than five times per year. We investigate the effectiveness of manual-based, multimodal cognitive behavioral therapy focusing on school-avoidant behavior and on the underlying mental disorders. METHODS: 112 school avoiders were recruited from an outpatient child and adolescent psychiatric clinic and adaptively randomized into two treatment groups. The first group received manual-based multimodal treatment (MT), the second group treatment as usual (TAU) in the child and adolescent mental health care system. The primary outcome of the study was the percentage of classes attended in the five days prior to first measurement (before the intervention), as well as 6 and 12 months afterward. In each of these periods, school attendance was characterized as regular, partial, or none. Secondary outcomes were the severity of anxiety and depressive symptoms, self-efficacy, and quality of family life. RESULTS: In both treatment arms, the percentage of regular school attenders rose to about 60% in 6 months, regardless of the intervention (MT 60.6%, TAU 58.3%; odds ratio [OR] for changes over baseline 6.94, 95% confidence interval [CI] 3.98-12.12, p< 0.001; OR for MT versus TAU 1.05, 95% CI 0.58-1.90, p = 0.875). The improvement persisted 12 months after inclusion. CONCLUSION: In accordance with earlier studies, we found that manual-based multimodal treatment did not improve school avoidance to any greater extent than treatment as usual. Future studies should focus on the conditions for successful reintegration in school and on the differential indicators for outpatient versus inpatient treatment.

[The differential classification of school avoidance- a cluster-analytic investigation]. / Differentielle Klassifikation schulvermeidenden Verhaltens.

OBJECTIVE: We investigated subtypes of school-avoiding children and adolescents in a German sample using cluster analysis. METHOD: 169 outpatients of a specialized outpatient unit for children and adolescents with school-avoiding behavior were subjected to cluster analysis using factor scores (principal factoring, varimax-rotation: measures of internalizing and externalizing symptoms, e.g., CBCL, YSR, and variables indicating the quality of school avoiding behavior, such as initial parental knowledge of school absence, activities during school absence). The resulting clusters were compared to other variables such as parental mental health problems, parental divorce, bullying in school, class repetition, and IQ. RESULTS: Three groups were identified: "school refusers" with low externalizing symptoms who mainly stayed at home with their parents and were informed about their school absence from the beginning. Second, the "truants" with strong externalizing symptoms who spent school time alone or together with peers outside their home and were absent in school without initial parental knowledge. In a third cluster, children showed more externalizing problems than the school refusers and less externalizing problems than the truants. Most of their parents were informed about the school absence from the beginning, although the dominant activity was staying at home alone. Internalizing symptoms had no impact on cluster formation. Comparisons of the three groups, however, showed higher internalizing problems for school refusers and the third cluster, which was then labeled "school avoidance with mixed symptoms." RESULTS AND CONCLUSIONS: In most cases, significant differences regarding potential stressors at home (e.g., parental mental health problems) or in school (e.g., bullying, class repetition) were not obtained.

Impact of an 18-month, NHS-based, treatment exposure for heroin dependence: results from the London Area Treat 2000 Study.

We set out to examine the impact of treatment for heroin dependence on drug use, injecting behavior, health problems, criminality, and physical and mental health over 18 months among heroin-dependent Londoners. A total of 100 heroin users were recruited for this longitudinal prospective cohort study with repeated measures (T0 as baseline, T1 after 9 months, and T2 after 18 months). The psychiatric evaluation and assessment of drug abuse levels were determined by the CIDI and the EuropASI. Additional evaluations included the WHO-DAS II for disability assessment and the UCLA-SSI for social support. The number of days of heroin use in the 30 days previous to each single assessment significantly reduced over time (p < .001). Similar reduction levels were observed for cocaine (p < .05), benzodiazepines (p < .001), and polydrug abuse (p < .001), but not for cannabis and alcohol. The number of injecting occasions reduced in parallel, with increase in days in work and reduction of money spent for drug acquisition activities and money obtained from criminal/illegal activities. The number of subjects experiencing suicidal ideation reduced over time (p < .05). In line with previous suggestions, significant reductions in drug use, criminality, psychopathology, and injecting behavior following treatment exposure for heroin dependence were observed. It is, however, of concern that alcohol and cannabis misuse levels remained unchanged.

School avoidance from the point of view of child and adolescent psychiatry: symptomatology, development, course, and treatment.

BACKGROUND: A considerable percentage of children and adolescents who avoid school have mental illnesses. This article reviews the typical manifestations, classification, development, course, and treatment of school-avoiding behavior. METHODS: Based on a selective review of recent literature, we present findings on the psychopathologically relevant features of school-avoiding children and adolescents, including psychiatric diagnoses, developmental, family-related, and psychological test variables. The emphasis is placed on our own studies of the subject. RESULTS: Although the evidence from the studies that have been performed to date is not definitive, the available findings show that school avoidance is associated with poor mental health and with unfavorable consequences onward into adulthood. Its causes include a number of individual and social stressors that place excessive demands on the affected children and adolescents and lead them to avoid school as a coping attempt. CONCLUSIONS: Many preventive and therapeutic interventions are now available, but the existing measures need to be better coordinated, and more effort needs to be directed to the early recognition and treatment of school-avoiding behavior. Physicians should consider the possibility of mental illness. Rather than writing sick notes or prescribing mother-child treatments at health resorts, which rather tend to sustain the problem, they should refer patients promptly to a child and adolescent psychiatrist.

Criteria for the successful completion of medical dissertations - A multicenter study.

OBJECTIVE: In order to acquire the academic title "doctor" in Germany, it is essential to complete a dissertation. A high number of publications at German universities are based on medical dissertations. The reasons why some dissertations are successfully accomplished and why some are not completed - despite far-reaching consequences - have been barely investigated to date. METHODS: 467 students in the ninth semester at five German universities participated in this study in 2003. A questionnaire (return rate 93.5%) was used, asking details about the circumstances of a current or completed dissertation (Group A), an abandoned doctoral project (Group B), or one which was never started (Group C). RESULTS: Students in Group A referred significantly more often to their supervisor as being essential for choosing the topic of their dissertation project. Furthermore, students in Group A worked together with other students in self-organized support groups to debate methodological questions. They also discussed their project more frequently with a statistician. Students in Group C gave "interference with undergraduate studies" and "no time" as the most common reasons for not starting a dissertation. CONCLUSIONS: As the supervisor seems to play an important role for the successful completion of dissertations, universities should think about professional programs that would prepare supervisors for this educational task. Courses for doctoral candidates in scientific research methodology could also be a helpful tool toward successfully accomplishing a doctoral thesis or scientific projects in general.

Differences between men and women in the course of opiate dependence: is there a telescoping effect?

According to the so-called telescoping effect, there is a gender-specific course of alcohol dependence with women starting alcohol use later than men and having a faster development of harmful consequences. There are inconsistent data regarding a telescoping effect in opiate dependence. In each of six European centres, 100 opiate addicts were investigated by a structured interview (mainly the EuropASI and CIDI) at admission to various kinds of treatment (TREAT project). In a secondary analysis of the TREAT data, women and men were compared regarding age at onset of heroin use and the current severity of addiction. In addition, a comparison of female (n = 140) and male (n = 140) addicts matched for age and study centre were carried out. Eventually, multiple logistic and linear regressions were done with the interaction term of gender and time of regular consumption as predictor for the severity of dependence, besides, other sociodemographic variables. There was no difference between genders regarding the age at onset of regular heroin consumption. Up to 4 years of regular consumption, there are gender-specific differences in the course of opiate dependence, e.g. a faster progression of legal problems in men and social problems in women. There were no differences in the severity of dependence other than more economic problems for women. A telescoping effect could only partially be observed in this large sample of opiate addicts. A gender-specific course was limited to the first years of consumption, and included domains with a faster progression for men. It has to be assumed that opiate dependence is a rapidly developing disorder with early chronification. Afterwards, only individual courses with influences of the national treatment system were observed.