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The psychosocial health of children and adolescents has been particularly affected by the COVID-19 pandemic. Containment measures have restricted social development, education and recreational activities, may have increased family conflicts and, in many cases, led to feelings of loneliness, sleep disturbances, symptoms of anxiety and depression. We conducted a systematic review to identify interventions that seek to ameliorate these detrimental effects of the COVID-19 pandemic and to build resilience in children and adolescents. Literature searches were conducted in the databases MEDLINE, EMBASE, PsycINFO, CENTRAL, WHO COVID-19 Global literature on coronavirus disease and Cochrane COVID-19 Study Register (up to 30 June 2022). The searches retrieved 9557 records of which we included 13 randomized-controlled trials (RCTs) for evidence synthesis. Included studies predominantly implemented online group sessions for school-aged children with either a psychological component, a physical activity component, or a combination of both. A meta-analysis of seven studies on anxiety and five on depressive symptoms provided evidence for a positive effect of interventions by reducing anxiety (Standardized Mean Difference (SMD) (95% CI): - 0.33 (- 0.59; - 0.06)) and depressive symptoms (SMD (95% CI): - 0.26 (- 0.36; - 0.16)) compared to the control interventions. Studies also showed improvements in positive mental health outcomes, such as resilience (n = 2) and mental and psychological wellbeing (n = 2). Exploratory subgroup analyses suggested a greater effectiveness of interventions that (i) are of higher frequency and duration, (ii) enable personal interaction (face-to-face or virtually), and (iii) include a physical activity component. Almost all studies were judged to be at high risk of bias and showed considerable heterogeneity. Further research may focus on the contribution of different intervention components or distinct subgroups and settings, and should examine children and adolescents over longer follow-up periods., Competing Interests: Declarations. Conflict of interest: AM, CJS, ER, MC were involved and cooperated in studies related to health in children in the COVID pandemic such as COVID KIDS Bavaria, COSMO and others. AMK is currently in training in child/adolescent CBT. Institutional review board statement: Not applicable. Informed consent: Not applicable., (© 2023. The Author(s).)

The COVID-19 pandemic has had profound effects on the mental health of children and adolescents worldwide, exacerbating existing challenges and introducing new stressors. This paper explores the impact of risk and protective factors on the mental well-being of young individuals during the pandemic. Using data from the German nationwide, population-based, longitudinal COPSY study (n = 2,471, girls: 50.0%, age 7-17 years) spanning nearly three years, this study investigates how factors such as gender, age, parental education, parental depressive symptoms, family cohesion, and social support influence mental health. Mental health problems were assessed using the Strengths and Difficulties Questionnaire (SDQ). Latent growth analysis and structural equation modeling were employed to analyze cross-sectional and longitudinal data collected at five measurement points (initial response rate: 46.8%). Findings revealed that boys and younger children are at a higher risk for mental health problems. Additionally, low parental education, single parenthood, parental burden due to the pandemic and parental depressive symptoms were significantly linked with mental health problems in children. Conversely, personal resources, family cohesion, and social support were associated with less symptoms. Family cohesion additionally buffered against the negative impact of parental depressive symptoms. The study underscores the importance of multi-level interventions that consider individual, familial, and societal factors in promoting positive mental health outcomes among children and adolescents during challenging times. Continued research and collaborative efforts are needed to develop evidence-based strategies for supporting the resilience of young individuals in the face of future adversities., (© 2024. The Author(s).)

A medium-to-high level of physical activity (PA) may have at least a short-term positive effect on psychopathology in children and adolescents. Hence, the objective of this study was to investigate the long-term effects of PA in non-adult age groups on their general mental health problems and/or ADHD symptoms, using trajectories of concurrent development over a period of 10 years. This study employed data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) collected at three time points (baseline, Wave 1, Wave 2, over 10 years) from 17,640 children and adolescents. Using parent-reported data from the Strengths and Difficulties Questionnaire (SDQ), different developmental trajectories of general mental health problems (SDQ-total) and ADHD symptoms (SDQ-H/I) were identified with latent class mixed models (LCMM) statistics. This was also applied to parent- and self-reported data of three levels of PA. The latter was assessed according to WHO recommendations. The joint probability of class membership for SDQ-total as well as ADHD symptoms with PA was calculated to generate the concurrent developmental trajectories between variables. Results showed a 4-class trajectory model for both SDQ-total and ADHD symptoms among boys and girls. The majority of children and adolescents showed "low general difficulties" and "low ADHD symptoms" over the period of 10 years. Three distinct trajectories in boys and four distinct trajectories in girls were found for PA. Most of the participants showed an "increasing-decreasing activity" trajectory. No statistically significant correlations were found between the different SDQ-total or ADHD symptom trajectories and the trajectories of PA in the two genders. Taken together, our findings did not indicate any significant relationship between waxing and waning PA course over 10 years and various classes of mental health problems for children and adolescents. In contrast to our cross-sectional findings, no steady long-term medium/high-level of PA was present, which could (at least partly) explain the non-significant findings., (© 2024. The Author(s).)

Affective dysregulation (AD) is characterized by irritability, severe temper outbursts, anger, and unpredictable mood swings, and is typically classified as a transdiagnostic entity. A reliable and valid measure is needed to adequately identify children at risk of AD. This study sought to validate a parent-rated screening questionnaire, which is part of the comprehensive Diagnostic Tool for Affective Dysregulation in Children (DADYS-Screen), by analyzing relationships with comprehensive measures of AD and related mental disorders in a community sample of children with and without AD. The sample comprised 1114 children aged 8-12 years and their parents. We used clinical, parent, and child ratings for our analyses. Across all raters, the DADYS-Screen showed large correlations with comprehensive measures of AD. As expected, correlations were stronger for measures of externalizing symptoms than for measures of internalizing symptoms. Moreover, we found negative associations with emotion regulation strategies and health-related quality of life. In receiver operating characteristic (ROC) analyses, the DADYS-Screen adequately identified children with AD and provided an optimal cut-off. We conclude that the DADYS-Screen appears to be a reliable and valid measure to identify school-aged children at risk of AD., (© 2023. The Author(s).)

Analyzing COVID-19-related stress in children with affective dysregulation (AD) seems especially interesting, as these children typically show heightened reactivity to potential stressors and an increased use of maladaptive emotion regulation strategies. Children in out-of-home care often show similar characteristics to those with AD. Since COVID-19 has led to interruptions in psychotherapy for children with mental health problems and to potentially reduced resources to implement treatment strategies in daily life in families or in out-of-home care, these children might show a particularly strong increase in stress levels. In this study, 512 families of children without AD and 269 families of children with AD reported on COVID-19-related stress. The sample comprised screened community, clinical, and out-of-home care samples. Sociodemographic factors, characteristics of child and caregiver before the pandemic, and perceived change in external conditions due to the pandemic were examined as potential risk or protective factors. Interestingly, only small differences emerged between families of children with and without AD or between subsamples: families of children with AD and families in out-of-home care were affected slightly more, but in few domains. Improvements and deteriorations in treatment-related effects balanced each other out. Overall, the most stable and strongest risk factor for COVID-19-related stress was perceived negative change in external conditions-particularly family conditions and leisure options. Additionally, caregiver characteristics emerged as risk factors across most models. Actions to support families during the pandemic should, therefore, facilitate external conditions and focus on caregiver characteristic to reduce familial COVID-19-related stress. Trial registration: German Clinical Trials Register (DRKS), ADOPT Online: DRKS00014963 registered 27 June 2018, ADOPT Treatment: DRKS00013317 registered 27 September 2018, ADOPT Institution: DRKS00014581 registered 04 July 2018., (© 2022. The Author(s).)

Background: The COVID-19 pandemic has disrupted the lives of children and adolescents worldwide. The German COPSY study is among the first population-based longitudinal studies to examine the mental health impact of the pandemic. The objective of the study was to assess changes in health-related quality of life (HRQoL) and mental health in children and adolescents and to identify the associated risk and resource factors during the pandemic., Methods: A nationwide longitudinal survey was conducted with two waves during the pandemic (May/June 2020 and December 2020/January 2021). In total, n = 1923 children and adolescents aged 7 to 17 years and their parents participated (retention rate from wave 1 to wave 2: 85%). The self-report and parent-proxy surveys assessed HRQoL (KIDSCREEN-10), mental health problems (SDQ with the subscales emotional problems, conduct problems, hyperactivity, and peer problems), anxiety (SCARED), depressive symptoms (CES-DC, PHQ-2) and psychosomatic complaints (HBSC-SCL). Mixed model panel regression analyses were conducted to examine longitudinal changes in mental health and to identify risk and resource factors., Results: The HRQoL of children and adolescents decreased during the pandemic, and emotional problems, peer-related mental health problems, anxiety, depressive and psychosomatic symptoms increased over time, however the change in global mental health problems from wave 1 to wave 2 was not significant, and some changes were negligible. Socially disadvantaged children and children of mentally burdened parents were at particular risk of impaired mental health, while female gender and older age were associated with fewer mental health problems. A positive family climate and social support supported the mental health of children and adolescents during the pandemic., Discussion: Health promotion, prevention and intervention strategies could support children and adolescents in coping with the pandemic and protect and maintain their mental health., (© 2021. The Author(s).)

The COVID-19 pandemic has caused unprecedented changes in the lives of 1.6 billion children and adolescents. First non-representative studies from China, India, Brazil, the US, Spain, Italy, and Germany pointed to a negative mental health impact. The current study is the first nationwide representative study to investigate the impact of the COVID-19 pandemic on health-related quality of life (HRQoL) and mental health of children and adolescents in Germany from the perspective of children themselves. A representative online survey was conducted among n = 1586 families with 7- to 17-year-old children and adolescents between May 26 and June 10. The survey included internationally established and validated instruments for measuring HRQoL (KIDSCREEN-10), mental health problems (SDQ), anxiety (SCARED), and depression (CES-DC). Results were compared with data from the nationwide, longitudinal, representative BELLA cohort study (n = 1556) conducted in Germany before the pandemic. Two-thirds of the children and adolescents reported being highly burdened by the COVID-19 pandemic. They experienced significantly lower HRQoL (40.2% vs. 15.3%), more mental health problems (17.8% vs. 9.9%) and higher anxiety levels (24.1% vs. 14.9%) than before the pandemic. Children with low socioeconomic status, migration background and limited living space were affected significantly more. Health promotion and prevention strategies need to be implemented to maintain children's and adolescents' mental health, improve their HRQoL, and mitigate the burden caused by COVID-19, particularly for children who are most at risk., (© 2021. The Author(s).)

Mental health and well-being are of great interest in health policy and research. Longitudinal surveys are needed to provide solid population-based data. We describe the design and methods of an 11-year follow-up of the German BELLA study in children, adolescents and young adults, and we report on age- and gender-specific courses of general health and well-being, long-term health-related outcomes of mental health problems, and mental health care use. The BELLA study is the module on mental health and well-being within the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Standardised measures were used at each of the five measurement points of the BELLA study. In the 11-year follow-up, young people aged 7-31 years participated (n = 3492). Individual growth modelling, linear regression and descriptive analyses were conducted. Self-reported general health and well-being were both better in younger (vs. older) and in male (vs. female) participants according to the data from all five measurement points. Mental health problems in childhood and adolescence (measured at baseline) predicted impaired health outcomes at 6-year and 11-year follow-ups. Approximately one out of four children with a diagnosed mental disorder was not undergoing mental health treatment. With its 11-year follow-up, the prospective longitudinal BELLA study provides new and solid data on mental health and well-being from childhood to adulthood in Germany, and these data are important for health promotion and prevention practices. These results are consistent with previous findings. Promising future analyses are planned., (© 2020. The Author(s).)

Children of parents with mental health problems (CPM) have an increased risk for behavioral and psychological problems. This study investigated the age- and gender-specific course as well as predictors of mental health problems in CPM using the longitudinal data (baseline 1- and 2-year follow-ups) of a German general population sample from the BELLA study. Children and adolescents aged 11-17 years (at baseline) who had a parent with mental health problems (n = 325) were analyzed. The mental health problems of the children were assessed by the self-reported version of the strengths and difficulties questionnaire (SDQ). We used individual growth modeling to investigate the age- and gender-specific course, and the effects of risk as well as personal, familial and social protective factors on self-reported mental health problems in CPM. Additionally, data were examined differentiating internalizing and externalizing mental health problems in CPM. Results indicated that female compared to male CPM showed increasing mental health problems with increasing age. Mental health problems in CPM were associated with lower self-efficacy, worse family climate and less social competence over time. Internalizing problems were associated with lower self-efficacy, less social competence and more severe parental mental health problems. Externalizing problems were associated with lower self-efficacy, worse family climate and lower social competence. The main limitations of the study are the short time period (2 years) covered and the report of mental health problems by only one parent. Our findings should be considered in the development of treatment and prevention programs for mental health problems in CPM.

We examined whether there are certain dysregulation profile trajectories in childhood that may predict an elevated risk for mental disorders in later adolescence. Participants (N = 554) were drawn from a representative community sample of German children, 7-11 years old, who were followed over four measurement points (baseline, 1, 2 and 6 years later). Dysregulation profile, derived from the parent report of the Strengths and Difficulties Questionnaire, was measured at the first three measurement points, while symptoms of attention deficit hyperactivity disorder (ADHD), anxiety and depression were assessed at the fourth measurement point. We used latent class growth analysis to investigate developmental trajectories in the development of the dysregulation profile. The predictive value of dysregulation profile trajectories for later ADHD, anxiety and depression was examined by linear regression. For descriptive comparison, the predictive value of a single measurement (baseline) was calculated. Dysregulation profile was a stable trait during childhood. Boys and girls had similar levels of dysregulation profile over time. Two developmental subgroups were identified, namely the low dysregulation profile and the high dysregulation profile trajectory. The group membership in the high dysregulation profile trajectory (n = 102) was best predictive of later ADHD, regardless of an individual's gender and age. It explained 11% of the behavioural variance. For anxiety this was 8.7% and for depression 5.6%, including some gender effects. The single-point measurement was less predictive. An enduring high dysregulation profile in childhood showed some predictive value for psychological functioning 4 years later. Hence, it might be helpful in the preventive monitoring of children at risk.

Data on mental health care use of children and adolescents in Germany is scarce. This study investigates the degree of mental health care use, its trajectories and influencing factors among children and adolescents in Germany, using longitudinal data of the BELLA study. The BELLA study is the mental health module of the representative German National Health Interview and Examination Survey for children and adolescents (KiGGS). Baseline data of N = 2,863 participants aged 7-17 years were collected between 2003 and 2006. The study sample was followed up in three additional measurement points, assessing general mental health problems and impairment, specific mental health problems, and mental health care use. In the current study, we analysed data from the first three measurement points. At baseline, 5.9 % of all participants used mental health care in the past 12 months. Among those with general mental health problems, 29.5 % sought professional help. Only a minority of participants reporting mental health care use at baseline also sought help at the following two measurement points. Analysing a random intercept only model, mental health care use was found to be more likely among participants living in larger communities as well as in the Eastern part of Germany, among those participants with impairment of mental health problems, and signs of externalizing problems. Our results indicate a temporary character of mental health care use. Participants' impairment was identified to be the strongest predictor of mental health care use.

Comparatively little information is available from population-based studies on subgroup trajectories of attention-deficit/hyperactivity disorder (ADHD) core symptoms of inattention and hyperactivity-impulsivity (particularly as defined by DSM-IV and ICD-10). Recent report of a subgroup with high and increasing inattention symptoms across development requires replication. To identify the different trajectory subgroups for inattention, hyperactivity-impulsivity and total symptoms of ADHD in children and adolescents aged 7-19 years. Eleven birth cohorts from 2,593 families with children and adolescents who had parent ratings for the outcome measures of inattention, hyperactivity-impulsivity or total symptoms were considered. Data were analysed using an accelerated longitudinal design and growth mixture modelling was applied to detect subgroups. For all three outcome measures, three trajectories with low (78.3-83.3 %), moderate (13.4-18.8 %) and high (2.8-3.2 %) symptom levels were detected. Course within these subgroups was largely comparable across outcome domains. In general, a decrease in symptoms with age was observed in all severity subgroups, although the developmental course was stable for the high subgroups of inattention and total symptoms. About 3 % of children in a community-based sample follow a course with a high level of ADHD symptoms. In this high trajectory group, hyperactivity-impulsivity symptoms decrease with age from 7 to 19 years, whilst inattention and total symptoms are stable. There was no evidence for an increase in symptoms across childhood/adolescence in any of the severity groups.

Background: Scientifically sound and valid information concerning course and prediction of mental health problems in children and adolescents in the general population is scarce, although needed for public mental health issues and daily clinical practice., Objectives: The psychopathological profiles of children and adolescents were analysed using the parent version of the Strengths and Difficulties Questionnaire (SDQ-P) in a longitudinal setting, also investigating the predictive value of the SDQ-scores., Methods: SDQ's total psychopathological difficulties, emotional symptoms and hyperactivity-inattention scores of n = 630 children and adolescents (age 6-18;11 years) were examined along four assessment measurement points (T0-T3) over 6 years, using data from the BELLA study. According to the English normative data, the participants were categorized as "normal", "borderline" or "abnormal" based on their SDQ-scores. Groups remaining within categories were descriptively determined by means of frequency analysis, a subsequent graphical evaluation displayed the transitions from T0 to T3 concerning the different categorical classifications. Finally, ordered probit regression was used to examine whether age, gender, socio-economic status (SES) and baseline impact-score (IS) correspond to the SDQ-predicted classification., Results: As expected, low SES and high SDQ-IS were associated with significantly increased scores on all examined SDQ-scales. Regarding the long-term aspect of SDQ-scores it could be shown that most children and adolescents remained "normal" over a measurement period of 6 years, while only a small number of children and adolescents steadily remained "abnormal" or newly developed mental health problems, respectively. For example, on the "hyperactivity-inattention"-scale, only 1 % of the children and adolescents changed from "normal" to "abnormal" (T0-T3), whereas on the "emotional symptoms"-scale, 7 % changed from "normal" to "abnormal" (T0-T3). In general, the SDQ-category "borderline" and specifically the subscale "emotional symptoms" change in both directions. Abnormal SDQ-scores at baseline, SES, gender and IS were related to the prediction of the SDQ-sores at T3., Conclusion: An SDQ-screening of children and adolescents may help for early detection, prediction and treatment planning. Also, these results may contribute to a better understanding of the course of mental health problems in childhood and concurrently may allow a better psychoeducation and prevention.

The high prevalence of mental health problems (MHP) in childhood and adolescence is a global health challenge of the 21st century. Information about age of onset, persistence and development of MHP in young people is necessary to implement effective prevention and intervention strategies. We describe the design and methods of the longitudinal BELLA study, which investigates developmental trajectories of MHP from childhood into adulthood, their determinants, and the utilisation of mental health services. First results on the developmental course of MHP in children and adolescents are reported over a 6-year period. The BELLA study is the mental health module of the German National Health Interview and Examination Survey for children and adolescents (KiGGS). BELLA examines the mental health and well-being of children and adolescents aged 7-17 years (a representative subsample of KiGGS, n = 2,863 at baseline). Standardised screening measures served to identify MHP at baseline and at follow-ups (1, 2, and 6 years later). Among children and adolescents participating at all measurement points (n = 1,255), 10 % showed clinically significant MHP at baseline (n = 130). Over the 6-year period, 74.3 % showed no signs of MHP (n = 933), 15.5 % had remitted (n = 194), 2.9 % showed persistent (n = 36) and 7.3 % acute or recurrent MHP (n = 92). Overall, MHP were more likely to occur between the age of 7 and 12 and after the age of 19 years. Regarding mental health service use, 33 % of the participants with acute or recurrent MHP (n = 30) and 63.9 % with persistent MHP used mental health services (n = 23). Mental health problems in children and adolescents have a high risk to persist into adulthood. In children and adolescents a low rate of mental health service use was observed, even among those with mental health problems.

Mental health problems in children and adolescents are frequent, with a high risk of persistence into adulthood. Therefore, the investigation of determinants of onset and course of mental health problems is of high importance. The present paper investigates the impact of protective and risk factors on the development of depressive symptoms in children and adolescents. The BELLA study is the mental health module of the German National Health Interview and Examination Survey for children and adolescents (KIGGS). Based on the first three measurement points of the BELLA study (covering a period of 2 years), the present analysis focused on children and adolescents aged 11-17 years at baseline (n = 1,643; 50.6 % female). A longitudinal growth modelling approach was used. Mental health problems in parents (parent-reports) predicted depressive symptoms in children and adolescents (self-reports) as well as the development of these symptoms over time. Further, child-reported protective factors of self-efficacy, positive family climate and social support were associated with less depressive symptoms at baseline. Additionally, positive changes in protective factors were associated with the development of less depressive symptoms over time. Finally, family climate and social support moderated the detrimental influence of parental psychopathology on child's depressive symptoms. The addressed determinants for the development of depressive symptoms in children and adolescents are highly relevant for prevention and intervention strategies. Future research should investigate specific risk and protective factors focusing in detail on further mental health disorders and their development in children and adolescents.

Psychosomatic health complaints (PHC) can significantly impair psychosocial development of children and adolescents and are therefore of considerable interest in health sciences and public health surveillance. Questions addressed the type of function that describes individual trajectories best, potential differences between these, and corresponding predictors from the perspective of both children and their parents. Based on the German population-based and representative BELLA cohort sample, 2,857 children and adolescents between 7 and 17 years of age at baseline were analysed over a period of 3 years with yearly follow-ups using mixed growth curve analyses. PHC were measured in accordance with the health behaviour in school-aged children-symptom checklist. The mean level of PHC was rather low, slightly lower for the parent report than for the self-report and significantly different between subjects. Concerning the parent report, the 2-year course is best described by a slowly increasing linear trend that decelerates somewhat over time. The increasing linear trend was more pronounced in the self-report from 11 to 17 years of age, but was significantly different for each subject and correlated with baseline scores. Trajectories could be explained by known predictors, most importantly by mental health problems of the child or adolescent. The results confirm the findings of previous studies and provide representative data about the individual short-term development of PHC in children and adolescents in Germany.

This study reports the outcomes of childhood and adolescent eating-disordered behaviour on the development of body mass index (BMI) and psychological functioning in young adulthood in a population-based sample in Germany (the BELLA study). Information at baseline and follow-up was obtained through a telephone interview and mailed self-report questionnaires. At both measurement points, BMI, eating disorder symptoms (SCOFF questionnaire), and symptoms of depression and anxiety were assessed in the same cohort of 771 participants (n = 420 females, n = 351 males). The age range at baseline was 11-17 years, and the age range at follow-up was 17-23 years. High scores for eating-disordered behaviour in childhood or adolescence significantly predicted eating-disordered behaviour in young adulthood (multiplicative effect estimate: 1.31; 95 % CI: 1.2-1.42, p < 0.0001), although there was a decline in prevalence (from 19.3 to 13.8 %, p = 0.002) and severity (mean decrease in SCOFF 0.07, 95 % CI: -0.01-0.14, p = 0.06). After accounting for potentially confounding variables at baseline (SES, probands' BMI, parental BMI, depressive symptoms), participants with more eating disorder symptoms at baseline had a higher risk of developing overweight (odds ratio (OR): 1.58; 95 % CI: 1.19-2.09, p = 0.001), obesity (OR = 1.67; 95 % CI: 1.03-2.66, p = 0.03), and depressive symptoms at follow-up (additive effect estimate: 0.45; 95 %CI: 0.19-0.7, p = 0.0006). Early symptoms of depression showed a significant relationship with extreme underweight in young adulthood (OR = 1.13; 95 %CI: 1.01-1.25, p = 0.02). The high stability of eating disorder symptoms and the significant association with overweight and worse mental health in adulthood underscore the need for early detection and intervention during childhood and adolescence. Youth with depression should be monitored for the development of restrictive eating disorders.

Although a higher prevalence of overweight/obesity was reported in clinical samples of patients with Attention-Deficit/Hyperactivity Disorder (ADHD), an association between overweight and ADHD has yet not been established in the general population in childhood. As both disorders are common and significantly affect psychosocial functioning, we investigated the prevalence of ADHD in overweight/obese youth and vice versa. In a cross-sectional nationally representative and community based survey 2,863 parents and their children aged 11-17 years rated symptoms on the Diagnostic and Statistical Manual of Mental Disorders-based German ADHD Rating scale. Weight and height were assessed by professionals. Body mass index was categorized according to national age and sex specific reference values. Overall, 4.2% of the respondents met criteria for ADHD. The prevalence of ADHD was significantly higher for overweight/obese (7%) than for normal weight (3.5%) and underweight (4.9%) children. In a logistic regression analysis controlling for age, gender, and socio-economic status, overweight/obese children were twice as likely to have an ADHD diagnosis (OR = 2.0). Vice versa, adjusting for all covariates, children with ADHD had an OR of 1.9 for overweight/obesity status. For all weight-status groups, children with ADHD more frequently reported eating problems as compared to their non-clinical counterparts. Overweight/obese respondents with ADHD displayed the highest level of health services utilization. A clinician should be aware of the significant risk for a child with ADHD to become overweight and for an overweight child to have ADHD. Longitudinal studies are needed to better understand the mechanisms underlying the association between ADHD and overweight/obesity.

Background: The consideration of impairment plays a crucial role in detecting significant mental health problems in children whose symptoms do not meet diagnostic criteria. The assessment of impairment may be particularly relevant when only short screening instruments are applied in epidemiological surveys. Furthermore, differences between childrens' and parents' perceptions of present impairment and impairing symptoms are of interest with respect to treatment-seeking behaviour., Objectives: The objectives were to assess parent- and self-reported impairment due to mental health problems in a representative sample of children and adolescents; to describe the characteristics of highly impaired children with normal symptom scores; and to investigate the associations between symptoms in different problem areas and impairment., Methods: The mental health module of the German Health Interview and Examination Survey for Children and Adolescents (the BELLA study) examined mental health in a representative sub-sample of 2,863 families with children aged 7-17. Self-reported and parent-reported symptoms of mental health problems and associated impairment were identified by the extended version of the strengths and difficulties questionnaire (SDQ) in children 11 years and older., Results: Considerable levels of distress and functional impairment were found with 14.1% of the boys and 9.9% of the girls being severely impaired according to the parental reports. However, self-reported data shows a reversed gender-difference as well as lower levels of severe impairment (6.1% in boys; 10.0% in girls). Six percent of the sampled children suffer from pronounced impairment due to mental health problems but were not detected by screening for overall symptoms. Childrens' and parents' reports differed in regard to the association between reported symptom scores and associated impairment with children reporting higher impairment due to emotional problems., Conclusions: The assessment of impairment caused by mental health problems provides important information beyond the knowledge of symptoms and helps to identify an otherwise undetected high risk group. In the assessment of impairment, gender-specific issues have to be taken into account. Regarding the systematic differences between childrens' and parents' reports in the assessment of impairment, the child's perspective should be given special attention.

Background: The strengths and difficulties questionnaire (SDQ) is a brief screening instrument that addresses negative and positive behavioural attributes of children and adolescents in the age range of 4-16 years and can be completed by parents, teachers, and as a self-report. Furthermore, the impact supplement of the extended SDQ surveys for perceived problems, impact, and burden., Objective: This paper aims to examine the psychometric properties of the parent form and to investigate differences in the SDQ scores for sociodemographic and socioeconomic subgroups. Patterns of association with other measures of mental health and descriptive comparison with the first normative sample are also reported., Methods: Within the BELLA study module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a total of 2,406 children and adolescents aged 7-16 years as well as their parents answered the items of the SDQ and the additional impact supplement. The internal consistency of scale responses was assessed via Cronbach's alpha (alpha). Likert scale assumptions of sufficient and similar item-total correlation and item variance were investigated. The factorial validity of the SDQ measurement model was tested by means of exploratory and confirmatory factor analysis. Mean score differences between males and females, age groups (7-10 years vs. 11-16 years), and socioeconomic status groups (Winkler index) were examined via ANOVA., Results: Factor analysis provided an exact replication of the original five-factor SDQ subscale structure. All subscales were sufficiently homogeneous. The mean total difficulties and SDQ subscale scores of the BELLA sample did not differ from the first German normative data. Younger children were more impaired on various SDQ scales than older children, girls were more emotionally affected, and boys showed more externalising problems., Conclusions: The present study confirmed the validity and reliability of the parent-reported SDQ scale structure. The SDQ was found to be a valid and helpful questionnaire for use in the framework of an epidemiological survey.

Background: Over the past decades the public health relevance of mental health conditions in children and adolescents has been of growing concern. However, so far no detailed epidemiological data has been available for a representative national sample in Germany., Objectives: The present paper reports prevalence rates of general and specific mental health problems among children and adolescents in Germany and describes the link between symptoms and impairment as well as the treatment situation., Methods: The mental health module (BELLA study) examines mental health problems in a representative sub-sample of 2,863 families with children aged 7-17 from the National Health Interview and Examination Survey among Children and Adolescents (KiGGS). Mental health problems were determined using the extended version of the strengths and difficulties questionnaire (SDQ). Further standardised screening measures were employed to screen for anxiety disorders (SCARED), conduct disorder (CBCL), attention deficit-/hyperactivity disorder (FBB-HKS, Conners' Scale) and depressive disorders (CES-DC). Furthermore, substance abuse and suicidal tendencies were assessed. Health-related quality of life (HRQoL) and health care use were determined., Results: Overall, 14.5% of the children and adolescents aged 7-17 fulfilled the criteria for at least one specific mental health problem associated with impairment, or had an overall mental health problem indicated by an abnormal SDQ score and present impairment. However, high comorbidity was found in the children concerned. Symptoms of overall mental health problems were present in 8.6% of the children and 6.6% of the adolescents. This number was reduced to prevalence rates of 6.3 and 4.9% when additional impairment was taken as a criterion. Irrespective of the type of disorder, fewer than half of the children affected were reported as receiving treatment. However, for those suffering from mental health problems, large impairments in HRQoL were observed., Conclusions: The observed prevalence of mental health problems as well as their large impact on well-being and functioning calls for early prevention. This is especially important with regard to the large decrease in HRQoL in the children and adolescents affected.

Background and Objective: To examine and compare the psychometric properties of two short screening instruments for children and adolescents suffering from attention deficit-/ hyperactivity disorder (ADHD). The Conners' Hyperactivity Index consists of ten items that assess symptoms of hyperactivity through self-report and parents' proxy. The German ADHD Rating scale (FBB-HKS/ADHS) consists of 20 items that assess the severity and perceived burden of inattention, hyperactivity, and impulsiveness as defined by the ICD-10 and DSM-IV., Methods: Within the BELLA module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), the parents of 2,863 children and adolescents rated the Conners' Hyperactivity Index and the FBB-HKS., Results: The internal consistency of item responses was assessed via Cronbach's alpha and showed that both instrument scores were able to obtain a reliable measurement. The factorial validity of the FBB-HKS measurement model as well as the unidimensionality of the Conners' scale was tested by means of exploratory and confirmatory factor analysis (EFA and CFA), indicating satisfactory goodness of fit for the FBB-HKS (RMSEA=0.06) and some deviation from the unidimensionality assumption of the Conners' scale. Stability of results across age could be confirmed with few exceptions. Mean scores differences were found between both sexes, age groups, and different socioeconomic status groups (Winkler-Index) with males, younger respondents, and children with low socioeconomic status displaying more ADHD-related behaviour. Correlation coefficients between the two instruments' scores and other scales assessing emotional and behavioural problems hinted at convergent validity., Conclusion: Both instruments' scores showed reliability as well as factorial and convergent/discriminant validity. The pros and cons of the two instruments as well as for which purpose and under which circumstances one of the measures can be favoured must be considered prior to applying such a measure.

Background: The self-perceived health or health-related quality of life of children and adolescents is increasingly recognised as a relevant outcome in medical practice and public health research. Identifying children and adolescents with particularly low health-related quality of life allows for an early detection of hidden morbidity and health care needs., Objectives: The present study investigates health-related quality of life in children and adolescents in Germany., Methods: In the Mental Health Module (BELLA study) of the German National Health Interview and Examination Survey for Children and Adolescents (KiGGS), the parents of 2,863 children and adolescents aged 7-17 years, and 1,700 children and adolescents aged 11-17 years completed the KINDL-R quality of life questionnaire., Results: The reliability (Cronbach's alpha=0.86) and validity of the measurements using the parent-reported KINDL-R were confirmed. Means and percentiles were calculated for the total sample as well as for strata defined by age, sex, geographical region (east/west), migration status and socioeconomic status. Expected differences in health-related quality of life of children and adolescents from different social backgrounds and with different health statuses were demonstrated by differences in the KINDL-R scores (effect size d up to 1.29)., Conclusion: This study provides representative, normative data (self-report and parent-report) on the test scores of health-related quality of life (KINDL-R) for the population of children and adolescents in Germany in general, as well as in sociodemographic and socioeconomic subpopulations.

Objective: To identify disordered eating behaviour and attitudes in a large representative population in order to determine the relationship with body weight status, and to assess associated psychopathology and health-related quality of life., Methods: A total of 11-17 year-old adolescents (n=1,895) were randomly selected from the national representative sample of 17,641 families participating in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Weight and height were assessed by trained staff. Mental health problems and health-related quality of life were examined by means of a telephone interview and different questionnaires. Eating disordered behaviour and attitudes were identified by the SCOFF, an instrument consisting of five questions originally developed to screen for eating disorders in clinical settings., Results: About one third of the girls and 15% of the boys reported disordered eating behaviour and attitudes, which were most prevalent in overweight youth. There was a significant association between the presence of disordered eating behaviour and psychopathology, which was comprised of internalising and externalising behavioural problems. In addition, adolescents with disordered eating behaviour reported reduced quality of life., Conclusion: The high prevalence of disordered eating in the general population of Germany is of great concern. Health professionals should not only be aware of disordered eating in underweight adolescents, but in all youth, especially overweight individuals. Disordered eating behaviour is associated with a wide range of psychopathological and psychosocial concerns. Thus, youngsters engaging in disordered eating behaviour should also be explored for other serious mental or social problems.

Background: The concept of health-related quality of life (HRQoL) involves the respondents' perception of well-being and functioning in physical, emotional, mental, social, and everyday life areas. Research in the area of subjective health has resulted in the development of a multitude of HRQoL instruments that meet satisfying psychometric standards with regard to reliability, validity, and sensitivity of the scales. One frequently used generic measure for children and adolescents is the KINDL-R questionnaire developed by Ravens-Sieberer and Bullinger (Qual Life Res 7:399-407, 1998)., Methods: Within the representative sample of the BELLA study, analyses regarding psychometric properties (namely reliability as well as discriminant and construct validity) are performed., Results: Psychometric testing of the KINDL-R questionnaire reveals good scale utilisation and scale fit as well as moderate internal consistency. Correlations with the KIDSCREEN-52 subscales are shown. Differences in KINDL-R scores exist between chronically ill and healthy children as well as between SDQ problem scores., Conclusion: The KINDL-R is a suitable instrument for measuring HRQoL in children and adolescents through self-report. The testing of the instrument in a representative sample of German children and adolescents as well as their parents provides reference values extending the potential of the KINDL-R questionnaire.

Background: In Europe, a considerable proportion of children and adolescents is affected by depressive symptoms, impairing their everyday life and social functioning., Objectives: The aim of this paper is to provide an overview of the depressive symptoms in children and adolescents in Germany, addressing risk factors, comorbidity, and impact of depressive symptoms on everyday life., Methods: In the BELLA study, the mental health module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a representative sample of young people aged 7-17 years was enrolled. Depressiveness, assessed by the CES-DC, as well as other mental health problems were examined in the context of risk and protective factors., Results: Depressive symptoms showed high prevalence in parent- and self-reports. Higher depression scores were found in those with a high number of psychosocial risks existing in the family, and they decreased as the number of protective factors the children and adolescents had at their disposal increased. Although only half of the boys and girls with high depression scores were regarded as significantly impaired, all of them had a much higher risk for additional mental health problems. Furthermore, their health-related quality of life was limited compared to their peers who had low depression scores., Conclusions: To differentiate between clinically significant depression and milder forms, it is necessary to take into account the different perspectives of children and their parents. Prevention and intervention should acknowledge the widespread distribution of depressive symptoms in children and adolescents, the high comorbidity of depressive and other mental health problems and the impact of depression on the aspects of everyday life.

Background: Since prevalence rates of mental health problems in children and adolescents are high and of considerable relevance to public health, determinants of mental health, such as risk and protective factors, are of special interest., Objectives: The present paper reports the frequencies and distributions of potential risk and protective factors and analyses their effects on children's mental health., Methods: The BELLA study is the mental health module of the German National Health Interview and Examination Survey among Children and Adolescents (KiGGS). Mental health problems and their assumed determinants are examined in a representative sub-sample of 2,863 families with children and adolescents aged 7-17. In order to identify mental health problems, the extended version of the Strengths and Difficulties Questionnaire was administered. Data on psychosocial risk factors as well as on protective factors in terms of personal, familial and social resources were collected by questioning the parents and, from the age of 11 years upwards, the children themselves., Results: Adverse family climate stands out particularly as a negative contributor to children's mental health. When several risk factors occur simultaneously, the prevalence of mental health problems increases markedly. Conversely, pronounced individual, family and social resources coincide with a reduced occurrence of mental health problems, especially in children with a limited number of risk factors., Conclusions: The results suggest that differential prevention strategies are needed depending on the risk level: in the low risk group, to which most children belong, effective prevention programmes should define strengthening resources as a key objective. In the smaller group of children with a high number of risk factors, more complex intervention designs are required, which must consider the reduction of risks as well as strengthening resources.

The BELLA study on mental health and well-being in children and adolescents is the mental health module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). The cross-sectional KiGGS survey collected comprehensive data on the health status of 17,641 children and adolescents, aged 0-17 years, living in Germany. The survey included physical examinations and tests, questionnaires filled in by parents and equivalent questionnaires for children aged 11 years or older. A computer-assisted personal interview was conducted by study physicians, and various laboratory tests, e.g. on blood and urine samples, were performed. The longitudinal BELLA study collected initial cross-sectional data from a representative KiGGS sub-sample of families with children aged 7-17 years. Of the 4,199 randomly selected families invited to participate in the BELLA study, 2,863 took part. A total of 48.5% of the participating children and adolescents were girls, 51.5% were boys. Within the BELLA study, trained interviewers conducted standardised telephone interviews with one parent and also the child, if it was at least 11 years old. Afterwards the families received additional questionnaires. The interviews and questionnaires included various standardised and ICD-10-oriented instruments examining overall mental health problems and associated burden, depression, anxiety, attention deficit-/hyperactivity and conduct disorders. Furthermore they covered a broad spectrum of aspects related to mental health and well-being, such as risk and protective factors and health-related quality of life. An analysis of the non-responders showed that the families who agreed to participate form a representative sample with respect to the German population. The sample deviated only slightly from the KiGGS sample structure regarding socioeconomic status and regarding parent-reported mental health problems. No such difference was observed for the children's self-reported mental health. A weighting procedure was applied to correct for deviations from the sociodemographic and socioeconomic structure of the target population.

Background: There is a lack of representative prevalence rates for attention deficit-/hyperactivity disorder (ADHD) according to DSM-IV criteria and hyperkinetic disorder (HD) according to ICD-10 criteria for German subjects., Objective: To report the results of analyses of categorical data on the prevalence rates of the symptoms of ADHD/HD and additional diagnostic criteria, as well as of the diagnoses of ADHD and HD according to symptoms and other diagnostic criteria, according to the ICD-10 and DSM-IV. Further, to report administrative prevalence rates of the diagnosis and rates of co-existing behavioural and emotional problems., Method: Within the BELLA module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a representative sample of parents of 2,452 children and adolescents aged 7-17 years completed an ADHD symptom checklist (FBB-HKS/ADHS) and additional questionnaires for the assessment of coexisting behavioural and emotional problems., Results: The prevalence rates for the diagnoses of ADHD according to DSM-IV criteria were 5.0% and the rate for HD according to ICD-10 criteria was 1.0%. Higher prevalence rates were found in boys and in younger children. The addition of other diagnostic criteria (impairment, pervasiveness, onset, duration) resulted in a significant decrease of the prevalence rates of ADHD and HD to 2.2 and 0.6%, respectively. Higher prevalence rates were found in families of lower socioeconomic status and families from urban areas. The lifetime administrative prevalence rate was 6.5%. Children with ADHD had an increased risk for coexisting behavioural and emotional problems, especially for aggressive and antisocial behaviour problems, but also for anxiety and mood problems., Conclusion: The results of the national sample are in line with community studies in other countries. The effects of the additional diagnostic criteria of impairment, situational pervasiveness, symptom onset and symptom duration on the prevalence rates have to be considered in other epidemiological studies.