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A slightly modified version of the Dialectical-Behavioral Therapy for Adolescents (DBT-A) for impulsive and self-injurious adolescents has been implemented in the Child and Adolescent Psychiatric Service in Zurich, Switzerland, since 2005. This DBT-A comprises individual therapy, skills training, and a single parent meeting over a 6-month period. This article reports on the translation of this approach into clinical practice and presents an evaluation based on the clinical quality of control assessments. Participants of the treatment program were 43 female adolescents aged 14 to 19 living in the Zurich area and showing impulsive and self-injurious behavior and problems regulating their emotions and relationships. Each skill group contained 4-6 adolescents. Our mostly positive experiences with this approach were supplemented by evaluation data from a quality control group based on self- and parent-report of a total of 19 participants. There is convincing evidence that DBT-A leads to reductions in both general and specific psychopathology.

Time-trends in the frequencies of mental disorders represent specific challenges for the planning of services. The present review addresses the specific question whether or not there are time changes in terms of an increase of prevalence and incidence rates of attention-deficit hyperactivity disorders (ADHD) based on findings from international epidemiological studies from several decades. While there is no evidence that prevalence rates of ADHD have systematically increased, various national and international incidence studies on ADHD but also prevalence and incidence studies on prescribed medication indicate that the number of treated people with ADHD has increased significantly in the recent past. This increase remains even after adjusting for the general increase in the number of persons admitted to psychiatry for any disorder. Thus, the gap between those in need of treatment and those who actually receive treatment for ADHD has narrowed over time. However, after years of an increase, in recent years German studies dealing with prescriptions of medications have shown also a declining trend.

Research on the long-term outcome of mental disorders originating in childhood and adolescence is an important part of developmental psychopathology. After a brief sketch of relevant terms of outcome research, the first part of this review reports findings based on heterotypic cohort studies. The major second part of this review presents findings based on long-term outcome studies dealing with homotypic diagnostic groups. In particular, the review focuses on the course and prognosis of ADHD, anxiety disorders, depression, conduct disorders, eating disorders, autism spectrum disorders, schizophrenia, and selective mutism. Findings mainly support the vulnerability hypothesis regarding mental disorders with early manifestation in childhood and adolescence as frequent precursors of mental disorders in adulthood. The discussion focuses on the impact of early manifesting disorders in the frame of general mental morbidity and of the effect of interventions, which is not yet sufficiently discernible.

The involvement of non-resident fathers with their child was analysed by use of a questionnaire in a sample of 74 divorced or separated families living in the city of Ziurich, Switzerland. Fathers, mothers, and one child separately rated the involvement of the father. The three perspectives were compared and showed significant differences in the dimensions of educational responsibility, cognitive and social support, and the quality of the emotional relationship. The temporal availability and leisure time activities did not show significant differences. The different family perspectives should be considered when assessing a father's involvement with his child. The quality of the relationship of the children to their fathers was primarily fostered by the emotional engagement of the father.

Objective: Incarcerated adolescents show a high prevalence rate of psychopathology and comorbid psychiatric conditions. Child and adolescent psychiatrists working in the penal system are confronted with the need to provide care and to develop specific treatment plans., Method: The data gathered from incarcerated juveniles were analyzed with a special focus on gender-specific treatment aspects. The Mini-International Neuropsychiatric Interview for children and adolescents was used to assess psychopathology in detained juveniles in Austria. The final study sample consisted of 333 juveniles (58 girls and 275 boys)., Results: 90 % of the juveniles in our sample suffered from at least one psychiatric disorder, and more than 60 % were diagnosed with two or more simultaneous psychiatric disorders. Using factor analyses we found three clinically relevant disorder patterns according to psychopathological characteristics for males: ADHD/conduct disorder and drug abuse; anxiety and depression; separation anxiety disorder/PTSD and alcohol abuse. In females, we found four disorder patterns: separation anxiety disorder/social phobia/dysthymia; PTSD and drug abuse in combination with either ADHD or conduct disorder; depression and alcohol abuse., Conclusions: Considering that juvenile detainees are burdened by high rates of psychopathology and comorbidity, it is essential to develop a substantiated diagnostic procedure in order when making treatment decisions; different disorder patterns must be considered in conjunction with detained juveniles. The patterns of psychopathology observed might be related to different characteristics in the development of delinquent behavior, in treatment needs, and legal prognosis.

The present contribution presents psychometric findings of a newly developed questionnaire on paternal engagement after parental separation based on a sample of 225 separated or divorced fathers living in the German part of Switzerland. Factor analyses led to the following five dimensions: educational responsibility, cognitive and social support, quality of the emotional relationship, temporal availability, and leisure activities. Internal consistency coefficients (Cronbach's Alpha) ranged from .86 to .91. The dimensions reflect significant differences of paternal engagement regarding child custody, living arrangements of the mother, and parental cooperation. These findings clearly indicate that paternal engagement after separation should be considered in a differentiated multidimensional way.

The present case report describes the successful treatment of a 17 year old male adolescent suffering for 10 years from selective mutism. Following a summary review of recent publications on therapy approaches, the report describes the treatment concept in the present case, including detailed assessment of co-morbid disorders, motivation for change, behaviour therapy with supporting drug intervention, and intensive co-operation with parents and other caretakers.

Objective: Numerous studies based on parent questionnaires reveal that obese children are subject to both physical and psychosocial strains. Children are not included as informants in the assessment procedure, and there is a lack of clinical interview studies assessing DSM-IV-based diagnoses in overweight children., Methods: Emotional and behavioural problems of treatment seeking obese children (N = 59; aged 8-12-years) attending a mental health service were assessed by means of clinical interviews (Kinder-DIPS) that included child and parent reports. In addition, Child Behavior Checklist (CBCL) data (N = 55) available for this clinical sample were compared with data of a representative sample of normal-weight children (N = 1,080). Furthermore, CBCL data of the clinical subsample of 10-12 year-old overweight children (N = 34) were compared with data of a subsample of 10-12 year-old overweight children (N = 33) and of the subsample of normal-weight (N = 386) children from a representative population, both matched by sex., Results: 23 children (39%) met full criteria for a psychiatric disorder according to DSM-IV, and 19 (34.5%), nearly one third, suffered from Binge Eating Disorder (BED). The overweight clinical sample and their normal weight peers differed significantly on 6 of the 8 primary syndrome scales, on the internalizing and the externalizing scores, and on the total problem score of the CBCL. The overweight children in the clinical sample scored significantly higher than the overweight children in the representative sample on the subscale measuring social problems and the total score, with BMI accounting for the difference in total score. Within the representative sample, overweight 10-12 year-old children scored significantly higher than their normal weight peers on two scales measuring delinquency and social problems., Conclusion: A third of the obese children had mental disorders and behaviour problems. This finding applies to clinically referred obese children and, to a much lesser degree, to nonclinical obese subgroups in the normal population. Clinically obese children constitute a patient group that is in urgent need of multimodal treatment. As a consequence, a major change in treatment and prevention of childhood obesity is warranted, i.e., from the mere treatment of eating and activity behaviours to the inclusion of treatment of co-morbid mental disorder and prevention of chronification.

A panel of experts from several European countries has accomplished a systematic review of published and unpublished data on the use of long-acting medications in ADHD and hyperkinetic disorder. Based on this analysis detailed recommendations about the use of these drugs in practice have been developed: (1) Long-acting preparations should be licensed and used; (2) They should not completely replace short-acting drugs (which will be the initial treatment for many children in view of cost and the greater flexibility of dosing). Individual clinical choices are necessary. (3) Both ATX and extended-release stimulants should be available. In addition, detailed recommendations will be made with regard to the criteria to be applied in choosing a preparation for the individual patient.

A panel of experts from several European countries has accomplished a systematic review of published and unpublished data on the use of long-acting medications in ADHD and hyperkinetic disorders, on the basis of which practical recommendations for the application of these medications have been developed. The current article outlines results of this analysis, comparing the effect sizes and numbers-needed to-treat for extended-release stimulant preparations and atomoxetine (ATX). It is concluded (1) that long-acting preparations should be licensed and used. (2) However, they should not completely replace short-acting medications, in view of costs as well as the greater flexibility of dosing. Individual choices of therapy are necessary. (3) Both ATX and retarded-release stimulants should be available.

Objectives: Reliability of the Global Family Environment Scale (GFES) which has been developed in Australia and translated into German., Method: Comparison of ratings and reliability of written case vignettes by international raters and clinicians of the own institution. Assessment of interrater-reliability of clinical cases before and after group trainings with introduction of the manual and discussion of written case vignettes., Results: The ratings of seven training case vignettes were rather similar by clinicians from Zurich and in an international study by the Australian authors. In the same way interrater agreements were similar in the two studies and satisfying. In the present study a single training session in comparison to reading the manual did not result in higher interrater agreement., Conclusions: The existing psychometric properties and the availability of a translation represent important prerequisites for the applicability of the GFES in the German-speaking countries.

After briefly defining the hyperkinetic disorder of childhood the typical process of clinical assessment is described. The latter includes the psychiatric interview with parents, child and teachers, the history of the child, the use of questionnaires and rating scales, neuropsychological testing and the physical examination of the child. Careful consideration of differential diagnoses is mandatory in order to avoid false negative and false positive diagnoses. The etiology is dominated by neurobiological concepts with a special emphasis on genetic causes. Treatment is multimodal giving special weight to pharmacotherapy with stimulants.

A German version of the Center for Epidemiological Studies Depression Scale (CES-D) was used in the Zurich Epidemiological Study of Child and Adolescent Psychopathology (ZESCAP). Psychometric analyses revealed clear evidence of a central factor of depression as reflected by the CES-D. Due to good reliability, a total score of the CES-D should be used in clinical diagnostics. The first cross-sectional wave of assessment within ZESCAP found that gender, nationality (indigenous vs. migrants) and residence (urban vs. rural) are important determinants of the total score. The article provides norms for adolescents. The study of the validity of the CES-D warrants further research.

This paper introduces the Zurich Intervention Planning and Evaluation Form (ZIPEF). The instrument covers (1) treatment problems, (2) interventions as to type, duration, and time expenditure, (3) treatment outcome and (4) causal factors. A total of 413 treatment problems were evaluated with the ZIPEF in a public child and adolescent psychiatric service. Depending on the target (e.g. symptoms, personality, relationship) the distribution of types of intervention differed. Time expenditures were significantly higher only for client-centred interventions than for parent counseling and similar for all other interventions. Treatment outcome and cooperation were independent from type of intervention. The main causal factor of treatment outcome for almost all types of interventions was cooperation followed by resources in some types of intervention. Complexity of the treatment problem tended to be another important determinant for treatment outcome. In summary, the ZIPEF can contribute to quality management in the area of intervention planning and evaluation of clienteles with mental health problems.

The short form of the Clinical Assessment Scale of Child and Adolescent Psychopathology (CASCAP) assesses psychopathological features only on the level of symptom domains and not on the level of single symptoms. The instrument is part of the basic documentation of child and adolescent psychiatry. Based on the multicenter study sample of CASCAP the ratings of the symptom domains in the different centers were analysed. Inpatients receive higher ratings than outpatients on nearly all symptom domains. Only minor differences could be found between the centres. Advantages and disadvantages of this short version are discussed.

Findings in intervention research are an important basis for the discussion of issues pertaining to quality control. In Switzerland such findings have been rare. The present study of the entire 1988-1995 referred child and adolescent population of the Child and Adolescent Psychiatric Service of the Canton of Zurich (N = 7538 treated patients) concentrated on the demographic, diagnostic, and therapeutic attributes of the outpatient, day clinic, and inpatient populations that comprised the referred population. Marked differences are found in comparable studies from Germany with regard to patients treated in an inpatient setting. For example, the mean age of the patients in the Zurich sample is lower and patients with conduct disorders are more frequently represented. On the other hand, patients with psychotic illness are missing and, on the average, the duration of treatment is considerably longer. The reasons for these differences are to be found in the various structural attributes of the cantonal services that are provided in Zurich. In the area of inpatient care, where in comparison to outpatient settings and also day care settings patients with severe disorders are treated, there is a lack of places for the short-term care of acutely ill patients--for example, psychotic patients. This is especially true for adolescent patients. The limitations of traditional outpatient settings are frequently marked by unsatisfactory treatment results in outpatients with conduct disorders, developmental disorders, and a high impact of abnormal psychosocial circumstances.

Goal of the multicenter study with the Clinical Assessment Scale of Child and Adolescent Psychopathology (CASCAP) in a sample of N = 5027 patients from the inpatient and outpatient clinics of psychiatry and psychotherapy of childhood and adolescence of the universities of Berlin (Virchow Clinic), Frankfurt, Cologne and Zurich is the comparison of the clinical populations of these institutions with respect to single symptoms, to symptom scales and to the supreme level of aggregation, the clinical diagnoses according to ICD 10. On the level of diagnoses similar distributions can be found in the centers, but there are also significant differences between the centers. This differences can be found again also on the level of symptom scales and single symptoms, though the deviations are comparatively low.

Guided by the most important clinical categories, child and adolescent psychiatric disorders are described that may manifest as emergency cases. The kind of intervention and treatment modalities that are effective are documented. Drug treatment is of special importance in emergency cases.

Data collected in the 1980's, before the reunification of Germany, and comparing 39 patients in former East Berlin and 60 patients in former West Berlin are presented in this second report on the Berlin longitudinal study of eating disorders in adolescence. The clinical profiles of patients of former East Berlin were found to differ from those of their West Berlin counterparts in the following assessed measures: younger age at disease onset and at admission for inpatient treatment; greater number of siblings; fewer accounts of the clinical symptoms lanugo, bradycardia, hypothermia, constipation; lower rate of premorbid psychopathological features; lower number of psychopathological findings; less frequent sibling rivalry; lower rate of psychopathological attributes among the siblings; lower incidence of maternal mental and physical illness; higher parental educational status; fewer number of complaints, and better sense of well-being.

After more than four years, ten patients in a cohort of 60 consecutively-assessed adolescent patients with eating disorders were no longer available for follow-up--four had died and six refused to participate further. The follow-up interviews indicated varying rates of impairment in relation to eating disorders, menstrual anomalies, sexuality and psychosocial functioning. The distribution of continuing disorders at follow-up was a) 10% anorexia nervosa, b) 4% anorexia nervosa with bulimia, c) 18% anorectic and bulimic partial syndromes. The remaining 68% were found to have recovered. During the course of illness, there were few instances of anorectic symptoms crossing over into bulimic ones. A uniform pattern in the disease course was observed throughout the various self-evaluation questionnaires: reduction of symptoms that occurred during the course of the inpatient treatment could also be observed at the time of the follow-up. As compared with the international literature on follow-up studies, these can be considered as favorable findings.

Data reflecting the clientele of the Child and Adolescent Psychiatric Service of the Canton of Zurich (Switzerland) spanning two decades between 1973 and 1993 were analyzed. Referral patterns, age distribution, sex ratio in relation to age, and family background are reported on. In addition, the distributions of diagnoses according to ICD-9 and ICD-10, respectively, are compared. Furthermore, four main types of child and adolescent psychiatric disorders are documented with regard to age distribution. Finally, abnormal psychosocial situations according to the multiaxial scheme of classification are reported.

This third report from the Berlin follow-up study of eating disorders in adolescence reports findings pertaining to evaluation and prognosis. Based on a systematic analysis of the relevant literature on the course of eating disorders, the following items were analyzed with respect to their value in predicting the psychopathological status of the patient at discharge from inpatient treatment and at follow-up: BMI at admission, age at onset of the disease, duration of symptoms before admission, personality features such as depression and neuroticism, the number of physical complaints, diagnosis (anorexia vs. bulimia), type of eating disorder (purger vs. restrictor), premorbid eating disorders or behavioral abnormalities, socioeconomic status, duration of in-patient treatment, and out-patient psychotherapy following discharge from the hospital. None of the factors predicted psychopathological status at either discharge or long-term follow-up.

A standardized documentation system for psychopathological findings allowing an assessment of psychiatric disorders in children and adolescents after clinical evaluation of the patient and his or her caregivers is presented. The symptomatology during the previous few months and the symptoms seen during the examination are rated separately. Altogether 113 items in 16 areas are assessed. In addition, motivation to participate in treatment is judged and a global assessment is made of symptom severity. A number of facilities are already employing this documentation system in their routine clinical work. In a first study 597 patients from a routine clinical population seen consecutively were assessed at the start of treatment. As expected, the most commonly recorded symptoms were those of expansive behavior. Such symptoms were seen much more rarely during the evaluation than outside this situation. The documentation system for psychopathological findings complements diagnosis by category according to ICD with a phenomenological description of psychiatric disturbances on the level of single symptoms. It enables simple and economical documentation of clinical findings after evaluation of the patient and his or her caregivers.

Following an introductory comment regarding the purpose of this longitudinal study on eating disorders in adolescence, findings based on assessment of the illness course during inpatient treatment are presented. A multidimensional research design that included both self rating and rating by others demonstrates a clear reduction of symptoms in a number of different areas. This is evident in the 'semantic differential' self-evaluation with regard to body-image and personality, the patient's attitudes toward eating, specific characteristics of the eating disorder syndrome, the self-concept, various personality attributes, physical complaints, and the sense of well-being. The analogous assessments made by therapists and ward staff members also indicated definite improvement with regard to those symptoms that are specific to eating disorders.

After some introductory remarks on definition and frequency, a classification of psychiatric disorders in children and adolescents is given. Due to limited space, the various disorders are discussed only in terms of their relation to phases of development in childhood and adolescence. Finally, a sketch of basic ideas of etiology and the most important therapeutic approaches is presented.

An outline of the classification of minor brain dysfunction and severe brain syndrome is followed by a short historical sketch of the development of the concept of minor brain dysfunction and a description of the clinical and diagnostic relevance of this concept. After evaluation of specific therapeutic approaches, selected empirical studies are reported to elucidate the course of the disorder. The issue concerning the existence of a behavioral syndrome that characterizes severe brain disorders is discussed. The presentation of selected research findings on psychopathological and neuropsychological sequelae of severe brain traumas provides the argument for the final discussion. The necessity of qualifying a highly specific, narrowly defined psychopathological syndrome in childhood is emphasized.

In a prospective study intrauterine growth retardation (IUGR) (less than 10. growth percentile at birth) was used as a predictor to diagnose intrauterine alcohol exposure. An interview about maternal alcohol consumption was performed prenatally--when IUGR was diagnosed by ultrasound--or postnatally. The children were followed up to 18 months of age. In 6/47 children we diagnosed various degrees of the Fetal Alcohol Syndrome FAS, with only one patient showing a full blown syndrome at birth. 5 patients could not be identified until the pediatric reexamination at the age of 8-18 months. IUGR and a maternal history of even moderate drinking during pregnancy should emphasize the possibility of an intrauterine alcohol damage, even in a normal child at birth.

Determinants of psychosocial adaptation in chronic illness and disability are outlined in the introduction. They include disease conditions, personality factors, and reactions of family and social environment. The increased risk of psychiatric disorders is documented based on both this model as outlined and empirical research. Finally, some fundamental considerations regarding psychological rehabilitation within pediatric care are presented.

Basic terms of medical and psychiatric classification are outlined in the introduction. This is followed by an historical sketch of German publications of early classification systems of child and adolescent psychiatry as found in the work of Tramer, Stutte, and Lutz. The main section deals with current classification systems. Deficits of the ICD-9 and recent improvements in the DSM-III-R and the ICD-10 are discussed. The paper concludes with considerations regarding the empirical foundation of child and adolescent psychiatric disorders and with criticism of psychiatric classification in general.

The course of encopresis in 41 children who had been presented at a child and adolescent university clinic was examined by means of a follow-up interview which took place on an average of 3;6 years after the initial visit. The symptoms in this sample diminished considerably: 76% of the children were free of symptoms at the time of the follow-up interview, whereby most of these children had experienced a spontaneous remission. Eighty-one percent of the children were evaluated as having improved in regards to their whole development while in about one third of all the children new problems arose. Remission occurred within the first two years of the initial consultation in 81% of the sample. An examination of the prognostic factors yielded the following relationships: the total remission of symptoms was considerably greater if the frequency of encopresis had been low, if the subjects were male, and if there had not been any therapeutic intervention. However, treatment was usually reserved for relatively serious cases. Favorable outcome tended to be marked by the following factors: normal psychosocial conditions, higher intelligence, the absence of constipation, a concurrently presenting enuresis, and a low degree of behavioral disorders as evaluated by a parental questionnaire. A comparison of the behavioral disorders at the time of the initial consultation and at follow-up revealed a significant reduction of emotional disturbances and hyperactivity. This favorable development was not evident for conduct disorders.

In addition to a preceeding report the relation of motor development to ataxia and age at onset of symptoms and therapy as well as psychopathological symptoms in relation to intelligence and sex in 32 children with hypothyroidism are reported.

This third and last paper on psychological aspects of chronic illness is childhood discusses tasks of the physician and the parents as well as aspects of social medicine.

The international literature on dietary treatment of the hyperkinetic syndrome is reported and analyzed critically. So far there is no sufficient scientific evidence in favour of this therapeutic intervention with hyperkinetic children.

This second out of three articles deals with some specific psychological problems of chronic illness and handicap in childhood, i.e. epilepsy, physical handicap, diabetes mellitus, congenital heartdisease, hemophilia, dwarfism, hemodialysis and renal transplantation, and malignant disease.

Data from pediatric, neurological, psychiatric and psychological examinations of 71 children suffering from alcoholembryopathy (AE) are reported. In comparison to a matched control group history revealed an increased rate of developmental retardation during the neonatal period and the toddler age. Besides the frequently described morphological characteristics neurological examinations frequently revealed deficits of fine motor coordination. Psychiatric examinations led to various symptoms indicating a marked psychoorganic syndrome. Impairment of cognitive functions was detected by psychological testing. Finally there were positive correlations between morphological and psychological damage.