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The interdisciplinary care of children and adolescents with mental disorders requires services from various German codes of social law and-within the medical care system-enclosing inpatient and outpatient services. The increasing demand, the increase in severity of disorders, and the general shortage of staff in social services put pressure on the structures of the interdisciplinary service networks resulting in long waiting periods, long distances, and regionally insufficient care. The medical field of child and adolescent psychiatry and psychotherapy (CAPP) plays the central and coordinating role within the cooperative care for children and adolescents with mental disorders. The CAPP is in clear need of reforms; however, these are markedly different from the reform needs of the German somatic medical care system and differ substantially from those of the (adult) psychiatry, psychotherapy, and psychosomatics disciplines. This discussion paper describes the reform requirements, the specifics of the CAPP structures, and suggestions to overcome sectors of service provision, enhance networking, intensify telemedicine, and develop evidence-based prevention and early recognition of child mental disorders., (© 2024. The Author(s).)

For children and adolescents in need of psychiatric and psychotherapeutic care, outpatient, day patient, and inpatient facilities are provided. A new development is called "inpatient equivalent treatment" that consists of home visits by a multiprofessional team. This paper depicts the landscape of Child and Adolescent Psychiatry (CAP) Services, covering its historical development and the structural, care policy, and financing backgrounds. Until 2014, there was free choice of private practice locations in the outpatient sector, leaving rural areas and marginalized neighborhoods partially undersupplied until today.The number of beds in the hospital sector decreased significantly between 1991 and 2004. It later rose again in favor of improved regional access and smaller units, with an additional 50% of day patient places. Inpatient equivalent treatments are equally effective, but not yet established nationwide; only a few innovative models have been negotiated. Regional networks of all social support systems, aiming for child psychiatric supply networks, are limited due to the pillarization of the social system. In conclusion, an imperative cooperation between all services of the Social Security Code and enabling true cross-sectoral services would benefit CAP patients., (© 2023. The Author(s).)

COVID-19 and Psychiatric Disorders in Minors: Changes in Inpatient Treatment According to Hospital Statistics Abstract: Increased rates of psychiatric disorders and psychiatric emergencies in children and adolescents stemming from the COVID-19 pandemic have been reported, with more children and adolescents suffering from internalizing disorders. This study analyzes whether the increased rates led to increased rates of inpatient treatment in child and adolescent psychiatric and pediatric hospitals in Germany as well as a change in diagnoses of the treated patients. We analyzed routine hospital data ("InEK" data, § 21 KHG data files) from a prepandemic (2019) and a pandemic (2021) half-year regarding changes in the number of cases, diagnoses, and length of stay (LoS) in child and adolescent psychiatry and pediatrics. We also investigated the development of psychiatric emergencies in minors. We found an increase in internalizing problems (depression, anorexia nervosa, trauma-related disorders) and a decrease in externalizing problems among the admitted psychiatric inpatients. Further, we observed a halving of cases treated for alcohol intoxication. However, we discovered no change for the frequency of psychiatric emergency treatments nationwide. A more detailed analysis revealed that, in areas with a low number of child and adolescent psychiatry inpatient beds, emergency care was prioritized and LoS decreased, whereas in areas with a fair bed-to-inhabitant ratio among minors, there was a trend toward increased LoS, also in pediatric departments. We recommend continued monitoring of inpatient care after the pandemic, with special attention paid to underprivileged children and adolescents such as those with externalizing problems.

From home treatment to psychiatric ward-equivalent treatment (StäB) - A systematic review of outpatient treatment in Germany Abstract. Objective: In the past, home treatment was not available in Germany for children and adolescents with mental health problems. However, enactment of the PsychVVG law on 1 January 2017 has changed this, so that intensive home treatment (stationsäquivalente Behandlung, StäB) can now be offered as an alternative to inpatient treatment. This literature review a) analyzes existing German home treatment studies for effectiveness, b) determines from international reviews criteria for effective home treatment, and c) aligns these with the standardized StäB criteria. Method: We performed a systematic literature search in PubMed, Scopus, PsycINFO, and Cochrane Library referencing "hometreatment AND children" as well as "hometreatment AND adolesc*. Results: Flexibility, mobility, multiprofessionality, a wide spectrum of possible interventions, the option of inpatient admission, 24/7 availability as well as daily treatment sessions have been found to be factors for effective home treatment. In German studies, home treatment was shown to enhance psychosocial functioning, parental competences, long-term effectiveness, and acceptance by the families. The highest effect for home treatment was demonstrated in children and adolescents with externalizing disorders. Conclusion: Intensive home treatment (StäB) meets the criteria identified in the literature and is a good addition to existing treatment options for children and adolescents with mental health problems in Germany.

Germany, in comparison to other countries, provides a good quality of services to distinct groups of patients. But as far as total expenditure for mental health services is concerned, it belongs to the top European states. The differentiation of services since the Expert Commission to the parliament (1975) was associated by fragmentation of the therapeutic alliances and the patient's relations in his or her personal social system. The management of intake to hospital treatment seems to need further improvement. Treatment paths which integrate distinct sectors are clinically tested in other countries and should be hold up as examples for politicians to further improve our mental health services. With the available resources, better and economically sound results could be reached. This is important for the future, a) because of increasing utilization of mental health treatment, b) to guarantee the quality of services for the chronic, severely mentally ill patients., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Intensive outpatient treatment - a therapy option for all patients in child and adolescent psychiatry or just for a few? Abstract. Objective: "Child and adolescent psychiatric ward-equivalent treatment" (= stationsäquivalente Behandlung, StäB) is an intensive daily home treatment that has now become available in Germany. Conditions for StäB services were negotiated were negotiated, authorized and came into force by German healthcare commissioners and hospitals on 1 January 2018. However, to date few hospitals in Germany offer StäB, and its feasibility has been questioned. This study evaluates the first 58 cases of StäB in the Department of Child and Adolescent Psychiatry, ZfP Südwürttemberg (2018-2019). Method: All patients admitted consecutively to StäB from 1 January 2018 to 15 August 2019 were included and evaluated solely using descriptive analyses in SPSS.25. Results: The average length of stay in StäB was 37.95 days (SD 15.35). 86.2 % of the families completed treatment, with 3 patients discontinuing treatment and 5 patients needing inpatient admission. Unlike in the literature, internalising disorders predominated (70.7 %), whereas externalizing disorders were diagnosed in only 27.8 % of the patients. The cost of treatment in StäB was on average 8779.25 €. Conclusions: StäB is a viable and well-accepted new treatment alternative for patients requiring inpatient admission. The multiprofessionality of treatment as well as daily contacts are required. Feasibility under the conditions set is given. The average length of stay is slightly longer, but the costs are lower than those of inpatient treatment.

Mental health disorders are one of the main diseases in children and adolescents, the persistence rate into adulthood being around 50%. Early intervention is therefore essential. However, present treatment options reach only 50% of children and adolescents with mental health problems.The objective of this article is to depict why legal deficits complicated the establishment of outreach treatment in the past and to illustrate recent legal changes that now allow innovative outreach treatment programs that meet the need of children and adolescents with mental health issues.This review is based on pertinent publications that were retrieved by a selective literature search in PubMed and Cochrane Library concerning types of home treatment in child and adolescent psychiatry, with due reference to the authors' own experience with intensive home treatment.The literature shows that outreach work has been effective in many other countries. In Germany however, clear separation in finances between outpatient and inpatient treatment did not allow the establishment of outreach teams in the past. On 01.01.2017 a new law, the PsychVVG, entered into force, and now provides a sound legal basis for outreach work. Home treatment in the form of, for example, intensive outreach work that equals the intensity and frequency of inpatient treatment (StäB) or continuum of care school (CCSchool), a project that joins school-based diagnostic elements with school-based treatment, can now be installed and evaluated.Intensive outreach work, especially in child and adolescent psychiatry, will now be a good alternative to inpatient treatment that integrates parents into the treatment approach.

Institutionalized and Individual Crisis Intervention Between Youth Welfare and Adolescent Psychiatry, Specified for Unaccompanied Minor Refugees Minor refugees put a challenge to the intercultural openness, including an abdication from diagnostic schemes. They need creativity, modification of treatment manuals and the therapist's ability to engage himself as a person. They need another notion of abstinence and the ability to cooperate with interpreters of language and culture. In cooperation with youth welfare institutions for unaccompanied minor refugees, principles that have been developed for institutional cooperation and individual crisis intervention plans have been modified: high threshold inpatient admission, multi-step-approach and reliability of cooperation.

In many countries hometreatment (HT) offers a cost-effective alternative to hospitalization for children and adolescents with mental health problems requiring intensive mental healthcare. However, the database on HT varies as HT may refer to different models and settings of intensive outpatient treatment. In Germany HT is not used routinely in mental healthcare in child and adolescent psychiatry, therefore the data on HT in Germany, especially in child and adolescent psychiatry, are scarce although funding for studies investigating the effectiveness of HT is available. This review represents a comprehensive search in electronic databases (1980-2014) of literature on HT. It provides as well an overview of the underlying concepts of and the present evidence for HT. In addition, the evidence base on HT for specific child and adolescent mental health disorders is reviewed. Future prospects for the development of HT in Germany facing the upcoming change in health service commissioning (PEPP = «pauschalierendes Entgeltsystem in Psychiatric und Psychosomatik>>) are discussed, as HT in child and adolescent psychiatry, when accurately indicated, can be a valid alternative to inpatient treatment.

Objective: How does the German child and adolescent psychiatry system respond to the increasing number of migrant children and adolescents?, Method: Senior doctors from German child and adolescent psychiatric hospitals (Association of Medical Hospital Directors in Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy in Germany, BAG) completed a specially constructed questionnaire about the treatment needs of migrant children, while a «random, representative» sample of child and adolescent psychiatrists in private practice (German Professional Association for Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, BKJPP) was administered a slightly modified version., Results: The 100 psychiatrists in private practice represented only about one-eighth of their group, whereas the 55 medical directors comprised a representative sample. One-third of the hospitals has treatments tailored to the specific needs of migrants. In both settings, however, competent interpreters were rarely found, despite the treatment problems arising from the understanding the illness by the parents, language problems, and the clinical knowledge of the patient. Cultural diversity is perceived as enriching. The migration background and the sex of child and adolescent psychiatrists influence the treatment of migrants., Conclusion: Facilitating the process of «cultural opening» in child and adolescent psychiatry involves enacting concrete steps, such as the funding of interpreter costs.

Objective: The main objective was to evaluate two models of care for children and adolescents requiring hospitalization due to severe mental illness. Model 1: early discharge followed by a newly established home treatment service enhanced by clinical elements according to need (BeZuHG); Model 2: admission to an inpatient unit (TAU)., Methods: 100 children and adolescents admitted to inpatient care were randomized to either a control group (regular inpatient stay) or an intervention group (BeZuHG group). Sociodemographic data, ICD-10 and DSM-IV diagnoses, health and social functioning, psychopathology, clinical impairment, and service use were assessed pre- and posttreatment regarding effectiveness, outcome, contact time, and acceptance within the families., Results: Clinical outcome in BeZuHG treatment was as effective as inpatient care. There was a good acceptance within the families, family resources enhanced treatment outcome, and a significant reduction in length of inpatient stay could be shown., Conclusions: The BeZuHG model should be a regular option in child and adolescent psychiatric care. Further rigorous evaluation of the model is required: A 1-year follow-up investigating the stability of the shown effects is planned.

Objectives: We examined the attitude towards the importance of medical psychotherapy among physicians working in a hospital. We focused on their opinion about the general role of medical psychotherapy within the health care system as well as on their opinion about the importance of medical psychotherapy in different clinical situations., Method: 105 physicians with various clinical specialties were interviewed using a questionnaire designed for this purpose., Results: From the point of view of the interviewed physicians, medical psychotherapy plays an important role. Especially medical psychotherapists are considered to be competent in cases of life-threatening situations resulting from mental disorders (such as suicide, anorexia nervosa), in psychopharmacological treatment as well as in cases of medically unexplained physical symptoms. Furthermore, medical competence in psychotherapy is requested wherever there is close connection to physical illness (such as stressful events in medical contexts)., Conclusions: Especially in times of increasing specialization of physicians there is a need for medical psychotherapy in inpatient health care and clinical consultation.

New legislation in the financing of psychiatric hospitals in Germany stipulates the introduction of a new reimbursement system for psychiatric child and adolescent psychiatric and psychosomatic hospitals in Germany by 2013. In several steps norms are to be empirically defined and services to be documented, and the current per diem system of hospital charges has to be replaced by a more specific system reflecting differences in the level of distinct patient groups. This discussion paper gives an overview of the legal framework as well as the risks and chances of the new system. An increased effort in documentation will be one of the clear consequences of the new system («much ado» ...). Psychiatric inpatient treatment will be much more transparent in detail, though it is not yet clear whether there will be a real improvement for patients (... «about nothing»). The new system also offers the chance to introduce modern treatment concepts like home treatment. Such chances for innovation should be implemented to the benefit of patients.

30% of children and adolescents in Germany are immigrated or descendents of immigrants. An overwiew of approaches to prevent psychiatric disorders is given. Eventually higher rates of mental distress may be explained by SES relativisms, aversive living conditions, negative school, vocational and life expectancies. Some psychoprotective functions specific to immigrants were identified in a higher use of breastfeeding, heightened family cohesion, and also the preservation of bilingualism paired with a good proficiency of German. Parent trainings like early enrichment to further integration in the host society have proved successful as well as easily accessible and bilingual counselling. All of these also apply to the prevention of delinquency. In the end, successful integration is prevention as well.

In a representative nationwide survey, the Psychiatry and Migration Working Group of the German Federal Conference of Psychiatric Hospital Directors (Bundesdirektorenkonferenz) examined the use of inpatient psychiatric and psychotherapeutic services in Germany by patients of immigrant origin. Questionnaires were sent to a total of 350 general hospital psychiatric clinics throughout Germany, and 131 clinics responded. As shown by the 2005 Microcensus [22], almost one-fifth (18.6%) of the German population is of immigrant origin. In our study, persons of immigrant origin comprised 17% of patients in the responding facilities. This indicates that the percentage of inpatient psychiatric services used by patients of immigrant origin is almost proportionate to these patients' percentage of the general population. The largest group of immigrant patients in our study were those of Russian heritage, followed by patients of Turkish, Arabic, or other origin. Almost two-thirds of the immigrant patients were born in Germany, and a considerably larger percentage were German citizens (74%). Sixty-two per cent of all patients of immigrant origin spoke a language other than German (e.g. Russian, Turkish, Polish) at home. Patients of immigrant origin were significantly more likely to receive an ICD-10 F2 diagnosis, and it was precisely patients with this diagnosis who were observed to experience difficulties in communication with caregivers.

The history of German legislation resulting in the developmental orientation of juvenile court law (JCL) led to setting the minimum age of criminal responsibility at the age of 14, which places Germany within the average range compared to other EU countries, even though most skills regarding the discernment of right- or wrong-doing are developed in earlier stages of life. The requirement put by section sign 3 JCL that legal discernment be emotionally grounded and the necessity to explore context factors (family or group, specific situation) make psychiatric evaluation of adolescents in court a delicate task. It is indispensable that new findings in neurobiology be considered upon making an assessment of the individual neuro-developmental status. In contrast, an assessment according to section sign 105 JCL considers the overall development irrespective of the crime(s). Developmental issues regarding legal prognosis are discussed for some types of offences (homicide, sexual offences, arson).

Although insight, positive attitude towards therapy and compliance are key to a successful treatment, in certain situations the use of coercive measures on mentally ill or disordered minors is the only way to prevent serious harm to the patient or others. The decision to use coercive measures, such as involuntary admission or detention, seclusion, mechanical or chemical restraint or involuntary treatment, is challenging for clinicians as they have to deal, not only with the patient and his or her parents who are in a disturbed emotional state, but also with some complex legal regulations. To protect the rights of patient and parents in these difficult situations and to prevent legal consequences for clinical personnel for unlawful acts, it is essential that staff be familiar with all concerned legal rules and procedures. Interdisciplinary co-operation between the involved professionals should be encouraged to ensure a standardised procedure according to legal specifications. A growing number of mental hospitals for children and adolescents have no special locked door units but open wards that can be locked when required. A placement of voluntarily and involuntarily committed patients in the same unit can cause problems if the freedom of voluntary patients is restraint due to the placement of an interned patient. Unlawful restraint must be avoided by a sufficient number of staff and clear proceeding guidelines.

Putting into practice legal prescriptions of both children's rights and the personal freedom guaranteed by the German basic constitutional law requires a reflected and sensitive use of freedom-restricting coercive measures. Such measures imply uncertainties and burdens for staff and patients in child and adolescent psychiatry. Using guidelines of psychiatric associations and instructions from three institutions, basic attitudes and quality characteristics of indication, performance, and participation with regard to freedom-restricting coercive measures are described.

We examined the influence of the admission mode of adolescents into inpatient psychiatric therapy - voluntary or involuntary - on the outcome. For statistics, a fully structured self-assessment form was applied some months after dismission, partly drawn up independently and partly containing items from the inventory for quality of life in children and adolescents (ILK). The initial psychological state was less favourable in patients who were admitted under constraint. However, both patient groups showed a comparable outcome. Positive effects of the patient information on their compliance and attitude towards the therapy were demonstrated, as well as a positive influence of the confidence in the therapeutic staff. Regarding the quality of life obtained at the end of treatment, the admission mode is apparently less important or is put into perspective by staff-patient-relations within the therapeutic relationship. On the other hand, the possibilities for participation and the patients' feeling to be taken seriously play a major role in improving compliance and, as a moderator variable, for therapeutic success as well. The results underline the importance of improving participation processes of hospitalized adolescent patients in psychiatry. This seems to be constitutive for a positive long-term treatment outcome.

Semi-structured bilingual interviews were conducted with 223 adolescents from Turkey and their parents in 77 volunteering immigrant families (field group) and in 40 outpatient families attending the adolescent service (CAP treatment group). Risks and resources for mental health were assessed in a qualitative approach based on contextual family theory, cohesion and adaptability according to Olson's Clinical Rating Scale. While adolescent psychiatric morbidity in the field group equalled an expected rate of 24%, families with psychologically healthy offspring significantly excelled in parental and child resources. Yet, resources did not separate symptomatic and non-symptomatic families (referring to child symptoms) as well as risks did. A parent without work constituted a risk factor of its own. Differentiating CRS from 3 to 4 steps of adequacy for child health (introducing a range of high cohesion or high rigidity alone as another step between normal and dysfunctional) led to classify 80% of non-symptomatic families as functional. Following our results, a resource oriented family therapy seems to be the most promising therapeutic approach. Social case management should be provided for at the same time.

A predictor for the individual length of stay (ILOS) was stable for 3 consecutive cohorts of annual inpatient admissions (n = 1.230, excluding drop-outs, crisis interventions for 14 days and less, longterm treatment for 250 days and more), in spite of decreasing average length of stay (ALOS). The predictor consists of CASCAP psychopathology variables, motivational and social functioning variables assessed by the therapist. ICD-10-diagnoses had no influence on ILOS. Improvement on MAS axis VI needed longer average LOS than improvement in symptoms. Unchanged patients had shorter LOS than improved ones, the lower limit of effective LOS being more than about 55 days for improvement of symptoms. Due to our findings, DRGs are not an adequate instrument to determine reimbursement of inpatient treatment in child and adolescent psychiatry.

The study reports experiences with two therapeutic apartments (12 residents) accommodating 30 young adults over a 5-year period. For this age group this kind of aftercare poses special problems: Contrary to previous evidence, patients suffering from psychotic or borderline disorders achieved a much lower level of autonomy than those with neurotic or psychosomatic disturbances and also did significantly worse regarding vocational integration and social contacts. Social contact behavior outside the group was the strongest predictor of the level of autonomy achieved. As the rehospitalization rate was high (50% of all residents), no economizing on inpatient capacities could be expected from this program. However, improvements in the number of staff and in the program itself did lead to a significant decrease in the length of rehospitalizations. Program-related factors that may increase the vulnerability of young people with psychosis are discussed in the context of the general state of psychiatric care.