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Development of an Online Intervention for Adolescents and Young Adults Engaging in Nonsuicidal Self-injury Nonsuicidal self-injury (NSSI) is a prevalent phenomenon in adolescence. Despite the existence of effective psychotherapeutic interventions, the majority of affected adolescents and young adults do not receive any treatment. Structural (e. g., no specific interventions, limited resources, limited accessibility) as well as individual factors (e. g., low help-seeking behavior) impede access to adequate clinical care for adolescent NSSI. Online interventions offer the possibility to provide specific interventions independent of one's location or local healthcare structures. Because of its high confidentiality and accessibility, the Internet also reaches adolescents with low help-seeking behavior. There is already evidence for online interventions concerning different mental health issues, like depression and anxiety. However, regarding NSSI, there are no effective, online interventions. Thus, we developed an online intervention based on an already evaluated short term program specific for adolescents and young adults with NSSI within the German STAR consortium (STAR: Self-Injury - Treatment, Assessment, Recovery). Within a randomised controlled trial, the intervention will be evaluated regarding its efficacy.

Relationship Between (Pathological) Internet Use and Sleep Problems in a Longitudinal Study Excessive or pathological Internet use has already been associated with sleep disorders, but the direction of the connection remains still uncertain. The relationship between (pathological) Internet use and sleep problems in adolescence was investigated by a representative longitudinal survey of data from a sample of 1,060 students from Heidelberg and the surrounding area (SEYLE study). The students, on average 15 years old, responded at a baseline and after one year to a survey on sleep and Internet use. In addition to the number of hours of Internet use, pathological Internet use was assessed using the Young Diagnostic Questionnaire (YDQ). Sleep duration and sleep problems were surveyed by self-assessment. The prevalence of adolescents with pathological Internet use was 3.71 % in the follow-up survey. Furthermore, 20.48 % of adolescents reported sleep problems. Pathological and excessive Internet use were predictors of sleep problems over the course of one year. Adolescents who met the criteria for Internet addiction to the baseline had a 3.6 times greater risk of developing sleep problems in the course of one year. Whereas sleep problems to the baseline increased the YDQ symptoms only by 0.22. Sleep problems often occur as a result of pathological Internet use and could have an addiction-enhancing effect as well as mediating further psychiatric comorbidities. Thus, sleep problems should be targeted for early intervention and therapeutic measures.

Despite the expansion of treatment options for adults with borderline personality disorder (BPD), research on treatment options for adolescent BPD is scarce. The aim of this study was to investigate the impact of dialectical behavior therapy for adolescents (DBT-A) on the individual trait level as primary outcome; and the frequency of suicide attempts and nonsuicidal self-injury, self-reported BPD core pathology, and general psychopathology as secondary outcomes. Seventy-two adolescents (aged 12–17 years) with full- or subsyndromal BPD were treated with DBT-A (25 single sessions, 20 sessions of skills training), and 13 patients (18.1%) withdrew during treatment. From baseline to post-treatment, the number of BPD traits decreased significantly (p ≤ .001). All secondary outcomes decreased significantly as well (p ≤ .001). Results of this uncontrolled study suggest that beside self-harm, DBT-A may also have a beneficial impact on other features of BPD.

Background. Predicting suicide attempts is a challenging task for clinicians and researchers, particularly among high-risk individuals (i.e. adolescents with lifetime suicide attempts). In this study, we examined whether adolescents were able to predict their own risk of attempting suicide in the future and whether borderline personality disorder (BPD) or depressive symptoms impacted the predictive value of self-ratings. Methods. Structured clinical assessments were conducted at baseline and after 12 months in a high-risk sample of treatment-seeking adolescents (n = 134; 12-17y.; 90% female) with at least one lifetime suicide attempt. Results. During the follow-up period, n = 51 participants (38%) attempted suicide at least once. Self-rated risk was a significant predictor for the recurrence of a suicide attempt, whereas BPD and depression were not. While there was no significant interaction between self-rated risk and BPD, a negative interaction emerged between self-rated risk and depression in the prediction of a suicide attempt. Greater depression severity diminished the predictive value of self-ratings. Limitations. Depression severity was measured using a questionnaire, not a clinical interview. The findings may not be applicable to less burdened samples. Conclusions. Asking high-risk adolescents to rate their own risk of attempting suicide appears to be an easy to apply method in improving the prediction of future suicide attempts in the clinical context.

Zusammenfassung Nichtsuizidales selbstverletzendes Verhalten (NSSV) stellt eine häufige Symptomatik im Jugendalter dar. Trotz der Existenz wirksamer psychotherapeutischer Interventionen berichtet die Mehrheit der betroffenen Jugendlichen und jungen Erwachsenen, keine Behandlung erhalten zu haben. Sowohl strukturelle (z. B. keine spezifischen Behandlungen, limitierte Ressourcen, mangelnde Zugänglichkeit) als auch individuelle Barrieren (z. B. gering ausgeprägtes Hilfesuchverhalten) verhindern die adäquate Versorgung des NSSV im Jugendalter. Online-Interventionen bieten die Möglichkeit, spezifische Interventionen unabhängig vom Standort und der Versorgungsstruktur zu vermitteln. Aufgrund des niederschwelligen Zugangs werden auch Jugendliche mit gering ausgeprägten Hilfesuchtendenzen angesprochen. Online-Interventionen wurden bereits erfolgreich bei verschiedenen psychischen Störungen eingesetzt. Hinsichtlich NSSV existiert noch keine wirksame Online-Intervention. Daher wurde im Rahmen des deutschlandweiten STAR-Konsortiums (STAR: Self-Injury – Treatment, Assessment, Recovery) am Standort Heidelberg eine onlinebasierte Intervention, basierend auf einem bereits evaluierten Kurzzeittherapieprogramm, speziell für Jugendliche und junge Erwachsene mit NSSV entwickelt. Im Kontext einer randomisiert-kontrollierten Studie wird die Intervention aktuell hinsichtlich ihrer Wirksamkeit evaluiert.

The Outpatient Clinic for Adolescent Risk-taking and Self-harm behaviors (AtR!Sk) - A Pioneering Approach of Outpatient Early Detection and Intervention of Borderline Personality Disorder Self-harm and risk-taking behaviors are frequently occurring problems in adolescents' everyday life and commonly challenge the present child and adolescent health-care system. Those behaviors are typical features of borderline-personality disorder (BPD), a severe mental disorder that is associated with immense psychological strain, increased risk of mortality and poor psychosocial functioning. Despite controversy in the past, recent evidence shows that BPD is a valid and reliable diagnosis in adolescence. Consequently, specified and effective intervention programs for this age group are necessary. Instead, present health-care services for children and adolescents in Germany are usually characterized by long waiting periods for specialized outpatient treatments and unnecessary expanses of unnecessary long inpatient stays. Alternatively, and in order to prevent serious long-term consequences, new concepts - integrated in an ambulatory setting and close to patients' daily routines - should focus on early detection and treatment of adolescents at-risk presenting with borderline personality features. The specialist outpatient clinic AtR!Sk at the University Hospital Heidelberg ensures a low-threshold initial contact service, comprehensive and accurate diagnosis of BPD features, and rapidly "tailored" therapy for young people presenting with any types of risk-taking and self-harm behavior. AtR!Sk - as a pioneering approach in south Germany - provides evidence-based early detection and intervention for adolescent BPD.

Background Non-suicidal self-injury (NSSI) is a clinically significant behavior affecting approximately 18% of adolescents and young adults worldwide. The importance of NSSI is supported by its association with a broad spectrum of mental disorders. Despite its high relevance, evidence-based, specific, time-, and cost-effective treatment approaches are scarce. Cognitive behavioral therapy (CBT) seems effective in reducing the frequency of NSSI in adolescents and young adults. However, young people are often reluctant to seek professional help and effective interventions adressing NSSI are not sufficiently available across all regions of Germany. Research indicates that the majority of youth with risk behavior (including NSSI) prefer technology-based interventions. To date, effective interventions for adolescents and young adults with NSSI that are deliverd online are not available. Methods The present project aims to develop and evaluate an online intervention for adolescents and young adults with NSSI based on the content of a recently evaluated face-to-face short-term program that includes elements of CBT and dialectical behavior therapy (DBT): “The Cutting Down Programme” (CDP). The efficacy of the new online CDP intervention will be tested in a randomized controlled trial (RCT) in which n = 700 youths engaging in repetitive NSSI will participate in either an online psychoeducation (n = 350) or online CDP (n = 350). Within a postline assessment four months after baseline (end of treatment; T1), and follow-up evaluations 12 and 18 months after baseline (follow-ups; T2 and T3), NSSI and comorbid symptoms as well as quality of life will be assessed. It is hypothesized that participants receiving online CDP report a greater reduction in the frequency of NSSI within the last three months at T2 (primary endpoint) compared to those receiving online psychoeducation. Exploratory analyses will focus on predictors of treatment outcome. Discussion We report on the development and evaluation of an online intervention for adolescents and young adults engaging in NSSI based on the CDP. If supported by empirical evidence, an online-based intervention for NSSI might help to overcome the limited availability of adequate interventions for youth. Trial registration German Clinical Trials Register, DRKS00014623. Registered on 22 May 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3501-6) contains supplementary material, which is available to authorized users.

Refuge in Digital Worlds - the Association of Critical Life Events with Pathological Internet Use in Adolescence The present study sought to clarify the potential relationship between critical life events and pathological internet use in adolescents. A cross-sectional survey was conducted within the framework of a European school-based study (SEYLE) which included a representative sample of 1,444 students from the Rhein-Neckar catchment area. The Young Diagnostic Questionnaire (YDQ) was used to assess pathological internet use, whereas a combination of the List of Threatening Experiences (LTE) and Life Events Checklist (LCE) was administered to assess critical life events over the period of the last six months. Statistical models were adjusted for the presence of psychopathological distress using the Strengths and Difficulties Questionnaire (SDQ). 4.8 % of the participating students reported pathological internet use, 14.5 % met criteria for risky Internet use. Overall, adolescents with risky or pathological internet use recalled more critical life events, particularly within the context of interpersonal relationships and academic performance. After adjusting for sociodemographic variables and psychopathological distress, results showed that an unexpected decrease in academic performance as well as the termination of a romantic relationship, both were significantly associated with pathological internet use. Adolescents with pathological internet use reported significantly more frequent interpersonal problems and an unexpected decrease of academic performance. Based on the cross-sectional nature of the investigation, causality of the association cannot be established. However, results point towards potential risk factors (academic performance, termination of relationships) which may guide the identification of adolescents with risky or pathological internet use in child- and adolescent psychiatry.

The Outpatient Clinic for Adolescent Risk-taking and Self-harm behaviors (AtR!Sk) - A Pioneering Approach of Outpatient Early Detection and Intervention of Borderline Personality Disorder Self-harm and risk-taking behaviors are frequently occurring problems in adolescents' everyday life and commonly challenge the present child and adolescent health-care system. Those behaviors are typical features of borderline-personality disorder (BPD), a severe mental disorder that is associated with immense psychological strain, increased risk of mortality and poor psychosocial functioning. Despite controversy in the past, recent evidence shows that BPD is a valid and reliable diagnosis in adolescence. Consequently, specified and effective intervention programs for this age group are necessary. Instead, present health-care services for children and adolescents in Germany are usually characterized by long waiting periods for specialized outpatient treatments and unnecessary expanses of unnecessary long inpatient stays. Alternatively, and in order to prevent serious long-term consequences, new concepts - integrated in an ambulatory setting and close to patients' daily routines - should focus on early detection and treatment of adolescents at-risk presenting with borderline personality features. The specialist outpatient clinic AtR!Sk at the University Hospital Heidelberg ensures a low-threshold initial contact service, comprehensive and accurate diagnosis of BPD features, and rapidly "tailored" therapy for young people presenting with any types of risk-taking and self-harm behavior. AtR!Sk - as a pioneering approach in south Germany - provides evidence-based early detection and intervention for adolescent BPD.

Previous research revealed significant relations between the experience of childhood adversity (CA) and the development of borderline personality disorder (BPD) in adulthood. However, it is still uncertain whether parental CA could have a transgenerational association with adolescent BPD. We investigated associations between parents' CA (antipathy, neglect, physical abuse) and BPD traits within a clinical adolescent sample and tested for mediating variables. The sample consists of 91 female inpatients, along with 84 mothers and 59 fathers. Adolescent BPD traits were assessed using the BPD module of the Structured Clinical Interview for DSM-IV Disorders (SCID-II). Adolescent and parental CA and parental subclinical BPD traits were measured using validated self-report questionnaires (CECA.Q; PSSI). The findings revealed significant associations between parental CA and adolescent BPD traits, which were partially mediated by parental subclinical BPD traits and by paternal but not maternal CA. The results underline that early intervention of BPD must target the family environment, including fathers.

Background: Diagnostic standards do not acknowledge developmental specifics and differences in the clinical presentation of adolescents with borderline personality disorder (BPD). BPD is associated with severe impairments in health related quality of life (HRQoL) and increased psychopathological distress. Previously no study addressed differences in HRQoL and psychopathology in adolescents with subthreshold and full-syndrome BPD as well as adolescents at-risk for the development but no current BPD. Methods: Drawing on data from a consecutive sample of N = 264 adolescents (12–17 years) presenting with risk-taking and self-harming behavior at a specialized outpatient clinic, we investigated differences in HRQoL (KIDSCREEN-52) and psychopathological distress (SCL-90-R) comparing adolescents with no BPD (less than 3 criteria fulfilled), to those with subthreshold (3–4 BPD criteria) and full-syndrome BPD (5 or more BPD criteria). Group differences were analyzed using one-way analysis of variance with Sidak corrected contrasts or Chi-Square test for categorical variables. Results: Adolescents with subthreshold and full-syndrome BPD presented one year later at our clinic and were more likely female. Adolescents with subthreshold and full-syndrome BPD showed greater Axis-I and Axis-II comorbidity compared to adolescents with no BPD, and reported greater risk-taking behaviour, self-injury and suicidality. Compared to those without BPD, adolescents with subthreshold and full-syndrome BPD reported significantly reduced HRQoL. Adolescents with sub-threshold BPD and those with full-syndrome BPD did not differ on any HRQoL dimension, with the exception of Self-Perception. Similar, groups with sub-threshold and full-syndrome BPD showed no significant differences on any dimension of self-reported psychopathological distress, with the exception of Hostility. Conclusions: Findings highlight that subthreshold BPD in adolescents is associated with impairments in HRQoL and psychopathological distress comparable to full-syndrome BPD. Findings raise awareness on the importance of early detection and question the diagnostic validity and clinical utility of existing cut-offs. Findings support a lower diagnostic cut-off for adolescent BPD, to identify those at-risk at an early stage.

The Young Diagnostic Questionnaire (YDQ) is the most frequently used unidimensional measure to assess pathological Internet use. To date, investigations on the factorial validity of the YDQ using confirmatory factor analysis (CFA) are not available in the scientific literature. Empirical findings on the psychometric properties of the German translation of the YDQ are also lacking. Data were collected on two German samples of 1444 and 2713 adolescents. A confirmatory factor analysis (CFA) was conducted. We also calculated reliability coefficients and correlations between the YDQ and external criteria of Internet use. The models showed excellent global goodness-of-fit and satisfying local parameters. A unidimensional model seems to fit the data very well. We observed rather low reliability coefficients. The results indicate an acceptable construct validity of the German YDQ. The German version of the YDQ is a suitable instrument for measuring pathological Internet use in adolescent populations.

Refuge in Digital Worlds - the Association of Critical Life Events with Pathological Internet Use in Adolescence The present study sought to clarify the potential relationship between critical life events and pathological internet use in adolescents. A cross-sectional survey was conducted within the framework of a European school-based study (SEYLE) which included a representative sample of 1,444 students from the Rhein-Neckar catchment area. The Young Diagnostic Questionnaire (YDQ) was used to assess pathological internet use, whereas a combination of the List of Threatening Experiences (LTE) and Life Events Checklist (LCE) was administered to assess critical life events over the period of the last six months. Statistical models were adjusted for the presence of psychopathological distress using the Strengths and Difficulties Questionnaire (SDQ). 4.8 % of the participating students reported pathological internet use, 14.5 % met criteria for risky Internet use. Overall, adolescents with risky or pathological internet use recalled more critical life events, particularly within the context of interpersonal relationships and academic performance. After adjusting for sociodemographic variables and psychopathological distress, results showed that an unexpected decrease in academic performance as well as the termination of a romantic relationship, both were significantly associated with pathological internet use. Adolescents with pathological internet use reported significantly more frequent interpersonal problems and an unexpected decrease of academic performance. Based on the cross-sectional nature of the investigation, causality of the association cannot be established. However, results point towards potential risk factors (academic performance, termination of relationships) which may guide the identification of adolescents with risky or pathological internet use in child- and adolescent psychiatry.

Direct self-injurious behaviour (D-SIB) is associated with suicidal behaviour and suicide risk. It is not known if D-SIB cessation reduces these risks. The aim of this study was to explore trajectories of D-SIB and their prospective influence on suicidal thoughts and behaviour during adolescence. Data (n = 506; 62.06 % females, 14.53 years) from the Saving and Empowering Young Lives in Europe study were analysed. D-SIB and suicidal thoughts and behaviour were assessed at baseline (T0), 1- (T1) and 2-year follow-up (T2). Onset and maintenance of D-SIB between T0 and T1 were associated with a two to threefold increased odds ratio for suicidal thoughts and behaviour at T2. Suicidal thoughts and behaviour in those terminating D-SIB before T1 were similar compared to those with no life-time history of D-SIB. Late onset and maintenance of D-SIB prospectively indicate risk for suicidal thoughts and behaviour. This is the first study showing that D-SIB cessation reduces later risk for suicidal thoughts and behaviour in adolescence. Suicide prevention efforts should set one focus on reducing adolescent D-SIB.

Previous studies on borderline personality disorder (BPD) development suggest a transgenerational transmission of parent-child relationship quality, which may also be influenced by parents’ mental health status. The aim of this study was twofold. First, we aimed to investigate the transgenerational effect of parental bonding experiences on the development of BPD in their offspring. Second, we examined the association between parents' mental health status and BPD in offspring. Ninety-one female adolescent psychiatric inpatients along with 87 mothers and 59 fathers were enrolled in the study. Adolescent BPD was assessed with the Structured Clinical Interview for DSM-IV-II, parental bonding with the Parental Bonding Instrument, and parents´ psychiatric symptoms with the Patient Health Questionnaire. We found that low parental care produced a transgenerational effect from mother to BPD in offspring. Further, significant associations were found between paternal psychiatric symptoms and adolescent BPD. High paternal stress levels mediated the association between maternal affect reported by fathers and BPD in daughters. There is evidence of a transgenerational effect of parental bonding specifically for female adolescents with BPD, compared with other clinical control subjects. Our findings highlight the importance of including both parents in future research and in early clinical treatment in adolescents with BPD.

In Germany, high prevalence rates for problematic alcohol use and problematic Internet use in adolescents were reported. The objective of the present study was to identify psychopathological factors associated with these two behavior patterns. To our knowledge, this is the first investigation assessing psychopathological factors for both problematic alcohol and problematic Internet use in the same sample of adolescents. We surveyed a sample of 1444 adolescents in Germany regarding problematic alcohol use, problematic Internet use, psychopathology and psychological well-being. We conducted binary logistic regression analyses. 5.6% of the sample showed problematic alcohol use, 4.8% problematic Internet use, and 0.8% both problematic alcohol and problematic Internet use. Problematic alcohol use was higher in adolescents with problematic Internet use compared to those without problematic Internet use. Conduct problems and depressive symptoms were statistically significant associated with both problematic alcohol and problematic Internet use. Prosocial behavior was related to problematic Internet use. Male gender and less peer problems were associated with problematic alcohol use. For the first time associations between adolescent problematic alcohol and problematic Internet use due to common psychopathological factors were identified. However, in addition to shared factors, we found also specific psychopathological correlates associated with these two behavior patterns.