Lost in between-the transition process from a child and adolescent eating disorder service to adult mental health services in the German health care system

INTRODUCTION

In young adults with anorexia nervosa (AN), the process of transition from a child and adolescent mental health service (CAMHS) to an adult mental health service (AMHS) has been recognized as critical, and many patients fear falling through the gap between the two types of service. As reports about the transition process in emerging adults with AN are scarce, the present study aimed to explore the problems and experiences of this age group.

METHOD

We screened our registry for patients with AN who had been treated as inpatients during childhood and/or adolescence and come of age during the last 3 years. Thirty-two female patients [mean age 20.3 (1.2) y.] agreed to participate in a semistructured personal or telephone interview assessing their demographic and clinical data, whether they had finalised the transition, and their wishes and experiences regarding the transition process.

RESULTS

Only approximately one-third of the participants had already undergone the transition. Nearly 60% of the former patients were still cared for by a CAMHS, and only 12.5% had stopped treatment for AN. Approximately 60% were exclusively or additionally cared for by their general practitioner. More than 50% of the participants still lived with their parents. Approximately 90% of the participants who remained in a CAMHS expressed concerns about transitioning, mostly about losing their trusted therapist and the assumption of personal responsibility.

CONCLUSION

Patients with AN often delay the transition from a CAMHS to an AMHS, which they experience as intimidating and overwhelming. Thus, patients should be better prepared for the transition, which should be linked to "developmental readiness" and not to chronological age. Because many patients still live with their family of origin, parents and their family physician should be closely involved in the transition process.

Increase in admission rates and symptom severity of childhood and adolescent anorexia nervosa in Europe during the COVID-19 pandemic: data from specialized eating disorder units in different European countries

BACKGROUND

The COVID-19 pandemic, associated with confinement and social isolation, seems to have impacted the course of many mental disorders in children and adolescents. An increase in hospital admission rates for juvenile anorexia nervosa (AN) has been documented in many regions of the world. However, data from Europe are scarce.

METHODS

We asked clinicians in specialized eating disorder units in hospitals of maximum care in France, Germany, Italy, Spain, Sweden, and the Netherlands to report on (i) overall (inpatient and outpatient) and (ii) inpatient admission rates for adolescents with AN during 2019 and 2020. Additionally, a modified version of the COVID Isolation Eating Scale (CIES) was used to assess the child and adolescent psychiatrists' estimations of a possible increase in symptom severity in children and adolescents with AN during the COVID-19 pandemic and to (iii) inquire about the contributing factors perceived by the caring professionals.

RESULTS

Four out of six representatives of European hospitals described a higher rate of overall admissions during the pandemic. Three hospitals out of six reported an increase in inpatient admissions, and two centres had constant high numbers of admissions of both outpatients and inpatients. The clinicians perceived a higher symptom severity in 2020 than in 2019, especially involving more frequent use of social media, longer duration of exercising, and more restrictive eating. They supposed an increase in social media consumption, a perceived "loss of control", and a lack of in-person assessments and weight controls as the main contributing factors for the deterioration in AN numbers and symptomatology.

CONCLUSIONS

The COVID-19 pandemic seems to have had a deep impact on symptom severity in AN, which is mirrored by a large increase in admission rates across Europe. An increase in exercise, social media consumption, a perceived "loss of control", and a lack of face-to-face health care seem to have contributed to this development. Further investigation is required to identify which factors may lead to the increase in incidence and deterioration of childhood and adolescent AN. Possible preventive means for the future could include educating paediatricians and health care workers about AN, regular weight assessment, and home-based treatments.

Psychological Impact of the COVID-19 Pandemic on Children and Adolescents With and Without Mental Disorders

Background: The previous and current studies highlight the psychological distress caused by coronavirus disease 2019 (COVID-19)-associated restrictions among the general population, especially among children and adolescents; however, few studies have examined children and adolescents with a mental disorder. The current study aimed to explore whether youth with mental disorders show a higher pandemic-associated psychological burden than healthy children and adolescents and to determine which psychiatric diagnoses are particularly associated with a higher distress level. Methods: In this study, 144 children and adolescents between the ages of 6 and 18 years with a mental disorder and 48 children and adolescents within the same age range without a mental disorder, and their caregivers, completed questionnaires assessing the pandemic-associated trauma symptoms (the Child Report of Post-Traumatic Symptoms [CROPS] and the Parents Report of Post-Traumatic Symptoms [PROPS]). Additionally, we asked specific questions about the pandemic-associated stress factors, such as financial problems, prolonged screen times, or loneliness. Results: Children and adolescents with a mental illness showed a significantly higher psychological burden than their mentally healthy peers. Female gender was a risk factor for a higher self-reported psychological burden, and younger age was associated with a more extensive parent-reported psychological burden. The patients with a depressive disorder showed significantly higher levels of psychological distress associated with the COVID-19 pandemic than the patients with an attention deficit and/or a conduct disorder. Conclusions: Children and adolescents with a mental illness, particularly, female children and individuals with a depressive disorder, are at an increased risk of suffering from pandemic-associated psychological distress. Adequate mental health care options, such as telepsychiatry, are indispensable.

Genome-wide analysis of rare copy number variations reveals PARK2 as a candidate gene for attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a common, highly heritable neurodevelopmental disorder. Genetic loci have not yet been identified by genome-wide association studies. Rare copy number variations (CNVs), such as chromosomal deletions or duplications, have been implicated in ADHD and other neurodevelopmental disorders. To identify rare (frequency ≤1%) CNVs that increase the risk of ADHD, we performed a whole-genome CNV analysis based on 489 young ADHD patients and 1285 adult population-based controls and identified one significantly associated CNV region. In tests for a global burden of large (>500 kb) rare CNVs, we observed a nonsignificant (P=0.271) 1.126-fold enriched rate of subjects carrying at least one such CNV in the group of ADHD cases. Locus-specific tests of association were used to assess if there were more rare CNVs in cases compared with controls. Detected CNVs, which were significantly enriched in the ADHD group, were validated by quantitative (q)PCR. Findings were replicated in an independent sample of 386 young patients with ADHD and 781 young population-based healthy controls. We identified rare CNVs within the parkinson protein 2 gene (PARK2) with a significantly higher prevalence in ADHD patients than in controls (P=2.8 × 10(-4) after empirical correction for genome-wide testing). In total, the PARK2 locus (chr 6: 162 659 756-162 767 019) harboured three deletions and nine duplications in the ADHD patients and two deletions and two duplications in the controls. By qPCR analysis, we validated 11 of the 12 CNVs in ADHD patients (P=1.2 × 10(-3) after empirical correction for genome-wide testing). In the replication sample, CNVs at the PARK2 locus were found in four additional ADHD patients and one additional control (P=4.3 × 10(-2)). Our results suggest that copy number variants at the PARK2 locus contribute to the genetic susceptibility of ADHD. Mutations and CNVs in PARK2 are known to be associated with Parkinson disease.

Effects of the DRD4 genotype on neural networks associated with executive functions in children and adolescents

Genetic variants within the dopamine D4 receptor gene (DRD4) are among the strongest and most consistently replicated molecular genetic findings in attentional functioning as well as attention deficit hyperactivity disorder (ADHD). Functionally, the 7-repeat allele of the DRD4-48 base pair repeat gene leads to a sub-sensitive postsynaptic D4 receptor, which is expressed at a particularly high density in the frontal lobes. We used fMRI to investigate the influence of the 7-repeat allele on BOLD (Blood Oxygen Level Dependency) responses in 26 healthy children and adolescents while they performed a combined stimulus-response Incompatibility Task (IC) and a Time Discrimination Task (TT).

7-repeat non-carriers exhibited increased neural activation of the left middle and inferior frontal gyrus (IFG) in the IC and greater cerebellar activation in the TT. Furthermore, the 7-repeat non-carriers exhibited a stronger coupling in haemodynamic responses between left IFG and the anterior cingulate cortex (ACC) during the IC and between cerebellar activation and brain regions that have high DRD4 density, including the IFG and the ACC during the TT. Our results indicate that the 7-repeat allele influences both regional brain activation patterns as well as connectivity patterns between neural networks of incompatibility and temporal processing.

Genome-wide association study in German patients with attention deficit/hyperactivity disorder

The heritability of attention deficit hyperactivity disorder (ADHD) is approximately 0.8. Despite several larger scale attempts, genome-wide association studies (GWAS) have not led to the identification of significant results. We performed a GWAS based on 495 German young patients with ADHD (according to DSM-IV criteria; Human660W-Quadv1; Illumina, San Diego, CA) and on 1,300 population-based adult controls (HumanHap550v3; Illumina). Some genes neighboring the single nucleotide polymorphisms (SNPs) with the lowest P-values (best P-value: 8.38 × 10(-7)) have potential relevance for ADHD (e.g., glutamate receptor, metabotropic 5 gene, GRM5). After quality control, the 30 independent SNPs with the lowest P-values (P-values ≤ 7.57 × 10(-5) ) were chosen for confirmation. Genotyping of these SNPs in up to 320 independent German families comprising at least one child with ADHD revealed directionally consistent effect-size point estimates for 19 (10 not consistent) of the SNPs. In silico analyses of the 30 SNPs in the largest meta-analysis so far (2,064 trios, 896 cases, and 2,455 controls) revealed directionally consistent effect-size point estimates for 16 SNPs (11 not consistent). None of the combined analyses revealed a genome-wide significant result. SNPs in previously described autosomal candidate genes did not show significantly lower P-values compared to SNPs within random sets of genes of the same size. We did not find genome-wide significant results in a GWAS of German children with ADHD compared to controls. The second best SNP is located in an intron of GRM5, a gene located within a recently described region with an infrequent copy number variation in patients with ADHD.

Was wissen wir über Langzeiteffekte von Methylphenidatbehandlung auf die Hirnentwicklung von Kindern und Jugendlichen mit einer Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS)?

Obwohl Psychostimulanzien zu den Behandlungsmethoden der ersten Wahl bei Kindern mit einer Aufmerksamkeitsdefizit/-Hyperaktivitätsstörung (ADHS) im Kindes- und Jugendalter gehören, sind mögliche Langzeitfolgen einer Stimulanzientherapie noch nicht ausreichend erforscht. Während eine kurzzeitige positive Wirkung von Stimulanzien auf Aufmerksamkeitsleistungen als gesichert gilt, sind die langfristigen Auswirkungen insbesondere einer Medikation in der frühen Kindheit sowie einer Dauermedikation noch weitestgehend unbekannt. Verschiedene Studien ergaben Hinweise auf einen Einfluss einer Dauermedikation mit Stimulanzien sowohl auf die strukturelle als auch auf funktionelle Hirnentwicklung. Des Weiteren sollten mögliche unerwünschte kognitive und motivationale Nebenwirkungen einer Medikation mit Methylphenidat genauer in Betracht gezogen werden. Insgesamt zeigt sich die Datenlage heterogen und es mangelt an Studien mit ausreichend großen Fallzahlen.

Neural mechanisms of interference control and time discrimination in attention-deficit/hyperactivity disorder

OBJECTIVE

Both executive functions and time perception are typically impaired in subjects with attention-deficit/hyperactivity disorder (ADHD). However, the exact neural mechanisms underlying these deficits remain to be investigated.

METHOD

Fourteen subjects with ADHD and 14 age- and IQ-matched controls (aged 9 through 15 years) were assessed with functional magnetic resonance imaging while they performed a combined spatial stimulus-response compatibility (SRC) and time duration discrimination (TD) paradigm using identical stimuli for all experimental conditions.

RESULTS

Children with ADHD performed less accurately in the SRC but not in the TD task compared with controls. On the brain level, subjects with ADHD showed significantly reduced neural activity in the left putamen during SRC and reduced fronto-cerebellar activation during TD when compared with the baseline conditions. Compared with subjects with ADHD, control subjects had increased activation in a left-hemispheric fronto-parietal network during the SRC task and in the right superior-frontal gyrus during the TD task. Functional connectivity analyses revealed abnormal fronto-parietal coupling during the SRC task and reduced fronto-cerebellar connectivity during the TD task in the ADHD group compared with controls.

CONCLUSIONS

Our findings suggest specific but distinct patterns of cerebral dysfunction associated with interference control and TD processing in ADHD, characterized by both reduced neural activation in regions critical for task performance and reduced co-activation of frontal cortex. Group differences on the behavioral level were controlled by several methodological approaches. Nonetheless, given the use of a block design, we cannot rule out the possibility that between-group differences in behavior confounded the neural activation patterns.

Familiality and molecular genetics of attention networks in ADHD

Indices from a more elementary neuropsychological level might be useful in the search for genes for complex psychiatric disorders, such as ADHD. In this study we investigated systematically whether attentional performance as measured with the Attention Network Test (ANT) is suited for the identification of endophenotypes of ADHD. Attentional performance in affected sib pairs with ADHD (n = 181) was compared to unaffected control siblings (n = 121). Intrafamilial correlation patterns were calculated. In addition, linkage and association analyses were conducted between quantitative scores of attentional functions and dopamine receptor D4 (DRD4) and dopamine transporter (DAT1 or SLC6A3) gene variants. Only the executive attention network was significantly impaired in subjects with ADHD compared to controls (P < 0.05) and showed evidence for familiality in both affected and unaffected families. Linkage analyses revealed the highest LOD score for a severity score based on DSM-IV inattentive symptoms in the DAT1 chromosomal region (LOD score 2.6 at 15 cM). However, a SNP (rs6350) at the DAT1 locus showed a tendency for association with both alerting performance (P = 0.02) and executive attention (P = 0.01) although it did not survive alpha adjustment for multiple testing. No evidence was found for association of any of the investigated phenotypes with the VNTR in the DRD4. Thus, our data suggest that the quantitative behavioral ratings of inattentive symptoms might be more useful when searching for new genes associated with ADHD, however, among the ANT measures the executive attention network seems to be best suited for further endophenotype analyses.

Aufmerksamkeitsstörungen im Kindesalter

Zusammenfassung. Der vorliegende Übersichtsartikel beschäftigt sich mit der Bedeutung der funktionellen Kernspintomographie (fMRT) für diagnostische und therapeutische Aspekte von kindlichen Aufmerksamkeitsstörungen. Nach einer kurzen Einführung in die Methode und ihre Besonderheiten bei der Anwendung im Kindesalter, werden Ergebnisse aus fMRT-Studien bei Kindern mit einem Aufmerksamkeitsdefizit/Hyperaktivitätssyndrom (ADHS) zusammengefasst. Abschließend werden weitergehende Chancen und Nutzen der funktionellen Kernspintomographie für die klinische Praxis und zukünftige Forschungsperspektiven diskutiert.