[The assessment of therapy outcome in child and adolescent psychiatry under naturalistic conditions--conception and implementation of the Marburg System of Quality Assurance and Therapy Evaluation]

OBJECTIVES

The objective of and concept behind the Marburg System of Quality Assurance and Therapy Evaluation (MARSYS) are presented. This a modular system with several instruments that is applicable for the evaluation of therapies with psychiatrically ill children and adolescents and can be employed in everyday routine care.

METHODS

The system was tested between 1999 and 2006 in the Marburg project on therapy evaluation in inpatient care. The article presents data from a complete user population with 1,321 patients. Data reporting on the practicability of the system comprise completeness of samples, dropout rates, acceptance of the evaluation among patients and parents, and the input of time and costs.

RESULTS

The results show that the system is very well suited to obtain significant findings with regard to the quality of outcome of the treatments.

CONCLUSIONS

The possibilities of implementing this system are discussed with regard to the matter of costs.

Schizophrene Erkrankungen im Jugendalter

This paper analyses sociodemographic, clinical, and descriptive data and data concerning cooperation in a sample of 305 consecutively treated inpatients with schizophrenia. The data of this group were compared with those from two other diagnostic groups (affective disorders, n=318; conduct disorders, n=982) who were treated as inpatients at the same time. Schizophrenic patients were significantly older at admittance (mean 17.6 years) than patients in the other two diagnostic groups (affective disorders 15.9 years, conduct disorders 13.1 years). On average, the inpatient treatment stay was longer in schizophrenic patients (by approximately 1 month) than in both of the other groups, and dropout was less frequent (5% vs 9% in affective disorders and 11% in conduct disorders). The treatment of the three patient groups was based on a multidimensional program following a model including five components: individual psychotherapy, family-centered measures, functional therapies, sociotherapeutic measures, and medication.

Lebensqualität bei psychisch kranken Kindern und Jugendlichen

Zusammenfassung: Fragestellung: Das neu entwickelte krankheitsunspezifische Instrument zur Messung der Lebensqualität von Kindern und Jugendlichen (ILK, Mattejat et al., 1998 ) sollte hinsichtlich seiner Differenzierungsfähigkeit zwischen ambulanten und stationären psychiatrischen Stichproben überprüft werden. Methodik: 626 kinder- und jugendpsychiatrische Patienten aus regional unterschiedlichen Kliniken und Praxen wurde der ILK-Bogen vorgelegt. Die so gewonnenen Daten werden deskriptiv dargestellt und mit Hilfe logistischer Regressionen genauer analysiert. Ergebnisse: Während eine rein deskriptive Betrachtung zeigt, dass stationär behandelte Kinder und Jugendliche durchweg alle Lebensbereiche als belastender erleben, relativiert sich dieses Ergebnis durch die Regressionsanalyse. Hier zeigt sich, dass die deskriptiv gefundenen Unterschiede zwischen stationären und ambulanten Patienten teilweise auf Alters- und/oder Geschlechtseffekte zurückzuführen sind; in einigen Lebensbereichen jedoch erweisen sich die Unterschiede zwischen der ambulanten und stationären Stichprobe unter Berücksichtigung von Alter und Geschlecht als Kovariaten als durchaus substantiell. Schlussfolgerungen: Das ILK ist als effizientes ökonomisches Verfahren in der Lage, Lebensqualität in Abhängigkeit von dem Schweregrad psychiatrischer Störungen zu erfassen; darüber hinaus ist es sensitiv für Alters- und Geschlechtseffekte. Indem das ILK Bereiche mit verminderter Lebensqualität schnell und sicher identifiziert, bietet es Ansatzpunkte für Indikationsstellung, Therapieplanung und erste therapeutische Interventionen.

[Reliability and validity of evaluation data collected by telephone]

OBJECTIVES

Follow-up telephone interviewing is an increasingly popular method of quality assurance and therapy evaluation in child and adolescent psychiatry. However, the reliability and validity of data gathered in telephone interviews has not been investigated sufficiently. The current article examines the quality of the information gathered from the parents of former inpatients of a hospital for child and adolescent psychiatry.

METHODS

In a sample of n = 32 cases a telephone interview was carried out, followed by a personal interview two weeks later. Data from both interviews were analyzed for correlations between the ratings by parents and experts.

RESULTS

The results from the telephone interviews indicate sufficient, respectively good reliability and underscore the validity of these data.

CONCLUSIONS

On the basis of these results, the standardized telephone interview developed in our group and used in the study can be applied as a reliable and valid method of controlling for treatment success in follow-up investigations. As the interview does not entail any great expenditures, it can be used in routine quality assurance.

[Value of telephone interview for quality assurance and therapy evaluation in child and adolescent psychiatry. Review of the literature and empirical results of participation quota and possible sampling bias]

OBJECTIVE

The incurred costs of telephone interviews are lower than those of other methods. Thus the question arises whether this method affords the necessary quality for therapy evaluation in child and adolescent psychiatry and psychopathology. A review of the literature shows higher rates of participation for telephone and personal interviews as opposed to those for questionnaires sent by mail. Results of investigations within the social sciences are inconsistent with regard to the quality of the data collected in telephone interviews. The few results available from samples from psychiatry permit no clear-cut conclusions as to the quality of such data.

METHOD

The results of two follow-up studies of former inpatients of a hospital for child and adolescent psychiatry are presented with regard to the rate of participation and the sample bias.

RESULTS

The empirical data show a higher rate of participation for telephone interviews (85%) than for either personal interviews or questionnaires sent by mail. Sample bias in telephone interviews is smaller than in the other assessment approaches.

CONCLUSIONS

Since the advantages of telephone interviews outweigh those of other methods, this method of interviewing should be used as a matter of routine for quality assurance and therapy evaluation.

The List of Individual Symptoms for Therapy Evaluation (LISTE)--an efficient method for individualized outcome assessment

An newly developed method for individualized assessment of therapy outcome, the "List of Individual Symptoms for Therapy Evaluation" (LISTE), is presented together with first empirical results on its testmetric properties and experience with this assessment instrument is reported. The LISTE method is an approach for objective 2-point assessment of therapy outcome which aims to use the advantages of individualized assessment methods while avoiding the known disadvantages to a considerable extent. So far, the results and experience with this method are very encouraging. The results of a first empirical evaluation indicate that the method supplies clinically relevant and objective data relating to treatment outcome, and that the method has acceptable testmetric characteristics in terms of sufficient reliability and validity values. Furthermore, the LISTE method is convenient for interviewing the therapist, parents and patients, it is neither expensive nor time consuming, and is compatible with clinical routine. The method requires little training and involves little additional effort. It can be used for face-to-face interviews or telephone interviews, and can also be applied as a paper-and-pencil test. Issues of application and the need for further studies are discussed.

The component model of treatment in child and adolescent psychiatry: theoretical concept and empirical results

The paper describes the theoretical concept and practical realization of the component model of treatment in child and adolescent psychiatry. Treatment procedures in a university department of child and adolescent psychiatry are analyzed based on a sample of 4545 patients in different settings (inpatient, day patient, and outpatient settings) and applying five different treatment components (individual psychotherapy with the patient, functional therapies, parent- and family-oriented interventions, other environmental interventions and psychotropic medication). These five treatment components were applied in variable combination to different disorders and in various settings. Treatment success based on therapists' ratings is described regarding a variety of ICD-9 diagnoses. Effect sizes were calculated for outpatient treatments (total sample 1682) and for inpatient treatments (total sample 1490). The effect size in the outpatient setting was 1.01 for normal completers vs. drop-outs, 1.27 for normal completers vs. non-beginners, and 0.34 for non-beginners vs. drop-outs. The corresponding effect sizes for inpatients were 0.74 for normal completers vs. drop-outs 1.27 for normal completers vs. non-beginners, and 0.84 for non-beginners vs. drop-outs. In spite of some methodological restrictions, the results of this naturalistic study can be used to improve empirically based treatment procedures under realistic clinical conditions.

Efficacy of inpatient and home treatment in psychiatrically disturbed children and adolescents. Follow-up assessment of the results of a controlled treatment study

In two German child and adolescent psychiatric treatment and research centers, a controlled treatment study was conducted in which two randomized treatment groups (in-patient treatment and home treatment) were compared. Subjects were children and adolescents with severe psychiatric disorders, for whom normal outpatient treatment was not sufficient (mean age of the patients was 11 years and 9 months at the beginning of treatment). The results showed no differences in therapy outcome between the two treatment modalities. In a further study, the results of which are presented here, a follow-up assessment (average follow-up interval: 3 years and 8 months) of the two treatment groups (follow-up sample of the inpatient treatment group: n = 33; home treatment group: n = 35) was undertaken in order to investigate the course of the psychiatric disturbances and the long-term effects of the treatments. As measurement categories for the outcome "adaption at school" and "number of marked symptoms" were used in pre-, post- and follow-up assessment. The most important results are 1) The number of marked psychiatric symptoms and the adaptation at school or work exhibit the same type of course over time. Post-treatment scores are much better when compared to pre-treatment scores, but decline slightly upon follow-up, although they remain significantly better than the pre-treatment scores. Thus, the study shows that improvements relating to the psychiatric symptoms are quite stable after several years. 2) There were no relevant differences between the treatment modalities "inpatient treatment" and "home treatment" in terms of effect-size upon follow-up, and in inferential analysis. Any tendency towards difference was in favor of home treatment. So the results give strong support to the conclusion that at least for a specific group of patients (about 15% of those patients usually treated in an inpatient setting) residential treatment can be replaced by home treatment and that the long-term therapeutic outcome of home treatment is stable and persistent. Thus, in terms of psychiatric care and clinical practice, our results provide empirical support to the idea that home treatment should be used more frequently and much more broadly in the future.

[Psychiatric illness from a multi-generational perspective: results of a longitudinal study with children and grandchildren of hospitalized depressed patients]

In a longitudinal empirical study data from three generations were gathered: Generation 1: formerly depressive patients, who had been treated as inpatients; generation 2: children of these patients; generation 3: grandchildren of the former patients. The first investigation of the children was carried out in the seventies, the follow-up-assessment of children and grandchildren was done in 1996. In the follow-up-study the meanwhile grown-up children of the depressive patients showed to a high degree psychic disturbances and were in treatment because of these problems. The majority of the grandchildren showed no relevant deviations. The severity of the depressive illness (in generation 1) and the psychopathological status of the former inpatient's spouse proved to be relevant prognostic factors with regard to the long-term development and resilience of children and grandchildren.

[Children of mentally ill parents. Research perspectives exemplified by children of depressed parents]

Children of psychiatrically ill parents represent a risk group that has received growing attention during the last years. The risk for this group to develop a psychiatric illness is markedly increased due to genetic and psychosocial factors. The development of effective preventive concepts requires a thorough knowledge of the psychosocial factors. In this paper, deficits and problems of research in psychosocial transmission mechanism are discussed taking the example of children of depressive parents. Conclusions from this exemplary considerations may serve as guidelines for future research. The authors suggest that the focus be rather placed on coping strategies and developmental psychopathology. Further, research criteria are formulated that refer to theoretical models as well as to study design.

[An inventory for assessing the quality of life of children and adolescents--a pilot study]

Up to now, the quality of life of children and adolescents with psychiatric disorders has rarely been investigated. Not many suitable instruments are available. A new one is the "Inventory for the Assessment of the Quality of Live in Children and Adolescents" presented here. Objectives and underlying conceptual assumptions are discussed, followed by an explanation of the instrument itself (questionnaires, rating scales, etc.). Finally, experiences with the application of the instrument are reported together with initial empirical results from a clinical sample and a sample of high school students. These indicate that the instrument usefully assesses clinically relevant information about the quality of life of the patients. A broader empirical analysis of this method is being prepared.

[Significance of family relations for coping with psychological disorders--results of an empirical study of therapy prognosis of children and adolescents with psychological disorders]

The importance of family relations for the therapy of psychiatric disorders in children and adolescents is discussed reporting results from an empirical study carried out in an inpatient sample of a child and adolescent psychiatric unit with regard to the quality of mother-child resp, father-child relation and its influence on coping processes. Whether adolescents suffering from a psychiatric disorder are able to cope with their problems during the course of a therapy, depends on their individual and social resources. Therapy outcome is to a great extent influenced by the emotional quality of their family relations. Hostility and rejection as well as unstructured and disorganized parental behavior contribute to a negative outcome. A differentiated analysis shows further that the relation between the adolescents and their fathers is particularly important for therapy prognosis. Nevertheless, one has to consider the respective relations with both parents for therapy prognosis, as problems with one parent may be partly compensated by a good relationship with the other parent. Finally, the cooperation between parents and clinical staff is discussed. Data and experiences show that interest and readiness of parents (mothers as well as fathers) for a close cooperation are higher than generally expected.

[Contributions of pediatric and adolescent psychiatric and development psychological research on objective definition of the child welfare concept]

The term of "child well-being" is a rather vague notion in the German jurisdiction and has to be reinterpreted according to each single case. The present article describes the historical context and different attempts to come to a more concrete definition of the term suitable to serve as a guideline for expert opinion and jurisdiction. The authors discuss the question in which way scientific findings may enhance an objectivation of "child well-being", stressing especially contributions coming from the fields of developmental psychopathology, attachment research, interaction and family research and research on risk factors and protective factors.

[Family diagnosis in psychological disorders of children and adolescents]

There are far more publications about family therapy than about family diagnostics. According to an old medical principle, however, diagnosis should always come first and therapy should follow. To help remedy this situation, over the past 15 years we have developed a family diagnostic inventory that is useful in clinical practice and allows development of adequate therapeutic approaches on the basis of a careful family diagnosis. The Marburg Family Diagnostic Scales, a part of this inventory, are described and their use is illustrated by examples from a clinical case report. The scales have shown to be useful for therapy planning and for the evaluation of family oriented interventions.

Follow-up investigation of family relations in patients with anorexia nervosa

In a group of 22 formerly anorectic inpatients (follow-up 3.8 years after treatment) and in a control group of 24 paralleled young women, the subjective perception of the family structure was assessed using the "Subjective Family Image (SFI)", in order to investigate the question whether the family structure of former anorectics differs from the controls and whether individual development of the former inpatients is associated with the experienced family structure. Empirical results are in favor of the following two hypotheses: 1) Compared to the control group, formerly anorectic inpatients experience family relationships as more complicated and less satisfying. The quality of family relationships in the patient group is reduced, even at the time of follow-up. 2) Individual outcome (individual course of the illness) and quality of family relationships at time of follow-up are associated. Patients with a good outcome experience family relationships as more positive than patients with a poor outcome. The accordance of these findings to other empirical results and their implications for clinical practice are discussed.

[Responsibilities and problems in quality assurance in psychiatry and psychotherapy in childhood and adolescence]

The goals of quality assurance in child and adolescent psychiatry and psychotherapy and related problems are reviewed. Three dimensions of quality assurance are differentiated: the substantive aspect (quality of the treatment process and results, quality of structural aspects of treatment facility) the area (diagnosis, therapy, staff training) and the tasks to be accomplished in the process of quality assurance (development of standards, assessment of the current situation, comparison of current situation with standards, planning and implementation of changes). Several important problems related to quality assurance are outlined and the most urgent tasks discussed in detail (development of quality standards and assessment of the current situation). It is proposed that quality assurance documentation is divided into four parts: documentation of structural characteristics of facility, basic documentation about patient, documentation of diagnostic and treatment services provided, and documentation of evaluation of services provided. An example of a therapy evaluation method (Questionnaire for Therapy Evaluation, QTE) is described.

[Children of psychotic parents--a neglected risk group]

Children of psychotic parents form a special risk group with an increased probability to develop psychiatric disorders. After an introductory presentation of the most important research findings, it is shown that, up to now, children of psychotic parents have not been paid much attention to in the literature. A concept for prevention is introduced that may serve as an orientation for planning and realizing preventive measures for children of psychotic parents. The prevention program comprises interventions aimed to improve coping strategies with the parental psychosis as well as specific preventive interventions to improve the situation of the children. Finally, principles are presented that should be acknowledged by specialists when doing preventive work.

[The value of various forms of therapy in a university child and adolescent psychiatric clinic and associated facilities. Methodological aspects and contents of therapy documentation within the scope of quality assurance]

This study is an extension of an investigation by the same authors in which the treatment provided by a university child psychiatry department and associated facilities was analyzed. First a system for the assessment of therapeutic measures for children and adolescents with psychiatric disorders and their families is presented. Then the frequency of use of the different forms of therapy in a sample of more than 10,000 referred children and adolescents is discussed. The statistical analysis was conducted separately for the different facilities (inpatient wards, outpatient clinic, day treatment ward, mobile child psychiatric service and child guidance clinic). The results show the relative importance of the different types of treatment in the field of child and adolescent psychiatry. Furthermore, they show how the frequency and intensity of use of the different treatment forms varies in the different facilities. In some treatment categories (e.g. pharmacological treatment) there are significant differences among facilities, whereas in others (e.g. parent counseling and family-oriented interventions) the rate of usage is about the same at all facilities. With regard to methodology, the question is discussed of how treatment effectiveness can be assessed and documented in a practicable and meaningful way.

[Therapeutic capacities of a university child and adolescent clinic with regional responsibilities and associated facilities]

In a clinical population of more than 10,000 children and adolescents the therapies used were analyzed statistically. The sample consisted of all children and adolescents referred to the Department of Child and Adolescent Psychiatry of the University of Marburg or one of its associated facilities between 1983 and 1991. Usage at each facility (inpatient wards, outpatient clinic, day treatment ward, mobile child psychiatric service and child guidance clinic) was analyzed separately. The facilities differed markedly regarding the age and sex distribution of the clients, diagnoses made, types of treatment used and overall duration of treatment. Furthermore, the duration and intensity of different types of treatment (psychotherapy, functional therapies, parent- and family-oriented interventions, other context-oriented interventions, pharmacological treatment) differed substantially at the different facilities. Overall a central component of treatment was work with the parents and other family members; in quantitative terms, drug treatment was of minor importance. With many patients and families a combination of two or more different types of treatment was used; therefore it is very important to integrate the different therapies into a treatment plan tailored to the individual and with consistent goals. The results are discussed in connection with quality assurance.

[Cooperation and termination of treatment: a study of the course of therapy of children with enuresis]

In an unselected sample of 45 subjects who received out-patient enuresis treatment data were collected with semi-structured interviews and other measures to examine conditions of successful participation in therapy. Subjects were assigned to three groups, first those who completed the course of therapy, second those who dropped out of therapy, and third those who didn't start with therapy after the initial interview. Results show that initially assessed variables like subjective suffering, capability and readiness to cooperate differentiate best between the groups. It was concluded that the manner of cooperating is a most significant factor in successful therapies and that therefore it is necessary to assess the individual manner of cooperating before applying standardized therapeutic procedures.

[Therapy evaluation in child and adolescent psychiatry: inpatient treatment, day care treatment and home treatment in comparison]

The aim of the present study was to compare inpatient, day hospital and home treatment of 10 child psychiatric disorders as defined in the Multi-axial Classification Scheme. The subjects were 109 patients from two child psychiatric hospitals who fulfilled clearly defined criteria. They comprised about 10 to 15% of the total clinical population of the two hospitals. The patient were assigned at random to the three treatment modalities. Treatment effectiveness was evaluated blind by experienced child psychiatrists not involved in the study. There were no significant differences between the treatment modalities in duration of treatment. Neither were there any significant differences between the treatment modalities with respect to treatment effectiveness, although there were some overall differences between different diagnostic categories. For a small group of carefully selected children day hospital and home treatment can therefore be looked upon as alternatives to inpatient treatment.