ABSTRACT: BackgroundThe consideration of impairment plays a crucial role in detecting significant mental health problems in children whose symptoms
do not meet diagnostic criteria. The assessment of impairment may be particularly relevant when only short screening instruments
are applied in epidemiological surveys. Furthermore, differences between childrens’ and parents’ perceptions of present impairment
and impairing symptoms are of interest with respect to treatment-seeking behaviour.
ObjectivesThe objectives were to assess parent- and self-reported impairment due to mental health problems in a representative sample
of children and adolescents; to describe the characteristics of highly impaired children with normal symptom scores; and to
investigate the associations between symptoms in different problem areas and impairment.
MethodsThe mental health module of the German Health Interview and Examination Survey for Children and Adolescents (the BELLA study)
examined mental health in a representative sub-sample of 2,863 families with children aged 7–17. Self-reported and parent-reported
symptoms of mental health problems and associated impairment were identified by the extended version of the strengths and
difficulties questionnaire (SDQ) in children 11years and older.
ResultsConsiderable levels of distress and functional impairment were found with 14.1% of the boys and 9.9% of the girls being severely
impaired according to the parental reports. However, self-reported data shows a reversed gender-difference as well as lower
levels of severe impairment (6.1% in boys; 10.0% in girls). Six percent of the sampled children suffer from pronounced impairment
due to mental health problems but were not detected by screening for overall symptoms. Childrens’ and parents’ reports differed
in regard to the association between reported symptom scores and associated impairment with children reporting higher impairment
due to emotional problems.
ConclusionsThe assessment of impairment caused by mental health problems provides important information beyond the knowledge of symptoms
and helps to identify an otherwise undetected high risk group. In the assessment of impairment, gender-specific issues have
to be taken into account. Regarding the systematic differences between childrens’ and parents’ reports in the assessment of
impairment, the child’s perspective should be given special attention.
European Child & Adolescent Psychiatry 04/2012; 17:42-51. · 2.82 Impact Factor
ABSTRACT: BackgroundThere is a lack of representative prevalence rates for attention deficit-/hyperactivity disorder (ADHD) according to DSM-IV
criteria and hyperkinetic disorder (HD) according to ICD-10 criteria for German subjects.
ObjectiveTo report the results of analyses of categorical data on the prevalence rates of the symptoms of ADHD/HD and additional diagnostic
criteria, as well as of the diagnoses of ADHD and HD according to symptoms and other diagnostic criteria, according to the
ICD-10 and DSM-IV. Further, to report administrative prevalence rates of the diagnosis and rates of co-existing behavioural
and emotional problems.
MethodWithin the BELLA module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a representative
sample of parents of 2,452 children and adolescents aged 7–17years completed an ADHD symptom checklist (FBB-HKS/ADHS) and
additional questionnaires for the assessment of coexisting behavioural and emotional problems.
ResultsThe prevalence rates for the diagnoses of ADHD according to DSM-IV criteria were 5.0% and the rate for HD according to ICD-10
criteria was 1.0%. Higher prevalence rates were found in boys and in younger children. The addition of other diagnostic criteria
(impairment, pervasiveness, onset, duration) resulted in a significant decrease of the prevalence rates of ADHD and HD to
2.2 and 0.6%, respectively. Higher prevalence rates were found in families of lower socioeconomic status and families from
urban areas. The lifetime administrative prevalence rate was 6.5%. Children with ADHD had an increased risk for coexisting
behavioural and emotional problems, especially for aggressive and antisocial behaviour problems, but also for anxiety and
ConclusionThe results of the national sample are in line with community studies in other countries. The effects of the additional diagnostic
criteria of impairment, situational pervasiveness, symptom onset and symptom duration on the prevalence rates have to be considered
in other epidemiological studies.
European Child & Adolescent Psychiatry 04/2012; 17:59-70. · 2.82 Impact Factor
ABSTRACT: BackgroundIn Europe, a considerable proportion of children and adolescents is affected by depressive symptoms, impairing their everyday
life and social functioning.
ObjectivesThe aim of this paper is to provide an overview of the depressive symptoms in children and adolescents in Germany, addressing
risk factors, comorbidity, and impact of depressive symptoms on everyday life.
MethodsIn the BELLA study, the mental health module of the German Health Interview and Examination Survey for Children and Adolescents
(KiGGS), a representative sample of young people aged 7–17years was enrolled. Depressiveness, assessed by the CES-DC, as
well as other mental health problems were examined in the context of risk and protective factors.
ResultsDepressive symptoms showed high prevalence in parent- and self-reports. Higher depression scores were found in those with
a high number of psychosocial risks existing in the family, and they decreased as the number of protective factors the children
and adolescents had at their disposal increased. Although only half of the boys and girls with high depression scores were
regarded as significantly impaired, all of them had a much higher risk for additional mental health problems. Furthermore,
their health-related quality of life was limited compared to their peers who had low depression scores.
ConclusionsTo differentiate between clinically significant depression and milder forms, it is necessary to take into account the different
perspectives of children and their parents. Prevention and intervention should acknowledge the widespread distribution of
depressive symptoms in children and adolescents, the high comorbidity of depressive and other mental health problems and the
impact of depression on the aspects of everyday life.
European Child & Adolescent Psychiatry 04/2012; 17:71-81. · 2.82 Impact Factor
ABSTRACT: Background and objectiveTo examine and compare the psychometric properties of two short screening instruments for children and adolescents suffering
from attention deficit-/ hyperactivity disorder (ADHD). The Conners’ Hyperactivity Index consists of ten items that assess
symptoms of hyperactivity through self-report and parents’ proxy. The German ADHD Rating scale (FBB-HKS/ADHS) consists of
20 items that assess the severity and perceived burden of inattention, hyperactivity, and impulsiveness as defined by the
ICD-10 and DSM-IV.
MethodsWithin the BELLA module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), the parents
of 2,863 children and adolescents rated the Conners’ Hyperactivity Index and the FBB-HKS.
ResultsThe internal consistency of item responses was assessed via Cronbach’s α and showed that both instrument scores were able
to obtain a reliable measurement. The factorial validity of the FBB-HKS measurement model as well as the unidimensionality
of the Conners’ scale was tested by means of exploratory and confirmatory factor analysis (EFA and CFA), indicating satisfactory
goodness of fit for the FBB-HKS (RMSEA=0.06) and some deviation from the unidimensionality assumption of the Conners’ scale.
Stability of results across age could be confirmed with few exceptions. Mean scores differences were found between both sexes,
age groups, and different socioeconomic status groups (Winkler-Index) with males, younger respondents, and children with low
socioeconomic status displaying more ADHD-related behaviour. Correlation coefficients between the two instruments’ scores
and other scales assessing emotional and behavioural problems hinted at convergent validity.
ConclusionBoth instruments’ scores showed reliability as well as factorial and convergent / discriminant validity. The pros and cons
of the two instruments as well as for which purpose and under which circumstances one of the measures can be favoured must
be considered prior to applying such a measure.
European Child & Adolescent Psychiatry 04/2012; 17:106-115. · 2.82 Impact Factor
ABSTRACT: BackgroundThe concept of health-related quality of life (HRQoL) involves the respondents’ perception of well-being and functioning in
physical, emotional, mental, social, and everyday life areas. Research in the area of subjective health has resulted in the
development of a multitude of HRQoL instruments that meet satisfying psychometric standards with regard to reliability, validity,
and sensitivity of the scales. One frequently used generic measure for children and adolescents is the KINDL-R questionnaire
developed by Ravens-Sieberer and Bullinger (Qual Life Res 7:399–407, 1998).
MethodsWithin the representative sample of the BELLA study, analyses regarding psychometric properties (namely reliability as well
as discriminant and construct validity) are performed.
ResultsPsychometric testing of the KINDL-R questionnaire reveals good scale utilisation and scale fit as well as moderate internal
consistency. Correlations with the KIDSCREEN-52 subscales are shown. Differences in KINDL-R scores exist between chronically
ill and healthy children as well as between SDQ problem scores.
ConclusionThe KINDL-R is a suitable instrument for measuring HRQoL in children and adolescents through self-report. The testing of the
instrument in a representative sample of German children and adolescents as well as their parents provides reference values
extending the potential of the KINDL-R questionnaire.
European Child & Adolescent Psychiatry 04/2012; 17:125-132. · 2.82 Impact Factor
ABSTRACT: BackgroundSince prevalence rates of mental health problems in children and adolescents are high and of considerable relevance to public
health, determinants of mental health, such as risk and protective factors, are of special interest.
ObjectivesThe present paper reports the frequencies and distributions of potential risk and protective factors and analyses their effects
on children’s mental health.
MethodsThe BELLA study is the mental health module of the German National Health Interview and Examination Survey among Children
and Adolescents (KiGGS). Mental health problems and their assumed determinants are examined in a representative sub-sample
of 2,863 families with children and adolescents aged 7–17. In order to identify mental health problems, the extended version
of the Strengths and Difficulties Questionnaire was administered. Data on psychosocial risk factors as well as on protective
factors in terms of personal, familial and social resources were collected by questioning the parents and, from the age of
11years upwards, the children themselves.
ResultsAdverse family climate stands out particularly as a negative contributor to children’s mental health. When several risk factors
occur simultaneously, the prevalence of mental health problems increases markedly. Conversely, pronounced individual, family
and social resources coincide with a reduced occurrence of mental health problems, especially in children with a limited number
of risk factors.
ConclusionsThe results suggest that differential prevention strategies are needed depending on the risk level: in the low risk group,
to which most children belong, effective prevention programmes should define strengthening resources as a key objective. In
the smaller group of children with a high number of risk factors, more complex intervention designs are required, which must
consider the reduction of risks as well as strengthening resources.
European Child & Adolescent Psychiatry 04/2012; 17:133-147. · 2.82 Impact Factor
ABSTRACT: ObjectiveTo identify disordered eating behaviour and attitudes in a large representative population in order to determine the relationship
with body weight status, and to assess associated psychopathology and health-related quality of life.
MethodsA total of 11–17year-old adolescents (n=1,895) were randomly selected from the national representative sample of 17,641 families participating in the German Health
Interview and Examination Survey for Children and Adolescents (KiGGS). Weight and height were assessed by trained staff. Mental
health problems and health-related quality of life were examined by means of a telephone interview and different questionnaires.
Eating disordered behaviour and attitudes were identified by the SCOFF, an instrument consisting of five questions originally
developed to screen for eating disorders in clinical settings.
ResultsAbout one third of the girls and 15% of the boys reported disordered eating behaviour and attitudes, which were most prevalent
in overweight youth. There was a significant association between the presence of disordered eating behaviour and psychopathology,
which was comprised of internalising and externalising behavioural problems. In addition, adolescents with disordered eating
behaviour reported reduced quality of life.
ConclusionThe high prevalence of disordered eating in the general population of Germany is of great concern. Health professionals should
not only be aware of disordered eating in underweight adolescents, but in all youth, especially overweight individuals. Disordered
eating behaviour is associated with a wide range of psychopathological and psychosocial concerns. Thus, youngsters engaging
in disordered eating behaviour should also be explored for other serious mental or social problems.
European Child & Adolescent Psychiatry 04/2012; 17:82-91. · 2.82 Impact Factor
ABSTRACT: BackgroundThe self-perceived health or health-related quality of life of children and adolescents is increasingly recognised as a relevant
outcome in medical practice and public health research. Identifying children and adolescents with particularly low health-related
quality of life allows for an early detection of hidden morbidity and health care needs.
ObjectivesThe present study investigates health-related quality of life in children and adolescents in Germany.
MethodsIn the Mental Health Module (BELLA study) of the German National Health Interview and Examination Survey for Children and
Adolescents (KiGGS), the parents of 2,863 children and adolescents aged 7–17years, and 1,700 children and adolescents aged
11–17years completed the KINDL-R quality of life questionnaire.
ResultsThe reliability (Cronbach’s α=0.86) and validity of the measurements using the parent-reported KINDL-R were confirmed. Means and percentiles were calculated
for the total sample as well as for strata defined by age, sex, geographical region (east/west), migration status and socioeconomic
status. Expected differences in health-related quality of life of children and adolescents from different social backgrounds
and with different health statuses were demonstrated by differences in the KINDL-R scores (effect size d up to 1.29).
ConclusionThis study provides representative, normative data (self-report and parent-report) on the test scores of health-related quality
of life (KINDL-R) for the population of children and adolescents in Germany in general, as well as in sociodemographic and
European Child & Adolescent Psychiatry 04/2012; 17:148-156. · 2.82 Impact Factor
ABSTRACT: ObjectivesTo examine the psychometric properties and test the theoretical quality of the German version of the Centre for Epidemiological
Studies depression scale for children (CES-DC), a 20-item screening instrument measuring the frequency of parent- and self-reported
depressive symptoms in children and adolescents.
MethodsUsing a population-based, representative sample of n=2,863 7 to 17-year-old German children and adolescents, factorial validity were determined by means of linear structural
equation modelling. Cross-sectional coefficients of reliability, inter-rater agreement as well as descriptive statistics of
the scales were calculated.
ResultsIn a population-based German sample, the four-factor version of the CES-DC following Radloff (Appl Psychol Meas 1:385–401,
1977) is considered to have good factorial validity and stability across age and informant versions. The main problems of
the questionnaire are the high item difficulties, strong floor effects of the scales and low cross-sectional reliability,
which are acceptable only for screening purposes. The low inter-rater agreement indicates that parental assessment can replace
self-assessment only to a limited degree.
ConclusionThe strengths and weaknesses of the CES-DC are discussed taking previous data and comparable tests into consideration. Particular
advantages are the existence of the parent-report form and the adult version, as well as its multifactorial structure. Parental
assessment should be supplemented by self-report data whenever possible.
European Child & Adolescent Psychiatry 11/2008; 17:116-124. · 2.82 Impact Factor