Attention, Externalizing and Internalizing Problems Mediated Differently on Internet Gaming Disorder Among Children and Adolescents With a Family History of Addiction as an Adverse Childhood Experience.

BACKGROUND: This study aimed to examine the factors associated with internet gaming disorder (IGD) and the mediating role of pediatric symptoms (attention, externalizing problems and internalizing problems) in children and adolescents with a family history of addiction as an adverse childhood experience (ACE). METHODS: A total of 2,586 children and adolescents (mean age = 14.04 ± 2.34; age range = 11-19 years; 50.5% boys) completed the Internet Game Use-Elicited Symptom Screen and the Pediatric Symptom Checklist-17. IBM SPSS Statistics 21 was used to calculate descriptive statistics and Pearson correlation coefficients and to conduct multiple regression analyses. Mediation analysis was performed using the Sobel test and the SPSS PROCESS macro. Serial multiple mediation analysis was performed using bootstrapping with 5,000 replications. RESULTS: The higher levels of Attention problems (ß = -0.228, P < 0.001) and externalizing problems (ß = -0.213, P < 0.001) were associated with IGD. Furthermore, the indirect effect of the independent variable on the dependent variable through the mediators was significant (Sobel's T: Z = -5.006, P < 0.001). These findings suggest that attention and externalizing problems mediate the effect of family history of addiction on IGD. CONCLUSION: This study demonstrated the associations among the family history of addiction, IGD, and pediatric symptoms (attention, externalizing problems, and internalizing problems) among Korean children and adolescents. Therefore, we need to pay attention to pediatric symptoms and develop systematic alternatives to improve mental health among Korean children and adolescents with a family history of addiction as ACEs.

Can We Notice the Suicidal Warning Signs of Adolescents With Different Psychometric Profiles Before Their Death?: Analysis of Teachers' Reports.

BACKGROUND: This study aimed to analyze the suicidal warning signs of Korean students with different psychometric profiles based on teacher reports. METHODS: This was a retrospective cohort study based on Korean school teachers' responses to the Student Suicide Report Form. In total, 546 consecutive cases of student suicide were reported from 2017 to 2020. After missing data were excluded, 528 cases were included. The report consisted of demographic factors, the Korean version of the Strengths and Difficulties Questionnaire (SDQ) for teacher reporting, and warning signs of suicide. Frequency analysis, multiple response analysis, the χ² test, and Latent Class Analysis (LCA) were performed. RESULTS: Based on the scores of the Korean version of the teacher-reported SDQ, the group was divided into nonsymptomatic (n = 411) and symptomatic (n = 117) groups. Based on the LCA results, four latent hierarchical models were selected. The four classes of deceased students showed significant differences in school type (χ² = 20.410, P < 0.01), physical illness (χ² = 7.928, P < 0.05), mental illness (χ² = 94.332, P < 0.001), trigger events (χ² = 14.817, P < 0.01), self-harm experience (χ² = 30.618, P < 0.001), suicide attempts (χ² = 24.072, P < 0.001), depressive symptoms (χ² = 59.561, P < 0.001), anxiety (χ² = 58.165, P < 0.001), impulsivity (χ² = 62.241, P < 0.001), and social problems (χ² = 64.952, P < 0.001). CONCLUSION: Notably, many students who committed suicide did not have any psychiatric pathology. The proportion of the group with a prosocial appearance was also high. Therefore, the actual suicide warning signals were similar regardless of students' difficulties and prosocial behaviors, so it is necessary to include this information in gatekeeper education.

Clozapine Blood Concentration Predicts Corrected QT-Interval Prolongation in Patients With Psychoses.

BACKGROUND: Corrected QT-interval (QTc) prolongation (QTP) is a rare but fatal adverse effect of antipsychotics. Clozapine is the only antipsychotic recommended for treatment of resistant schizophrenia; however, clozapine has been reported to cause QTP. We sought factors predictive of QTP in patients who had antipsychotic polypharmacy involving clozapine. We explored whether the clozapine blood concentration might predict QTP. METHODS: We included 133 patients with schizophrenia spectrum disorder who had antipsychotic polypharmacy involving clozapine. We used the χ2 and nonparametric tests to compare clozapine therapeutic drug monitoring (TDM) values and QTc-prolonged person (QTPP) status. Multivariate regression and mediator models were used to identify risk factors for QTPP status and QTP. RESULTS: In total, 111 patients were prescribed clozapine. The QTPP rates were 31.3% (20) for men and 23.2% (16) for women. Compared with the non-QTPP group, the QTPP group exhibited significantly higher daily dose of all antipsychotics including clozapine, a higher clozapine dose, and elevated clozapine and norclozapine TDM values. Furthermore, such patients were prescribed a greater number of antipsychotics. Multivariate logistic regression revealed that only the clozapine TDM value could be predictive factor for QTPP status (P = 0.018). A clozapine TDM value above the therapeutic range (>600 mg/dL) was associated with a high risk of QTPP status (adjusted odds ratio, 6.5; 95% confidence interval, 1.7-25.2; P = 0.006). The mediator model revealed that the clozapine TDM values completely mediated the association between the clozapine dose and the QTc interval. CONCLUSIONS: The clozapine blood concentration reliably predicts QTP in patients with clozapine use.

Gaming patterns and related symptoms in adolescents using cluster analysis: Baseline results from the Internet User Cohort for Unbiased Recognition of Gaming Disorder in Early Adolescence (iCURE) study.

PURPOSE: The risk and protective factors of Internet gaming disorder (IGD) could vary by individual. The identification of more homogeneous subgroups may lead to better understanding of gaming behaviors and their consequences in adolescents. The purpose of this study was to investigate the prevalence of IGD among the subgroups defined by cluster analysis in adolescents. METHODS: A total of 2319 adolescents were enrolled in the Internet User Cohort for Unbiased Recognition of Gaming Disorder in Early Adolescence (iCURE) study at baseline. Self-reported IGD was assessed with a DMS-5 adapted measurement. Smartphone addiction, musculoskeletal discomfort, and dry eye symptoms were evaluated by self-administered questionnaires. Cluster analysis was performed using risk and protective factors of IGD after considering multicollinearity. RESULTS: Three different clusters were identified. Cluster 1 (19.2%) was users with combined potential psychological and social issues. Cluster 2 (32.3%) was users with potential social but no psychological issues. Cluster 3 (45.6%) was users with no potential issues of either a social or psychological nature. Adolescents from both clusters 1 and 2 showed higher degrees of IGD, smartphone addiction, musculoskeletal discomfort, and dry eye symptoms than did those from cluster 3. Also compared with adolescents in cluster 3, those in cluster 1 showed statistically higher risks of IGD (aOR:11.9, 95%CI:7.5-19.9), smartphone addiction (aOR:5.4, 95%CI:4.0-7.2), musculoskeletal discomfort (aOR:2.6, 95%CI:2.1-7.4), and dry eye symptoms (aOR:3.8, 95%CI:3.0-4.9). Those in cluster 2 also showed statistically higher risk of IGD, smartphone addiction, musculoskeletal discomfort, and dry eye symptoms compared with cluster 3 (aOR:4.5, 95%CI:2.8-7.6; aOR:2.8, 95%CI:2.1-3.7; aOR:1.6, 95%CI:1.3-1.9; and aOR:1.9, 95%CI:1.6-2.4, respectively). CONCLUSIONS: Clustering based on the risk and preventive factors of IGD may be suitable for determination of high risk of IGD in adolescents. However, we need to confirm the usefulness and clinical application of the classifications by observing their longitudinal changes.

Efficacy of the 'Children in Disaster: Evaluation and Recovery (CIDER)' Protocol for Traumatized Adolescents in Korea.

BACKGROUND: We aimed to evaluate the feasibility of trauma-focused group therapy in adolescents exposed to traumatic events in Korea. METHODS: We recruited 22 adolescents (mean age, 16 years; standard deviation, 1.43; range, 13-18 years). Children in Disaster: Evaluation and Recovery (CIDER) V1.0 is a trauma-focused group therapy comprising eight 50-minute-long sessions. The effectiveness of the intervention was evaluated using the Korean version of the Children's Response to Traumatic Events Scale-Revised (K-CRTES-R), the Beck Depression Inventory (BDI), the State Anxiety Inventory for Children (SAIC), and the Pediatric Quality of Life Inventory (PedsQL). The data were analyzed by the Wilcoxon signed-rank test. RESULTS: A significant improvement was revealed in trauma-related symptom scores (Z = -2.85, P < 0.01), depressive symptom scores (Z = -2.35, P < 0.05) and quality of life scores (Z = -3.08, P < 0.01). Additionally, a marginally significant improvement was found in anxiety symptom scores (Z = -1.90, P = 0.058). CONCLUSION: CIDER is a potentially effective intervention for adolescents exposed to traumatic events. Larger controlled trials are needed. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0004681.

Exposure to Adverse Childhood Experiences (ACEs) and Stress among the Community-based Urban Pediatric Population in Korea.

BACKGROUND: This study aimed to investigate the impact of exposure to adverse childhood experiences (ACEs) and stress among the community-based urban pediatric population in Korea. METHODS: In 2017, the analysis was conducted on 3,937 children and adolescents in an urban area in Korea based on the impact of actual traumatic experience, addiction, and mental health. The respondents were excluded if they were missing data on the survey, resulting in a final sample size of 3,556. The collected data were analyzed by applying cross-sectional and correlation analyses. RESULTS: Among the respondents in the study group (mean age = 13.77), 43.1% were boys (n = 1,532) and 56.9% were girls (n = 2,024). Overall, 23.5% (n = 835) reported at least one ACE and 1.8% (n = 63) reported experiencing four or more ACEs. Emotional abuse (13.2%) was the most commonly reported ACE, followed by abandonment (7.7%) and physical abuse (7.5%). Self-reported measures of stress were associated with the ACE scores. CONCLUSION: This is the first study of self-reported ACEs from a community-based pediatric population in Korea. We found that the number of the students revealed more than one ACEs was similar to the data in the US community study with self-reporting among the community samples and exposure to adverse experiences is highly correlated with various stress responses.

The Mediating Effect of Depressive Symptoms on the Relationship between Adverse Childhood Experiences and Problematic Internet Use in Children and Adolescents.

The purpose of this study was to evaluate the mediating effect of depressive symptoms on the relationship between adverse childhood experiences (ACEs) and problematic internet use. The study participants were 180 students between the ages of 9 and 18 years. Path analysis was performed to measure the relationships among ACEs, depressive symptoms and problematic internet use. ACEs significantly affected depressive symptoms (standardized regression weight, 0.36; P < 0.01), and depressive symptoms also affected problematic internet use (standardized regression weight, 0.40; P < 0.01). We found that depressive symptoms had a significant mediating effect on the relationship between problematic internet use and ACEs. The management of depressive symptoms would be important to prevent problematic internet use in children and adolescents with ACEs.

Psychiatric Symptoms and Clinical Diagnosis in High School Students Exposed to the Sewol Ferry Disaster.

BACKGROUND: Two hundred and fifty 11th grade students and teachers from Danwon High School drowned, during a school trip, in the Sewol Ferry Disaster. The goal of this study was to investigate the experiences of the psychiatrists who volunteered and provided psychiatric services to the students at Danwon High School. METHODS: From the second day to the 138th day after the disaster, pro bono psychiatrists provided post-disaster interventions to the 10th and 12th-grade Danwon High School students who did not attend the trip. Officially, 167 psychiatrists conducted outreach in approximately 550 encounters. The study questionnaires were distributed retrospectively to psychiatric volunteers who conducted outreach at Danwon High School. We surveyed the pro bono psychiatrists about their experiences, including the students' chief complaints, psychiatric problems, clinical diagnoses, and psychiatrists' treatment recommendations. RESULTS: We reached 72 (43.1%) of the 167 volunteers, and they reported on 212 (38.6%) of the 550 encounters. The common chief complaints were mental health problems, companion problems, and family problems. The most frequent psychiatric symptoms were anxiety (76.89%), depressive mood (51.42%), and concentration difficulty (50.94%). The most frequent clinical diagnoses of the students were normal reaction (41.04%), acute stress disorder (24.53%), adjustment disorder (17.92%), anxiety disorders (9.43%), and posttraumatic stress disorder (6.60%). More than half of the students needed "additional counseling/therapy" (41.04%) or "referral to psychiatric treatment" (14.15%). CONCLUSION: During the acute aftermath of the Sewol Ferry Disaster, volunteer psychiatrists were able to provide services. These services included psychiatric assessments, crisis counseling, psychological first aid, and referrals for ongoing care. More than half of the students were perceived to have a psychiatric diagnosis, and a substantial proportion of students needed further treatment. Future research should focus on the short- and long-term effects of psychiatric interventions and the characterization of post-disaster mental health needs and service provision patterns.

Exploring the Differences between Adolescents' and Parents' Ratings on Adolescents' Smartphone Addiction.

BACKGROUND: Smartphone addiction has recently been highlighted as a major health issue among adolescents. In this study, we assessed the degree of agreement between adolescents' and parents' ratings of adolescents' smartphone addiction. Additionally, we evaluated the psychosocial factors associated with adolescents' and parents' ratings of adolescents' smartphone addiction. METHODS: In total, 158 adolescents aged 12-19 years and their parents participated in this study. The adolescents completed the Smartphone Addiction Scale (SAS) and the Isolated Peer Relationship Inventory (IPRI). Their parents also completed the SAS (about their adolescents), SAS-Short Version (SAS-SV; about themselves), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). We used the paired t-test, McNemar test, and Pearson's correlation analyses. RESULTS: Percentage of risk users was higher in parents' ratings of adolescents' smartphone addiction than ratings of adolescents themselves. There was disagreement between the SAS and SAS-parent report total scores and subscale scores on positive anticipation, withdrawal, and cyberspace-oriented relationship. SAS scores were positively associated with average minutes of weekday/holiday smartphone use and scores on the IPRI and father's GAD-7 and PHQ-9 scores. Additionally, SAS-parent report scores showed positive associations with average minutes of weekday/holiday smartphone use and each parent's SAS-SV, GAD-7, and PHQ-9 scores. CONCLUSION: The results suggest that clinicians need to consider both adolescents' and parents' reports when assessing adolescents' smartphone addiction, and be aware of the possibility of under- or overestimation. Our results cannot only be a reference in assessing adolescents' smartphone addiction, but also provide inspiration for future studies.

Prescription Trends of Psychotropics in Children and Adolescents with Autism Based on Nationwide Health Insurance Data.

Children with autism are often medicated to manage emotional and behavioral symptoms; yet, data on such pharmacotherapy is insufficient. In this study, we investigated the Korean National Health Insurance Claims Database (NHICD) information related to autism incidence and psychotropic medication use. From the 2010-2012 NHICD, we selected a total of 31,919,732 subjects under 19 years old. To examine the diagnostic incidence, we selected patients who had at least one medical claim containing an 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for pervasive developmental disorder, F84, not diagnosed in the previous 360 days. Psychotropics were categorized into seven classes. Then, we analyzed the data to determine the mean annual diagnostic incidence and psychotropic prescription trends. Diagnostic incidence was 17,606 for the 3 years, with a mean annual incidence per 10,000 population of 5.52. Among them, 5,348 patients were prescribed psychotropics. Atypical antipsychotics were the most commonly used, followed by antidepressants. An older age, male sex, and the availability of medical aid were associated with a higher rate of prescription than observed for a younger age, female sex, and the availability of health insurance. Psychotropic drugs were used for less than one-third of patients newly diagnosed with autism, and prescription differed by sex and age. Increased diagnostic incidence is associated with an increased prescription of psychotropic drugs. Therefore, medication-related safety data and policies for psychotropic drugs in autism should be prepared.

Naturalistic Pharmacotherapy Compliance among Pediatric Patients with Attention Deficit/Hyperactivity Disorder: a Study Based on Three-Year Nationwide Data.

We examined short- and long-term medication compliance among youth with attention-deficit hyperactivity disorder (ADHD), using data from the National Health Insurance database in Korea. Of the 5,699,202 6-14-year-old youth in 2008, we chose those with at least 1 medical claim containing an ICD-10 code for diagnosis of ADHD (F90.0) and no prescription for ADHD within the previous 365 days. We tracked the data every 6 months between 2008 and 2011, to determine treatment compliance among newly diagnosed, medicated patients. Further, we checked every 1 month of the 6 months after treatment commencement. Treatment continuity for each patient was calculated by sequentially counting the continuous prescriptions. For measuring compliance, we applied the medication possession ratio (MPR) as 0.6, 0.7, and 0.8, and the gap method as 15- and 30-days' intervals. There were 15,133 subjects; 11,934 (78.86%) were boys. Overall 6-month treatment compliance was 59.0%, 47.3%, 39.9%, 34.1%, 28.6%, and 23.1%. Monthly drop-out rates within the first 6 months were 20.6%, 6.5%, 4.7%, 3.7%, 3.0%, and 2.5%, respectively. When applying MPR more strictly or shorter gap days, treatment compliance lessened. This is the first nationwide report on 36-month treatment compliance of the whole population of 6-14-year-olds with ADHD. We found the beginning of the treatment, especially the first month, to be a critical period in pharmacotherapy. These results also suggest the importance of setting appropriate treatment adherence standards for patients with ADHD, considering the chronic course of ADHD.

Maternal Stress and Depressive Symptoms and Infant Development at Six Months: the Mothers and Children's Environmental Health (MOCEH) Prospective Study.

Our objective is to evaluate the relationships between prenatal maternal stress and depressive symptoms, respectively, and infant neurodevelopment at 6 months, adjusted for heavy metals and oxidative stress. This research is a part of a multi-center birth cohort study in South Korea. Information on stress and depressive symptoms was collected during the first trimester using Psychosocial Well-Being Index Short Form (PWI-SF) and Center for Epidemiological Studies Depression Scale (CES-D). The Korean Bayley Scales of Infant Development-II assessment (BSID-II), which includes the standardized mental development index (MDI) and psychomotor developmental index (PDI), and Korean Ages & Stages Questionnaires (K-ASQ) were applied to infants at six months of age. A higher index score indicates better development. Among 641 babies, 320 were female (50%). Maternal PWI ≥ 29 (vs. PWI ≤ 18) during early pregnancy was associated with a decrease in MDI scores of 5.37 points (P = 0.02) after adjusting for socioeconomic factors. Maternal CES-D ≥ 26 (vs. CES-D ≤ 10) during early pregnancy was associated with a decrease in MDI scores of 8.18 points (P = 0.01). The associations remained significant even after adjustment for lead, cadmium, and MDA levels (P < 0.05). However, no association was found between maternal PWI/CES-D and PDI score. No interaction was observed between stress and lead exposure. We found an inverse association between prenatal maternal stress and depressive symptoms, and MDI scores in 6-month-old infants after adjustment for prenatal lead exposure, which is known to affect cognitive function negatively.

Differences in Utilization Patterns among Medications in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: a 36-Month Retrospective Study Using the Korean Health Insurance Review and Assessment Claims Database.

We evaluated the differences in utilization patterns including persistence and adherence among medications in children and adolescents with attention deficit hyperactivity disorder (ADHD). The current study was performed using data from the Korean Health Insurance Review and Assessment claims database from January 1, 2009 to December 31, 2013. Our study sample consisted of 10,343 children and adolescents with ADHD who were not given their newly prescribed medication in 360 days before the initial claim in 2010. Data were followed up from the initiation of treatment with ADHD medications in 2010 to December 31, 2013. Discontinuation rates for 4 ADHD medications in our sample ranged from 97.7% for immediate-release methylphenidate to 99.4% for atomoxetine using refill gap more than 30 days and from 56.7% for immediate-release methylphenidate to 62.3% for extended-release methylphenidate using refill gap more than 60 days. In the number of discontinued, we found significant differences among medications using refill gap more than 30 days. Among 4 ADHD medications, extended-release methylphenidate and atomoxetine had more days than immediate-release methylphenidate and osmotic-controlled oral delivery system methylphenidate. In logistic regression analyses, extended-release methylphenidate, osmotic-controlled oral delivery system methylphenidate, and atomoxetine showed less discontinuation compared to immediate-release methylphenidate group when a refill gap more than 30 days was used. In logistic regression analysis of adherence, we could not find any differences among 4 medication types. We suggest that the utilization patterns should be assessed regularly in order to improve future outcomes in children and adolescents with ADHD.

Subthreshold attention-deficit/hyperactivity disorder is associated with functional impairments across domains: a comprehensive analysis in a large-scale community study.

This study compared children who experience attention-deficit/hyperactivity disorder (ADHD) symptoms but do not meet criteria (i.e., subthreshold ADHD) with those with the full syndrome and healthy controls. Presence of ADHD symptoms was determined in a nationwide community sample of 921 children, aged 8-11 years. The main outcome measures comprised attentional symptoms, comorbidity profiles, academic performance, and neurocognitive ability (i.e., ADHD Rating Scale, Child Behavior Checklist, Learning Disability Evaluation Scale, and Stroop Color-Word Test, respectively). Subthreshold ADHD was equally prevalent in boys and girls, and more prevalent in low-income families. Throughout all the outcome measurements, subthreshold ADHD was both a significantly milder condition than full syndrome ADHD and a significantly more severe condition than non-ADHD status. The findings were consistent across the total as well as the subtest scores, and after correction for multiple comparisons (p < 0.0017). Children with subthreshold ADHD were found to experience significant symptoms and functional impairments. The results of this study support the clinical relevance of subthreshold ADHD in a childhood population. Subthreshold diagnostic criteria for ADHD may be more sensitive in detecting ADHD symptoms in girls than the full syndrome criteria, and subthreshold clinical, cognitive, and behavioral symptoms of ADHD may occur in a subset of children who are possibly more sensitive to their environment. Further consideration about the diagnostic threshold for ADHD may particularly benefit girls and children in low-income families.

Internet Gaming Disorder and Mental Health Literacy: A Latent Profile Analysis of Korean Adolescents.

OBJECTIVE: This study identified latent subtypes of mental health literacy (MHL) for Internet gaming disorder (IGD) and explored their characteristics and differences in various factors in adolescents. METHODS: This study analyzed secondary data from the 2019 Youth Smart Digital Media Survey and included data from 1,936 middle and high school students (14-18 years old). Thirteen items of the MHL questionnaire were used for latent profile analysis. We compared the characteristics and predictors of the identified types using various statistical analyses, including one-way ANOVA, chi-square test, and multinomial logistic regression. RESULTS: We identified three subtypes of MHL for IGD in adolescents: "low perception-prefer informal resources," "moderate perception-preferred resources unclear," and "high perception-prefer professional resources." Subtypes showed significant differences in sex, age, family affluence, e-learning time during weekdays, mental health risks, level of problematic smartphone use, and IGD. All variables except IGD predicted one or more latent types. CONCLUSION: Practical interventions are required to improve IGD MHL, including customized prevention based on the differences between the three types.

Promising Effect of the Children in Disaster: Evaluation and Recovery Intervention on Trauma Symptoms and Quality of Life for Children and Adolescents: A Controlled Study.

OBJECTIVE: The Children in Disaster: Evaluation and Recovery (CIDER) program in Korea was developed to treat children and adolescents exposed to trauma. This study aimed to demonstrate the effectiveness of the CIDER through a comparison with controls. METHODS: A total of 85 participants consisted of the intervention group (n=41) and control group (n=44). We assessed the changes in trauma-related symptoms, depression, anxiety, and improvements in quality of life before and after the intervention. RESULTS: In total, bullying and school violence (44.7%) were the most common trauma, followed by sexual abuse (17.6%). Acute stress disorder and post-traumatic stress disorder (PTSD) accounted for 41.2%, and attention-deficit/hyperactivity disorder (ADHD) and developmental disorder were the most common comorbidities (51.8%). The symptoms of trauma, depression, anxiety, and quality of life improved significantly in the intervention group, while the control group did not show significant changes. CONCLUSION: Compared with the control group, the CIDER improved symptoms and quality of life in children and adolescents who had experienced trauma. The CIDER program was practical and easy to apply, even for different ages, types of traumas, and comorbidities.

Suicide warning signs that are challenging to recognize: a psychological autopsy study of Korean adolescents.

BACKGROUND: In South Korea, the leading cause of youth death has been suicide for about 20 years. In this study, we conducted a multi-method psychological autopsy to identify the psychiatric diagnosis, developmental history, personality traits, family history, school life, warning signs of suicide, and risk factors related to suicide for the first time in Korea. METHODS: This was a postmortem, retrospective, and descriptive study of 36 adolescents who died by suicide between August 2015 and July 2021 in South Korea. We obtained qualitative and quantitative data from the Korean Psychological Autopsy of Adolescent, conducted by the Suicide and School Mental Health Institute, the official student mental health policy-focused research institute of the Korean Ministry of Education. RESULTS: The adolescents comprised equal percentage of girls and boys. Approximately half of the deaths (55.6%) occurred at home and most (72.2%) involved jumping from a height. Most of the adolescents (97.2%) had one major psychiatric disorder before death, with depressive disorder being the most prevalent (75%). They were at a high risk for internet addiction before death. The most common personality trait was avoidance (28.6%), followed by submissiveness (27.3%). Half of the parents reported that the adolescents were satisfied with their school life and the teachers observed that they had no behavioral problems. One year before death, seven (19.4%) adolescents injured themselves and five (13.9%) had attempted suicide. Most of the deceased (80.6%) had expressed suicide warning signs to their families within one year before death. Adolescents had a long experience of family-related adverse events. CONCLUSIONS: Most of the adolescents had mental health disorders and expressed suicidal intentions using verbal and nonverbal signs. However, it was challenging for families to recognize the risk signs because of adolescents' personality traits or a good school life. To prevent adolescent suicide, adolescents, parents, and teachers need to be educated to recognize signs of suicide warning signs and equipped to guide adolescents to appropriate care.

Bisphenol A in relation to behavior and learning of school-age children.

BACKGROUND: Bisphenol A (BPA) has been shown to affect brain and behavior in rodents and nonhuman primates, but there are few studies focusing on its relationship to human neurobehavior. We aimed to investigate the relationship between environmental exposure to BPA and childhood neurobehavior. METHODS: Urinary BPA concentrations and behavioral and learning characteristics were assessed in a general population of 1,089 children, aged 8-11 years. The main outcome measures were the Child Behavior Checklist (CBCL) and the Learning Disability Evaluation Scale (LDES). RESULTS: Urinary levels of BPA were positively associated with the CBCL total problems score and negatively associated with the learning quotient from the LDES. The linear association with the CBCL anxiety/depression score and the quadratic association with the LDES listening score were significant after correction for multiple comparisons. CONCLUSIONS: Environmental exposure to BPA might be associated with childhood behavioral and learning development. The results suggest possible nonmonotonic relationships.

Impact of family environment on the development of tic disorders: epidemiologic evidence for an association.

BACKGROUND: Although family education generally is recommended in the treatment of tic disorders, few studies have focused on the relationship between family environment and diagnosis of tic disorders. METHODS: Presence of DSM-IV tic disorders was determined in a general population of 921 children in Korea from 2008 to 2009. Clinical risk factors were assessed, including comorbidity with attention-deficit/hyperactivity disorder; family-related factors such as the number of family members and primary caretaker of the child; and socioeconomic factors in the form of paternal education level and household yearly income. Multivariable logistic regression analyses were performed to estimate the association between a list of clinical, familial, and social variables and the odds of developing tic disorders. RESULTS: At Bonferroni corrected thresholds, a higher risk of tic disorders was significantly associated with the number of changes in primary caretaker, whereas a lower risk was associated with increasing number of children in the family. CONCLUSIONS: Family-related environmental factors may play a role in the development or exacerbation of tic disorders. The results advocate the importance of family education when treating children with tic disorders, and further research is needed on the contextual risk factors of tic disorders.

Relationship between blood manganese levels and children's attention, cognition, behavior, and academic performance--a nationwide cross-sectional study.

Manganese (Mn) is neurotoxic at high concentrations. However, Mn is an essential element that can protect against oxidative damage; thus, extremely low levels of Mn might be harmful. Our aim was to examine whether either high or low environmental Mn exposure is related to academic and attention function development among school-aged children. This cross-sectional study included 1089 children 8-11 years of age living in five representative areas in South Korea. Blood Mn, blood lead, and urine cotinine were measured. We assessed IQ with the Wechsler Abbreviated Scale of Intelligence; attention with a computerized continuous performance test called the Attention-deficit/hyperactivity disorder (ADHD) Diagnostic System (ADS), the Korean version of the Stroop Color-Word Test, the Children's Color Trails Test (CCTT), and the ADHD Rating Scale; academic functions with the Learning Disability Evaluation Scale (LDES); and emotional and behavioral problems with the Korean version of the Child Behavior Checklist (CBCL). We further assessed the presence of ADHD using a highly structured diagnostic interview, the Diagnostic Interview Schedule for Children Version IV (DISC-IV). The median blood concentration of Mn was 14.14 µg/L. We observed a nonlinear association between the CCTT2 completion time and the CPT commission error (F=3.14, p=0.03 and F=4.05, p=0.01, respectively). We divided the data into three groups: lower (<8.154 µg/L), and upper 5th percentile (>21.453 µg/L) and middle 90th percentile to determine whether a lack or overload of Mn could cause adverse effects. After adjusting for urine cotinine, blood lead, children's IQ, and other potential confounders, the high Mn group showed lower scores in thinking (B=-0.83, p=0.006), reading (B=-0.93, p=0.004), calculations (B=-0.72, p=0.005), and LQ (B=-4.06, p=0.006) in the LDES and a higher commission error in the CPT (B=8.02, p=0.048). The low Mn group showed lower color scores in the Stroop test (B=-3.24, p=0.040). We found that excess Mn in children is associated with lower scores of thinking, reading, calculation, and LQ in the LDES and higher scores of commission error in the ADS test. In contrast, lower Mn in children is associated with lower color scores in the Stroop test. The findings of this cross-sectional study suggest that excess exposure or deficiency of Mn can cause harmful effects in children.