Antagonistic regulation of the gibberellic acid response during stem growth in rice.

The size of plants is largely determined by growth of the stem. Stem elongation is stimulated by gibberellic acid1-3. Here we show that internode stem elongation in rice is regulated antagonistically by an 'accelerator' and a 'decelerator' in concert with gibberellic acid. Expression of a gene we name ACCELERATOR OF INTERNODE ELONGATION 1 (ACE1), which encodes a protein of unknown function, confers cells of the intercalary meristematic region with the competence for cell division, leading to internode elongation in the presence of gibberellic acid. By contrast, upregulation of DECELERATOR OF INTERNODE ELONGATION 1 (DEC1), which encodes a zinc-finger transcription factor, suppresses internode elongation, whereas downregulation of DEC1 allows internode elongation. We also show that the mechanism of internode elongation that is mediated by ACE1 and DEC1 is conserved in the Gramineae family. Furthermore, an analysis of genetic diversity suggests that mutations in ACE1 and DEC1 have historically contributed to the selection of shorter plants in domesticated populations of rice to increase their resistance to lodging, and of taller plants in wild species of rice for adaptation to growth in deep water. Our identification of these antagonistic regulatory factors enhances our understanding of the gibberellic acid response as an additional mechanism that regulates internode elongation and environmental fitness, beyond biosynthesis and gibberellic acid signal transduction.

Parental perception matters: Reciprocal relations between adolescents' depressive symptoms and parental perceptions.

A large body of research has shown that parents play a vital role in the development of adolescents' depression. However, previous research has overlooked the effects of a potentially critical factor, namely, parental perceptions, and beliefs about adolescents' depression. The present study examined whether parental perceptions of an adolescent's depressive symptoms predict longitudinal changes in adolescents' symptoms (i.e., the parental perception effect). The longitudinal relationship between adolescents' depressive symptoms and parental perceptions of the adolescents' symptoms was analyzed in three independent groups of parent-adolescent pairs (in total N = 1,228). Parental perception and monitoring effects were found in Studies 1B and 2 only in the depressive mood subscale. While a decreased enjoyment subscale showed a perception effect in Study 1A, we obtained null results from other studies. We synthesized the results by applying meta-analytic structural equation modeling to obtain a more robust estimate. The analysis qualified both perception and monitoring effects in both subscales. Our results suggest that when parents believe that their adolescent child is depressed, adolescents are cognitively biased by their parental perceptions over time, resulting in more severe depressive symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Guided parent-delivered cognitive behavioural therapy for Japanese children and parents: a single-arm uncontrolled study.

BACKGROUND: Guided parent-delivered cognitive behavioural therapy (GPD-CBT) is an effective low-intensity treatment for childhood anxiety disorder in Western countries and can increase access to evidence-based psychological therapies. AIM: This study aimed to examine its feasibility in a Japanese sample. METHOD: Twelve children with anxiety disorders and their parents participated in the study, and ten children and parents completed the program. Participants were assessed at pre-, post- and one-month follow-up using a diagnostic interview for anxiety disorders, self- and parent-report measures for anxiety, depression, parental behaviour, and parental anxiety. RESULTS: Four children (40% of completers) were free from their primary diagnoses immediately following the brief treatment, and seven children (70%) at the one-month follow-up. Changes in disorder severity, child and parent reported anxiety symptoms, and child reported depression symptoms were consistent with those found in Western trials of GPD-CBT and of Japanese trials of more intensive CBT for child anxiety disorders that involves both the child and the parent. Moderate increases were also found in child reported parental autonomy behaviours; however, there were only small changes in parent self-reported anxiety. CONCLUSION: These results support the potential of GPD-CBT to increase access to evidence-based treatments for anxiety disorders in Japanese children.

Longitudinal Association between Maternal Autonomy Support and Controlling Parenting and Adolescents' Depressive Symptoms.

Most studies on autonomy support and controlling parenting rely on children's perceptions, despite the limitations of this approach. This study investigated congruency between autonomy support and controlling parenting reported by mothers and adolescents and their association with adolescents' depressive symptoms via basic psychological needs satisfaction. Participants included 408 Japanese mother-adolescent (Mage = 13.73, SD = 0.90, 52% female) pairs who completed a questionnaire at two time points four months apart. Results demonstrated low to moderate levels of mother-adolescent agreement. Cross-lagged regression models revealed that mothers' reported autonomy support positively predicted adolescents' basic psychological needs satisfactions, which was negatively associated with depressive symptoms. The independent roles of parenting reported by mothers and adolescents for adolescents' well-being were discussed.

Heteromeric interactions of ripening-related ethylene receptors in tomato fruit.

Ripening of climacteric fruits is initiated when the gaseous plant hormone ethylene is perceived by the cell. Ethylene binding to membrane-associated ethylene receptors (ETRs) triggers a series of biochemical events through multiple components, resulting in the induction of numerous ripening-related genes. In tomato (Solanum lycopersicum L.), there are seven members of the ETR family, which each contribute to the regulation of fruit ripening. However, the relative contribution of each individual receptor to ethylene signaling remains unknown. Here, we demonstrated the formation of heteromeric receptor complexes across the two ETR subfamilies in tomato fruit. Immunoprecipitation of subfamily II SlETR4 resulted in co-purification of subfamily I (SlETR1, SlETR2, and SlETR3), but not subfamily II members (SlETR5, SlETR6, and SlETR7). Such biased interactions were verified in yeast two-hybrid assays, and in transgenic Arabidopsis plants, in which heterologous SlETR4 interacts with subfamily I ETRs. Our analysis also revealed that the receptor complexes engage the Raf-like protein kinases SlCTR1 and SlCTR3, which are potential regulators of signaling. Here, we suggest that tomato receptor members form heteromeric complexes to fine-tune signal output to the downstream pathway, which is similar to that of the Arabidopsis system but appears to be partially diverged.

Development of the Anger Children's Cognitive Error Scale and the Anger Children's Automatic Thought Scale.

BACKGROUND: Empirical studies between anger and anger-provoking cognitive variables in children and adolescents are lacking, despite numerous studies on internalising and externalising problems. AIM: The purpose of this study was to develop new questionnaires for anger-provoking cognitive errors and automatic thoughts, and examine relationships between anger, cognitive errors, and automatic thoughts in children and adolescents. METHOD: Participants were 485 Japanese children and adolescents aged 9-15 years old (254 females; average age 12.07; SD = 1.81). They completed the Anger Children's Cognitive Error Scale (A-CCES) and the Anger Children's Automatic Thought Scale (A-CATS), which were developed in this study, as well as the Anger Scale for Children and Adolescents and the Japanese version of Short Spence Children's Anxiety Scale. RESULTS: Both the A-CCES and the A-CATS had adequate reliability (internal consistency) and validity (face validity, structural validity and construct validity). A hierarchal regression analysis indicated that automatic thoughts were positively and moderately related to anger (ß = .37) after controlling for age, gender, anxiety symptoms, cognitive errors and interaction term. Moreover, a mediation analysis indicated that automatic thoughts significantly mediated the relationship between cognitive errors and anger (indirect effect, 0.24; 95% CI: .020 to .036). CONCLUSIONS: This study developed the new questionnaires to assess anger-provoking cognitive errors and automatic thoughts. In addition, this study revealed that automatic thoughts rather than cognitive errors are associated with anger in children and adolescents.

Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders - an international consensus statement.

BACKGROUND: Anxiety disorders in children and young people are common and bring significant personal and societal costs. Over the last two decades, there has been a substantial increase in research evaluating psychological and pharmacological treatments for anxiety disorders in children and young people and exciting and novel research has continued as the field strives to improve efficacy and effectiveness, and accessibility of interventions. This increase in research brings potential to draw together data across studies to compare treatment approaches and advance understanding of what works, how, and for whom. There are challenges to these efforts due largely to variation in studies' outcome measures and variation in the way study characteristics are reported, making it difficult to compare and/or combine studies, and this is likely to lead to faulty conclusions. Studies particularly vary in their reliance on child, parent, and/or assessor-based ratings across a range of outcomes, including remission of anxiety diagnosis, symptom reduction, and other domains of functioning (e.g., family relationships, peer relationships). METHODS: To address these challenges, we convened a series of international activities that brought together the views of key stakeholders (i.e., researchers, mental health professionals, young people, parents/caregivers) to develop recommendations for outcome measurement to be used in treatment trials for anxiety disorders in children and young people. RESULTS AND CONCLUSIONS: This article reports the results of these activities and offers recommendations for selection and reporting of outcome measures to (a) guide future research and (b) improve communication of what has been measured and reported. We offer these recommendations to promote international consistency in trial reporting and to enable the field to take full advantage of the great opportunities that come from data sharing going forward.

Long-term follow up of hospitalized pediatric anorexia nervosa restricting type.

BACKGROUND: Information on long-term follow up of childhood-onset anorexia nervosa is scarce. This study investigated long-term (>10 years) course, outcome and prognostic factors for hospitalized childhood-onset anorexia nervosa restricting type (ANR). METHODS: Forty-one ANR girls admitted to a single regional center participated. Median age at first admission was 13.3 years (range, 8.6-15.6 years). The longitudinal clinical course was retrospectively determined for a median follow-up period of 17.1 years (range, 10.4-21.1 years). We analyzed physical, psychological, and social variables to predict partial remission (PR) and full remission (FR). RESULTS: The completion rate of follow up >10 years was high at 97%. At final evaluation (n = 38), distribution of prognosis was as follows: FR, n = 27 (71%); PR, n = 6 (16%); and non-remission, n = 5 (13%). The cumulative ratio of PR and FR increased during the first 5-6 years, and gradually reached a plateau at around 10 years. More than 10 years after the onset, one patient eventually achieved FR, and one patient died. Seven patients were rehospitalized and two died due to suicide during the entire follow up. On multivariate analysis, family disorders/problems rating score was a significant predictor of PR and FR. CONCLUSIONS: This study included hospitalized ANR children aged ≤15 years, the youngest cohort ever reported. Long-term prognosis is generally favorable, but the mortality rate was 5%. Careful long-term follow up >10 years is needed to evaluate outcome of childhood-onset ANR, and family therapy is important in high-risk patients with family disorders/problems.

Importance of Second-look Endoscopy on an Empty Stomach for Finding Gastric Bezoars in Patients with Gastric Ulcers.

　Most gastric bezoars can be treated with endoscopic fragmentation combined with or without cola dissolution, whereas laparotomy or laparoscopic surgery is generally inevitable for small intestinal bezoars because they cause small bowel obstruction. Therefore, early diagnosis and management of gastric bezoars are necessary to prevent bezoar-induced ileus. To investigate the incidence of overlooked gastric bezoars during the initial esophagogastroduodenoscopy, we retrospectively reviewed the cases of 27 patients diagnosed with gastrointestinal bezoars. The bezoars were diagnosed using esophagogastroduodenoscopy (n=25), abdominal ultrasonography (n=1), and barium follow-through examination (n=1). Bezoars were overlooked in 9/25 patients (36.0%) during the initial endoscopy examination because the bezoars were covered with debris in the stomach. Of the 9 patients, 8 had concomitant gastric ulcers, and the other patient had gastric lymphoma. Although a computed tomography (CT) scan was performed before the second-look endoscopy in 8 of the 9 patients, the bezoars were mistaken as food debris on CT findings and were overlooked in these patients. In conclusion, gastric bezoars may not be discovered during the initial esophagogastroduodenoscopy and CT scan. In cases with debris in the stomach, second-look endoscopy is essential to detect bezoars.

Mental Health Problems among Undergraduates in Fukushima, Tokyo, and Kyoto after the March 11 Tohoku Earthquake.

On March 11, 2011, the Great East Japan Earthquake devastated the Tohoku region, which led to a tsunami and a nuclear disaster. While these three disasters caused tremendous physical damage, their psychological impact remains unclear. The present study evaluated traumatic responses, internalizing (i.e., anxiety and depression), and externalizing (i.e., anger) symptoms among Japanese young people in the immediate aftermath and 2.5 years later. A total of 435 undergraduates were recruited from universities in three differentially exposed regions: Fukushima, Tokyo, and Kyoto. They completed a set of questionnaires retrospectively (i.e., September to December 2013) to measure their traumatic responses, anxiety and depressive symptoms, functional impairment, and anger immediately after the disaster and 2.5 years later. Participants in Tokyo had the highest level of traumatic response and internalizing symptoms immediately after the earthquake, whereas those in Fukushima had significantly higher levels of trait anger, anger-in (holding one's anger in), and anger-out (expressing one's anger externally). In Kyoto, the levels of anxiety and depression after 2.5 years were significantly higher than they were immediately after the disasters. In conclusion, anger symptoms were high among young people who lived at or near the center of the disasters, while anxiety and depression were high among those who lived far away from the disasters. These findings suggest the importance of providing mental health services to young people who did not live near the disaster area as well as to those living in the directly affected area.

A parental report of children's anxiety symptoms in Japan.

Using parental reports, the current study investigated anxiety symptoms among Japanese children as part of the process of developing the Japanese version of the Spence Children's Anxiety Scale for Parents (SCAS-P). The participants were 677 parents and children aged 9-12 years. Confirmatory factor analysis on 568 parents and children supported that the SCAS-P had a 6-factor structure. The scale showed satisfactory internal consistency and good convergent validity. A MANOVA indicated no significant gender or age differences except for the obsessive-compulsive disorder subscale. Among Japanese children, the most prevalent symptoms within the parental report were items related to fear of the dark and of insects/spiders. Finally, we observed very low correlations between parental and child reports of anxiety symptoms; the relationships between child and parental reports were rather poor among Japanese children. We briefly discuss the utility of the SCAS-P as a screening instrument assessing parental reports of anxiety symptoms.

Three-dimensional and multienergy gamma-ray simultaneous imaging by using a Si/CdTe Compton camera.

PURPOSE: To develop a silicon (Si) and cadmium telluride (CdTe) imaging Compton camera for biomedical application on the basis of technologies used for astrophysical observation and to test its capacity to perform three-dimensional (3D) imaging. MATERIALS AND METHODS: All animal experiments were performed according to the Animal Care and Experimentation Committee (Gunma University, Maebashi, Japan). Flourine 18 fluorodeoxyglucose (FDG), iodine 131 ((131)I) methylnorcholestenol, and gallium 67 ((67)Ga) citrate, separately compacted into micro tubes, were inserted subcutaneously into a Wistar rat, and the distribution of the radioisotope compounds was determined with 3D imaging by using the Compton camera after the rat was sacrificed (ex vivo model). In a separate experiment, indium 111((111)In) chloride and (131)I-methylnorcholestenol were injected into a rat intravenously, and copper 64 ((64)Cu) chloride was administered into the stomach orally just before imaging. The isotope distributions were determined with 3D imaging after sacrifice by means of the list-mode-expectation-maximizing-maximum-likelihood method. RESULTS: The Si/CdTe Compton camera demonstrated its 3D multinuclear imaging capability by separating out the distributions of FDG, (131)I-methylnorcholestenol, and (67)Ga-citrate clearly in a test-tube-implanted ex vivo model. In the more physiologic model with tail vein injection prior to sacrifice, the distributions of (131)I-methylnorcholestenol and (64)Cu-chloride were demonstrated with 3D imaging, and the difference in distribution of the two isotopes was successfully imaged although the accumulation on the image of (111)In-chloride was difficult to visualize because of blurring at the low-energy region. CONCLUSION: The Si/CdTe Compton camera clearly resolved the distribution of multiple isotopes in 3D imaging and simultaneously in the ex vivo model.

Birefringence of magnesium fluoride in the vacuum ultraviolet and application to a half-waveplate.

Spectro-polarimeteric observations in the vacuum-ultraviolet (VUV) region are expected to be developed as a new astrophysics diagnostic tool for investigating space plasmas with temperatures of >10(4) K. Precise measurements of the difference in the extraordinary and ordinary refractive indices are required for developing accurate polarimeters, but reliable information on the birefringence in the VUV range is difficult to obtain. We have measured the birefringence of magnesium fluoride (MgF2) with an accuracy of better than ±4×10(-5) around the hydrogen Lyman-α line (121.57 nm). We show that MgF2 can be applied practically as a half-waveplate for the chromospheric Lyman-alpha spectro-polarimeter (CLASP) sounding rocket experiment and that the developed measurement method can be easily applied to other VUV birefringent materials at other wavelengths.

Psychopathological symptoms in two generations of the same family: a cross-cultural comparison.

PURPOSE: The main aims of the present study were to compare the frequency and correlates of psychopathological symptoms in two generations of the same family in Japan and in England. METHODS: The sample included 689 adolescents and one of their parents/guardians. All participants completed a set of questionnaires to measure psychopathological symptoms, self-construals, and perceived social support. RESULTS: In both parent and adolescent data, the Japanese sample reported significantly lower psychopathological symptoms than the English sample. The relationship between parental and adolescent psychopathology was significant in England, but not in Japan. In both countries, perceived social support and independent self-construal were generally associated with less psychopathological symptoms, and interdependent self-construal was associated with more symptoms. Additionally, in England, a significant interaction effect was found between social support and the self-construals. Participants with low independent and high interdependent self-construal had elevated levels of psychopathological symptoms when perceived social support was low. CONCLUSIONS: The present study illustrates the importance of culture in the transmission of psychopathological symptoms across different generations in the same family.

Long-term effects of a universal prevention program for depression in children: a 3-year follow-up study.

BACKGROUND: The present study evaluates the long-term effects of a universal prevention approach for depression in children. It looks into the 2- and 3-year follow-ups of previously reported postintervention and 1-year outcomes. METHOD: One hundred and eighty-nine 3rd grade (8-9 years old) children participated in a five-session, school-based, universal prevention program designed to encourage social skills and peer support. The study was conducted from 2006 to 2009 in two public schools in Miyazaki, the south main island of Japan. RESULTS: Depressive symptoms decreased significantly from the pre to the postintervention periods, and this effect was maintained. Furthermore, children in the prevention group showed significantly lower depression than the normative sample. CONCLUSIONS: This study reveals the beneficial long-term effects of a universal approach.

Preliminary assessment of the behavioral activation model in Japanese undergraduate students.

Many studies have reported that behavioral activation is an effective intervention for depression. The behavioral activation model is based on several formulations. For example, depressive mood leads to avoidant behaviors, avoidance negatively affects social contacts, decreased socialization lessens opportunities for positive reinforcement, and a decrease in positive reinforcement results in more depressive mood. The purpose of this study was to examine relationships among avoidant behavior, social contact, frequency of positive reinforcement, and depressive mood by using structural equation modeling to assess support for aspects of this behavioral activation model. Participants were 630 Japanese undergraduate students and vocational school students. Results provided preliminary support for the model. Treating both avoidance and activating behavior might contribute to decreased impairment.

Evaluating the long-term effects of cognitive behavioural therapy as an early intervention for at-risk anxiety disorders among preschool children in Asia.

There are few evaluations of early intervention for the prevention of anxiety disorders in East Asia, and those that exist generally evaluate outcomes to a maximum of 6-12 months. The current study evaluated the long-term effect (5 years) of an anxiety prevention program presented to preschool children and their parents in Japan. Participants for the study were 10 inhibited children 5-6 years old and their parents. The parent's and children's program comprised group sessions of a cognitive-behavioural program. Parents and teachers completed the anxious/depressed, withdrawn and behavioural inhibition at pre-post-intervention and 3-month follow-up. Five years after starting the intervention, participants were invited to a diagnostic interview, Anxiety Disorders Interview Schedule (ADIS) to examine a long-term preventive effect of the intervention. The majority of children showed a reduction in anxious/depressed, behavioral inhibition, and approximately half showed reliable change according to parents' and teachers' reports. Moreover, the results indicated that 9 of the 10 children did not met the diagnostic criteria for anxiety disorders. These results suggested that the early intervention had preventive effects because the diagnostic criteria for anxiety disorders were not met in the follow-up assessment conducted five years later.

Implementation of a Transdiagnostic Universal Prevention Program on Anxiety in Junior High School Students After School Closure During the COVID-19 Pandemic.

School closures due to the coronavirus disease 2019 (COVID-19) pandemic have worsened mental health problems for children and adolescents worldwide. We aimed to examine the follow-up effectiveness of a transdiagnostic universal prevention program for anxiety of junior high school students after a nationwide school closure during the COVID-19 outbreak in Japan. A total of 117 junior high school students were included in the analysis. We used the Unified Universal Prevention Program for Diverse Disorders (Up2-D2) program; the Up2-D2 comprises cognitive-behavioral and positive psychological interventions provided over twelve 45-minute sessions. The program was originally implemented between June and July 2020, immediately after pandemic-related school closures had ended in Japan. The program assessments were based on students' responses to a questionnaire incorporating five scales to measure indicators such as internalizing and externalizing problems. Assessments were carried out before, immediately after, two-month, and six-month after implementing the program. Mixed models for the whole sample showed small anxiety improvement effects immediately post-intervention and two-month, and six-month assessments (g = -0.25, g = -0.44, and g = -0.30, respectively). The anxiety reducing effects were even greater for the higher-anxiety group at the post-, 2-month, and 6-month assessments (g = -1.48; g = -1.59; g = -1.06, respectively). Although there was no control group, these results indicate that the transdiagnostic universal prevention intervention reduce only anxiety, but not other outcomes (depression, anger, and self-efficacy) in junior high students returning to school following school closures related to the COVID-19 pandemic in Japan.

Cultural Adaptation and Implementation of Cognitive-Behavioral Psychosocial Interventions for Anxiety and Depression in Japanese Youth.

The present article reviews the current status of cognitive-behavioral therapy (CBT) interventions for anxiety and depression in Japanese youth. First, a literature review of youth CBT programs for anxiety and depression is provided. Through this process, we identify which program/protocol has been most researched within Japan. Second, through a systematic interview to the authors, the development process of four predominant programs is outlined. The programs included were a family CBT program for anxiety disorders (the Japanese Anxiety Children/Adolescents Cognitive Behavior Therapy program), two school-based prevention programs for anxiety and depression (Journey of the Brave and Phoenix Time), and a transdiagnostic protocol for anxiety and depression (Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents). Third, cultural adaptation and modification of the programs are discussed from the scope of user-centered design principles as described by Lyon and Koerner (Sci Pract 23:180-200, 2016). As a result, changes in program content and material, as represented by the use of culture-friendly program names, acronyms, illustrations, and characters were endorsed in all of the programs. Structured but flexible session formats helped increase learnability and efficiency while keeping the cognitive load of providers and consumers low. A careful selection of providers, as well as quality training and consultation are important factors to maximize competency and ensure appropriate implementation. Application of existing time frames and staff who work in each setting were effective ways to increase scalability. Overall, it was shown that many of the modifications adopted overlap among successful programs; these represent the most basic and essential requirements for a program to be applicable to a wide range of contexts. Implications and further directions are explored.

Randomised controlled trial of cultural-adapted and programme-adopted cognitive behavioural therapy for children and adolescents' anxiety in Japan: protocol for a Multi-, Inter-, and Cross-cultural Clinical Child Study (MIXCS).

INTRODUCTION: The primary objective of the Multi-, Inter-, and Cross-cultural Clinical Child Study (MIXCS) is to evaluate the hypothesis that the effects of cultural-adapted cognitive behavioural therapy (CA-CBT) and programme-adopted cognitive behavioural therapy (PA-CBT) for children and adolescents' anxiety are both superior to a psychological control (moral education control: MEC) for reducing child and adolescent anxiety disorders and symptoms as well as related constructs. The secondary objective is to explore commonalities and differences in therapy factors between CA-CBT and PA-CBT. METHOD AND ANALYSIS: The study has been designed as a randomised, controlled and assessor masked multicentre superiority trial with three groups: CA-CBT, PA-CBT and MEC. Primary outcome is remission of primary anxiety disorders evaluated by independent evaluators. Secondary outcomes are clinician's severity ratings, child self-reported anxiety symptoms, depressive symptoms, cognitive errors and family accommodation, as well as parent-reported anxiety symptoms, and family accommodation. Competence and adherence of treatment, therapy factors in treatment sessions are also measured based on behavioural observation. Finally, satisfaction and comprehension are collected. We aim to recruit at least 99 families for the analysis. Treatment will be delivered weekly for 10 sessions and assessment will be conducted 2 weeks before the treatment (pre), 3 months after the base date when the treatment starts (post), 6 months (six months follow-up) and 12 months (12 months follow-up) after the postassessment. ETHICS AND DISSEMINATION: The MIXCS study was approved by Doshisha University Research Ethics Review Committee, Kwansei Gakuin University Institutional Review Board for Medical and Biological Research Involving Human Subjects and Shinshu University Certified Review Board of Clinical Research. Regardless of the results, the primary outcome will be published in a journal, and if the efficacy and effectiveness of CA-CBT and/or PA-CBT are empirically supported, the authors will encourage dissemination of the programmes including the assessment system through key stakeholders in education, health, and welfare areas. TRIAL REGISTRATION NUMBER: UMIN000038128.