The Impact of Maternal Adverse Childhood Experiences on Offspring’s Internalizing and Externalizing Problems

Objective@#Adverse childhood experiences (ACEs) are associated with negative physical and mental health outcomes across the lifespan, but research on intergenerational transmission of maternal ACEs and its impact on the offspring’s mental health problems are limited. The study examines the effects of maternal ACEs on the risk of internalizing or externalizing problems among offspring. @*Methods@#There were 450 mother-child dyads. Mothers completed the Adverse Childhood Experiences Questionnaire. The child outcomes included internalizing and externalizing problems assessed by the Korean Child Behavior Checklist (K-CBCL) and Korean Youth Self-Report (K-YSR), depression assessed by the Center for Epidemiological Studies Depression Scale for Children (CES-DC) and anxiety assessed by the Screen for Child Anxiety Related Emotional Disorders (SCARED). @*Results@#36.1% of mothers experienced at least one ACE, and 11.1% experienced three or more ACEs. Cumulative maternal ACEs were associated with internalizing problems, externalizing problems, depression and anxiety in the offspring. Household dysfunction from maternal ACEs was significantly associated with delinquent behavior, anxiety/depression, and somatic complaints in the offspring. @*Conclusion@#The findings support the hypothesis that maternal ACEs are related to mental health problems in the offspring. Further research is needed to determine the factors mediating intergenerational transmission as well as intervention strategies to prevent ACEs and mental health problems in the offspring.

The Concept and Historical Background of Custody Evaluation

This article reviews a wide range of literature on the standards and process of child custody evaluation in the US, and proposes custody evaluation standards appropriate to Korea. Custody evaluation refers to the process of making psychiatric and psychological evaluations of each parent and the child during a custody dispute and presenting to the family court a report of custody evaluation with the aim of safeguarding the best interests of the child. In the past, it was thought that children arethe fathers’ possessions or that younger children should be raised by the mother; however, currently, custody rights are evaluated in accordance with the principle of the best interests of the child. The principle is all-encompassing and vague and hence, the court makes increasingly more requests to mental health professionals for custody evaluation. Since the Seoul Family Court introduced the expert consultation system in 2017, the involvement of mental health professionals in child custody decisions has increased in Korea. Custody evaluators should try to be neutral and find the objective facts, keeping in mind that their role is to aid the court in making a custody decision.

Custody Evaluation Process and Report Writing

As in western countries, divorce rates in South Korea have recently been rising, and family disruption has become one of serious social problems. Parents are able to express their opinions and wishes confidently, but the thoughts and wishes of children, especially infants and young children, tend to be ignored. Children can also experience several emotional and behavioral problems during the process of and after their parents’ divorce. When South Korean family courts determine custody arrangements, they typically do not have a systematic strategy and process based on custody evaluation to help children and their parents overcome conflicts and build healthy parent-child relationships after divorce. Furthermore, under the current court system, it is difficult for mental health specialists and child psychiatrists to intervene in familial conflicts as mediators or therapists during the course of divorce proceedings. Acknowledging these limitations, the South Korean family court system implemented a formal program for custody evaluations by child psychiatrists and psychologists in 2017. However, they have faced challenges such as a shortage of experienced specialist and lack of a training system or instruments for evaluation. In this paper, the authors aim to share professional knowledge of and experiences with aspects of the custody evaluation process, such as indications, procedures, methods, psychological tests, resources, and final report writing, to better serve children and their parents undergoing a painful divorce process.

Custody Evaluation in High-conflict Situations Focused on Domestic Violence and Parental Alienation Syndrome

In a divorced family, child-centered custody evaluation is essential to ensure the child’s best interests and healthy adaptation. A mental health professional’s role and involvement are required in gaining an in-depth understanding of various environments and dynamics surrounding the child and family. Domestic violence, including child abuse and intimate partner violence (IPV) or parental alienation syndrome (PAS), is often observed in cases of custody evaluation in high-conflict divorced families, sometimes accompanied by allegations.Such cases warrant an extremely careful approach by the evaluator, who needs to be competent in interpreting the familial dynamics based on a reasonable context understanding. Genuine professionalism is a must for a custody evaluator to best help the child and carry out a high-quality custody evaluation process, and evaluators need to be ready for this task through adequate preparation and empowerment. This article is devoted to examining custody evaluation in divorced families in cases of IPV, child abuse, and PAS.

The Concept and Historical Background of Custody Evaluation

This article reviews a wide range of literature on the standards and process of child custody evaluation in the US, and proposes custody evaluation standards appropriate to Korea. Custody evaluation refers to the process of making psychiatric and psychological evaluations of each parent and the child during a custody dispute and presenting to the family court a report of custody evaluation with the aim of safeguarding the best interests of the child. In the past, it was thought that children arethe fathers’ possessions or that younger children should be raised by the mother; however, currently, custody rights are evaluated in accordance with the principle of the best interests of the child. The principle is all-encompassing and vague and hence, the court makes increasingly more requests to mental health professionals for custody evaluation. Since the Seoul Family Court introduced the expert consultation system in 2017, the involvement of mental health professionals in child custody decisions has increased in Korea. Custody evaluators should try to be neutral and find the objective facts, keeping in mind that their role is to aid the court in making a custody decision.

Custody Evaluation Process and Report Writing

As in western countries, divorce rates in South Korea have recently been rising, and family disruption has become one of serious social problems. Parents are able to express their opinions and wishes confidently, but the thoughts and wishes of children, especially infants and young children, tend to be ignored. Children can also experience several emotional and behavioral problems during the process of and after their parents’ divorce. When South Korean family courts determine custody arrangements, they typically do not have a systematic strategy and process based on custody evaluation to help children and their parents overcome conflicts and build healthy parent-child relationships after divorce. Furthermore, under the current court system, it is difficult for mental health specialists and child psychiatrists to intervene in familial conflicts as mediators or therapists during the course of divorce proceedings. Acknowledging these limitations, the South Korean family court system implemented a formal program for custody evaluations by child psychiatrists and psychologists in 2017. However, they have faced challenges such as a shortage of experienced specialist and lack of a training system or instruments for evaluation. In this paper, the authors aim to share professional knowledge of and experiences with aspects of the custody evaluation process, such as indications, procedures, methods, psychological tests, resources, and final report writing, to better serve children and their parents undergoing a painful divorce process.

Custody Evaluation in High-conflict Situations Focused on Domestic Violence and Parental Alienation Syndrome

In a divorced family, child-centered custody evaluation is essential to ensure the child’s best interests and healthy adaptation. A mental health professional’s role and involvement are required in gaining an in-depth understanding of various environments and dynamics surrounding the child and family. Domestic violence, including child abuse and intimate partner violence (IPV) or parental alienation syndrome (PAS), is often observed in cases of custody evaluation in high-conflict divorced families, sometimes accompanied by allegations.Such cases warrant an extremely careful approach by the evaluator, who needs to be competent in interpreting the familial dynamics based on a reasonable context understanding. Genuine professionalism is a must for a custody evaluator to best help the child and carry out a high-quality custody evaluation process, and evaluators need to be ready for this task through adequate preparation and empowerment. This article is devoted to examining custody evaluation in divorced families in cases of IPV, child abuse, and PAS.

An Update on Mental Health Problems and Cognitive Behavioral Therapy in Pediatric Obesity / 대한소아소화기영양학회지

Clinical Application of Meditation in Children and Adolescents / 신경정신의학

Meditation is one of the psychological therapeutic techniques that can be applied to many conditions, including stress reduction. Meditation can be an alternative to overcoming the limitations of existing therapies, including medication. In particular, this can be helpful for children who have limitations in using medication due to brain development and limitations of psychotherapy, which is done mainly by language. Previous studies have shown that mindfulness meditation helped enhance attention, increase the coping ability, reduce stress, and reduce depression and anxiety in children and adolescents, but there is insufficient evidence to use it as a primary treatment. A larger number of well-controlled studies will be needed to obtain an evidence base for expanding clinical application.

The Effect of Community-Based Parent Education Program on Parenting Stress According to Adult Attachment Styles

OBJECTIVES: The aim of this study was to measure the effect of a group-based parent education program on parenting stress and attitude and comparing the same according to adult attachment styles.

Differences in Parenting Stress, Parenting Attitudes, and Parents' Mental Health According to Parental Adult Attachment Style

OBJECTIVES: We aimed to compare the differences in parenting stress, parenting attitudes, and parents' mental health between different adult attachment styles. METHODS: Forty-four parents who completed a parental education program were enrolled in our study. They completed the Korean version of the Experience of Close Relationship Revised, Korean-Parenting Stress Index-Short Form, Maternal Behavior Research Instrument, and Symptom Checklist-90-Revised. RESULTS: The avoidant attachment score positively correlated with parenting stress. The anxious attachment score showed a positive relationship with parenting stress, hostile parenting attitude, and psychopathology, but a negative association with an affectionate parenting attitude. The secure attachment group exhibited a more autonomous, affectionate parenting style and a less hostile parenting attitude and less parenting stress than the insecure attachment group. Dismissing-avoidant attachment parents reported significantly higher parenting stress scores than secure attachment parents. Preoccupied and fearful-avoidant attachment parents displayed a more hostile parenting style than secure attachment parents. Dismissing-avoidant and preoccupied parents reported a less affectionate parenting attitude than secure attachment parents. CONCLUSION: There were differences in parenting stress, parenting attitudes, and parents' mental health depending on the adult attachment style. More specific education and interventions based on parental attachment type are necessary for parents.

Temperament and Character Profiles Associated with Internalizing and Externalizing Problems in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE: This study aimed to identify temperament and character profiles associated with internalizing and externalizing problems in children with attention deficit hyperactivity disorder (ADHD). METHODS: Children with ADHD (n=114, 8.51±1.87 years) were selected from the Department of Child and Adolescent Psychiatry at Jeju National University Hospital. They were diagnosed by Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version and evaluated using the Advanced Test of Attention and Korean Wechsler Intelligence Scale for Children-Fourth Edition. Their parents completed the ADHD Rating Scale, Korean-Child Behavioral Checklist, and Junior Temperament and Character Inventory. RESULTS: The participants with both internalizing and externalizing problem had more severe ADHD symptoms and significantly higher novelty seeking, harm avoidance, and self-transcendence, as well as lower self-directedness and cooperativeness than those who had not comorbid problems. Harm avoidance was correlated with their level of internalizing problems regardless of severity of ADHD symptoms. In addition, novelty seeking and sex (male) were being associated with the level of externalizing problems. CONCLUSION: Differences were observed in the temperament and character profiles of children with ADHD according to their comorbid psychopathology. Results suggested that temperament and character profiles may affect the comorbid psychopathology in children with ADHD regardless of ADHD symptom severity.

Effects of a Class-Based School Violence Prevention Program for Elementary School Students

OBJECTIVES: This study was conducted to investigate the effectiveness of a class-based school violence prevention program for elementary school student. METHODS: 29 students were assigned to the school violence prevention program of 8 sessions, 28 students have been assigned to the control group. We assessed participants at baseline and post-intervention, through their self-report questionnaires such as Children's Depression Inventory (CDI), Strengths and Difficulties Questionnaire and school violence experience, awareness about school violence, and coping ability to school violence. We compared the baseline and post-intervention result of each group and compared the post-test scores between the intervention group and the control group. RESULTS: Comparing the intervention group and the control group, the post-intervention CDI total score and the awareness about school violence showed significant improvement in the intervention group. When compared according to gender, male students' perception of school violence was improved, and female students showed significant differences in CDI scores. CONCLUSION: The CDI total scores and the perception of school violence were improved in the intervention group compared to the control group. And there are differential pattern of intervention effects according to gender. These findings have important implications to develop effective violence prevention programs.

Association between the Brain-Derived Neurotropic Factor and Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a common childhood psychiatric disorder. Recently, it has been suggested that brain-derived neurotropic factor (BDNF) may play a role in the pathogenesis of ADHD. Our aim of this review is to understand the physiological functions of BDNF and its potential relationship with ADHD and therapeutic approaches of ADHD. Searches were conducted in Pubmed and Research Information Service System (RISS). In this review, we summarized important literatures for the physiological functions of BDNF in neurodevelopment, change of serum BDNF level in ADHD, association of BDNF polymorphism and ADHD and potential association of treatment of ADHD with serum BDNF level. Further studies are required to more clearly understand the source and the role of BDNF in ADHD and to develop BDNF based-ADHD treatement.

Factors that Affect the Adherence to ADHD Medications during a Treatment Continuation Period in Children and Adolescents: A Nationwide Retrospective Cohort Study Using Korean Health Insurance Data from 2007 to 2011

OBJECTIVE: Several factors, such as male gender, older age, type of insurance, comorbid conditions, and medication type, have been associated with attention-deficit/hyperactivity disorder (ADHD) medication adherence rates, but the results have been inconsistent. We analyzed data to answer several questions: 1) How old were patients who first refilled their treatment medications used primarily for ADHD, regardless of the medication type? 2) What socio-demographic factors are associated with medication adherence? 3) What medical conditions, such as medication type and comorbid diagnosis, influence adherence? METHODS: We analyzed National Health Insurance data, which comprised continuously enrolled Korean National Medical Insurance children (6–18 years) with at least 2 ADHD prescription claims (January 2008–December 2011). The persistence of use regarding the days of continuous therapy without a 30-day gap were measured continuously and dichotomously. Adherence, using a medication possession ratio (MPR), was measured dichotomously (80% cut-off). RESULTS: The cumulative incidence of index cases that initiated medication refills for ADHD treatment during the 4 year period was 0.85%. The patients who exhibited a MPR greater than 80 comprised approximately 66%. The medication type, high school age groups, physician speciality, treatment at a private clinic, and comorbid conditions were associated with medication adherence during continuous treatment using a multivariate analysis. CONCLUSION: A better understanding of ADHD treatment patterns may lead to initiatives targeted at the improvement of treatment adherence and persistence. Other factors, including the severity, family history, costs, type of comorbidities, and switching patterns, will be analyzed in future studies.

Mental Health Problems in Child and Adolescent Obesity

OBJECTIVES: The purpose of this study was to investigate mental health problems in obese child and adolescent patients. We assess the frequency of mental health problems and their differences according to sex, school grade and severity of obesity. METHODS: The sample consisted of 106 children and adolescents aged 8-16 years (61 boys with mean age 10.98±2.26, 45 girls with mean age 9.74±1.96, p=.004) who were diagnosed with obesity and recruited at the Department of Pediatrics of Jeju National University Hospital. The participants completed the Korean-Child Behavior Checklist (K-CBCL), Children's Depression Inventory (CDI), Korean version of the Eating Attitude Test-26 (KEAT-26), and somatotype drawings. RESULTS: The percentage of participants having a T-score in clinical range on one or more CBCL subscale was 37.7%. The percentage of participants in the high risk group for depression (CDI score above 17) was 20.8% and that in the high risk group for eating disorder (EAT-26 score above 20) was 6%. The girls showed significantly lower CBCL T-scores in social competence (48.39±15.66 vs. 38.91±22.04, p=.011), adjustment function (49.51±17.35 vs. 40.38±22.58, p=.020) and school competence (53.34±10.47 vs. 48.22±15.11, p=.042) than the boys, but the percentages of boys and girls in clinical range were not significantly different. The middle school students showed (significantly) higher CBCL T-scores in somatic symptoms (60.86±9.44 vs. 55.74±6.76, p=.005), aggressive behavior (58.81±6.74 vs. 54.68±6.22, p=.009), total problems (59.86±9.91 vs. 54.88±9.76, p=.039) and externalizing problems (57.90±10.57 vs. 52.44±9.38, p=.022) than the elementary school students. The severe obesity group showed significantly higher CBCL T-scores in attention problems (59.18±9.45 vs. 54.15±5.34, p=.001), social problems (59.25±8.59 vs. 55.96±6.50, p=.038), delinquent behavior (58.07±6.97 vs. 54.73±6.00, p=.017) and total problems (59.21±11.65 vs. 54.67±9.03, p=.037) than the mild to moderate obesity group. CONCLUSION: Significant proportions of obese children and adolescents suffer from mental health problems. Clinicians need to pay attention to the mental health risk, especially in obese adolescents and severely obese children and adolescents.

A Multicenter Study Investigating Empathy and Burnout Characteristics in Medical Residents with Various Specialties

We assessed empathy in medical residents, including factors modifying empathy and the relationship between empathy and burnout. Participants (n = 317 residents, response rate = 42%) from 4 university hospitals completed a socio-demographic questionnaire, the Jefferson Scale of Empathy (Health Professional version, Korean edition), and the Maslach Burnout Inventory (MBI). Participants were classified by medical specialty: “people-oriented specialty” (POS group) or “technology-oriented specialty” (TOS group), with more women in the POS than in the TOS group, χ2 = 14.12, P < 0.001. Being female, married, and having children were factors related to higher empathy (gender, t = -2.129, P = 0.034; marriage, t = -2.078, P = 0.038; children, t = 2.86, P = 0.005). Within specialty group, POS residents showed higher empathy scores in the fourth as compared to the first year, F = 3.166, P = 0.026. Comparing POS and TOS groups by year, fourth year POS residents had significantly higher scores than did fourth year TOS residents, t = 3.349, P = 0.002. There were negative correlations between empathy scores and 2 MBI subscales, emotional exhaustion (EE) and depersonalization (DP). Additionally, first year POS residents had higher DP scores than did first year TOS residents, t = 2.183, P = 0.031. We suggest that factors important for empathy are type of medical specialty, marriage, siblings, and children. Burnout state may be related to decreasing empathy.

The Code of Medical Ethics for the Korean Academy of Child and Adolescent Psychiatry: Why Is It Important?

This article provides an overview of the developmental history and rationale of medical ethics to establish the code of ethics and professional conduct of the Korean Academy of Child and Adolescent Psychiatry (KACAP). Most medical professional organizations have their own codes of ethics and conduct because they have continuous responsibility to regulate professional activities and conducts for their members. The Ethics and Award Committee of the KACAP appointed a Task-Force to establish the code of ethics and conduct in 2012. Because bioethics has become global, the Ethics Task Force examined global standards. Global standards in medical ethics and professional conduct adopted by the World Medical Association and the World Psychiatric Association have provided the basic framework for our KACAP's code of ethics and professional conduct. The Code of Ethics of the Americal Academy of Child and Adolescent Psychiatry has provided us additional specific clarifications required for child and adolescent patients. The code of ethics and professional conduct of the KACAP will be helpful to us in ethical clinical practice and will ensure our competence in recognizing ethical violations.

Impact of Peer's Suicide on Mental Health of Adolescents

OBJECTIVES: This study examined the impact of peer's suicide on mental health of middle-school students. The aim of this study was to describe the course of posttraumatic stress and grief reaction, suicide ideation, and depression score among adolescents after exposure to peer's suicide and to examine the relationship between posttraumatic stress and other mental health scores in these subjects. METHODS: Thirty seven middle school students who were exposed to the suicidal death of a peer completed self-report measures to assess levels of depression, grief reaction, post-traumatic stress, and suicide ideation at 1 month and 8 months after the peer's suicide. RESULTS: There was no significant change in mental health scores between 1 month and 8 months. Level of posttraumatic stress after 8 months was related to acute grief response. Subjects who experienced a clinically significant level of suicidal ideation and posttraumatic stress showed more mental health problems. CONCLUSION: The results suggested that peer's suicide strongly impacted mental health issues of adolescents at a critical time of adolescent development. Clinicians should perform a thorough evaluation of mental health problems for youth who experienced peer's suicide and help them in management of their grief reaction.

The Treatment Effect of Neurofeedback Training on Executive Function in Attention-Deficit Hyperactivity Disorder

OBJECTIVES: Children with attention-deficit hyperactivity disorder (ADHD) have been shown to display more inhibitory deficits and executive function deficits. This study investigated the treatment effects of neurofeedback (NF) training on executive function by comparing the results of neuropsychological tests of the trained children at pre- and post-training. METHODS: Fifteen children with ADHD, aged 6 to 14 years, participated in the study. The NF treatment consisted of slow cortical potential (SCP) training and these sessions took place once a week. The ADHD children performed 20 sessions of NF training within 6 months. Pre-training and post-training assessments encompassed Continuous Performance Test (CPT), Stroop Test, Children's Color Trails Test I&II (CCTT) and Wisconsin Card Sorting Test (WCST). RESULTS: Patients receiving NF training showed significant improvement in visual commission error and standard deviation of auditory response time on CPT ; and total errors on WCST. But there was no significant improvement in the Stroop test and CCTT. CONCLUSION: SCP training using NF improves the self-regulatory capacities and impulsivity in ADHD patient, especially impulsivity in visual stimulation tasks. This study showed evidence of clinical efficacy of NF on executive function in ADHD.