Analysis of the Status and Future Direction for Digital Therapeutics in Children and Adolescent Psychiatry

Digital therapeutics based on software, such as artificial intelligence, virtual reality, games, and smartphone applications, are in the spotlight as new therapeutic alternatives in child and adolescent psychiatry. It draws attention to overcoming conventional therapeutics’ limitations, such as toxicity, cost, and accessibility, and encourages patients to participate in the treatment attractively. The growth potential of the digital therapeutics market for psychiatric disorders in children and adolescents in Korea and abroad has been highlighted. Clinical studies and Food and Drug Administration approvals for digital therapeutics have increased, and cases approved by the Ministry of Food and Drug Safety have emerged in Korea. As seen above, digital transformation in child and adolescent psychiatry will change treatment paradigms significantly. Therefore, as this new field has just begun to emerge, it is necessary to verify the effectiveness and scope of the application of digital therapeutics and consider preparing a compensation system and institutional arrangements. Accordingly, this study analyzed the development trends and application status of digital therapeutics in children and adolescents and presented limitations and development directions from the perspective of application in healthcare. Further, the study is expected to identify the utility and limitations of digital therapeutics for children and adolescents and establish effective application measures.

A Survey on the Journal of the Korean Academy of Child and Adolescent Psychiatry: Implications for Growth and Development

Objectives@#This study aimed to assess the status of the Journal of the Korean Academy of Child and Adolescent Psychiatry (JKACAP) and propose measures for its growth and development. @*Methods@#The study was conducted using a questionnaire survey targeting members of the Korean Academy of Child and Adolescent Psychiatry. The six key elements analyzed were Access to the journal, Convenience following conversion to English, Recognition as an international journal and institutional achievements, Author perspectives on manuscript submission,Transition to an online-only journal, and Content and identity of the journal. @*Results@#The survey revealed that email notification was highly effective for Journal Accessibility, with the website and search engines also frequently being used by members. Conversion to English in 2018 initially impacted readability and submission rates, but these concerns have decreased over time. However, the Recognition of JKACAP as an international academic journal was still not on par with SCIE journals, highlighting the need for further efforts towards SCIE inclusion. Despite these challenges and limited research opportunities, there was an active intention among members to submit manuscripts. Respondents showed a notable preference for the Transition to an online-only journal. Regarding content and identity of the JKACAP, members predominantly favored review articles and perceived the journal as a research and communication platform for Korean child and adolescent psychiatrists. @*Conclusion@#The results indicate the need for JKACAP to enhance its digital accessibility, provide more support for domestic and international authors, and actively seek SCIE indexing. Addressing the varied content preferences of its members, improving the submission process, and transitioning to an online-only format could further its growth and solidify its position as an internationally recognized academic journal in the field of child and adolescent psychiatry.

Old Age, Female Sex, and Psychotropic Medications Predict Hyposalivation But Not Heart Rate Variability

Objective@#To explore risk factors for dry mouth and examine the clinical utility of the heart rate variability (HRV) test in the prediction of dry mouth. @*Methods@#Every outpatient, who underwent tests for both unstimulated salivary flow and HRV, was retrospectively reviewed. After excluding seven subjects, the demographics and clinical factors in 70 total patients were collected. Based on objective salivary flow rates, patients were classified into normal (≥0.2 mL/min) or hyposalivation groups (<0.2 mL/min), and inter-group comparisons were performed with a two-tailed statistical significance of 0.05. @*Results@#Patients with subjective dry mouth were significantly more likely to show hyposalivation. Advanced age, female sex, and current use of psychotropic medications were identified as risk factors for dry mouth. However, dry mouth was not associated with any HRV parameters. @*Conclusion@#HRV test did not demonstrate a clinical utility in predicting dry mouth. Because subjective dry mouth is significantly associated with objective hyposalivation, a simple probing question would be useful for early recognition of dry mouth. Clinical attention is required for patients meeting criteria of older age, female, and/or using psychotropic prescriptions. Prompt management of hyposalivation may improve quality of life and clinical outcome by enhanced treatment adherence.

The Thirty-First Year Journey, the Journal of the Korean Academy of Child and Adolescent Psychiatry

Objectives@#The Journal of the Korean Academy of Child and Adolescent Psychiatry (JKACAP) has had a 31 year-long history, sharing research and reviews of children and adolescents’ mental health to promote voluntary participation and communication of the members of this society. Here, we have reviewed the detailed history of the journal from the perspective of developmental progression of JKACAP and discussed the direction of further development. @*Methods@#& Results: We reviewed the journey of the journal by focusing on the effort it took to take the journal to a global standard, and discussed the future direction of progress of JKACAP, based on the opinions raised at the Editor-in-Chiefs’ reunion. @*Conclusion@#JKACAP has just stepped on the path to globalization by being indexed in Emerging Sources Citation Index, PubMed Central, and Scopus. It is time to progress to another dimension, by acknowledging and overcoming more complicated issues, such as augmenting impact of the journal, expanding domains of interdisciplinary collaboration, and more global cooperation.

The Effects of Group Cognitive Behavioral Therapy on the Improvement of Depression and Anxiety in Adolescents with Problematic Internet Use

OBJECTIVES: The overuse of the Internet among adolescents has increased dramatically in recent years, leading to pathological or problematic Internet use. Cognitive behavioral therapy (CBT) is known to be effective for the treatment of problematic Internet use, particularly for adolescents. The aim of the present study was to evaluate the therapeutic efficacy of group CBT for problematic Internet use in adolescents. METHODS: A total of 17 patients aged 12–17 years who met Young's diagnostic questionnaire criteria of problematic Internet use participated in a school-based eight-session group CBT program. The level of problematic Internet use among participating students was measured using Young's Internet Addiction Scale (IAS). Depression and anxiety levels were evaluated using the Children's Depression Inventory (CDI) and the State-Trait Anxiety Inventory (STAI), respectively. Each construct was assessed at baseline, immediately after the intervention, and at a one-month follow-up visit. Statistical significance was based on a p-value of < 0.05. RESULTS: Immediately after the program, the IAS, CDI, and State Anxiety Inventory (SAI) scores were significantly lower than before the program. At the one-month follow-up assessment, the IAS scores remained low, and the CDI and SAI scores were even lower than immediately after the program. CONCLUSION: Group CBT was effective for adolescents with problematic Internet use, and was also demonstrated to improve depression and anxiety.

Relationship between Depression and Sleep Patterns of Middle School Student in Seoul / 신경정신의학

OBJECTIVE: This study examined the association between the sleep patterns and depression of middle school students in Seoul. METHODS: 450 adolescents attending middle school (mean age 14.07 years, 40% male) responded to the survey. The participants answered the self-administered questionnaires about sleep patterns (Morningness-Eveningness Questionnaire, MEQ), sleep problems (Insomnia Severity Index, ISI ; Epworth Sleepiness Scale, ESS), and depressive symptoms (Children's Depression Inventory, CDI). RESULTS: The depressive group represented 25.9% of the total study sample with females exhibiting higher depressive index scores than males. Although the difference in the total sleeping time between the depressive group and control group was unspecified, the ISI and ESS scores were significantly higher in the depressive group than in the control group. In addition, there was a significant positive correlation between the total ISI and CDI scores. Those who scored higher than 8 on the ISI were 2.24 times more likely to belong to the depressive group, and those who scored higher than 7 on the ESS were 2.23 times more likely to belong to the depressive group. CONCLUSION: The depressive group tended to suffer from insomnia and experience more severe daytime sleepiness than students in the control group. In addition, students suffering from more severe insomnia tended to have higher CDI scores than their counterparts. Furthermore, students suffering from insomnia and/or experiencing daytime sleepiness were at least twice as likely to develop depression than other students.

Familial, Cognitive, and Behavioral Characteristics of Adolescents with Depression

OBJECTIVES: Adolescent depression is a complex disorder influenced by a variety of personal and familial factors. In this study, we compared the familial, cognitive, and behavioral characteristics of adolescents with and without diagnosed depression. METHODS: Forty adolescents with depressive disorder were recruited from two psychiatric clinics, along with 46 healthy adolescents from a middle school and a high school. We then compared the participants' cognitive and behavioral characteristics and the child-rearing attitudes of their parents. RESULTS: Compared to the healthy adolescents, the adolescents with depression exhibited lower self-esteem, higher emotional reappraisal, greater disruptive behavior, and lower attention. Furthermore, compared to the mothers of the healthy adolescents, the mothers of those with depression reported less affective, less autonomic, and more rejecting parenting attitudes towards their children. CONCLUSION: We found that attentional problems, negative parenting attitudes, negative self-cognition, and expressive suppression are all associated with adolescent depression. Parenting education and interventions appear to be needed to correct the negative cognitions of adolescents with depression.

The Relationship of Sexual Abuse with Self-Esteem, Depression, and Problematic Internet Use in Korean Adolescents

The association of sexual victimization with self-esteem, depression, and problematic internet use was examined in Korean adolescents. A total of 695 middle and high school students were recruited (413 boys, 282 girls, mean age, 14.06±1.37 years). The participants were administered the Early Trauma Inventory Self Report-Short Form (ETISR-SF), Rosenberg's Self-Esteem Scale (RSES), the Children's Depression Inventory (CDI), and Young's Internet Addiction Test (IAT). The associations between sexual abuse and the level of self-esteem, depressive symptoms, and problematic internet use were analyzed. Adolescents who had experienced sexual abuse showed lower self-esteem, more depressive symptoms, and greater problematic internet use compared with adolescents who had not experienced sexual abuse. In the path model, sexual abuse predicted lower self-esteem (β=−0.11; 95% CI=−0.20, −0.04; p=0.009), which predicted higher depressive symptoms (β=−0.34; 95% CI=−0.40, −0.27; p=0.008). Depressive symptoms predicted problematic internet use in a positive way (β=0.23; 95% CI=0.16–0.29; p=0.013). Sexual abuse also predicted problematic internet use directly (β=0.20; 95% CI=0.12–0.27; p=0.012). The results of the present study indicate that sexually abused adolescents had a higher risk of depression and problematic internet use. For sexually abused adolescents, programs aimed at raising self-esteem and preventing internet addiction, as well as mental health screening, are needed.

The Inhibitory Effect of Korean Antismoking Advertisement on Smoking Urge / 신경정신의학

OBJECTIVES: This study compares the emotional reaction and inhibitory effect on smoking urge between foreign antismoking advertisements and Korean antismoking advertisements. METHODS: Twenty-seven male smokers responded to a self-report survey including a Questionnaire on Smoking Urge and on emotional reactions such as disgust, anger and fear after watching a foreign antismoking advertisement, neutral images, and a Korean antismoking advertisement. We compared the smoking urge between the foreign antismoking advertisement and Korean antismoking advertisement and investigated emotional reactions associated with reduction in the smoking urge. RESULTS: The foreign antismoking advertisement inhibited the smoking urge but Korean antismoking advertisement did not. A significantly higher emotional response was evoked by the antismoking advertisements than in neutral images. However, among the emotions respondents reported about the foreign antismoking advertisement, only disgust was significantly associated with smoking urge. CONCLUSION: These results support published research, in that warning labels with high-rated emotional reactions are associated with reduction in the smoking urge. High emotional reactions such as disgust may enhance the effect of Korean antismoking advertisements.

No Evidence of Association of the Alpha-2A-Adrenergic Receptor Gene with Methylphenidate Response in Attention Deficit Hyperactivity Disorder / 신경정신의학

OBJECTIVES: The aim of this study was to examine the association of the ADRA2A MspI and DraI polymorphisms with methylphenidate (MPH) response in Korean children with ADHD. METHODS: The present study included 112 children and adolescents with ADHD (mean age=9.1+/-2.1 years), consisting of 92 boys (82.1%) and 20 girls (17.9%). ADHD was diagnosed based on the DSM-IV criteria using the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). For the clinical evaluation of the ADHD subjects, the ADHD Rating Scale-IV (ADHD-RS) and Clinical Global Impression (CGI) were administered at baseline and 8 weeks after MPH treatment. ADRA2A MspI and DraI polymorphisms were genotyped. The chi2 test was used to evaluate the relationship between the ADRA2A genotype and the response to MPH. The correlation between the genotype of ADRA2A and the change in the ADHD-RS scores after MPH treatment was assessed using the analysis of variance test and t-test. The significance level was set at p=0.01. RESULTS: No significant association was found between the genotypes of the ADRA2A MspI or DraI polymorphisms and MPH treatment response according to the CGI-improvement score (p>0.05). Comparing the changes in ARS scores after MPH treatment according to the genotypes of the MspI or DraI polymorphisms, we found no significant differences between subjects with different genotypes (p>0.05). CONCLUSION: Our results do not support the significant association between the MspI genotype and MPH response in Korean ADHD subjects, which was previously reported. In addition, we document no evidence of association between the DraI polymorphism and MPH treatment response in the Korean ADHD population.

Differences in Performance of ADHD Children on a Visual and Auditory Continuous Performance Test according to IQ

OBJECTIVE: Continuous performance tests (CPTs) are frequently used in clinical practice to assess the attentiveness of ADHD children. Although most CPTs do not categorize T scores by intelligence, there is great diversity of opinion regarding the interrelation between intelligence and CPT performance. This study aimed to determine if ADHD children with superior IQs would perform better than ADHD children with average IQs. Additionally, we aimed to examine the need for CPTs' to categorize according to IQ. METHODS: Participants were 326 outpatients, aged 5-15 years, diagnosed with ADHD. All participants completed the Wechsler Intelligence Scale for Children-Revised and a CPT. After excluding those who meet exclusion criteria, we had 266 patients for our analysis. RESULTS: The "Highly Intelligent Group" (HIG), patients with IQs 120 and above, performed superiorly to the "Normally Intelligent Group" (NIG) patients, with IQs between 70 and 120, with regard to omission and commission errors on the visual-auditory CPT, even after controlling for age and gender. The HIG had higher ratios of subjects with T scores <65 on the visual and auditory CPT variables than the NIG did. CONCLUSION: The results of this study suggest this CPT is not sensitive for discerning ADHD in children with superior IQs; thus, there is a need to standardize the variables based on IQ, as well as on age and gender. Moreover, clinicians need to pay attention to the effect of IQ in interpreting CPT scores; that is, a "normal" score does not rule out a diagnosis of ADHD.

The Effectiveness of School Based Short-Term Social Skills Training in Children with Attention-Deficit/Hyperactivity Disorder(ADHD)

OBJECTIVES: Children with attention-deficit hyperactivity disorder (ADHD) often have difficulties in social behavior. The aim of this study was to evaluate the effectiveness of a short-term training program for improving social skills, selfperception and attention deficits. METHODS: The subjects were nine children diagnosed with ADHD with (or without) other mental disorders using the Diagnostic Interview Schedule for Children (DISC-ADHD) module. Children were given eight sessions of a social skills training program. Parents of children simultaneously participated in their own training which was designed to support their children's generalization of skills. Assessments included child, parent and teacher ratings of social skills, self-perception and attention deficit at baseline and post-treatment. RESULTS: Social skills training led to significant improvements in child-reported measures of self-esteem, in teacherreported measures of social skills, and in parent-reported measures of attention deficit. CONCLUSION: This study suggests that short-term social skills training programs for children with ADHD may improve their social skills, self-perception and attention deficits.

Clinical Characteristics of Early Onset Bipolar Disorder: A Retrospective Chart Review Study / 신경정신의학

OBJECTIVE: Bipolar disorder is a disease with diverse clinical profiles and outcomes. In recent years, it is suggested that if bipolar disorder occurs early in one's life, functional and symptomatic prognoses are poor. The prognoses include severe symptoms, frequent psychotic symptoms, comorbidity of mental illnesses, slow improvement of the symptoms, and high suicide rate. We investigated the clinical characteristics of early onset bipolar inpatients. METHOD: The subjects of this study were selected from the patients who were discharged after hospitalization between January 1, 2001 and May 31, 2005 and diagnosed with bipolar disorder according to DSM-IV criteria. These patients were examined for the following data; the type of bipolar disorder, comorbid psychiatric disorders, the age at onset of the illness, the acuteness of the disorder, and the duration of the disorder. The presence of four major clinical psychopathology, rapid cycling, psychotic symptoms, comorbid psychiatric disorders, and suicide attempt, was also examined. The patients whose onset of the illness was before the age of 19 were classified as the early onset group and after the age of 19 were classified as the late onset group. Data on demographics, family histories, four major clinical psychopathologies and other clinical variables were compared between the early onset group and the late onset group. RESULTS: Of the 53 patients, 19 patients belonged to the early onset group. There was higher incidence of psychotic symptoms in the early onset group than in the late onset group, and the difference was statistically significant according to the Chi2-test (84.2% vs 44.1%, p=0.005). The incidence of comorbid psychiatric disorders was higher in the early onset group than in the late onset group, and the difference was also statistically significant according to the Chi2-test (52.6% vs 23.5%, p=0.032). However, there was no statistically significant difference between the groups regarding the incidence of rapid cycling and suicide attempt. The result of logistics regression showed correlation of psychotic symptoms (OR=6.756; 1.655< or =95% CI< or =27.580) and comorbid psychiatric disorders (OR=3.611; 1.088< or =95% CI< or =11.984) with the early onset group. CONCLUSION: Early onset of bipolar disorder is related to the manifestation of psychotic symptoms and frequently accompanies comorbid psychiatric disorders. The results of this study will help understand the mechanism of the onset of complex bipolar disorder and estimate the prognosis.