Clinical Utility of the Korean Version of the WHO Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale Screener

OBJECTIVE: The aim of this study was to compare the performance of the 18-item Korean version of the World Health Organization adult attention-deficit/hyperactivity disorder self-report scale (ASRS) with the six-item ASRS Screener for predicting attention-deficit/hyperactivity disorder (ADHD) group. METHODS: The study sample included 51 adult patients with ADHD and 158 normal controls. All participants completed the ASRS and were interviewed individually using the Mini-International Neuropsychiatric Interview. Receiver operating characteristic (ROC) curves were used to compare the ASRS (ASRS-18) with the ASRS Screener (ASRS-6) in Korean samples. RESULTS: The ADHD group had higher ASRS and ASRS subscale scores than those of the control group. ROC curve analysis revealed the ASRS was more powerful to predict ADHD group than the ASRS Screener, but the ASRS Screener also had strong concordance with clinician diagnoses. CONCLUSION: This study shows that the 18-question ASRS outperforms the six-question ASRS Screener. However, the weighted Screener is also a valid and useful screening instrument both in epidemiological surveys and in clinical settings.

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.

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.

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.

The Early Childhood Care and Education Policy in the United Kingdom and Similar Policies in Korea: A Comparison of the Sure Start Children's Centres and Dream Start

In an effort to expand working opportunities for women and encourage childbirth, the government of Korea introduced the free infant care policy in 2013. This policy, however, was controversial with regard to issues, such as budget shortages and dissatisfaction based on socioeconomic status. In addition, the lack of evidence-based data regarding adequate age criteria for the entry of children into childcare facilities was noted as a challenge. As child development professionals who are concerned with mental health issues, we investigated the influence and challenges of the free infant care policy with regard to infant mental health. In this review, we examined the policies enacted by developed countries, such as the United Kingdom (UK), and compared them with those in Korea. The childcare systems in Korea and the UK differ historically and socially, but show some similarities, such as maternal responsibility for parenting and household issues. Like Korea, the need for UK childcare facilities increased in the 1990's in response to market recovery and associated increase in female employment. Among the new policies in the UK, the Sure Start program has begun to provide integrated services for infants, particularly to those 0-4 years of age, who are vulnerable to social exclusion. Similar to the Dream Start program in Korea, it has been successful in providing family-related services, resulting in improvements in problematic behaviors of children, enhanced parenting skills, and decreased rates of severely injured children.

Current Situation and Policies of Early Childhood Care and Education in North Korea

In order to resolve the decline in population due to low birthrates, the South Korean government is expanding its free child care policies with an increased budget. In anticipating the effects and problems of our system, it will be worthy of attention to refer to the child care systems of other countries. In this paper, we reviewed the past and present policies and the current situation of the child care system in North Korea. North Korea started its free child care system earlier than that of South Korea, for the purpose of utilizing the women's labor force and rearing children to be revolutionary men of Juche type (Kimilsungism), in order to construct a communistic society. 'Child Care Education Law', which is the legal foundation of the child care system, regulates institutions for nursery schools and kindergarten and informs people that the country is responsible for support of child care. Despite their interest and progress in both quantity and quality in the child care system until the 1980s, the free child care system was partially disrupted, and discrepancies between ideology and actual situation were revealed due to economic difficulties from the 1990s. Because people's survival and physical health have been threatened, it is barely possible to find any study investigating the effect of institutional child care from early childhood and the instillation of unique ideology by group education from the preschool period on mental health.

Influence of Early Childhood Care and Education on Children's Mental Health (I) - Status and Prospects of Child Care and Education Policies of Korea -

Most preschool children in Korea attend kindergarten (KG) or a child care center (CCC). CCCs, which focus on caring for the child, belong to the ministry of health and welfare. On the other hand, KGs are responsible for education, and belong to the ministry of education, science and technology. In order to resolve the decline in population due to low birthrates, the government is expanding the free child care and education policies. CCCs and KGs are combined together to form the 'NURI curriculum' and supporting funds have been increased in both governmental departments. In addition, economic support is provided for homeschooling households. Because this is a nationwide policy and applies to every single household, thorough preparation regarding the effect and side effects must be made. This policy is currently being implemented, and as child and adolescent psychiatrists, great consideration should be given to the influence on the population. Therefore, the Korean Academy of Child and Adolescent Psychiatry intends to investigate the effects and problems of the nationwide policy by analyzing the current condition of Korea's free child care and education and foreign policies. In the current paper, we reviewed the developmental process of Korea's free child care and education policy, as well as suggested future directions.

Attachment and Behavior Problems in Adolescents: Internalizing and Externalizing Problems / 신경정신의학

OBJECTIVE: The purpose of this study was to examine the relationship between attachment and behavior problems in adolescents. METHOD: A sample of 792 high school students were examined. Revised Adult Attachment Scale, Self-report Attachment Style, Youth Self-Report Child Behavior Checklist (YSR) were used to measure the attachment quality, the attachment pattern and the behavior problems respectively. RESULTS: As to the attachment quality, high score in fear of rejection, low dependability and low intimacy were related to the development of adolescent's internalizing problems. As to the attachment pattern, preoccupied and fearful with attachment experience were linked to the internalizing behavior problems of higher level as well as 'Attention problems' and 'Aggressive behavior' sub-scales of externalizing ones on YSR. CONCLUSION: High fear of rejection, low dependability and low intimacy characterise the insecure attachment. So the insecure attachment might predict the development of all internalizing behavior problems, attention problems and aggressive behavior in adolescents. Also the result suggested that the adolescents classified as Dismissing attachment may have a positive view of the self and may minimize the self reported behavior problems.

A Study of Adolescent Problem Behaviors and Parenting Behaviors / 신경정신의학

OBJECTIVES: The purpose of this study is to evaluate the problem behaviors of adolescents and to discriminate between parenting behaviors of problem behavior groups and those of non-problem behavior group. METHODS: The subjects of this study were 792 high school students in Seoul. We administered 'Parenting Behavior Inventory' and Korean version of Youth Self-Report(K-YSR) to the subjects in order to evaluate the parenting behaviors perceived by adolescents and the problem behaviors of adolescents. We analyzed the relationship between parenting behaviors and problem behaviors. We classified the subjects into problem behavior groups(internalizing group, externalizing group, internalizing-externalizing group) and a non-problem behavior(normal) group. We studied the differences of parenting behaviors among the groups. RESULTS: The results are as follows. 1) There were significant negative correlations between the positive parenting behaviors such as affection, reasoning, and monitoring and the problem behaviors of adolescents. By contrast, there were significant positive correlations between the negative parenting behaviors such as physical abuse, intrusiveness, over-expectation, neglect, and inconsistency and the problem behaviors of adolescents. 2) Adolescents of the internalizing group perceived significantly more parental abuse, intrusiveness, over-expectation, neglect, and inconsistency than those of normal group. Meanwhile, they perceived significantly less affection than normal adolescents. Adolescents of the externalizing group also perceived significantly more parental abuse, intrusiveness, over-expectation, neglect, and inconsistency than those of normal group. Also, they perceived significantly less monitoring than normal adolescents. 3) Adolescents of the internalizing-externalizing group perceived significantly more intrusiveness from both parents than those of either the internalizing or the externalizing groups. Adolescents of the internalizing-externalizing group perceived significantly less affection and more neglect from their mothers than those of the internalizing or the externalizing groups. In addition, adolescents of the internalizing-externalizing group perceived significantly more physical abuse from their fathers than those of the internalizing or the externalizing groups. CONCLUSION: Parenting behaviors such as abuse, intrusiveness, over-expectation, neglect, and inconsistency are associated with both internalizing and externalizing problems. In contrast, our results suggest that parenting behaviors such as affection, monitoring, and reasoning might decrease the various problem behaviors of adolescents.

Differences in Cognitive Function and Activities of Daily Living between Alzheimer Patients with Depression and Those without Depression / 신경정신의학

OBJECTIVES: Coexistence of depression is one of the important behavioral symptoms in patients with dementia of Alzheimer type. The study on the relationship between depression and cognitive abilities and/or functional abilities emerges as very important one. The aim of this study was to investigate whether depression is related to the impairment of daily activities and to certain areas of cognitive function in mild to moderate dementia of Alzheimer type. METHODS: In this study, 48 patients with dementia of Alzheimer type among elderly community-residents in Kwangju, Kyunggi province, aged 65 and older, were finally included. We examined their demographics and administered Korean Version of the Mini-Mental State Examination(MMSE-K), Korean Version of the Neurobehavioral Cognitive Status Examination(Korean version of NCSE), Korean Form of Geriatric Depression Scale(KGDS), Activities of Daily Living(ADL), and Instrumental Activities of Daily Living(IADL) to the subjects. We classified the subjects into two groups, dementia with and without depression on the basis of KGDS scores. The two groups were compared using X2 test and independent ttest. RESULTS: The results show that the two groups did not differ in sex, age, education, and scores of MMSE-K. The depressed dementia group showed significantly poorer performance in bathing, one item of ADL, than the nondepressed dementia group. The depressed dementia group showed significantly more impairment in total scores of IADL and each score of three items(shopping, housework, handling finances) than the non-depressed dementia group. However, the two groups showed no significant differences in five major cognitive ability areas of Korean version of NCSE. CONCLUSION: These results suggest that depression in patients with dementia of Alzheimer type is highly related to the functional impairments, instrumental activities of daily living and part of activities of daily living, beyond the effects of cognitive impairments.

A Clinical Significance of the Subjective Experiences of Negative Symptoms in the Patients with Schizophrenia / 신경정신의학

OBJECTIVE: Since the evaluation of negative symptoms has depended on the clinician's objective observation, the patients' subjective experience of negative symptoms has been neglected. However, in fact, a lot of patients are aware of their negative symptoms. There are several reports suggesting that patients suffer from the subjective experiences of their deficit symptoms, even though the objective positive and negative symtoms cannot be observed. Under these circumstances, we have attempted this study with the idea that it would be helpful in understanding the psychopathology of schizophrenia. Also it would help clarifying the relationship between subjective experience of negative symptoms and objective positive and negative symptoms, depression, anxiety symptoms, and extrapyramidal symptoms. METHOD: All the 37 patients satisfied the diagnostic criteria of DSM-IV for schizophrenia . The subjective experiences of negative symptoms were evaluated using Scale for the Subjective Experience of Negative Symptoms, Korean version(K-SENS), and for the depression, anxiety, extrapyramidal symptoms, we used Hamilton Rating Scale for Depression(HAM-D), Hamilton Rating Scale for Anxiety (HAM-A), and Extrapyramidal Symptom Rating Scale(ESRS). The correlation between each psychopathology was tested by calculating Spearman correlation coefficient. RESULTS: There was a significant correlation between the ratio of items experienced as uncomfortable symptoms among 24 items of K-SENS, and the score of PANSS positive subscale(gamma=-0.40, p0.05), or negative subscale score(gamma=-0.20, p>0.05), or general psychopathology subscale score(gamma=-0.08, p>0.05), respectively. There was no significant correlation between the ratio of items experienced as uncomfortable symptoms among 24 items of K-SENS, and HAM-D(gamma=-0.01, p>0.05), or HAM-A(gamma=-0.11, p>0.05), ESRS(gamma=0.34. p>0.05), respectively. CONCLUSION: These results revealed that the negative correlation between the subjective negative symptoms experienced as an uncomfortable ones and the objective positive symptoms such as grandi-osity, suspiciousness/persecution, and hostility. From these results, the possibility that positive symptoms are used as a defense to hide from the subjectively experienced negative symptoms, or that patients may not be aware of their negative symptoms because they are overwhelmed by their positive symtpoms. is suggested. These results also suggest that subjective experiences of negative symptoms are independent from depression, anxiety and extrapyramidal symptoms.

Effects of Emotional Management Training in Schizophrenic Patients / 신경정신의학

OBJECTIVES: Schizophrenic patients having a disturbance of cognition and emotion are least likely to identify emotional (especially negative) stimuli and cue in tense background stimuli. Also, schizophreinic patients tend to experience relapse if they are exposued to a situation which is emotionally laden. Although emotion itself is important, emotional processing has not been a therapeutic target and skill trainig which improves social competence has provided patients with emotional load. Therefore, we introduced Emotional Management Trainig (EMT) which deal with indirect and direct emotional processing, applied it to schizophrenic patients, and investigated the therapeutic effects. METHODS: We applied the Emotional Management Training (EMT) to 30 schizophrenic patients for 12 weeks, 2 times every week and psychoeducation to 23 schizophrenic patients as control group attention-placebo for 12 weeks, during the same period. Before and after treatment, we used the Trait Meta Mood Scale-short form (TMMS-S) as emotional proper, Social Perception Scale, Verbal Fluency Test, Verbal Paired Associates, and Similarities for cognitive functions. We also used Positive And Negative Syndrome Scale (PANSS) as psychopathology measurement and Social Problem Solving Scale (SPSI) as various kinds of social problem solving function measurement before and after treatment. RESULTS: The results showed that EMT group appeared to be more effective in improving the visual perception of social perception scale, verbal fluencies, positive symptoms, general psychopathology, and total score in PANSS than the control group. Also EMT group seemed to be more effective in total score and Problem Orientation score in SPSI than the control. But there were no differences in abstract function and verbal memory, negative symptoms, and Problem-Solving Skill score between the two groups. CONCLUSION: This study suggests that despite the limitations of the generalizability and the questions for the persistence of effectiveness, EMT might help schizophrenics get the motivational aspects, the familiarity with emotional-loaded situation, and initial processes, for social problem-solving.

Development of the Social Perception Scale for Cognitive Rehabilitation in Patients with Schizophrenia / 신경정신의학

OBJECTIVES: This research was performed in order to develop the social perception scale which could detect the deficits of the social perception, composed of visual perception and contextual perception, in the patients with schizophrenia and might have the desirable reliability and discriminating power between the patients with schizophrenia and the normal controls, and so as to be appropriate to the schizophrenics' cognitive rehabilitation strategy of Brenner, et al. METHODS: We selected 10 photographs among 30 photographs which could show the variable social situations according to the consensus of the staff members of the Integrated Psychological Therapy. Then we developed the questions, composed of visual perception subscale and contextual perception subscale, which we called preliminary social perception scale. We tested the above scale to the 20 patients with schizophrenia in the chronic mental hospital. Then we tested the above scale to both the 20 patients meeting DSM-IV criteria for schizophrenia in the closed ward of the university psychiatric hospital and the 20 normal controls. We developed the final social perception scale to exclude the items of inadequate reliability. We compared the item difficulties of social perception scale between the patients in the chronic mental hospital and those in the university psychiatric hospital. finally, we compared the scores of social perception scale between the patients with schizophrenia and the normal controls. RESULTS: The final 6 items were selected to become the social perception scale according to the values of the item-total correlation, test-retest reliability, and interrater reliability. The final social perception scale showed similar rank of item difficulties between two groups with schizophrenia. The patient group differed significantly fiom the normal control group on the scores of contextual perception subscale(t=-3.09, p<.01) and the total scores of social perception scale(t= -3.33, p<.01). CONCLUSION: This study suggests that the above social perception scale which has excellent internal consistency, test-retest reliability, interrater reliability and the discriminating power. This scale can be applied to both the cognitive rehabilitation strategy in the patients with schizophrenia and the evaluation of the effectiveness of the cognitive rehabilitation.

Effects of Integrated Psychological Therapy for Schizophrenic Patients / 신경정신의학

OBJECTIVES: This study, as a preliminary one attempting to develop the Korean version of Integrated Therapy for the rehabilitation of schizophrenic patients, was designed to investigate the results of Integrated Psychological Therapy(IPT) and review the problems during the program application. METHODS: Cognitive Differentiation Scale, Problem-Solving Scale, and PANSS(Positive And Negative Syndrome Scale) were administered to schizophrenic inpatients before and after IPT incorporating cognitive differentiation, social perception, verbal communication, social skill and interpersonal problem-solving skill subprograms. The therapy groups were offered activities three times per week during the 12-week program. The control groups were attention-placebo groups for control ling factors such as group interaction and social attention, and were offered psychoeducation. RESULTS: The 12-week IPT groups, compared with the control groups, demonstrated significant improvements in the general psychopathology and the total symptoms of PANSS, but did not in cognitive functions and problem-solving skill. Significant improvements in cognitive functions were found only after cognitive differentiation subprogram and social skill subprogram had limited effects on social skills. But within 12-week IPT groups significant improvements in the positive symptoms, negative symptoms and general psychopathology were found. CONCLUSION: These findings support some effectiveness of IPT, but do not address the unique contribution by cognitive components. Applied to schizophrenic patients in this country, this modality had the problems such as differences in sociocultural and lingual background, duration of treatment, homogeneity in the level of the functioning among group members, management of emotions in activities, and the therapists' skill in the training of cognitive components. So the modification of this modality will be required.

Efficacy of Risperidone in Treatment-Resistant Patients with Chronic Schizophrenia / 대한정신약물학회지

OBJECTS: This open study was designed to investigate the efficacy and safety of risperidone in the treatment-resistant patients with chronic schizophrenia. 24 patients were entered on the 8-week open trial. A total of 3 patients discontinued risperidone treatment before the end of the study. METHODS: We investigated risperidone's efficacy and its side effects in 21 patients with treatment-resistant chronic schizophrenia, who had previously been treated with different kinds of classical antipsychotic drugs but with insufficient clinical effect or distressing extrapyramidal side effects, over a 8-week period. After 3- 7 days of placebo wash-out period, patients were assigned to receive risperidone. The overall clinical efficacy was assessed at the 1st, 2nd, 4th, and 8th week of the treatment using the PANSS and the CGI. Safety and tolerability were assessed by the ESRS, the UKU side effect rating scale, the vital signs, and the laboratory tests including CBC, urinalysis, liver function test, and ECG. RESULTS: Clinically PANSS total score and CGI severity score on the end study point showed a significant improvement compared with baseline state. Significant improvements in both PANSS positive and negative subscale scores was as early as week 1 through week 8. Nine(43%) among of the 21 patients showed at least a 20% decrease in total PANSS scores. The tolerability of risperidone was geneally found to be good. Insomnia(52%), fatigue(52%), and sedation(52%) were the most common side effects. CONCLUSION: These results suggest that risperidone may be a effective antipsychotic agent in the treatment of refractory schizophrenia. However, double-blind comparative trial between risperidone and clozapine should be performed to further clarify the efficacy of risperidone in treatment-resistant patients with chronic schizophrenia.