Clinical Utility of the Minnesota Multiphasic Personality Inventory-Adolescent Restructured Form in the Assessment of Internalizing and Externalizing Disorders in Adolescents: A Preliminary Approach

Objectives@#This study investigated whether the Minnesota Multiphasic Personality Inventory-Adolescent Restructured Form (MMPI-ARF) can differentiate between two groups of adolescents, one diagnosed with internalizing disorders and another with externalizing disorders, and examined the clinical utility of the MMPI-A-RF by examining which subscales can significantly discriminate between these two groups. @*Methods@#A total of 105 adolescents aged 13–18 years completed the MMPI-A-RF (53 internalizing disorder and 52 externalizing disorder groups). Independent t-test, chi-square test ( χ 2 ), and discriminant analysis were used to examine whether MMPI-A-RF can distinguish between the two groups. @*Results@#Sixteen MMPI-A-RF scales best predicted differences between the groups with internalizing and externalizing disorders.Fourteen scales (Higher-Order Scale [Emotional/Internalizing Dysfunction], Restructured Clinical [RC] Scale [RC demoralization, Somatic Complaints (RC1), and Low Positive Emotions (RC2)], Personality Psychopathology Five Scale [Introversion/Low Positive Emotionality-Revised, Negative Emotionality/Neuroticism-Revised], Somatic/Cognitive Scale [Malaise, Head Pain Complaints, and Gastrointestinal Complaints], Internalizing Scale [Stress/Worry, Self-Doubt], Externalizing Scale [Negative School Attitudes], Interpersonal Scale [Social Avoidance, Shyness]) were associated with the internalizing disorder group, whereas two scales (Externalizing Scale [Conduct Problems, Negative Peer Influence]) were associated with the externalizing disorder group. @*Conclusion@#The MMPI-A-RF can be an efficient assessment tool for a quick diagnosis as it can classify individuals with internalizing and externalizing disorders in clinical settings that lack a variety of assessment tools for children and adolescents.

Clinical Utility of the MMPI-A-RF’s Internalization and Externalization Higher-Order Scales: Comparison With the K-CBCL’s Internalization and Externalization Scales / 정신신체의학

Objectives@#：The purpose of this study was to examine the clinical utility of the internalization and externalization higher-order scales of the Minnesota Multiphasic Personality Inventory-Adolescent Restructured Form (MMPI-A-RF), compared with those scales of the Korean Child Behavior Checklist (K-CBCL). @*Methods@#：43 adolescents with internalizing disorders and 44 adolescents with externalizing disorders and their parents were administered the MMPI-A-RF and K-CBCL each. To verify the difference between the internalization and externalization scales of the MMPI-A-RF and K-CBCL for each group, independent-sample t test was performed. To compare the agreement between the MMPI-A-RF and K-CBCL, correlation analysis was also conducted. Lastly, to identify which scales significantly best predict each of the internalizing and externalizing disorder, logistic regression analysis was conducted. @*Results@#：Internalization scales of the MMPI-A-RF and K-CBCL were significantly higher in the internalizing disorder group, and the externalization scales were significantly higher in the externalizing disorder group. The positive correlation was significant only for internalization problems between the two evaluation measures in both groups (each r=0.360, p<0.05, r=0.572, p<0.05). In addition, the scales significantly predicted internalizing and externalizing disorders were the internalization and externalization scales of the MMPI-A-RF, followed by the externalization scale of the K-CBCL (R2 =0.407, p<0.05). @*Conclusions@#：The internalization and externalization higher-order scales of the MMPI-A-RF were found to reliably reflect the characteristics of each disorder in adolescents and be useful evaluative scales to differentiate dis-orders. Moreover, if adolescents show externalization problems, additional information from the K-CBCL can be more useful to differentiate disorders.

Psychological Characteristics of Suicide Attempters with Major Depressive Disorder using the Minnesota Multiphasic Personality Inventory-2 Restructured Form / 정신신체의학

Objectives@#：This study was conducted to investigate differences in psychological characteristics between major depressive disorder (MDD) patients with and without suicide attempt using MMPI-2-RF. @*Methods@#：Subjects were 107 MDD patients who had visited the department of psychiatry of hallym university hospital and met the DSM-IV diagnostic criteria of MDD by the korean version of MINI-Plus 5.0.0. The patients were divided into suicidal attempters (n=43) and non-suicidal attempters (n=64) using C-SSRS. The one-way ANOVA was used to compare MMPI-2-RF scale scores between two groups. Additionally, ANCOVA was conducted considering the severity of depressive symptom and comorbidity as covariate. @*Results@#：Our results showed that Suicide/Death Ideation (SUI), Inefficacy (NFC) and Interpersonal Passivity (IPP) scales were significantly higher in the MDD patients with suicidal attempt compared to MDD patients without suicidal attempt (p<0.05). However, after controlling for the severity of depressive symptom and comorbidity, SUI scale showed a significant tendency (p<0.10). @*Conclusions@#：The result suggests that MMPI-2-RF scales could be a useful tool for identifying patients transitioning to actual suicidal attempts in the moderate or severe major depressive disorder group. Limitations of this study and directions for further research are also discussed.

Serotyping and Antimicrobial Susceptibility of Salmonella Isolated in Korea in 2015 / 대한임상미생물학회지

BACKGROUND: Salmonella is an important pathogen that causes gastroenteritis and sepsis in humans. Recently, changes in serotype prevalence and an increase in antimicrobial resistance have been reported. This study investigated the distribution of Salmonella serotypes and determined the antimicrobial susceptibility of various strains. METHODS: We collected 113 Salmonella isolates other than Salmonella serotype Typhi from 18 university hospitals in 2015. The serotypes were identified by Salmonella antisera O and H according to the Kauffman White scheme. Antimicrobial susceptibility tests for 12 antibiotics were performed using the disk diffusion method or E-test. RESULTS: We identified 22 serotypes. Serotype group B (44.2%) was the most common, followed by groups C (34.5%) and D (21.2%). Salmonella I 4,[5],12:i:- (23.0%), S. Enteritidis (16.8%), and S. Typhimurium (12.4%) were the most common species. Resistance rates for ampicillin, chloramphenicol, ceftriaxone, and trimethoprim/sulfamethoxazole were 46.9%, 18.5%, 8.8%, and 5.3%, respectively. The intermediate resistance rate to ciprofloxacin was 29.2%. Six isolates were extended-spectrum β-lactamase (ESBL) producers, including 5 bla(CTX-M-15) and 1 bla(CTX-M-55). CONCLUSION: There have been changes in the serotype prevalence and antimicrobial resistance of Salmonella in Korea, with a high prevalence of CTX-M 15-positive strains. Continuous monitoring of Salmonella serotypes and antimicrobial resistance is warranted.

Antimicrobial Susceptibility and Genetic Analysis of Campylobacter jejuni Isolated from Diarrhea Patients in Busan / 대한임상미생물학회지

BACKGROUND: Campylobacter jejuni is an important food-borne pathogen that causes human gastroenteritis. This study was conducted to investigate the incidence of isolation, antimicrobial susceptibility pattern, and C. jejuni genotype from diarrhea patients in Busan, Korea. METHODS: A total of 97 C. jejuni were isolated from diarrhea patients during five food-borne outbreaks from 2014 to September 2017. Antimicrobial susceptibility tests were carried out by the broth microdilution method for ciprofloxacin (CIP), nalidixic acid (NAL), tetracycline (TET), chloramphenicol, azithromycin (AZI), erythromycin (ERY), streptomycin (STR), gentamicin, and telithromycin. To investigate C. jejuni genotypes, pulsed-field gel electrophoresis (PFGE) profile analysis was performed. RESULTS: The isolation rate of C. jejuni was 2.0% for the last 4 years and increased annually. Antimicrobial resistance rates of C. jejuni were shown to be in the order of NAL (90.9%), CIP (89.4%), TET (13.6%), AZI (3.0%), ERY (3.0%), and STR (1.5%). The proportion of multidrug-resistance was 18.2%, and they commonly contained quinolones (CIP-NAL). Analysis of PFGE patterns of SmaI-restricted DNA of C. jejuni isolates showed 17 clusters; cluster 11 was the major genotype pattern. CONCLUSION: This study will provide useful data for the proper use of antimicrobials and the management of resistant C. jejuni. Also it will help to provide data for the epidemiological investigation of foodborne diseases caused by C. jejuni, which is expected to increase in the future.

Relationship of Working Memory, Processing Speed, and Fluid Reasoning in Psychiatric Patients

OBJECTIVE: The present study aimed to investigate relationship among cognitive factors (working memory and processing speed) and fluid reasoning (Gf) in psychiatric patients using a standardized clinical tool. METHODS: We included the responses of 115 heterogeneous patients who were diagnosed with the MINI-Plus 5.0 and WAIS-IV/WMS-IV was administered. For our analysis, structured equation modeling (SEM) was conducted to evaluate which cognitive variables are closely related to the Gf. RESULTS: The results showed that the visual working memory was the strongest predictor of the Gf compared to other cognitive factors. CONCLUSION: Processing speed was capable of predicting the Gf, when visual working memory was controlled. The inter-relationship among the Gf and other cognitive factors and its clinical implications were further discussed.

Modality-Specific Working Memory Systems Verified by Clinical Working Memory Tests

OBJECTIVE: This study was to identify whether working memory (WM) can be clearly subdivided according to auditory and visual modality. To do this, we administered the most recent and universal clinical WM measures in a mixed psychiatric sample. METHODS: A total of 115 patients were diagnosed on the basis of DSM-IV diagnostic criteria and with MINI-Plus 5.0, a structured diagnostic interview. WM subtests of Korean version of Wechsler Adult Intelligence Scale-IV and Korean version of Wechsler Memory Scale-IV were administered to assess WM. Confirmatory factor analysis (CFA) was used to observe whether WM measures fit better to a one-factor or two-factor model. RESULTS: CFA results demonstrated that a two factor model fits the data better than one-factor model as expected. CONCLUSION: Our study supports a modality model of WM, or the existence of modality-specific WM systems, and thus poses a clinical significance of assessing both auditory and visual WM tests.

Does Emotional Intelligence Fluctuate within Clinical Depressive Condition?

OBJECTIVE: Emotional intelligence (EI) is regarded an important factor related to psychiatric disorder. Most of previous studies of EI and depression only dealt with EI in present of depressive symptoms. Our study investigated EI both before and after remission of depression and to identify which component of EI is changeable by depression condition. METHODS: EI was evaluated for 23 depression patients and 44 normal control participants. Adult Emotional Quotient Test (AEQT) was used as subjective EI measure and Emotional Literacy Test (ELT) was used as objective EI measure to both groups. RESULTS: During the initial evaluation of the subjective EI, patient group reported significantly lower scores than control group on all AEQT sub-domains except ‘empathy’. However, group difference on ‘utilization’ disappeared after the remission evaluation. There was no significant difference within the objective EI measure. CONCLUSION: According to the result of the study, EI could be sub-divided into trait-dependent EI and state-dependent EI. Further implication, strength and limitation were discussed.

Does Emotional Intelligence Fluctuate within Clinical Depressive Condition?

OBJECTIVE: Emotional intelligence (EI) is regarded an important factor related to psychiatric disorder. Most of previous studies of EI and depression only dealt with EI in present of depressive symptoms. Our study investigated EI both before and after remission of depression and to identify which component of EI is changeable by depression condition. METHODS: EI was evaluated for 23 depression patients and 44 normal control participants. Adult Emotional Quotient Test (AEQT) was used as subjective EI measure and Emotional Literacy Test (ELT) was used as objective EI measure to both groups. RESULTS: During the initial evaluation of the subjective EI, patient group reported significantly lower scores than control group on all AEQT sub-domains except ‘empathy’. However, group difference on ‘utilization’ disappeared after the remission evaluation. There was no significant difference within the objective EI measure. CONCLUSION: According to the result of the study, EI could be sub-divided into trait-dependent EI and state-dependent EI. Further implication, strength and limitation were discussed.

The Effect of Stress and Depression on Unmet Medical Needs

BACKGROUND: Mental health issues such as stress and depression have been regarded as major social problems in Korea. We investigated the relationship between stress and depression with unmet medical needs (UMN). METHODS: Using the nationwide database of 2010 Korea National Health and Nutritional Examination Survey (K-NHANES), subjects aged 19 years or above were selected (n=6,055). In the K-NHANES questionnaire, subjects were asked about their UMN experience, severity of stress, and perceived depression lasting at least 2 weeks over the past year. The effects of stress and depression on UMN were analyzed in 4 models established by adding predisposing, enabling and need factors in a step-wise fashion. The risks for UMN were also assessed according to the causes of UMN. RESULTS: Individuals who felt stress ‘very often’ (odds ratio (OR) 3.28, 95% CI=2.23-4.86) and ‘often’ (OR 2.53, 95% CI=1.93-3.31) and who experienced depression (OR 1.68, 95% CI=1.35-2.10) reported significantly elevated UMN rates, and these effects were substantial especially for the individuals who had UMN due to economic constraint. Females, lower education level, lower income, unemployed status, and negative perceptions about health status were found to be additional risk factors for UMN. CONCLUSION: Our results confirmed the risks of stress and depression on UMN. It is strongly advisable to create initiatives to improve mental health, particularly stress and depression, and to fulfill individuals' medical utilization needs.

Development of the Computerized Mathematics Test in Korean Children and Adolescents

OBJECTIVES: This study was conducted in order to develop a computerized test to measure the level of mathematic achievement and related cognitive functions in children and adolescents in South Korea. METHODS: The computerized Comprehensive Learning Test-Mathematic (CLT-M) consists of the whole number computation test, enumeration of dot group test, number line estimation test, numeral comparing test (magnitude/distance), rapid automatized naming test, digit span test, and working memory test. To obtain the necessary data and to investigate the reliability and validity of this test, 399 children and adolescents from kindergarten to middle school were recruited. RESULTS: The internal consistency reliability of the CLT-M was high (Cronbach's alpha=0.76). Four factors explained 66.4% of the cumulative variances. In addition, the data for all of the CLT-M subtests were obtained. CONCLUSION: The computerized CLT-M can be used as a reliable and valid tool to evaluate the level of mathematical achievement and associated cognitive functions in Korean children and adolescents. This test can also be helpful to detect mathematical learning disabilities, including specific learning disorder with impairment in mathematics, in Korea.

Distribution of Rhizosphere and Endosphere Fungi on the First-Class Endangered Plant Cypripedium japonicum

Endangered native plant habitats and populations are rapidly disappearing because of climate and environmental changes. As a representative, the abundance of the first-class endangered wild plant, Cypripedium japonicum, has been rapidly decreasing in Korea. The purpose of this study was to evaluate the distribution of rhizosphere and endophytic fungi on C. japonicum in its native habitat. A total of 440 rhizosphere and 79 endosphere fungi isolates were isolated and identified on the basis of their molecular characteristics. Sixty-five genera and 119 fungi species were identified in this study. The genus Trichoderma showed the highest abundance among both rhizosphere and endosphere fungi. Mortierella, Hypocrea, and Penicillium spp. were also relatively dominant species on C. japonicum. The community structures of rhizosphere and endosphere fungi were similar, but endosphere fungi showed greater diversity.

Clinical Characteristics of Psychiatric Patients with Military Issues Using MMPI-2-RF / 정신신체의학

OBJECTIVES: The purpose of this study was to examine psychological characteristics of patients who visited psychiatric clinic for medical certificate for military service using MMPI-2-RF. We compared target group with general psychiatric patients with same age range. METHODS: A total of 165 male patients for medical certificate and 154 general psychiatric patients were collected from the Department of Psychiatry of three university hospitals. There were significant differences of age and educational level between two groups. We used independent t-test, ANCOVA, χ² test to examine differences between two groups. RESULTS: Medical certificate group scored higher on the validity scales, the Higher-Order(H-O) scales, the Restructured Clinical(RC) Scales, the Specific Problems(SP) Scales, and the Personality Psychopathology Five (PSY-5) Scales. Especially, EID, RC7, HLP, SFD, SAV, SHY, DSF, and INTR-r showed significant differences between two groups on all three statistical tests. CONCLUSIONS: The present study showed that psychiatric patients who received psychological evaluation for military service have significantly higher emotional distress, helplessness, lower self-confidence, and lower quality of interpersonal relationships. And the difference of validity scales between two groups could be related with psychological burden of compulsory military service in the study sample which causes elevation on scales of infrequent responses. MMPI-2-RF would be helpful instrument to assess these emotional and psychological characteristics.

Standardization of the Comprehensive Learning Test-Reading for the Diagnosis of Dyslexia in Korean Children and Adolescents

OBJECTIVES: The aim of this study was to develop the computerized Comprehensive Learning Test-Reading (CLT-R) to evaluate the cognitive processes and achievements related to their basic reading ability and identify dyslexia in children and adolescents in South Korea. We also obtained the normative data and evaluated the reliability and validity of the test. METHODS: We developed the CLT-R, including the word attack/nonword decoding, paragraph reading, sound blending, nonword repetition, rapid automatized naming, letter-sound matching, visual attention, orthography awareness, and digit span tests, for the purpose of diagnosing dyslexia. We investigated the reliability and validity of the tests and gathered the normative data from 399 subjects (male 48.9%), aged 5-14 years, from the last grade in kindergarten to middle school, dwelling in Seoul and Gyeonggi Province, South Korea. RESULTS: No statistical differences were observed between the means of the tests and retests of the CAT. The mean of the correlation coefficient of the test-retest scores was 0.85. According to the construct validity test calculated by principal constant analysis using the oblique rotation method, 4 factors explained 70.0% of the cumulative variances. In addition, the normative data were obtained for all of the CLT-R subtests. CONCLUSION: The computerized CLT-R can be used as a reliable and valid tool to evaluate the reading achievement and reading related cognitive process in Korean children and adolescents in schools, clinics, and research institutes.

Impact of Depression and Emotional Intelligence on Suicidal Ideation of Patients with Major Depressive Disorder / 대한정신약물학회지

OBJECTIVE: There is much research on risk factors of suicide, but studies about what can play a protective role on suicide are limited. This study was conducted to investigate the impact of depression and emotional intelligence on suicidal ideation of patients with depression. We focused more on the role of emotional intelligence as a protective factor. METHODS: The participants (n=100) underwent a psychiatric interview which included the Mini International Neuropsychiatric Interview and the Columbia University Suicide Severity Rating Scale (C-SSRS). Beck's Depression Inventory (BDI) was also completed. For measuring emotional intelligence, both a self-report questionnaire (the Adult Emotional Quotient Test, AEQT) and an objective measurement based on ability model (Emotional Literacy) were conducted. RESULTS: In linear regression analysis, depressive symptom score was significantly associated with suicidal ideation. It was also shown that 'emotional expression' of AEQT and 'emotion perception' of Emotional Literacy are significantly associated with suicidal ideation. CONCLUSION: Against our expectation that emotional intelligence would be a protective factor on suicidal ideation, emotional expression and emotion perception might rather be a risk factor for suicidal ideation. The limitations of this study and suggestions for further research are also discussed.

The Relationship between Low Self-Esteem and Suicide Attempt in Patients with Major Depressive Disorder: A Pilot Study / 대한정신약물학회지

OBJECTIVE: Depression is a major risk factor for suicide, and several psychological factors such as low self-esteem are involved in suicide. The aim of this study was to investigate the difference in self-esteem between non suicide attempters and suicide attempters with major depressive disorder. METHODS: The study subjects consisted of 52 patients who received inpatient or outpatient treatments at the Hallym University Sacred Heart Hospital. All participants were diagnosed as major depressive disorder by Korean version of the Mini-International Neuropsychiatric Interview. Columbia Suicide Severity Rating Scale (C-SSRS) was used to evaluate patient's suicide attempt. They completed a questionnaire that included Rosenberg Self-Esteem Scale, Beck Depression Inventory (BDI) and Beck Scale for Suicide Ideation (BSI). RESULTS: A total of 52 subjects were evaluated by C-SSRS, and among them, 32 were non suicide attempters and 20 were suicide attempters. Compared to non suicide attempters, suicide attempters showed significantly lower levels of self-esteem (t=3.492, p=0.001) and higher levels of BSI (t=-4.890, p<0.001). Although there was no significant difference between two groups for severity of overall depressive symptoms, negative attitude subscale of BDI was higher in suicide attempters than non suicide attempters (t=-2.596, p=0.014). A stepwise multivariate logistic regression analysis showed that low self-esteem was significant association with suicide attempt after adjusted by negative attitude subscale of BDI and BSI (odds ratio=0.779, p=0.042). CONCLUSION: The present study indicated that low self-esteem plays a significant role in suicide attempters with major depressive disorder. Assessment of suicide risk should include not only suicide ideation and severity of overall depressive symptoms but also low self-esteem.

Pancreatic adenocarcinoma up-regulated factor (PAUF) enhances the expression of beta-catenin, leading to a rapid proliferation of pancreatic cells

It is not yet understood how the enhanced expression of pancreatic adenocarcinoma up-regulated factor (PAUF; a novel oncogene identified in our recent studies), contributes to the oncogenesis of pancreatic cells. We herein report that PAUF up-regulates the expression and transcriptional activity of beta-catenin while the suppression of PAUF by shRNA down-regulates beta-catenin. The induction of beta-catenin by PAUF is mediated by the activities of Akt and GSK-3beta, but inhibition of downstream ERK does not reduce beta-catenin expression. To test whether PAUF emulates either the Wnt3a-mediated or the protein kinase A-mediated signaling pathway for the stabilization of beta-catenin, we examined the phosphorylation status of beta-catenin in the presence of PAUF compared with that of beta-catenin during treatment with Wnt3a or dibutyryl cAMP, a cell permeable cyclic AMP analogue. PAUF expression induces phosphorylation at Ser-33/37/Thr-41 and Ser-675 of beta-catenin but no phosphorylation at Ser-45, indicating that a unique phosphorylation pattern of beta-catenin is caused by PAUF. Finally, the expression of PAUF up-regulates both cyclin-D1 and c-Jun, target genes of beta-catenin, leading to a rapid proliferation of pancreatic cells; conversely decreased PAUF expression (by shRNA) results in the reduced proliferation of pancreatic cells. Treatment with hexachlorophene (an inhibitor of beta-catenin) reduces the proliferation of pancreatic cells despite the presence of PAUF. Taken together, we propose that PAUF can up-regulate and stabilize beta-catenin via a novel pattern of phosphorylation, thereby contributing to the rapid proliferation of pancreatic cancer cells.

Development and Effects of an e-Learning Program in Operating Room Nursing for Nursing Students

PURPOSE: This study was conducted to develop an e-Learning program that assists nursing students' clinical practice in operating room nursing and to examine the learning effects. METHODS: Based on content and need analysis, 9 learning modules were developed for nursing care in operating rooms and with operating equipment. To verify the effects of the program, a quasi-experimental pretest-posttest control group design was employed. The participants in this study were 74 third-year nursing students (34 in the experimental and 40 in the control group) from a junior college in G-city, Korea, who were engaged in a one week clinical practicum in an operating unit. Frequencies, chi2-test and t-test with the SPSS program 17.0 were used to analyze the data. RESULTS: Knowledge was significantly higher in the experimental group compared to the control group (p=.018). However, there was no significant difference between the two groups in self-directed learning. The experimental group had significantly higher motivation toward learning, which was examined posttest only (p=.027). CONCLUSION: These results indicate that the implementation of an e-Learning program needs to be continued as an effective educational tool, but more research on the best way to implement e-Learning in students' practicum is needed.

A Case of Supernumerary Tooth within Fungus Ball in the Maxillary Sinus / 대한이비인후과학회지

The ectopic eruption of a supernumerary tooth can occur in the sinonasal area, but due to its rarity, few cases of ectopic tooth eruption in the maxillary sinus have been reported. A fungus ball in the paranasal sinuses usually involves just one sinus, most frequently the maxillary sinus. Here, the authors present a case of an ectopic supernumerary tooth embedded in a fungus ball of the maxillary sinus.

Standardization of the Comprehensive Attention Test for the Korean Children and Adolescents

OBJECTIVES: This study was conducted in order to develop and obtain the normative data of the computerized Comprehensive Attention Test (CAT) in Korean children and adolescents. It also aimed to evaluate the reliability and validity of the CAT. METHODS: We developed the computerized CAT which includes the selective attention task, the sustained attention to response task, the flanker task, the divided attention task, and the spatial working memory task. We investigated the testretest reliability and the construction validity of this computerized version by using the data from 21 children, and gathered the normative data of 912 subjects, aged 4 to 15 years, dwelling in the Metropolitan Seoul area in 2008. RESULTS: No statistical differences between means of the tests and retests of the CAT were observed. The mean of the correlation coefficient of the test-retest scores was 0.715. The results from the factor analyses explained 51.7% of the cumulative variance. In addition, the normative data for all of the CAT subtests were obtained. CONCLUSION: The computerized CAT can be used as a reliable and valid tool in both clinical and research settings for Korean children and adolescents with or without neuropsychiatric conditions such as attention deficit.