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Severe burn injuries have profound mental health impacts on individuals, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Many burn survivors also report positive psychosocial changes, termed posttraumatic growth (PTG). This study investigated long-term mental health of severe burn injury (i.e., PTSD, MDD, and PTG) and the longitudinal influences of coping strategies and social support.Ninety-nine adult burn survivors of the 2015 Formosa Fun Coast Water Park fire disaster participated in the 5-year follow-up (Wave 3, W3), with 93% completing the earlier 2- (Wave 1, W1) and 3-year follow-up (Wave 2, W2). Participants averaged 22.1 years of age at burn, and 62.6% were females. The mean total body surface area burned (TBSA) was 50.3%, with a mean length of hospital stay of 87.6 days.Five years after the 2015 fire disaster, 13.1%, and 14.1% of the survivors met probable DSM-5 PTSD and MDD, while 51.5% reported significant PTG. After controlling for demographic, burn-specific, and baseline outcome variables, avoidance coping at W2 prospectively predicted PTSD and depressive symptoms at W3 (p = .003 and 0.04), with medium-to-large and medium effect sizes (srRates of probable PTSD and MDD were still relatively high in long-term burn survivors. However, PTG continued to be highly prevalent. Our findings highlight the importance of coping in affecting the long-term mental health of severe burn injury.

PurposeThis study develops a universal game-based blended museum learning service (UGBMLS) to engage museum visitors of different ages and promote their return visits. This study aims to provide a single service with flexible learning content matching the diverse needs and preferences for different ages. The contextual influences are considered to promote participatory experiences and meaningful social interactions. An experiment is conducted herein to understand how visitors of different ages experience the museum's services as well as to address the design issues in aiming to satisfy the different age groups' needs.Design/methodology/approachA UGBMLS, which includes a real-world adventure game system with flexible learning content and various types of learning support, was provided for different age groups. To investigate how the visitors of different ages evaluate their experiences with the UGBMLS, a mixed-method study was conducted. In total, two questionnaires were employed to examine the visitors' museum experiences and subjective measurements of cognitive load. In addition, observation and group interviews were used to explain the quantitative results.FindingsThe results show that the UGBMLS can engage diverse visitors of different ages in museum visits and promote their revisit motivations. However, there are significant differences among different age groups. The design issues in seeking to satisfy the diverse needs of different age groups are noted.Practical implicationsThis study provides a feasible and cost-effective approach to support diverse visitors of different ages learning in museums.Originality/valueThis study provides an effective solution for engaging diverse visitors of different ages with a unified service. The results can be used to better understand the needs of different age groups and to effectively improve their museum experiences, thereby boosting their motivation regarding return visits. This study provides a feasible and cost-effective approach to support diverse visitors' learning in museums.

Little research has examined burn injury in the pediatric population with autism spectrum disorder (ASD). We used data from Taiwan’s National Health Insurance Research Database to identify 15,844 participants aged

Objective: This study examined preschoolers with teacher-reported or parent-reported situational hyperactivity, and whether they differed in terms of behavioral problems, attentional problems, and parenting perceptions. Method: We used the Conners’ Kiddie Continuous Performance Test and the Color Flanker Task to assess 99 preschoolers with pervasive high-ADHD-symptoms (42), school-situational high-ADHD-symptoms (30), or home-situational high-ADHD-symptoms (27), plus 111 preschoolers with pervasive low-ADHD-symptoms. Parents and teachers reported externalizing/internalizing behavioral problems. Parenting perceptions were measured with the Parenting Stress Index-Short Form and a parenting perceptions scale. Results: Preschoolers with school-situational high-ADHD-symptoms had deficits in attentional control. Parents of preschoolers with home-situational high-ADHD-symptoms had higher levels of parental stress and perceived their parenting to be harsher. Preschoolers with pervasive high-ADHD-symptoms had deficits in attentional control, increased parental stress, and parents with harsher parenting perceptions. Conclusion: Preschoolers with situational high-ADHD-symptoms may have different contextual risk factors related to ADHD symptoms reported by parents versus teachers.

Purpose: Investigate the quality of mothers’ interactions with children with ADHD and a marginal disturbance in socioemotional competence (MDSC). Research Methods: A total of 49 mother-boy dyads were included, and we observed their communication on neutral and conflict topics for children with ADHD and MDSC, children with ADHD alone, and children with typical development (TD). The Chinese version of the Specific Affect Coding System 20-code was used to examine the affective presentation in communication. Results: Mothers of children with ADHD and MDSC had less negative disengagement affect compared with those of children with ADHD alone. Boys with ADHD and MDSC and boys with TD had constant positive engagement between neutral and conflict conditions in parent-child interaction. Boys with ADHD and MDSC had significantly less positive affect and more neutral affect than children with ADHD only. Conclusions and Implications: Boys with ADHD and MDSC and their mothers had worse quality of observed mother-child communication than children with ADHD only and their mothers.

School bullying and cyberbullying victimization and perpetration are prevalent in adolescents with autism spectrum disorder (AASD). However, the levels of adolescent–caregiver agreement regarding the bullying involvement of AASD and the factors associated with these levels remain to be evaluated. In the present study, we evaluated the levels of adolescent–caregiver agreement on the school bullying and cyberbullying involvement experiences of AASD and the factors associated with the levels of agreement. This study included 219 dyads of AASD and their caregivers. The school bullying and cyberbullying involvement experiences of the participating AASD were assessed using the School Bullying Experience Questionnaire and the Cyberbullying Experiences Questionnaire, respectively. Attention-deficit/hyperactivity disorder, oppositional defiant disorder (ODD), depressive and anxiety symptoms, and autistic social impairment were also assessed. AASD and their caregivers had poor to fair levels of agreement regarding the school bullying and cyberbullying victimization and perpetration experiences of AASD. Severe inattention, hyperactivity–impulsivity, ODD, depressive and anxiety symptoms, and autistic social impairment were associated with high levels of adolescent–caregiver agreement. When assessing the bullying involvement experiences of AASD, mental health professionals should obtain information from multiple sources. In addition, the factors influencing the levels of agreement should be considered.

Behavioral flexibility (or set-shifting), which is regulated by the prefrontal cortex (PFC), is often impaired in patients with attention-deficit/hyperactivity disorder (ADHD), which is characterized by poor inhibitory control and reinforcement learning. Transcranial direct current stimulation (tDCS) has been proposed as a means of noninvasive brain stimulation and a potential therapeutic tool for modulating behavioral flexibility. Animal studies can pave the way to know if tDCS application can potentially benefit rule- and goal-based activities in ADHD. Spontaneously hypertensive rats (SHRs) and inbred Wistar-Kyoto (WKY) rats were used as an animal model of ADHD and controls, respectively, and their strategy set-shifting abilities, including initial discrimination, set-shifting, and reversal learning tasks under 0-s or 15-s reinforcer delivery delay conditions, were evaluated. The tDCS treatment had a limited effect on the performance of the SHRs and WKY rats in initial discrimination task under 0-s delay condition. Under the 15-s delay condition, the SHRs had longer lever-press reaction times and/or more trial omissions than the WKY rats did when completing set-shifting and reversal-learning tasks. Among the SHRs, tDCS treatment improved the rats' reaction times and/or reduced their trial omissions in the set-shifting and reversal-learning tasks. Although tDCS may improve delayed reinforcement learning set-shifting performance in SHRs, further studies are required to clarify the responsible mechanism.

Background The Devereux Early Childhood Assessment for Toddlers (DECA-T), which is one of the few standardized, norm-referenced behavioral rating scales related to young children's mental health, resilience, and social-emotional development, was developed for toddlers aged between 18 and 36 months. Objective The aim of this study was to test the clinimetric properties of the Chinese (Traditional) version of the DECA-T (C-DECA-T) using a classical test theory analysis and an item response theory analysis. Methods Seventy-five community-based toddlers aged from 18 to 36 months and 50 clinic-based participants recruited in hospitals in northern Taiwan participated in this study. Social-emotional competence was assessed by the C-DECA-T and children's behavior problems were rated via the Child Behavior Checklist 1.5 to 5 (CBCL/1.5-5). Homogeneity of the C-DECA-T was assessed by Mokken analysis; sensitivity and specificity were assessed via receiver operating characteristic curve. Results The results showed the C-DECA-T demonstrated good test-retest reliability (r=0.8) and high internal consistency (Cronbach's alpha = 0.94). Inter-rater reliability between father and mother was fair (ICC = 0.46). Convergent validity of the CBCL/1.5-5 total behavior problems (r=-0.26) demonstrated acceptable psychometric performance. The overall measure of the sampling adequacy of the C-DECA-T assessed by principal component analysis was 0.93. Mokken scale analysis showed the 36-items of the C- DECA-T formed a weak unidimensional scale (Hs =0.35), supporting its construct validity. The area under curve of the C-DECA-T in prediction of social-emotional disturbance was 0.70. The optimal cutoff of the Total Protective Factor score of the C-DECA-T was a T score of 40.1 (T40.1), with a sensitivity of 95% and a specificity of 68%. Item 2 ("show affection for a familiar adult") and item 33 ("calm herself/himself") provide a good amount of information for the assessment of social-emotional strength and needs of a toddler in clinical practice. Conclusion The C-DECA-T showed good psychometric properties. Our findings of high internal consistency of the three subscales and total score of the C-DECA-T suggest symptom manifestation of social-emotional competence and needs in Taiwanese toddlers is not culturally different from American toddlers. The clinimetric properties of the C-DECA-T examined by a classical test theory analysis approach and an item response theory analysis approach suggest that the C-DECA-T is a reliable and valid instrument for measuring social-emotional strength and needs in the population in Taiwan.

Objective The association between antipsychotic use and gastric cancer risk remains unclear. Therefore, this study aimed to determine the association between antipsychotic exposure and the incidence of gastric cancer. Methods Using a nested case‐control design, a total of 34 470 gastric cancer patients and 163 430 nongastric cancer controls were identified from Taiwan's National Health Insurance Research Database between 1 January 1997 and 31 December 2013. We analyzed the data using a conditional logistic regression model to adjust for possible confounding variables. Results Antipsychotic use was independently inversely associated with gastric cancer risk after controlling for potential confounding factors including income, urbanization, medications, physical and medical illness, aspirin use, nonsteroidal anti‐inflammatory drug use and triple therapy. In addition, dose‐dependent trends against gastric cancer risk were also shown with individual antipsychotic compounds including thioridazine, haloperidol, sulpiride, clozapine, olanzapine, quetiapine, amisulpride, and risperidone. A sensitivity analysis showed that second‐generation antipsychotics had significant dose‐dependent effects in reducing the risk of gastric cancer risk in patients with and without peptic ulcer disease. Conclusions Antipsychotic use was inversely associated with gastric cancer risk, and dose‐dependent effects against gastric cancer were also seen with several individual antipsychotic compounds.

Background Studies have reported an association between allergy and panic disorder. However, few studies have explored the relationship between allergic rhinitis and panic disorder. Previous studies were limited by cross-sectional study designs, self-reported symptoms, absence of matched controls, and lack of consideration of the influence of steroid and comorbidities. This study aimed to explore the longitudinal association between allergic rhinitis and panic disorder in a large population-based cohort of young people. Methods In this study, 79,917 new cases of allergic rhinitis between 1998 and 2012 in individuals younger than 20 years were identified from Taiwan's National Health Insurance Research Database. One control (nonallergic rhinitis) per case (allergic rhinitis) was randomly selected from the remaining sample, matching for age, sex, residence, and insurance premium. Both groups were followed until the end of 2013 for incidence of panic disorder. Cox regression analysis was performed, adjusting for sex, age, residence, insurance premium, systemic steroids, asthma, atopic dermatitis, allergic conjunctivitis, attention deficit hyperactivity disorder, depression, and Charlson index. Results Allergic rhinitis was associated with a 2-fold increase in risk for panic disorder after adjustment for other variables. Additional independent risk factor of panic disorders were female sex, older age group, and depression. Limitations Lifestyle, substance use, smoking by the patient or family members, and psychosocial stressors were not evaluated. Conclusions Allergic rhinitis was associated with increased risk of panic disorder. Assessment and intervention of allergy rhinitis among young people with panic disorder are critical.

The pathophysiology of attention deficient hyperactivity disorder (ADHD) is still obscure. Some studies have discussed that magnesium levels are lower in the serum and erythrocytes of children with ADHD. However, these findings are controversial. The aim of our study is to identify whether magnesium levels are in fact lower in children with ADHD. We conducted a thorough search of the literature and examined the connection between magnesium insufficiency and ADHD. A total of twelve studies were included into the current meta-analysis. The results of our meta-analysis found that peripheral blood magnesium levels, either in plasma, serum, or whole blood, of children diagnosed with ADHD were significantly lower than those in controls (k = 8, Hedges' g = -0.547, 95% CI = -0.818 to -0.276, p .001). The subgroup meta-analysis with serum sample sources also suggested that peripheral serum magnesium levels of children diagnosed with ADHD were significantly lower than those in controls (k = 6, Hedges' g = -0.733, 95% CI = -0.911 to -0.555, p .001). The subgroup meta-analysis focusing on subjects with ADHD diagnosed by definite diagnostic criteria also suggested significantly lower peripheral serum magnesium levels in ADHD children than those in controls (k = 4, Hedges' g = -0.780, 95% CI = -0.985 to -0.574, p .001). We also noted that magnesium levels in the hair of children diagnosed with ADHD were significantly lower than those in controls (k = 4, Hedges' g = -0.713, 95% CI = -1.359 to -0.067, p = .031). In this meta-analysis, we found that children diagnosed with ADHD have lower serum and hair magnesium levels than children without ADHD. Further study may be needed to investigate the behavioral influence on ADHD due to lower magnesium levels, the association between brain and serum magnesium levels, and the effects brought about by larger longitudinal cohort studies.

This study examined the prevalence and related factors of multiple (two or three) types of harassment victimization, including school bullying, cyberbullying, and teacher harassment, and their cumulative effects on depression, anxiety, self-esteem, and suicidality in adolescents with autism spectrum disorder (ASD) but without intellectual disability.A total of 219 adolescents with ASD but without intellectual disability and their parents participated in this study. Their experiences of school bullying, cyberbullying, and teacher harassment were evaluated. The related factors of multiple types of harassment victimization, including demographic characteristics, socio-communicative skills, comorbid attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) symptoms, were examined. Moreover, the effects of multiple types of harassment victimization on depression, anxiety, self-esteem, and suicidality were examined.In total, 20.54% of participants were victims of multiple types of harassment. Hyperactivity or impulsivity and ODD symptoms were positively associated with multiple types of harassment victimization. Adolescents with ASD who experienced multiple types of harassment victimization had higher severities of depression and anxiety and were more likely to have suicidality than nonvictims and those who experienced only one type of harassment victimization.Experiencing more than one type of harassment victimization was significantly associated with the development of mental health problems in adolescents with ASD. ODD and hyperactivity/impulsivity symptoms predicted the risk of experiencing multiple types of harassment.

The posterior superior temporal sulcus is a potential therapeutic target of brain stimulation for autism spectrum disorder. We conducted a 4-week randomized, single-blind parallel sham-controlled trial, followed by additional 4-week open-label intervention to evaluate the feasibility and efficacy regarding intermittent theta burst stimulation over the bilateral posterior superior temporal sulcus in autism spectrum disorder. In total, 78 intellectually able children and adolescents were randomized to the active ( n = 40) and sham groups ( n = 38). During the first 4 weeks, the active group received two-session/week intermittent theta burst stimulation, whereas the sham group received the same number of sham stimulation. After unblinding, both groups received eight-session real stimulation over the additional 4 weeks. In total, 91% participants completed the protocol with mild and transitory side-effects. There was no significant group-by-time interaction for active versus sham group on clinical symptoms and social cognitive performances in the first 4 weeks. The within-group analysis revealed 8 weeks (including a 4-week blind trial and a 4-week open-label intervention) of intermittent theta burst stimulation achieved greater efficacy than 4-week interventions. Participants with higher intelligence, better social cognitive performances, alongside less attention-deficit hyperactivity disorder severity at baseline, were more likely to be responders. Our study demonstrated the feasibility of long-term intermittent theta burst stimulation over the posterior superior temporal sulcus in children and adolescents with autism spectrum disorder. However, the findings from the first 4-week blind trial do not support the therapeutic efficacy of intermittent theta burst stimulation over the posterior superior temporal sulcus on the clinical symptoms and cognitive performance of social impairment, given the current stimulation protocol. The exploratory analyses suggest that the therapeutic efficacy might be moderated by several individual characteristics and more intermittent theta burst stimulation sessions. Lay abstract Intermittent theta burst stimulation is a varied form of repetitive transcranial magnetic non-invasive brain stimulation technique used to treat several neurological and psychiatric disorders. Its feasibility and therapeutic effects on the bilateral posterior superior temporal sulcus in children with autism are unknown. We conducted a single-blind, sham-controlled parallel randomized clinical trial in a hitherto largest sample of intellectually able children with autism ( N = 78). Participants randomized to the active group received two-session/week intermittent theta burst stimulation for continuous 8 weeks. Those in the sham group received two-session/week sham stimulations in the first 4 weeks and then active intervention for the following 4 weeks after unblinding. First, we found that continuous 8-week intermittent theta burst stimulation on the bilateral posterior superior temporal sulcus in children with autism is safe and tolerable. Second, we found that 8-week intermittent theta burst stimulation produced greater therapeutic efficacy, although we did not find any significant effects of 4-week intermittent theta burst stimulation on core symptoms and social cognitive performances in autism. Further analysis revealed that participants with higher intelligence and better social cognitive performance, alongside less attention-deficit hyperactivity disorder severity at baseline, were more likely to be responders. This study identified that the factors contribute to responders and the results suggest that longer courses of non-invasive brain stimulation may be needed to produce therapeutic benefits in autism, with consideration of heterogeneous responses.

Little research has examined burn injury in the pediatric population with autism spectrum disorder (ASD). We used data from Taiwan's National Health Insurance Research Database to identify 15,844 participants aged18 years with ASD and 130,860 participants without ASD. Our results revealed that the hazard ratios differed across three age ranges. The ASD group had a lower risk of burn injury than the non-ASD group when they were less than 6 years of age, a higher risk from 6 years to 12 years of age, and no difference when they were older than 12 years of age. More research is required to study the characteristics and causes of burn injury in the pediatric population with ASD.

A growing body of literature examining the neurocognitive processes of interpersonal linguistic interaction indicates the emergence of neural alignment as participants engage in oral communication. However, questions have arisen whether the study results can be interpreted beyond observations of cortical functionality and extended to the mutual understanding between communicators. This review presents evidence from electroencephalography (EEG) and functional near-infrared spectroscopy (fNIRS) hyperscanning studies of interbrain synchrony (IBS) in which participants communicated via spoken language. The studies are classified into: knowledge sharing; turn-taking speech co-ordination; cooperation, problem-solving and creativity; and naturalistic discussion paradigms according to the type of interaction specified in each study. Alignment predominantly occurred in the frontal and temporo-parietal areas, which may reflect activation of the mirror and mentalizing systems. We argue that the literature presents a significant contribution to advancing our understanding of IBS and mutual understanding between communicators. We end with suggestions for future research, including analytical approaches and experimental conditions and hypothesize that brain-inspired neural networks are promising techniques for better understanding of IBS through hyperscanning.

Reaction times (RTs) are typically slower and more variable in individuals with attention-deficit/hyperactivity disorder (ADHD). Analysis of the ex-Gaussian RT distribution, which is described by mu, sigma (mean and standard deviation, respectively, of the normal distribution) and tau (that of exponential distribution), reveals that individuals with ADHD do not display overall slower RTs but have a high proportion of extremely slow RTs, represented by a high tau value. Although this is a vital component for describing ADHD-related RT variability in school-aged children, adolescents, and adults, it has not been thoroughly studied at the preschool age. We assessed 65 preschoolers at risk of ADHD and 98 typically developing preschoolers with the Conners' Kiddie Continuous Performance Test (K-CPT) and parental and teacher reports of ADHD symptoms. We found that preschoolers at risk of ADHD had greater values for RT standard deviation, sigma, and tau than typically developing preschoolers at long inter-stimulus intervals (ISIs) (3 s), but not at short ISIs (1.5 s). This suggests that attention problems in preschool children may only be apparent in the tasks with a relatively slow event rate. Our study demonstrates that the ex-Gaussian tau value is essential for describing the inattentive component of task performance in preschoolers with heightened ADHD symptoms. Furthermore, the fact that the tau effect was modulated by ISI suggests that the longer duration (3 s vs. 1.5 s) is a non-optimal energetic state in preschoolers at risk of ADHD, and that this might account for the subtle attentional flaw in task performance.

Single-brain neuroimaging studies have shown that human cooperation is associated with neural activity in frontal and temporoparietal regions. However, it remains unclear whether single-brain studies are informative about cooperation in real life, where people interact dynamically. Such dynamic interactions have become the focus of interbrain studies. An advantageous technique in this regard is functional near-infrared spectroscopy (fNIRS) because it is less susceptible to movement artifacts than more conventional techniques like electroencephalography (EEG) or functional magnetic resonance imaging (fMRI). We conducted a systematic review and the first quantitative meta-analysis of fNIRS hyperscanning of cooperation, based on thirteen studies with 890 human participants. Overall, the meta-analysis revealed evidence of statistically significant interbrain synchrony while people were cooperating, with large overall effect sizes in both frontal and temporoparietal areas. All thirteen studies observed significant interbrain synchrony in the prefrontal cortex (PFC), suggesting that this region is particularly relevant for cooperative behavior. The consistency in these findings is unlikely to be because of task-related activations, given that the relevant studies used diverse cooperation tasks. Together, the present findings support the importance of interbrain synchronization of frontal and temporoparietal regions in interpersonal cooperation. Moreover, the present article highlights the usefulness of meta-analyses as a tool for discerning patterns in interbrain dynamics.

Chiao-Fan Lin,1,2,* Hsiang-Lin Chan,1,2 Yi-Hsuan Hsieh,1,2 Hsin-Yi Liang,1,2 Wei-Che Chiu,3,4,* Yena Lee,5 Roger S McIntyre,5,6 Vincent Chin-Hung Chen2,7,81Department of Child Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; 2Department of Psychiatry, Chang Gung University, Taoyuan, Taiwan; 3Department of Psychiatry, Cathay General Hospital, Taipei, Taiwan; 4School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan; 5Mood Disorders Psychopharmacology Unit, Brain and Cognition Discovery Foundation, Toronto, Ontario, Canada; 6Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; 7Medical Research Department, Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan; 8Department of Psychiatry, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan*These authors contributed equally to this work Background: The association between antidepressant exposure and nasopharyngeal cancer (NPC) has not been previously explored. The purpose of this study was to investigate the association between antidepressant prescription, including novel antidepressants, and the risk of NPC in a population-based study.Materials and methods: Data for the analysis were derived from National Health Insurance Research Database. We identified 16,957 cases with a diagnosis of NPC and 83,231 matched controls by using a nested case–control design. A conditional logistic regression model was used, with adjustments for potentially confounding variables (eg, comorbid physical diseases, comorbid psychiatric diseases, and other medications).Results: We report no association between NPC incidence and antidepressant prescription. For all classes of antidepressants, antidepressant exposure, regardless of cumulative dose, had no significant effect on NPC incidence (adjusted odds ratio of cumulative selective serotonin reuptake inhibitor exposure ≥336 defined daily dose was 1.18 [95% CI: 0.90–1.53]; tricyclic antidepressant exposure ≥336 defined daily dose was 1.18 [95% CI: 0.80–1.74]).Conclusion: There was no association between antidepressant prescription and incident NPC.Keywords: nasopharyngeal cancer, antidepressants, Taiwan national insurance

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder, and nutritional deficiency may play a role in the development of ASD. A relationship between ASD and iron levels/iron deficiency (ID) has been reported; however, the results have been inconsistent. Therefore, we conducted this meta-analysis to examine the relationship between ASD and ID following the Meta-Analysis of Observational Studies in Epidemiology guidelines. We performed a systematic search of PubMed, ScienceDirect, Embase, ProQuest, ClinicalTrials.gov, and Cochrane CENTRAL databases up to September 22, 2017. Studies providing data on peripheral iron levels and/or the prevalence of ID in children with ASD vs those without ASD (non-ASD) were included. Primary outcomes included the difference in peripheral iron levels in children with ASD compared with those without ASD, and the odds ratio of ASD in children with ID compared with those without ID. Twenty-five articles met the inclusion criteria. We found that peripheral iron levels were not significantly different between the ASD and non-ASD groups, including serum ferritin (k = 4, Hedges g = 0.016, 95% confidence interval [CI] = -0.482 to 0.515, P = .949) or hair iron (k = 12; Hedges g = -0.219, 95% CI = -0.551 to 0.113, P = .196). There was no significant difference in the amount of iron in food content between the ASD and non-ASD groups (k = 6; Hedges g = -0.458, 95% CI = -1.246 to 0.330, P = .254). However, the reciprocal comorbidity of ASD and ID was significantly higher than in the children without these disorders. Our analysis showed that the available evidence is inconsistent with regard to whether children with ASD have lower iron levels. Future longitudinal studies are required to confirm or refute these associations and elucidate potential mechanisms.

Personality and motivation have been identified as influential variables associated with foreign language learning; however, few studies have investigated their effect on oral presentations. This study addresses the importance of both personality and motivation in students’ collaborative oral presentation performance. A Big Five personality trait questionnaire measuring Extraversion, Agreeableness, Conscientiousness, Neuroticism and Openness to Experience, together with the Collaborative Inquiry-based Project Questionnaire measuring Task, Project Work, Reinforcement, Social Learning and Social Pressure motivational constructs were employed to evaluate 257 university students. In general, the results showed that Extraversion, Project Work and Social Pressure were significant correlates of oral presentation scores. The first result suggests that extraverts possess superiority in situations where oral language production is central to communication. This was particularly true for lower-level students, inferring that extraverted personalities can compensate for a lower English language ability. The second indicates that the inquiry-based nature of the assignments was an intrinsic motivator especially valued by extraverts. The third implies that extrinsic motivation was a factor influencing student performance. These findings extend previous research by highlighting the contextual relationships between these affective variables and performance in collaborative oral presentation contexts.

There is growing recognition that the risk of attention-deficit hyperactivity disorder (ADHD) in children may be influenced by micronutrient deficiencies, including iron. We conducted this meta-analysis to examine the association between ADHD and iron levels/iron deficiency (ID). We searched for the databases of the PubMed, ScienceDirect, Cochrane CENTRAL, and ClinicalTrials.gov up to August 9th, 2017. Primary outcomes were differences in peripheral iron levels in children with ADHD versus healthy controls (HCs) and the severity of ADHD symptoms in children with/without ID (Hedges’ g) and the pooled adjusted odds ratio (OR) of the association between ADHD and ID. Overall, seventeen articles met the inclusion criteria. Peripheral serum ferritin levels were significantly lower in ADHD children (children with ADHD = 1560, HCs = 4691, Hedges’ g = −0.246, p = 0.013), but no significant difference in serum iron or transferrin levels. In addition, the severity of ADHD was significantly higher in the children with ID than those without ID (with ID = 79, without ID = 76, Hedges’ g = 0.888, p = 0.002), and there was a significant association between ADHD and ID (OR = 1.636, p = 0.031). Our results suggest that ADHD is associated with lower serum ferritin levels and ID. Future longitudinal studies are required to confirm these associations and to elucidate potential mechanisms.

espanolIntroduccion. Este estudio examina la desatencion, la hiperactividad y la impulsividad autoinformadas de los estudiantes universitarios, y su relacion con su desempeno en una prueba de proficiencia en ingles de altas exigencia, teniendo en cuenta el genero. Metodo. Los atributos de falta de atencion, hiperactividad e impulsividad se evaluaron mediante el cuestionario de la Auto-Reported Scale (ASRS) del Trastorno de Deficit de Atencion de Adultos / Hiperactividad (ADHD). Un total de 229 estudiantes universitarios matriculados en cursos EFM de segundo ano completaron la version china del ASRS. Se uso una prueba de proficiencia en ingles de alto nivel, como requisito de graduacion para medir su habilidad en el rendimiento de lectura y lectura en ingles. Resultados. Los resultados del analisis de varianza (ANOVA) no revelaron diferencias entre los grupos alto y bajo de deficit de atencion, hiperactividad e impulsividad con respecto a la audicion, la lectura y las puntuaciones totales de la prueba de proficiencia en ingles. Sin embargo, la separacion de la muestra total en alto y bajo deficit de atencion, la hiperactividad y la impulsividad grupos de multiples comparaciones de grupos podria demostrar diferencias significativas entre los generos. Las puntuaciones de alta deficit de atencion, hiperactividad e impulsividad se asociaron con menor audicion, lectura y puntuaciones totales para los estudiantes varones. Discusion y conclusion. Los hallazgos se discuten en relacion con la investigacion relevante en el campo y se consideran las implicaciones instruccionales EnglishIntroduction. This study examines university students’ self-reported inattention, hyperactivity and impulsivity, and their relation to performance on a high-stakes English proficiency test while taking gender into consideration. Results. Analysis of variance (ANOVA) results revealed no differences between high and low attention deficit, hyperactivity and impulsivity groups with regard to listening, reading and total scores of the English proficiency test. However, after separating the total sample into high and low attention deficit, hyperactivity and impulsivity groups multiple group comparisons demonstrated significant differences according to gender. High attention deficit, hyperactivity and impulsivity scores were associated with lower listening, reading and total scores for male students. Discussion and Conclusion. The findings are discussed in relation to relevant research in the field and pedagogical implications are considered.

Autism spectrum disorder (ASD) refers to a group of conditions variably affecting communicative and social interactive abilities presenting alongside behaviors with various restricted and repetitive patterns. In addition to genetic factors that influence the onset of the symptoms, there is growing interest in the potential involvement of non-genetic environmental factors. Some aspects of breastfeeding practices, including rates, timing, or optimality, have been put forward as environmental risk factors for autism. However, previous studies showed a controversial relationship between ASD and breastfeeding.A meta-analysis on the association between maternal breastfeeding and ASD in children was conducted. We also explored potential moderating factors which might influence this association. Articles reporting the association between breastfeeding and a diagnosis of ASD were included.Seven articles were included in the meta-analysis. Cumulatively, children with ASD (n = 1463), either in the form of clinical diagnosis or self-report, were significantly less likely to have been breastfed than children without ASD (n = 1180) (OR = 0.61, 95% CI = 0.45-0.83, P = 0.002). Subgroup analyses revealed that results remained significant for children who were breastfed with additional supplementation.This meta-analysis provides evidence that breastfeeding (exclusively or including additional supplements) may protect against ASD. Prospective longitudinal research is required to disentangle the complex relationships and to explore potential pathophysiological mechanisms.

Preventive effect of stimulants on the risk of brain injuries had been reported. The aim of this study is to determine the extent to which methylphenidate (MPH) prescription moderates the risk of traumatic brain injuries (TBI) in individuals with attention-deficit/hyperactivity disorder (ADHD). Individuals with a recent diagnosis of ADHD between January 1997 and December 2013 (n = 163,618) were identified from Taiwan's National Health Insurance Research Database. A total of 124,438 adolescents and children with ADHD and without prior TBI diagnoses were included and evaluated for subsequent TBI. Methylphenidate prescription duration was subgrouped by the annual average cumulative defined daily dose (DDD): 0, >0 to ≤28, > 28 to ≤84, and >84. We identified 11,463 diagnoses of TBI among 124,438 adolescents and children with ADHD. A Cox regression model was used to investigate whether MPH prescription influenced the risk for TBI after adjusting for sex, age, level of urbanization, seizure, autism and sedative-anxiolytics use. A reduced TBI incidence was observed with MPH prescription DDDs > 84. The protective effect of MPH against TBI persisted after adjusting for confounding factors [hazard ratio (HR) = 0.49; 95% confidence interval (CI): 0.47-0.51]. There was also statistically significant difference in risk for TBI in subjects receiving > 0 to ≤28 or >28 to ≤84 DDDs of MPH treatment (HR = 0.88, 95% CI = 0.83-0.92; HR = 0.76, 95% CI = 0.72-0.80, respectively) when compared with subjects not receiving treatment with MPH. Treatment with MPH for greater than 84 DDDs reduced the risk for TBI among children with ADHD.

Hsuan Lee,1,* Vincent Chin-Hung Chen,2,3,* Yao-Hsu Yang,4– 6 Ting-Yu Kuo,4 Tzu-Chin Lin,7,8 Shu-I Wu,9,10 Kai-Liang Kao,11,12 Jun-Cheng Weng,3,13 Brent Allan Kelsen,14,15 Sophie Hsin-Yi Liang2,16 1Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan; 2Department of Medicine, Chang Gung University, Taoyuan, Taiwan; 3Department of Psychiatry, Chang Gung Memorial Hospital at Chiayi,Chiayi,Taiwan; 4Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi Branch, Chiayi,Taiwan; 5Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital,Taiwan; 6School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; 7Bethel Psychiatric Clinic, Taipei, Taiwan; 8Institute of Science, Technology and Society, National Yang-Ming University Taipei, Taiwan; 9Mackay Memorial Hospital, Section of Psychiatry, Taipei, Taiwan; 10Department of Medicine, Mackay Medical College, Taipei, Taiwan; 11Department of Pediatrics, Far Eastern Memorial Hospital, Taipei, Taiwan; 12Department of Industrial Management, Oriental Institute of Technology, Taipei, Taiwan; 13Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan; 14Language Center, National Taipei University, New Taipei City, Taiwan; 15Department of Psychology, Auckland University of Technology, Auckland, New Zealand; 16Department of Child Psychiatry, Chang Gung Memorial Hospital at Taoyuan, Taoyuan, Taiwan*These authors contributed equally to this workCorrespondence: Sophie Hsin-Yi LiangDepartment of Child Psychiatry, Chang Gung Memorial Hospital at Taoyuan, No. 123, Dinghu Road, Guishan Township, Taoyuan 333, TaiwanEmail sophie.lhy@gmail.comBackground: Young individuals with attention-deficit hyperactivity disorder (ADHD) may have an elevated risk of influenza because of the difficulty in complying with the behavioral procedures that help protect against influenza. Moreover, the effects of sufficient methylphenidate treatment on influenza have received little attention.Objective: This study evaluated the association between ADHD medication usage and influenza and assessed the effect of duration of ADHD treatment on the risk of influenza using a nationwide population-based database.Methods: This study investigated methylphenidate usage and the risk of influenza among children and adolescents with ADHD. We identified 5259 young individuals aged less than 18 years who were diagnosed as having ADHD between 1996 and 2013 from the National Health Insurance Research Database of Taiwan, and we tested whether methylphenidate use affects influenza risk using Cox proportional hazard models.Results: After controlling for confounding factors, the results indicated that influenza risk significantly reduced in the group of ADHD patients who were prescribed methylphenidate for 90 days and more (hazard ratio [HR]: 0.62, 95% confidence interval [CI]: 0.52– 0.75, p< 0.001), demonstrating a 38% reduction in the risk of influenza in this group. However, this was not observed in the group of ADHD patients who used methylphenidate for 1– 90 days (HR: 0.69, 95% CI: 0.89– 1.05, p=0.12).Conclusion: The lower incidence of influenza observed in the group prescribed with methylphenidate for a longer period highlights the importance of compliance to medication and psychoeducation with regard to ADHD management.Keywords: ADHD, influenza, methylphenidate

Key Points Question Is attention-deficit/hyperactivity disorder (ADHD) associated with higher early mortality risk among patients in Taiwan? Findings In this Taiwan nationwide population-based cohort study, there were 275 980 patients with ADHD and 1 931 860 matched controls. After adjustment for potential confounders, patients with ADHD had significantly elevated early mortality risk for suicide, homicide, and unintentional injuries compared with the non-ADHD group. Meaning These findings suggest that ADHD may be associated with excess mortality from injury causes., This nationwide cohort study in Taiwan evaluates whether attention-deficit/hyperactivity disorder (ADHD) is associated with higher risk of mortality from all causes, suicide, unintentional injury, homicide, and natural causes., Importance Few studies have investigated levels of mortality in patients with attention-deficit/hyperactivity disorder (ADHD), and findings have been inconsistent and lacking information on specific causes of deaths. Objective To investigate the association between ADHD and causes of death in Taiwan. Design, Setting, and Participants A nationwide population-based cohort study was conducted using a cross-national Taiwanese registry. The ADHD group comprised 275 980 individuals aged 4 to 44 years with a new diagnosis between January 1, 2000, and December 31, 2012. All individuals with ADHD were compared with 1 931 860 sex- and age-matched controls without ADHD. Exposures The association between ADHD and mortality was analyzed using a Cox regression model that controlled for sex, age, residence, insurance premium, outpatient visits, congenital anomaly, intellectual disability, depression disorder, autism, substance use disorder, conduct disorder, and oppositional defiant disorder. The analysis of suicide, unintentional injury, homicide, and natural-cause mortality was performed by a competing risk adjusted Cox regression controlling for other causes of mortality and potential confounding factors. Main Outcomes and Measures Data on mortality from all causes, suicide, unintentional injury, homicide, and natural causes collected from a national mortality database. Results There were 275 980 individuals with ADHD and 1 931 860 comparison individuals without ADHD in this study. Sex and age at index date were matched. The mean (SD) age was 9.61 (5.74) years for both groups. Most of the participants were male (209 406 in the ADHD group; 1 465 842 in the non-ADHD group; 75.88% for both groups). A total of 4321 participants from both cohorts died during the follow-up period (15.1 million person-years), including 727 (0.26%) from the ADHD group and 3594 (0.19%) from the non-ADHD group. Of those who died, 546 (75.1%) in the ADHD group and 2852 (79.4%) in the non-ADHD group were male. After adjusting for potential confounders, compared with the non-ADHD group, patients with ADHD showed higher overall mortality (adjusted hazard ratio, 1.07; 95% CI, 1.00-1.17) and higher injury-cause mortality from suicide (adjusted hazard ratio, 2.09; 95% CI, 1.62-2.71), unintentional injury (adjusted hazard ratio, 1.30; 95% CI, 1.10-1.52), and homicide (adjusted hazard ratio, 2.00; 95% CI, 1.09-3.68). No increased risk of natural-cause mortality was observed after adjustment. Conclusions and Relevance In this study, ADHD was associated with higher injury-cause mortality, particularly that due to suicide, unintentional injury, and homicide. Although the risk of injury mortality was significantly higher in patients with ADHD than in the non-ADHD group, the absolute risk of mortality was low.

The present study examined the associations between cyberbullying involvement and sociodemographic characteristics, autistic social impairment and attention-deficit/hyperactivity disorder and oppositional defiant disorder (ODD) symptoms in 219 adolescents with high-functioning autism spectrum disorder (ASD). Moreover, the associations between cyberbullying involvement and depression, anxiety, and suicidality were also examined. Adolescents self-reported higher rates of being a victim or perpetrator of cyberbullying than were reported by their parents. Increased age and had more severe ODD symptoms were significantly associated with being victims or perpetrators of cyberbullying. Being a victim but not a perpetrator of cyberbullying was significantly associated with depression, anxiety, and suicidality. Cyberbullying victimization and perpetration should be routinely surveyed in adolescents with high-functioning ASD.

Background The Devereux Early Childhood Assessment for Toddlers (DECA-T), which is one of the few standardized, norm-referenced behavioral rating scales related to young children’s mental health, resilience, and social-emotional development, was developed for toddlers aged between 18 and 36 months. Objective The aim of this study was to test the clinimetric properties of the Chinese (Traditional) version of the DECA-T (C-DECA-T) using a classical test theory analysis and an item response theory analysis. Methods Seventy-five community-based toddlers aged from 18 to 36 months and 50 clinic-based participants recruited in hospitals in northern Taiwan participated in this study. Social-emotional competence was assessed by the C-DECA-T and children’s behavior problems were rated via the Child Behavior Checklist 1.5 to 5 (CBCL/1.5–5). Homogeneity of the C-DECA-T was assessed by Mokken analysis; sensitivity and specificity were assessed via receiver operating characteristic curve. Results The results showed the C-DECA-T demonstrated good test–retest reliability (r=0.8) and high internal consistency (Cronbach's alpha = 0.94). Inter-rater reliability between father and mother was fair (ICC = 0.46). Convergent validity of the CBCL/1.5–5 total behavior problems (r=−0.26) demonstrated acceptable psychometric performance. The overall measure of the sampling adequacy of the C-DECA-T assessed by principal component analysis was 0.93. Mokken scale analysis showed the 36-items of the C- DECA-T formed a weak unidimensional scale (Hs=0.35), supporting its construct validity. The area under curve of the C-DECA-T in prediction of social-emotional disturbance was 0.70. The optimal cutoff of the Total Protective Factor score of the C-DECA-T was a T score of 40.1 (T40.1), with a sensitivity of 95% and a specificity of 68%. Item 2 (“show affection for a familiar adult”) and item 33 (“calm herself/himself”) provide a good amount of information for the assessment of social-emotional strength and needs of a toddler in clinical practice. Conclusion The C-DECA-T showed good psychometric properties. Our findings of high internal consistency of the three subscales and total score of the C-DECA-T suggest symptom manifestation of social-emotional competence and needs in Taiwanese toddlers is not culturally different from American toddlers. The clinimetric properties of the C-DECA-T examined by a classical test theory analysis approach and an item response theory analysis approach suggest that the C-DECA-T is a reliable and valid instrument for measuring social-emotional strength and needs in the population in Taiwan.

The aim of this study was to examine the prevalence of self-reported and parent-reported bullying victimization, perpetration, and victimization-perpetration and the associations of autistic social impairment and attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms with bullying involvement in adolescents with high functioning autism spectrum disorder (ASD). A total of 219 adolescents with high functioning ASD participated in this study. The associations of sociodemographic characteristics, parent-reported autistic social impairment on the Chinese Social Responsiveness Scale, and parent-reported ADHD and ODD symptoms on the Short form of the Swanson, Nolan, and Pelham Version IV Scale (SNAP-IV)-Chinese version with self-reported and parent-reported bullying victimization, perpetration, and victimization-perpetration evaluated using the Chinese version of the School Bullying Experience Questionnaire were examined using logistic regression analysis. The agreement between self-reported and parent-reported bullying involvement was low. Compared with bullying involvement experiences reported by adolescents themselves, parents reported higher rates of pure bullying victimization (23.7% vs. 17.8%) and victimization-perpetration (28.8% vs. 9.1%) but a lower rate of pure bullying perpetration (5.9% vs. 9.1%). Deficit in socio-communication increases the risk of being pure victims and victim-perpetrators. Parent-reported victim-perpetrators had more severe ODD symptoms than did parent-reported pure victims. The agreement between self-reported and parent-reported bullying involvement of adolescents with high functioning ASD was low. Deficit in socio-communication and ODD symptoms were significantly associated with a high risk of bullying involvement in adolescents with high functioning ASD.

Background No study has examined how child and maternal psychopathological difficulties and family factors contribute to the health-related quality of life (HRQOL) of mothers of children with attention deficit hyperactivity (ADHD). Aims To investigate the impact of children’s diagnosis of ADHD, children’s and maternal psychopathology and significant sociodemographic variables of the children, parents and family on HRQOL of mothers of children with ADHD and those of children with typical development (TD) in Taiwan. Methods and procedures Children with ADHD (n = 257) and children with typical development (n = 324) and their mothers were recruited from a psychiatric clinic of a medical center and 10 elementary schools and four high schools in northern Taiwan. Maternal HRQOL was assessed with the World Health Organization Quality of Life – BREF, while the other factors were screened using the Chinese version of the Childhood Autism Spectrum Test for autistic traits, the Swanson, Nolan, and Pelham, version IV scale for ADHD symptoms, the Child Behavior Checklist for behavioral and emotional problems, The Center for Epidemiologic Studies Depression Scale for maternal depression and interpersonal problems, the Adult ADHD Self-report Scale for maternal ADHD symptoms, and the Family APGAR for family support. Outcomes and results Mothers of children with ADHD had significantly worse HRQOL in all four domains compared with those of children with typical development. Multiple regressions found that factors consistently related to the HRQOL of mothers of children with ADHD and those of children with TD were maternal depression and perceived family support after controlling for several familial, parental and child variables. HRQOL of mothers of children with ADHD and those of children with TD was more closely related to her own and family factors rather than mother- or teacher-rated ADHD symptoms, clinical diagnosis of ADHD or psychopathology of the child. Conclusions and implications Screening for maternal HRQOL, depressive symptoms and family support systems and mental health services for mothers of children with ADHD are warranted based on these findings.

Background Depression happens commonly in cancer patients. However, there is limited literature on uterine cancer. In this study, we aimed to evaluate the association between uterine cancer and depression as well as the moderating effect of age and hormone replacement therapy (HRT). Methods This was a population-based study using Taiwan's National Health Insurance Research Database. We conducted a matched cohort study and identified 6526 patients with uterine cancer and 65 260 controls. We adopted the competing risk analysis model as the statistical method and adjusted for potential confounding factors. Results From 1997 to 2008, 71 786 patients were included (6526 patients with uterine cancer and 65 260 controls). In the study, uterine cancer was not linked to depression. However, when we stratified the different age groups, those cancer patients aged