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Weng Y, Wu T, Wei Y, Chen L, Liu X, Cai K, Chen C. Unified and distinct cognitive control deficits in adolescents with cognitive disengagement syndrome and learning burnout. Front Psychiatry 2024; 15:1399122. [PMID: 39022757 PMCID: PMC11251943 DOI: 10.3389/fpsyt.2024.1399122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/19/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Cognitive disengagement syndrome (CDS) is a psychological disorder characterized by daydreaming, mental fogginess, and slow thinking, while learning burnout (LB) is characterized by a passive and inattentive attitude toward learning. These two disorders are closely related but can be challenging to differentiate from one another. The present study aimed to identify shared and distinct cognitive control deficits between CDS and LB. Methods We recruited 136 adolescents (aged 14 to 17 years) from an initial screening of CDS and LB (N = 476) and divided them into four groups: CDS, LB, CDS + LB, and typically developing control. After a second screening, 129 adolescents completed two tasks to assess their attentional networks and cognitive control capacity (CCC). Results Adolescents with high CDS symptoms (both CDS group and CDS+LB group) exhibited impaired disengaging effect of attention and lower CCC, indicating deficits in orienting attention and the upper limit of information processing for cognitive control specifically. Furthermore, support vector machine modeling identified CCC as the most significant parameter differentiating the CDS and LB groups. Discussion Our findings suggest that while adolescents with high CDS and high LB symptoms have similar outward manifestations in the adolescent's school life, deficits in attention and cognitive control, particularly in the CCC, may distinguish between the two groups.
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Affiliation(s)
- Yuhan Weng
- School of Psychology, South China Normal University, Guangzhou, China
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education, South China Normal University, Guangzhou, China
- Center for Studies of Psychological Application, South China Normal University, Guangzhou, China
- Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou, China
| | - Tingting Wu
- Beijing Key Lab of Learning and Cognition, School of Psychology, Capital Normal University, Beijing, China
| | - Yunfang Wei
- Shantou Special Economic Zone Linbaixin Middle School, Swatow, China
| | - Ling Chen
- School of Psychology, South China Normal University, Guangzhou, China
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education, South China Normal University, Guangzhou, China
- Center for Studies of Psychological Application, South China Normal University, Guangzhou, China
- Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou, China
| | - Xiqin Liu
- School of Foreign Languages, South China University of Technology, Guangzhou, China
| | - Kexin Cai
- School of Psychology, South China Normal University, Guangzhou, China
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education, South China Normal University, Guangzhou, China
- Center for Studies of Psychological Application, South China Normal University, Guangzhou, China
- Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou, China
| | - Caiqi Chen
- School of Psychology, South China Normal University, Guangzhou, China
- Key Laboratory of Brain, Cognition and Education Sciences, Ministry of Education, South China Normal University, Guangzhou, China
- Center for Studies of Psychological Application, South China Normal University, Guangzhou, China
- Guangdong Key Laboratory of Mental Health and Cognitive Science, South China Normal University, Guangzhou, China
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DesRuisseaux LA, Gereau Mora M, Suchy Y. Computerized assessment of executive functioning: Validation of the CNS Vital Signs executive functioning scores in a sample of community-dwelling older adults. Clin Neuropsychol 2024:1-23. [PMID: 38763890 DOI: 10.1080/13854046.2024.2354953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/09/2024] [Indexed: 05/21/2024]
Abstract
Objective: Computerized assessment of cognitive functioning has gained significant popularity over recent years, yet options for clinical assessment of executive functioning (EF) are lacking. One computerized testing platform, CNS Vital Signs (CNS-VS), offers tests designed to measure EF but requires further validation. The goal of the present study was to validate CNS-VS executive scores against standard clinical measures of EF. We also sought to determine whether a modified CNS-VS composite score that included variables purported to measure inhibition, switching, and working memory would outperform the currently available CNS-VS Executive Function Index. Method: A sample of 73 cognitively healthy older adults completed four tests from the Delis-Kaplan Executive Function System, the Digit Span subtest from the Wechsler Adult Intelligence Scale-fourth edition, and three CNS-VS tasks purported to measure inhibition, switching, and working memory. Results: Performances on the CNS-VS tests were predicted by performances on standard paper-and-pencil measures. Although the currently available CNS-VS Executive Function Index predicted unique variance in a well-validated paper-and-pencil EF composite score, our Modified CNS-VS EF composite accounted for unique variance above and beyond the original CNS-VS Executive Function Index, while the reverse was not true. Conclusions: The present results support the construct validity of CNS-VS EF tests but also suggest that modifications to their current composite scores would improve the prediction of EF performance.
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Affiliation(s)
| | | | - Yana Suchy
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
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Wu ZM, Liu J, Wang P, Wang YF, Yang BR. Neuropsychological characteristics of children with Attention-Deficit/Hyperactivity Disorder and Sluggish Cognitive Tempo. J Atten Disord 2022; 26:1631-1639. [PMID: 35470726 DOI: 10.1177/10870547221090662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The present study aims to explore the neuropsychological features of children with Attention-Deficit/Hyperactivity Disorder (ADHD) and Sluggish Cognitive Tempo (SCT). METHODS Fifty-eight children with ADHD+SCT, 480 children with ADHD-SCT, and 105 healthy controls (HC) were recruited. Neuropsychological tests and the Behavior Rating Inventory of Executive Function (BRIEF) were used. RESULTS The ADHD+SCT group performed worse than the HC in processing speed (p = .005), set-shifting (p = .0003), interference control (p = .00014), and visual memory (p = .007), while the ADHD-SCT group performed worse than the HC in sustained attention measurements (all p < .0001). The ADHD+SCT group scored higher than the ADHD-SCT group in the following factors from BRIEF: plan/organize (p = .00083), working memory (p < .001), and shift (p = .0054). CONCLUSION Our results indicated that SCT symptoms are associated with worse executive function in children with ADHD except for sustained attention.
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Affiliation(s)
- Zhao-Min Wu
- Shenzhen Children's Hospital, Shenzhen, China
| | - Juan Liu
- Shenzhen Children's Hospital, Shenzhen, China
| | - Peng Wang
- Cardiac Rehabilitation Center, Fuwai Hospital, CAMS & PUMC, Beijing, China
| | - Yu-Feng Wang
- Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China.,Peking University, Beijing, China
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Braverman ER, Dennen CA, Gold MS, Bowirrat A, Gupta A, Baron D, Roy AK, Smith DE, Cadet JL, Blum K. Proposing a "Brain Health Checkup (BHC)" as a Global Potential "Standard of Care" to Overcome Reward Dysregulation in Primary Care Medicine: Coupling Genetic Risk Testing and Induction of "Dopamine Homeostasis". INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5480. [PMID: 35564876 PMCID: PMC9099927 DOI: 10.3390/ijerph19095480] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 12/27/2022]
Abstract
In 2021, over 100,000 people died prematurely from opioid overdoses. Neuropsychiatric and cognitive impairments are underreported comorbidities of reward dysregulation due to genetic antecedents and epigenetic insults. Recent genome-wide association studies involving millions of subjects revealed frequent comorbidity with substance use disorder (SUD) in a sizeable meta-analysis of depression. It found significant associations with the expression of NEGR1 in the hypothalamus and DRD2 in the nucleus accumbens, among others. However, despite the rise in SUD and neuropsychiatric illness, there are currently no standard objective brain assessments being performed on a routine basis. The rationale for encouraging a standard objective Brain Health Check (BHC) is to have extensive data available to treat clinical syndromes in psychiatric patients. The BHC would consist of a group of reliable, accurate, cost-effective, objective assessments involving the following domains: Memory, Attention, Neuropsychiatry, and Neurological Imaging. Utilizing primarily PUBMED, over 36 years of virtually all the computerized and written-based assessments of Memory, Attention, Psychiatric, and Neurological imaging were reviewed, and the following assessments are recommended for use in the BHC: Central Nervous System Vital Signs (Memory), Test of Variables of Attention (Attention), Millon Clinical Multiaxial Inventory III (Neuropsychiatric), and Quantitative Electroencephalogram/P300/Evoked Potential (Neurological Imaging). Finally, we suggest continuing research into incorporating a new standard BHC coupled with qEEG/P300/Evoked Potentials and genetically guided precision induction of "dopamine homeostasis" to diagnose and treat reward dysregulation to prevent the consequences of dopamine dysregulation from being epigenetically passed on to generations of our children.
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Affiliation(s)
- Eric R. Braverman
- The Kenneth Blum Institute on Behavior & Neurogenetics, Austin, TX 78701, USA; (E.R.B.); (C.A.D.)
| | - Catherine A. Dennen
- The Kenneth Blum Institute on Behavior & Neurogenetics, Austin, TX 78701, USA; (E.R.B.); (C.A.D.)
| | - Mark S. Gold
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA;
- Department of Psychiatry, Tulane School of Medicine, New Orleans, LA 70112, USA;
| | - Abdalla Bowirrat
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel 40700, Israel;
| | - Ashim Gupta
- Future Biologics, Lawrenceville, GA 30043, USA;
| | - David Baron
- Division of Addiction Research & Education, Center for Psychiatry, Medicine & Primary Care (Office of Provost), Western University Health Sciences, Pomona, CA 91766, USA;
| | - A. Kenison Roy
- Department of Psychiatry, Tulane School of Medicine, New Orleans, LA 70112, USA;
| | - David E. Smith
- Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA 94158, USA;
| | - Jean Lud Cadet
- The Molecular Neuropsychiatry Research Branch, NIH National Institute on Drug Abuse, Baltimore, MD 21224, USA;
| | - Kenneth Blum
- The Kenneth Blum Institute on Behavior & Neurogenetics, Austin, TX 78701, USA; (E.R.B.); (C.A.D.)
- Division of Addiction Research & Education, Center for Psychiatry, Medicine & Primary Care (Office of Provost), Western University Health Sciences, Pomona, CA 91766, USA;
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Başay Ö, Çiftçi E, Becker SP, Burns GL. Validity of Sluggish Cognitive Tempo in Turkish Children and Adolescents. Child Psychiatry Hum Dev 2021; 52:191-199. [PMID: 33432461 DOI: 10.1007/s10578-020-01110-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
The internal and external validity of sluggish cognitive tempo (SCT) relative to attention-deficit/hyperactivity disorder-inattention (ADHD-IN) was evaluated with Turkish children and adolescents. Parents completed the SCT, ADHD-IN, ADHD-hyperactivity/impulsivity (HI), oppositional defiant disorder (ODD), callous-unemotional (CU), anxiety, depression, social impairment, and academic impairment scales of the Child and Adolescent Behavior Inventory (CABI) on 1015 Turkish children and adolescents (56% girls; ages 6-15 years; Mage = 10.05, SDage = 2.32), including 762 recruited from the community and 253 recruited from outpatient psychiatric clinics. SCT symptoms demonstrated excellent internal validity with the ADHD-IN symptoms. SCT symptoms also showed invariance across boys and girls as well as across community and clinical samples. SCT showed stronger first-order and unique associations than ADHD-IN with anxiety and depression whereas ADHD-IN showed stronger first-order and unique associations than SCT with ADHD-HI, ODD, and academic impairment. SCT and ADHD-IN showed equal associations with CU behaviors and social impairment. The current study is the first to support the validity of CABI SCT scores with Turkish children and adolescents and also replicates the findings from similar studies with children from South Korea, Spain, and United States. These findings thus further strengthen the transcultural validity of CABI SCT scale scores.
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Affiliation(s)
- Ömer Başay
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Pamukkale University, Denizli, Turkey.
| | - Erol Çiftçi
- Child and Adolescent Psychiatry, Bayburt State Hospital, Bayburt, Turkey
| | - Stephen P Becker
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - G Leonard Burns
- Department of Psychology, Washington State University, Washington, USA
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Tahıllıoğlu A, Ercan ES. Atomoxetine might be more effective in improving sluggish cognitive tempo symptoms after switching from methylphenidate: A case report. Clin Case Rep 2021; 9:612-617. [PMID: 33598212 PMCID: PMC7869347 DOI: 10.1002/ccr3.3592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/02/2020] [Accepted: 11/10/2020] [Indexed: 11/12/2022] Open
Abstract
Although there is no proven evidence regarding pharmacotherapy of Sluggish Cognitive Tempo (SCT), we experienced atomoxetine had more effects in decreasing SCT symptoms after switching from methylphenidate in a case with SCT and subthreshold ADHD.
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Affiliation(s)
- Akın Tahıllıoğlu
- Department of Child and Adolescent PsychiatryEge University Faculty of MedicineIzmirTurkey
| | - Eyüp Sabri Ercan
- Department of Child and Adolescent PsychiatryEge University Faculty of MedicineIzmirTurkey
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Mitchell JT, Davis NO, Kollins SH, Lunsford-Avery JR. Sluggish cognitive tempo (SCT) in an adult outpatient sample seeking an attention-deficit/hyperactivity disorder assessment: Age of onset and assessment method impact on SCT rates. J Psychiatr Res 2020; 131:203-208. [PMID: 32992100 PMCID: PMC7983554 DOI: 10.1016/j.jpsychires.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/18/2020] [Accepted: 09/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sluggish cognitive tempo (SCT) is associated with-but distinct from-attention-deficit/hyperactivity disorder (ADHD). This study examined SCT rates in adult outpatients seeking an ADHD assessment, differences in rates based on ADHD status, impact of assessment method (i.e., reporting source, symptom count, and functional impairment), and age of SCT symptom onset. METHODS Outpatients (n = 124) completed an SCT measure (n = 120 other-reporters). SCT was based on reporting source (i.e., self-report, other-report, either reporting source ["or" rule], and both reporting sources ["and" rule]), symptom count (i.e., age-based norms at or near the 93rd percentile, and a higher symptom count threshold of five), and functional impairment (i.e., 0, 1, and ≥2 domains). RESULTS SCT rates varied based on assessment method for the full sample (26%-82%) and among those with (32%-91%) and without (16%-66%) ADHD. Rates decreased with stricter functional impairment and symptom count criteria. SCT was higher in the ADHD group than the non-ADHD group based on other-reporters and the "or" rule, but not the "and" rule. Functional impairment and symptom count criteria did not impact these comparisons. For self-reported SCT rates, ADHD/non-ADHD group comparisons did not differ based on age-based symptom count threshold, but did with a symptom count threshold of five. Self-reported SCT symptom onset was 13.36 years-old and was significantly younger for the ADHD group (11.69 years) than the non-ADHD group (16.36 years). CONCLUSIONS Elevated SCT symptoms and related impairment are common among adults seeking an ADHD evaluation. These rates and ADHD/non-ADHD group differences vary substantially based on diagnostic methods.
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Affiliation(s)
- John T. Mitchell
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Naomi Ornstein Davis
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Scott H. Kollins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Bolat H, Ercan ES, Ünsel-Bolat G, Tahillioğlu A, Yazici KU, Bacanli A, Pariltay E, Aygüneş Jafari D, Kosova B, Özgül S, Rohde LA, Akin H. DRD4 genotyping may differentiate symptoms of attention-deficit/hyperactivity disorder and sluggish cognitive tempo. ACTA ACUST UNITED AC 2020; 42:630-637. [PMID: 32491038 PMCID: PMC7678899 DOI: 10.1590/1516-4446-2019-0630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 01/17/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Studies to reduce the heterogeneity of attention-deficit/hyperactivity disorder (ADHD) have increased interest in the concept of sluggish cognitive tempo (SCT). The aim of this study was to investigate if the prevalence of two variable-number tandem repeats (VNTRs) located within the 3'-untranslated region of the DAT1 gene and in exon 3 of the dopamine D4 receptor (DRD4) gene differ among four groups (31 subjects with SCT but no ADHD, 146 individuals with ADHD but no SCT, 67 subjects with SCT + ADHD, and 92 healthy controls). METHODS We compared the sociodemographic profiles, neurocognitive domains, and prevalence of two VNTRs in SCT and ADHD subjects versus typically developing (TD) controls. RESULTS The SCT without ADHD group had a higher proportion of females and lower parental educational attainment. Subjects in this group performed worse on neuropsychological tests, except for psychomotor speed and commission errors, compared to controls. However, the ADHD without SCT group performed significantly worse on all neuropsychological domains than controls. We found that 4R homozygosity for the DRD4 gene was most prevalent in the ADHD without SCT group. The SCT without ADHD group had the highest 7R allele frequency, differing significantly from the ADHD without SCT group. CONCLUSION The 7R allele of DRD4 gene was found to be significantly more prevalent in SCT cases than in ADHD cases. No substantial neuropsychological differences were found between SCT and ADHD subjects.
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Affiliation(s)
- Hilmi Bolat
- Department of Medical Genetics, Balikesir Atatürk City Hospital, Balikesir, Turkey
| | - Eyüp S Ercan
- Department of Child and Adolescent Psychiatry, Ege University, Izmir, Turkey
| | - Gül Ünsel-Bolat
- Department of Child and Adolescent Psychiatry, Balikesir University Faculty of Medicine, Balikesir, Turkey
| | - Akin Tahillioğlu
- Department of Child and Adolescent Psychiatry, Ege University, Izmir, Turkey
| | - Kemal U Yazici
- Department of Child and Adolescent Psychiatry, Firat University, Izmir, Turkey
| | - Ali Bacanli
- Department of Child and Adolescent Psychiatry, Baskent University, Izmir, Turkey
| | - Erhan Pariltay
- Department of Medical Genetics, Ege University, Izmir, Turkey
| | | | - Buket Kosova
- Department of Medical Biology, Ege University, Izmir, Turkey
| | - Semiha Özgül
- Department of Bioistatistics and Medical Informatics, Ege University, Izmir, Turkey
| | - Luis A Rohde
- Programa de Transtornos de Déficit de Atenção/Hiperatividade (ProDAH), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Instituto Nacional de Psiquiatria do Desenvolvimento para Crianças e Adolescentes, São Paulo, SP, Brazil
| | - Haluk Akin
- Department of Medical Genetics, Ege University, Izmir, Turkey
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Ünsel-Bolat G, Baytunca MB, Kardaş B, İpçi M, İnci İzmir SB, Özyurt O, Çallı MC, Ercan ES. Diffusion tensor imaging findings in children with sluggish cognitive tempo comorbid Attention Deficit Hyperactivity Disorder. Nord J Psychiatry 2020; 74:620-626. [PMID: 32543999 DOI: 10.1080/08039488.2020.1772364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: The construct of Sluggish Cognitive Tempo (SCT) is characterized by daydreaming, mental confusion, staring blankly and hypoactivity. Our main goal was to explore neuropsychological differences in Attention Deficit Hyperactivity Disorder-Inattentive presentation (ADHD-IA) groups with and without SCT symptoms compared to healthy controls. After detecting specific neuropsychological differences, we examined white matter microstructure using Diffusion Tensor Imaging (DTI) data obtained from 3.0 Tesla MRI scans of the cases with SCT symptoms comparing to Typically Developing (TD) controls.Method: In this study, we included 24 cases in the ADHD-IA group with SCT symptoms, 57 cases in the ADHD-IA group without SCT symptoms and, 24 children in the TD group. We applied tract-based spatial statistics to the DTI measures for obtaining fractional anisotropy (FA), axial, radial and mean diffusivity (AD, RD, MD) to explore white matter differences for the whole brain.Results: Omission error scores and longer reaction time scores were specifically associated with inattention symptoms. Commission error scores were significantly and specifically related to SCT symptoms. Cases with SCT symptoms presented increased FA in the bilateral anterior and posterior limb of the internal capsule, bilateral cerebral peduncle, and the fornix than TD group.Conclusions: Neurobiological differences in ADHD cases are still relatively unexplored. We suggest that including an assessment for SCT in the neuropsychological and neuroimaging studies of ADHD may provide more consistent results.
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Affiliation(s)
- Gül Ünsel-Bolat
- Department of Child and Adolescent Psychiatry, Balıkesir University, Balıkesir, Turkey
| | | | - Burcu Kardaş
- Department of Child and Adolescent Psychiatry, Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Melis İpçi
- Department of Clinical Psychology, Hasan Kalyoncu University, Gaziantep, Turkey
| | | | - Onur Özyurt
- Institute of Biomedical Engineering, Bogazici University, Istanbul, Turkey
| | - Mehmet Cem Çallı
- Department of Radiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Eyüp Sabri Ercan
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, Izmir, Turkey
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