Objective: This study examines the associations of childhood attention-deficit/hyperactivity disorder (ADHD) risk status with subsequent parental social network characteristics and caregiver strain in adolescence; and examines predictors of adolescent mental health service use. Methods: Baseline ADHD screening identified children at high risk (n = 207) and low risk (n = 167) for ADHD. At eight-year follow-up, parents reported their social network characteristics, caregiver strain, adolescents’ psychopathology and mental health service utilization, whereas adolescents self-reported their emotional status and ADHD stigma perceptions. Analyses were conducted using ANOVAs and nested logistic regression modeling. Results: Parents of youth with childhood ADHD reported support networks consisting of fewer spouses but more healthcare professionals, and lower levels of support than control parents. Caregiver strain increased with adolescent age and psychopathology. Increased parental network support, youth ADHD symptoms, and caregiver strain, but lower youth stigma perceptions were independently associated with increased service use. Conclusions: Raising children with ADHD appears to significantly impact parental social network experiences. Reduced spousal support and overall lower network support levels may contribute to high caregiver strain commonly reported among parents of ADHD youth. Parental social network experiences influence adolescent ADHD service use. With advances in social networking technology, further research is needed to elucidate ways to enhance caregiver support during ADHD care. Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with significant public health implications, because it is 1) common, affecting more than 1 in 20 children  common,  and theiParental social networks may be one important contributor to such disparities, influencing all stages of the help-seeking process and illness career trajectories for pediatric chronic health conditions . Most inAnother important predictor of child mental health service utilization is parental stress or perceived burden of the child’s mental disorder. High amounts of parental stress, common in parents of children with ADHD ,22,23,24Furthermore, the relationship between social networks, caregiver stress and youth health care utilization has been examined for parents of young children with ADHD ,34,35, b(1) To compare social network characteristics of parents of adolescents with and without a history of childhood ADHD. We hypothesize that childhood ADHD is associated with smaller parent network size and less emotional and instrumental support as the children reach adolescence.(2) To identify predictors of caregiver stress in in parents of adolescents. We hypothesize that adolescent age and psychopathology are positively associated with caregiver stress experiences; and conversely, that larger network size and greater support are associated with reduced caregiver stress.(3) To ascertain whether parental network composition and stress predict mental health service utilization for adolescents, after controlling for mental health need and adolescents’ ADHD stigma perceptions. No hypothesis was advanced, due to the absence of existing research informing this question.This research uses observational data from the study “ADHD: Detection and Service Use” . A randoSociodemographic information about child age, gender, race, and subsidized status was obtained from school registration records and verified during interviews. Symptoms of common mental health problems were assessed by parent report using the Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS). Parents completed the 47-item VADPRS, used to assess symptoms of ADHD, oppositional defiant disorder (ODD), conduct disorder (CD), anxiety and depression. The VADPRS uses a 4-point scale , and the scores for each disorder corresponds to the total sum. The reliability, factor structure, and concurrent validity have been found to be acceptable and consistent with the DSM-IV and other accepted measures of ADHD . To assess child functional impairment, parents and adolescents completed the Columbia Impairment Scale (CIS), a 13-item survey which yields an overall impairment score that can range from 0 to 52, with scores of 15 or greater indicating definite impairment . The CIST scores, with higher ratings indicative of greater impairment [Adolescents completed the Behavior Assessment System for Children Self Report of Personality (BASC-SRP), a 186-item instrument using a true/false answer format which yields an overall summary score of emotional and behavioral functioning, the Emotional Symptom Index (ESI) . The BASpairment .Adolescents completed the 26-item ADHD Stigma Questionnaire (ASQ) to assess public stigma perceptions related to ADHD . AdolescThe Norbeck Social Support Questionnaire (NSSQ) was adapted to assess parents’ perceived level of network support specific to their caregiver role, defined as persons whom caregivers talk to and depend on when they have concerns about their child’s health, behavior, or emotions . The NSSThe impact of caring for a child with emotional or behavioral problems on the parent was assessed using the Caregiver Strain Questionnaire (CGSQ), a 21-item adult self-report instrument . CaregivReceipt of mental health treatment services was assessed using the Child and Adolescent Services Assessment (CASA) , a pareni.e., percent of support types in each structure). For comparison of this composition . Spearman correlational testing was performed to examine the relationship of network variables  with global caregiver strain. To examine the dependent variable of global caregiver strain and the network variables in the correlational analysis after adjusting for the explanatory predictors , a multiple regression model was constructed. Comorbid ODD was considered as an additional predictor in the multiple regression model, but the extent of multicollinearity with ADHD was unacceptable (r > 0.70). For the series of logistic models presented in Data were checked for implausible values, outliers, distributional form and missing information. Source of support was categorized into five “informal” types  and two “formal” types . To describe networks of the parent participants reported in Family support sources were the most commonly reported, with 61% (n = 230), 44% (n = 165), and 60% (n = 227) of the caregivers listing spouses, their own parents or other family members, respectively. Friends represented 52% (n = 195) of the caregiver supports, and formal network supporters like healthcare providers or teachers, were only listed as a support source by 14% (n = 54) and 4% (n = 15) of the caregivers. Not surprisingly, the mean contact frequency, relationship length and emotional closeness were greater for informal than formal network supporters, and geographical distance was least for spouses. Informal network supports also provided higher levels of affective/affirmative and instrumental support than informal sources, with the most distinct differences in instrumental support experiences. Details on network structure and support levels are summarized in p < 0.0001). The support networks of parents whose teen had a history of childhood ADHD were composed of fewer spouses compared to parents of teens without such history (14% versus 36%). Conversely, support networks of parents whose teen had a childhood ADHD history indicated more distal network support than parents of teens without such history, including more teachers (4% versus 0%), healthcare professionals (7% versus 0%), and other non-family connections (15% versus 3%). As shown in p < 0.0001) or Caucasian peers (p < 0.0001). In addition, the average contact frequency was high, 4.5 (SD 0.6), indicating near daily contacts and did not vary by childhood ADHD status, but by poverty status and race/ethnicity. Poor or African American caregivers had more frequent contact than non-poor (p < 0.0001) or Caucasian peers (p < 0.0001).As summarized in p < 0.0001 and p < 0.01, respectively), but did not vary by poverty status or race. Average instrumental support was only 2.7 (SD 1.0) and varied by all three conditions, with caregivers of youth with childhood ADHD status (p < 0.0001), non-poor (p < 0.05) and Caucasian caregivers (p < 0.0005) reporting lower instrumental supports than caregiver peers of the opposite classification.Receipt of affective and affirmative support averaged 3.4 (SD 0.8) and 3.3 (SD 0.7), respectively, and was lower for caregivers of youth with childhood ADHD status than those of caregivers without (p < 0.0005) and ADHD and anxiety/depression symptom scores ; and at a trend level, with caregiver’s affective support . No independent relationships were found between global caregiver strain and the remaining demographic  or network characteristics .Global caregiver strain was independently associated with adolescents’ age  were not associated with adolescents’ mental health service use. However, parental receipt of network affirmational support  was associated with increased odds of adolescents’ mental health service use in Model 1 , and remained an independent predictor after accounting for parental perspectives of adolescents’ psychopathology and their own caregiver strain experiences , and after controlling for adolescents’ need  and ADHD stigma perceptions . Parental receipt of instrumental support  was associated with lower odds of adolescents’ mental health service use in Model 1 , but did not retain significance after accounting for parental and adolescent perspectives in Models 2 and 3, respectively. Network size and affective support  associated with lowered strain scores. Total network size, affirmational and instrumental support were also not related to parent stress. Our findings are in contrast to other studies reporting that greater social support is related to reduced stress [As expected, caregiver stress increased with youth age and the degree of adolescent psychopathology, as indicated by ADHD and anxiety/depression symptom levels. High levels of caregiver burden have been reported in other studies of ADHD patients transitioning into adolescence and adulthood, with burden being a function of the affected young person’s unmet need, especially depression/anxiety and behavioral problems . Howeverd stress ; howeverd stress , and thei.e., getting help with parenting responsibilities) lowered the odds of mental health service use of children [i.e., having a confidant that agrees with the caregiver’s parenting decisions) increased the odds of mental health service use of adolescents. We speculate that this observed relationship may reflect the parent’s active assembly of network supporters who view mental health treatment as beneficial  and who do not impose courtesy stigma on parents for seeking mental health treatment for their adolescent. Considering the study’s findings regarding spousal support, we note that previous research has documented the reluctance of fathers to accept medical frameworks for understanding ADHD [Furthermore, findings suggest that affirmational support from the parents’ social network, caregiver stress, youth ADHD symptom level, and reduced adolescent perceived stigma were predictive of mental health service utilization among teens. To our knowledge, this is the first study to specifically address the question of how parental network composition and stress play a role in mental health service utilization for adolescents, even after controlling for their mental health needs and teens’ ADHD stigma perceptions. Interestingly, whereas earlier research found that caregivers’ instrumental support,  such as Facebook, Twitter, LinkedIn, and MySpace have greatly increased in popularity, with the number of American adults who use SNSs nearly doubling from 26% in 2008 to 47% in 2010 . HoweverStudy findings suggest that raising children with ADHD significantly impacts parental social network experiences. Reduced spousal support and overall lower network support experiences may contribute to high caregiver stress commonly reported among parents of ADHD youth. Parental social network experiences appear to influence adolescent mental health service use. With advances in social networking technology, a better understanding is needed on how to integrate SNS use into management models for chronic conditions like ADHD. For example, SNS users reportedly have more diverse social networks, more social ties, and interact more with members of their social network in both offline and online settings than non-users ,62. Alon


Background: Children suffer from attention deficit hyperactivity disorder (ADHD) are very difficult to handle. It can be very frustrating and needs an outstanding tolerance. Behavioral difficulties in ADHD children may increase the risk of child abuse for them. The aim of this research was to compare child abuse, and neglect between ADHD group and normal children.Methods: In this cross-sectional study, 30 ADHD students (10 girls and 20 boys) were selected from regional mental behavior disorder clinics and matched with 30 normal students. Data were collected using Child Abuse Self Report Scale. Descriptive statistics, one-way multivariate analysis of variance (MANOVA) and Least Significant Difference (LSD) was performed by using SPSS software.Result: The result of the research showed that almost 60% of participants had experienced neglect and 35% psychological abuse. Neglect and psychological abuse are more frequent than other maltreatments. Neglect, psychological and physical abuses are significantly higher in the ADHD group.Conclusion: The findings showed that the rates of neglect and psychological abuse are higher in the ADHD group. Therefore, it can be suggested that the society and families should be trained to deal better with ADHD children. Behavioral difficulties in ADHD such as hostile-intrusive behavior, bossiness, and impulsiveness almost interfere with the basic rights of others at school and home. As a result, these children have lots of conflict with teachers, classmates and parents.2ADHD children are frequently careless about rules and restrictions that set by adults; therefore, parents, teachers or other students may feel tired and helpless in dealing with them. For example, other children may not want to play with them at school or teachers ignore them easily in the classroom or among other students.3 Many teachers are not qualified for working with special needs children. They have not been trained to manage behavioral difficulties in children. A study in New Zealand showed that teachers accepted the fact that they have not enough knowledge about dealing with special needs children.4Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with symptoms which can be divided into two domains, inattention and impulsivity/hyperactivity.5 It means many children with ADHD have parents suffering from adult ADHD. Children whose parents are suffering from mental health disorders receive poor parenting.6 Research shows that adults with ADHD have difficulty parenting. For example, they experience more stress,7 they get frustrated easier, argue with family members more, and have lower self confidence.8 On the other hand, general public, especially teachers and parents, commonly are not familiar with ADHD.9 They do not consider ADHD as a mental disorder.10 They always use the phrase “Boys are boys” as an excuse for accepting behaviours linked with ADHD. For example, 36% of a research participants had not heard about ADHD at all and 22% of those who had heard about ADHD believed ADHD is not a “real” disease.10 In general, when people have negative stereotypes, beliefs and attitudes about mental health or they are not able to recognize a mental problem correctly, they will respond inappropriately to the situation. Attitudes towards mental disorders are often important factors for seeking treatment. People who recognize mental health will manage or prevent it more quickly and effectively also they are more optimistic about the treatment outcomes. The term Mental Health Literacy has been defined as a person’s sufficient knowledge about a specific disorder and the skills he/she has about the interaction with the patient.11,12 Public knowledge about ADHD is important because it shows the public perception about ADHD and the way they interact with such cases. As a result, only half of children with ADHD receive medical treatment.13 This is even worse in developing countries.14 Because of disregarding the ADHD behaviours, some parents are unable to help or communicate correctly with an ADHD person. Some researchers have shown that fathers of children with ADHD show a strong resistance for treatment of ADHD.15-17 Sometimes parents have incorrect beliefs about the method of interventions. There are a number of facts that people who do not have mental health literacy; they probably behave more imperfectly toward others who have mental health problems.18 The combination of ADHD child’s temperament problems, the residual symptoms of ADHD in parents, and mental health illiteracy cause the family members to develop ineffective communication and aggressive relationship with others.19 Effective communication and healthy relationships within the family are very important because it enables the members to communicate with each other in a secure and respectful way. On the other hand, impulsiveness and externalizing problems cause unhealthy communication and child maltreatment in the family.20 Child abuse is a common problem in the world and in Iran.21 According to National Center for Juvenile in 1993, about 3 million children in the United States of America were abused. Nearly half of them experienced serious or moderate injury for that reason.22 The results of a study in Tehran showed that the prevalence of child abuse among students of district 20 of Tehran School Board was between 37% and 46%.  Reuters also reported a prevalence rate between 16% and 24%   for district 3 of Tehran School Board.23 Child maltreatment occurs in many different forms. National Society for Prevention of Cruelty to Children (NSPCC) defines the types of child abuse. a) Physical abuse: which involves every action that causes physical injury to a child b) Emotional Abuse: which involves every action that affects the child’s self-esteem negatively. c) Neglect: which involves ignoring the child’s essential needs .24 Evidence shows that children with mental health and developmental problems are at risk of physical abuse and neglect.25 For example, 18.5% of children with autism had been physically abused26 or 14.3% of girls with ADHD are at risk of abuse. These rates are significantly higher in comparison with other groups.27 Parents are one of the major sources of child abuse in Iran.23Genetic research shows that ADHD is mainly a heritable disorder.As the parent-child relationship is highly affected by cultural habits, cultural beliefs and cultural mental health literacy, the aim of this research was to examine whether Iranian children with attention-deficit/hyperactivity disorder (ADHD) are more at risk of child abuse and neglect in comparison with normal children. The methodology applied in the present research is a cross-sectional one with two groups of ADHD and normal. The ethical aspect of the study was approved by the research council of the regional school board and oral consent was obtained from each subject. Subjects in both groups were matched for sex, age and grade of study. Data were collected over a period of four months. Each subject completed the Child Abuse Self Report Scale by the help of an assistant psychologist separately. After establishing the rapport, the assistant read clearly each item of the questionnaire for the participant and helped the subject to record the answers.Thirty ADHD students (10 girls and 20 boys) aged 7-12 were selected through a systematic sampling from the list of clients who were registered for receiving cognitive behavioral intervention in one of the children’s behavior disorder clinics of Shiraz school board from September to December of 2011. The subjects were included in the ADHD group when his/her file showed he/she was diagnosed as ADHD by a psychiatrist, after meeting the DSM-IV criteria for ADHD. We excluded the participants with a current major depression, bipolar disorder, psychotic disorders, a lifetime history of traumatic brain injury, autistic disorder, and mental retardation. Thirty control subjects (10 girls and 20 boys) were recruited through multistage cluster sampling from Shiraz elementary public schools. To recruit the sample, we first randomly selected one girls’ and one boys’ public school from the list of public schools in each region of the Shiraz school board (Shiraz school board has four regions), and then 30 students were selected from the selected schools randomly.The subjects were included in the normal group when they had no history of mental health problems. There was no significant difference between the ages of both groups (P>0.00). 28 The writers made CASRS for use in Iran. They showed that the test is a good tool for measuring child abuse in Iran. CASRS is a 38-item self-report questionnaire measuring four areas of abuse.  Each response is rated at four points of Likert scale ranging from never to always. The  authors who made the test reported its internal consistency between 0.87 and 0.95 and the test-retest reliability of the scales between 0.82 and 0.89. They also reported strong discrimination ability, and convergent and construct validity for CASRS.28 Each item is scored from 0-3. A score of “0” is given for no abuse or neglect responses and a score of “3” is given for severe abuse or neglect. As the number of items in each subtest is different, the users calculate the mean of each subtest; thus, the scores for the test and each subtest range from 0-3. In addition, the researcher collected some demographic data including age, gender, parents’ education and parent s’ age.Data were collected using Child Abuse Self Report Scale (CASRS).Descriptive statistics were used to describe the percentage of child abuse. The severity of abuse was classified into three levels based on each participant’s mean. When the average score of a subject was under 0.75, she/he was classified into the no abuse group. In case the average was over 1.75, we classified the subject into the moderate abuse group. Scores between 0.76 and 1.74 were put in the mild abuse group. We held each type of child abuse as a dependant variable and to test significant differences in child abuse between groups a one-way multivariate analysis of variance (MANOVA) was performed. To follow-up after rejecting null hypothesis or post-hoc test, we applied the Least Significant Difference (LSD) procedure for the matched groups. Data analysis was performed using SPSS 16 version. Multivariate analysis of variance (MONOVA) was used to analyze the data. As As a follow up, ANOVA with pair-wise comparisons using the LSD procedure was applied to determine which of the possible comparisons between the means of the two groups was indeed statistically significant.  The result is shown in ADHD children in comparison with normal children had experienced more psychological, physical and neglect maltreatment. It means, ADHD persons were more likely to be a victim of abuse than normal children. 29,30 A meta-analysis research with the use of 13 independent samples provided a global estimate of the prevalence of neglect. They reported 16.3% for physical neglect and 18.4% for emotional neglect.30Psychological abuse and neglect are linked to each other and can be categorized as one item.31 Some researchers definetwo subtypes of neglect. Physical neglect refers to the ignorance of children’s physical needs, such as providing sufficient food, clothing, and care. Emotional neglect refers to ignorance of children’s emotional needs, such as providing adequate attention and affection.32 Emotional abuse and neglect are the most hidden and underestimated form of child maltreatment because there is no simple definition of them and they do not leave any physical traces on the victims. As a result, many offenders do not believe that they have abusive behaviour. They point out that their behavior was not intentional and they were weakly equipped with parenting information to manage efficiently children’s demands.33 Some researchers indicated that emotional abusive parents did not know how they can deal effectively with children they showed fewer coping skills, fewer child supervision strategies, and more trouble in establishing a relationship.33 It is unfortunate that less parenting literacy is more likely to be involved in child maltreatment. The results revealed a significant difference between the total score of abuse in the two groups of ADHD and normal. Further results of this study indicate that children with ADHD received significantly more maltreatment than the normal group. There are some reasons for this result. ADHD parents may be completely unaware of the effect of psychological abuse on children, so they use a strict discipline when they are under stress or tired of their children’s behavior. Another reason is lack of parenting skills particularly lack of knowledge about alternative positive behavior.The current result showed that many participants are subject to neglect and psychological abuse in their lives.  The frequency of such abuse for them is higher than other types of abuse. Nearly 60% of participant experienced neglect and 35% psychological abuse. These rates are higher than those already reported. Depending on the definition and measurement tools, the prevalence of psychological abuse was reported between 0.69 to 25.7 percent of children.34 The majority of parents and caregivers have limited knowledge about children with special needs. They have not learned coping strategies to help to communicate and deal with ADHD children. They need to achieve some parenting education, especially on non-violent interventions. A parent educational program is a systematic workshop that is run by a mental health professional including a psychologist, psychiatrist and psychiatric nurses aiming at improving one’s parenting skills  while he/she is working with ADHD children. The other aims of the parent educational programs are increasing self-confidence of the parents and reducing parental stress.35The result of the current research suggests that we have to work on primary prevention strategies in the field of child abuse before it occurs. Since emotional abuse may occur in very subtle varieties, primary prevention is very difficult. Two common interventions, such as parent education and home visiting programs, are suggested.36The aim of a home visiting program is to improve the wellbeing of the child and family by assessing family problems and resources. Home visiting program is run almost by a nurse. A home visitor helps family members to move ahead to reach self efficacy, effective communication and decrease the risk of child maltreatment. Sometimes she may refer them for other supports or professional aids.Based on the findings of this research, we can conclude that ADHD children are more likely to be victims of violence and neglect. They receive more psychological abuse and neglect. Therefore, we suggest mental health education and training for the society and families.


Although the prevalence of substance use disorder (SUD) with co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) is relatively high in adult patients, there is hardly any knowledge about these dual diagnoses. A recent study reported met- and unmet needs for several life domains regarding these patient groups. To improve treatment, it is necessary to identify the everyday life consequences of SUD and co-occurring ADHD or ASD in adult patients.Qualitative study using in-depth interviews. 11 SUD + ADHD and 12 SUD + ASD patients participated in the study. The interview transcripts were coded and analysed according to the seven steps for descriptive phenomenology by Colaizzi.Both patients with ADHD and patients with ASD can get caught in a jumble of thoughts and emotions which can often lead to agitation and impulsivity in the case of ADHD or passivity and melancholia in the case of ASD with co-occurring SUD in both cases. Initially substance use ameliorates the symptoms and related problems, but both patient groups can later experience even greater problems: difficulties with the structuring of daily life due to a lack of planning (SUD + ADHD) or due to a lack of initiative (SUD + ASD). Both groups indicate that structure helps them function better. They also recognize that substance use disorganizes their lives and that an absence of structure contributes to substance use in what becomes a vicious circle which needs to be broken for effective treatment and care.This study provides insight into the daily life consequences of SUD with a co-occurring ADHD or ASD. Substance use is reported to solve some ADHD- or ASD-related problems in the short run but have negative consequences in the long run . Insight is provided into what clinicians can do to break this vicious circle and thus help ADHD patients to refrain from action and ASD patients to take action. For clinical purposes and needs assessment, current co-occurrence is more important than life-time co-occurrence.Mental disorders can frequently co-occur with a substance use disorder (SUD) or some other disorder. Such co-occurrence is often referred to as a n = 122, n = 54 and n = 70 respectively) in these studies, however.The co-occurrence of SUD and other mental disorders is very common: about 50% of individuals with severe and persistent mental disorders are affected by substance use -3. Some A very recent study showed about 1% of the general population to have adult ADHD with a co-occurring SUD while 0.1-0.2% of the general population has an ASD with a co-occurring SUD .Studies have further shown the co-occurrence of SUD with other psychiatric disorders to be associated with not only ineffective treatment and care but also an unfavourable treatment course and outcome -14. In aIn light of the above, we undertook a qualitative, interview study to answer the following research question: What are the everyday life consequences of substance use in adult patients with a substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) from a patient’s perspective?A qualitative, interview study was conducted among a population of treatment-seeking patients with a dual diagnosis of SUD and ADHD or SUD and ASD.Open, in-depth semi-structured interviews were used in which patients in both groups were questioned about the consequences of their illness for everyday life using the patient’s perspective as the guiding principle. The study was approved by a certified medical ethics committee (Commissie Mensgebonden Onderzoek Regio Arnhem-Nijmegen) and by the institutional review board of Dimence (Commissie Wetenschappelijk Onderzoek). All participants signed informed consent for participation in the study.The interviews were conducted first with a group of SUD + ADHD patients in the period of December 2011 to May 2012 and then with a group of SUD + ASD patients in the period of June 2012 to October 2012. All of the interviews were conducted by one of two researchers who thus conducted half of the interviews for each patient group. The interviews were then transcribed verbatim.Patients with SUD and a co-occurring ADHD or ASD were recruited using the following inclusion and exclusion criteria. Inclusion: outpatient treatment for SUD; age 18–65; IQ >80; current DSM-IV diagnosis of SUD and current DSM-IV diagnosis of ADHD or ASD; mastery of the Dutch language. Exclusion: diagnoses of SUD and both ADHD and ASD. All patients were recruited from an outpatient, dual diagnosis, treatment facility in the Netherlands.both ADHD and ASD in addition to SUD and therefore excluded from further inclusion, leaving a total of 63 eligible patients.Out of 122 patients, 72 told that they were willing to participate in the further study. Of these 72 patients, nine were diagnosed with A total of 37 SUD + ADHD patients were then approached for this study: seven patients could no longer be reached and 13 refused to participate despite their initial willingness to do so. An interview was thus planned for 17 patients, but 5 did not show up then. One patient also had to be excluded due to hospitalization at the time of the planned interview. This left 11 SUD + ADHD patients to participate in the study.A total of 26 SUD + ASD patients were approached for this study as well: 5 could no longer be reached and 7 refused to participate despite initial willingness to do so. An interview was planned for 14 patients, but 2 of them did not show up. In the end, 12 SUD + ASD patients were interviewed for a total of 23 patients participating in the present study.Impairments, unmet needs, and clearly met needs were probed for a number of life domains . Then both interviewers independently selected and coded significant statements (steps 2 and 3). Related codes were then identified and grouped together under the themes they represented (step 4). Thereafter, a subset of 6 of the 23 interview transcripts was coded by both researchers and the findings compared.After the completion of the first 7 interviews for each of the patient groups, an interim analysis was performed (step 5). The results of this analysis were then used to guide the subsequent interviews. The emerging themes and insights were thoroughly discussed in preparation for the subsequent interviews.In the subsequent interviews, the themes identified in step 5 were used to determine whether new codes would emerge which could not be grouped within the existing themes or data saturation was reached.In the next step of the analyses, the interviews from the two groups were examined as a whole but also compared to identify general and group-specific themes (step 6). The outcomes of the analyses were then summarized and sent to the participants for feedback and validation of the results . Unfortunately, none of the participants responded to our request for a written member check.For both patient groups , the need for care according to the EuropASI  thinking that fast and much, and often we [people with ADHD] fill in many things by ourselves, and pick things up, a lot. That’s why things come on stronger to us [people with ADHD] and stick longer. (SUD + ADHD 11)The jumble of emotions experienced by both groups of patients led to a vicious circle of negative thinking and feeling which led to vicious circle of symptoms and substance use. Both groups mentioned getting caught in this vicious circle and not being able to get out of it by, for instance, stopping the flow of negative thoughts and emotions.The patients in the SUD + ADHD group frequently stated that they could not handle the flood of thoughts and emotions which they experienced. This could lead to agitation, which could trigger further impulsiveness. What is meant here is that patients cannot put the break on and therefore race past their own and others limits with serious negative consequences, such as using more addictive substances and/or experiencing more interpersonal conflicts.I always go on, and on, and on (…) you just get tired and more tired. The consequence of this is becoming less focused, and that makes you more and more impulsive. (SUD + ADHD 11)Especially when I’m tired and worn out, I become very hyper (…) then you go bouncing. Becoming more inefficient. (…) what I’ll often do then, when I’m totally worn out, is use drugs … really lots of them.... (SUD + ADHD 7)I’ve got the idea that I can get lost in my head, in thought, which makes me lose time sometimes and that is what’s keeping me from getting to action. (SUD + ASD 3)By now I know my mind is processing data very slowly, and if I want to live a pleasant and meaningful life then I’ll have to stop working as hard as I did before and I shouldn’t want to anymore. But that’s a hard nut to crack. (…) and to me that’s still intense and it really makes me worry about if I’ll get a girlfriend ever? Will I ever get to live with someone? (…) And sometimes that really makes me sad (…). It makes me feel lonely. (SUD + ASD 2)I was longing for a relationship for a long time, because that’s the standard. However, it being the standard is not a very good reason to have a relation, I guess. (…) I’ve been in bed with a girl sometimes, and then I’m lying there and I just don’t know what to do, how to act, what’s normal. (SUD + ASD 4)In contrast, patients in the SUD + ASD group frequently expressed that the overload of stimuli caused by the jumble of thoughts and emotions made them passive and melancholic. This obviously had a negative impact on their quality of life. Feeling lonely and searching for some perspective in life are frequently mentioned by patients with SUD + ASD. In a relationship or similar contact, passive and melancholic feelings were also often reported to stand in the way of sexual activity.Giving myself a bit of peace, so it doesn’t get out of control. That my brain stops thinking, particularly. Stops going on, and on, and on. (SUD + ADHD 8)Then we had children, and the stress got higher. (…) Well, I started drinking, just to inhibit the stimuli, to subdue them. (….) that helped me get through the evening. It was just to survive, not for the booze. (SUD + ASD 3)Substance use was reported to serve a clear purpose for both of the patient groups. It suppressed the jumble of thoughts and emotions, the agitation, and the melancholia. For the SUD + ADHD group, substance use served to decrease the level of hyperactivity but was also often boundless: one bottle of beer led to the drinking of an entire case. For the SUD + ASD group, substance use was reported to help suppress the jumble of thoughts and emotions, to help them relax and get through the day, and to help them escape feelings of pure boredom.Especially when I had a relapse or used again, then I noticed becoming disordered for a long period. (…) and that’s when you let impulses rule you. (SUD + ADHD 11)It has the effect that I don’t function properly, and that I hardly eat (…) Everything gets worse by using. (SUD + ASD 10)At the same time, the patients from both groups reported substance use to worsen their symptoms and the problems stemming from their ADHD or ASD.I can’t restrain that, I just do it. I’ll blow, quaff or snort, there’s no restraint whatsoever. I can’t go and drink one beer, one beer becomes a case. (SUD + ADHD 6)Stopping with substance use was reported to produce clear benefits by most of the SUD + ADHD patients. They experienced better physical and mental health as a result of quitting. They nevertheless indicated that quitting was a struggle because everything which their substance use had suppressed came to the surface … and then more intensively. They further observed that balanced use or controlled substance use in moderation was something which they could not manage and therefore not an option.… I have decided that I won’t be quitting drinking fully, because I noticed a great part of my social life will be gone and to me that’s not worth it, and I don’t know how it could be done without the booze. (SUD + ASD 2)One of the SUD + ASD patients reported that it had been relatively simple to stop and that he was not using anymore, but the remainder of the SUD + ASD group reported still using. These patients also reported searching for a way to achieve a kind of balanced use — mostly with professional guidance.But, if you get me sitting at home, then you’ve got another alcoholic, that doesn’t work out. To me, that’s my structure, my work and so forth. (SUD + ADHD 5)A company for career counselling helps me to reintegrate in work, and I told them I don’t want to work in a big warehouse or with a boss or colleagues that will rouse me, because that will go wrong. And I don’t want to go back to my old lifestyle, that I’ll just have to smoke a joint in the evening. (SUD + ASD 6)I noticed that when I neglect the housekeeping I also get more noise, more thoughts in my head (…) so I am very occupied with getting more discipline in housekeeping. (SUD + ASD 2)Both groups indicated that structure made them function better in many areas of life: daily activities, social relationships, finances, physical health, and sexuality. Having daily activities, a job, and family further helped them structure their lives and gave it meaning. Structure contributed to break out of passivity and control impulsiveness.lack of structure contributed to substance use and substance use contributed to a further lack of structure.When I don’t have a reason to get up in the morning (…) then I tend to stay in bed and take it easy. I’ll smoke a joint in the morning and will go back to sleep again. So, I noticed, I need structure in my life. (SUD + ADHD 3)I find it hard to fill my time — I don’t have many hobbies — although structure is very important. It happened that I got so bored that it made me think: let’s drink tonight, so tomorrow I’ll sleep it off and then another half day is filled. (SUD + ASD 5)Both groups further noted — as indicated in the preceding and following quotations — that substance use disorganized their lives. In a vicious circle, I plan my time very inaccurately, and that takes a lot of energy, takes a lot of effort. (…) Yes, that’s the result. I get distracted by impulses, and I get distracted easily, and that is what makes you spend time on the wrong things. (SUD + ADHD 11)I don’t know what to do if someone shares his emotions, that makes me become very nervous. So I’ll walk away. I had an affair with a woman for four years, and when things went wrong I walked away. I don’t know how to handle that. That’s not my cup of tea. (SUD + ADHD 5)A lot of debts, once 3000 euros (…) because of my impulsivity, of course. Not because of using weed, no, I just bought all kinds of things. (SUD + ADHD 10)Patients in the SUD + ADHD group reported frequent problems with the actual structuring of activities. They mentioned knowing what they wanted to do, having the necessary skills for social relationships or to make plans, and believing that they could handle matters effectively. But they found it hard to prioritize, keep focus on the task at hand, and stay tuned into to not only their own needs but also the needs of others. The result was major difficulties with maintaining structure, sustaining relationships, and managing finances.Things get into a routine, that’s what I don’t recognize. (…) It may happen that I don’t get myself to work or do other things for half a day (…) things seem to get stuck in my head, like a needle in the groove of a record, and I can’t get out of it. (SUD + ASD 11)It doubles the handicap that you’ve got, makes it really hard to take stock of situations. And the drugs make you think even more … like … well … like passive. You get even more passive. (SUD + ASD 6)The SUD + ASD patients also experienced problems with structure but, in contrast to the SUD + ADHD group: they hardly knew how to spend their spare time, how to initiate a social relationship, and how to handle other matters; such as their finances or household.But, when I have got to sit in sober, that really gives me the jitters. (SUD + ASD 5)… it [using alcohol] makes it easier to put things in words, put it in words more quickly, react faster. (SUD + ASD 3)The thought of starting a social relationship or becoming socially active is reported to make most of the patients in the SUD + ASD group feel anxious and insecure. They reported not being able to easily join in with others and use substances to help them do this. Substance use suppressed feelings of insecurity and overstimulation/oversensitivity, made it easier for them to tune into people/situations, and helped them focus and react during interactions.I handed over financial and administrative matters to an administrator, voluntarily. In the past, those were daily activities that I didn’t get to. I noticed it, of course, that pile of bills lying there. But no, I was too scared to start on them. (SUD + ASD 4)A number of the patients in the SUD + ASD group also reported lacking sufficient insight in their finance, because they did not take initiative and felt they were not able to keep track of their finances.Overall, the interviews showed the patients getting caught in a vicious circle of symptoms and substance use in every life domain.underlying mechanisms appear to differ for the groups  but that the everyday life consequences of having a dual disorder are similar: both groups get caught in a vicious circle of symptoms and substance use. The cycle is more or less the same for the two groups: a jumble of thoughts and emotions; increased symptoms ; decreased structure; increased substance use; and occurrence of even more jumbled thoughts and emotions . The problems that are solved by EF are essential for adequate social functioning. EF is essential for adequate functioning in two main domains: inhibition and meta-cognition. Inhibition refers to the ability of the individual to inhibit motor, verbal, cognitive, and emotional activities. Meta-cognition refers to the individual’s nonverbal working memory, verbal working memory, planning abilities, problem-solving abilities, and emotional self-regulation .For alcohol-dependent patients, research shows that almost all executive functions are impaired -21. For Barkley  recentlyASD is also associated with impairments of both inhibition and meta-cognition ,23. PatiThe results of this qualitative, interview study show how SUD creates a vicious circle of symptoms and substance use in patients with a dual diagnosis of SUD and ADHD or ASD. We also gained insight with this information into what clinicians can do to break the vicious circle of symptoms and substance use: SUD + ADHD patients should be helped to refrain from action and SUD + ASD patients should be helped to take action. Patients should be helped to create and maintain structure in their lives, and their self-management skills need to be strengthened to do this. In addition, SUD + ASD patients may initially be offered controlled substance use in the absence of appropriate behavioural alternatives for the realization of a treatment goal. A patient with SUD + ASD, for example, may be helped to engage in social activities with reduced drinking  and thus to master the behavioural repertoire needed to participate in social activities .help but are not very likely to fully restore the cognitive functioning of individual with a dual diagnosis of SUD and ADHD or ASD. The goal of the treatment and care for these patients should thus be maximization of their long-term welfare — however the patient defines this — by helping them to break the vicious circle of symptoms and substance use. Support, reinforcement of available skills, and viable alternatives for cognitive impairments should always thus be considered.Clinicians should nevertheless realize that reduced substance use or total abstinence will not always result in better planning, greater structure, or increased initiative. The cognitive impairments arising from SUD add to the often chronic, cognitive impairments associated with ADHD and ASD, which means that reductions in substance use may The conduct of the interviews in the present study by two independent researchers increases credibility and reliability . AnalysiThe group of responders and non-responders were comparable with regard to the intensity of care, which suggests that our patient population was representative. A limitation of the study was that the researchers did not use cross-over blind coding, which would have added to the reliability. Other possible limitations were that the SUD + ASD group included only males and that co-occurring mental health conditions aside from ADHD and SUD or ASD and SUD were not assessed.With regard to the everyday life consequences of SUD with co-occurring ADHD or ASD, it can be concluded that the underlying mechanisms appear to differ for the groups  but that the everyday life consequences of having a dual disorder are the same: both groups get caught in a vicious circle of symptoms and substance use. Our findings show SUD co-occurring with ADHD or ASD to be associated with EF impairments and thus have consequences for the daily life functioning and social interactions of patients. To help patients cope with these cognitive deficits, their treatment and care should be aimed at the areas of time management, organization, problem solving, self-control, motivation, and the regulation of emotions . An inteFurther examination of the actual experiences of patients is needed to provide a clear basis for their treatment. The treatment and care experiences of patients with ADHD or ASD and a co-occurring SUD should be examined, for example, in order to gain insight into their opinions about what contributes to their recovery and which coping strategies should be reinforced and stimulated.


Background: Adults who present ADHD symptoms have an increased risk for vehicle accidents. One conceivable overlooked account for this association is the possibility that people with ADHD symptoms use rewarding technologies such as social networking sites (SNS) while driving, more than others. The objective of this study was to understand if and how ADHD symptoms can promote SNS use while driving and specifically to conceptualize and examine mechanisms which may underlie this association. To do so, ADHD is viewed in this study as an underlying syndrome that promotes SNS use while driving in a manner similar to how addictive syndromes promote compulsive seeking of drug rewards.Methods: Time-lagged survey data regarding ADHD, stress, self-esteem, SNS craving experience, SNS use while driving, and control variables were collected from a sample of 457 participants who use a popular SNS (Facebook) and drive, after face-validity examination with a panel of five users and pretest with a sample of 47. These data were subjected to structural equation modeling (SEM) analyses using the frequency of ADHD symptoms measured with ASRS v1.1 Part A as a continuous variable, as well as multivariate analysis of variance using ADHD classification based on ASRS v1.1 scoring guidelines.Results: ADHD symptoms promoted increased stress and reduced self-esteem, which in turn, together with ADHD symptoms, increased one's cravings to use the SNS. These cravings ultimately translated into increased SNS use while driving. Using the ASRS v1.1 classification, people having symptoms highly consistent with ADHD presented elevated levels of stress, cravings to use the SNS, and SNS use while driving, as well as decreased levels of self-esteem. Cravings to use the SNS among men were more potent than among women.Conclusion: SNS use while driving may be more prevalent than previously assumed and may be indirectly associated with ADHD symptoms. It is a new form of impulsive and risky behavior which is more common among people with symptoms compatible with ADHD than among others. Consistent with addiction and decision making models, SNS use while driving can be viewed as a form of a compensatory reward seeking behavior. As such, prevention and reduction interventions that target the mediating perceptions and states should be devised. This [using smartphones for email and social networking while driving] is much worse, but we blindly accept this clash of technologies which is costing thousands of lives” Hanlon, .Attention deficit/Hyperactivity disorder (ADHD) is a neurodevelopmental psychiatric impairment which normally develops before the age of 7 years; it manifests through symptoms involving high distractibility, poor sustained attention, and high impulsiveness-hyperactivity  while driving makes accidents 23 times more likely  before completing the online surveys, and were given bonus points in their courses in exchange for their time. We began with a panel of five SNS users for face-validity examination, followed by a pilot study of 47 participants  for scale pre-testing and validation. The pilot survey captured additional conceptually related measures (urge to use the SNS and the Temptation and Restraint inventory applied to SNS) as a means to establish internal validity, as well as self-reports of one's extent of SNS use as a way to establish predictive validity.Time-lagged data for testing the model were then collected from a sample of 457 participants  from the same university, using the same exclusion-inclusion criteria used in the pilot study. Data from this sample were collected at two points in time, one week apart, using online surveys posted on the class website. ADHD, self-esteem and control variables  were measured at week 1. Stress, craving and SNS use while driving experienced after the first wave of data collection (“over the last week”) were captured in the second wave, at week 2. The time-lag design was employed to increase support in causality arguments and for reducing potential common method bias. Sample characteristics are outlined in Table n = 47) measured craving to use the target SNS, Facebook, using the Facebook Craving Experience (FaCE) scale which is an adaptation of the Alcohol Craving Experience (ACE) questionnaire  adapted from Raylu and Oei  and cognitive-behavioral control efforts regarding Facebook use . Predictive validity was established through association with self-reported extent of Facebook use  adapted from Turel  ADHD  stress  facilities of AMOS 23 following the two-step approach  as well as correlations among them were calculated. These are given in Table 2/df = 2.40, CFI = 0.95, IFI = 0.95, GFI = 0.93, RMSEA = 0.056, and SRMR = 0.066. Therefore, the structural model was estimated. In this model, ADHD, stress and self-esteem were modeled as latent factors and craving was modeled with an index which was calculated based on the procedure described in Statham et al.  model was estimated with the multiple item constructs: ADHD, self-esteem, and stress and components of the FaCE scale. It presented good fit: χm et al. . The modp < 0.01) and 0.07 (p < 0.01), respectively. This further validates the proposed two-step indirect effect of ADHD on Facebook use while driving.First, the proposed model implies a two-step partial mediation of the effect of ADHD on SNS use while driving, through stress, self-esteem and then through cravings. In order to examine these indirect effects, we employed the bootstrapping procedure described in Preacher et al.  with 200n = 110, 24%) or not . This binary variable represents a rough initial clinical assessment of potential ADHD  = 9.2, p < 0.000). The differences between groups for each variable were also significant , which together with ADHD symptoms exacerbated cravings to use the SNS . The elevated levels of cravings directly drove SNS use while driving, lending support to H3.The findings based on a two-wave survey of users of a popular SNS who drive to work/school lend support to these views. They show that the severity of ADHD symptoms is positively associated with SNS use while driving. There are also significant differences between the self-reported SNS use while driving behaviors of those who have symptoms highly consistent with ADHD and those who do not. The The first contribution of this study is in pointing to an important yet unexplored risky behavior associated with ADHD symptoms, namely SNS use while driving. Thus far, research has primarily focused on a family of risky behaviors associated with ADHD, which includes deviant work and interpersonal behaviors, gambling and substance use behaviors  behavior; and in essence prevent the translation of ADHD symptoms into this behavior. Specifically, our findings imply that the use of SNS while driving can be reduced through decreasing one's cravings to use the target SNS and his or her stress, while increasing his or her self-esteem. While we did not test techniques for achieving these changes, prior research implies that such changes may be attained through behavioral therapy interventions  and the traffic conditions. Such variables may be accounted for in future research. Third, while we imply association of the examined processes to brain systems involved in impulsions, cravings and inhibition, these were not tested. We hence call for future research to use additional techniques, such as fMRI, to corroborate our findings, and add a brain functioning layer to our understanding of the association between the examined constructs. Lastly, this study has focused on one instance of SNS, Facebook. While Facebook is perhaps the most popular SNS, there are many other SNS which can be presumably also used while driving. Future research should examine our model with other SNSs and/or risky and rewarding behaviors in order to increase its generalizability.ADHD and addictive syndromes are rooted in deficits in similar brain systems involved in impulsion generation and control. In this study we showed that consequently, risky behaviors among people with symptoms consistent with ADHD can be explained using an addictive symptom perspective. We also demonstrated that SNS use while driving is a growing problem in society, and that it is more prevalent among people with symptoms consistent with ADHD. Future research should further study these phenomena and explore ways for reducing risky technology use while driving.The first author (OT) was involved in study design, implementation, execution, data analysis and write-up. The second author (AB) was involved in study design, theorizing and write-up.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood.This study was designed to estimate the prevalence of ADHD in adult psychiatric outpatients in several European countries.ADHD diagnosis was made using the Diagnostic Interview for ADHD in Adults, version 2.0 (DIVA), according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) and 5th Edition (DSM-5).Of 5662 patients present/approached, 2284 (40.3 %) consented, of whom 1986 patients (87.0 %) completed the study. Based on the DIVA, and applying DSM-IV-TR or DSM-5 criteria, 15.8 %  or 17.4 % (95 % CI 15.7 %-19.0 %) of patients were diagnosed with ADHD, respectively. The prevalence of ADHD was 15.3 % when counting as non-ADHD those patients who screened positive but did not complete the DIVA (DSM-5).Estimates from this study indicate that a relevant part of the psychiatric outpatient care population suffers from ADHD. There is growing recognition that undiagnosed and untreated attention-deficit/hyperactivity disorder (ADHD) can result in multiple negative consequences for the individual’s life as well as for society. Adults with ADHD tend to suffer from major socioeconomic disadvantage , functioADHD is also associated with a number of comorbid psychiatric disorders, such as mood, anxiety, and substance use disorders . KnowingThere are a number of studies available regarding the prevalence of ADHD in the general population. For example, a meta-analysis by Simon and colleagues  determinPrevalence of ADHD is expected to be higher in the psychiatric outpatient population than in the general population, but only a few estimates are available. Almeida Montes and colleagues  found inThis was a multinational study conducted in Austria, Belgium, Denmark, Germany, The Netherlands, Spain, Sweden, and the United Kingdom. The study aim was to reflect the situation and presence of adult patients with ADHD in the psychiatric outpatient health care system in each country or a pool/group of countries with a similar mental health care organization. Therefore, the study was not conducted at specialized ADHD centres, but at sites providing general psychiatric care to a population as unselected as possible in the respective health care system. Four types of sites were defined to achieve this goal: general psychiatry outpatient clinics linked to general hospitals, private psychiatric practices, community mental health centres, and outpatient clinics of psychiatric hospitals. The distribution of sites was intended to reflect the different levels and various settings of outpatient mental health care in each participating country and to examine a representative population of adults using outpatient psychiatric care. However, for some countries, because of the limited number of sites able to participate, the results might not be as representative as intended.At each study site, all patients, regardless of their existing diagnoses (including ADHD), were invited to participate in the study. The sites were asked to approach all patients during their normal clinic days during prespecified times and days of the week until their predefined number of entered patients per week was reached. These prespecified inclusion periods varied over the course of the study to cover all working days and times (to ensure that a representative population of that specific facility was included). Inclusion criteria were 1) males or females attending psychiatric outpatient care, ages 18 to 65 years; and 2) having signed an informed consent to release information prior to any procedure. Exclusion criteria were 1) mental disability or disease state to an extent that prevents the patient from understanding the nature of the study or that prevents the patient from reliably following procedures; and 2) psychotic disorder at presentation or from patient’s history , however, treatment with antipsychotics for other indications was not an exclusion criterion.This study was submitted to ethical review boards (ERBs) for approval whenever required by local law. In addition, regardless of local law, this study was submitted to at least one independent body  per country for review and to confirm that the study was considered noninterventional in that country. Regulatory authorities were notified and approval sought as required by local laws and regulations. Progress reports were submitted to ERBs and regulatory authorities as required by local laws and regulations. This study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki and that are consistent with good clinical practice (GCP) and applicable laws and regulations of the countries where the study was conducted.After having provided their informed consent for the release of their anonymized data, patients were assessed clinically, using solicited questions and diagnostic instruments . Screening procedures closely followed the guidance given in the European Consensus Statement of the European Network Adult ADHD . After cA positive screen according to the ASRS (at least 4 out of 6 responses exceeding threshold) or the PDI-4 ADHD questions (at least 3 out of 4 responses exceeding threshold), a previous ADHD diagnosis, or suspicion of ADHD by clinical impression resulted in further assessment using the Diagnostic Interview for ADHD in Adults (DIVA)  accordinThe following scales/questions were given to all subjects, regardless of the outcome of ADHD screening. Clinical Global Impressions-Severity (CGI-S) , a cliniIn addition, patients were asked questions covering known ADHD related aspects concerning general health and conduct of life.Since the analyses were largely descriptive and exploratory, p-values were not calculated. Confidence intervals  were used as descriptive measures only and were not meant to support statistical inferences. No correction for multiplicity was done.The prevalence of ADHD in outpatient psychiatric care was estimated using the DIVA. The denominator comprised all patients who completed the screening instrument, excluding any who had a positive screen but were not assessed using the DIVA. A sensitivity analysis was also completed to assess the effect of excluding these patients.The association of ADHD diagnosis with a subset of endpoints was analyzed using regression models , adjusting for age, gender, and country.Of 5662 outpatients present at sites during the study and approached, 2284 (40.3 %) were included. Reasons for ineligibility in the study are listed in Fig. Based on the DIVA (using DSM-IV-TR criteria), 15.8 %  of all participating patients suffered from ADHD  and females (median 34 versus 43 years old). Of the 349 patients who were diagnosed with ADHD using the DIVA, 53.9 % had not been previously diagnosed with ADHD. Most of the patients who were diagnosed with ADHD with the DIVA had not been treated for ADHD in childhood (93.1 %), adolescence (90.8 %), or adulthood (67.3 %). Among patients with a known ADHD diagnosis prior to the study, average age at diagnosis was 28.1 (standard deviation 13.62) years.Considerable variability in ADHD rates was associated with country (range: 9.0 % to 30.8 %) Fig. . This vaThe prevalence of ADHD in women was less than in men . However, a greater percentage of women than men were diagnosed with ADHD for the first time during the study (60.4 % versus 47.8 %). Patients with ADHD were more likely to have a first-degree relative diagnosed with ADHD than patients without ADHD (14.9 % versus 3.7 %).The most common type of comorbid psychiatric disorder among patients with ADHD was depression. Within the ADHD group, depression was more commonly diagnosed among patients who were diagnosed with ADHD during the study  than among patients whose ADHD was known prior to the study . Anxiety disorder was also common among ADHD and non-ADHD patients  as well as more respiratory dysfunction (12.3 % versus 6.3 %). Diagnoses related to higher age were less common in patients with ADHD .Treatment with psychotropic non-ADHD medications is substantial for both groups. Logistic regression analysis indicated that patients with ADHD were less likely to be prescribed antidepressants than patients who did not have ADHD Table . HoweverOverall, the percentage of patients receiving psychotherapy was similar between the ADHD and non-ADHD groups, but the odds ratio (OR) points toward lower use of psychotherapy for patients with ADHD Table . PatientThere was a trend toward greater use of “other” therapy by patients with ADHD Table . Also, pOverall, ADHD and non-ADHD patients were similar in the number of visits to a psychiatrist Table . HoweverPatients with ADHD, as compared to patients without ADHD, had higher CGI-S scores (mean 95 % CI] 3.8 [3.7-3.9] versus 3.3 [3.2-3.3] points) and were more likely to be “moderately,” “markedly,” or “severely” ill (63.9 % versus 46.7 %). Among patients with ADHD, patients who were only diagnosed during the study were less ill (mean [95 % CI] CGI-S = 3.6 [3.4-3.8]) than patients previously treated for ADHD (mean [95 % CI] CGI-S = 4.1 [3.9-4.3]). On the SDS , the reverse of what we found.  Rao and Place [To our knowledge, this is the first multinational, cross-sectional study to evaluate the prevalence of ADHD in outpatient general psychiatric care in Europe. Given the high rate of psychiatric comorbidities in adult individuals with ADHD , 2, it snd Place  reportedWe found that the most common subtype of ADHD in our sample was the combined subtype (63.2 %). However, a recent meta-analytic review found that the most common form of ADHD in the general adult population is the inattentive type . It is pOverall, we noted considerable variability in prevalence of ADHD associated with country, possibly reflecting differences in the referral selection process in their respective health care systems.But what is even more relevant to patients, their treating mental health professionals, and the respective national health care system, is the impact of ADHD, in terms of well-being, functioning, and impairment. We found that, compared with patients who did not have ADHD, patients with ADHD had higher CGI-S scores (were more ill), which is an indicator of functional disability, as well. This observation was affirmed in that they reported more problems performing their usual activities on the EQ-5D, and more disability overall. The SDS results indicate that, on average, patients with ADHD have moderate to severe impairments in work, family, and social functioning, while the impairment of the other outpatients without ADHD is between mild and moderate. The high level of impairment may be related to the fact that ADHD is causing a chronic impairment in multiple domains, in contrast to episodic impairment in depression and impairment limited to one or a few domains as is usually the case with anxiety disorders . In addiIn agreement with previous studies from various geographic areas , 29–31, We also found that patients with ADHD tended to have lower academic achievement and were less likely to be employed full time (women only), even in comparison to patients with other psychiatric disorders. Though these results may be partially explained by the younger age of the patients with ADHD, we also found that those patients were more likely to have received vocational training than patients who did not have ADHD. These findings support earlier work showing that adults with ADHD, compared with controls, trended toward having lower occupational attainment and had significantly more academic problems in school .These data are also in line with earlier reports that adult patients with ADHD tend to have lower socioeconomic status , more fuFinally, we found that the prevalence of ADHD was slightly higher (17.4 % versus 15.8 %) according to DSM-5 criteria, as compared to DSM-IV-TR criteria. A similar conclusion was made in a study of patients seeking treatment for substance use . HoweverThe prevalence of ADHD in the general psychiatric outpatient population is so high that systematic screening for it is recommended, especially since the symptoms and complaints may relate to comorbid disorders so severe that genuine ADHD symptoms are masked. However, in this population the specificity of the common screening tools, like the ASRS, are weak, with only half of the patients screening positive having a confirmed diagnosis. Therefore, a thorough diagnostic assessment of ADHD, like we did with the DIVA instrument, is necessary. Because such an assessment takes a considerable amount of time (at least 1 hour per patient), it would be very useful to look for additional screening criteria that could improve the specificity of the existing tools with minimal loss of sensitivity.First, as this was an observational study, we cannot draw any conclusions regarding causality. We can present data regarding how certain patient characteristics are associated with an ADHD diagnosis, but we do not know if ADHD caused or contributed to any of those characteristics.Secondly, we have a substantial sample size for Europe overall, but our ability to make comparisons between countries is limited because of the small sample size for some countries and because settings, which had their own variability, were different between countries. However, our study procedures were set up to minimize selection effects by approaching each and every patient attending a study facility during carefully specified times. Careful attention was given to site selection for each country with the intention that the patients were representative. However, for some countries, because of the limited number of sites able to participate, the results may be less representative. In addition, variability in training/experience in assessing patients may have affected estimates of ADHD prevalence in different centers and countries.Third, other studies have shown that patients with ADHD tend to underreport lifetime inattention problems when giving their history and when completing scales ; howeverFourth, the high exclusion rate brings into question the generalizability of our estimates of ADHD prevalence. However, there appeared to be no relationship between exclusion rates and ADHD prevalence when measured by country.Fifth, patients who screened negative were not further tested using the DIVA, so we do not have an estimate of false negatives. However, the ASRS is a very sensitive instrument, so false negatives should have been minimal. In addition, a positive screen on the PDI-4 ADHD questions, a previous ADHD diagnosis, or suspicion of ADHD by clinical impression also resulted in a positive screen, further reducing the chances of false negatives.Our findings indicate that ADHD is present in a substantial proportion of nonpsychotic patients seeking psychiatric help. Compared to other psychiatric outpatients, they are among the most impaired and their medical resource needs are comparable and in some aspects higher than in patients without ADHD. It is hoped that data from this study contribute to a better understanding of the presence, the pattern of clinical presentation, and clinical picture of patients and of implications of ADHD in adult mental healthcare. This knowledge may be the basis for a better allocation of appropriate diagnostic and treatment resources and lead to a reduction of primary and secondary costs due to a more focused treatment once the diagnosis of ADHD can be properly confirmed or dismissed. Proper application of these findings may also result in a reduced burden to the patient due to earlier therapeutic interventions and as a consequence possibly better outcomes for patients with ADHD.Ethics commission, Medical University Vienna, Borschkegasse 8b/6, A-1090 Vienna, AustriaEthics commission for the state, Salzburg, SEBASTIAN-STIEF-GASSE 2, 5010 SALZBURG, AustriaEthics commission of the city Vienna, Thomas-Klestil-Plaz 8, A-1030 Vienna, AustriaEthics commission for the state, Niederösterreich, Landhausplatz 1, Haus 15B, A-3109 St. Pölten, AustriaAZ Sint-Lucas Brugge, Ethisch Comité, Sint-Lucaslaan 29, 8310 Brugge, BelgiumSint-Andriesziekenhuis Tielt, Lokale Commissie voor Ethiek, Krommewalstraat 11, 8700 Tielt, BelgiumAlgemeen Stedelijk Ziekenhuis - Campus Aalst, Ethisch Comité/ Dr. Fosselle, Merestraat 80, 9300 Aalst, BelgiumFreiburger Ethik-Kommission GmbH International, Mozartstraße 21, 79104 Freiburg, GermanyEthikkommission der Fakultät für Medizin der Technischen Universität München, Ismaninger Straße 22, 81675 Munich, GermanyEthikkommission an der Medizinischen, Fakultät der Universität Rostock, St.-Georg-Str. 108, 18055 Rostock, GermanyOtto-von-Guericke-Universität Magdeburg, Medizinische Fakultät, Universitätsklinikum Magdeburg A. ö. R., Ethikkommission, Leipziger Straße 44, 39120 Magdeburg, GermanyIRBN, Postbus 85, 6600 AB Wijchen, NetherlandsEC in Stockholm, SwedenCEIC Hospital U. Príncipe de Asturias, Secretaría Técnica, Ctra. Alcalá-Meco s/n 28805 Alcalá de Henares, Madrid, SpainCEIC Unidad de Investigación e Innovación/CEIC FHAG, Fundación Hospital Asil de Granollers, Av. Francesc Ribas s/n, 08402 Granollers, Barcelona, SpainCEIC Hospital Virgen de la Salud., Comité Ético de Investigación Clínica, Antigua Escuela de Enfermeras, Mª Ángeles Jimenez, C/ Alicante, s/n,1ªplanta-Despacho 4, 45005 Toledo, SpainCEIC de Euskadi, Dirección de Farmacia, Departamento de Sanidad, C/Donostia-San Sebastian, n°1, 01010 Vitoria- Gobierno Vasco, SpainCEIC Consorci Sanitari de Tarrasa, CONSULTA MEDICA CERCLE EGARENC., C/San Pere, 48. 3ªplanta, 08221-Tarrasa, SpainCEIC Central de Asturias, Centro Saludo Mental Siero., C/Maestro Martín Galache, SN., Pola de Siero. Asturias, SpainCEIC Hospital Ramón y Cajal. Planta −2 Dcha. Carretera Colmenar km 9.100, 28034 MADRID, SpainNHS, Health Research Authority, NRES Committee South Central - Berkshire B, Bristol REC Centre, Whitefriars, Level 3, Block B, Lewins Mead, BS1 2NT Bristol, United Kingdom


To the Editor: Human contact with wildlife is a leading cause of disease spillover. Bats, in particular, host numerous zoonotic pathogens, from henipaviruses to lyssaviruses (Eidolon helvum) frequently and closely interacts with humans through roosting in urban areas and human harvesting of bushmeat. Large colonies live in Accra, the capital city, and >128,000 bats, on average, are hunted for food yearly in southern Ghana alone  in Accra. We used 3 testing approaches: culture, PCR, and indirect immunofluorescent assays for serologic testing. We tested serum specimens for antibodies against B. henselae, B. quintana, B. clarridgeiae, B. vinsonii vinsonii, B. elizabethae, and Bartonella strain E1–105, which had been isolated from E. helvum bats (We obtained serum samples from 335 volunteers from Accra and the Volta region who had close contact with Bartonella species. One human serum sample was positive for B. clarridgeiae by PCR, which was confirmed by repeat testing. No other human samples were consistently positive by PCR. Of 70 animal blood clots and 62 serum samples tested by using PCR, 1 serum sample from a cat tested positive for B. henselae. One human serum sample was positive by immunofluorescent assay for antibodies against B. henselae at titers of 1:128, another had reactivity to B. henselae at 1:64, and 1 sample was reactive at 1:32. Five human serum samples were reactive to B. quintana at titers of 1:32.All culture results for human and domestic animal samples were negative for Bartonella suggests that the species isolated from E. helvum bats never or rarely infects humans in Ghana. If Nycteribiidae bat flies serve as the vector for Bartonella transmission between bats as hypothesized, then the high host specificity of these vectors (Bartonella species or that these ectoparasites only bite bats. These facts must be confirmed because bat flies are occasionally found on other animals and whether the parasites can successfully use these animals as hosts is unknown (Bartonella species infection in E. helvum bats, as well as the species’ zoonotic potential, the current risk of spillover of this bat-associated Bartonella species appears low in West Africa. This fact may be useful in directing limited public health resources.The absence of evidence of any human exposure to bat-associated B. henselae in healthy human participants in this study was <1%. The low levels of seropositivity to B. henselae and B. quintana are consistent with those found in the only other study on Bartonella in humans in sub-Saharan Africa: a survey of 155 subjects in the Democratic Republic of Congo showed 1% seroprevalence of B. henselae and <1% seroprevalence of B. quintana (The seroprevalence to Bartonella species. For example, a study of febrile patients in Thailand found serologic evidence of exposure to Bartonella infection in 25% of patients (The results of study in the Democratic Republic of Congo and this study contrast with some studies in Asia and Europe, which show higher rates of human exposure to Bartonella infection in humans in Africa. Our study contributes to this nascent effort of understanding Bartonella on the continent. Because a substantial proportion of Bartonella prevalence studies have been done on hospital patients, our study provides a survey of the general population to help determine background infection rates and illuminate the complex risks posed by this zoonosis.Laudisoit et al. (


Autism spectrum disorder (ASD) symptoms frequently occur in subjects with attention deficit/hyperactivity disorder (ADHD). While there is evidence that both ADHD and ASD have differential structural correlates, no study to date has investigated these structural correlates within a framework that robustly accounts for the phenotypic overlap between the two disorders. The presence of ASD symptoms was measured by the parent-reported Children’s Social and Behavioural Questionnaire (CSBQ) in ADHD subjects (n = 180), their unaffected siblings (n = 118) and healthy controls (n = 146). ADHD symptoms were assessed by a structured interview (K-SADS-PL) and the Conners’ ADHD questionnaires. Whole brain T1-weighted MPRAGE images were acquired and the structural MRI correlates of ASD symptom scores were analysed by modelling ASD symptom scores against white matter (WM) and grey matter (GM) volumes using mixed effects models which controlled for ADHD symptom levels. ASD symptoms were significantly elevated in ADHD subjects relative to both controls and unaffected siblings. ASD scores were predicted by the interaction between WM and GM volumes. Increasing ASD score was associated with greater GM volume. Equivocal results from previous structural studies in ADHD and ASD may be due to the fact that comorbidity has not been taken into account in studies to date. The current findings stress the need to account for issues of ASD comorbidity in ADHD. Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are both severely impairing, highly heritable neurodevelopmental disorders Quantitative measures that reflect the severity of ASD and ADHD symptoms may be useful to characterise both disorders in terms of a continuous distribution in which clinical disorders represent extreme variants of typical behaviour Brain volume abnormalities are important indicators of pathophysiological processes that likely reflect disorder etiology. A number of meta-analyses have found reduced brain volume in ADHD in the majority of studies investigated (with ages ranging from ∼10–37 years of age) It is of note that the profile of changes in brain volume in ASD is different from that of ADHD, with findings suggesting that the brain undergoes a period of accelerated growth in the first four years of life before reaching a plateau within a normal range by adolescence, which in turn is followed by volume decline in adulthood relative to typically developing controls [21], [22–27]. Importantly, in young children with autism (2–3 years old) WM enlargement has been shown to be greater than GM enlargement  [28]. This WM enlargement in young children was then found to be reversed in 12–16 year old children with autism, with WM volume reduced relative to controls [28]. In older individuals with autism, voxel-based methods have also shown less WM intensity than in age-matched controls . However, a more recent meta-analysis has indicated consistent increases in WM volume in the right arcuate fasciculus and left inferior frontoocciptal and uncinate fasciculi in adults as well as in children and adolescents with ASD [31].For GM, several studies in adolescents and adults with ASD have reported a 6–12% increase in GM volume relative to controls Significant age-related improvements in ASD have been documented in adolescents and adults For ADHD, the ontogenetic onset of smaller brain size is not known, but there is some evidence that smaller brain volumes in ADHD persist to the end of adolescence Therefore, while there is evidence that both ADHD and ASD have specific and differential structural correlates, no study to date has investigated these structural correlates within a framework that robustly accounts for the phenotypic overlap between the two disorders. Only one study to date has directly compared brain volumes in ASD and ADHD The present study was based on the premise that the extent to which ASD symptoms occur in ADHD may have a pronounced effect on the profile of structural brain volumes in ADHD. Thus, MRI volumetric correlates of ASD symptoms in a large sample of ADHD probands, their unaffected siblings, as well as healthy controls were investigated. Mixed effects models, which controlled for ADHD symptom levels in the random effects structure of the model, were used to assess the relationship between global WM, GM and autism spectrum symptoms. As previous studies have found raised GM volume The study was approved by the Radboud University Medical Centre Research Ethics Committee and was in accordance with the Declaration of Helsinki. All participants over 18 years of age provided informed written consent. For participants under 18 years of age, informed written consent was obtained from the next of kin, caretakers, or guardians on behalf of the participants. This procedure was approved by the Radboud University Medical Centre Research Ethics Committee.SD = .72). For the present analyses, subjects were selected from the total data set (n = 1084) when the following data was available: a high quality T1-weighted MPRAGE image, complete information from the Children’s Social and Behavioural Questionnaire (that provides information on the autism spectrum symptoms), complete information from the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL) Participants were part of the NeuroIMAGE study. This is a prospective longitudinal MRI study (2009–2012) of the Dutch subsample of the International Multicenter ADHD Genetics (IMAGE) study performed between 2003–2006 All participants were assessed using a semi-structured diagnostic interview (Dutch translation of the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL) The Children’s Social and Behavioural Questionnaire (CSBQ) The CSBQ contains 49 items on a 3-point Likert scale. It contains items that refer directly to the DSM-IV criteria for autism, but it also captures more subtle symptoms of ASD. Therefore, it is suitable for measuring behavioural problems as seen in children with milder variants of ASD. CSBQ items are grouped into the following six subscales: (1) tuned, (2) social interest, (3) orientation, (4) social understanding, (5) resistance to change, and (6) stereotypy. It was administered in the parent-report form.All items contained within each subscale are found in the supplemental information . The CSBAn aggregate score from the four subscales, (1) social interest, (2) social understanding, (3) stereotypy and (4) resistance to change, was used in the current study to capture the core symptoms of ASD. This aggregate score has been successfully used to selectively probe ASD symptoms in previous studies 3, GRAPPA acceleration 2. Brain tissue probability maps for white matter (WM), grey matter (GM) and cerebrospinal fluid (CSF) were estimated using the unified segmentation algorithm as implemented in the VBM8 toolbox of SPM8 Whole brain T1 weighted MPRAGE images were acquired at 1.5T using a product 8 channel phased array headcoil on a Siemens Sonata scanner at the Free University in Amsterdam and a 1.5T Siemens Avanto MR scanner at the Donders Institute for Brain, Cognition and Behaviour in Nijmegen. A breakdown of the distribution of subjects scanned at the two sites is included in The following formula was used to compute normalised volumes of global GM and WM:3)/ICV (mm3)×1000.total volume of GM (mm3)/ICV (mm3)×1000.total volume of WM , while controlling for additional factors associated with the subjects (i.e. random factors).R statistical software (Version 2.15.1) Models were created using normalised WM and GM volumes. Including both WM and GM variables allowed us to determine not only the extent to which GM and WM drive changes in ASD scores, but also the nature of the interactions between the explanatory variables. WM and GM volumes were co-linear (i.e. correlated with each other) and the models developed took this into account by orthogonalizing these regressors relative to each other to isolate the unique contribution of each explanatory variable independent from what is shared between them. A WM residual term was derived from the regression residuals when WM was regressed against GM. This enabled us to use GM together with a WM residual term (WM resid) in our mixed effect model. A model using WM together with a GM residual term (GM resid) was also created. Un-biased analyses and comparisons could then be carried out based on the models.The models were fitted by maximum likelihood estimation. The starting model using GM resid and WM terms was:The starting model using GM and WM resid terms was:To determine if the model using GM resid or the WM resid term was a better predictor of ASD symptoms, the fits of the two final models was compared using the “anova” function in R The significant interaction between GM and WM was visualized by means of a contour plot. Normalised WM and GM volumes were used for creating this contour plot. ASD scores were modelled as follows: model = lm (ASD score∼GM*WM resid); where “∼” means modelled against, “*” means interacting with, and, “lm” is used to fit a linear model in R. A matrix was created for the WM and GM volumes, and the function was run from the minimum to the maximum GM value within the matrix, and also from the minimum to the maximum WM value within the matrix. The contour plot enabled changes in ASD scores to be visualised by means of a colour key with darker colours representing lower ASD symptoms and lighter colours representing higher ASD symptoms.The demographic characteristics of the cohort are shown in Following model simplification based on AIC, the optimal model for ASD symptoms is shown in For the fixed effects of the WM resid:GM model, the following terms were significant: WM resid (p = 0.019); ADHD diagnosis (p<0.0001); male gender (p = 0.006); WM resid×GM interaction (p = 0.028); ADHD diagnosis×age (p = 0.001).As the range of ASD scores in control and unaffected siblings is limited, a mixed effect model was also developed based on the inclusion of participants with an ASD score of 20 or higher. This model also returned a significant WM resid×GM interaction  has been successfully used to probe ASD symptoms in the past Overall, the current results highlight a specific volumetric profile that is associated with elevated ASD symptoms. This is the first study in a large cohort that robustly accounts for the phenotypic overlap between the ADHD and ASD. Equivocal findings in previous volumetric studies of ADHD and ASD may be due to the fact that issues of comorbidity have generally been ignored in studies to date. Assessing the range of volumetric profiles associated with ADHD coupled with mild ASD symptoms, through to ADHD coupled with severe ASD symptoms, will help to develop a more nuanced understanding of the pathophysiology associated with the continuous distribution and overlap of these two disorders.Table S1Medication Information.(DOCX)Click here for additional data file.Table S2Distribution of Scanning over Two Sites.(DOCX)Click here for additional data file.Table S3Correlation between ASD score and ADHD symptom levels.(DOCX)Click here for additional data file.Table S4Final, generalised mixed-effect model for ASD score modelled against Grey MatterResidual and White Matter Volumes.(DOCX)Click here for additional data file.Table S5Final, generalised mixed-effect model for ASD score modelled against Grey Matter and White Matter Volumes using only participants with an ASD score of 20 or higher.(DOCX)Click here for additional data file.Diagnostic Algorithm S1Diagnostic algorithm for ADHD in the NeuroIMAGE sample.(DOCX)Click here for additional data file.Questionnaire Items S1Children’s Social and Behavioural Questionnaire (CSBQ) Summary.(DOCX)Click here for additional data file.