Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders, and in the majority of patients persists into adulthood. There is a lack of data regarding the risks of ADHD medication during pregnancy and breastfeeding. While some women may be able to discontinue without adverse effects, others may experience significant functional impairment. Due to the rising number of ADHD medication prescribed to women at child-bearing age, it is important to determine which medications can be considered relatively safe in pregnancy and lactation.We aim to review recent evidence on the risks of stimulant and non-stimulant treatment in pregnancy and lactation.Literature review on the topic through PubMed and Google Scholar using the search terms: “ADHD”, “ADD” , “Pregnancy”, “Lactation OR breastfeeding”, “Stimulants”, “Methylphenidate OR Amphetamine OR lisdexamfetamine OR atomoxetine OR modafinil”. Only original research papers written in English were included.We identified twelve studies investigating the use of ADHD medication in pregnancy and four studies regarding lactation. Most of the studies did not find an elevated risk for congenital malformations by treatment with methylphenidate or medical amphetamines during pregnancy. A report suggested a moderate risk for congenital defects in infants exposed to modafinil in utero. The teratogenic effects of atomoxetine and guanfacine have not been investigated. Regarding lactation, only case reports and case series were found. Methylphenidate seems to be safe, with little transfer into breast milk and no reported adverse effects for the baby. Amphetamines transfer into breast milk and reach relatively high concentrations, and although the overall risk for intoxication seems to be low it cannot be fully excluded.Prescription of ADHD medication to pregnant and lactating women should be considered after an individual risk-benefit estimation. In severe cases, when medication cannot be discontinued, the overall risk for adverse outcomes seem to be relatively low. More higher quality studies are needed on the topic.None Declared


This study investigated the prevalence and comorbidities of attention deficit hyperactivity disorder (ADHD) among adults and children/adolescents in Korea.This study used data from the Korea Health Insurance Review and Assessment Service collected from 2008 to 2018. Study participants comprised patients with at least one diagnosis of ADHD . Prevalence rates and psychiatric comorbidities were also analyzed.We identified 878,996 patients diagnosed with ADHD between 2008 and 2018. The overall prevalence rate of diagnosed ADHD increased steeply from 127.1/100,000 in 2008 to 192.9/100,000 in 2018; it increased 1.47 times in children/adolescents (≤ 18 years) and 10.1 times in adults (> 18 years) during this period. Among children/adolescent and adult ADHD patients, 61.84%  and 78.72% (95% CI 78.53−78.91) had at least one psychiatric comorbidity, respectively.Our results showed that the prevalence rate of diagnosed ADHD has increased in Korea; however, it is lower than the global average. Further studies are required to identify and treat vulnerable populations appropriately.None Declared


Attention Deficit/Hyperactivity ‘Disorder’ (ADHD) is a form of neurodivergence, characterised by lifelong differences in attention, impulsivity, and hyperactivity. University students with ADHD underachieve academically and tend to have lower levels of self-esteem. Medical schools have an obligation to minimise barriers for students with ADHD. Understanding the experiences of medical students with ADHD is vital to promote inclusive approaches. Our exploratory research question was: “What are the experiences of medical students with ADHD?” This was an interpretive phenomenological study. Loosely structured interviews were conducted with participants  over Zoom. Subsequent transcripts were analysed using interpretive phenomenological analysis. Six people participated. Our analysis identified the following themes: Identity and diagnosis; ADHD profile; system issues; conflict, competition and compensation; improving the experience. Participants reported experiences of bullying and isolation at medical school, perpetrated by doctors and peers, as well as feelings of alienation when unable to conform on placement and in exams. From this, participants adopted survival strategies, such as masking, to avoid being ostracised. All recognised their ADHD status when their mental health deteriorated during their medical studies. Of those who disclosed their diagnosis, none were offered personalised support. Participants feared disclosure, largely due to weaponised professionalism and the effects of toxic competitiveness in medicine. They yearned for a sense of belonging. Participants reported strengths associated with ADHD such as empathy and working well under pressure, which are highly desirable aptitudes for doctors. This study has highlighted areas where medical schools can be instrumental in cultivating an environment where medical students with ADHD can thrive, not just survive. This may take the form of peer support groups, alongside reasonable adjustments throughout medical school–particularly for Objective Structured Clinical Examinations, for example. Enabling these students to thrive may help to prevent early burnout and subsequent attrition from medicine. Under the neurodiversity paradigm, Attention Deficit/Hyperactivity ‘Disorder’ (ADHD) is a form of neurodivergence, alongside others such as autism or dyslexia . More spCurrent diagnostic criteria for ADHD are reliant on identifying deficits in function, consistent with the medical model of disability . This enConsidering external expectations is particularly important within a medical context. The wider literature is replete with studies arguing that the culture of medical schools is both toxic and competitive –particulMore broadly, university students with ADHD have consistently been shown to underachieve academically  and to hGiving voice to the experiences of students from marginalised groups is a fundamental step towards achieving social justice. These groups are often discredited and dismissed when sharing their experiences–a concept known as epistemic injustice . In the This qualitative study used an interpretive phenomenological approach–seeking to explore and interpret lived experience through the perspectives of the participants . An inteThe first author of this paper, Meg (MGH), is a fourth-year medical student. She was diagnosed with ADHD at the end of her second year of medical school.“Hi, I’m Meg! I’m a 4th year medical student. Forgetful, fidgety and fickle. These were the embarrassing aspects of my personality that I found most difficult to deal with until I was diagnosed with ADHD between second and third year of medical school. I spent more time worrying about seeming “unprofessional” than I did engaging with teaching” (MGH–first author).Meg’s interest in this study stemmed from her own experiences of being signposted to support for dyslexic students in the absence of conclusive support for those with ADHD. This study itself was born of her own experiences, following discussion with Seb (SCKS), the second author of this paper, who is a doctor and researcher with ADHD. Seb is also autistic and dyslexic."Hi, I’m Seb! I’m a lecturer in medical education. I came late to my ADHD diagnosis, during my specialty training. The lack of ADHD voices in the literature led me to not recognise this important aspect of my own intersectional identity. Diagnostic criteria aside, I attribute many of my strengths to my ADHD. For example, my creativity and resourcefulness have proved to be a blessing within the world of qualitative research” (SCKS–second author).Prior to the study, Meg reflected on her own experience, facilitated by Seb. This reflective process enabled her to acknowledge and contextualise her preconceptions and feelings so that they could be used to positively influence the project . This isThis study was approved by the BSMS Research Governance and Ethics Committee (reference: ER/BSMS9E80/2).A purposive sampling approach was used. Following gatekeeper approvals, a recruitment advertisement was emailed to all medical students at a single medical school in the South of England. People who were interested were invited to contact Meg by email. They were then sent a participation information sheet and consent form to read. Informed consent was received and audio-recorded at the start of each interview.Drawing on the wider literature, Meg created an interview topic guide see  iterativLearning environmentsEmotional and social experiencesDisclosureLearning about ADHD at medical schoolMedicationInterviews were audio-recorded, transcribed, and encrypted using Zoom’s internal software. Once Meg had reviewed and corrected the transcripts to ensure they were verbatim, they were stored securely on the university OneDrive.The transcripts were analysed using the approach of Smith, Flowers and Larkin to the interpretive phenomenological analysis framework . This inSix individuals participated . ParticiFive GETs were constructed .Participants identified with their ADHD uniquely, and whilst some embraced it wholeheartedly, others found aspects challenging. Acquiring a formal diagnosis was tortuous, but participants valued the advantages it brought, including validation.you’ve always had it. So, you don’t know what you would be like if you didn’t have it.” This was a double-edged sword, as some feared their ADHD identity could be quickly removed at a formal psychiatric assessment if found to not have ADHD. Kate explained “I was so scared because I was like oh my god, what happens if I don’t have it… I was petrified.” They recognised the contextual nature of ADHD, dependant on the environment and the person. Zara reflected “it’s not one size fits all… everyone’s experience is going to be different.” Some felt there should be a shift towards identity-first language. Emma explained “I don’t think I have ADHD. I think I am an ADHD person.” For Amar, the chronicity and perceived lack of positives of ADHD was difficult.Participants felt ADHD was an intrinsic and inseparable part of their identity. Zara explained ““people love like the good characteristics of ADHD… But I feel like there’s a lot of stigma with… the bad side of ADHD… there’s still so many negative connotations of ADHD in med school. And I think there’s a lot of gaslighting of it, especially for women”. Some were subsequently apprehensive about their future in medicine. Emma explained “a lot of the medical training isn’t suited to people with different… ways of thinking, with neurodivergence let’s say.”Kate explained the impact of ADHD on her identity in medicine: “ADHD is downplayed quite a lot… it’s like how people say… ‘everyone’s a little bit ADHD’”. Identifying with portrayals of ADHD on social media was challenging, particularly the superpower rhetoric. Emma explained “apparently, it’s big on social media, so I think it’s less stigmatized, but it doesn’t feel that way… I feel like they very much glamorize or romanticize the things that I struggle with… I clearly have something else. I’m clearly more broken somehow, more incapable somehow.”Social media had a notable effect on participants’ identities. Increased awareness brought positives and negatives. The depathologisation of ADHD was harmful. For example, Amar explained hearing people’s experiences online made me think “Oh, that sounds like me. I should get assessed” … [I’m now implementing] lots of like study hacks that I saw on TikTok or Youtube”.However, in the absence of an open culture at medical school, participants found affirmation in hearing similar experiences on social media. It was helpful for suggesting potential coping strategies–both for study and life management–as well as signposting support and treatment outlets. For example, Taylor explained how it has been helpful for them: “as a woman with ADHD, nobody had, I guess, caught on that this could be what it was because I was high achieving.” Differing presentations of ADHD in gender could have been a barrier to diagnosis. Kate argued “I think that’s just because we’re way better at hiding our symptoms, and we’re kind of able to slightly use them more to our advantage.” Participants experienced diagnostic overshadowing, whereby receiving diagnoses of anxiety and depression meant they were not further investigated, despite unresolved challenges at medical school.Participants had difficulty recognising and identifying with their ADHD due to stereotypes of laziness, unintelligence, and disorganisation. They also noted how the stereotype of ADHD only affecting young boys was a hindrance. Emma explained “it was honestly like ground-breaking, because I genuinely thought everyone was like me”. The impact of their ADHD status not being recognised earlier was felt profoundly. Kate explained “it’s like… a mourning for kind of everything you struggled with when you were younger.”Some had not realised how vastly their experiences differed to their neurotypical peers until their ADHD was recognised. Kate explained “you get like confirmation that it’s just that’s how your brain works, you’re not just being lazy or being stupid, which is quite validating.” Formal diagnosis was helpful in validating their need for medication. Kate described “diabetes is a deficit of insulin… ADHD is a deficit of dopamine. And I found that so useful in… accepting the condition… I physically am lacking in something.” The diagnosis was also instrumental for participants’ self-discovery journey. Kate explained “the diagnosis made me understand myself better and like made me kind to myself… I feel more in control of who I am.” As well as being kinder to themselves, participants felt better at empathising with others, including patients. Amar explained “I’ve definitely appreciated ADHD a lot more… so I think that can definitely be a positive um, especially… when I was doing psychiatry.”The main benefit of diagnosis was the professional validation of their experiences and struggles. Zara explained, “Participants reflected on their strengths and challenges. They felt there were several advantages of having ADHD, as well as areas of medicine being well-suited to individuals with ADHD. However, challenges were experienced throughout medical school, affecting their relationships, mental and physical health.Thinking outside the box and questioning”, as Taylor put it. Being highly empathetic was noted to be a positive, enabling them to easily build rapport with patients. Emma explained “the way that I respond and react to emotional things… I think it helps me better relate to patients… And I think I’m quite bubbly… which makes people comfortable”.Participants felt their ADHD led them to be more inquisitive, lateral thinkers. “I am able to focus quite a lot… get work done, especially when I’m enjoying it… when I get started, and when I’m in the zone I can keep going for hours”. Participants felt that their dynamic learning methods would benefit neurotypical people, and feedback from peer teaching had shown this. Kate explained “the ways we learn to like compensate it are so fool proof that, like it just works for everyone”.Participants all described their ability to hyperfocus for extended periods of time. Additionally, they work most efficiently under pressure. This was beneficial for studying and working in the National Health Service (NHS). Amar explained, ““I knew it would always like be a stimulating environment. And like, I love learning. And I love talking to people”. Kate explained “I love it, and I think my ADHD really suits me [in the emergency department]. I’m really empathetic and intuitive… I’m able to adapt easily to different scenarios”.Some reflected on how ADHD can be advantageous for medical work, especially in emergency medicine. Taylor explained It doesn’t look like I’m listening because I need to do multiple things at once to keep engaged… a lot of people have gotten very angry”. Participants felt their effort to match the communication of their neurotypical peers was not reciprocated. Kate explained “it’s really difficult actually to turn around to someone… to say to them actually that really hurt me, or actually that’s really insensitive… people can be very stubborn about it”.Participants felt a mismatch in communication between themselves and surrounding neurotypical people. Participants’ body language was often misinterpreted, causing tension. Emma explained ““I think, because of so much content, so many new people, just so many new environments. It just overwhelmed me… There was no kind of safety in anything”. Emma felt that medical school had been the catalyst for her diagnosis, explaining “if I wasn’t in medical school I would never have been in that situation where everything felt out of control and unsupported”.No participants were diagnosed with ADHD prior to reaching breaking point in medical school. For most, this came in their clinical years, when they experienced the greatest number of transitions–an absence of continuity and increased responsibility for orchestrating their learning without accountability. Kate explained they were like ‘this doesn’t sound like you’re struggling with anything more than a normal medical student would be struggling with’”. Participants spiralled without support, unable to study with their deteriorating mental health. However, some precluded themselves from accessing vital ADHD support from the medical school and mental health services due to confidentiality concerns. Amar said “how anonymous is something that’s offered by the medical school. Uh that I would be a bit sceptical of”.In a cyclical nature, participants felt their mental health deteriorated in the absence of support, but that help was inaccessible with the normalisation of poor mental wellbeing at medical school. For example, Emma repeatedly reached out for help, but experienced discounting: “"I’ve had to learn… sometimes my friends don’t mean to be mean. They don’t realize what they’re doing is bad”. Whilst hyper-empathy was viewed as an advantage, it was also problematic for some. Emma was aiming for a less patient-facing specialty because “I struggle with like separating my emotions. I think that I react very strongly to the way that other people are feeling. Um, and I take it home with me, and I ruminate on it”.Participants reflected on how their strong emotive responses have been challenging, especially when not shared by neurotypical peers. Kate explained, “people with neurodivergent conditions aren’t lesser, it’s just society.” Throughout medical school, participants felt they had to overcome additional hurdles to survive.Participants examined how they were disabled by the environment around them, rather than an intrinsic impairment. Zara explained “I used to hate lectures, just sitting there—horrible… I literally had no idea half the time what they were saying.” But with mandatory attendance, participants had no choice but to attend and compensate later for missed content. Zara explained “if any lectures aren’t recorded, that’s a nightmare, because you even if you’re trying… if you’re paying attention as much as you can throughout the lecture you’ll never like, it just doesn’t pick up as well.” Kate reflected, “we know that this stupid, old-fashioned way of teaching just is not productive and examining people, and yet we still continue to do it.”Experiences of lectures felt ableist. This educational approach was physically restrictive and unengaging, placing participants at disadvantage. Kate explained “having to be so flexible, I find really difficult, and it makes me really stressed… there’s no empathy or sense of understanding as to how much this can actually impact somebody like me’s life”. This was exacerbated difficult when participants had additional appointments, essential for maintaining their wellbeing.Participants felt that the medical school expected an unreasonable amount of flexibility for last minute timetable changes. When this was combined with participants’ innate challenges with organisation, they suffered overwhelming stress. Emma explained OSCEs were particularly disabling for participants, largely due to inflexibility in timings and the structure of these assessments. Kate describes her most recent OSCE:“I felt completely alienated. I felt different, and I knew I had a disability in that moment… all the instructions were verbal. All the questions were verbal. I couldn’t mouth read anyone. I couldn’t, you know, just sit there, and stop for a minute, everything was on the clock… I’ve had to ask them to write out the question, because I don’t know what they’re asking. And they’ll write that down the feedback that would be like ‘oh, you were struggling to like, understand the question’… Because it’s too much noise, and it’s like that auditory processing… The fact you can’t ask certain questions. You can’t check things. No OSCE I’ve been in has been alike to any clinical scenario I’ve ever been in.”notice I’m like a bit fidgety… but they think it’s like anxiety. I’m like no, it’s just me… it’s because I’ve got ADHD, and I’m fidgety.” Echoing such issues, Zara reflected:Participants felt their communication style was a disadvantage in exams, with most having failed at least one spoken assessment . The OSC“You just appear less kind of calm about your responses and… the way you speak is less, um, structured. So, it seems like you’re less confident… definitely fidgeting and structuring answers is always something that comes up, and it’s something I really struggle with, because to me my answer does seem structured. But to them they’re like ‘Oh, no, you’re just jumping about everywhere’”.I think the medical school like to sort of claim that they’re inclusive and supportive and do reasonable adjustments… but I don’t always think that it’s true.” Taylor reflected “the school’s offered nothing for ADHD in terms of support.” Participants were offered extra time and extensions to deadlines, regardless of helpfulness. Kate explained “I wish it was more personalized in the learning plan. We’re all different, and we all have different needs.” Participants’ repeated efforts in getting more support were met with resistance by their medical school. This led to helpless states, whereby participants stopped trying to advocate for adjustments. Emma explained “it’ll be like pulling teeth to get that information from the med school” when asking for exam guidance. Participants attributed these negative responses to cost or feelings that their concerns were seen as insignificant.Participants reported a lack of true supports, in favour of keeping up appearances. Emma illustrated “I know I’m very privileged, being like cisgender, like heterosexual woman, white… I feel really comfortable going in and being like, ‘okay, I struggle with this thing, and I want to talk about it’… Every day you’re having to say, if not twice a day, you’re having to go up to someone and explain why you are the way you are… And then you also have that extra like emotional burden of having to take on the fact that probably 80% of people aren’t going to listen to you, or fully take on what you’re saying”.Participants felt a responsibility to spend time and resources advocating for their needs–if they did not, then who would? Some tried but were met with discounting and disbelief. Kate explained, “It’s just up to their judgment of what it is they decide to attribute to ADHD and what they don’t, uh, rather than necessarily based on your personal experience.” Kate explained “we’ve all been having to cope with it so long. We know what helps us”.Stonewalling led participants to feel helpless. Amar explained “sometimes I think that I need to get a taxi. I’ll get a taxi, and then they won’t reimburse it because there is a bus… on the bus where it’s crowded, lots of different people. Everybody’s loud. Everybody is talking, lots of different smells, lots of different things happening.” Zara was embarrassed when she explained “I’ve really struggled with… traveling to kind of new places like when it’s a one off or not very frequent… Like… the planning of like the travel and things like that.”Costs associated with being in a minority student group, known colloquially as ‘minority tax’, refers to uncompensated efforts and responsibility to reduce inequalities between themselves and their peers. There was a minority tax associated with having ADHD at medical school, taking its toll in time, money, energy, and emotions. Travel was particularly costly, especially in placements far from home. These involved distance from their usual support systems and unfamiliar and/or complex journeys. Emma explained, ““I’m not quite as focused as the normal person still. But it’s enough for me to cope with”.Medication alleviated many struggles, reducing unhealthy coping mechanisms such as smoking, drinking alcohol and binge eating. These improvements allowed energy and time to be diverted towards studying and engaging with placement. Whilst this was a dramatic improvement, medication cost money and was not the ‘magic bullet’ in providing equity with peers. Kate explained I think if other people have support whether that be coping strategies or therapy, or assessments or support groups then that would help people”.Taylor regularly attended therapy, enabling them to cope better with the emotional and social impacts of ADHD at medical school. However, Taylor acknowledged their privilege in being able to access multiple avenues of support privately. They felt that the medical school could play a role in achieving equity. They said, “Interactions with peers and staff significantly impacted participants’ experiences of medical school. Some experienced direct discrimination against their ADHD, causing overtly negative attributions. However, experiences of additional microaggressions invariably contributed to feelings of mistrust, isolation, and internalised ableism.“it made me cry because I was trying really hard, and [the doctor] essentially told me that I shouldn’t be a doctor… [I] was reprimanded in a really cruel way”. Taylor also experienced bullying on the ward by a consultant, they said “I went and cried for a bit in the toilets, did my deep breathing, and then went back… we get on with our day”. When Taylor experienced bullying, they blamed themselves for being upset, explaining “someone who was less sensitive or maybe more resilient might have been able to handle it”. Throwaway comments from consultants about ADHD and participants’ ability to achieve was damaging to their self-esteem. Emma explained “that’s still made me doubt to a certain extent whether I can do this, and that’s something I think I’m gonna struggle with daily”.The experience of being bullied by doctors, particularly senior doctors, was normalised amongst participants. Emma recited her first-time history taking, being new on the ward or being new in a place, and you just don’t know how people are going to react to you… But then, after that, you’ve met them once at least, so you can kind of do better”. More often than not, however, participants were simply ignored. Zara explained “they just ignore you… it feels like there’s no point in you being there because you’re not taking anything in.” When they tried to actively engage, they faced hostility. Emma explained, “I have to be really ballsy, and like, ask a lot of questions to keep myself engaged in learning… and then the consultant will be like, “Why are you interrupting my ward round? Why are you talking?” But they won’t answer my questions if I ask.”New clinical placements triggered anxiety. Participants feared how new teams would receive them, embedded in feelings of personal inferiority. Zara explained ““I’ve got like tougher skin… consultants call me stupid, I move on… I know a lot of the consultants… so I know how I need to react to them.”Participants developed survival strategies to avoid humiliation–rigorously self-regulating and forming a protective shield. Subsequently, survival became easier with time. Emma explained I do things so people don’t comment”, but later explained “everything is so much easier [with medication] …and not like being so depleted of… all of my spoons”. There was little reserve for learning when participants prioritised masking. Emma explained, “that extra worry of… making sure that you’re not seeming distracted, and you’re seeming engaged, and you’re making the patient feel safe and comfortable and able to talk to you… that’s a lot of things to have to do all at once”.A vast amount of energy was expended masking (hiding) their ADHD. Take Taylor, for example, who said that ““there are literally like a week’s worth of dishes just lying around… Like it’s a mess in here, and the reason it’s a mess is because I’ve got a lot going on at university.”Exhaustion from masking on placement exacerbated executive functioning differences and thus negatively impacted motivation for self-study. As a result, basic activities of daily living, such as eating, felt insurmountable with their little remaining energy and executive functioning capabilities. Emma explained I’ve forgotten my laptop. I’ve forgotten chargers, I’ve forgotten clothes. I like really struggle with packing week to week, and so often found kind of I don’t have the things that I need.” Most experienced time blindness, and despite implementing coping strategies, they consistently arrived late. Or worse–lost marks in assessments due to not managing time ‘appropriately’. For example, Tiah explained “I’m like pretty much late to everything. I always, always feel stressed about it… I find the whole concept of OSCEs very tricky because I struggle so much with time and organizing myself”.Seemingly small mistakes significantly worsened participants’ experience of medical school, especially at regional placements. Zara explained “I have an inherent distrust of medical schools.” There was a scepticism of the premise for collecting disability data from medical schools and the GMC. Emma explained, “I worry that because people don’t understand it… they will not… inform me of opportunities that they don’t believe that I can do”. Professionalism concerns had been raised relating to ADHD traits. Kate experienced a strong sense of moral injury when a consultant criticised her professionalism for consoling a distressed patient and fidgeting in clinic. Kate left, explaining “it felt like such an attack on who I am and everything I stand for”. She also felt her gender had a part to play in being perceived as unprofessional, explaining “like female characteristics they just were so against”.Fear of weaponised professionalism was a barrier to participants disclosing their ADHD to the medical school. Weaponised professionalism in this context refers to characteristics inherent to ADHD being perceived inappropriately as unprofessional, despite these characteristics likely bearing no true impact on their performance as medical students, or on patient care. Seeing ADHD be used to ‘prove’ incompetence of a peer deterred Amar from disclosing his diagnosis, explaining ““I think my ADHD characteristics [at work] has always been viewed so positively… but I find that in med school, I think I’m negatively treated because of it”. Many experiences with peers centred around either overt judgement or a fear of judgement. This negatively impacted disclosure and wellbeing. Emma recalled, “the way [peers] talk about [ADHD] before they find out that I’m like that makes me self-conscious and hyper-aware and hyper-vigilant and makes me struggle to be sociable.” Kate echoed this, “everyone just talks negative about [ADHD] which kind of pulls you down a bit”.Participants were wary of disclosing their ADHD to peers, but not to people outside of medicine. As Kate explained, “I think up till now it’s kind of been viewed, if you say things that are disabilities or health issues that you’re making an excuse. I think it’s very toxic”. They felt there was a perceived weakness of ADHD in medicine. Amar explained “at the end of the day… I don’t think I would get much empathy from anyone… I don’t think they would take me like, you know, um, seriously”.Participants attributed negative interactions with peers to a toxically competitive environment at medical school. Kate argued “I think it feels a bit like cheating because you know that like the medication you take, other students take to study”.Some felt ashamed that they needed ADHD medication to survive medical school. Competitiveness led to likening use of ADHD medication to cheating. Emma explained, I’ve previously always been known to be… hyper-organised. [In] hindsight, that was me compensating”. Participants set impossible expectations for their studies causing overwhelm and frustration. Zara explained “when you have ADHD you don’t know what’s normal and what’s not normal. You just think you’re kind of like lower in the general ability compared to your peers”.A combination of feelings of inferiority and the competitive environment led to perfectionist mindsets. In turn, this further fostered masking behaviours in an attempt to hide their secret shame. Kate explained “suffering with all that imposter syndrome stuff and feeling like a fraud”.Participants had difficulty recognising their hard work and the contributions this has to their success. They attributed success to luck, but failures to their own wrongdoings. Some felt fraudulent in having an ADHD diagnosis itself–worried they were just making excuses for not coping. Emma, for example, avoided disclosing initially due to “Participants reflected on their positive experiences and how aspects of these could be applied elsewhere in medical school. They also explored how negative experiences could have been improved.“those are the ones I take the most from… where you get the chance to speak.” Enjoyment on placement correlated with positive engagement from the team. Participants valued having a friendly face on the ward, such as a clinical fellow. It enabled them to quickly become comfortable in potentially hostile environments, maximising learning opportunities that may have otherwise been missed.Environments where participants were encouraged to engage, without fearing repercussions, were most conducive for learning. Examples included small-group sessions and simulation. Amar said, just having more checking ins… I… think it’s quite useful… because it has that outside accountability”. Their attempts at undirected studying with peers had limited success because they often digressed from the task at hand. Instead, they felt academic tutors that provided accountability would be more beneficial.Participants needed accountability to stay motivated and engaged with the course. For example, some found regular contact and soft deadlines valuable. Zara explained “they don’t provide very clear guidelines, or like lists of things that need to be covered, and so that… it gives me too much freedom to do what I actually enjoy, and then I end up, not covering the stuff I need to be covering”. Participants found initiating self-study in the clinical years became almost impossible with the lack of routine.In their pre-clinical years, a checklist of lectures required for exams was beneficial for participants who had difficultly planning self-study. In the clinical years, however, participants had to fend for themselves, leaving them unable to prioritise and rationalise which knowledge was needed. Emma explained, “Like in the clinical years, I just want something that says I’ve got these things, this is what helps me. Just to show that I’m not bull*******g”. It was felt that neurotypical allies could strive to make clinical spaces more inclusive for their colleagues.When participants were proactive in accessing support, this was financially and emotionally expensive. To reduce minority tax on placement, Kate suggested the use of learning support cards. She explained “Nobody talks about it… Why don’t we talk about it? [Meeting other medics with ADHD] made me feel like I wasn’t so strange”. They yearned for belonging. Taylor explained “humans like to form communities with people who are similar to them in environments that are different and challenging”. Participants wanted to exchange experiences with other medical students with ADHD, signposting helpful resources and ultimately providing validation. Kate explained “I love when I get to chat to other medics with ADHD… it kind of fulfils everything I feel about myself”. Participants with an overbearing fear of disclosure were particularly isolated. As Amar described, “you would be the first medical student I know… I’m not aware of medical students or doctors with ADHD.”A culture of silence was isolating for participants, who then felt liberated when meeting other students with ADHD. Emma explained “to see that there are doctors who can achieve the things that people sometimes say “Oh you maybe don’t go for that… don’t aim so high’… It was very encouraging to see that you can aim high and you can achieve it, and it doesn’t stop you from doing anything”.Role modelling was important for participants’ self-esteem, providing validation and encouragement. Connecting with doctors with ADHD and senior medical students provided reassurance that their dreams were achievable with ADHD, not despite it. Emma explained ““I’d love to go chat someone just be like ‘how is it?’, and I hope they would get paid for it as well”, acknowledging the often-unremunerated nature of mentoring. Meeting a doctor with ADHD on placement meant Emma saw a different style of working, providing her with the confidence and permission to develop her own style of doctoring. Kate also noted the benefit of having visible ADHD role models from an early age. On her paediatrics rotation, parents informed her of the positive impact she had for being proud and unapologetically ADHD.Some thought it would be helpful to hear how challenges of ADHD in medicine can be overcome through mentoring. Kate explained This was the first study to explore the experiences of medical students with ADHD. Whilst positives, such as cognitive dynamism and increased empathy, were noted, overall experiences were overwhelmingly negative. Ableism was pervasive. In particular, internalised ableism coloured their entire lifeworlds–if they could not pass within the neuromajority, how could they have a place in medicine? Such internalised ableism is associated with low self-esteem, reduced wellbeing, and increased feelings of isolation . Some paParticipants were exhausted from the constant masking. The overbearing pressure to conform–to meet the social norms amongst neurotypical peers–and to embody the cultural norms of medicine more broadly, took its toll. This pressure increased once reaching clinical placements, through fear of weaponised professionalism. The weaponisation of professionalism is not a new phenomenon. The concept of professionalism itself is historically grounded in cultural norms associated with the white, cis-gendered, heteronormative, able-bodied male experience . Our parParticipants felt alienated from peers, educators, and the institution, following experiences of direct discrimination and microaggressions. A mismatch in communication styles with neurotypical peers and educators also seemed to contribute to feelings of isolation. This concept is best described by the double empathy problem, often seen in the context of autism, whereby communication difficulties are due to reciprocal mismatches in communicative style between neurotypes rather than a social deficit in the non-neurotypical . TherefoWhilst participants received negative feedback for their communication styles, a body of doctors with diverse communication styles may better meet the needs of the diverse patient population–in line with GMC Welcomed and Valued . ParticiParticipants felt social media negatively impacted their self-esteem with inaccurate and romanticised depictions of ADHD, which is congruent with recent studies that show over 50% of videos about ADHD on TikTok and YouTube are misleading, especially when they are produced by non-healthcare workers , 49. As Compassion and self-compassion are protective factors against emotional exhaustion and burnout in medical students and doctors . HoweverTheir medical school’s potentially tokenistic approach to inclusion–as reported by our participants–may not be fully in keeping with the UK Medical Schools Council’s active inclusion guidance . The GMCAs this is a qualitative study, our results are not generalizable. Instead, our study presents an in-depth exploration of the experiences of a sample of mostly cis-gender females from one medical school in England. This sample was well-suited for phenomenological research, enabling intimate exploration of participants’ experiences. The study strived for an in-depth analysis of the experiences of current medical students with ADHD. Therefore, it did not include the voices of those whose ADHD may be unrecognized, nor did it include those who may have left medical school.Others involved in participants’ subjective reports of their experiences may have different recollections of events. However, the purpose of the study is to understand the perspectives of our participants. There may also be an element of volunteer bias, whereby participants chose to volunteer because they have powerful stories to tell. However, this does not mitigate or lessen their own experiences.This is the first study of the experiences of medical students with ADHD. Meg’s insider status was key to building rapport with participants and to engaging with and understanding their stories during the analysis. It is also worth acknowledging here that, given our insider status, there is a possibility our own subjective experiences and perceptions could have influenced which examples of participants’ reported experiences were focused on. Whilst a positivist or critical realist perspective may consider this a limitation, this may also be considered a strength through a social constructionist approach to interpretive phenomenological research , 50.Participants reported strengths associated with ADHD such as empathy and working well under pressure, which are highly desirable aptitudes for doctors. However, participants also reported experiences of bullying and isolation at medical school, perpetrated by doctors and peers, as well as feelings of alienation and inferiority when unable to conform on placement or in exams. From this, participants adopted survival strategies, such as masking, to avoid being ostracised. All recognised their ADHD status when their mental health deteriorated during their medical studies. Of those who disclosed their diagnosis, none were offered personalised support. Participants feared disclosure, largely due to weaponised professionalism and the effects of toxic competitiveness in medicine. They yearned for a sense of belonging. This study suggests a key starting point for medical schools is to listen to their medical students, and take action to support each individual student. To have a wider impact, medical schools should evaluate how they deliver OSCEs and consider additional training for examiners.This study has highlighted areas where medical schools can be instrumental in cultivating an environment where medical students with ADHD can thrive, not just survive. Further research is now needed to identify which adjustments are effective and to explore the experiences of non-ADHD medical students and staff in relation to medical students with ADHD.S1 Appendix(DOCX)Click here for additional data file.


N = 2,229), we evaluated associations between ADHD symptoms around age 11 and educational level around age 14, as well as between ADHD symptoms around age 14 and 16 years and subsequent changes in educational level around age 16 and 19, respectively. We assessed the potential mediating role of family functioning, and social support by teachers and classmates, all measured around ages 11, 14, and 16, while additionally evaluating interactions between ADHD symptoms and these hypothesized mediators. ADHD symptoms were associated with poorer family functioning, less social support by teachers and classmates, and lower education throughout adolescence. No conclusive evidence of mediation was found, because unique associations between family functioning and social support by teachers and classmates and education were largely absent. Furthermore, we found no interactions between ADHD symptoms and family functioning and social support by teachers and classmates. Although social support by teachers and classmates and good family functioning may benefit the wellbeing and mental health of adolescents with high levels of ADHD symptoms, they will not necessarily improve their educational attainment.Few studies have explored the contribution of family and school factors to the association between ADHD symptoms and lower education. Possibly, having more ADHD symptoms contributes to poorer family functioning and less social support, and consequently a lower educational level . Moreover, the negative effects of ADHD symptoms on education may be stronger for adolescents with poorer family functioning or less social support . Using data of the Dutch TRAILS Study (The online version contains supplementary material available at 10.1007/s10802-023-01047-y. Symptoms of attention-deficit/hyperactivity disorder (ADHD) are associated with significant impairments in adolescents’ academic functioning, as well as a lower level of education  are associated with lower educational attainment in young adults with a previous ADHD diagnosis  in adolescents who felt socially accepted by peers  as mediators in the association between ADHD symptoms and (changes in) educational level from early adolescence to young adulthood in the Dutch educational system. While doing so, we allowed for potential interactions between ADHD symptoms and family and school factors using interventional effects for mediation analysis . A detailed description of the cohort can be obtained elsewhere  of the TRacking Adolescents’ Individual Lives Survey (TRAILS), a population-based prospective cohort study of Dutch adolescents  and the Youth Self-report (YSR) of the Achenbach System of Empirically Based Assessment (ASEBA), completed at wave 1, 2, and 3   selection into a particular educational track, based on cognitive tests and the advice of the primary school. There are four tracks in the Dutch educational system, each consisting of a specific type of secondary school followed by tertiary education at the corresponding level  by parent-report using a modified version of the Dutch version of the General Functioning Scale of the McMaster Family Assessment Device (FAD), which is a mean score of 12 items with each four response categories: 1 = ‘totally disagree’, 2 = ‘disagree’, 3 = ‘agree’, 4 = ‘totally agree’.  by adolescent-report using the mean score of the corresponding affection (4 items) and behavioural confirmation (4 items) subscales adapted from the Social Production Functions (SPF) Questionnaire  by adolescent-report using the mean score of the corresponding affection (4 items) and behavioural confirmation (4 items) subscales adapted from the Social Production Functions (SPF) Questionnaire  include children’s IQ, which was estimated using the Block Design and Vocabulary subtests of the Revised Wechsler Intelligence Scale for Children (WISC-R), as well as parents’ socioeconomic status (SES), constructed as the mean score of five indicators (standardized): maternal and paternal educational attainment, maternal and paternal occupational position , and family income. Furthermore, we included gender and ethnicity as demographic covariates. Children were classified as having non-Dutch ethnicity if at least one of their parents was born outside the Netherlands. Finally, we adjusted for adolescent age, which was measured contemporaneously with each assessment of ADHD symptoms.First, we computed descriptive statistics of the study population by cross-tabulating baseline characteristics (mean age 11) with early adolescent educational track membership at wave 2 (mean age 14), as well as ADHD symptoms and family and school factors with concurrent educational level from wave 2 to wave 3 (mean age 19). In mediation analyses, we modelled the association between ADHD symptoms and initial educational level in early adolescence . Subsequent changes in educational level were estimated by regressing educational level around 16 and 19 on previous measurements of educational level . We assessed the potential mediating role of family functioning, and social support by teachers and classmates, all measured concurrently with ADHD symptoms , in the association between ADHD symptoms and (changes in) education, whilst additionally evaluating interactions between ADHD symptoms and these hypothesized mediators Fig. . All conN = 81) of the original participants no longer participated in the study. At wave 3 this was the case for 18.44% (N = 411), and at wave 4 for 15.66% (N = 349) of the original participants. Adolescents with greater age, male gender, non-Dutch ethnicity, lower educational level and IQ, as well as those from lower SES households were more likely to drop out of the study . Education was considered as missing for these participants. This missing information together with missing values on all other variables was addressed using multiple imputations by chained equations under fully conditional specification , whose educational level was assessed incompletely, who did not respond to questions on education, or who had left the educational system permanently  estimator in Mplus 8.8. These models allow for ordinal outcomes, while assuming the absence of exposure-mediator interactions Figs. -S3. In mTable Mediation analyses Table  revealedResults regarding mediation in our sensitivity analysis allowing for ordinal outcomes were consistent with our main analysis Figs. -S3. HoweIn order to gain further insight into why we found no mediation when modelling ADHD symptoms and family and school factors contemporaneously, we conducted sequentially adjusted regression analyses of associations between family functioning and social support by teachers and classmates and subsequent (changes in) education Table . These aIn this study, we investigated the role of family functioning and social support by classmates and teachers as mediators within associations between symptoms of ADHD and educational level, while also evaluating potential interactions between ADHD symptoms and these family and school factors. Significant direct effects revealed that ADHD symptoms were associated with being in a lower educational track in early adolescence, and that adolescents with high levels of ADHD symptoms more frequently decreased in their educational level over the course of adolescence, relative to their peers with low levels of ADHD symptoms, irrespective of family functioning and social support by teachers and peers. In addition, ADHD symptoms were associated with worse family functioning, as well as lower levels of social support by teachers and classmates throughout the whole study period. Yet, significant indirect effects were absent in all but one model in our sensitivity analyses, in which ADHD symptoms around age 11 were allowed to influence social support by classmates approximately three years later. Whenever family and school factors were modelled contemporaneously with ADHD symptoms , no mediation was found. This is likely due to the small magnitude of associations between family and school factors and subsequent (changes in) education after adjustment for covariates, which were even completely absent after also adjusting for concurrent measures of ADHD symptoms. Lastly, we observed no interactions between ADHD symptoms and family and school factors, suggesting that associations between ADHD symptoms and education do not differ in the presence of varying levels of family functioning and social support by teachers and peers. Overall, our results highlight the robustness of the detrimental associations of ADHD symptoms with educational level throughout adolescence, which persist even in the presence of positive social relationships within the family and with teachers and peers.Despite robust and consistent relations of ADHD symptoms with both educational level and family and school factors, contrary to our hypotheses, we found little empirical support that these factors contribute much to the association between ADHD symptoms and lower education as mediators. Mediation was largely absent given that we only observed negligible to small associations between family functioning and social support by teachers and classmates and (changes in) education, which were no longer significant following adjustment for covariates and ADHD symptoms, if those symptoms were assessed within the same social contexts as family and school factors. One exception was an extremely small indirect effect via social support by classmates in the sensitivity analysis in which family and school factors were measured approximately three years after ADHD symptoms. This was unexpected, given that we deemed mediation more likely with ADHD symptoms and family and school factors measured at the same time. Our findings contrast past research highlighting the importance of the social environment at home and at school for adolescents’ educational attainment  important for the education of adolescents  may still have affected our results. As these characteristics are also important determinants of adverse outcomes in young adulthood, further research on at-risk groups is necessary Below is the link to the electronic supplementary material.


Low birth weight (LBW) is a public health problem strongly associated with infant mortality. This study aimed to identify the spatial distribution of infant mortality in newborns with LBW  at term (≥37 weeks of gestation), due to their being small for gestational age, analyzing its association with mother-related determinants, as well as to identify priority areas of mortality in the State of São Paulo, 2010–2019.Infant mortality rate was analyzed in the division of neonatal mortality and postneonatal mortality of newborns with LBW at term. The empirical Bayesian method smoothed the rates, the univariate Moran index was used to measure the degree of spatial association between the municipalities, and the bivariate Moran index was employed to identify the existence of a spatial association between the rates and the selected determinants. Thematic maps of excess risk and local Moran were prepared to identify spatial clusters, adopting 5% as a significance level.The excess risk map showed that more than 30% of the municipalities had rates above the state rate. High-risk clusters were identified in the southwest, southeast, and east regions, mainly among more developed municipalities. The determinants of adolescent mothers, mothers over 34 years of age, low education, human development index, social vulnerability index, gross domestic product, physicians, and pediatric beds showed a significant association with the rates evaluated.Priority areas and significant determinants associated with reduced mortality in newborns with LBW were identified, suggesting the need for intervention measures to achieve the Sustainable Development Goal. When LBW is associated with prematurity or fetal growth restriction, the risk of newborn death is higher. Therefore, the lower the birth weight and the lower the gestational age, the higher the risk of death, in difference to LBW newborns with adequate gestational age.Low birth weight (LBW), defined as less than 2,500 grams, is considered a public health problem, as it is one of the main determinants associated with neonatal, postneonatal, and infant mortality, and the risk of future diseases, and more than 80% of neonatal deaths occur in newborns with LBW, given that they have a higher risk of dying in the first 28 days of life.Furthermore, it is estimated that each year more than 20 million newborns worldwide have LBW, which is equivalent to between 15 and 20% of births. In 2012, member states of the World Health Organization (WHO) committed to reducing LBW cases by 30% by 2025, to achieve the Millennium Development Goal of reducing infant mortality by 2015, and the Sustainable Development Goal of reducing neonatal mortality to at least 12 per thousand live births by 2030.In this scenario, the reduction of cases of newborns with LBW has been recognized as a health goal of many countries to reduce infant mortality. In 2017, the value was 8.5%, and the Brazilian States with a high prevalence of LBW were: the Distrito Federal, Minas Gerais, Rio Grande do Sul, and São Paulo, while the States with the lowest prevalence of LBW were Paraiba, Acre, and Rondonia.In Brazil, the so-called LBW paradox has been observed, which is characterized by a high prevalence in more developed regions of the country, and lower values in less developed areas. In addition, since 1995 (7.9%) the prevalence trend of LBW has increased. Furthermore, low weight is considered a determining factor of infant mortality, especially in the neonatal period, in addition to other determinants related to biological, social, and assistance aspects, such as maternal age and education, among others.Regarding mortality in Brazil, live births with LBW have high rates. Besides, thanks to geographic information systems (GIS) and spatial distribution studies, it is possible to analyze and apply geographic analytical methods to spatial data for mapping and identifying clusters and risk areas in health problems.Thus, given the efforts of many countries to reduce mortality, in recent years several studies have analyzed cases of LBW and their association with mortality, in which a high-priority intervention is important to minimize mortality and LBW in newborns.Spatial distribution studies carried out with LBW data in different Brazilian States or municipalities showed that risk areas can be identifiedIn this context, the objective of this study was to analyze the spatial distribution of infant mortality in newborns with LBW at term, and its spatial autocorrelation with maternal-related determinants, as well as to identify risk areas for the reduction of mortality in the municipalities of the State of São Paulo, period 2010–2019.Departamento de Informática do Sistema Único de Saúde — DATASUS). The State of São Paulo has more than 41 million inhabitants registered in the 2010 census, and a human development index (HDI) equal to 0.78 (high), ranking second in the States (Instituto Brasileiro de Geografia e Estatística — IBGE).An exploratory ecological study was carried out based on death data of newborns with LBW at term in the 645 municipalities of the State of São Paulo, between 2010 and 2019, obtained from the Department of Informatics of the Unified Health System .The database for this study included all municipal records of infant deaths with LBW  at term (≥ 37 weeks of gestation) from resident mothers, as these babies are considered small for gestational age. In addition, the analysis was carried out in the neonatal (0 to 27 days of life), and postneonatal (28 to 364 days of life) death division, extracted from the Mortality Information System (Sistema de Informação de Nascidos Vivos — SINASC). These variables were calculated by the ratio of their number and the total number of live births in each municipality.The variables selected for the analysis of spatial autocorrelation related to the mother were: the proportion of mothers under 20 years old, over 34 years old, and low education levels (up to seven years), obtained from the Live Birth Information System .The variables related to care were the rate of physicians per thousand inhabitants , and the rate of pediatric beds per thousand live births, collected from the National Registry of Health Establishments  for the year 2010. The gross domestic product (GDP)per capita per year was obtained from the State Data Analysis System Foundation , and the average GDP corresponding to the analyzed period was calculated.The HDI and the social vulnerability index (SVI)Infant mortality rate (IMR), neonatal mortality rate (NMR), and postneonatal mortality rate (PNMR) per thousand live births with LBW at term were calculated by municipality, using the number of newborns with LBW at term as a denominator..Crude mortality rates for each municipality were plotted on thematic maps using the quartile category. In addition, a map of excess mortality risk was calculated and generated, which is the relationship between the number of deaths observed in each municipality and the expected number of deaths with LBW in the StateThe empirical Bayesian method was used to calculate the smoothed rates, to stabilize and reduce the high variability observed in the crude rates. The equation for estimating the smoothed rate is given by:im is the average rate of the analyzed area, ix the crude rate of municipality i, and iC depends on the population size of the area with values between 0 and 1.Where mI) was used with the smoothed rates to measure the degree of spatial association in the analyzed area, testing the null hypothesis (H0 = 0) of spatial independence. The mI is calculated as follows:The univariate Moran index  was used with the univariate local Moran index to identify patterns of spatial association, such as atypical points or clustersThematic maps were prepared using the Moran map to identify spatial clusters, with the division by categories showing associations according to high-high, low-low, high-low and low-high.bI) was used to identify the existence of spatial autocorrelation between the IMR, NMR, and PNMR with the selected determinants. The bivariate index with a positive value indicates the existence of a positive linear relationship between the values of the two variables, and a negative value indicates a negative linear association. The bI is calculated as follows:On the other hand, the bivariate Moran index  of live births at term had LBW. In addition, there were 68,781 infant deaths in the State, of which 41.0%  were children with a weight between 750 and 2,500 g, and 11.9%  were live births with LBW at term. Of these deaths, 1,918 (57.1%) occurred in the neonatal period, and 1,439 (42.9%) in the postneonatal period.The average IMR in the State of São Paulo in the period 2010–2019 was 15.8/1,000 live births with LBW at term. In the same period, the NMR was 9.0/1,000 live births with LBW, and the PNMR was 6.8/1,000 live births with LBW.In the analysis of the spatial distribution of the consolidated values for the period 2010–2019, evaluated by the criterion of the quartiles of the IMR , it was In the NMR , 74.7%  found 19The PNMR  found thmI = 0.09), NMR (mI = 0.04) and PNMR (mI = 0.09) in newborns with LBW at term.From the spatial autocorrelation analysis, statistically significant spatial clusters  were found for the smoothed values of IMR  and 14.0% (90) were significant in the NMR  and PNMRRegarding the PNMR , high-hiIn the bivariate analysis , differeA positive association was identified between the infant and neonatal mortality rates in newborns with LBW at term and mothers under 20 years of age and with low education level. Moreover, a negative association was found with mothers over 34 years old, HDI and GDP. The rate of physicians and pediatric beds showed a statistically significant negative association only with the NMR. The SVI did not show a statistically significant association with infant and neonatal mortality.The PNMR in newborns with LBW at term showed a different behavior among the associations found. Maternal age below 20 years and low education were negatively associated with postneonatal mortality, while maternal age above 34 years, HDI, SVI, GDP, physicians, and pediatric beds were positively associated.It should be noted, first of all, that in the literature similar studies of spatial analysis of mortality in newborns with LBW were not found for the 645 municipalities in the State of São Paulo. In this study, through spatial analysis, priority areas of municipalities with high rates of infant, neonatal and postneonatal mortality in term newborns with LBW were indicated, located mainly in the southwest, southeast and east regions, especially risk clusters in more developed cities.Furthermore, the determinants showed a significant association with IMR, and their results were similar when deaths in the neonatal period were evaluated alone, differently from deaths in the postneonatal period. Thus, the observed risk areas can be included in the design of specific interventions to reduce the mortality and prevalence of LBW.. These results do not differ much from those observed in some studies in Brazil, which show that, between 2011 and 2018, almost three-quarters of neonatal deaths occurred in the first six days of life, and the risk of mortality is even greater for LBW or premature newborns.Infant mortality has decreased worldwide from 1990 to 2015, mainly reflecting the drop in postneonatal mortality, and the number of neonatal deaths has not had the same reduction. These rates were calculated considering all records of live births and deaths with LBW, including preterm infants.In 2017 alone, according to the Ministry of Health report (released in 2019), an IMR equal to 89.0/1,000 live births with LBW was recorded in Brazil, and the State of São Paulo ranked fourth among the states with high LBW prevalence in Brazil, as monitoring the municipalities can positively contribute to reducing the number of deaths.The findings of this study show that the number of neonatal deaths is greater than the number of postneonatal deaths, and this difference does not change even if only the deaths of newborns with LBW at term are considered. In the State of São Paulo, in the period 2010–2019, about 41% of infant deaths were LBW, more than 11% were newborns with LBW at term, and more than 57% of infant deaths with LBW at term occurred in the neonatal period. Therefore, reducing LBW and identifying its determinants is one of the keys to reducing mortality rates, but there are municipalities with rates above the state rate . The analysis of excess risk showed that more than 30% of the municipalities had infant and neonatal mortality rates higher than the average mortality rate in the State of São Paulo; in the postneonatal period, the rate was close to 23% of the municipalities. In addition, it was observed that most municipalities with rates above the state average rate are located mainly in the south region, possibly because it is one of the poorest regions of the state.In the analyzed period, the State of São Paulo had an IMR equal to 15.8/1,000 live births with LBW at term, in addition to 9.0/1,000 and 6.8/1,000 live births with LBW in the NMR and PNMR, respectively. Apparently, mortality rates are relatively lowmI = 0.27; p-value=0.02) in the south and southeast regions of the Brazilian territory. These regions are the most developed in the country and showed a higher prevalence of LBW, as well as a decreased risk of LBW in adolescent mothers, a higher risk in adult mothers, and a higher risk in mothers with higher education, especially in the north region. In the state of Paraná, no spatial patterns were identified in the prevalence of LBW among its 399 municipalities. In the municipality of Rio de Janeiro, no spatial patterns were identified in LBW , showing a random spatial distribution. In the municipality of Salvador, spatial clusters of high NMR  were identified in the southwest and central regions, and clusters of LBW prevalence  in the north and south regions. Similarly, clusters of high prevalence of LBW were observed in the eastern and western regions of the municipality of Taubaté .On the other hand, the identification of spatial clusters of the health conditions of live births, as well as the BPN, have been the object of study in recent years. In Brazil, the records of LBW in the 27 federative units were analyzed, identifying high-prevalence risk areas (. Likewise, according to studies, neonatal deaths can be avoided, even if they are newborns with LBW or premature, given a possible association with socioeconomic inequality and the quality of care received by the pregnant woman and the newborn.Clusters with high mortality rates are usually associated with several determinants. The SVI showed no significant association with IMR and NMR. HDI, GDP and SVI were positively associated with PNMR, showing that municipalities with high values of SVI and low values of HDI and GDP will result in lower cases of mortality with LBW in the postneonatal period. This paradox reflects that, even with social inequality, care for newborns in these municipalities is possibly adequate to reduce the risk of death.The HDI and GDP showed a negative association with IMR and NMR, indicating that the increase in these determinants in the priority areas would possibly result in a drop in mortality in newborns with LBW, in addition to emotional and reproductive immaturity in adolescent mothers and aging of the reproductive system in women over 34 years of age.Regarding maternal age, mothers younger than 20 years old or older than 34 years old showed a positive and negative association, respectively, for infant and neonatal mortality. Adolescent mothers and adult mothers are at greater risk of having babies with LBW, and this is related to socioeconomic factors, marital status, occupation, education, etc.. Low education level was positively associated with infant and neonatal mortality. The association was negative with postneonatal mortality, possibly due to other factors involved with education not identified in this study.The mother's schooling can be considered a reflection of the family's socioeconomic level and financial stability, since low values in family income are associated with LBW and the baby's development during pregnancy. Possibly these results were obtained because many municipalities had low rates of physicians and pediatric beds for the total number of live births.The rate of physicians and pediatric beds showed a significant association with neonatal and postneonatal mortality, showing the need for improvement in the planning of physical and human resources to enhance newborn care. The results reinforce what has already been described in other studies, suggesting the need for intervention and implementation of health programs and public policies to maintain care for mothers and newborns in municipalities with spatial dependence, with the objective of reversing the negative effects of LBW and mitigating the risk of infant death.Finally, the associations identified in the analyzed area make it possible to assess the services and the socioeconomic development of the region; however, the variables used in this study were not affected by this incompleteness. Data collected from the 2010–2019 period were used in a consolidated manner.It should be noted that among the limitations of this work is the use of secondary data made available mainly by DATASUS. Specifically, notifications of infant deaths at term with LBW were obtained from SIM, and the other variables from SINASC, CNES, and SEADE. It was not possible to analyze the dataset in the division of early and late neonatal mortality, as many municipalities were observed with values of zero. Data quality is still affected by incomplete fieldsIn conclusion, priority areas were identified mainly among more developed municipalities located in the southwest, southeast and east regions. Significant associations were found between the determinants analyzed and infant mortality in newborns with LBW at term. In addition, the information produced in this study can contribute to the formulation of intervention strategies for the control and prevention of LBW and mortality in newborns with LBW, among the cities at risk in the State of São Paulo.


Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder affecting children and causing significant impairment. It is not clear to what extent ADHD differs between population groups. This study aims to assess prevalence, diagnosis and treatment of ADHD among Arab and Jewish children of primary school age in Israel.Cross-sectional survey, including 517 parents of children ages 7–10 (225 Jewish and 292 Arab) and 60 homeroom teachers of the corresponding children. Both parents and homeroom teachers completed the ADHD Rating Scale-V-RV. ADHD was defined according to DSM-5 ADHD criteria by both parents and teachers, or clinical diagnosis. In addition, parents reported ADHD medication and adherence to medication.Prevalence of ADHD was similar for both groups. Yet, seeking diagnosis was lower among Arab Muslim children (9.2%) compared to Jewish children (17.8%). Arab Muslim children received significantly less medication compared to Jewish children. Parental decision to seek diagnosis was associated with education , not ethnicity. Ethnicity predicted parents’ decisions to pharmacologically treat their children with ADHD  and adherence to medication .Education is critical in the help-seeking process, affecting the rate of ADHD diagnosis. Pharmacological treatment and adherence are correlated with ethnicity. Parents with limited education and minorities should be targeted for interventions to increase awareness regarding ADHD and treatment. Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common and most studied neurodevelopmental disorder of childhood . ADHD isThe reported prevalence of ADHD in children ranges from 2 to 18% depending upon the diagnostic criteria and the population studied . PrevaleThere is no definitive medical test or biological marker that confirms the presence of the disorder . ADHD syIn general, treatment for children with ADHD has expanded considerably and there is significant progress toward standardization of assessment and diagnostic procedures . NeverthIn Israel, according to the Ministry of Health’s regulations, only a specialist in pediatric neurology and child development, a specialist in pediatric and youth psychiatry, a specialist in adult neurology or psychiatry, and a pediatrician with at least 3 years’ experience in child development, can diagnose a child with ADHD. This is performed usually according to the most recent DSM criteria. In fact, the essential components of the diagnostic procedure include meeting DSM criteria and evaluation following completion of a validated diagnostic questionnaire by parents and teachers .Medical services, are available for all Israeli residents by law. In practice, however, socioeconomically disadvantaged population groups and peripheral populations suffer from poor access to these services .Most studies on the prevalence of ADHD in school age children in Israel were conducted by examination of stimulant medication prescriptions which are recommended as a first line treatment –21. The As observed in other studies, over one third of children with ADHD do not use stimulants and about one third of children prescribed stimulants are not diagnosed with ADHD . The difThe purpose of our study was to assess the prevalence of ADHD among elementary school age children in representative Arab and Jewish populations in Northern Israel, by using the DSM-5 criteria for ADHD. We also assessed the prevalence of help seeking for medical diagnosis, pharmacological treatment and adherence to medication. In addition, we studied the concordance between teachers’ and parental assessments in both populations.The study was a cross-sectional telephone survey targeting Arab and Jewish parents in the Northern region of Israel. The research protocol was approved by the Ethics Committees of the Ministry of Education and the University of Haifa. The same sampling techniques were utilized in order to obtain representative samples from each population, drawing a random stratified cluster sample from each population. First, ten villages and towns were randomly selected in the Northern district based on ethnicity (Jewish and Arab) and socioeconomic level . Second,The study was conducted from October 2021 through May 2022. The survey included 517 parents of children aged 7–10 (from second through fifth grade), in 15 Arab and Jewish elementary schools in Northern Israel (292 Arab Muslims and 225 Jewish children). All parents and 60 homeroom teachers of these children (28 Jewish and 32 Arab homeroom teachers) provided written informed consent for participation in the study. Twenty-one questionnaires were not completed and were therefore excluded from analysis. All Arab participants in the study were Muslims.The ADHD– Rating Scale-V (ADHD-RS-V) questionnaire includes 18 items based on the diagnostic criteria for ADHD as described in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association in 2013 (DSM-5) . The tooAs mentioned before, both parents and homeroom teachers completed the ADHD– Rating Scale-V (ADHD-RS-V) questionnaire for each child. The interviews with the homeroom teachers were conducted to identify children at high risk for ADHD, in order to validate parental reports regarding the possible presence of ADHD in their children. We purposefully chose the second and third trimesters of the school year in order to make sure that the teachers were well acquainted with their pupils.A positive ADHD diagnosis was considered according to the ADHD–Rating Scale-V (ADHD-RS-V) if both parent and teacher endorsed at least 6 of 9 inattention or hyperactivity/impulsivity symptoms with a score of 2 or higher (presence of impairment in two settings: home and school), or if parents reported that their child was clinically diagnosed by a physician, including a pediatric neurology and child development specialist, a specialist in pediatric and youth psychiatry, a specialist in adult neurology or psychiatry, and a pediatrician with at least 3 years’ experience in child development.The survey for parents also included: Parents’ Socio-demographic variables: sex, age, town, education, income level, number of children, marital status, ethnicity, religion and employment status. Education was coded as non-academic education (1) and academic education (2). Parental income: Self-reported family income (parent report) was measured by three levels: below, equal to, or above the average net monthly income per family per household in Israel according to the data of the Central Bureau of Statistics. These were then grouped into two categories: Low to medium income levels and high- income level. Marital status was reported as married or living with spouse (1); and single, divorced or widowed (0). Employment was dichotomized as: employed (1) and unemployed (0). Participants were also asked to define their ethnicity as Jewish or Arab.In addition, the parent’s questionnaire included questions concerning seeking diagnosis and medication. “Have you approached a specialist seeking ADHD diagnosis for your child?” “Has your child been diagnosed with ADHD?” “Did the doctor recommend medication for your child?” “Does your child receive medication for ADHD?” In addition, questions concerning the child’s adherence to medication (for children diagnosed with ADHD): the parents were asked to indicate whether they followed the doctor’s recommendations on a four-point scale  and whether the child opposed taking the medication on a scale ranging from 1-very often to 4-never.We used descriptive statistics to characterize the study sample. Chi square and Fisher’s tests were used to examine the variables associated with the parents’ decision to approach a doctor to seek clinical diagnosis for their children, the parents’ decision to treat with medication and adherence to medication. Finally, we ran multivariable logistic regression models, presenting odds ratios, confidence intervals and p-values. The variables added to the regression model were those associated with the dependent variables and that had low multicollinearity with other variables in the model. Analyses were performed using SPSS version 27.The parents’ sample included 292 Arab Muslim parents and 225 Jewish parents. The average age of Arab Muslim parents was 38.0 years, and 43.6 for Jewish parents. There were significant between group differences regarding socio-economic characteristics . More Jewish parents had academic education (95.6% compared to 43.8% of the Arab parents). Lower income levels were reported by Arab parents . Jewish parents had a lower average number of children (2.78 for Jewish families compared to 3.36 in the Arab families), and a higher percentage were employed (96% of the Jewish parents compared to 50.7% of the Arab parents) Table .Of the 517 children reported on by their parents and homeroom teachers, 255 were boys (49.3%) and 262 were girls (50.7%) from second grade through fifth grade. Of the 517 children screened, 153 children (82 Arab children and 53 Jewish children) fulfilled at least one of the three diagnostic criteria based on the parent’s questionnaire, teacher’s questionnaire, or a doctor’s clinical diagnosis. Of these, 88 children  met the diagnostic criteria of DSM-5 based on both parents’ and teachers’ questionnaires. In addition, six children were clinically diagnosed with ADHD by a doctor, however with only one questionnaire suggestive of ADHD (completed by parents or teachers). A total of 94 children (18.2%) were categorized as having ADHD in this study sample (Table Table Among ADHD positive children (N = 94), 76.2% of the Jewish parents approached a doctor seeking clinical diagnosis for their children, compared to only 36.5% of the Arab children (P < 0.001). Thus, more Jewish children were diagnosed (73.8%), compared to 26.9% of the Arab children (P < 0.001), and more Jewish children received prescriptions for pharmacological treatment . In addition, a higher percent of Jewish parents reported treating their children diagnosed with ADHD with medication . Yet, 4.8% of the Jewish children with ADHD reported discontinuing the pharmacological treatment because of the medication adverse effects, and 1.9% of the Arab children discontinued treatment, because the child opposed taking the medication. Significantly, higher adherence with medication was reported by parents of Jewish children as 72.2% of the Jewish children, which were prescribed medication, adhered to the medication compared to 22.2% of the Arab children.The prevalence of ADHD subtypes: 68.1% had predominantly Inattentive type, 9.6% had predominantly Hyperactive-Impulsive type and 22.3% combined type (Inattentive and Hyperactive-Impulsive type), with more Jewish children having the Inattentive type, and more Arab children having the Hyperactive-Impulsive and combined types  and ethnicity, after adjusting for parents’ education, parents’ income levels and employment status, among children with ADHD. Two models are presented for each dependent variable. The first model presents the results before adjusting for parents’ education, and the second model after adjusting for parents’ education , model 1 indicates that parents’ decision for seeking clinical diagnosis for their children was significantly associated with ethnicity, suggesting that Jewish parents were more likely to seek clinical diagnosis for their child with ADHD compared to Arab parents , the association between seeking clinical diagnosis and ethnicity was not significant, therefore we suggest that education can explain the difference between Arabs and Jews in seeking diagnosis and eliminates the association with ethnicity. The gaps between Arab and Jewish parents were explained by parents’ education  have been shown to be related to help-seeking and may explain the between group differences in ADHD diagnoses, and its effects on health inequalities , 48. In Parents’ decision to pharmacologically treat their child is a complex and multi-faceted process influenced by various individual, social and cultural factors. Minority groups report more barriers to seeking mental treatment. These barriers include self and social stigma, cultural beliefs against treatment, lack of cultural and linguistic adaptation of services, and cost and transportation problems , 53. CulIt’s important to note that in Israel, medical services are available for all Israeli residents by the National Health Insurance (NHI) Law. All individuals in Israel are covered by a comprehensive health insurance including physician services, hospitalization, medication, and other services . Every cAlthough in Israel, Arabs have equal access to healthcare, in practice, a different pattern of use of these services is observed in the two communities. Jews utilize the specialist services more often than Arabs . We assuThis study has several methodological limitations; first: the sample size of children with ADHD is relatively small. Second: selection bias, conducting the study required engaging consent from several parties including the school principals, homeroom teachers and the parents. Obtaining cooperation from the relevant parties and gaining their consent to participate in the study was more difficult among the Jewish population, resulting in lower response rates. Therefore, the Jewish sample is only partially representative of the general Jewish population, because it included mainly high socio-economic and highly educated parents, though we tried to engage participants from schools of lower socio-economic levels. Third, the study is based on parent and homeroom teacher reports, and was not confirmed by medical records or clinical assessment. This may introduce a recall bias. On the other hand, estimating ADHD prevalence by referring to medical reports would not enable us to reach children who have ADHD but are not diagnosed. So, estimating ADHD prevalence through elementary schools enabled us to reach children who are not diagnosed. Combining teacher and parent information may yield the strongest psychometric approach for identifying cases in a community . In addiTo conclude, diagnosis and treatment of ADHD is of high importance. This study exposes the gaps between the Arab and Jewish populations in seeking medical services in order to diagnose and treat ADHD, which will enable intervention programs to develop culturally suitable medical services, increase diagnosis and treatment of ADHD among children of minority groups and minimize the existing gaps. Overall, education plays a critical role in identifying children with ADHD. Low educated parents and minority groups should be targeted for interventions to increase awareness regarding ADHD and its treatment. Arab minorities are less likely to receive medical treatment for ADHD compared to their Jewish counterparts. Factors such as cultural beliefs and attitudes towards mental health, access to healthcare and language barriers may contribute to these gaps in utilization. It is important for healthcare providers to recognize and address these disparities to ensure that all children receive the necessary care for ADHD, regardless of their ethnicity.Our results can be generalized to other minorities worldwide as inequality in diagnosing and treating minorities is not uniquely an Israeli phenomenon. A study focusing on attitudes and knowledge concerning ADHD diagnosis and treatment may contribute to the understanding of the gaps between different ethnic groups in Israel and throughout the world.