Growing evidence is now available on the use of S100B protein as a valuable marker of brain damage and its role as a neurotrophic factor. Bearing in mind, among different S100B protein properties that are still being investigated, the possibility of measuring this protein in different biological fluids renders it suitable for use in several disciplines. This is the case with perinatal medicine where even more noninvasive techniques are particularly desirable in order to ensure the minimal handling diagnostic and therapeutic strategies. In this setting, the present minireview reports data on the presence and the usefulness of S100B protein as brain damage marker and as a neurotrophic factor in the so-called unconventional biological fluids such as saliva and human milk, respectively. Results offer new possibilities for the use of S100B in perinatal medicine as a key-protein for the investigations focusing on central nervous system development and damage. The term S100B refers to a member of a multigenic family of calcium-modulated proteins first identified in 1965 by Moore –6. S100BS100B protein has been measured in several biological fluids  by a series of immunoassays, which have been variously used in different fluids. Cerebrospinal fluid (CSF)was the first of various biological fluids in which the role of S100B as a marker of active brain damage was demonstrated , 15. In The idea of measuring S100B into blood was based on the hypothesis that during active brain injury at least some of the S100B released from the damaged tissue could spread into the systemic circulation , also asIn the urine S100B concentrations at birth were significantly higher in preterm newborns developing intraventricular haemorrhage and/or brain damage. In a cross-sectional study using urine obtained from preterm newborns, the protein has been found to be a valuable predictor of early neonatal death –28.In the amniotic fluid S100B concentration has been shown to correlate with gestational age and with cerebral ultrasound scanning results in healthy fetuses . In addiAmong human biological fluids, in the perinatal period, the studies aimed at investigating the presence of S100B protein in biological fluids, namely “unconventional” biological fluids such as saliva and milk, are especially intriguing. In particular saliva, which is more easily collected than CSF, blood or urine offers the hope of simple non-invasive tests especially useful in perinatal medicine. This possibility could even represent the reaching of the so called “gold standard” for non-invasive longitudinal monitoring of occurring brain damage eagerly awaited in clinical practice. Future prospects also include the possibility of monitoring the true effectiveness of the even more risky therapeutic strategies such as mechanical ventilation, brain cooling and experimental medications. Even more interesting prospects are offered by the detection of S100B in breast milk, candidating the protein as a participant in the biochemical communication between mother and child. This might contribute to the identification of biochemical markers with a series of unknown functions that to date confirm that the role of maternal milk instead of artificial ones in brain maturation involvement is unique.The possibility that S100B could be assessed in different biological fluids has been substantiated in the last decade, thanks to continuous interactions among physicians of several disciplines. In this regard, the concept of minimal handling of patients derives from neonatologists and perinatologists who need, in the phase of critical intensive care medicine, non-invasive parameters able to detect cases at risk of brain damage at the earliest stage in order to prevent it. Among non-invasive biological fluids saliva meets the optimality requirements since it can be collected any time without newborn stress, its measurements are reproducible and can be compared with other “invasive” biological fluids.Studies of human fetuses have shown that members of the S100 protein family are present in different tissues of the salivary glands during ontogenesis. Results showed that different S100 proteins are expressed during different phases of pregnancy up to adulthood, whilst S100B in particular has been found to be essentially absent from fetal salivary glands from 32 weeks of gestation onwards , 37. DatThe hypothesis of assessing the protein in a so complex biological fluid was based on the following elements: (i) S100 proteins are highly conserved in amino acid composition among vertebrate species, suggesting a pivotal, although still unknown, biological role for the protein ; (ii) S1Finally, apart from the possible trophic role on the newborn exerted by the maternal breast milk, the examination of S100B level in this unconventional biological fluid could offer new prospects in the investigation of maternal physiopathological conditions with a potential direct impact on the newborn health.


To compare the prevalence of symptoms consistent with attention deficit hyperactivity disorder (ADHD) and related problems in adults in the general population, out-patient psychiatry , and female convicts.A questionnaire based on the DSM-IV criteria of ADHD, reported childhood symptoms, reading and spelling problems, difficulties and suffering, and general assessment of functioning (GAF) was distributed to samples of the general population, open care psychiatry, and female prison inmates. Completed questionnaires were received from 517/1000, 349/400, and 50/65 of the three samples, respectively. Symptoms consistent with ADHD were more than three times higher in out-patient psychiatry than in the general population (6.6% versus 2.1%), with a male-to-female ratio of 1.6–1.7. The severity of symptoms and frequencies of associated disabilities were similar in men and women. ADHD symptoms and related problems occurred in 50% of the female prisoners, which is similar to male prisoners according to the literature.The high prevalence of symptoms and disabilities of ADHD in women should lead to awareness of the disorder in both sexes and be addressed in terms of diagnostic work-up, treatment, and rehabilitation. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) , attentiFollow-up studies of afflicted children into adulthood have shown persistence of syndromatic ADHD or ADHD in partial symptomatic remission with continued functional impairment in a majority of cases . The preSeveral reviews of adult ADHD have been published during recent years ,9. The a.Co-morbidity of ADHD with other mental and neuropsychiatric disorders is common  and has Gender disparities have been observed for both childhood and adult ADHD . In chilSeveral studies have demonstrated a high prevalence of psychiatric diagnoses such as conduct disorder (CD), antisocial personality disorder (ASPD), substance use disorder (SUD), ADHD and learning disorder among mainly male prison inmates –28, and The aims of the study were to survey the frequency and severity of self-reported ADHD-related symptoms, difficulties and suffering, general assessment of functioning (GAF), and reading and spelling difficulties in patients seeking psychiatric care for common mental problems, the majority of whom are females, and in female prisoners convicted of severe crimes, in comparison with a sample of the general population. Our hypothesis was that ADHD-related symptoms, associated co-morbidity, and reading and spelling difficulties are over-represented in out-patient psychiatry and in female prisoners.Three groups of study participants (see below) were surveyed in parallel during the same time period using a questionnaire covering childhood and current symptoms of ADHD, disabilities, and co-morbidity to be filled out anonymously. Since no personal information on non-participants was obtained, no analyses of missing data could be performed. The study was approved by the Uppsala University Ethics Committee. Informed consent in writing was obtained from each participant.At the time of this investigation in 2003, Uppsala County consisted of 300,379 inhabitants. A sample of 1000  between 18 and 55 years of age was randomly selected from the population registry by an independent company . The questionnaire was mailed to the selected persons, and they were reminded twice by mail after the initial request to participate.Out of the 1000 questionnaires distributed by mail 529 were returned; 12 incompletely filled out questionnaires were excluded from analyses. Thus, the total number of participants included was 236 men and 281 women, representing a participation rate of 52% (517/1000). The general population sample was not asked about current mental disorders or on-going medication.n = 468) patients were offered to participate in the study, of which 400 volunteered to take part. Out of the 400 questionnaires distributed 369 were returned, 20 questionnaires were excluded due to incomplete answers, leaving 77 men and 272 women for analysis, representing a participation rate of 75% (349/468).The target population consisted of adult psychiatric out-patients in Uppsala County, women being in majority, seeking care mainly for affective, anxiety, sleep, and personality disorders, i.e. common co-morbid disorders in adult ADHD. Patients with previously diagnosed alcohol and/or substance use disorders (SUD), known to have a high frequency of ADHD, and chronic psychoses were not considered for inclusion. Four hundred questionnaires were distributed among local teams serving separate catchment areas within Uppsala County, each team receiving a number of questionnaires proportional to their average monthly attendance rate. The teams were instructed to hand out a copy of the questionnaire to every Swedish-speaking patient between 18 and 55 years of age after information about the study had been given orally and in writing by the reception staff. Four hundred and sixty-eight  for seeking psychiatric care among participants who volunteered to respond were consistent with the following diagnostic groups: affective disorders (45%), anxiety disorders (47%), sleep or eating disorders (14.1%), personality disorders (2.6%), various other disorders (14.1%), unknown (2%). Only two participants mentioned ADHD as their main complaint.A question about on-going medication was answered by 340 patients. The reported drugs were: selective serotonin re-uptake inhibitors (42.9%), other antidepressants (24.3%), anxiolytics (19.4%), antipsychotic drugs (6.8%), mood stabilizers (5%), hypnotics (21.2%), other psychoactive drugs and analgesics (12.9%), and medication for somatic disorders (12.6%). Only one participant was prescribed central stimulants.The Hinseberg prison is the largest prison for women in Sweden with the highest security level and is intended for female convicts from the whole country sentenced to long-term (6 years on average) imprisonment. The two most common crimes of conviction were severe drug crimes and murder/manslaughter—44% and 21%, respectively. Of the study group 57% (37/65) were Swedish, 5% (3/65) were citizens of other Nordic countries, and 38% (25/65) were citizens of other foreign countries (participants not speaking Swedish were assisted by interpreters). At the time of the study the number of inmates was 104; 65 high-security internees were available for the study and were invited to participate. Excluded from participation were: 17 inmates who had been transferred to a special unit for treatment of alcohol and drug addiction; 18 internees being transferred to an open-wing section since they were convicted of minor crimes; 4 being admitted to hospital. A total of 50 participants gave informed consent and, thus, the overall participation rate was 77% (50/65). Drugs for treatment of somatic disorders were prescribed to 18% of the female inmates, and 20% were prescribed antidepressants, antipsychotics, or hypnotics. None were treated with central stimulants or atomoxetine for ADHD.The first part of the questionnaire covered the 18 symptoms of ADHD according to DSM-IV. Each question was supplemented by a short description of possible adult expressions of the symptoms. The response format was four-fold, depending on current presence and burden of symptoms of ADHD: never/seldom, sometimes, often, and very often. Each answer corresponded to a score from 0 to 3, giving the questionnaire a maximum score of 54 and a maximum total score of 27 for hyperactivity-impulsivity and inattention, respectively. A score of 2 or more of at least six out of nine symptoms of inattention and/or six out of nine symptoms of hyperactivity-impulsivity was required to be categorized as inattentive and/or hyperactive types of adult ADHD. Questions about ADHD symptoms during childhood as reported to the participant by parents or other informants were asked separately.The second part of the questionnaire included questions on age and sex, reading and spelling difficulties (Yes/No answers). Functional impairment was assessed by asking the participants to rate difficulties and suffering caused by the current ADHD-related symptoms, using two 100-mm visual analogue scales (VAS)  as well as a request to self-rate their global assessment of functioning (GAF)—according to DSM-IV—during the last year and the last two weeks ,31. The Participants from the general population and out-patient psychiatry samples were divided into two main groups, ‘Hyperactive’ and ‘Not hyperactive’. Hyperactive participants were those who endorsed current ADHD symptoms (a score of 2 or 3 on at least six out of nine symptoms of hyperactivity-impulsivity) and hyperactivity-impulsivity in childhood. The hyperactive group was split into three subgroups. ‘Childhood only’ was fulfilled if the patient confirmed a history of hyperactivity in kindergarten, preschool, or primary school without endorsement of symptoms of adult hyperactivity-impulsivity. ‘Childhood and Adult’ was fulfilled if a history of childhood hyperactivity was reported and a rating of 2 or 3 on six or more DSM-IV symptoms of hyperactivity-impulsivity was endorsed in the questionnaire. ‘Adult only’ was fulfilled if six or more DSM-IV symptoms of hyperactivity-impulsivity were rated 2 or 3 and no report of childhood hyperactivity. The not hyperactive group, serving as a comparison group, consisted of participants not reporting childhood hyperactivity and with less than six DSM-IV symptoms of hyperactivity-impulsivity rated 2 or 3 according to the questionnaire.The female prison inmate participants reporting childhood and/or adult ADHD symptoms of hyperactivity-impulsivity and/or inattention constituted the ‘ADHD group’. Participants without childhood symptoms and not fulfilling the criteria of a score of 2 or more on at least six out of nine symptoms of inattention or hyperactivity-impulsivity constituted the ‘Non-ADHD group’ and served as a comparison group. Each group consisted of 25 participants.P-values of less than 0.05 were considered statistically significant.Data were analysed using SPSS, version 12.0.1. The chi-square test or Fisher's exact test was used to test for significant differences in frequencies between groups. Since symptom and GAF scores were not normally distributed, differences in mean scores were analysed using the Mann-Whitney U-test. Confounding by skewed gender proportions and higher prevalence of hyperactivity in the out-patient sample was corrected for by Mantel-Haenszel statistics. P < 0.001). There was no statistically significant difference in age between females and males in the two samples. The mean age of the prisoners was 35 ± 10 years .The mean (± SD) age of the participants was 33 ± 10  years in the out-patient sample and 37 ± 11  years in the general population sample . The prevalence of adult and childhood hyperactivity-impulsivity was approximately three times higher among participants in out-patient psychiatry as compared to the general population (6.6% versus 2.1%). The prevalence of hyperactivity-impulsivity was higher in men than in women, 19.5% versus 11.4% (ratio 1.7) in the general population (P < 0.01), and 45.5% versus 27.7% (ratio 1.6) in out-patient psychiatry (P < 0.05).As shown in P < 0.001), the childhood only (P < 0.001), and the adult only (P < 0.01) subgroups, and the not hyperactive group (P < 0.001). Interestingly, the symptom scores were similar in the out-patient psychiatry and the general populations for the childhood and adult subgroup. There were no statistically significant differences in total symptom scores, inattention scores, or hyperactivity-impulsivity scores between men and women for the hyperactive groups in the two samples (data not shown).P < 0.001). Within the general population sample only the childhood and adult subgroup had significantly higher levels of both difficulties and suffering as compared to the not hyperactive group. In the out-patient sample all subgroups had significantly higher levels of both difficulties and suffering as compared to the not hyperactive group. There were no major differences between men and women within the two samples (data not shown).As shown in P < 0.001). In the general population sample, only the childhood and adult subgroup had significantly lower GAF scores as compared to the not hyperactive group, both during the past year and the past two weeks . The adult only subgroup had a significantly lower GAF score during the past two weeks as compared to the not hyperactive group (P < 0.05), whereas no difference was found with respect to the past year. The GAF scores for men and women did not differ significantly. In the out-patient psychiatry sample, the hyperactive group and all subgroups had significantly lower GAF scores than the not hyperactive group with the exception of the past two weeks for the childhood hyperactivity only subgroup. The GAF scores were not significantly different for men and women.As shown in P < 0.001 and 0.01, respectively); see P < 0.001 and 0.05, respectively). The frequencies of spelling difficulties in the hyperactive group were similar in both samples, whereas reading difficulties were more frequent in the out-patient sample (P < 0.05). For the childhood and adult subgroups the frequencies of reading and spelling difficulties were similar between the two samples. In the general population sample the subgroups with childhood hyperactivity as well as childhood and adult hyperactivity had significantly higher frequencies of both reading and spelling difficulties than did the not hyperactive group (P < 0.001 and < 0.001 respectively). There were no statistically significant differences between men and women in the two samples. In the out-patient psychiatry sample most hyperactivity subgroups were found to have higher frequencies of reading and spelling difficulties than did the not hyperactive group. The percentages in women were similar to those in men.There was a significantly higher prevalence of reading and spelling difficulties in the out-patient sample than in the general population sample  reported inattention only in childhood. Fifteen (30%) had both childhood inattention and adult symptoms of ADHD. Seven of those endorsed a rating of 2 on six or more symptoms of inattention matching the inattentive type of ADHD, and another seven endorsed a rating of 2 on six or more symptoms of both inattention and hyperactivity-impulsivity matching the combined type of ADHD. One participant endorsed a rating of 2 on six or more symptoms of hyperactivity-impulsivity but not inattention, thus matching the hyperactivity-impulsivity type of ADHD. Four participants (8%) endorsed current ADHD symptoms (i.e. only as adults), one having a rating of 2 on six or more symptoms of inattention, another on six or more symptoms of hyperactivity-impulsivity, and two on six or more symptoms of both inattention and hyperactivity-impulsivity.P < 0.05; Mann-Whitney U-test). Difficulties and suffering attributed to symptoms of ADHD, the GAF ratings for the past year and for the past two weeks, and reading and spelling difficulties were also statistically significantly lower in the ADHD group than in the non-ADHD group.The symptom scores of ADHD, difficulties and suffering attributed to symptoms of ADHD, global assessment of functioning (GAF), and reading and spelling difficulties were compared between the 25 participants in the ‘ADHD group’ and the 25 participants in the ‘non-ADHD group’. As shown in P < 0.001; chi-square test).The frequencies of inmates fulfilling the criteria for conduct disorder (CD), antisocial personality disorder (ASPD), and adult ASPD without a childhood history of CD according to the DIP-Q self-report were statistically significantly more common in the ADHD group versus the non-ADHD group  is within the range of published prevalence figures of clinically diagnosed adult ADHD (cf. Introduction).The main finding in psychiatric out-patients was that the hyperactive group was twice as large compared to the general population. The subgroup with ADHD-related symptoms of hyperactivity-impulsivity in combination with a childhood history of hyperactivity was three times higher in the out-patient psychiatry sample mainly suffering from mood and anxiety disorders than in the general population (6.6% versus 2.1%). Almeida Montes et al.  comparinThe out-patient psychiatry sample had higher symptom scores (both for hyperactivity-impulsivity and inattention) than did the general population and higher ratings of difficulties and suffering attributed to ADHD-related symptoms. Self-rated GAF scores were lower within out-patient psychiatry than in the general population, both in the hyperactive and the not hyperactive group. There was also a higher prevalence of reading and spelling difficulties among out-patients as compared with the general population, both for the hyperactive and the not hyperactive group.Interestingly, only two participants in the out-patient psychiatry group were seeking care because of symptoms of ADHD, and only one received treatment for ADHD despite histories of childhood hyperactivity-impulsivity and the presence of ADHD-related symptoms.Hyperactivity-impulsivity was more prevalent in men than in women in both samples with a male-to-female ratio of 1.6–1.7, which is commensurate with previous reports . HoweverThe female prison inmates belonging to the ‘ADHD group’, comprising 50% of the participants, all reported childhood inattention and were characterized by higher rating scale scores, higher levels of difficulties and suffering attributed to ADHD-related symptoms, lower GAF scores, more reading and spelling difficulties, and higher frequencies of conduct disorder (CD) and current antisocial personality disorders (ASPD), as compared with the ‘non-ADHD group’. Thus, there seems to be a high degree of co-occurrence of childhood inattention, CD and ASPD, and ADHD-related problems in female convicts. In all rating measures the ‘ADHD group’ differed from the general population sample and had similar ratings and frequencies to the hyperactivity group in the out-patient psychiatry sample. The ‘non-ADHD group’ had similar scores and frequencies as the not hyperactive group in the general population sample.The literature on ADHD in female offenders has recently been reviewed in a study by Rosler et al. . They reThe participation rate among patients within out-patient psychiatry was 75%, and 77% in the prisoners. Although the participation rate among randomly selected participants in the general population was lower, 52%, it was still acceptable compared to similar studies in the literature ,8.There are certain limitations of the present study. Results are based on surveys of self- reported symptoms and not on clinical evaluations. However, the aim of the study was to substantiate the impression that adult ADHD is under-recognized in clinical practice. The robust findings of the study support our hypothesis that ADHD and related problems are over-represented in psychiatry and emphasize the need for proper clinical studies and improved assessments of patients in clinical practice in general. In order to secure honest answers and a high participation rate we chose to perform this survey anonymously, which, however, precluded analyses of missing data. Also, ADHD-related symptoms in combination with reading difficulties might be more frequent among non-participants leading to a falsely low prevalence estimate of ADHD-related symptoms in the samples under study. The low number of participants in some subgroups precluded detailed statistical analyses. The ADHD rating scale used in the present study was constructed on the basis of the DSM-IV criteria for ADHD. The questions of the present scale are similar or almost identical to the later published official WHO rating scale to evaluate adult ADHD: the Adult ADHD Self-Report Scale (ASRS) –38, whicPatients and convicts with known alcohol or substance use disorders, known to be associated with high prevalence rates of ADHD and related problems, were not included in the present surveys. This might deflate the prevalence rates observed. The advantage, however, is that it could be shown that the frequency ADHD and related problems among non-addicts are common and need to be acknowledged.The present study indicates that there is a high prevalence of adult ADHD both in general psychiatry and in convicts. In addition, the high prevalence and severity of ADHD-related symptoms and problems in women is highlighted. This prompts further clinical investigations using presently available assessment instruments and physician-administered rating scales in order to confirm and extend the present findings. Our results are consistent with the emerging literature on adult ADHD, a neglected issue in psychiatry and in the rehabilitation of convicts.


Attention deficit hyperactivity disorder is one of the most common child psychiatry disorders. General physicians (GP), as primary care providers, can have an important role in screening and treatment of ADHD. This study aimed to survey GPs' knowledge, attitude, and their views of their role in the screening, diagnosing and managing children with ADHD.Six hundred and sixty five general physicians in Shiraz, Iran, answered a self-reported questionnaire on ADHD. The questionnaire consisted of questions regarding socio-demographic characteristics such as age, the duration of practice as a GP, marital status, general knowledge about ADHD, and the management of ADHD.Less than half of them believed that they have adequate knowledge and information about this disorder. They usually do not like to be the primary care providers for children with ADHD. The majority of them prefer to refer the children to related specialists, mostly psychiatrists or psychologists. More than one third of them believed that sugar is a cause of ADHD. Only 6.6% of them reported that ADHD persists for the whole life. Their knowledge about methylphenidate is reasonable.As many other countries worldwide, the knowledge of GPs about ADHD should be improved. They do not asses and manage children with probable ADHD by themselves without referring to related professionals. They do not opt for the use of methylphenidate. ADHD symptoms are very common among children and its rate in Iran was reported up to 10.1% . For exaAlready, the knowledge of GPs about intellectual and developmental disabilities has been studied in some countries such as Singapore, Pakistan, and Australia. They usually reported significant deficits due to inadequate training during medical education courses ,6,7. A sA previous study reported that GPs should be more informed about ADHD . There wThis cross-sectional descriptive study included GPs from Shiraz, Southern Iran. About 900 GPs were registered in Shiraz Medical Council. 665 GPs privately answered the self-reported structured questionnaire to assess their knowledge, attitude, the source of acquired information about ADHD, and competence about the diagnosis and management of ADHD. The questionnaire was mailed to them and they were reminded to return their responses. The participants were provided with enough time to fill it, taking about 10 to 15 min. The questionnaires which were not returned at the time of gathering the data were not included in the analysis. The questionnaire had already been used in the previous studies on teachers and pharmacists . Its valThe questionnaire also asked their knowledge and attitude about methylphenidate and its use for ADHD management. Those questions were: "Is medication therapy necessary for treatment of ADHD? What is the clinical implication of methylphenidate? Which medication do you recommend as the best treatment for ADHD?" Which of the following medications  does methylphenidate belong to? Do you agree that methylphenidate should not be administered in ADHD except in children with severe symptoms or specific difficult circumstances and that its prescription should be avoided?The questionnaire was used in a pilot study on a small number of GPs to survey whether it can be administered easily and it has enough conceptual clarification. All of the participants were informed about the study and reassured that participation in the study is voluntary and anonymous. It was stressed that their responses would not be used for any other purpose. The study was approved by the office of chancellery for research affairs in Shiraz University of Medical Sciences.Statistical analysis was conducted using SPSS-11. Frequencies were calculated for the demographic categorical data. The numerical values of age and the years of practice were reported as mean and standard deviation (SD).665 questionnaires were returned. Excluding 316 (47.5%) of them who did not report their gender, 195 (55.6%) were male and 155 (44.4%) were female. The mean age of the whole sample was 39.3 (SD = 9.3) with a range of 24 to 80 years. 316 of them did not indicate their age. 73.2% of them were married. The mean years of their practice as a GP was 10.4 (SD = 8.5). Their familiarity with the statements associated with ADHD is displayed in Table Just 3.8% of the GPs believed that the IQ of children with ADHD was lower than that of non-ADHD children. 68.6% of them mentioned that their IQ was similar to their peers and 24.8% responded that their IQ was more than that of their peers. Less than two thirds of them agreed that educational achievement of ADHD children is less than that of their peers. 6.6% reported that ADHD would persist for the whole life. 69.3% of the GPs indicated that Ritalin is a stimulant medication. 51.6% of the sample reported that Ritalin should not be administered for management of ADHD, unless in severe cases. 93.5% believed that Ritalin is used to increase attention and concentration.Medical journals  were the most common source of information. Media/magazines (n = 165) and colleagues/peers (n = 119) were the next common sources of their information. The minority of them (n = 65) have passed special courses on ADHD. About 46.6% of them believed that they have adequate knowledge and information about this disorder.The GPs reported that ADHD should be managed by a psychiatrist (70.5%), psychologists (20.3%), neurologist , and other specialists (1.1%). Five percent of them asses and manage children with probable ADHD by their own without referring to experts. 44.5% of them refer these children without conducting any further assessment. 18.0% reported that they accept to manage them in follow ups.As to the serious outcomes of ADHD, the most prominent finding is that many of the GPs have not sufficient information about at least some of the statements surveyed in the current study. According to a previous study in a clinical setting, less than 5% of the children with ADHD were suggested to be a possible case of ADHD for the first time by the GPs . This maIt is interesting that only 6.6% of the respondents agree that ADHD is a lifelong disorder. This rate is much lower than those reported in Turkey (35.2%) and Singapore 27%) . . 8]. TheHowever, near 80% of the GPs disagreed that it is not a serious problem and does not need to be managed. This rate is higher than that of 26.7% reported by the parents of children with ADHD . About 3While most of them had a good knowledge about methylphenidate, half of them were against the use of methylphenidate for these children except for severe cases. It may indicate that their concerns about the use of the medication need to be considered in continued medical education (CME) programs. This gap has also been reported in a similar study on pharmacists .The rates of the source of information were very similar to those of a similar study on GPs and pediatricians in Pakistan . They reThe majority of the GPs reported that ADHD should be managed by a psychiatrist (70.5%) or psychologists (20.3%) and the GPs do not asses and manage children with probable ADHD by their own without referring to other experts. Our results regarding the necessity of management by psychiatrists/psychologists are very similar to those of the study from Pakistan, indicating that about 79% of them agreed with it . The finThere are some limitations in the study that should be considered. Although the sample size was large, the answer of the questions was the binary response of false or true. So, the respondants had 50% chance to guess the correct answer.Moreover, as much as ADHD is a common psychiatric disorder, it is a complex problem with many controversies, e.g. about three quarters of children with ADHD have at least one co-morbid psychiatric disorder . OppositGPs as the primary care physicians should improve their knowledge regarding ADHD through participation in CME courses. Even, more emphasis is required on teaching and training regarding ADHD screening in undergraduate medical curricula. Meanwhile, for more training, GPs should be taught how to use structured diagnostic tools . KSADS FThe authors declare that they have no competing interests.A.G. conceived the study. A.G. and N.Z. jointly contributed to the study design. N.Z was responsible for gathering of the data. A.G. drafted the manuscript. A.G. and N.Z. performed the statistical analysis. All authors contributed to interpreting the results, and read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/11/5/prepub


Children with attention-deficit/hyperactivity disorder (ADHD) show a marked temporal variability in their display of symptoms and neuropsychological performance. This could be explained in terms of an impaired glial supply of energy to support neuronal activity.We pursued one test of the idea with measures of a neurotrophin reflecting glial integrity (S100B) and the influences of 8 cytokines on the metabolism of amino-acids, and of tryptophan/kynurenine to neuroprotective or potentially toxic products that could modulate glial function. Serum samples from 21 medication-naïve children with ADHD, 21 typically-developing controls, 14 medicated children with ADHD and 7 healthy siblings were analysed in this preliminary exploration of group differences and associations.There were no marked group differences in levels of S100B, no major imbalance in the ratios of pro- to anti-inflammatory interleukins nor in the metabolism of kynurenine to toxic metabolites in ADHD. However, four trends are described that may be worthy of closer examination in a more extensive study. First, S100B levels tended to be lower in ADHD children that did not show oppositional/conduct problems. Second, in medicated children raised interleukin levels showed a trend to normalisation. Third, while across all children the sensitivity to allergy reflected increased levels of IL-16 and IL-10, the latter showed a significant inverse relationship to measures of S100B in the ADHD group. Fourthly, against expectations healthy controls tended to show higher levels of toxic 3-hydroxykynurenine (3 HK) than those with ADHD.Thus, there were no clear signs (S100B) that the glial functions were compromised in ADHD. However, other markers of glial function require examination. Nonetheless there is preliminary evidence that a minor imbalance of the immunological system was improved on medication. Finally, if lower levels of the potentially toxic 3 HK in ADHD children were confirmed this could reflect a reduction of normal pruning processes in the brain that would be consistent with delayed maturation (supported here by associations with amino-acid metabolism) and a reduced metabolic source of energy. Childhood attention-deficit/hyperactivity disorder (ADHD) is characterised by poor attention-related abilities, restless activity along with cognitive and behavioural impulsivity. All 18 features of the diagnosis are prefaced by the word "often" in the DSM-IV. Such variability is also typical of laboratory measures of the children's abilities, and is well illustrated by response times (RTs) in neuropsychological tests for all subgroups . Thus, aThis pilot study examines levels of the cytokine-related neurotrophin S100B as a putative biomarker of the integrity of glial function, hypothesising that altered levels could reflect dysfunction and an impaired energy supply for neuronal activity. Serum S100B levels correlate strongly with CSF measures  and theyHowever, in cell culture prolonged glucose deprivation can down-regulate S100B mRNA expression and eventually lead to reduced S100B release . A regioMarkers of one of the potential causes of glial dysfunction were also sought. These markers reflect the nature of tryptophan metabolism. From 80 to 95% of brain levels of l-tryptophan are metabolised in the kynurenine pathway with the remainder contributing to the synthesis of 5-HT . ActivitFinally, an important determinant of the production of glial kynurenine and its metabolites is the activity of the indoleamine and tryptophan 2, 3-deoxygenases (IDO and TDO). The activity of these enzymes is modulated in part by the balance between pro- and anti-inflammatory interleukins. An imbalance would also provide evidence for or against anomalous kynurenine metabolism and glial function. Altered ratios of the interleukins and kynurenine metabolism have indeed been described for depression and bipolar illness -27.The proinflammatory cytokines suitable for measurement include the interleukins IL-1β, IL-2, IL-6, tumour necrosis factor-α (TNF-α) and interferon-gamma (IFN-γ) for contrast with the antiinflammatory cytokines IL-10 and IL-13 . Also inLastly, our analysis included a number of amino acids not only as a control for the tryptophan measures, but because branched-chain amino acids can provide an alternative energy supply to neurons. Amino acids such as leucine, isoleucine and valine can be broken down in glial cultures to metabolites that can enter the tricarboxlic acid cycle directly or even produce lactate itself -37.In summary, we report on a pilot study of serum samples from medication-naïve children with and without ADHD, and a group taking psychostimulants for 1) S100B, 2) tryptophan metabolites, 3) 17 amino-acids, and 4) a set of pro- and antiinflammatory interleukins as potential indicators of the integrity of glial cell function (hypothesis 1: decreased in ADHD), of the presence of toxic over-protective features of amino-acid metabolism (hypothesis 2: in ADHD) and the immunological activity influencing metabolism . A high variability of RT (coefficient of variance) for children with ADHD was established on a continuous performance task (CPT) prior to entry to the study.Participants included 21 medication-naïve children referred consecutively to the Clinic for Child and Adolescent Psychiatry in Essen who were given a DSM-IV diagnosis of ADHD combined type. A second older group of 14 children for whom the same diagnosis had been made 4 years previously and were receiving medication were also recruited (ADHDmed). One was receiving atomoxetine, one Ritalin and the others a retard formulation . A control group (CON) of 21 typically developing children for the ADHD group was recruited by advertisement. An attempt to recruit controls for the ADHDmed group from their healthy siblings resulted in only 7 participants (SIBS). The gender, age, IQ, and body-mass index (BMI) of the children, and the socio-economic status of the father are shown in table A research diagnosis was made using a semi-structured parent interview . InfIn addition, the nature of any allergy, current or past and its severity (0-3) was also recorded. The IQ was assessed with the standardized version of the CFT-20-R  or for sElecsys S100™, Roche Diagnostics, Switzerland). The lowest detectable concentration of S100B was 0.02 μg/L. Intra- and inter-assay coefficients of variation were < 5% and < 8%, respectively.Fasting venous blood (20 ml) was withdrawn in the morning (08:00-09:00), the serum separated and stored at -80°C for later analysis by technicians blind to the source of the sample . S100B cThe cytokines IFN-γ, IL-1β, IL-2, IL-3 IL-6, IL-10, IL-13, IL-16, LIF, and TNF-α were analysed in the serum using ELISA test kits from R&D systems as described in the manufacturer's instruction. For determination of IL-1β, IL-6, IL-10 and TNF-α we used high sensitive assays. All samples were below the detection limit for leukaemia inhibitory factor (LIF: limit: 7.8 pg/ml), and IL-3 (limit: 15.6 pg/ml), and for 40/63 samples IL-1β (detection limit: 0.063 pg/ml) was not detected. These samples were excluded from further calculation.For amino acid determination the AccQ Tag method was used . This analysis concerned the 5 tryptophan-competing amino acids  and 12 other amino-acids . Briefly, after pre-column derivatization using 6-aminoquinolyl-N-hydroxy-succinimidyl carbamate, the samples were injected to a HPLC system consisting of a 2695 separations module connected to a 2475 fluorescence detector (Waters). The gradient used the AccQ Tag eluent, acetonitrile, and HPLC grade water with a flow rate of 1.0 ml/min at a temperature for the AccQ Tag column (3.9 × 150 mm) of 37°C. The detection wave lengths were λex = 250 nm and λem = 395 nm.For tryptophan, kynurenine and their metabolites the analytes were extracted from samples and calibrators/controls using Waters Oasis MCX 1 cc (30 mg) extraction cartridges. The eluent was evaporated to dryness under nitrogen and reconstituted with 150 μl 0.1 M PBS. Reconstituted samples/calibrators/controls were transferred to microinjection vials and the analyses run on a Waters 2695 chromatograph connected to a Waters Model 2487 dual-l UV detector and a 2475 fluorescence detector. For determination of 5-HIAA, kynurenine, KA and 3HK, 100 μl of the samples were loaded onto a 250 mm × 4 mm Supersphere 60 RP-select B, C8 column . Due to the relatively higher concentration, a second 10 μl injection was performed for the determination of tryptophan. The gradient elution used a mobile phase consisting of a mixture of 0.05 M sodium acetate , acetonitrile (solvent C), and methanol (solvent D). The flow rate was 0.80 ml/min with the column temperature set to 35.0°C, while the samples were cooled to 4.0°C. Tryptophan  and 5-HIAA  were measured by fluorescence detection; kynurenine (365 nm), KA (330 nm), and 3-HK (365 nm) were measured by UV detection. Run times after injection until detection of the compounds were about 20.4 min for tryptophan, 13.4 min for kynurenine, 22.5 min for KA, and 7.0 min for 3HK. Data were processed using EMPOWER for Windows 2000 software (Waters). The concentrations were established through comparison of peak heights of the single analytes with the peak heights of the respective calibration curves.tryptophan availability index, 100 × tryptophan/sum of the competing amino acids; (2) The tryptophan breakdown index that reflects the sum of the activities of the TDO and ID enzymes, kynurenine/tryptophan, and (3a) the neuroprotective index, KA/3HK. It may be noted that neuroprotection would be increased with a larger index value. This third index differs from that used by Myint et al. [Three indices of activity in the tryptophan metabolic path were calculated from the above serum analyses. (1) The t et al.  who calcP values are 2 tailed and unless otherwise stated partial correlations that controlled for age or gender are cited. The significance of the reported tests at α = 5% can be assessed against a rough false discovery rate (FDR) criterion of p ≤ 0.02. Values up to α = 10% (FDR: p ≤ 0.05) are noted as trends or tendencies.The groups were compared on demographic data and behavioural ratings (questionnaire and biochemistry) with the use of ANOVA for continuous variables and the t-test for other variables. They were compared initially after controlling for age, BMI, gender and allergy. The covariates in the final analysis are noted in the results section, and are usually restricted to age/gender as the significant correlates. (Age proved to be a good proxy for BMI in the absence of overweight cases.) Homogeneity of variance was usually evident where the larger subject groups were examined (Levene's test). The analyses consider separately S100B, the interleukins, the amino aids and kynurenine metabolites. Pearson correlations between biochemical measures were computed and, being of an exploratory nature, are reported uncorrected. Nonetheless, ancova  = 1.49, p = 0.23, η2 = 0.03).Group characteristics and the mean serum concentrations of S100B are given in table We then examined whether the severity or nature of the symptoms influenced levels of S100B. Using the norm T-values for the sub-scales of the Conners' ratings to contrast ADHD- and control children with high  and low  total DSM or inattentive DSM CPRS ratings showed there were no differences in the levels of S100B. However, across all children the CPRS ratings of anxiety (not inattention or opposition) showed a weak bivariate tendency to relate to S100B levels . Indeed, on a closer examination the presence of internalizing symptoms contributed to the relationship of decreasing S100B levels with increasing DSM total symptom ratings in the ADHD and the combined ADHD groups. In both instances the partial correlations for anxiety controlling for ratings of oppositionality approached significance . A similar relationship was not evident for other ratings (e.g. inattention) or for the controls.In summary, independent of age, BMI and gender there were no group differences in the level of serum S100B between those with and without a diagnosis of ADHD. However, S100B levels were lower in those children expressing higher levels of non-externalizing symptoms .2 = 0.09, power 0.62: covariates age and gender). Controlling for BMI or allergy marginally attenuated the significance (F = 3.3). Ancovas  for tryptophan availability and breakdown confirmed higher and lower levels (respectively) in the combined ADHD than in the control groups  = 2.97/4.93, p = 0.09/0.03, η2 = 0.05/0.08, power 0.40/0.59, respectively: table Comparison of the measures of tryptophan and 5 competing amino acids in 4 subject groups, showed a trend for higher levels of tryptophan alone in the ADHD subjects independent of medication  it is notable that the levels of metabolites in the two different pathways for tryptophan breakdown (kynurenine and 5-HIAA) did not differ between groups with or without controlling for age, gender or BMI. However, the tendency for lower 3HK levels in the ADHD groups than in the controls  = 3.15, p = 0.08) merited closer attention: the same trend was evident in the neuroprotection 3a index that contrasts the KA/3HK pathways . Partial correlations (accounting for age and BMI) showed, as expected, a strong relationship for tryptophan with kynurenine (but not 5-HIAA) in ADHD, ADHDmed and control groups . But, in contrast to the relationships between kynurenine and the neuroprotective KA in all groups , the relationship of kynurenine to the toxic metabolite 3HK was marked in the controls , and absent in the ADHD group (p = 0.35). Medication partially restored the association in ADHDmed children (p = 0.01).In summary, there was a tendency for ADHD children to show higher levels of tryptophan and tryptophan availability than those without ADHD. While associations of tryptophan levels with the 5-HT metabolite were not evident in any group, kynurenine breakdown was biased towards the potentially toxic 3HK in the control group alone (cf. hypothesis 2).2 = 0.19-0.25): significance levels were reduced with age as a covariate. Only glycine showed elevated levels in the ADHD group compared to each of the other groups  = 3.29, p = 0.028, η2 = 0.15), although, noting the medium effect size, phenylalanine showed a descriptively similar trend with age as covariate  = 2.27, p = 0.09, η2 = 0.11).Most of the 17 amino-acids studied showed non-significantly higher concentrations in the ADHD than the control groups: the exceptions with lower values were isoleucine, cystine, methionine and proline , methionine and threonine . But, in the ADHD group there was only a minor negative relationship with proline . Second, in controls there were negative relationships for the antiinflammatory IL-13 with arginine  and the proinflammatory IL-6 with cystine . In contrast, the only associations for the ADHD group were that proinflammatory TNF-α levels tended to be positively related to those for alanine  and glutamate .We explored bivariate correlations of the levels of amino-acids with cytokines in ADHD and control groups. The following two patterns emerged with partial correlations accounting for age. (1) CON: 6 amino-acids correlated strongly and exclusively with kynurenine and 3HK: . (2) ADHD: correlations were restricted entirely to the neuroprotective index for Thr and Met . (3) ADHDmed: 12 amino-acids correlated positively with kynurenine and 10 correlated negatively with the tryptophan breakdown index and with no other item: .Exploring the correlations for amino-acid levels with kynurenine metabolism strikingly different patterns for each subject group emerged. First S100B levels related to some amino-acids in control but not ADHD children. Second, a few amino-acids were related to a proinflammatory cytokine in the ADHD group in contrast to the negative relationship seen in the controls. Striking is that many amino-acids related to kynurenine and its toxic metabolite 3HK in controls supporting the evidence (above) for marked catabolic activity in healthy children. This was not evident in the ADHD group. Medication was associated first with a reinstatement of amino acid associations with kynurenine levels, and secondly decreasing amino acid levels were inversely related to the tryptophan breakdown index.In summary, amino-acid concentrations were related differentially with cytokine levels and kynurenine metabolism in each subject group. 2 = 0.13) and for IL-13  = 3.73, p = 0.07, η2 = 0.16) after controlling for age and gender with quite strong effect sizes in both comparisons.Six of the 8 interleukins measured showed non-significantly higher levels in the ADHD than control groups: only the small number of proinflammatory IL-1β measures was lower in ADHD children. TNF-α levels were similar in ADHD and CON groups table . All theIL-16 levels did not differ significantly between control and ADHD groups (F = 0.62). But across all subjects IL-16 levels correlated positively with the severity of allergy . Such a relationship was also seen for the antiinflammatory IL-10 . The IL-16 relationship was not significant for any group alone: but, there were indications of a possible association with oppositional and hyperactive symptoms  rather than the inattentive ratings implicated in the genetic study (see introduction). This association was reduced in a partial correlation controlling for allergy severity. Interestingly, there were positive and negative partial correlations respectively for IL-16 and IL-10 levels with those for S100B  in the ADHD, but not in the control groups.sd 0.10; CON 0.35, sd 0.12) to increase on medication  = 3.1, p = 0.06, η2 = 0.18, covariates age and gender). However, the ratios of proinflammatory IL-2 and IL-6 to antiinflammatory IL-10, IL-13 and IFN-γ did not differ between groups. In contrast, the low levels of the proinflammatory IFN-γ to antiinflammatory IL-13 ratio (but not IL-10) in the ADHDmed versus the ADHD group  = 11.76, p = 0.003) were attenuated with the same covariates  = 3.70, p = 0.07, η2 = 0.16), suggesting a partial contribution of the age and gender differences. Lastly, despite relatively few data, the ratios of IL-1β to IL-10, IL-13 and IFN-γ were lower in the ADHD than the control group and increased in the ADHDmed children  = 3.5-5.5, p = 0.05-0.02, η2 = 0.29-0.54: e.g. IL-1b/IL-10, CON 0.45, sd 0.41; ADHD 0.21, sd 0.14; ADHDmed 0.72, sd 0.81).The ratios of pro- to antiinflammatory interleukins provide indices of the balance that influences enzyme activity in the kynurenine metabolic pathway (hypothesis 3). For example, the ratio of proinflammatory TNF-α to antiinflammatory IL-13 (but not IL-10) showed a trend for low ADHD values  = 1.18, p = 0.32, η2 = 0.05). However, the ratio correlated positively with CPRS ratings of oppositional behaviour after controlling for age . The correlation was reduced after control for allergic sensitivity and was absent in the ADHDmed group (r = -0.08).IL-16/IL-10 ratios were of interest because of the relationship to allergic sensitivity. Compared to controls they were non-significantly lower in the ADHD and higher in the medicated group , a potential homeostatic imbalance for others  is evident from group specific relationships.The principle results of this study may be summarised as follows.a) There were no group differences for levels of S100B (ADHD ± medication):b) In general, S100B levels were positively related to anxiety, but in ADHD children  the relationship of lower S100B levels with anxiety was negativec) Decreasing S100B levels in ADHD groups related to decreasing levels of IL-16, but increasing levels IL-10 (independent of age), - where IL-16 and IL-10 correlated with allergy sensitivity. IL-16 relationship to oppositional/hyperactive symptoms depended partly on allergy sensitivity.a) There were no clear group difference for interleukin levels or ratios of pro/anti-inflammatory interleukinsb) Psychostimulant medication tended to normalise the slightly altered levels of pro-and anti-inflammatory interleukins and significantly increased some pro/anti-inflammatory interleukin ratiosc) Common to each group were associations between TNF-α, IFN-γ and IL-13, suggesting intact control systems. But relations of TNF-α and IFN-γ to IL-2 and IL-6 to IL-10 were specific to ADHD, ADHDmed and controls, respectively, suggesting condition/state-dependent influences in the 3 groups.a) Tryptophan availability was moderately increased in both ADHD groups over control values.b) A strong association of kynurenine to its toxic metabolite 3HK exclusively in controls contrasted with modest associations for neuroprotective indices in all groupsc) Medication moderated the production of 3KA in the ADHDmed group.d) Amino acid levels and their group-specific associations with 3HK support marked catabolic activity that may indicate neural pruning activity in controls rather than ADHD children.Our main hypothesis of altered serum levels of S100B in ADHD was not upheld. A trend towards lower levels of this putative biomarker of astrocyte integrity in patients with symptoms of anxiety, disturbed mood and poor self-esteem could indicate an inefficient energy supply to support active neuronal function in a subgroup of children without conduct problems. This decrease was partly predicted by the original hypothesis ,19 and oThe failure of this first test of impaired astrocyte function across the whole group of ADHD children has not disproved hypothesis-1. First, synthesis of S100B is not unique to astrocytes . AlteratThe neuromodulator 5-HT, for which tryptophan is a precursor, has become a major focus of interest in ADHD. Relatively speaking levels of the metabolite 5-HIAA excreted are often higher than for DA metabolites and negatively related to measures of signal detection and attention ,23,52. IKA is an NMDA antagonist mostly of glial provenance. In the nanomolar concentrations found in the mammalian brain it reduces glutamate induced excitotoxicity that often results from insult (e.g. hypoxia). As KA is also an antagonist of α7 nicotinic cholinergic binding sites , reducedStriking was a marked association of kynurenine with 3HK levels in the controls, that was absent in the ADHD groups. The implication of enhanced catabolic processes in controls was supported by the amino acid analysis. The levels of 6 amino acids correlated with kynurenine and 3HK exclusively in controls, whereas the ADHD group showed merely two associations with the neuroprotective index. The absence of a predominant metabolic direction in the ADHD group was not altered by medication, but became ordered to the extent that numerous amino acid levels related to kynurenine production and the tryptophan-breakdown index.These results suggest that toxic metabolites are not influencing CNS function in young ADHD subjects, or alternatively the energy supply through NAD as a metabolite of 3HK, was available to healthy children, but restricted in ADHD . The firIn the presence of pathology one would expect an increase in the tryptophan breakdown index (kynurenine/tryptophan) associated with an upregulation of proinflammatory IFN-γ and TNF-α that modulate the activity of the enzyme IDO . CompareThe idea to study selected interleukins came from reports of their influence on tryptophan metabolism . As theyOf the 8 interleukins measured, 6 showed a marginal increase in the ADHD group. IL-1β levels showed a small decrease. These measures all tended to be corrected in the ADHDmed group. These trends reached borderline significance for IFN-γ and IL-13. Hirschberg et al.  observedThe ratios of pro- to antiinflammatory cytokines did not distinguish ADHD cases from controls (hypothesis -3), and thus there is no evidence for an imbalance that would affect the induction of the enzymes (IDO and TDO). This contrasts with findings of elevated proinflammatory cytokines from adults suffering from depression ,86 and mLastly, the role of the pro-/antiinflammatory IL-16 cytokine is worthy of further study. In a genome wide scan of ADHD subjects , 2 SNPs The principle limitations in this study relate to the small number of subjects in each group, that in turn limits the power of the analyses. The number of sibling controls volunteering to participate was also smaller than anticipated. It was necessary to control for an imbalance in gender and age in the analyses. This arose through the difficulty of persuading children to provide samples for research rather than clinical reasons. Technical difficulties in the biochemical analyses further reduced the number of data for some measures. However, the study was intentionally preliminary and the aims entirely exploratory without conservative correction, to see if there were any indications of alterations in the levels of potentially relevant cytokines that merited a follow-up with an intensive study. Further, an interpretation of the effects of medication is limited by the cross-sectional between-group design of the study. It would be preferable for a future in-depth study to employ a longitudinal within-subject design.Over the last 10 years it has become recognized that inflammation may represent a common mechanism of neuropsychiatric disorders as well as somatic disease . In the brain this can be represented by excitotoxicity and impairment of glial function. We show here that one marker of glial function (S100B) is not dysfunctional across the major manifestations of ADHD, even though its activity may be low in those with internalizing comorbidities. We also show that there is no major dysfunction in the balance of pro- and anti-inflammatory interleukins that modulate the production of toxic and protective kynurenine-related metabolites of tryptophan. However, the results do show a certain disorder of catabolism that together may influence features of ADHD . Nonetheless, there were two stronger findings. The first is that toxic kynurenine metabolites are a feature of late healthy childhood and this may point to the nature of the mechanism of pruning of neural elements widely reported in normal development. The second is that there is a normalising influence of psychostimulant medication on immunological characteristics that points to a widely neglected locus of pharmacotherapeutic action, namely glial function. This parallels previously documented actions of antidepressant therapy .th edition; 5-HIAA: 5-hydroxy-indole-acetic acid; HPLC: High Performance Liquid Chromatography; 5-HT: Serotonin; IL: Interleukin; IFN-γ: Interferon gamma; KA: Kynurenic acid; 3HK: 3-hydroxy-kynurenine; LIF: Leukemia inhibitory factor; MRS: Magneto-resonance spectroscopy; PACS: Parental Account of Children's Symptoms; RT: Response time; SES: Socio-economic scale; Sibs: Siblings; SD: Standard Deviation; TNF-α: Tumour necrosis factor alphaADHD: Attention-deficit/hyperactivity disorder; BMI: Body mass index; CON: Control; DA: Dopamine; DSM-IV: Diagnostic and Statistical Manual of the American Psychiatric Association, 4RDO, MD and BGS declare that they have no competing interests beyond the source of finance for the study (see below). AMM & MJS have patented the use of tryptophan pathway metabolites as neurodegenerative markers for depression and related psychiatric diseasesRDO was involved in conceiving and organizing the study as well as analysing the data and writing the report. The organization was refined by BGS who with MD was involved in recruitment, diagnosis and logistics. MJS and AMM advised on the biochemical items for study, organized and ran the biochemical analyses and contributed to the strategy for the study and report. The ideas and hypotheses derived from discussion of the work of AMM and RDO. All authors contributed to and approved the final manuscript.th Psychoimmunology Expert meeting at Ulm/Günzburg, 12-14th Nov. 2009  and psychoimmunology (basic research) for whom certain elements may be more or less familiar and include negative and positive findings that may both guide future investigations. Some of these data were communicated at the 10v. 2009 .


Attention Deficit/Hyperactivity Disorder (ADHD), formerly regarded as a typical childhood disorder, is now known as a developmental disorder persisting over the lifespan. Starting in preschool-age, symptoms vary depending on the age group affected.According to the variability of ADHD-symptoms and the heterogeneity of comorbid psychiatric disorders, a broad review of recent studies was performed. These findings were summarized in a developmental psychopathological model, documenting relevant facts on a timeline.Based on a genetic disposition and a neuropsychological deregulation, there is evidence for factors which persist across the lifespan, change age-dependently, or show validity in a specific developmental phase. Qualitative changes can be found for children in preschool-age and adults.Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 56, 2008, S. 265-274.These differences have implications for clinical practice as they can be used for prevention, diagnostic proceedings, and therapeutic intervention as well as for planning future studies. The present article is a translated and modified version of the German article "Entwicklungspsychopathologie der ADHS", published in  Formerly regarded as a typical disorder in childhood and adolescence, Attention-Deficit/Hyperactivity-Disorder (ADHD) is increasingly discussed as a serious psychiatric disorder in adulthood -6. ThereConsidering the developmental course of ADHD over the lifespan, evidence exists that increasing age has an influence on the heterogeneity of ADHD-symptoms and associated impairments. Regarding the fact that in many cases hyperactivity is not primarily associated with the typical deficits of adult ADHD, a developmental change is discussed . SymptomToday ADHD-specific-studies, instruments for psychological assessment, and intervention programs are available mainly for the treatment of children and adolescents. However, in consideration of relevant publications in the last five years, there is strong evidence for the occurrence of ADHD-related symptoms in preschool age and adulthood which has implications for the development of assessment procedures and intervention programs -13. FromToday ADHD is considered a multifactorial psychiatric disorder, based on genetic predisposition and neurobiological deregulation. These lead to a neuropsychological inhibitory deficit which contributes to the specific impairments typical for ADHD -18.There is strong evidence for a genetic disposition as a basis for ADHD. Numerous twin-studies exist that indicate a familiar interrelation . FaraoneIn case of ADHD, the functional impairment of attention performance is regarded as resulting from a dysfunction of frontal-cortical-networks. Many symptoms in ADHD-afflicted persons  are comparable with symptoms from patients suffering from frontal lobe damage, which highlights the importance of the frontal cortical networks ,7. NumerRegarding the developmental course ADHD seems to become more unspecific in its psychopathological characteristics over time, although it is based upon the same neuropsychological dysfunctions as in childhood and adolescence. This leads to two fundamental questions:• During which part of the developmental pathway can qualitative changes be observed?• What are the reasons for these qualitative changes?To answer both questions, a broad review of recent studies (published between January 1997 and January 2009) was performed. To this end, scientific databases  were searched, using the keywords or keyword combinations of *ADHD*, *prevalence*, *preschool*, *childhood*, *adolescence*, *adulthood*, *lifespan*, *comorbidity*, *developmental*, *genetic*, *neuropsychology*, *neurobiology*. Based on the evidence for a genetic/neurobiological deregulation as the basis of the developmental course of ADHD, studies highlighting preschool age, school age/adolescence, and adulthood were selected. In a first step, these findings were described under consideration of actual prevalence rates and the specific developmental course (e.g. frequent comorbid disorders and resulting problems). In a second step, findings were summarized in a developmental model and discussed regarding the above mentioned questions and the specific phenomenology of each age group.Until now, only little representative international data on the prevalence rate of ADHD in preschool children exist. The results of the German Child- and Youth Health Survey  can be mIn this age group, ADHD symptoms are usually assessed by means of rating scales and behavior observations . Today a• problems with prolonged maintenance of attention,• a high distractibility,• being on the go often,• excessive running/climbing,• not adhering to instructions,• having trouble to sit still.It is necessary to state that in this age group already, a high comorbidity with other behavioural disorders exists. In the Preschool ADHD Treatment Study (PATS) Posner et al. reported comorbid disorders in seventy percent of ADHD cases, the most frequent being oppositional defiant disorder (52.1%), communication disorders (24.7%) and anxiety disorders . These findings underline the need for an early intervention and highlight the early impact ADHD can have on the developmental course over the lifespan .The prevalence rate of ADHD among school children and adolescents diverges from 3.2% to 15.8%, depending on the classification system used. Prevalence rates between 5% and 7% are reported most often ,35. FurtThere are numerous different diagnostic instruments for this age group. Questionaires and rating scales are based on external sources  or self-report, depending on the age group . For the neuropsychological assessment of attention capacity, computer based instruments are used in which attention regulation  and attention load  are measured. Untreated ADHD constitutes a high risk for a further negative development, which is especially due to frequent comorbid disorders. During adolescence, ADHD can negatively impair more and more areas of functioning ,40.Among children with ADHD, in up to 65% of cases oppositional behavior is found  and amonFor the transition to adulthood, studies document the persistence of behavioural problems in 40-60% of the cases. Prevalence rates between 1-7.3% were found ,10,52-54The developmental course is extremely heterogeneous, which, among other things, results from the varied comorbid disorders. Different studies report a strong relationship, particularly with substance abuse, affective disorders, antisocial and borderline personality disorder. The reasons for these overlaps are manifold and are related to the similarity of the neurobiological processing mechanisms of the different disorders Table  56]..56].Due to the comorbidity and deficits caused by ADHD, other impairments often emerge which negatively influence the social and emotional well being of the affected person. Difficulties in the organization of daily duties can lead to problems at work, at home, and in social relationships. Problems with emotion regulation can provoke negative social interactions which further intensify the psychological strain of the affected person and his/her relatives and in turn heighten the risk of developing comorbid disorders. A negative spiral can be detected whose severity differs depending on an individual's characteristics and available resources. The following detailed description of comorbid disorders will underline this.Prospective studies show an increased rate of substance abuse ,57. In mEmotional instability and emotional reactivity often occur in adult ADHD. Many patients for example show extreme reactions to frustrating events. Rapid mood changes without apparent reason are also characteristic of the pathology. In one study, a comorbidity of ADHD and major depression was found in 15% of the cases . FurtherMany ADHD affected persons have developed  strategies to avoid the confrontation with anxiety-laden situations in order to manage their disorder. But even though an unavoidable confrontation with individual anxiety-laden situations is assumed to have effect on ADHD symptomatology, no causal direction between ADHD and anxiety can be stated . An overThe presence of oppositional behavior and, consequently, the development of a conduct disorder elevate the risk of developing an antisocial personality disorder . In adulThe comorbidity of ADHD and borderline personality disorder can be regared as the biggest diagnostic challenge. One reason is the substantial overlap of the diagnostic criteria ,10. An aThe above cited findings, in association with observations and diagnostic findings from the clinical experience in the treatment of persons affected by ADHD reveal age group specific dysfunctions as well as persistent behavioral factors which result from the neurobiological basis of ADHD  and the resulting deficits in social competences that often go along with a diminished quality of social contacts must be stressed. At this point in time, preventive steps should be taken to counteract the negative effects of ADHD.The transition into adulthood can be regarded as a second crucial developmental transition point. The assumption that ADHD is a disorder that only occurs in childhood has dominated clinical psychology for many years. Due to the high comorbidity with other disorders, ADHD symptoms are often overlooked; they do, however, seem to play an important role in the manifestation of other comorbid disorders. This complicates the diagnostic process because symptoms of ADHD and comorbid disorders can overlap. Affective disorders, as for example the borderline personality disorder and the antisocial personality disorder, can be mentioned here. For this reason and for the diagnostic assessment in clinical practice, the developmental aspect of ADHD is fundamental. Evidence for childhood ADHD is a diagnostic criterion for ADHD in adulthood and knowledge of the developmental course improves possibilities for a comprehensive intervention.To expand our knowledge one could ask a second question, namely what causes the differences between symptom manifestation of ADHD in childhood and adulthood? According to neuropsychological findings, the same neurobiological model underlies ADHD over the whole life course. The symptomatological differences between ADHD in childhood and adulthood seem to be caused by environmental and social interaction factors. As mentioned already, ADHD symptoms begin to occur during preschool and elementary school age. These symptoms are more clearly circumscribed than is the case in adulthood. Consequently, it can be assumed that over the developmental course, on the one hand more areas of functioning will be negatively affected by ADHD (which is the case at the transition to adulthood), and on the other hand a higher comorbidity can be found. Here again, the relation with the secondary disorder becomes apparent , which hADHD: Attention-Deficit/Hyperactivity Disorder; APS: Antisocial Personality Disorder; fMRI: functional Magnetic Resonance Imaging.The authors declare that they have no competing interests.SC and FP were equally responsible for defining the research question. FP was responsible for the description of the developmental course of ADHD in childhood and adolescence. SC was responsible for the phenomenology of adult ADHD and the realization of the developmental model. Both authors read and approved the final version.The pre-publication history for this paper can be accessed here:


Anger is an ignored research area in children and young adolescents with Attention deficit hyperactivity disorder (ADHD) in the school setting. This study compares school anger dimensions in children and young adolescents with ADHD and a control group.The subjects were a clinical sample of 67 children and young adolescents with ADHD and their parents, with a sample of 91 children from the community of similar age and gender as control group. Anger was measured by the Farsi version of the Multidimensional School Anger Inventory (MSAI).The scores of the two components of "Hostile Outlook" and "Positive Coping" were different between the groups. The mean scores for the Anger components did not statistically differ between the children with ADHD and ODD and ADHD without ODD, boys and girls, or different types of ADHD.Children with ADHD do not report higher rates of experience of anger and they do not apply destructive strategies more than the control group. However, children with ADHD appear to have a more hostile outlook toward school and their coping strategy is weaker than that of the control group. Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in children and adolescents. The corAnger is a state of arousal resulting from social conditions involving threat or frustration. It is a strong feeling of displeasure that includes a sense of antagonism. Anger expression is not the equivalent construct of aggression. Aggression consists of verbal and/or physical acts aimed at hurting or upsetting another human being either directly or indirectly. Aggression is a behavior that may be associated with anger . Anger iAnger expressed by aggression may lead to punishment of the student, such as being removed from the class or even expulsion from the school. Aggression in young people has become a major concern and self-reported aggressive and violent behaviors have risen among children. In one self-report study, 54.3% of the students reported committing at least one act of violence in the current academic year; and about one third of the students reported high levels of anger-expression . FurtherIn the light of these serious unfavorable outcomes of anger, studying anger in students is very important. The influence of anger is largely unexplored and has received less attention probably because it is difficult to quantify or discretely categorize anger. Anger can be assessed by self-reports from about seven years old onwards . These cGender differences do not appear to be significant in terms of anger . ChildreThis current study compares school anger dimensions in ADHD children and a control group of children from the community of a similar age range. It also surveys the impact of gender and co-morbidity of ODD on school anger dimensions in ADHD children. It was hypothesized that children with ADHD experience more anger and use more destructive expressions of anger than a control group of their peers. To the best of the authors' knowledge, there is no prior study exploring the relationship between anger and ADHD in children and younger adolescents as young as those in the current study.The study sample consisted of 158 children: 67 children and adolescents diagnosed as having ADHD and their parents, and 91 children from general population of similar age and gender.ADHD was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Text Revised criteria using . The chiThe control group consisted of 91 schoolchildren from Shiraz, Southern Iran. The demographic data of the control group were collected using a self-administered questionnaire which asked for children's age, gender, and the rank of birth. The age range was nine to fifteen years, with the school classes surveyed being selected to correspond to the age range of the sample group. The trained evaluator distributed the questionnaires among the middle school students. He briefly explained the study objectives and provided the necessary instructions. The students then completed the questionnaires during the class time. The questionnaires were anonymous and taking part in the study was voluntary. The response rate of the sample was about 85%.Anger was measured by the Farsi version of the Multidimensional School Anger Inventory (MSAI). MSAI is a self-report questionnaire that measures anger components within a school context . Its comThe Farsi version of MSAI has 28 items, each with a four-point Likert-type response format. There are four different categories with their own response type: the School Anger Experience Index, the Hostile Outlook, the School Anger Expression Index (Positive Coping) and the School Anger Expression Index (Destructive Expression). The 12 Anger Experience Index items have the following responses: one , two (I'm a little bit angry), three(I'm pretty angry), and four (I'm very angry. I'm furious). This category assesses anger experience with hypothetical but common school situations in which the students report their own real or likely level of anger. The range of possible scores on this component is 12 to 48. Examples of the questionnaire items within School Anger Experience are: "You tell the teacher that you are not feeling well but he/she doesn't believe you", "You ask to go to the bathroom and the teacher says no", and "Somebody calls you a bad name". The responses of the six Hostile Outlook items are: one (strongly disagrees), two (disagree), three (agree), and four (strongly agree). The range of possible scores on this component is 6 to 24. This component assesses the students' level of school hostility to a series of statements. Some of the items of this component are: "School is really boring", "Grades at school are unfair", and "Rules at school are stupid". The responses of the 10 items of School Anger Expression component are: one (never), two , three (often), and four . This component represents positive or destructive coping strategies in which the students reported how often they may use them in dealing with their anger. The range of possible scores on both Positive Coping of School Anger Expression Index and Destructive Expression for School Anger Expression Index categories is 5 to 20. Destructive expression includes aggressive responses and positive coping includes more socially acceptable responses. Some of the items of Positive Coping of School Anger Expression Index are: "When I'm upset, I calm myself down by reading, writing, painting, or some similar activity" and "Before I explode, I try to understand why this happened to me". Some of the anger Expression Index (Destructive Expression) items are: "When I'm mad, I break things", "I get so mad that I want to hurt myself", and "If I get mad, I'll throw a tantrum". Higher scores in the components of School Anger Experience, Hostile Outlook and Anger Expression Index (Destructive Expression) suggest high levels of anger coupled with poor coping mechanisms with anger. Conversely, higher scores in the positive coping category suggest better and more pro-social coping mechanisms with respect to anger.The Farsi version of MSAI has acceptable validity and reliability. The internal consistency reliability for the questionnaire categories are as follows: of Anger Expression 0.89, of Hostile Outlook 0.79, of Positive Coping Anger Expression 0.66 and of Destructive Expression 0.71. The reliability of the questionnaire as a whole is 0.81 .The protocol for the research project conforms to the provisions of the Declaration of Helsinki in 1995 as revised in Edinburgh 2000. All of the patients and their parents agreed to participate in the study and gave informed consent.Chi-square tests and means t-tests were used to compare demographic characteristic of the two groups where they were applicable. The mean differences of scores on the categories of the MSAI between the ADHD children and control group were compared using t-tests. Mann-Whitney Tests were used to compare the mean differences of questionnaire categories between ADHD children co-morbid with ODD and those ADHD children without ODD co-morbidity. The Kruskal-Wallis Test was used to compare the mean score of the different questionnaire categories among subtypes of ADHD.2 = 0.63, df = 1, P = .4). The age range of the ADHD children group was 8 to 14 years and 9 to 15 years for the control group (exact ages in months and years were not collected). The mean (SD) age of the ADHD children and control group was 10.6(1.4) and 11.7(1.8) years, respectively, with no significant difference between the two groups . Amongst the children in the ADHD sample group, the breakdown of ADHD subtypes were 24(35.8%), 29(43.3%), 14(20.9) for Inattentive, Combined, and Hyperactive-Impulsive types, respectively  scores on the MSAI of children with ADHD would be higher than those of the control group, with the School Anger Expression Index (Positive Coping) scores being correspondingly lower. We did not find that the School Anger Experience Index scores or the School Anger Expression Index (Destructive Expression) scores of children with ADHD were different from those of the control group. However, the Hostile Outlook scores were higher and the School Anger Expression Index (Positive Coping) scores were lower in children and young adolescents than that of the control group. This suggests that children with ADHD may not experience anger or apply destructive and harmful anger strategies more than the general population within the school context. However, the results also suggest that children with ADHD may re-appraise angry situations or try to get away from these situations less frequently than their peers. Further, the results suggest that their ability to take a cognitive approach to resolving anger may also be weaker. We hypothesize that the attitude of children with ADHD toward school may be more negative and that they may interpret situations in the school context as providing more cause for anger, more frequently. These hypotheses are consistent with results from a similar previous study which studied anger in an older group of young people with ADHD .It should be noted that the participants with ADHD in the current study are relatively young and newly diagnosed. This group may not as yet have experienced the longer-term negative effects of ADHD or adopted negative attitudes as a result of consequent difficulties in school and peer relationships. As children and young adolescents with ADHD move into older adolescence and adulthood, they face different negative outcomes and consequences of their symptoms and these may lead to the development of higher levels of anger and hostility than we have found in this study. This therefore does not rule out the possibility that children and young adolescents with newly-diagnosed ADHD who have relatively few problems with anger in the school context may experience more anger and engage in more destructive expression as they grow older. Alternatively, children may learn to repress their anger more extensively with increasing age because they no longer believe that they should express negative emotions as freely . MoreoveThe MSAI Hostile Outlook scores of children with ADHD were significantly higher than that of the control group. This finding suggests that the children with ADHD have a more hostile outlook towards school. Some of the items of this component are "School is worthless" and "School is really boring". This finding of higher levels of hostility towards school is consistent with a study of a clinical sample of children with school refusal which reported that ADHD was one of the commonest co-morbid psychiatric disorders in this group .The lack of association between anger components and different types of ADHD found in this study does not tend to support any hypothesis that ADHD children of the hyperactive-impulsive type experience and express more anger than the other subtypes. However, the numbers in each subgroup were low and the study probably did not have sufficient power to demonstrate any differences between subgroups. This study did not find that boys and girls with ADHD had any differences in their scores in the categories of the MSAI. This is inconsistent with other research which suggests that girls generally display less anger than boys . This faWe did not find any differences between scores in the anger expression categories of the ADHD children with and without ODD. Children usually display their anger more extensively in specific settings such as their homes. It is possible that children with ADHD, both with and without ODD, feel unsafe to express anger in the school setting; or that they have learned not to share those feelings in school.There are some limitations to this study. This was a cross-sectional study of self-perceived anger with a single informant, which means that recall bias and minimization of negative emotions and behaviour may limit its generalization. It is known that children with ADHD underreport their symptoms , which sChildren and young adolescents diagnosed with ADHD report more hostility towards school and a lower positive coping strategy for controlling anger in school. The results suggest that an awareness of this hostility towards school and less positive coping in children and young adolescents with ADHD may be clinically useful as these could be promising targets for school-based early interventions. School nurses and educational and clinical psychologists could be involved in identifying and recommending the interventions for children and young adolescents with ADHD who have frequent anger problems in school . The schThe authors declare that they have no competing interests.AG conceived the study. AG designed the study. HBH and AG were responsible for gathering of the data. AG drafted the manuscript. AG and HB performed the statistical analysis. All authors contributed to interpreting the results, and read and approved the final manuscript.