Child with Low Birth Weight (LBW) has a higher risk of infant mortality, learning difficulties in childhood due to stunted growth and impaired neurodevelopment, is more likely to develop heart diseases and diabetes in adulthood. This study aimed to evaluate the latest demographic and health surveys (DHSs) across multiple countries in South Asia to determine the factors associated with LBW among these countries. Latest available DHS data across Afghanistan , Bangladesh , Nepal , and Pakistan  were analysed. Complex survey adjusted generalized linear models were fitted to investigate the association of birth weight with sociodemographic and decision-making factors. Pakistan had the highest proportion of LBW at 18% followed by Afghanistan and Bangladesh at around 14% and Nepal had the lowest (13%). Children born in Pakistan were more likely to have LBW children than Afghanistan . Mothers living in rural areas , with highly educated partners and belonging to richer families were less susceptible to having child with LBW. To reduce 30% LBW in-line with the World Health Organisation’s 2025 goal, policymakers in SA should focus on women in urban areas with low-educated partners belonging to poor households to ease LBW burden. Child with low birth weight (LBW) have a higher risk of infant mortality, learning difficulties in childhood due to stunted growth and impaired neurodevelopment, and are more likely to develop heart disease and diabetes in adulthood ,2,3,4. ASeveral research determined a few factors that were found to be associated with LBW including socio-economic status, maternal age, parity, pregnancy interval, non-pregnant weight, maternal height, haemoglobin level, BMI, trimester bleeding, tobacco consumption, alcohol consumption, gestation age, antenatal care (ANC), and maternal nutritional status ,6,7. FurLBW is one of the major public health concerns, as it is estimated that 20 million children born each year are underweight and is more prevalent in low-middle income countries (LMICs), with 28% of all LBW children born in SA, 13% in sub-Saharan Africa (SSA) and 9% in Latin America (LA) , and a tPrior studies into LBW in SA were mostly country specific. This study aimed to address the gap in identifying the common socio-economic factors of LBW in the selected multiple countries to aid policymakers in comparing their policies and assess the action plan or interventions that have worked thus far in achieving target set by the WHO.This study, thus, aimed to evaluate the latest population surveys of multiple LMICs in SA including Afghanistan, Bangladesh, Nepal, and Pakistan to determine the effects of socio-economic factors, decision-making power of women (DPW), and intimate partner violence (IPV) have on LBW among these countries.Furthermore, insights into DPW and IPV can setting policies to improve women’s quality of life and to enhance United National gender equality target related to Sustainable Development Goal 5  as well This study analysed comparable population-based cross-sectional demographic and health surveys (DHS) data across four LMICs in SA conducted between 2015–2021. These surveys collected data on women aged between 15 to 49 years old. The data custodians of DHS ensure the population in surveyed countries are well presented by implementing two-stage stratified sample of households. The first stage involves using probability proportion to size (PPS) to select the most appropriate enumeration areas (EAs) from Census file, the second stage involves using an updated list of households to select the sample of households in each EAs .The most recent DHS survey for Afghanistan 2015) consists of 29,461 women, Bangladesh (2018) with 20,127 women, Nepal 2016) with 12,862 women, and Pakistan (2018) with 15,068 women were used were 98%, 99%, 98% and 96%, respectively [ consists with 12,The outcome variable for this study was low birthweight—a dichotomous measure with children with birthweight < 2500 gm is considered as ‘LBW’, otherwise noted as ‘normal’ weight.Literature review on LBW in LMICs in SA identified seven covariates as predictors for LBW and was included in this study. These are place of residence , maternal age at birth of child , respondent’s education level , partner’s education level , respondent’s employment status (yes/no), wealth index  derived from principal component analysis on data such as household assets owned , and resTwo targeted covariates of this study are DPW and justification to IPV. DPW—a binary variable—depends on respondents’ contribution on three major household decisions such as ‘respondent’s health care’, ‘large household purchases’, and ‘visits to family/relatives’. Respondents were considered to contribute to household decisions if they made these decisions alone or co-decided with partners . Otherwiversion 4.1-1) was used to input survey design elements and apply modeling. All analyses were conducted on R (version 4.1.2).This study explored the primary unweighted bivariate association between LBW and the covariates through Chi-square eviously ,20. SurvAmong the four countries assessed, Pakistan had the highest proportion of LBW at 18.7% and Nepal had the lowest at 11.3%. Both Afghanistan and Bangladesh were similar at around 14%. Pakistan had the highest proportion of LBW in all sociodemographic factors except for mothers with no education/preschool and higher education level. Bangladesh had highest proportion of LBW where mother had no education/preschool, and Afghanistan had highest proportion of LBW where mother had higher education level. Nepal had lowest proportion of LBW in all sociodemographic factors except for material age <20 and richer wealth index, where Afghanistan had lower proportion of LBW.p = 0.011). While the proportion of children with LBW decreases as mother’s age at childbirth increases for Nepal, it is a V-curve for Pakistan and Bangladesh and is inverted-U shape for Afghanistan. Younger mothers (<20-year-old) in Pakistan had much higher proportion of LBW than the other countries, and Afghanistan had the lowest LBW rate (13.9%) compared with Nepal (15.2%) and Bangladesh (15.5%). For mother’s education, while LBW of children in Bangladesh and Nepal decreased as mother’s education level increased, in Pakistan LWB rate was lower among mothers with higher education compared with other education levels. All four countries show the same trend for partner’s education level; LBW decreases when partner’s education level increases that is proportional of children with LBW decreased when partner’s had secondary or higher level.Results obtained from unweighted bivariate analysis presented in p < 0.001), Nepal (p = 0.045) and Pakistan (p = 0.001). The proportion of LBW was lower for mothers who contributed to household decisions, and the difference was significant for Nepal (p = 0.023) and Pakistan (p = 0.046). Women in Afghanistan and Nepal who felt intimate partner violence (IPV) is justified had slightly lower proportion of LBW than those who believed IPV is not justified although the differences are not significant (p > 0.05), whereas in Pakistan it is the reversed and the difference is significant (p < 0.001).Mother’s employment status did not show any primary association with LBW of children in the bivariate analysis. Children with LBW were typically more common among mothers residing in lower wealth indices households and wealth index was found to have an association for all for countries. Mothers who were not exposed to media had a higher percentage of children with LBW and showed significant association between LBW and exposure to media for Afghanistan (p < 0.05) with LBW Children from Pakistan had 2.17 times higher odds of being LBW compared to those from Afghanistan . Children were less likely to be born with LBW when mothers live in rural area , have partner with higher education level , and belong to poorer  or richer  wealth quantile compared to poorest households.This study investigated the factors associated with LBW among children in Afghanistan, Bangladesh, Nepal, and Pakistan using comparable population-based cross-sectional DHS conducted between 2015–2021. The study results showed that the proportion of LBW was lower than previously reported national level studies in the region, with LBW proportions in Afghanistan, Bangladesh, Nepal and Pakistan was 16%, 20%, 15.4% and 25%, respectively and now they are 14.6%, 14.3%, 11.3% and 18.7%, respectively ,21,22,23Among the studied countries, Pakistan needs a greater effort to reduce its higher prevalence of LBW among newborns. This could be because currently Pakistan is behind the other countries in providing adequate medical care for expecting mothers and newborn children , and majAlthough the results obtained from unadjusted bivariate analysis showed a higher proportion of LBW children in rural compared urban areas, especially in Pakistan, the survey weight adjusted model revealed that mothers from urban areas have higher odds of having LBW children compared to their rural counterparts, which is consistent with findings from previous studies in this region ,7,12. HoIt was found that as fathers’ education level increased the proportion of children’s LBW decreased. Children with well-educated parents are less likely to be LBW and is consistent with previous studies in this region ,21,22,23Mothers belonging to the poorest quantile generally had the highest proportion of LBW children with exceptions in Nepal, and the model results showed strong evidence that higher wealth groups were less likely to have children with LBW. In accordant with previous studies in the same region ,23,31 thThe strengths of this study are the use of comparable population-based cross-sectional DHSs across multiple countries LMICs in SA providing a snapshot of the whole region as well as comparing country-wise differences. Some interesting avenues for future research were revealed; particularly, the urban rural unexpected finding that rural areas were performing better with lower likelihood of LBW among children. This calls for further studies across different regional areas. Furthermore, education of mother’s, which is typically an indicator for health outcomes in newborns, did not show any strong evidence of association with LBW among children. This could be due to confounding effect and an impact of change in distribution when multiple survey data were merged. The study had some limitations. First, this study used cross-sectional study therefore cannot make causal inferences. Second, this study could not include all LMICs in SA due to lack of available DHS data. Third, as surveys in all four countries were not conducted in the same year there could be minor inconsistencies. Fourth, some confounders such as maternal comorbidity and parity of mothers were not adjusted in the current study models as they were not available in the DHS data sets. Future studies with an extensive data set can explore this. Lastly, the study only included the latest single birth from each household, and some of surveyed birth weights were based on mothers’ memory and can induce some memory bias.LBW is a global health issue which is more prevalent in LMICs in SA. To meet the WHO’s target countries in this region can accelerate their relevant public health programs and social policies by leveraging and learn of each other, such as District Investment Case program implemented by Nepal  and Incl


Objectives: The majority of earlier studies on knowledge and attitudes around ADHD have been focused on parents of children with ADHD, the child themselves, primary care providers, teachers, and children’s families, and they have found that they have negative perceptions of ADHD. This study aimed to explore community knowledge about ADHD in Saudi Arabia. Methods: A cross-sectional study using an online survey was conducted in Saudi Arabia in January 2022 to explore community knowledge about ADHD in Saudi Arabia. The convenience sampling technique was used to identify eligible participants and invite them to take part in the study. Logistic regression analysis was used to identify ADHD knowledge predictors. Results: A total of 718 participants were involved in this study. The participants in our study showed a weak level of knowledge about ADHD with a mean score of 6.4 (SD: 2.2) out of 17 . Males, those who work outside the healthcare sector, and those who are retired were less likely to be knowledgeable about ADHD compared to others (p ≤ 0.05). At the same time, participants who reported that they work inside the healthcare sector were more likely to be knowledgeable about ADHD compared to others (p ≤ 0.01). Conclusions: Our study showed that there is insufficient public knowledge about ADHD. The development of educational interventions is necessary to raise public awareness of ADHD. Social media platforms can be used to deliver education campaigns. All members of the community, including parents and those who want to get married, should be the target of these initiatives. One of the most common psychological disorders is attention deficit hyperactivity disorder (ADHD), which affects between 5% and 8% of children worldwide. The majority of those affected are boys, and it frequently lasts into adulthood ,2,3. TheThe three main symptoms of ADHD are (a) hyperactivity ; (b) inattention (inability to focus); and (c) impulsivity  ,10. The The majority of earlier studies on knowledge and attitudes around ADHD have been focused on parents of children with ADHD, the child themselves, primary care providers, teachers, and children’s families, and they have found that they have negative perceptions of ADHD ,19,20,21In the KSA, many studies have found an insufficient level of knowledge about ADHD, and this was evaluated among the following groups: a sample of teachers in the Al-Rusaifah district in Makkah city , female A cross-sectional study using an online survey was conducted in Saudi Arabia in January 2022 to explore community knowledge about ADHD in Saudi Arabia.The convenience sampling technique was used to identify eligible participants and invite them to take part in the study. This sampling technique falls under the category of non-probability sampling. This study included eligible people who satisfied our inclusion criteria and were available to participate in the study. Social media platforms (Facebook and WhatsApp) were used to reach out to the general public and invite them to take part in this study. We have distributed the study link and the initiation letter through various Facebook pages and WhatsApp groups that are relevant to the general public and not only for a specific group in order to reach the Saudi Arabian population as a whole.All participants gave their informed consent voluntarily and were therefore exempt from providing written consent. At the beginning of the survey, the aims and objectives of the study were presented in detail. The participants received no compensation.Participants who were at least 18 years old and were currently living in Saudi Arabia met the inclusion criteria. If a participant was under 18 years old or could not read or understand Arabic, they were not allowed to participate.An extensive literature review served as the foundation for the study tool’s development. There were three sections with a total of 27 questions. The participants’ demographics were covered in the first section, which included five questions concerning age, gender, education level, residence, and employment status. The second section of the questionnaire consisted of 17 multiple-choice questions (MCQ) that probed participants’ knowledge about ADHD. Each correct response was given a weight of one, while each incorrect response was given a weight of zero. The maximum score was 17, with a higher score denoting more knowledge. Participants’ knowledge of the risk factors, symptoms, consequences, and treatment options for ADHD was tested by knowledge questions. The third section of the questionnaire consisted of five multiple-choice questions (MCQs) that asked the participants about their knowledge of ADHD, whether they knew anyone in their family who had the condition, how much they knew about its treatment, whether they knew which centers in their area managed ADHD, and where they got their information about the condition.The demographic characteristics of the participants were described using descriptive statistics. For variables that were normally distributed, continuous data were reported as mean ± SD. Categorical data were reported as percentages (frequencies). The odds ratios (ORs) and 95% confidence intervals (CIs) for individuals who are more likely to be knowledgeable about ADHD were calculated using logistic regression. The cut-off for the logistic regression was based on the mean knowledge score of the study participants. The mean knowledge scores for various demographic groups were compared using an independent samples t-test and a one-way analysis of variance (ANOVA). The statistical analyses were carried out using SPSS (version 27).A total of 718 participants were involved in this study. The majority of the study participants (73.4%) were females. Around one-third of the study participants (28.4%) were aged 18–25 years. The vast majority of the study participants (92.8%) were residents of the eastern area. Around one-third of the study participants (35.4%) reported that they were working in the healthcare sector. More than half of the study participants (68.2%) reported that they held a bachelor’s degree. A similar percentage of them (61.0%) reported that they knew some information about ADHD. Around one-fifth of the study participants (20.2%) reported that they have a family member diagnosed with ADHD. Only 10.3% of the study participants reported that they had good information about the treatment of ADHD. Around one-fifth of the study participants (18.4%) reported that they know centers specialized in treating ADHD in their area. Around half the study participants (51.5%) reported that social media is their main source of information about ADHD. p ≤ 0.01). Females, young participants (aged 18–25 years), those who work inside the healthcare sector, those with higher level of education and those who have a family member diagnosed with ADHD had a higher knowledge score about ADHD compared to others. The participants in our study showed a weak level of knowledge about ADHD with a mean score of 6.4 (SD: 2.2) out of 17 . The mean ADHD knowledge score showed a statistically significant difference between participants from different demographic groups based on their gender, age, employment status, education and having family member diagnosed with ADHD (p ≤ 0.05). At the same time, participants who reported that they work inside the healthcare sector were more likely to be knowledgeable about ADHD compared to others (p ≤ 0.01)  .The key findings of our study are: (1) only 10.3% of the study participants reported that they have good information about the treatment of ADHD, (2) around one-fifth the study participants reported that they know centers specialized in treating ADHD in their area, (3) around half the study participants reported that social media is their main source of information about ADHD, (4) the participants in our study showed a weak level of knowledge about ADHD, (5) males, those who work outside the healthcare sector, and those who are retired were less likely to be knowledgeable about ADHD compared to others, and (6) participants who reported that they work inside the healthcare sector were more likely to be knowledgeable about ADHD compared to others.Only 10.3% of our study participants reported that they have good information about the treatment of ADHD. The participants in our study showed a weak level of knowledge about ADHD with a mean score of 6.4 (SD: 2.2) out of 17 . This confirmed the findings of a previous study that was conducted in Indonesia by Murtani et al. , which rAround half the study participants (51.5%) reported that social media is their main source of information about ADHD. This supported the findings of a prior study carried out in Saudi Arabia, which found that the internet and social media were the primary sources of information about ADHD . InteresMales, those who work outside the healthcare sector, and those who are retired were less likely to be knowledgeable about ADHD compared to others. A previous study in Taiwan reported that housewives spend more time controlling their kids’ behavior, and as they gain parenting experience, they become more knowledgeable about ADHD . SimilarThere are many advantages to this study. The fact that this is one of the few research studies among Middle Eastern Arabic-speaking countries to look into public knowledge of ADHD increases the generalizability of the results. However, there are some limitations. Our ability to determine causation between research variables was constrained by the study’s methodology, a cross-sectional survey design. Our inability to compare our results with those of Arabic-speaking countries with a comparable environment and culture was due to the fact that no earlier research had been performed on the general population exclusively, as the subjects of earlier studies were parents and teachers. We were not able to estimate the response rate for our study as we employed a convenience sampling technique, which might lead to non-response bias. The majority of the participants in this study were from the Eastern region, which restricts the generalizability of the study findings. Despite this, we assume that the findings of this study are of huge value due to the important characteristics of the Eastern region. In 2017, the Eastern region had a population of 4,900,325 people. The Eastern region is the most eastern of Saudi Arabia’s 13 provinces. It is the province with the biggest land area and the third most inhabitants in Saudi Arabia . In addiOur study showed that there is insufficient public knowledge of ADHD. The development of educational interventions is necessary to raise public awareness of ADHD. Social media platforms can be used to deliver education campaigns. All members of the community, including parents and those who want to get married, should be the target of these initiatives.


The second part of the article asks what is done with the ADHD diagnostic entity and with the idea that it represents a natural neurodevelopmental state within an individual—something an individual has—as represented in the DSM-5. Drawn from our previous research, we analyze how ADHD becomes real in discourse practice as a powerful semiotic mediator through analysis of the various functions and forms in which it takes shape in institutional, social, and individual levels. We conclude that the frequent changes in the diagnostic criteria of ADHD do not reflect any real scientific progress. Among other reasons, they change to match better the maneuvers of individuals when navigating an increasingly psychiatrized society in the search for recognition, support, category membership, immunity, sympathy, and sense of belonging.The contemporary conceptualization of Attention Deficit Hyperactivity Disorder (ADHD) as a complex, multifactorial neurodevelopmental disorder cannot be understood as such without a complex assemblage of political, economic, and cultural processes that deem the conceptualization to be valuable and useful. In this article we use the notion of psychiatrization as a lens through which to see parts of these processes that make up ADHD what it is. In the first part of the article, we critically assess the scientific basis of the ADHD diagnosis  The existence and realness of Attention-Deficit/Hyperactivity Disorder (ADHD) has been under ontological, epistemological, and axiological debate since the diagnosis was introduced in the second edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1968 by the American Psychological Association (APA) . DSM-5 represents a descriptive approach to diagnosis, that is using behavioral indicators, called symptoms, alone for the diagnosis without the necessity to understand or identify any presumed underlying causes or dynamics  genetic evidence on ADHD is inadequate  make their own interpretations and judgements about the abovementioned issues, making the assessment biased toward subjective and cultural meaning making processes. For instance, race and ethnic background of children subjected to rating as well as of those utilizing the rating instruments affect how behaviors are interpreted as being “symptomatic” and “diagnosed” as manifesting a “disorder” ”  in the quantity of criteria required for the diagnosis, and (b) in the age of onset before which someone must display the behaviors described in the criteria. Regarding the quantity of the criteria, DSM-5 requires that at least six of the nine criteria for “Inattention” and at least six of the nine criteria for “Hyperactivity and Impulsivity” must be met for the diagnosis. The number of criteria required for a diagnosis of ADHD has been set arbitrarily in DSM-5. No scientific justification has been presented nor method used for deciding how many criteria should be required for any disorder in the manual Davies, . InsteadArbitrariness is also evident in setting the age of onset of symptoms. The age of onset of symptoms increased from “before 7 years” in DSM IV-TR , others , or institutions . Thus, when it comes to behavior, performance, or functioning associated with the ADHD diagnosis, it is the mismatch between expectations and capabilities to meet them that fortify their pathological nature over the normal variation of human behavior, performance and functioning, and name their moral and ethical outcomes. Embodied experiences are given contextual meanings, relevance, and significance in social interactions vis-à-vis social and cultural expectations and requirements that DSM translates into language of individualistic psycho-medical models of deficit, disorder, and disability.social intelligence. Certain behaviors are more likely to be interpreted by other “normal” individuals as rude or intruding. The actual criterion being used here is the annoyance threshold of the observer; observed behavior is dependent to the emotion of the observer, and thus is subject to be reconstructed as a symptom of the one being observed  causes, rather than to situational  causes . For example, behaviors such as “often fidgets with or taps hands or feet or squirms in seat” and “often talks excessively” , or is interacting in one-on-one situations ”  that characterizes those diagnosed with ADHD. Authors of DSM-5 explicitly acknowledge that comorbidity is a frequent phenomenon in relation to the ADHD diagnosis by stating that “in clinical settings, comorbid disorders are frequent in individuals whose symptoms meet criteria for ADHD”  Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity- impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.That is to say, children diagnosed with “Predominantly inattentive presentation” may not share common “symptoms” with children diagnosed with “Predominantly hyperactive/impulsive presentation.”Descriptive diagnoses do not have any explanatory power. Instead, they are prone to the Begging the Question Fallacy, that is circular reasoning Tait, . ChildreTautology is masqueraded as scientific explanation  and with the ones being diagnosed. Meanings and ideas originate in action but also (de)legitimize the forms of action and, thus, shape action as well as how it should be perceived. ADHD is a semiotic mediator; a sign that acts as catalyst for the processes of human acting, feeling, and thinking , it only materializes if recognized as such in practices of institutions , pertinent professionals , or laypeople . The idea of ADHD as a complex, multifactorial neurodevelopmental disorder becomes real To better understand how these processes work, we will next focus on meanings given to the ADHD diagnostic entity and their functions deployed through cultivating psycho-medical discourse of ADHD in institutional and social practices. Drawing from our previous research on how identities, agencies, and moral responsibility are negotiated in relation to the ideas about ADHD psychiatric concept, ADHD represents a natural neurodevelopmental state within an individual—something individual has. DSM and alike “identification” manuals, law and national care guidelines applying the text of these manuals, and international consensus statements cultivating and strengthening the text of these manuals are examples of top-down processes through which the idea that ADHD represents a (complex) neurodevelopmental state become naturalized.As a bottom-up process, this naturalization typically happens in interactions between and among school representatives and parents, in which the psycho-medical discourse of ADHD is distributed as an account for school failure resulting from a naturally occurring deficit in brain functioning  Is that not a fair description of the difficulties at hand?Psychiatric professional: Yes, I think it is. And what are you thinking in relation to treatment?Psychiatrist: I think we should give her some medicine.Psychiatric professional: Yes.Psychiatrist: They have already provided a lot of support, placement in a special educational unit, structure, and a family consultant at home.Psychiatric professional: Yes. Psychiatrist: It is extensive support. (...) And of course, we also need to offer the parents an ADHD parenting course .via a thorough assessment of the adequacy, quality and execution of the means of support provided at home and school, for example. Diagnosis of ADHD is an institutional legitimization for an alleged condition, serving as a means to communicate between authorities and institutions  about the veracity of needed professional support. Institutional practice transforms ADHD from a natural state to an institutionally recognized position: Not only do individuals “have” the condition, now they also have the diagnosis, which in turn legally entitles them to societal and institutional recognition of certain kinds.ADHD becomes real as a psychiatric disorder treatable with medication based on information communicated from various professionals instead of Diagnosing ADHD followed by special need education resolution at school is a typical sequence of events in institutional practice  little choice but find diagnostic categories for “disorderly” students medical diagnosis functions within intertwined spaces of institutional and social practice. Not only did the ADHD label discharge the son from legal but also from moral liability for his actions. In addition, the mother fended off potential blame of poor parenting by becoming the guardian of a disabled son. The psycho-medical discourse is harnessed to counter normative assumptions and judgments regarding “normal” development, behavior, performance, functioning, parenting, teaching, and so on—broadly put, cultural blame. In and through this discourse, ADHD diagnosis is mobilized as an emancipation of moral liability, or as Reid and Maag  concludewithin the child.For parents, a child's diagnosis absolves the culture of blame of what may be seen as poor parenting, since asserting that a child “suffers” from a neurobiological disorder is not as delicate a matter as asserting that the child manifests unwanted ADHD-like symptoms in response to an unsteady home life  because teacher's initial stance is that there has to be something wrong with the family because the child behaves like (…) it just showed how much they lack knowledge (Mother).It was quite a disappointment that they [teachers and principals] were of the opinion that this doesn't exist, ADHD doesn't exist, that only poorly behaving kids with behavioral disorders exist, and it is caused by conditions at home (Father).Diagnosis is expected to reframe and change the way child and parents are viewed, regarded and treated by others, and translate psycho-medical discourse into pedagogies that promote learning and positive self-image; to direct the focus from behaviors and performance that may be of concern to an individual characterized by neurodiversity. With this new interpretation frame then, an ADHD diagnosis functions as a means to normalize the parents as well as the child, who can now establish their moral status as competent educators and caregivers through received/internalized emotional reprieve from guilt and blame , the diagnosis also entails a promise for empathetically receiving and treating oneself. Hence, the diagnosis also takes form as an instrument of empowerment, serving as a means to come to terms with the idea of ADHD as an individual trait and characteristic—with the neurodiverse self/individual—and embrace it as such. This is illustrated below by excerpts from Gajaria et al.  research“ADHD is a great Personality enhancer!! I think we are all blessed in that field!!” .“I feel sorry for people who don't have ADD. Seriously, I think we have waaaay more fun!” .Such accounts on ADHD-selves rely on the essentialist idea of self-discovery  are not meaningful parts of our identities outright unless they are recognized as such in portraying what kind of a person one is by self and/or others. Natural states gain force as identities through discourse in institutional  and social practices .Once officially diagnosed, the hypothesized natural state becomes legitimized by institutional authorities. Now the nature identity is strengthened and paired with the imposed institutional identity, as the one diagnosed becomes subjected to certain level of institutional and social means of monitoring, support and/or treatments. Since diagnostic entity ADHD functions as a means to be emancipated from legal and moral liability as well as to cultivate sympathy and empathy it is unlikely for diagnosed children to avoid forming their identities in relation to ADHD in one way or another after being diagnosed. On the other hand, adults diagnosed in adulthood will have likely started monitoring themselves according to the psycho-medical discourse of ADHD prior to official diagnosing, now receiving a pathway to re-creating themselves empowered by authorities . The nature and institution identities thus mutually support and sustain each other.The third perspective on ADHD identities is discourse Gee, , as ADHDachieving a certain kind of ADHD discourse identity for the child. Parents tend to receive diagnosis for their children and recognitions for certain kinds that follow. Children on the other hand play no active role in the process. They are diagnosed, and the basis for the ADHD discourse identities is ascribed to them.In this regard, Tomlinson  has arguthem from majority of people with so-called “neurotypical brains,” the movement advocates that neurobiological differences are part of natural variation among the human population, hence, “neurodiverse people” such as those “with” ADHD are not to be cured nor treated but rather recognized as part of human specificity like sex or race.The mobilization of ADHD-related stereotypes and lay diagnoses, or the act of lay or self-diagnosing are other examples of forming discursive ADHD identities without them being warranted by institutional authorities. Discursive identities are dynamic and enable detachment from the official psycho-medical model of deficit, disorder, and disability by reconstructing of what ADHD as an individual trait is about. Contemporary western zeitgeist is characterized with new emerging discourses with an aim at changing the ways people “with” ADHD are recognized. Take the empowering nature of the diagnostic entity as an example. It resonates with the claims of a social movement called the neurodiversity movement, originally coined by and for people labeled with what is currently described as the autism spectrum  and make oneself understandable (humanize), it simultaneously distances one from “normalcy” and imposes stigma ,” “neurodiverse people”] widens the gap between The philosopher of science Hacking  notes thIn this article we have demonstrated how making up “ADHD-people” takes shape as both top-down and bottom-up processes through discourse, institutional and social practices. We started off by problematizing the mainstream notion of western clinical psychiatry, exemplified in the DSM. The ontology of the claim about ADHD existing and being a real disorder lies not in nature nor does its epistemology point to clinical practices successfully “identifying” the condition. The onto-epistemological premises of ADHD are rather founded on pragmatism and utilitarianism Tait, ; on the For this reason, we reckon that the frequent changes in the diagnostic criteria of ADHD do not reflect any real scientific progress. Among other reasons, they change to match better the maneuvers of individuals when navigating an increasingly psychiatrized society in the search for recognition, support, category membership, immunity, sympathy, and sense of belonging. Psychiatric diagnoses produce a “looping effect” of human kinds Hacking, . This reThe act of naming and making sense of behaviors, experiences, or persons through psychiatric nomenclature such as ADHD is a moral goal-oriented discursive practice with actual consequences for those subjected to it. We have illustrated that ADHD diagnosis has various functions that take specific forms related to specific objects that are negotiated. Fighting for legal rights or for discharge from liability, explaining behaviors, performance and functioning, allocating, planning, and implementing means of supports and treatments, involving parents in school, and cultivating sympathy, empathy and valued identities and agency are built on the idea of an ADHD as a valid neurobiological entity within an individual. These negotiation processes with the diagnostic entity have institutional , social , and psychological  consequences.them—and guides the kinds of action that should be targeted for us to intervene positively in their lives and potential life trajectories. The well-meaning discourse also forms the subject of which it speaks, such as a patient, a sufferer of a disorder, (a parent of) a person “with” ADHD or an achieved entrepreneur. It enables a subject's maneuvering within the discourse for achieving certain kinds of recognition while simultaneously limiting subjects' access to other discourses (van Dijk, Psycho-medical discourse of ADHD forms the object of which it speaks, that is the person “with” ADHD and various traits associated with the label. It directs focus on individuals—having or being ADHD but becoming and performing ADHD through deploying psycho-medical discourse provided in the DSM. The diagnostic label is a sociocultural means of making meaning of embodied, material, and social experiences that may conflict with social contexts, and a means of communicating about these experiences and reacting to them in societal, institutional, social, and individual levels. ADHD is better understood as a social category that eliminates human diversity and enforces the standard model of what an individual should behave and be like in order to navigate within the cultural boundaries of normalcy and be a productive citizen.To conclude, diagnosis does not represent The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author/s.JH was in charge of the second part of the article and the analysis of the forms and functions of the diagnostic entity. AK was in charge of the first part of the article focusing on critical assessment of the diagnostic criteria presented in the DSM-5. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


For decades, psychostimulants have been the gold standard pharmaceutical treatment for attention-deficit/hyperactivity disorder (ADHD). In the United States, an astounding 9% of all boys and 4% of girls will be prescribed stimulant drugs at some point during their childhood. Recent meta-analyses have revealed that individuals with ADHD have reduced brain volume loss later in life (>60 y.o.) compared to the normal aging brain, which suggests that either ADHD or its treatment may be neuroprotective. Crucially, these neuroprotective effects were significant in brain regions  where severe volume loss is linked to cognitive impairment and Alzheimer’s disease. Historically, the ADHD diagnosis and its pharmacotherapy came about nearly simultaneously, making it difficult to evaluate their effects in isolation. Certain evidence suggests that psychostimulants may normalize structural brain changes typically observed in the ADHD brain. If ADHD itself is neuroprotective, perhaps exercising the brain, then psychostimulants may not be recommended across the lifespan. Alternatively, if stimulant drugs are neuroprotective, then this class of medications may warrant further investigation for their therapeutic effects. Here, we take a bottom-up holistic approach to review the psychopharmacology of ADHD in the context of recent models of attention. We suggest that future studies are greatly needed to better appreciate the interactions amongst an ADHD diagnosis, stimulant treatment across the lifespan, and structure-function alterations in the aging brain. Attention-deficit/hyperactivity disorder is one of the most common psychiatric disorders in children . The psyOne of the defining characteristics of ADHD is the heterogeneity of behavioral presentations, yet the diagnosis replicates with reasonable success rates across practitioners . Early dIt is evident that variations in the epidemiology and pharmacoepidemiology of ADHD are found across the globe. A meta-analysis of worldwide prevalence in 27 countries in children and adolescents with ADHD was reported at 3.4%  . For exaA number of studies have examined the trajectory and stability of ADHD symptoms across the lifespan. In children, approximately 5%  prevalence rates are generally reported e.g., . In contTaken together, these reports suggest that there may be at least two different disease trajectories, and the potential for the existence of multiple etiologies . There iDespite copious research, a clear link between the clinical features of ADHD and its biological substrates remains at least somewhat elusive. However, neuropsychological, imaging and genetic studies have converged on a few central features with correlates across domains. Contemporary neurocognitive models of ADHD consider deficits in executive functioning, specifically response disinhibition, to be a core deficit . NeuropsAttention-deficit/hyperactivity disorder is mitigated by pharmacological medications that increase concentrations or residence time of dopamine and norepinephrine in the synapse. According to evidence-based guidelines and meta-analyses of pharmacological management of ADHD, stimulants are considered the first-line treatment in both children  and adulHere, we suggest that more studies should focus on examining pharmacotherapy-based treatment for ADHD across the lifespan. However, isolating the effects of psychostimulant treatment is difficult for a number of reasons. First, the high rate of psychiatric comorbidity in adults  and chilLastly, and most importantly, a delay in brain degeneration was observed in adults with ADHD regardless of medication status. Given these concerns, it is critically important to review how psychostimulant treatment for ADHD affects the structural integrity of the brain throughout the lifespan and how these treatments should best be administered to patients with ADHD, given that medication may resolve differences in the ADHD brain, and thus counteract the potential for ADHD itself to provide neuroprotection in late life. Bridging multiple levels of description from a molecular to a system levels of abstraction may improve our understanding of how these substances enhance or attenuate behavioral symptoms across ADHD presentations. It may also lead to quantitative metrics that aid in individualized treatment regimens during early and late stage titration periods across the lifespan.In this paper, we first review the pharmacology of drugs commonly prescribed to children and adults with ADHD. We then discuss structural and functional neuroimaging differences in the ADHD brain. Interestingly, there is mixed evidence as to whether or not pharmaceutical treatment normalizes these structural differences. Here, we review this evidence in the context of recent findings which note a delay in late life neurodegeneration in the ADHD population, particularly in brain regions noted to decline in Alzheimer’s disease (AD). An important future line of inquiry may address the overlap or lack thereof between ADHD, neurodegenerative diseases, and their respective genetics. Finally, we suggest that improved models of ADHD and pharmaceutical treatment across the lifespan may help update clinical decision-making in light of recent evidence. Our method for identifying relevant literature for inclusion in this review is described in One of the defining characteristics of ADHD is its heterogeneity of symptom presentation, and multiple genetic variations have been linked to increased risk for the ADHD . A recenSeveral genetic markers of ADHD identified to date involve alterations in dopamine (DA) and noradrenaline signaling (NA) . There aTherefore, there are relatively few candidate pathways that are thought to be involved in the ADHD phenotype, in contrast to many other psychiatric disorders . Here, wvia these key stimulant drugs while also noting its long-term effects.Stimulants are considered the gold standard pharmaceutical treatment and generally recommended as a first line of treatment for children and adults with severe or moderate ADHD . An estiAmphetamine , the active component of drugs like Adderall, Dexedrine, and Vyvanse, acts as an indirect agonist to catecholamines. The term amphetamine typically refers to the racemic mixture, or equal parts mixture, of dextro and levo amphetamine, though the drugs themselves typically have varying mixtures of these enantiomers, as well as derivations thereof. The cellular signaling pathways altered by AMPH are complex. Repeated exposure to psychostimulant drugs can lead to both acute and enduring effects on neurobiological substrates in the brain . The privia direct diffusion across the cellular membrane , including VMAT1 and VMAT2, as well as interacting with excitatory amino acid transporters , which are also biological substrate targets for non-stimulant drugs   . In partoxetine) . The incoxetine)  such as oxetine) , driven radients . TherefoAmphetamine is also a powerful agonist for trace amine-associated receptor 1 (TAAR1), a G-protein coupled receptor, which acts in conjunction with plasma membrane monoamine transporters to regulate the extracellular concentrations of these monoamine neurotransmitters . By actiS-amphetamine, D-amphetamine) and levoamphetamine . Presently, the modern formulation of amphetamine for ADHD treatment is a combination of racemic amphetamine and d-amphetamine , active in drugs such as Ritalin, Methylin, Concerta, and Focalin, blocks dopamine (DAT) and norepinephrine (NET) transporter , which lin vitro to rodent to human studies suggest that the d enantiomer is thought to mediate therapeutic effects for the behavioral symptoms of ADHD  appears to alter transporter functionality  with AMPH (in vitro studies have demonstrated that longer exposure (>∼30 min) results in DAT internalization -4,5-dihydro-1H-imidazole-2-amine] is an imidazoline derivative and a non-selective α2 adrenergic agonist. It binds to all subtypes of α2-adrenergic receptors -2-acetamide] is a selective agonist drug for α2A adrenergic receptors, with a 60x and 20x higher affinity to these receptors than to α2B- and α2C-receptors, respectively -3-phenylpropane-1-amine; brand name Strattera] is a noradrenergic antagonist drug that inhibits reuptake of NE by blocking NETs -ing NETs , leadinging NETs . In addiing NETs . For exaing NETs . Atomoxeing NETs . Clinicaing NETs  in adulting NETs  and pediing NETs , althouging NETs . Atomoxeing NETs . The preing NETs , such asing NETs  and hypeing NETs . A systeing NETs .The antidepressant and smoking cessation agent Bupropion  is an off-label, non-FDA approved use for treating ADHD . Efficacin vivo. In this section, we will review structural and functional brain differences in youths and adults who are ADHD medication naive, ADHD medicated with pharmacotherapy, and typically developing (TD) controls, as measured by (1) PET, (2) structural MRI, and (3) DTI at drug naivety and pharmacotherapy intervention.Structural and functional neuroimaging techniques permit non-invasive imaging of the anatomy and physiology of the human brain 99MTc]TRODAT, [11C]PE2I, [11C]cocaine, [11C]-altropane), L-amino acid transporters , and D2/D3 receptors  , and measurements therefore can be used to determine the number of available binding sites for specific receptors . Radiotrlopride) . Comparelopride) , suggestlopride) . In addithalamus , 2009, sug abuse . In anotug abuse .2/D3 receptors after intake of MPH, which may reflect increased extracellular DA (Positron emission tomography (PET) studies have generally found that stimulant treatment for ADHD tends to increase the rate of dopamine release into synapses from striatal brain regions. However, few studies have examined children due to concerns about PET radiation. A meta-analysis of 9 PET and 10 SPECT studies revealed that patients with ADHD had 14% greater striatal DAT density than in TD, but this was influenced by previous exposure to ADHD medication with lower DAT density in medication naïve ADHD subjects . Methylplular DA . The amolular DA . For exalular DA .A range of structural brain alterations have been reported in structural magnetic resonance imaging (sMRI) studies examining children and adults with ADHD at baseline (medication naïve). These abnormalities are often reported in the frontostriatal circuitry , but alsSimilar to volumetric results, there were significant findings in cortical surface area and cortical thickness metrics. Lower surface area values were found in children with ADHD, localized to the frontal, cingulate, and temporal areas , as wellAnatomical MRI studies of ADHD are often cross-sectional, but prospective longitudinal studies have enabled researchers to detect patterns of aberrant developmental trajectories in ADHD groups compared to healthy subjects. It has long been argued that ADHD children have a delay in brain maturation , 2012 duNevertheless, persistent brain abnormalities are found in adult ADHD and are elevated due to severity levels, behavioral profiles, environmental factors. Adults with childhood ADHD showed sustained dysfunctions in the lateral fronto-striatal and ventromedial orbitofrontal during attention- and reward-related tasks similar to pediatric ADHD . Rate ofThere is mounting evidence to suggest neural anatomical alterations in ADHD as a result of psychotherapeutic intervention . NumerouOverall voxel-based morphometry (VBM) studies have yielded mixed results when considering the effects of stimulant medication on brain structure. In general, studies that reported significant effects suggest that certain subcortical and cortical nuclei are normalized in medicated ADHD children compared to medication naïve ADHD children. A meta-regression analysis found no association between gray matter volume abnormalities and long-term stimulant medication use from ADHD patients across childhood and adulthood ages . VillemoContrary to results that showed brain normalization, Interhemispheric laterality findings of stimulant medication have been mixed. Patterns of absolute asymmetry volumes appear to increase in the caudal anterior cingulate and isthmus cingulate for medicated ADHD youths compared to medication naïve ADHD youths . In a loIn contrast, other cross-sectional studies have found no volumetric differences in the ADHD brain as a result of medication intake. Greater  or smallA variety of studies suggest that more localized morphological alterations appear to resolve or normalize after treatment with stimulants that enhance DA signaling. For example, 2 per year) compared to controls (rate of increase 0.54 mm2 per year)  . In aduler year) . Similarer year) . van Elser year)  and one er year)  examineder year)  thus suger year) . Anotherer year) . Thus, ier year) . Figure Diffusion tensor imaging (DTI) examines direction and displacement of water molecules in the brain in order to infer white matter (WM) architecture . Region The impact of ADHD medication on WM microstructure remains unclear. Catecholaminergic brain systems, such as dopamine (DA) and norepinephrine (NE), are important neuromodulators that control attention. In light of their shared biosynthesis, intracellular signaling, and innervation pathways, it is critically important to differentiate their functions within a unified paradigm to explain the pathophysiology of ADHD. Computational psychiatry attempts to develop neurocomputational models that can describe the cognitive deficits typical of ADHD as they relate to brain function. While extent attempts are scarce, they are promising see . BehavioDopamine was discovered as a neurotransmitter in 1957 by neuropharmacologist Arvid Carlsson during exploits of DA in the basal ganglia and motor function in patients with Parkinson’s disease , 1993. IP(π) = σ(−γ⋅G(π)), whereby P prior distributions over policies π is equal to policies selected based on free energy G multiplied by an inverse temperature parameter −γ corresponding to precision of beliefs  about policies over a softmax normalized exponential σ. Here, γ reflects the rate of DA firing. Encoding of dopamine as a ‘precision signal’ is illustrated in a number of empirical studies such as repetition suppression during learning  . A Markolearning , hippocalearning , and errlearning . Besideslearning , critic learning , hierarclearning , judgmenlearning , qualitylearning , values learning , and futlearning .Several behavioral markers of ADHD can be explained by theories of reinforcement learning and precision error. For example, the decision temperature parameter determines if a subject will choose the optimal response or a variable response amongst all other alternative options . Increasvia ascending projections from LC to the cortex   .Noradrenergic signaling influences attention through learning, saliency, and exploitative-exploratory behavioral avenues. NA action selection models, such as the decision temperature  and learPharmaceutical treatment for ADHD often leads to regional, but not global, brain alterations as observed across numerous structural neuroimaging modalities . StimulaIn longitudinal PET and SPECT studies , typicalInterestingly, with increasing age, certain brain regions tend to normalize on their own without the help of psychostimulant treatment. For example, caudate volume seems to normalize by mid-adolescence to early-adulthood in ADHD participants, both stimulant-treated and non-treated populations , 2002. IDespite the importance of these findings, most ADHD studies are confounded by relatively small sample sizes, cross-sectional study design, and un-matched patient subgroups. These methodological issues currently hamper structural neuroimaging’s contribution to the diagnostic assessment of ADHD. Thus, standard clinical approaches to medication adjustment remain the best course when treatment ceases to provide positive effects . EssentiNeuroimaging studies have suggested that children with ADHD have diminished brain volume in certain subcortical structures compared to healthy controls . RecentlThe findings in this review paper have their limitations and their interpretations merit great caution. We did not use established methods of systematic review protocols and risk of bias , insteadIn summary, subjects with ADHD may present differential trajectories of brain structure across the lifespan, with early abnormalities followed by a delay in brain degeneration later in life relative to controls. Drug treatment for ADHD does not always appear to increase global brain volume or attenuate morphology abnormalities across all white and gray matter. Rather, treatment seems to increase brain volume in a region-specific manner that normalizes ADHD brain structure, though these effects may vary throughout the lifespan. Indeed, additional studies are needed to determine the extent to which an ADHD diagnosis may be neuroprotective later in life. If so, determining the mechanisms that subtend this neuroprotective effect is essential. For example, it is reasonable to suggest that ADHD individuals switch more rapidly between stimuli to which they attend either externally (in hyperactive) or internally (in inattentive presentations). In this sense, the switching may in some sense exercise the brain. The delay in maturation hypothesis has continued to be a predominant theory in the field. Future studies may therefore focus on linking this maturation delay with delay in degeneration later in life. Unsupervised techniques   may alsoAll authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Adults with ADHD describe self-medicating with cannabis. A small number of psychiatrists in the US prescribe cannabis medication for ADHD, despite there being no evidence from trials. The EMA-C trial  was a pilot randomised placebo-controlled experimental study of a cannabinoid medication, Sativex Oromucosal Spray, in 30 adults with ADHD. The primary outcome was cognitive performance and activity level using the QbTest. Secondary outcomes included ADHD and emotional lability (EL) symptoms. From 17.07.14-18.06.15, 30 participants were randomly assigned to the active (n=15) or placebo (n=15) group. For the primary outcome, no significant difference was found in the intent-to-treat analysis although the overall pattern of scores was such that the active group usually had scores that were better than the placebo group . For secondary outcomes Sativex was associated with a nominally significant improvement in hyperactivity/impulsivity (p=0.03) and a cognitive measure of inhibition (p=0.05), and a trend towards improvement for inattention (p=0.10) and EL (p=0.11). Per-protocol effects were higher. Results did not meet significance following adjustment for multiple testing. One serious (muscular seizures/spasms) and three mild adverse events occurred in the active group and one serious (cardiovascular problems) adverse event in the placebo group. Adults with ADHD may represent a subgroup of individuals who experience a reduction of symptoms and no cognitive impairments following cannabinoid use. While not definitive, this study provides preliminary evidence supporting the self-medication theory of cannabis use in ADHD and the need for further studies of the endocannabinoid system in ADHD.During this work-RC was a Ph.D. student funded by a grant to PA from Vifor Pharma. PA received funds  from Shire, Lilly, Novartis, Janssen, PCMScientific, Vifor Pharma, QBTech. Sativex was free from GW Pharm


This national administrative investigation of Republic of Korea compared the risk of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders(ASD) in preschool amblyopic children and identified factors that possibly mediate this association. After propensity score (PS) matching, 7762 amblyopic children and 31,030 non-amblyopic children were included. Amblyopia was associated with ADHD  but not with ASD . Fine motor skill impairment was a mediating factor in association of amblyopia with ADHD, accounting for 4.2% . In conclusion, amblyopic children have a greater risk of ADHD, and deficits in fine motor skills mediate this association. We suggest increased attention given to fine motor skill underdevelopment in amblyopic children to prevent the development of ADHD. Joly and Franko4 defined amblyopia as the reduction of best-corrected visual acuity to less than 6/9 in Snellen optotype or at least two-line difference in LogMAR optotype between the eyes. This reduced visual acuity is not caused by structural abnormalities of the eye, and typically cannot be corrected by glasses alone.Amblyopia is a common cause of vision impairment whose prevalence rate is approximately 2% in preschool children and 3% in adults7, motor skill development9, and neurodevelopmental diseases, such as attention-deficit hyperactivity disorder (ADHD) and autism spectrum disease (ASD)14. Although previous studies reported a linkage of amblyopia as a single factor with delayed child development or with neurodevelopmental diseases, the mediation factors among amblyopia, neurodevelopmental diseases, and delayed child development such as motor dysfunction, are not well known.Some studies reported an association between visual deficits and reduced psychosocial development16. The frontal aslant tract (FAT) in white matter of the brain, which connects the inferior frontal gyrus with the supplementary and presupplementary motor areas, is regarded to be involved in visuomotor processing. Altered FAT might be involved in the neuromechanism underlying defective upper limb coordination in patients with amblyopia resulting in fine motor impairment17. Also laterality of the microstructural properties of the FAT was associated with greater attention and executive function problems, providing new potential structural biomarker to assess ADHD or associated executive dysfunction during development18.Recent studies demonstrated that the abnormal perceptual experience caused by impaired vision in these patients can influence the microstructural integrity of white matter and lead to cortical changesIn this study,. we investigated whether developmental delay in children with amblyopia, including reduced motor skills, was associated with neurodevelopmental diseases such as ADHD and ASD. A better understanding the association between motor dysfunction and neurodevelopmental diseases in children with amblyopia may help to improve treatments and help to correct motor dysfunctions during early childhood. We used the nationwide database of the Republic of Korea to analyze the effect of amblyopia on the risk of ADHD and ASD and to identify factors that possibly mediated this association.We first examined the basic sociodemographic and clinical characteristics of children in the amblyopia and non-amblyopia groups Table . Before Between-group differences in baseline characteristics were compared using standardized differences in unmatched and PS matched samples. A differences greater than 10% was considered meaningful. PS matched risk ratios and 95% CIs were obtained using modified Poisson regression, and PS matched risk differences and 95% CIs were obtained using a binomial regression model with an identity link function. The mediation analysis focused on the identification of factors that mediate the association of amblyopia with neurologic diseases. To increase the robustness of the results, analyses were adjusted for the same covariates used in PS matching. This analysis was implemented using the difference in coefficients, in which the change in the logistic regression coefficient β associated with amblyopia  was assessed with subsequent adjustment for potential mediating factors. Two-tailed P values less than 0.05 were interpreted as significant. All analyses were conducted using SAS version 9.4 . The mediation analysis was performed in three stages.The association of amblyopia with different neurodevelopmental characteristics was first assessed by calculating the least-squares estimate of the mean risk according to the presence of amblyopia. Dichotomous factors were coded as 0 or 1, so the mean for each variable was equivalent to the proportion with the characteristic. The least-squares means and 95% CIs were reported for children with and without amblyopia, and the differences and 95% CIs of these differences were calculated.vs. without each factor was calculated using the same logistic model, and absolute differences were calculated as the differences in these proportions. The 95% CIs for proportions and differences were calculated using bootstrap methods with 1000 replicates.The effect of neurodevelopmental factors in mediating the association of amblyopia with ADHD was determined by calculating odds ratios (ORs) and using logistic regression to adjust for covariates . All ORs were presented according to the presence or absence of each potential mediating factor. The proportion of the population with ADHD among those with The magnitude of the mediating effects identified in Stage 2 was assessed as the difference in the β coefficient for two logistic models used to predict ADHD after adjusting for sex, residence at birth, birth year, income quintile, prematurity, birth weight, hospital utilization within 4 months, perinatal conditions, and congenital/chromosomal abnormalities. The 95% CIs for the differences in the β coefficients between the two models were calculated using bootstrap methods with 1000 replicates.We then assessed the risk of ADHD and ASD in the amblyopia and non-amblyopia groups Table . This anWe analyzed the result of Korean-Ages and Stages Questionnaire (K-ASQ) assessing the judgment ability, communication skills, gross motor skills, fine motor skills, problem-solving ability, and sociability which was considered as potentialmediating factors in case of underdevelopment, between amblyopia and ADHD in boys Table . The leaWe performed the same analysis for girls Table . The leaThis study demonstrated that children with amblyopia had a higher risk of ADHD than those without amblyopia, and that children with amblyopia also had delayed childhood development characterized by lower cognitive abilities , social skills , and motor skills. Our mediation analysis suggested that fine motor skill impairment mediated part of the relationship between amblyopia and ADHD in boys and girls.12. This supports the hypothesis that impaired visual perception during childhood caused by amblyopia can hamper childhood development and make children more vulnerable to neurological disorders such as ADHD. The currently accepted hypothesis is that amblyopia arises from a mismatch of the images from the two eyes. In other words, the brain favors information from one eye and suppresses information from the other eye, possibly because of cortical neural loss in the region associated with the unfavored eye. A brain imaging study showed that amblyopia was associated with neural loss in V1, known as the primary visual cortex15. Other studies suggested that visual cortex abnormalities might be related to impairments in early-stage attentional mechanisms and therefore increase the likelihood of ADHD19. The present study provides evidence that vision problems caused by amblyopia are associated with underdevelopment of attentional mechanisms, which may lead to delayed development of fine motor skills and contribute to ADHD. The limited ophthalmic experiences of children with amblyopia is likely to interfere with the normal development of ophthalmic function derived from the visual cortex, and eventually lead to inadequate development of regions in the brain related to attention. Amblyopia should therefore be considered a risk factor for ADHD.Previous studies also reported that ADHD was associated with ocular abnormalities, including amblyopia, especially when diagnosed at a younger ageChildren who have amblyopia have delayed development and a higher risk of ADHD, and deficits in the development of fine motor skills appears to mediate part of the increased risk for ADHD in these children. Our study thus suggests that increased attention should be devoted to the underdevelopment of fine motor skills in children with amblyopia to reduce the risk of ADHD. In other words, the lack of normal visual development in children with amblyopia may hinder their development of motor skills and cognitive functions that are essential for normal brain development. This may manifest as altered development of the ophthalmic system and general health.The key strength of this study is that it had a population-based design with a relatively large sample of preschool children, meaning that our results can be considered generalizable. However, this study had some limitations. First, the diagnoses of amblyopia and other comorbid diseases were entirely based on ICD-10 codes. Second, the visual acuity examination was based on home screening or screening conducted in public healthcare centers, and it was not possible to obtain accurate information about best-corrected vision acuity, which is considered a reliable indicator of potential visual function. For this reason, our database had no information on the severity of amblyopia, and we could not investigate different subtypes of amblyopia as surrogates for different levels of visual performance.Nevertheless, the findings of our study demonstrated an increased risk of neuronal developmental problems in children with amblyopia. This suggests that suboptimal development of visual acuity may be associated with other general health problems that are related to development and other neurological disorders. Additional longitudinal research should therefore examine the functional correlation between the severity of visual impairment and other systemic disorders.12. Some previous studies reported an association between visual deficits and reduced visuomotor skills or psychosocial development7, and other studies suggested a relationship between ophthalmic disorders and some specific diseases20. These findings are consistent with our results that the risk of ADHD was higher in children with amblyopia and that impaired development of fine motor skills mediated some of this effect.The primary target in this population-based cohort study of data from a nationwide health insurance research database were children with amblyopia. The prevalence of amblyopia was 1.8% in this sample of 917,707 Korean preschool children, comparable to other studies of preschool children21. A total of 917,707 children were included .This retrospective population-based cohort study was conducted using data from the National Health Insurance Service (NHIS) of Korea, which has mandatory participation for all residents. Data were from the National Investigation of Birth Cohort in Korea study 2008 (NICKs-2008), which has information on children born in 2008 and 2009The NHIS maintains health records regarding healthcare utilization, prescriptions, and national health screening programs for all residents of Korea. The National Health Screening Program for Infants and Children (NHSPIC) database includes information on developmental screening, which was implemented from second round to the seventh round when children were 9–71 months-old. NHIS health records up to December 2017 were analyzed, and included the results of the fifth, sixth, and the seventh NHSPIC of the study population. The use of de-identified individual data for research purposes was authorized under the current National Health Insurance Act. The protocol of this study was reviewed and approved by the Institutional Review Board of the Korea National Institute for Bioethics Policy (P01-201603-21-005). All study conduct adhered to the tenets of the Declaration of Helsinki. Informed consents were obtained from all participants of the study.th revision (ICD-10). ADHD was diagnosed when a child had ICD-10 code F90.0A, F90.0B, or F90.0C at least twice, with an interval between codes of more than 1 year22; ASD was diagnosed when a child had ICD-10 code F84.0, F84.1, or F84.9 at least twice, with an interval between codes of more than 6 months23. The clinical diagnoses of ADHD and ASD in the registration database has high validity24.Demographic characteristics, health care utilization, and outcome data of all participants were obtained from the NICKs-2008 database. The developmental screening tool used for the NHSPIC was the K-ASQ, a parent-based screening test. The K-ASQ evaluates six domains in child development: judgment ability, communication skill, gross motor skills, fine motor skills, problem-solving ability, and sociability. The diagnosis of ADHD and ASD was based on codes from the International Classification of Diseases 10The main cohort consisted of children who were enrolled in NICKs-2008, participated the first round of the NHSPIC, participated in at least one round from the fifth to seventh rounds of the NHSPIC, and had properly recorded K-ASQ results through the NHSPIC. Children who died were excluded. A total of 401,852 children met the inclusion and exclusion criteria, 8100 were diagnosed with amblyopia and the other 393,752 children did not have amblyopia. Amblyopia was identified by ICD-10 codes of H53.00 (Unspecified amblyopia), H53.01 (Deprivation amblyopia), H53.02 (Refractive amblyopia), or H53.03 (Strabismic amblyopia), with evaluation by ophthalmologists based on the NHSPIC and visual acuity examination.Propensity score (PS) matching was performed using appropriate covariates Table  to reducAll outcomes were prespecified. The primary outcome was the risk of ADHD and ASD and the secondary outcome was the risk of delayed development. Developmental problems were assessed using K-ASQ data collected during the fifth to seventh rounds of the NHSPIC, when children were 42–72 months-old. Mediation analysis was performed separately for boys and girls to evaluate the effect of developmental problems in mediating the association of amblyopia with neurologic diseases. Mediation analysis estimates the proportion of an association  that can be attributed to potential mediating factors .Supplementary Information.


Low birth weight (LBW) is a major risk factor of child mortality and morbidity during infancy (0–3 years) and early childhood (3–8 years) in low and lower-middle-income countries, including Bangladesh. LBW is a vital public health concern in Bangladesh. The objective of the research was to investigate the socioeconomic inequality in the prevalence of LBW among singleton births and identify the significantly associated determinants of singleton LBW in Bangladesh.The data utilized in this research was derived from the latest nationally representative Bangladesh Demographic and Health Survey, 2017–18, and included a total of 2327 respondents. The concentration index (C-index) and concentration curve were used to investigate the socioeconomic inequality in LBW among the singleton newborn babies. Additionally, an adjusted binary logistic regression model was utilized for calculating adjusted odds ratio and p-value (<0.05) to identify the significant determinants of LBW.P = 0.029), with a higher concentration of LBW infants among mothers living in the lowest wealth quintile (poorest). Regression analysis revealed that maternal age, region, maternal education level, wealth index, height, age at 1st birth, and the child’s aliveness  at the time of the survey were significantly associated determinants of LBW in Bangladesh.The overall prevalence of LBW among singleton births in Bangladesh was 14.27%. We observed that LBW rates were inequitably distributed across the socioeconomic groups . Governments, agencies, and non-governmental organizations should address the multifaceted issues and implement preventive programs and policies in Bangladesh to reduce LBW. Low birth weight (LBW) is a leading public health concern. It is a vital risk factor of perinatal survival, infant and child mortality, and morbidity in infancy and early childhood 3–8 years), and it contributes prominently to the overall burden of infant mortality , 2. Infa–8 years,To the best of our knowledge, no existing study investigated the socioeconomic inequality in the prevalence of LBW using the nationally representative BDHS data. Thus, the objectives of the present study were to statistically investigate the socioeconomic inequality in the prevalence of LBW in Bangladesh and identify the significantly associated determinants of LBW, using data from the most recent BDHS (2017–2018).st stage, 675 enumeration areas (EAs) were selected via probability proportional sampling, wherein 250 were urban and 425 rural areas. In the 2nd stage, sorting the taken households and provided a complete sampling frame. A systematic random sample of 30 households was chosen from each EA in the 2nd stage to estimate the key demographic and health-related indicators. A total of 20,250 residential households were chosen to participate in face-to-face interviews with questionnaires. About 20,100 ever-married women with an age range of 15–49 were expected to complete the interviews [The dataset utilized in this study was taken from Bangladesh Demographic and Health Survey (BDHS), 2017–18 . The BDHterviews . Each rehttps://dhsprogram.com) can be found in the BDHS reports [The present study utilized current public domain survey datasets, which are freely accessible online; that is why it does not require any additional ethical approval. A detailed description of the ethical procedures followed by the DHS program , and recorded a binary response variable with a membership class label: LBW and non-LBW . The memst birth interval, antenatal care (ANC) initiation at 1st trimester , number of antenatal visits , during pregnancy iron tablet , place of delivery , delivery by CS , and child is alive ; environmental characteristic: toilet facility ; and exposure to mass media: newspaper , and television . Based on WHO criteria, nutritional status of mothers was measured by body mass index (BMI) with underweight (BMI<18.5 kg/m2), normal (18.5≤BMI≤24.9 kg/m2), overweight (25≤BMI≤29.9 kg/m2), and obese (≥ 30.0 kg/m2).The explanatory variables included in this study are based on the earlier research papers on literature , 27–34. 1: maternal age, X2: division, X3: mother’s education level, X4: wealth index, X5: height, X6: weight, X7: parity, X8: age at 1st birth, X9: antenatal care initiation at 1st trimester, X10: number of antenatal visits, X11: delivery by CS, X12: child is alive, X13: toilets; X14: newspaper) represent explanatory variables; β0 is intercept; β =  represents the regression coefficients; and ε denotes random error term. Odds ratio (OR) with 95% confidence intervals (CIs) was calculated aimed at assessing the directions as well as the strength of the effect of the explanatory variables. The explanatory variable with a p-value <0.05 was considered statistically significant for the determinants of LBW. Data processing/preparation and all statistical analyses were carried out by SAS 9.4 software .Data was prepared using the survey weights before the statistical analysis. In bivariate analysis, Pearson’s chi-squared test of independence –40 was ii: LBW, μ: mean of LBW, Ri: ith individual’s fractional rank in the socioeconomic distribution [The concentration index (C-index) was computed to quantify the degree of socioeconomic inequality of newly born babies with LBW among singleton births. C-index is a well-known and suitable measurement for measuring socioeconomic inequality in health-related variables . The CI ribution . The ranribution , 46. If nd highest proportion (24.65%). More than half of the mothers were secondary educated (51.08%), whereas 2.67% of mothers had no education, 15.34% were primary literate, and 30.92% had higher degrees. About 52% of mothers initiated antenatal care during pregnancy at the 1st trimester, and most of mothers delivered their babies by cesarean section (62.72%). In addition, a larger proportion of mothers had ≥4 ANC visits (68.01%), 15–25 years age at first birth (89.52%), hygienic toilet facility (82.79%) and lived in the Dhaka division (17.59%).In our study population, the overall prevalence of LBW was 14.27% . The preP = 0.023). The Sylhet division was found to have the highest prevalence rate of LBW (19.25%), while the Mymensingh division had the lowest LBW rate (9.47%). The division was significantly associated with LBW status. Non-educated mothers were found to have higher LBW babies (24.56%) compared to primary (17.38%), secondary (15.02%), and higher (10.59%) educated mothers. Parents’ education level and LBW were also statistically significant. Underweighted mothers exhibited the highest LBW rate (15.85%) followed by the mothers with normal BMI (14.60%). Mothers who gave birth to their first babies at age <15 years were found to have a higher prevalence of LBW (22.22%) than others (15–25 years: 14.47% and >25 years: 6.99%), exhibiting the statistically significant association between age at first birth and LBW status. Mothers who did not initiate ANC at the first trimester during their pregnancy period were found to have a significantly higher prevalence rate of LBW compared to their counterparts . The prevalence of LBW was significantly higher among the mother who had < 4 ANC visits than those who had >4 ANC visits . This indicates that number of ANC visits was significantly associated with LBW. Mothers who had normal delivery  exhibited higher prevalence rate of LBW in a comparison with those who delivered by cesarean (16.44% versus 12.98%) and the association of LBW with model of delivery was statistically significant (P = 0.027). Families having no toilets facilities had a significantly higher prevalence of LBW than the families with hygienic toilets facilities , which indicates a significant association between toile facility and LBW. In terms of exposure to mass media, not reading newspaper was significantly associated with LBW . Area of residence, religion, sex of the child, mother’s BMI, marriage to 1st birth interval, wanted pregnancy, taking iron tablet during pregnancy, place of delivery, and watching television were not significantly associated with LBW.The distribution of the explanatory variables by LBW status is presented in S1 Table demonstrated that the predictors maternal age, residence, division, parental education, BMI, parity, age at first birth, Marriage to 1st birth interval, ANC initiation at 1st trimester, number of antenatal visits, taking iron tablet during pregnancy, place of delivery, mode of delivery, toilet facility, reading newspaper, watching television were significantly associated with the socio-economic status (P<0.005).P = 0.029) demonstrated that there was a higher concentration of babies with LBW among mothers living in the lowest wealth quintile.P<0.001) and middle-class  households were more likely to have LBW babies compared to the mothers who were from the richest households. After adjusting for other confounders in the MLR model, mothers from the poorest families  and middle income households  were more likely to deliver LBW babies than the richest mothers. In unadjusted LR, mothers aged >40 years exhibited almost 5-fold higher odds of having LBW babies compared to the 21–30 years old mothers ; whereas in adjusted LR, they showed almost 4-fold higher odds of having LBW babies . Simple LR analysis demonstrated 2.227 times, 2.28 times and 74% higher likelihood of having LBW babies among the mothers who were from Sylhet , Chittagong , and Rajshahi  division, respectively, compared to those who were from Mymensingh division. Likewise, adjusted LR revealed that mothers who lived in the Sylhet , Chittagong , Rajshahi , and Dhaka  division were more likely to have babies with LBW compared to mothers who lived in Mymensingh division. Both unadjusted and adjusted LR analyses showed that the mothers who had no education, primary education, and completed secondary education were more likely to give birth to LBW babies than the higher educated mothers. Maternal height was found to be a significant risk factor for LBW.P = 0.002) or between age 15–25 years  had respectively 4-fold and 2-fold higher odds of giving birth to LBW babies than those who had their 1st babies at the age >25 years. Similarly, adjusted LR revealed that women who were <15 years old at 1st birth  were more prevalent to give birth to babies with LBW than >25 years old mothers at 1st birth. Mothers who lost their previous child were found to have higher odds of LBW babies compared those whose previous child was alive. Similarly, parity, antenatal care initiation at 1st trimester, number of antenatal visits, delivery by CS, the child is alive, toilet facility, and newspaper reading habit were also statistically significant risk factors of LBW.Unadjusted LR showed that mothers who gave their first birth at age <15 years  followed by the mothers who lived in Sylhet  and Chittagong  division.The present study aimed to investigate the socioeconomic inequality in the prevalence of LBW among singleton births in Bangladesh and to identify the significant determinants using the latest BDHS (2017–18) data. We found that the overall prevalence of LBW among singleton births in our study population was 14.27%, which is much higher than other countries, including Russia (6.0%), Germany (7.0%), and Japan (10.0%) . Lorenz Unadjusted and adjusted binary logistic regression analysis found that the wealth index is a critical gradient because women from the poorest households were at a higher odds of having babies with LBW than those from the richest households. Earlier studies showed similar findings for LBW and other outcomes (noncommunicable diseases and underweight) in LMICs –61. WomeSpecific to Bangladesh, our study indicates that women who live in eastern divisions (Sylhet and Chittagong divisions) are more likely to give birth to LBW infants. Similar findings were reported by Khan et al. . In the The present study, based on BDHS 2017–18, revealed that singleton infants with LBW were more concentrated among mothers living in the poorest socioeconomic quintile in Bangladesh. Wealth index, maternal education level, maternal age, geographic region or administrative division, mother’s height, and maternal age at first birth were all significantly associated determinants of LBW. The highest risk of LBW was found among the infants born to uneducated women in the lowest socioeconomic quintile who lived in the eastern divisions  of Bangladesh. Intensive initiatives and efforts, by government and non-government organizations and agencies, to develop and implement policies and programs that addresses factors such as equitable access to health care, nutrition and education, focusing on communities at highest risk, are needed to reduce the prevalence of LBW infants in Bangladesh.S1 Table(DOCX)Click here for additional data file.