Attention Deficit Hyperactivity Disorder (ADHD) is found in up to 20% adults with Substance Use Disorder (SUD). ADHD + SUD is associated with a more complex clinical presentation and poorer outcomes than each disorder alone. In the presence of SUD, adult ADHD is particularly difficult to diagnose as both disorders can mimic or hide the symptoms of each other. Our university hospital in Paris recently started an extensive outpatient diagnostic procedure for adult patients with SUD to ascertain or refute ADHD diagnosis and to provide therapeutic guidance. Here, we report the acceptability of the assessment procedure for patients and the preliminary description of the current and lifetime clinical profiles as a function of the final diagnosis “ADHD vs. no ADHD.”Adult SUD patients with suspected ADHD were included in the current pilot study after stating they had no objection that their de-identified data were used for research purposes, according to French ethical procedures. Patients were evaluated for ADHD, comorbid mental disorders, cognitive state and dimensional psychological variables. They were assessed by trained psychologists and psychiatrists using standardized tools over a day. ADHD diagnosis was mainly based on the Diagnostisch Interview Voor ADHD for DSM-5 (DIVA-5).Out of 18 eligible patients, 17 were included in the cohort (1 excluded) and none was opposed to using their data. Thirteen (76%) participants were diagnosed with ADHD. All patients appointed for the ADHD diagnostic procedure came, respected schedules and finished the evaluation. All patients were impaired on cognitive functioning and were highly comorbid, but ADHD patients seems to suffer even more from those conditions, especially for cannabis and stimulant use disorders.Preliminary results show high acceptability of the procedure by ADHD-SUD patients. This result could be explained by all the organization adapted to the psychopathology. Patients' baseline motivation to participate also represents an uncontrolled variable that could promote the ability to follow the procedure. Acceptance results of the protocol are promising and represent a starting point to identify the best procedures to design patient-centered pharmacological and non-pharmacological therapies. Attention Deficit Hyperactivity Disorder (ADHD) is a pervasive neurodevelopmental disorder that is likely to persist into adulthood . In the Comorbid ADHD is associated with more severe patterns of SUD , includiThe overlapping symptoms between ADHD and SUD represent a challenge for ADHD diagnosis procedure and treatment . Both diDiagnostisch Interview Voor ADHD (DIVA-5) has recently been translated in French and allows for both child and adult ADHD diagnosis while assessing functional impairment. The first validation study of the DIVA-5 concluded that it seemed to be a reliable tool in a Korean population  is often considered as the golden standard to diagnose ADHD, including in SUD adult population. Unfortunately, it remains only available in English and Dutch and, while providing in-depth investigations such as age at onset of each ADHD symptom, it remains mostly based on DSM-IV classification and its length can be a downside in SUD populations. When compared with the CAADID, the ADHD section of the Psychiatric Research interview for Substance and Mental Disorders (PRISM) showed good psychometric properties to detect ADHD in SUD population , yet agapulation . OverallIn this context of unmet diagnostic needs for ADHD, neurocognitive measures may hold promises in the ADHD diagnosis procedure, particularly regarding processing speed and working memory . Howevervice-versa.Available evidence highlighted that assessing ADHD among SUD population is profitable to both the diseases , 25. TheIn order to address the major issue of diagnosing ADHD in SUD individuals, we developed an extensive assessment procedure that occurs over a day in our public academic hospital. Our main research aims are to validate the French versions of several diagnostic instruments in their DSM-5 versions and to detect potential neurocognitive profiles of ADHD in this population. For the current report, we chose to provide the preliminary descriptive and comparative statistics of the first case series of included patients. We focused on participants' ability to undergo the full procedure and on the SUD and main cognitive characteristics of those eventually diagnosed with ADHD vs. those who were not. Our hypotheses were that at least 5% participants would have serious difficulties in fulfilling all assessments and that ADHD would show clinical profiles suggestive of increased severity.Participants were unpaid adult French-speaking outpatients receiving medical or psychological care for SUD. Fifty three percent presented a severe SUD pattern and 24% were in early remission. Recorded by the Weiss Functional Impairment Rating Scale self-report (WFIRS), the largest functional impairment is reported in self-concept, followed by school field and life skills. Inclusion criteria for the current study were the same as the expert assessment that is conducted at our day hospital for addiction medicine. Patients were referred from primary or tertiary addiction care settings by word-of-mouth to ascertain or refute adult ADHD diagnosis. They underwent a full diagnostic procedure, whichever their comorbidities, provided that they fulfilled a set of screening questionnaires, including: a free text form summarizing the referral's motives for assessment and participants' current treatment and medical history; Adult ADHD Self-Report Scale 6 items version for DSM-IV ; the Wender Utah Rating Scale, 25-items (WURS-25), the Alcohol Use Disorder Identification Test (AUDIT); the Cannabis Use Disorder Identification Test (CUDIT) and the Fagerström Test for Nicotine Dependence (FTND).There was no additional inclusion criteria for the current study. Additional exclusion criteria were: unable to complete assessments due to unstable medical condition (including acute intoxication), compulsory admission, or current guardianship. According to the French ethical bylaws, patients could be included without signing written informed consent, if they did not express their opposition to participate and that their data were pseudonymized. The study was conducted according to the tenets of the Declaration of Helsinki  and of Paris-Nanterre University ethics committee rules .Before assessments, all participants were contacted by phone to properly describe the whole assessment procedure and to arrange an appointment, which was further confirmed by phone text-message. Once they arrived on site, they were also accompanied by a nurse to carry out administrative procedures and to collect vital signs . This moment also allowed flexibility for late arrivals.All assessments were conducted face-to-face with trained psychiatrists and psychologists, who were assigned different questionnaires between participants. A typical assessment day includes :An anamnestic interview for the main clinical and socio-demographic background, including the number of DSM-5 criteria for the main current substance use;We assessed a range of cognitive functions in two steps, using:- three subtests of the Wechsler Adult Intelligence Scale (WAIS-IV) encompassing Processing Speed and Working Memory . The WAIS  is the m- a screening of cognitive dysfunction with the Brief Evaluation for Alcohol Related Neuropsychological Impairment (BEARNI) and the Frontal Assessment Battery (FAB).Psychiatric and addictive comorbidities were then ascertained using the Mini International Neuropsychiatric Interview Simplified for DSM-5 (MINI-S). The MINI-S provides categorical diagnoses for 13 psychiatric disorders, including SUDs, and their current remission status. To date, the Mini-S had been validated for the depressive symptoms . HoweverLifetime history of suicidal attempt was collected using the “suicide” section of the Diagnostic Interview for Genetic Studies, v 4.0 (DIGS 4.0) . The firParticipants were then offered lunch onsite for 60 min. Afterwards, they were asked to complete four self-rating scales aimed to estimate (i) the functional impact of their symptoms using the Behavior Rating Inventory of Executive Function Adult version – BRIEF-A  and the Finally, all participants underwent the Diagnostic Interview for ADHD in adults (DIVA-5) to investigate ADHD symptoms during childhood and adulthood and ascertain the diagnosis, regardless from the results on ADHD screening scales. Importantly, this questionnaire allows collecting hetero-anamnestic data from child health record, parents' testimony, teachers' evaluations and comments on academic transcripts to reinforce diagnostic reliability. The DIVA is one of the structured interviews recommended in adults with SUDs, for whom ADHD is suspected by clinicians, whether the screening was positive or not .a priori in order to maintain a good balance between collecting data relevant for the clinics and research and yielding a feasible assessment procedure.The time allowed for each assessment  attended, respected their schedule and attended the entire evaluation procedure. One participant showed external signs of discomfort and irritability. The others reported good subjective tolerance to the procedure. They pointed out to the protocol length and reported subjective tiredness but found it bearable due to previous notice regarding the evaluation procedure and internal motivation to investigate their symptomatology. One of these, however, was excluded of the protocol because of unstable medical condition, leaving a study sample of 17 participants.All participants (p = 0.02).Sample characteristics are described in Thirteen (76%) participants were diagnosed with ADHD according to the DIVA-5. Seven patients (41%) presented with any comorbid mood disorder and eight (47%) with any comorbid anxiety disorder.ADHD cases seemed older and better-educated than non-ADHD cases, with a possibly higher proportion of women (46 vs. 25%). The distribution of marital and employment status seemed similar in both groups .Several interesting patterns appeared between ADHD and non-ADHD patients in Both cocaine (38 vs. 0%) and cannabis use (54 vs. 25%) and their related disorders  seemed more frequent in ADHD vs. non-ADHD participants . Tobaccop = 0.037, Cohen's d = 1.06 for cocaine use)  .SD = 3.8), which corresponded to moderate/severe impairment. ADHD participants  appeared significantly more altered than non-ADHD  on total score  (SD = 2) which seems normal compared to the test norms and no significant difference was observed between the two groups. However, ADHD patients had lower scores on the Go-No Go subscale , compared to non-ADHD participants  but after the Holm's correction the difference was not significant   . The FAB= 0.025) . The WAIIn this first case series of a sample of treatment-seeking SUD outpatients, who was thoroughly assessed for adult ADHD using a wide range of clinical and neurocognitive measures, participants did not report difficulties to attend and undergo all evaluations. Using exploratory analyses, we identified possible cognitive impairment associated with ADHD and relevant relationships between child vs. adult ADHD symptoms load and cocaine use—both warranting further exploration. We relied on a selected set of validated tools chosen to cover a wide range of symptoms and functioning domains.The extensive diagnosis strategy applied to SUD patients for diagnosing ADHD seemed extremely feasible. First, all patients attended and respected their schedule. This was not straightforward given the well-documented difficulty to plan and remind appointments for ADHD  and SUD a priori tiring evaluation procedure well. During the final feedback interview, ADHD and non-ADHD patients reported moderate tiredness and argued that internal motivation to explore ADHD symptomatology helped them to support the procedure. We plan to incorporate proper satisfaction and feasibility measures in our assessments for the near future to assess theses subjective data using a more empirical method.ADHD diagnosis among SUD adults already has been reported as feasible using the Conners' Adult ADHD Diagnostic Interview for DSM-IV , a thoroThis preliminary study supports the feasibility of using the DIVA-5 as the core diagnostic instrument for ADHD among a full set of evaluations. However, a larger sample will be required in order to formally investigate its psychometric properties. Nonetheless, extensive strategy to diagnose ADHD in adults suffering from SUD seems relevant. A similarly extensive strategy has been used by Swedish researchers to diagnose participants in an interventional study , with noIn our case series, the males:females ratio for ADHD was ~1 (46% women), thus possibly differing from the 1.5:1 usually reported . This maADHD participants were more likely to use cannabis and to suffer from cannabis use disorder than non-ADHD patients, and the same patterns were observed for cocaine. This may be due to the high score of sensation seeking  often reOn the whole sample, BEARNI total scores corresponded to moderate/severe impairments (<16), according to the test validation , with ADThe aim of this study was to describe patients' ability to undergo the full procedure and describe preliminary results on cognitive characteristics. Since both screening questionnaires and diagnostic interviews were used, we are able to report their initial diagnostic accuracy. ASRS-6 and WURS-25 sensibility was good when the scales were used separately or combined, however, they showed a non-acceptable false positive rate. The ASRS psychometric properties in SUD population have already been described, but remain inconsistent across studies. The false-positive rate appeared very high in one study , and accGiven the likely effect of substance type on the validity of screening questionnaires, one should bear in mind the crucial role of clinical interview and follow-up to diagnose adult ADHD in SUD populations. However, such a relatively unstructured approach seems more efficient when it is combined with standardized instruments. This may be explained by the fact that the clinical expression and impact of ADHD changes substantially over the lifespan. Thus, compared to childhood, adult ADHD is strongly represented by internalizing symptoms, impaired functioning and much higher comorbidity rates , 60. If Finally, neuropsychological assessments are also often used to support the diagnosis procedure, as significant differences were identified between ADHD and non-ADHD on processing speed and work memory , 62. HowOne of the main aims of the evaluation procedure presented in the current manuscript was to provide therapeutic guidance to the clinician and explain it to the patient. This guidance included both pharmacological and non-pharmacological strategies, and the “hows and whens” of each proposed strategy. Although available evidence remains scarce, we relied on ADHD type (levels of inattention and hyperactivity), comorbidity profiles and functioning (both cognitive and daily life) to propose a personalized care plan to each participant, following the general recommendation for adult ADHD .- As for stimulant medication, we recommended long-acting methylphenidate for five ADHD participants with strong functional impairment (combined and inattentive types) and atomoxetine in three participants. Atomoxetine was suggested because of age-associated risk factors of methylphenidate, potential comorbidity with bipolar disorder and current injection of psychostimulants , 66. For- Specific Cognitive and Behavioral Therapy (CBT) was systematically recommended in addition to pharmacological treatment in ADHD participants .- The full procedure allowed to diagnose previously unidentified psychiatric comorbidities such as anxiety or mood disorders—especially PTSD and bipolar disorder; and cognitive impairment. Thus, in addition to recommendations on ADHD care and because of overlap between ADHD and comorbidities, we also suggested some interventions about these comorbidities. For instance, specific CBT for anxiety disorder was recommended for two ADHD participants and a specific exploration of bipolar disorder was suggested for one participant.- Complete neurocognitive evaluation was recommended for two ADHD participants because of low scores in neurocognitive assessments  and/or recent exacerbation of neurocognitive symptoms. Also, neurocognitive assessments led to recommend cognitive remediation for ADHD participants with strong executive difficulties.- Finally, for non-ADHD participants, specific intervention targeting anxiety and mood disorders could be recommended.The whole evaluation procedure resulted in personalized proposals for ADHD treatment, taking comorbidities into consideration as well as cognitive and emotional difficulties. Relevant psychological dimensions could also be identified in some cases, further increasing the personalization of both pharmacological or psychotherapeutic interventions. Also, the number of assessments facilitated the differential diagnosis to avoid false positive for ADHD. A major goal for treating burdensome mental conditions is functional recovery. We expect the personalized interventions proposed through our procedure to eventually lead to significant improvement of functional impairment, as was evidenced in the French expert centers for bipolar disorder, which use similarly thorough assessments as ours .We found a prevalence of ADHD of 76% among SUD outpatients. This frequency is considerably higher than others studies among SUD patients where ADHD is found for 15–25% of SUD patients , 8. It iThe study has several limitations. First, the sample was very small, thereby reducing statistical power and results interpretation: a dimensional approach to describe ADHD symptoms intensity and evolution across a developmental spectrum would be interesting. Second, there might be a selection bias because of the entry procedure requirements. Patients had to complete several questionnaires to be evaluated and their clinicians had to complete a referral letter. As a result, maybe this procedure included only patients who did not had difficulties in assessments completion. Third, the procedure is fairly demanding in terms of resources. Moreover, there was no control group and no formal assessment of the tests scoring fidelity. Finally, we did not record age of onset of ADHD and SUD nor patients' background or developmental history which could have been helpful for a more comprehensive assessment of ADHD and SUD.We report here a detailed methodology for a reliable assessment of complex dual diagnoses such as ADHD, paving the way for a future validation study of major tools in the field. With a larger sample, we will be able to precisely describe the clinical and neurocognitive correlates of adult ADHD in severe SUD. Additionally, we will strive to identify the minimum set of assessments required for a reliable ADHD diagnosis in SUD populations, since not all clinicians or care settings will gather enough resources for using as many evaluations as we did.These assessments are useful to refer patients to specific care settings for ADHD and SUD patients, that remain to be further developed, as specific Cognitive Behavioral Therapy for ADHD-SUD and specific neurocognitive interventions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was conducted according to the tenets of the Declaration of Helsinki  and of Paris-Nanterre University ethics committee rules. It was formally approved by the relevant Ethics Committee .NT: conceptualization, methodology, investigation, formal analysis, and writing—original draft. LR: methodology, validation, writing—review and editing, and supervision. AM: investigation. AD: methodology, investigation, and resources. FV: resources and validation. EK: methodology, investigation, and writing—review and editing. RI: methodology, investigation, formal analysis, writing—review and editing, validation, and supervision. All authors contributed to the article and approved the submitted version.The positions of the clinicians who conducted the research are funded by Assistance Publique - Hôpitaux de Paris and Université Paris-Nanterre.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.


Dissociative identity disorder(DID) is characterized by the existence of two or more distinct identities which involve changes in consciousness, emotion, memory, and behavior. It is associated with childhood traumatic experiences and other psychiatric disorders. Comorbidity in DID can lead to complex clinical presentations, poor treatment responses. Thus, it is crucial to identify patients with comorbidity and take them into the treatment plan.We aim to report a case of DID and Attention-Deficit/Hyperactivity Disorder(ADHD) comorbidity.A case report is presented alongside a review of the relevant literature regarding “dissociative identity disorder” and “attention deficit hyperactivity disorder”.We describe the case of a 39-year-old woman with DID, onsetting at age 25, who had consistently responded poorly to long-term psychotherapy and pharmacological treatment. She presented with anxiety, distinct personality states, alterations in memory, consciousness and behavior problems in functioning, and high Dissociative Experiences Scale(DES) scores. Throughout the interviews, we noticed that she had limited attention, excess movements. After a detailed evaluation, diagnosis of ADHD is established, using the Diagnostic Interview for ADHD(DIVA) and ADHD Self-Reporting Scale(ASRS). Methylphenidate was prescribed in addition to previous medication. İmprovement in the severity of both ADHD and DID symptoms was presented with lower scores in DES and ASRS after the introduction of methylphenidate with progressive dose adjusting till 60mg/day.Although previous studies demonstrated ADHD symptoms are related to dissociation, there is no well-established strategy for this. We believe that this case report provides a better approach to the comorbidity of ADHD and DID.No significant relationships.


Attention Deficit Hyperactivity Disorder (ADHD) is associated with emotional regulation and cognitive processing challenges throughout life. Not well-understood is how ADHD genetic risk (ADHD-GR) affects depressive symptoms (DepSx) and cognitive functioning in older age. Furthermore, less is known about the mechanisms through which some individuals show better outcomes despite higher ADHD-GR. We evaluated potential mechanisms using the Health and Retirement Study with data from 7,871 European Americans (EAs) and 1,226 African Americans (AAs), ages 50-93, and ADHD-GR calculated from a mixed ancestry genomewide scan. Mediators included closeness of parental relationships during childhood, sense of purpose in life in adulthood, and educational attainment. Outcomes included validated scales for DepSx and cognitive functioning. Structural equation models were stratified by race/ethnicity due to potential differences in genetic effects, adjusted for age, gender, ancestry, and health conditions with DepSx and genetic risk for dementia with cognitive functioning. Among EAs, ADHD-GR significantly predicted lower sense of purpose (p<.05) and worse parental relationships (p<.001), with higher levels of both, in turn, predicting less DepSx (p's< 0.01). ADHD-GR also showed significant direct effects on DepSx (p<.01), controlling for mediators. Additionally, ADHD-GR predicted less education (p<.001), but more education predicted better cognitive functioning (p< 0.001). No relationships with ADHD-GR were significant among AAs. Findings imply that among EAs, mediators could be targets to mitigate negative effects on psychological and cognitive health, two hallmark challenges for individuals with ADHD. More work is needed to characterize ADHD-GR on outcomes among older AAs.


Lactobacillus rhamnosus GG and for multi-species probiotic supplementation. Elimination diets have scarce evidence and lead to nutritional deficiencies, so caution is advised. Overall, more robust scientific evidence is required for these dietary interventions to be implemented as part of ADHD therapy.Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood, affecting ~7% of children and adolescents. Given its adverse health outcomes and high healthcare and societal costs, other treatment options beyond pharmacotherapy have been explored. Case-control studies have shown that dietary patterns may influence the risk of ADHD, and specific dietary interventions have been proposed as coadjuvant treatments in this disorder. These include nutritional supplements, gut microbiome-targeted interventions with biotics, and elimination diets. The purpose of this review is to examine which dietary patterns are most associated with ADHD and to summarize the existing evidence for the clinical use of dietary interventions. The literature showed that non-healthy dietary patterns were positively associated with ADHD, whereas healthy patterns were negatively associated. As for nutritional supplements, only vitamin D and vitamin D + magnesium appeared to improve ADHD symptoms when baseline levels of vitamin D were insufficient/deficient. Regarding biotics, evidence was only found for  Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder mainly characterized by hyperactivity, inattention, and impulsivity symptoms ,2. BeyonThe etiology of ADHD relies on both genetic and environmental factors . Diet, aRecently, specific nutrients, such as vitamin D, zinc, iron, and polyunsaturated fatty acids (PUFAs), have been proposed as coadjuvants in the treatment of ADHD . NumerouThe main objective of this review is to summarize the existing evidence for the clinical use of dietary interventions in ADHD patients, as well as reviewing which dietary patterns are most associated with ADHD.Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood, affecting about 7% of children and adolescents worldwide ,15. It bDiagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). According to the DSM-5, at least six symptoms of inattention, hyperactivity, or both, before the age of 12 years and in two or more settings, are required for the diagnosis of ADHD  study and found an association between the Few-Foods Diet (FFD) and a decrease in thermoregulation problems, gastrointestinal complaints, eczema, and sleep problems. The INCA results show a clinically relevant reduction in the FFD group compared to the control group and the open-label BRAIN results confirmed the outcomes of the FFD group. However, no association was detected between the decrease in physical complaints and the decrease in ADHD symptoms. In a systematic review of meta-analyses of double-blind, placebo-controlled trials, Pelsser et al. [Pelsser et al.  analyzedr et al.  also fouThe oligoantigenic diet (OD) is another restrictive diet that consists in the elimination of individually allergenic food items from the diet. Dölp et al.  found thThe findings of the observational studies emphasize a potential role of dietary patterns in ADHD; however, these study designs are unable to establish a causal relationship between diet and ADHD. Moreover, associations between adherence to healthy diets and low prevalence of ADHD do not necessarily imply healthy foods consumed during childhood have a protective effect. The associations between dietary habits and ADHD risk may be caused by other factors that were not recorded. Lifestyle factors  influence dietary patterns and may be important factors in ADHD symptomatology . Even whWhile some studies reported that dietary supplements have beneficial effects, severe methodological limitations were observed, such as extremely short intervention periods, as well as a lack of randomization, placebo, and prospective monitorization of the long-term effects of the supplementation. Increasing evidence suggests that treating ADHD with diet interventions might be particularly useful for specific subgroups of children and adolescents, but more studies about the effects of these diet interventions in ADHD are still needed.From the clinical point of view, restriction and elimination diets can lead to nutritional deficiencies and, consequently, poor growth in children with ADHD, so the nutritional status of these children must be rigorously monitored , and theTo the best of our knowledge, elimination diets as part of ADHD treatment are not currently used in clinical practice; however, they could potentially be useful in specific cases of children resistant to the medication or too young to start it. Nevertheless, these interventions, as for all dietary interventions, do not work for all patients, so a precision/personalized medicine approach must be considered , especiaIn this narrative review, we aimed to summarize the existing evidence for the clinical use of dietary interventions in ADHD patients and review which dietary patterns are most associated with ADHD. As such, we selected and described the most recent high-quality studies within this line of research in order to examine this topic. Nonetheless, as this is a narrative review, we merely provided a description and critical reflection of the current knowledge. Hence, unlike in a systematic review, a detailed search strategy along with an objective assessment of the quality of the studies and the robustness of their results was not carried out. Still, we predominantly reported data from RCTs, systematic reviews, and meta-analyses, which have the highest level of evidence.In ADHD, dietary patterns appear to play a significant role in the risk of developing or aggravating disease symptoms, with unhealthy patterns being most positively associated with this pathology, and healthy eating patterns being inversely associated with ADHD. Altered levels of nutrients, such as vitamin D, iron, zinc, and PUFAs, have also been associated with the aggravation and progression of ADHD. Therefore, diet has emerged as a treatment option for ADHD. Notwithstanding, more robust scientific evidence is required for these dietary interventions to be implemented as part of ADHD therapy.


Neurofeedback (NF) and self-management training (SMT) may be viable treatment options for patients with attention deficit hyperactivity disorder (ADHD) if they alleviate core symptoms, enhance the patients’ self-concept and improve their quality of life (QoL). Aim of the current study is evaluating both interventions accordingly and to test whether specific improvements in core symptoms lead to more general improvements in self-concept and QoL.N = 139 children with ADHD were screened for eligibility, of which 111 fulfilled inclusion criteria and participated in the study in accordance with the CONSORT 2010 statement. These were randomly assigned to NF vs. SMT interventions. Changes from pre- to post-intervention in core ADHD symptoms relying on parent and teacher reports (CONNERS 3) and objective tests (Qb-Test) as well as self-concept (interview with the children) and QoL assessments (using the KINDL-R self-report) were compared between patients receiving NF or SMT.In a psychotherapeutic outpatient clinic in Germany, a total of Significant improvements in ADHD symptoms were achieved similarly in both treatment groups, whilst QoL and self-concept improved after SMT only.This treatment study provides further evidence that SMT and NF may reduce core symptoms, but SMT may also improve patients’ self-concept and QoL and may thus in its current form be the favorable treatment option in naturalistic settings. However, several limitations of the current study implicate that further research is required before definitive conclusions and recommendations for clinical practice can be given.www.clinicaltrials.gov], identifier [NCT01879644].[ Both quality of life (QoL) and self-concept are central intrinsic aspects of health and well-being. The World Health Organization . InFollowing this call for patient-reported outcomes, QoL and psychosocial outcomes have recently come into the focus of research and clinical practice to prove whether a certain therapy improves both ADHD’s clinically relevant cardinal symptoms as well as the children’s general QoL.As these efforts are still quite new, there are some randomized controlled trials (RCTs) of psychopharmacological treatments .via real-time feedback and operant principles), and as the next step utilizing this ability (by transfer) to improve everyday life functioning .n = 22 did not meet inclusion criteria and n = 2 refused participation (see N = 115) was intended to treat, stratified for sex and medication and randomly assigned to SMT (n = 58) or NF (n = 57) interventions. As the study was planned as a naturalistic therapy study, n = 2 subjects assigned to NF had their treatment changed to SMT as recommended by the supervisor, so a total of n = 55 subjects started their NF intervention according to protocol and were included in the modified intention-to-treat (mITT) analyses. Parents of children were also randomized to one of two conditions: either parent training focusing on psychoeducation (PE) or PE involving additional social support (SU).The study took place between 2011 and 2022 in the psychotherapeutic child and adolescent outpatient clinic at Philipps-University Marburg, Department of Clinical Child and Adolescent Psychology. A total of 139 children aged 6–11 years were screened for eligibility, of which tion see . The remn = 49 children completed SMT and n = 46 NF interventions and were included in the per protocol (PP) follow-up (T3) analyses  with SMT . Both inThis RCT study was examined and approved by the local ethics review board of the Department of Psychology of Philipps-University Marburg (AZ: 2010-04) in accordance with the CONSORT 2010 statement  and is rprimary outcome, these include ADHD symptoms assessed via theIn this study, we focused on the primary and secondary outcome measures, as described in the study protocol . As the •Conners-3 scales for parents and teachers that assess the three core symptoms Inattention, Hyperactivity/Impulsivity, as well as executive functioning, learning problems, defiance/aggression, peer- and family relationships, oppositional defiant disorder and conduct disorder rated on a 4-point Likert scale  is a continuous performance test (CPT) with a combined registration of motor activity that quantifies ADHD core symptoms  with the between-subject factor treatment (SMT vs. NF). Treatment outcome was tested in mITT and per-protocol (PP) analyses regarding change(Δ)-scores (T3 − T1) using GLMs with the between-subject factor treatment (SMT vs. NF); significant improvement  was tested for each treatment with confidence intervals of stics 26 .t-values were then tested for significance. Factor loadings between the two groups were also tested for significant differences. We considered a p-value of ≤0.05 to be significant. A limitation of this method is that there is no global goodness-of-fit criterion.In addition, we performed Multigroup Analyses (PLS-MGA) within the Partial Least Squares Structural Equation Modeling framework (PLS-SEM). PLS-SEM can be regarded as a variant of structural equation modeling which uses an ordinary least square regression-based method (OLS) in contrast to the maximum likelihood estimation procedure in covariance-based structural equation modeling. PLS-SEM is a variance-based approach and can handle small sample sizes, complex models, multiple variables, and makes almost no assumptions about the level of measurement of data and their distribution . This isThe internal consistency of latent constructs with more than one manifest variable is measured by the composite reliability and Cronbach’s alpha scores. Values of 0.60 to 0.70 are acceptable in exploratory research, but in more advanced stages of research values of 0.70 to 0.90 should be achieved while values above 0.95 are undesirable, as they signal redundant items . The aven = 1 (1%) to n = 20  missing values. The nearest neighbor approach is fully non-parametric and less prone to model misspecification. These calculations were done with the SmartPLS 3 program (The method of k-nearest neighbor (kNN) using R package VIM  was appl program .(in) = 0.10) from the variables sex, age, IQ, parent-rated Conners DSM-Inattention, and DSM-Hyperactivity/Impulsivity presentation and medication for treating ADHD (psycho-stimulants or atomoxetine).Prediction analyses were conducted separately in the SMT and NF treatment groups, with a regression analysis predicting the parent-rated ADHD Δ change with forward selection of regressors  and medium-sized between-subjects effects . Considering that the difference between SMT and NF may not exceed d = 0.2 and significance level was set at conventional level of α = 0.05, the power we achieved was not larger than 1-β = 0.18 .The available total sample intended to treat at T1 comprised 113 children (77% boys) with ADHD  with a mean age of nine years and 1 month , and an estimated mean WISC-IQ of 104 (range 81–138). The sample size enabled us to detect at least small to medium sized within-subject Δ change scores  < 1, ps > 0.5, see χ2(2) = 1.15, p = 0.56) and almost all primary and secondary outcome parameters , with the exception of trends for parent-rated Conners’ Inattention  = 3.6, p = 0.06, part. η2 = 0.03, more difficulties in patients receiving SMT) and the self-concept interview regarding peers  = 3.2, p = 0.08, part. η2 = 0.03, more positive self-concept in those receiving SMT).The samples receiving SMT and NF did not differ in these demographics  treated with NF. Treatment effects were assessed with Δ change scores, computed as simple differences between measures at T3 minus T1; missing data was imputed, as described above and indicated in The modified ITT analyses comprise data from all participants who received the allocated treatment according to randomization; these are Conners parent-rated ADHD symptoms Δ ADHD-Index, Δ Hyperactivity/Impulsivity (DSM), and Δ Inattention (DSM) were eminent after both interventions  < 1, p > 0.34, part. η2 < 0.01).Regarding primary outcome measures, improved Qb-Test quantified lower Δ Hyperactivity, Δ Impulsivity, and Δ Inattention after SMT whilst following NF only lower Δ Impulsivity was apparent. As a tendency, SMT was followed by stronger Δ Inattention improvements than NF  = 6.5, p = 0.07, part. η2 = 0.03). QoL as assessed with the KINDL revealed improved in Total and in particular regarding Self-Esteem and at school for SMT, whilst no improvements in QoL were eminent after NF  = 4.2, p = 0.04, part. η2 = 0.04, Δ Self-Esteem: F = 4.9, p = 0.03, part. η2 = 0.04). Moreover, the self-concept interview indicated also improvements at school following SMT, but no difference between treatments.Secondary outcome measures also revealed less difficulties after interventions. In particular, the r NF see ; consequThe respective outcomes of the PP analyses with and without imputations of missing values are given in There were no differences between the two groups in Conners’ subscales of parent and teacher ratings, as all differences between path coefficients were not significant. All but the path coefficient of the Conners’ Inattention Teacher ratings signaled significant changes from T1 to T3 within groups  = 6.2, p < 0.01), including parent-rated DSM Inattention  = −2.9, p < 0.01) and parent-rated DSM Hyperactivity/Impulsivity  = −2.2, p = 0.03): patients with more difficulties improved more. NF outcome PP is predicted  = 6.0, p = 0.02) by parent-rated Conners’ DSM-Inattention  = −2.5, p = 0.02), and we noted a greater reduction in symptoms in patients with more Inattention difficulties. Interestingly, sex (both p > 0.32), age (both p > 0.11), IQ (both p > 0.77), and pharmacological treatment for ADHD (both p > 0.12) did not predict treatment outcome following SMT or NF.We analyzed the mITT sample regarding the primary outcome Conners parent-rated Δ ADHD-Index. Treatment outcome for those receiving the SMT PP is predicted by the regression model  = 3.5, p = 0.07, standardized β = 0.24, T(55) = 1.9, p = 0.07); no prediction was significant in the NF group.Improved QoL in KINDL Total scale was only predicted as a tendency in those receiving SMT by parent-rated DSM Inattention behavioral therapies that dwell on self-regulation in children with ADHD regarding their beneficial impact on the core symptoms, QoL and self-concept. To this end, we chose a naturalistic setting to investigate (1) whether SMT and NF interventions lead to improvements in QoL and self-concept that go beyond reducing symptoms, (2) whether the two treatments have a differential impact on the QoL and self-concept, and (3) whether we would be able to predict for whom NT or SMT is especially beneficial in alleviating (a) ADHD core symptoms, (b) in QOL, and (c) in self-concept. We hypothesized that SMT and NF would significantly reduce core ADHD symptoms and improve QoL and self-concept .The main results for the ADHD core symptoms showed on the one hand that particularly the proximal, but unblinded parent-rated Conners’ ADHD symptom scores decreased in both groups compared to baseline, while more distal and probably blinded teacher ratings revealed improved Hyperactivity/Impulsivity only. This discrepancy may also reflect true differences in reference and perception, as teacher rely on more structured situations in light of academic achievement (where hyperactivity/Impulsivity may be more disturbing and get more noticed), whilst parents rate their children in less structured situations at home . On theThe mandatory primary outcome of treatment for ADHD is that it must reduce the core symptoms. In the present study, we observed this effect in the Conners’ parent ratings of DSM Inattention and Hyperactivity/Impulsivity, and in ADHD Index ratings after both treatments. However, these promising findings may be rather unspecific, as parents are entirely aware of the treatments and may overrate treatment benefits, e.g., through placebo effects . SIn addition to behavioral ratings, we also assessed ADHD symptoms with the Qb-Test as a standardized, objective test for ADHD symptoms that may be largely unbiased , 108. ItThe results of the PLS-MGA are generally in line with the GLMs tested above: on the one hand, improvements in primary and secondary outcome measures appeared following both interventions, but differences between SMT and NF were not significant. Besides general agreement, this stands in contrast to SMT’s superiority regarding improved Qb-Attention, Total QoL, and improved self-concept at school detected in the conventional analyses of GLMs. One may speculate whether the parametric analyses had more statistical power, and it is important to consider the violation of the statistical assumptions, though PLS-SEM considers the psychometric properties within the model and is robust against violation.per se are supposed to improve as children grow up and seem to be better in those with higher cognitive ability. One may speculate whether such associations are perhaps not be prominent enough in our sample of relatively young patients within a limited age-range (7–12 years and a SD of about 1.3 years). In contrast, IQ was within normal range and spread largely  and differences according to IQ would have been expected.The prediction of treatment outcome in terms of lower ADHD behavioral problems showed that children with more Inattention difficulties achieved greater improvements after both treatments, while those with elevated Hyperactivity/Impulsivity problems were more effectively treated with SMT. This result is in line with the those of Krepel et al. , who fouSomewhat surprisingly, but because of the quasi-experimental variation in our study difficult to interpret, is the lack of significant beneficial effects of medication on neither SMT nor NF outcomes. Superiority of combined psychopharmacological and behavioral treatment over each element administered alone was indicated by several RCTs, e.g., the MTA-Study in which medication with psychostimulants, behavioral treatment, a combination of both and standard community care were randomly assigned to a large sample of children with ADHD . In contThe study by Rocco et al.  demonstrThere are some indicators that QoL as measured with the KINDL in Total and at school, as well as the self-concept in school situations improved particularly after treatment with SMT, but clearly not after NF. This is in line with Strehl et al. , who alsAttention deficit hyperactivity disorder impacts many areas of everyday life including cognitive, academic, social, and occupational development, as well as the patient’s self-concept and QoL , 111–114In addition, the NF training sessions need stimulating variation, as that can influence motivation . For thiIt is very important that the transfer to everyday life also be integrated within therapy, especially for NF, so that self-control of certain brain activity can be practiced in relevant settings such as school , 115. TrPsychosocial interventions have often implemented psychoeducational parenting training interventions to improve psychosocial outcomes like QoL –52. We iOur RCT was implemented in a psychotherapeutic outpatient clinic with both treatments (SMT and NF) provided (a) by psychologists trained for the study, but not yet licensed trainers and (b) as a high-frequency intervention.First, the KINDL-R and self-concept interview should be interpreted with caution due to their low internal consistency. In the KINDL-R, this is especially true for the emotional, school, and physical scales, and in the self-concept interview, this concerns in particular the Body scale. These scales consist only of four items, which may have made it difficult to achieve internal consistency within an acceptable range.Another aspect is that such high-frequency therapy was challenging for families due to other responsibilities like work, caring for siblings, and other daily commitments, which also contributed to some families dropping out of the study. There were quite a few non-starters or drop-outs in this study, which influenced our sample size and hence statistical power. The available sample size enabled us to detect the expected medium-sized within-subject improvements following SMT and NF, but the expected rather small difference between these two probably effective treatments may remain uncovered. Consequently, our study may suffice for detecting treatment effects, but is clearly limited when it comes to a direct comparison between SMT and NF.In planning this study, we focused on the high personal burden of children with ADHD , and we In addition, we have already discussed the problem associated with our study protocol’s non-blinded setting, as well as the need to involve parents in the therapy of children with ADHD . HoweverDespite the difficulties associated with a naturalistic clinical study in an outpatient setting, we were able to demonstrate that all in all, both NF and SMT treatments are potentially effective in helping children with ADHD to not just reduce their core symptoms, but also to raise their QoL and self-concept. In light of our investigation’s limitations, further research is required before definitive conclusions and recommendations for routine care can be given, but the present report illustrates that therapy guidelines should also consider psychosocial outcomes and predictors of effectiveness when evaluating treatments.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the local ethics review board of the Department of Psychology at the Philipps-University Marburg. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.A-KK collected part of the data, cleaned and analyzed the data, and drafted the manuscript. OH and BA analyzed the data and drafted the manuscript. M-LC drafted the manuscript. HC conceived the study and drafted the manuscript. All authors contributed to the article and approved the submitted version.


ADHD is associated with deficits in executive functions. Cognitive training is a promising nonpharmacological intervention for ADHD, however, there is insufficient evidence to guide the selection of training for individuals with ADHD. This pilot study aims to investigate the efficacy of executive function training targeting key executive dysfunctions in ADHD, compared with general executive function training which targets other executive functions.A total of 127 subjects (6–12 years) diagnosed with ADHD were allocated to receive one of two different cognitive trainings. ADHD symptoms and cognitive functions were evaluated using parent-rated scales and CANTAB cognitive assessments. All participants were required to complete 48 training sessions within a two-month period.94 out of 127 children completed the required training and assessments. Both ADHD executive function training group and general executive function training group showed significant improvement in ADHD symptoms on the ADHD Rating Scale and in executive function on the assessment of CANTAB. There was no significant difference in improvements between the two groups. Subgroup analysis suggested that children who had ADHD-RS total scores less than or equal to 28 at baseline showed greater improvement following ADHD executive function training.This study indicates that cognitive training can improve ADHD symptoms and executive function, with no difference in efficacy between targeted and generalized cognitive training. In addition, individuals with lower symptom severity may benefit more from training targeting key ADHD executive dysfunctions. Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental disorder typically characterized by age-inappropriate inattention and/or hyperactivity-impulsivity . It is oTreatment strategies for ADHD include pharmacological and non-pharmacological interventions. Pharmacological treatment for ADHD is highly efficacious and widely prescribed, however unfavorable side effects  and concCognitive training, which targets executive function deficits associated with ADHD, has been investigated as a potential non-pharmacological treatment of ADHD. Executive function is generally thought to include three core components: inhibition control, working memory and cognitive flexibility; and higher-order cognitive processes such as reasoning, problem solving and planning . PreviouWhile traditional cognitive training uses a pen-and-paper method and relies on in-person therapy with a trained professional, in recent years studies have increasingly validated computerized cognitive training for people with ADHD . ComputeRecently, it has been found that transfer effect of working memory training is significant not only in working memory but also in attention and real-life behaviors , supportThe primary objective of this study was to compare the effects of multiple component training with different executive function combinations on ADHD symptoms and cognitive dysfunctions. In addition, the efficacy and safety of at-home digital cognitive training intervention for eight weeks with ADHD children will be discussed.This study was a clinical trial conducted from April 2021 to January 2022 at Shenzhen Children’s Hospital. This study was approved and reviewed by the Ethics Committee in Shenzhen Children’s Hospital.Participants were recruited from outpatient clinics at Shenzhen Children’s Hospital. From previous literature review , 16 and ADHD children aged 6 to 12 years old were diagnosed by child psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the diagnoses were confirmed using Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children Present-Lifetime version (K-SADS-PL parent version) . Other eAt baseline, participants completed a computer-based cognitive assessment  . SpecifiAt the same time, parents completed the following questionnaires:(1) ADHD-Rating Scale-4th edition (ADHD-RS-IV)  which ev(2) Behavior Rating Inventory of Executive Function (BRIEF)—Parent Form  which ev(3) Conner’s Parent Symptom Questionnaire (PSQ)  which as(4) Strengths and Difficulties Questionnaire (SDQ)  which as(5) Child Behavior Checklist (CBCL)  which asAfter allocation, participants and parents were instructed on software use and training requirements by a remote technical assistant who was unmasked to treatment allocation but did not participate in clinical assessments or communicate with study personnel. Participants were allowed to use either a computer or tablet to undertake the training. Participants in both groups were asked to complete a total of 48 sessions of training within eight weeks at home, or at least 6 sessions of training each week. Each session includes 4 tasks and takes from 25 to 40 min to complete based on individual ability. A reward system which gave out stars based on the child’s performance was utilized to motivate children to engage with the training. Parents would be kindly reminded with a message by the remote technical assistant if their child did not participate in training over 72 h. Post-intervention visits were arranged within one week of completion of 48 training sessions.AET, designed and developed by Infinite Brain Technology, is a battery of several digital cognitive trainings designed to improve impaired executive functions related with ADHD, including attention, working memory, and response inhibition. The AET training tasks were adapted from N-back task, visual-spatial memory task, Schulte Grid, Go/ No-go task, and mental calculation. Difficulty is automatically adjusted to match participants’ progressive skills to give them sufficient cognitive stimulation while not being frustratingly difficult.GET is a multiple component training targeting cognitive functions which are not closely associated with ADHD, such as processing speed, reasoning, and planning. Choice reaction time task, non-symbolic numerical comparison task, path planning task, jigsaw puzzle and continuous performance task are included in the GET training. Required training time and difficulty level adjustment algorithms were the same as the AET group.d effect size.An Intention-To-Treat (ITT) approach was used to compare the treatment effects between the AET group and the GET group. Baseline characteristics and assessment data were summarized using the mean with standard deviation (SD) when appropriate. Normality assumptions were tested using the Shapiro–Wilk test. Baseline assessment scores were compared between the two groups via independent sample t-tests or Mann–Whitney U test if non-parametric. For within-group changes in outcomes, two-tailed paired sample t-tests  were used. For between group comparison of outcomes, independent sample t-tests  were applied to compare changes between groups. Additionally, the standardized mean difference (SMD) was given using Cohen’s Posthoc subgroup analysis was conducted using the post–pre difference of ADHD-RS total scores as the outcome variable. Linear regression was first used to select potential variables for subgroup analysis. Then, model-based recursive partitioning (MOB)  clusterip-values < 0.0017 [0.05/19] were considered significant in the within-group and between-group analyses. All statistical analyses were performed using R statistical software version 4.1.1.All statistical tests were conducted assuming two-tailed contrasts and the alpha significance level at 0.05. Bonferroni corrections were used to counteract multiple comparison problems, only The participant flow chart is presented in Fig. As shown in Table β = − 0.59, p < 0.01) at baseline predicted training performance but age , gender , and ADHD subtype  did not. Among all variables collected at baseline, those with correlation coefficient less than 0.3 were selected as partition variables to avoid potential multicollinearity. A linear regression tree was recursively fitted on the dataset with age as a prognostic factor and other potential partition covariates . Figure In order to further understand whether certain subgroups of patients responded differently to different types of cognitive intervention, we conducted post-hoc subgroup analyses. The result of the linear regression model suggested that ADHD-RS total scores  in the GET group. In the ADHD medication studies, symptom improvement in clinical setting has been usually defined as 30% decrease in symptoms . While tWhen comparing two training paradigms, one focusing on ADHD specific executive dysfunctions and one that does not, we found very little difference in treatment effect between the two groups, suggesting that the effects of comprehensive cognitive training for children with ADHD remains robust despite changes in training component. Therefore, excessive focus on working memory or any single cognitive component seems unnecessary. We assume that higher cognitive functions work as a complex web of interacting components (as discussed in , rather Though the effect of the AET training and GET training seems to be similar, some interesting outcomes have been found upon further subgroup identification analysis. The result indicates that treatment has different impacts on specific subgroups. Individuals with ADHD-RS total scores below 28 could benefit more from AET, while GET is more beneficial for subjects with ADHD-RS total scores above 28. These unexpected results suggest that people with ADHD may not benefit equally from cognitive training targeting key executive dysfunctions in ADHD. In addition, ADHD is characterized by neurocognitive heterogeneity , therefoThere are several limitations to the current study. First, we did not include a negative control group, therefore we are unable to ascertain the extent to which placebo effects affected the overall treatment effect. The aim of the study, however, is not to validate the treatment efficacy of cognitive training, but to compare the effect of two different multiple component trainings, therefore negative control group is not necessary for our study question. Second, the length of training was not strictly limited in this study, resulting in some participants exceeding the training period of two months. From the results of our linear regression model, we found that training duration was not predictive of ADHD-RS total scores, therefore this issue has limited effect on the study conclusion. Next, we did not investigate the long-term effect of training. Previous studies have shown that cognitive training has long-lasting benefits for children with ADHD upon follow-up . The preIn all, the present study investigates the effects of two different computerized multiple component cognitive training in children with ADHD. The present results suggest that different multiple component training targeting various executive dysfunctions may be effective to improve cognitive function and ADHD symptoms. Subgroup identification found that baseline disease severity as measured by ADHD-RS may predict treatment benefit for individuals. These results suggest that different subgroups may benefit from different multiple component training, which warrants further study. Overall, cognitive training is a promising intervention that improves executive function and symptoms in children with ADHD. In order to provide individualized treatment for children with ADHD, more research is required to better understand individual responses to different cognitive interventions.


Since 2021, pharmacists in Poland have been authorised to administer vaccinations against COVID-19, which is of particular significance in the efforts towards preventing the spread of the pandemic. The primary objective of this study was to evaluate the patients’ satisfaction with delivering vaccinations through national vaccination centres.This study was conducted in 2021. The research tool was an anonymous questionnaire distributed to patients after vaccination. The questionnaire was developed specifically for the purpose of the study. Ultimately, 628 patients participated in this study.Nearly 97% of the respondents agreed that the administration of vaccinations by pharmacists had been convenient, and pharmacists possessed the relevant skills to provide this service. Almost 90% of the respondents expressed their readiness to be vaccinated by pharmacists again. Nearly all the respondents indicated that pharmacists should also provide other vaccinations.Patients in Poland have a positive attitude toward vaccinations administered by pharmacists in national vaccination centres.The online version contains supplementary material available at 10.1186/s12913-022-08720-w. Since 2021, pharmacists in Poland have been authorised to administer vaccinations against COVID-19, which is of particular significance in view of the spreading pandemic. This was the first opportunity for Polish pharmacists to provide a vaccination service. At the end of December 2021, more than 3.5 million people in Poland have been infected with COVID-19 (about 10% of the population), and nearly 80 thousand people have died [Protective vaccinations administered by pharmacists have been common for many years in many countries worldwide, e.g. Great Britain, Canada and the USA –5. LiterIn Poland, pharmacists with appropriate qualifications are authorised to qualify for and administer vaccinations. These qualifications are acquired at a two-stage course that includes theoretical and practical training. The theoretical part concerns medical (e.g. indications and contraindications for vaccinations) and technical/informatical  issues. In the first weeks after obtaining the right to administer vaccinations, several thousand pharmacists in Poland completed this course .Since the COVID-19 pandemic, vaccination centers have been established in Poland. This was to increase the availability of the vaccination service for patients and to vaccinate as many patients as possible in the shortest possible time. Until now, vaccinations were performed in medical institutions, mainly by nurses.Given the above, the primary objective of this study was to evaluate patient satisfaction with vaccinations administered by pharmacists in national vaccination centres, while a secondary objective was to indicate the influence of the basic sociodemographic variables on patient satisfaction with the vaccinations.This study of the opinions of patients was carried out in the period of May to September 2021. The research tool was an anonymous questionnaire developed for the purposes of this study consisting of 4 questions on patient satisfaction with vaccinations, 3 questions on the symptoms of COVID-19 and any adverse events following immunisation, as well as personal data. These required a single-choice answer from ready multiple-choices (apart from 2 open questions). The questionnaire developed for this study is provided as Additional file The questionnaire was distributed to patients after vaccination. Each patient vaccinated by a pharmacist received the questionnaire immediately after vaccination. The inclusion criteria for patients were: age over 13 and literacy. Ultimately, 628 patients took part in the study. Patients filled in the questionnaire in the waiting room and gave it to the indicated person. Each patient who received the questionnaire completed it. If the respondent was a minor (a person under 13 years of age), consent to the study was obtained from the parent who accompanied the child to the vaccination.The study was approved by the Bioethics Committee of the National Geriatrics, Reumatology and Rehabilitation Institute in Warsaw (decision no. KBT – 3/3/2021).www.statsoft.com and Excel.The statistical analyses have been performed using the statistical suite StatSoft. Inc. (2014). STATISTICA . version 12.0. The quantitive variables were characterized by the arithmetic mean of standard deviation or median or max/min (range) and 95% confidence interval. The qualitative variables were presented with the use of count and percentage.p = 0.05 has been used.In order to check if a quantitive variable derives from a population of normal distribution the W Shapiro-Wilk test has been used. Whereas to prove the hypotheses on homogeneity of variances Leven (Brown-Forsythe) test has been utilized. In order to determine dependence, strength and direction between variables, correlation analysis was used by determining the Pearson or Spearman’s correlation coefficients. In all the calculations the statistical significance level of The study group distribution was 52% women and 48% men. The mean age of the respondents was 31.8 years. The largest group of respondents lived in cities above 500 thousand inhabitants (80.5%). Slightly more than half of the respondents declared being single (53.2%). Over 61% of the respondents had higher education (Table The respondents largely agreed that vaccinations administered by pharmacists were convenient (the sum of responses ‘Agree’ and ‘Strongly agree’ was 96.9%). Nearly 97% of the respondents were of the opinion that pharmacists possessed the appropriate skills to administer vaccinations. Almost 90% of the respondents indicated that they would get vaccinated by pharmacists if it were possible. A similar percentage of respondents would like pharmacists to also be able to administer other vaccinations Table .Table 2TR = -0.10, p = 0.0197). A similar dependency was recorded in relations to the increase in education . In addition, as education increased, the scale regarding the opinion of having the skills to provide vaccinations decreased , while the scale regarding the possibility of being vaccinated again by a pharmacist increased  . Married respondents and those living in a partnership were significantly more likely to have their next vaccination administered by a pharmacist (p = 0.0134).As far as sex is concerned, women were significantly more likely to have their next vaccination administered by a pharmacist (p = 0.0192), yet SARS-CoV-2 had been detected in 6 out of 73 respondents with COVID-19 symptoms.In the past 6 months, 11.7% of the respondents developed symptoms of COVID-19 Table  – fever In the past 6 months, slightly more than 5% of the respondents took sick leave due to coronavirus symptoms, with a mean length of 9.1 days (SD = 15.5).p = 0.0001). Patients who did not report adverse events following immunisation were significantly older than those who reported these events (p = 0.0045).Nearly 7% of the respondents experienced adverse events following immunisation: a sore arm (25.6%), fatigue (18.6%), headache (16.3%) and fever (16.3%). Statistical analysis showed that women significantly more often than men experienced adverse events following immunisation  was about 97%, which is similar to studies carried out in other countries, e.g. Australia  and EstoConsidering the medical data of the respondents, pharmacist engagement in providing vaccinations as part of pharmaceutical care is particularly significant. In our study group, nearly 12% of the respondents developed symptoms that could indicate COVID-19, yet the test confirmed this infection in only a few of them. In the case of symptoms, many of those respondents had the opportunity to receive professional pharmaceutical help, e.g. an appropriate selection of medications in relation to symptoms, which could largely shorten the length of sick leave and thus reduce global economic and social costs. Similarly, pharmacists with extensive knowledge of medications can to a large extent help patients deal with the adverse events experienced by nearly 7% of the respondents.While some studies indicate that it is mainly women who get vaccinated by pharmacists and the results of studies are differentiated by multiple demographic variables , our stuConsidering the number and availability of pharmacists in Poland, it seems that this group of medical staff can greatly impact public health. Pharmacies  are frequently the patients’ first contact points with healthcare staff. For this reason, activities performed by pharmacists, particularly within health promotion and prophylaxis, can largely improve patient health results , 17.Previous data on vaccinations in Poland indicate a very low vaccination coverage level. For example, in the case of flu, it is about 6-7% , compareThe willingness of pharmacists in Poland  and otheThe results of our study indicate high patient satisfaction with the services provided by pharmacists in vaccination centers. Nevertheless, it is possible that the results may not represent a material impact if a larger, random sample, was used.Another limitation is the lack of knowledge of how many people in Poland were vaccinated by pharmacists. Therefore, we do not know which sample of patients we included in our study.Patients in Poland are satisfied with vaccinations administered by pharmacists who in their opinion are properly qualified for this service. These results are of great importance, taking into account the fact that Polish pharmacists have recently been able to perform the vaccination service. The vast majority of the respondents indicated their trust in pharmacists and their willingness to have their next vaccination administered by a pharmacist. Pharmacists are a large and accessible professional group ready to provide further vaccinations. Expanding pharmaceutical services with vaccinations administered by pharmacists in Poland can impact the overall vaccination coverage level and relieve the burden on other medical professions.Additional file 1. Questionnaire


Adults may continue suffering AHDH symptoms after this condition is recognized and typified in children. Different works provide evidence that adults have an even more complicated variety of psychiatric disorders than children, as an increased risk of problems stemming from substance abuse, depression, anxiety, increased risk of traffic accidents, and also sexual transmission diseases.There was known that adults could continue suffering symptoms derived from his infantile ADHD. We wonder if the majority of the young males derived to our consultation present compatible symptoms with adult ADHD. This condition promotes the onset of substance use and may lead to latent psychosis onset.We analyzed 39 patients derived by suspicion of psychiatric pathology, aged between 17 and 35. They stem to clinical psychology for study of features of personality (Million Questionnaire). Another questionnaire was used also autoapplied for sifted of the ADHD in adults (ASRS_V1:1). According to the criteria DSM-IV TR, the patient had moderate symptoms of ADHD if it was fulfilling 6 or more diagnostic criteria according to their answers in the screening questionnaire.The results supported the existence of impulsivity, aggression, irritability, problems with compliance and substance abuse.ADHD is not only a problem of distractibility or worry, but a deeper and extensive alteration caused by the deterioration of a set of cerebral activities. An early treatment in the childhood could prevent devastating consequences for their development, since they include the majority of the functional areas of the patient and it impedes their later social and labor adjustment.No significant relationships.


The Bangladeshi community living in the East London borough of Tower Hamlets is one of the UK's most socioeconomically deprived communities. Despite being a highly disadvantaged ethnic group with suboptimal health, the data suggests the uptake of several childhood vaccinations including the MMR vaccine is notably higher amongst this group, relative to other ethnic groups in Tower Hamlets.This study employs a qualitative research design. One-to-one, semi-structured interviews will be conducted with Bangladeshi parents, alongside relevant healthcare and public health professionals involved in vaccination delivery in Tower Hamlets to understand the barriers and enablers to childhood vaccinations. Interviews will be conducted in English by the researcher or in Bengali/Sylheti using an interpreter. Interviews will be audio-recorded, transcribed, translated and analysed using a thematic analysis. The socioecological model will be utilised as a theoretical framework to guide the data collection and analysis.The preliminary results indicate parental trust in the safety of vaccinations, perceived health importance of childhood vaccinations, ease in accessibility and positive attitudes towards vaccinations within the community are notable enablers. Regarding barriers, parents have expressed reluctance on religious grounds towards childhood vaccinations which contain animal derivatives. The data also suggests differences exist between immigrant and non-immigrant parents in the decision-making process to undertake the vaccinations, with non-immigrant parents demonstrating a higher level of agency in their decision-making.The study provides valuable insight into the barriers and enablers for childhood vaccinations amongst the Bangladeshi community in Tower Hamlets. This data may inform tailored initiatives to improve childhood vaccination uptake amongst other underserved communities with suboptimal uptake.


There is widespread concern that elections polarize societies along group lines. Meanwhile, enmity between religious communities is rising globally—a phenomenon often attributed to the dynamics of electoral competition. I examine one implication of this broader hypothesis by testing for the presence of electoral cycles in religious intolerance. Pooling responses from 1,086 country-level “values and attitudes” surveys, I evaluate whether people interviewed shortly before or after national elections are more likely to express intolerant attitudes toward those belonging to different religions or sects than people interviewed outside of election seasons. I find no statistical evidence that this is the case, either overall or among theoretically relevant subpopulations. Individuals interviewed close to elections also do not voice greater distrust in other people generally. Mass elections are key mechanisms for collective decision-making. But they are also blamed for creating intergroup enmity, particularly while they are underway; politicians use polarizing campaign strategies, and losing sides feel resentful and marginalized after results are announced. I investigate the impact of election proximity–that is, closeness to elections in time–on social cleavages related to religion, a salient form of group identity worldwide. Integrating data from ∼1.2 million respondents across 25 cross-country survey series, I find no evidence that people interviewed shortly before or after national elections are more likely to express negative attitudes toward religious outgroups than those interviewed at other times. Subgroup analysis reveals little heterogeneity, including by levels of political competition. Generalized social trust, too, is unaffected by election calendars. Elections may not pose as great a risk to social cohesion as is commonly feared. Do elections strengthen or undermine social cohesion? On the one hand, political scientists have long argued that inclusive democratic institutions represent humanity’s best mechanism for collective decision-making. They enable disagreements between individuals and communities to be resolved peacefully, and in a manner broadly acknowledged as legitimate –4. They Yet, others stress the potential for mass elections, and the popularity campaigns they necessitate, to become dangerous flashpoints—especially during the period when they are happening –8. “[E]lThis paper aims to rigorously test, for a wide spectrum of cases, whether the time periods immediately surrounding elections see greater religious intolerance than other time periods. In particular, I investigate whether election campaigns and their aftermath catalyze popular hostility toward religious outgroups, meaning those who subscribe to a religion different from one’s own. Religion, definable as “a unified system of beliefs and practices relative to sacred things” , is far A 2012 Pew estimate suggests that 16% of the global population is unaffiliated with a formal religion, although even “many of the unaffiliated hold some religious or spiritual beliefs;” see http://www.pewrsr.ch/3H9tLJ5. Religious conflict structures political competition in both low- and high-income settings. Violence has been perpetrated in the name of God for millennia .Case studies give ample reason to suspect that election seasons exacerbate interreligious group tensions. Poland’s first postcommunist polls saw a surge in antisemitism . Hindu–MEmpirically, there are challenges in ascertaining whether a systematic relationship exists between elections and religious intolerance. Few countries keep a running tally of the attitudes of their citizens toward various religious communities, and isolating a causal connection is a tall order. In seeking to overcome these hurdles, this paper asks whether levels of religious intolerance fluctuate within countries when elections are near in time. Importantly, I do not set out to estimate the effect of elections per se. Since most countries today hold elections, a key question is how, counterfactually, religious intolerance would look had elections never been instituted. Unfortunately, this question is unlikely to be answerable: comparing average intolerance rates across countries that do and do not host elections runs clear risks of confounding and reverse causality, and, so far, no credible natural experiment has been proposed. I later discuss how learning about election cycles in religious intolerance might nevertheless shed some light on the matter of elections’ overall impacts.SI Appendix, Tables S8). I collect responses to all questions in which sampled individuals were asked to cast a personal judgment about a member of a religious or sectarian group different from their own. Questions cover trust in members of religious outgroups, favorability toward them, levels of comfort or discomfort in their presence, and willingness to have them as neighbors, friends, work acquaintances, citizens, or family members. To standardize, I recode all answers to take the value of one if the respondent offered an intolerant attitude toward the religious group they were asked about and zero if they offered a neutral or tolerant attitude . This yields approximately 2.6 million date-stamped, consistently coded question-items, which come from 1,225,173 unique interviews conducted in 150 countries—1,086 country-level surveys in total—between the years 1982 and 2022. To my knowledge, this constitutes the largest integrated body of microdata on religious intolerance compiled to date.I identify and harmonize 25 multinational “attitudes and values” survey series that measure intolerance toward religious outgroups  socially divisive campaigning concentrates in the months just before an election takes place, as politicians try to sway voters’ minds; and ii) feelings of resentment and exclusion among losing-side supporters—as well as any residual bad blood from campaigns—will be most intense in the months just after the declaration of a winner. If elections engender group-wise animus, those interviewed shortly before or after an election can thus be expected to express more negative sentiments toward religious outgroups than those interviewed further from an election in time.SI Appendix, Table S11)]. Observations are respondent/question-items. The benchmark model controls for country, question-type, and question-target fixed effects,SI Appendix, Table S3) as well as rates of nonresponse to questions about religious tolerance . While estimates are valid only for the sample at hand, the data are encompassing. There is no within-country evidence that elections marred by violence and civilian deaths are either more or less likely to have had surveys fielded close to them in time than peaceful elections . I later show that the results are unchanged after omitting elections whose timing may have been strategic . While the present design cannot disentangle these parts, both are of interest, and both may be shifted by the election context. Perceptions of social norms have been shown to influence behaviors , 26. HisSI Appendix, Table S5).Do individuals express more intolerant attitudes toward religious outgroups when elections are close in time? Across a raft of specifications, I find no evidence to support this claim. SI Appendix, Fig. S1). I estimate the effects for the four largest global survey series separately; strikingly, there are statistically significant effects in opposite directions for two of the biggest series , underlining the value of meta-studies like this one. Results do not appreciably vary across global regions  nor across the religious groups detailed in the question-text  Conclusions are unchanged when entering pre- and post-election period indicators jointly into the regression . There is no perceptible relationship between the outcome and a continuous coding of the treatment variable .I assess the sensitivity of the results to key analytical decisions. In a specification curve analysis, I show that the study’s conclusions do not hinge on the choice of weighting scheme, fixed effects, standard-error clustering level, or on the exclusion of less precisely dated observations . I now summarize the findings in accordance with the numbered headings provided in The results show that attitudes toward religious outgroups do not track elections. But the aggregate findings may mask subgroup variability. We might expect election cycles in religious intolerance to be manifest in democracies, where opposition parties have the opportunity to contest freely, and not in electoral autocracies, where campaigns tend to be tightly choreographed by authoritarian incumbents. However, the estimated effect of election proximity is null for democracies and autocracies.By a similar logic, election proximity effects may be present in electorally competitive environments, where campaign stakes are high and elite incentives to lean on polarization strategies are strongest, but not in uncompetitive ones. Yet, the results turn out to be null for both subgroups.Proportional representation has been portrayed as an election rule that fosters consensus-building, whereas plurality voting systems are said to encourage majoritarianism . ElectioPolitical federalism might promote the emergence of regional identities and so lessen the significance of “macro cleavages” like religion . AlternaThe existence of major religious parties within the national political system might bolster the likelihood that religion becomes politicized in the lead-up to elections; it could also proxy for the greater salience of religion in politics generally. No such pattern is evident in the data, however.Countries with a previous history of violent religious conflict—involving 25 or more battle deaths—do not see electoral cycles in religious intolerance nor do countries without such a history.Results are similar when grouping countries by the terciles of intolerance depicted in Election proximity effects are not apparent in countries with either higher or lower degrees of religious fractionalization (the probability that two randomly selected people from a country do not belong to the same religion) suggesting that the demographic balance between religious groups is not a conditioning factor.The same is true when partitioning the sample according to a measure of religious polarization, for which higher values indicate that the distribution of religious groups is more bipolar.The coefficient on the treatment indicator remains statistically insignificant when restricting the sample to individuals interviewed between two elections that were both held on time, according to a preset calendar . This analysis addresses the possibility that election timing could be endogenous to the occurrence of waves of religious intolerance in certain cases—e.g., if elections are postponed because of social conflict or, inversely, called early because far-right incumbents think they might profit from religious unrest.Being surveyed 6 mo before an election does not measurably increase expressions of religious intolerance in either higher- or lower-income countries.There are no statistically significant effects of being interviewed just before an election, regardless of whether the respondent is affiliated with their country’s plurality religion or not.There are no discernible effects of electoral proximity for respondents with more or less education.SI Appendix, Fig. S11, while SI Appendix, Table S7 presents estimates of subgroup effects for democratic countries only. The null results persist in virtually all models.Heterogeneous treatment effects for the other treatment indicators are displayed in One explanation for the slate of overwhelmingly insignificant effects is that religious divisions are not sufficiently entrenched in enough countries for elections to make a difference. On this theory, cyclical effects would be apparent in an investigation centered on other, more locally relevant ethnic cleavages .I underscore that this possibility does not undermine my central finding of elections’ noneffect on religious intolerance, a domain of foremost policy interest, notably within the United Nations and the US government.SI Appendix, Fig. S8 further demonstrates either no effects or scattered negative effects for subgroups based on higher (versus lower) levels of ethnic, linguistic, and religious fractionalization, answering the concern that generalized social distrust may pick up attitudes toward in-groups in places with clear ethnic majorities. Taken together, the evidence on this extra outcome broadens the case for elections’ minimal social effects.SI Appendix, Table S2), I find no backing for that hypothesis here.The middle and bottom panels of 31Tajfel famously concluded that “[o]utgroup discrimination is extraordinarily easy to trigger” . As foca35What are we to make of the clear if unexpected finding that election timing is unrelated to hostility toward people aligned with other religions? It could be that outgroup prejudice is “hardwired”: the product of childhood socialization and thus not amenable to short-term flux. However, this account is hard to square with randomized controlled trials showing that individual prejudice against outgroups responds quickly, inter alia, to brief in-person conversations , radio sAnother explanation is that, in an era of mass communications, electioneering—and exposure to it—is not confined to the immediate election period but is a near-permanent fixture of daily life in highly connected societies. Accordingly, the absence of cyclical patterns in attitudes toward religious outgroups may reflect a ceiling effect. “Ethnic entrepreneurs” are perennially fanning the flames of communal animosity with the next election in mind, and grievances from past group disputes do not dim. Note, this line of argument would also be consistent with the view that prolonged experience of elections may aggravate religious intolerance—compared to a world with no elections—even though within-country election cycles in intolerance do not occur. There are reasons to be skeptical, however. Cutting against the claim, the mean rate at which individuals offer a religiously intolerant attitude is 31% in the sample, indicating plentiful room for growth. Next, even in the most politicized countries, there is a step-change in the volume of campaigning that goes on just before the polling day; rates of partisan self-identification rise around that time too . If elecSI Appendix, Table S1). SI Appendix, Fig. S13 plots histograms from a granular investigation of parties in 88 countries, from which I estimate that the mean national vote share secured by parties dependent on various forms of religious mobilization lay between 25% and 30% when the expert survey was taken in 2008-09. Religion, then, structures partisan coalitions in numerous countries. In conjunction with the lack of any consistent pattern of subgroup effects according to the variables just noted , we are left with the conclusion that election cycles in religious intolerance do not systematically materialize even in circumstances where religious and partisan cleavages align.The significance of political party bases also merits consideration. For societies characterized by cross-cutting cleavages, Posner  theorizeA simpler rationalization is that most elections in most countries are not searingly contentious events. For better or worse, many citizens take little interest in formal politics. Those who cast ballots routinely do so for moderate parties—not always because of group animosity but because of “bread and butter” issues. While religious parties flourish in many countries, other states enforce laws that ban ethnoreligious parties and identity-based campaign messaging altogether . AuthoriTo be sure, the null estimated effects should not be taken to imply that elections never have adverse social ramifications. Studies have shown that victory by extremist candidates can embolden attitudes against minorities , 48. NarI describe the empirical strategy for estimating the relationship between temporal proximity to elections and expressions of religious intolerance.SI Appendix, Table S8. To find such surveys, I relied on the “Historical Overview of International Data Resources” maintained by the Gesellschaft Sozialwissenschaftlicher Infrastruktureinrichtungen  and the extensive survey list maintained by the Association of Religion Data Archives (available at: bit.ly/3yt1Q3T). Surveys that were considered but not included are listed in SI Appendix, Table S9, which also gives the reasons for surveys’ exclusion.I combine data from (to the best of my knowledge) all multinational “attitudes and values” survey series that a) have asked questions about individuals’ attitudes toward members of a religious community that is not their own; b) make respondent-level microdata freely and publicly available online; and c) gathered survey data after the year 1980. Included survey series, along with brief descriptions, are listed in Most included surveys were fielded among nationally representative samples of adults; others were administered to representative samples of well-defined demographic subpopulations . I opted not to include surveys or survey series carried out in a single country owing to concerns about data consistency and quality. I excluded respondents below the age of 15. Eighty-nine percent of subjects in the integrated dataset were interviewed in-person; the rest were interviewed by phone, mail, or through the internet.I found that attitudes and values surveys have quizzed respondents about personal tolerance toward religious outgroups in four ways: i) by asking about respondents’ willingness to accept a member of a religious outgroup occupying a social role near to or far from them—as a family member, friend, neighbor, work-acquaintance, or citizen ; or by asking about respondents’ ii) trust in, iii) favorability toward, and iv) level of comfort with members of other religious groups. The analysis dataset pools together all four question types.Whereas some question-wordings inquire about respondents’ attitudes toward “people of a different religion,” others specify a “target religion” . In instances where a target religion is stated, I only code outcomes for individuals who personally identify with a religion that is different from the target religion mentioned, ensuring that observations always capture judgments about religious outgroups (from the respondent’s perspective). I omit from the main estimation sample individuals who state that they have no religion—including atheists and agnostics—since it does not make sense for them to have attitudes toward someone of a different faith.A small minority of questions measure attitudes toward religious sects/denominations  rather than whole religions. Since those questions still pertain to views about religious outgroups, I include them in the dataset.Many surveys queried respondents about their attitudes toward multiple religious outgroups . Each such response is assigned its own row in the analysis dataset; thus the unit of analysis in the main statistical model is the respondent/question-item. Analysis weights and standard-error clustering account for this feature of the dataset construction.The main analyses use binary treatments built from two data sources. First, election dates come from the National Elections Across Democracy and Autocracy (NELDA) dataset, which provides a complete list of all national-level executive, legislative, and constituent assembly elections held between 1945 and 2020. Both democratic elections as well as elections held under autocratic or hybrid regimes appear on the list. I consider all national elections in the main analysis. Subgroup tests break down estimated effects by regime type.SI Appendix, Fig. S1).Second, survey dates come from the surveys themselves. There is variability in the precision with which individual survey dates are recorded, both across and within survey series. For 58% of respondents in the sample, the original datasets give either the exact day or month on which a survey was administered. For the remaining cases, the survey organizations’ technical documentation only provides the range of dates between which surveys were fielded in each country . Where I lack the exact individual dates, therefore, I merge this information into the dataset and impute the individual survey date using the midpoint of the given date-range. Note, the median size of the date ranges for this segment of the sample is just 30 d, meaning that any imprecision is quite minimal. Nonetheless, I probe the sensitivity of the results to dropping observations associated with wider date ranges .Finally, I calculate the number of days between the date on which an individual was surveyed and a) the date of the next upcoming national election, and b) the date of the most recent (prior) national election. Using these quantities, I define nine treatment variables: indicators for whether an individual was surveyed 3, 6, or 9 mo i) before an election, ii) after an election, and iii) before or after an election. I also code a continuous measure describing what percentage way through the current election cycle the interview took place . T is the (variously specified) treatment indicator for whether the question-response was recorded within a given time-window surrounding an election, and β is the estimated effect of election proximity, under the identifying assumptions. Standard errors are clustered at the level of the country/election cycle. Importantly, the number of outcomes measured per country/election cycle varies by how many surveys happen to have been administered at a given time and place, and how many questions about religious outgroups happen to have been asked. I weight each observation by 1 divided by the number of complete question item-level outcomes from that country/election cycle, such that each country/election cycle contributes equally in estimation.Here, Appendix 01 (PDF)Click here for additional data file.