Parents reported on school factors and HLD; pre-existing anxiety and co-occurring difficulties; anxiety, ADHD, and oppositional symptoms; demographics; and medications. Parents retrospectively reported more children often looked forward to school pre-pandemic, than during the pandemic. Anxiety symptoms, but not pre-existing anxiety disorder status, were associated with HLD after accounting for covariates. ADHD inattention symptoms were also associated with HLD. Results support recommendations to continue pre-pandemic supports to assist with ADHD symptoms during home learning, and strategies/supports for families are discussed.The COVID-19 pandemic has markedly impacted functioning for children and adolescents including those with attention-deficit/hyperactivity disorder (ADHD). We explored home learning difficulties (HLD) during COVID-19 restrictions in Australian children (aged 5–17) with ADHD, aiming to: (1) describe home learning experiences, and (2) examine associations between child anxiety  and HLD. Baseline data from the longitudinal ADHD COVID-19 Survey were used (The online version contains supplementary material available at 10.1007/s10578-022-01338-3. The COVID-19 pandemic has profoundly disrupted daily life for children and adolescents (henceforth ‘children’) and their families. Emerging literature suggests that clinical groups such as children with neurodevelopmental conditions, including Attention-Deficit/Hyperactivity Disorder (ADHD) and mental health challenges, may be more negatively impacted by the pandemic than peers without pre-existing conditions . It is iSchool and learning present challenges for children with ADHD in the traditional school environment, relative to children without ADHD –7. The cDuring the pandemic, children in Australia, and in many countries around the world, were required by the government to swiftly transition to learning remotely from home (henceforth ‘home learning’) unless they had an approved exemption, such as a parent working in essential healthcare. While it is likely all children have faced challenges related to this rapid and unexpected shift , this trN = 238; ages 15–17) indicated that almost a quarter of the sample were reported to have not engaged in any home learning during the survey period. Of the adolescents who had engaged in home learning, almost three-quarters spent an average of three or fewer total hours of schoolwork on school days; below the recommended quantity to learn new material and reinforce material learnt previously (3–4 h of learning activities for grades 7–12 students in United States guidance) [N = 49; ages 6–17 years) and caregivers in rural United States showed that most were not receiving the recommended quantity of direct online instruction; and that the majority of support services  had been discontinued during home learning [The small body of existing research on home learning experiences in children with ADHD suggests that children with ADHD and their families have experienced greater home learning difficulties (HLD) compared to children without ADHD during the pandemic , 13. Oneuidance) , which mN = 606; ages 6–17 years) [HLD were also reported in a survey of parent perceptions of home learning experiences among three combined samples, comprised of children and adolescents with and without ADHD from the United States, and the Australian sample used in this study (7 years) . Study rN = 49; ages 6–17 years) found that higher adaptive coping skills in the children were associated with greater total daily schoolwork completed, while parent employment was associated with more HLD [Understanding factors predictive of HLD in children with ADHD may aid efforts to identify at-risk children requiring support both during- and post-pandemic, as well as potential protective factors. The aforementioned study of children with neurodevelopmental disorders and caregivers in rural United States , quantity and timing of schoolwork and attention, and enthusiasm for school and home learning, before and during the pandemic.Examine the association between anxiety  and HLD. It was hypothesized that anxiety symptom severity, as well as pre-existing anxiety disorder status (present/not present), would be associated with HLD scores, before and after adjusting for age, gender, learning/speech/language disorders, ASD, medication use, oppositional and ADHD symptoms, and socio-economic status.The purpose of the current study was to examine home learning experiences in children with ADHD during the COVID-19 pandemic, and the association between anxiety and HLD. Understanding learning arrangements and experiences for this population was anticipated to give background context to the examination of anxiety and HLD in children with ADHD. HLD was indicated by a combination of parent and child difficulties, as well as parent confidence in facilitating home learning. Specifically, in a sample of children with ADHD aged 5–17 years during the COVID-19 pandemic, this study aimed to:This study used baseline data from the ADHD COVID-19 Survey, a longitudinal study completed by parents of children aged 5–17 years with ADHD during the COVID-19 pandemic . During n = 122), which meant that families who had not engaged in any home learning were not included. There were no systematic differences between those included and excluded from the sample on key characteristics (see Supplementary Table 1).Two hundred and twenty-one families consented to participate in the study. Eligible parents were living in Australia, were at least 18 years old, and had a child aged 5–17 years at baseline who had been diagnosed with and/or treated for ADHD. For families with more than one child with ADHD, parents completed the survey about their eldest child within the age range. Participants were included in analyses if they provided data on all three measures of interest: home learning difficulties (HLD), anxiety symptoms and pre-existing anxiety disorder measures (SD = 3.04) and 74.6% were male . This study was advertised by Australian ADHD organisations and support groups, who emailed the advertisement to families and posted it on their social media sites. Interested parents read the participant information and provided informed consent to participate in a longitudinal online survey. Data were collected and managed using the Research Electronic Data Capture (REDCap) software platform , 32.M = 1,000, SD = 100), where higher scores indicate relative socio-economic advantage.Parents reported on child characteristics , and on their individual and family characteristics . Study-designed questions captured the child’s current medications, and were collapsed into an antidepressant medication , and a stimulant and/or non-stimulant medication for ADHD . The Socio-Economic Indexes for Areas (SEIFA) is presented for participants, which ranks areas of Australia according to the relative level of socio-economic disadvantage based on geographical area . SEIFA sParents reported (yes/no) whether their child had been diagnosed with any of the following: anxiety disorders, depressive disorder, ASD, Oppositional Defiant Disorder, Conduct Disorder, Obsessive–Compulsive Disorder, learning/speech/language disorders, and Tourette’s Syndrome/Tics.Parents reported their child’s anxiety symptoms using the Brief Spence Children’s Anxiety Scale – Parent Report (SCAS-P-8) . This 8-The Swanson, Nolan and Pelham Rating Scale (SNAP-IV)  is a 26-Parents completed home learning questions if they reported that their child was school age, had stopped attending school in person or had participated in any online learning in the past fortnight. Questions were from the Home Adjustment to COVID-19 Scale (HACS)   including percentage of children who looked forward to going to school (pre-pandemic) and to home learning (during the pandemic), arrangements for classes and resources, quantity and time of schoolwork completed and time of day when child appears to best attend to schoolwork. Fisher’s exact test was used for between-groups analysis of reported hours of schoolwork completed for primary versus secondary students. Associations between anxiety symptom severity and HLD scores and pre-existing anxiety disorder status  with HLD scores (aim 2) were examined using unadjusted and adjusted linear regression analyses. Adjusted models accounted for ADHD inattention and hyperactivity/impulsivity symptoms, medication use, age, socio-economic index, oppositional symptoms, gender, ASD and learning/speech/language disorder status. Correlation coefficients between variables are also reported. Variance inflation factor and tolerance diagnostic statistics indicated no evidence of multicollinearity. A sensitivity analysis was also conducted, excluding HLD items overlapping with ADHD-I items .n = 63) of children with ADHD looked forward to going to school, compared to parents reporting that 21.3% (n = 26) of children had been looking forward to home learning on most days during the pandemic. Furthermore, prior to the pandemic, 20.5% (n = 25) of children with ADHD rarely or never looked forward to going to school, compared to 50.8% (n = 62) who rarely or never looked forward to home learning during the pandemic.Parents reported retrospectively that on most days prior to the pandemic, 51.6% . Parents reported on the average hours of schoolwork their child was completing at home on school days, with a quarter (24.6%) completing zero or less than one hour, and half (50.8%) completing 2–4 h. The average hours of schoolwork completed at home on school days did not differ between primary and secondary students (p = .090). Most parents (77.5%) reported the time of day when their child attends best to home learning was the morning, and most reported their child completed most of their work at home in the mornings (61.3%). Most parents reported receiving home learning materials from their child’s school via online portals (83.6%).Table M, SD) are provided in Supplementary Table 2 and correlations between variables of interest can be found in Supplementary Table 3.Details of HLD measure scores for this sample  as outcome variables (see Supplementary Tables 4–6). A similar pattern of results was revealed. Anxiety symptoms were uniquely positively associated with the parent difficulties subscale, but not the child difficulties or parent confidence subscales, in adjusted analyses. ADHD-I symptom severity was the only other variable uniquely associated with the HLD subscales in all three adjusted models.Pre-existing anxiety disorder status was not associated with HLD in unadjusted or adjusted models; see Table This study described the home learning experiences of a sample of Australian children with ADHD, and associations between anxiety and HLD during COVID-19-related restrictions. Parents retrospectively reported that, pre-COVID-19, more children looked forward to school compared to during the pandemic. Parents also perceived children to be less engaged in schoolwork during COVID-19 home learning relative to engagement at school pre-pandemic, which may suggest that children learning from home are spending less time engaging with both new content and reinforcing old content; however, there does not appear to be a set Australian standard for the quantity of learning activities on school days. Results of the current study are consistent with a prior study that reported children in their sample received less than two hours of direct instruction from teachers during home learning, with most children completing an average of only 0–3 h of schoolwork on school days . LongituIn the current sample, there was a unique association between anxiety symptom severity, but not pre-existing anxiety disorder status, and HLD. Anxiety symptom severity was positively associated with HLD, before and after adjusting for covariates. However, there was no association between anxiety disorder status and HLD in unadjusted or adjusted analyses. Symptoms of oppositionality or other co-occurring domains were not associated with HLD. Individuals with mental health difficulties such as anxiety have been reported to be more impacted by COVID-19-related difficulties than peers without mental health difficulties . The resThe results of this study also point to the importance of continued supports to help with ADHD symptoms during home learning to optimise educational outcomes. Results suggest that ADHD-I symptoms were more strongly linked to HLD than anxiety, ADHD-H symptoms or other co-occurring factors examined in this study. This is consistent with previous research that found ADHD-I symptoms to be more strongly associated with academic difficulties compared to ADHD-H symptoms . AlthougDespite almost 88% of children in this sample taking one or more medications during the examined period, children with ADHD were still experiencing substantial HLD. This suggests that in addition to pharmacological interventions, children with ADHD and their families are likely to benefit from other strategies to assist with home learning. Established strategies routinely recommended for children with ADHD at school  –48, applStrategies parents have reported as effective in supporting home learning during COVID-19 include limiting environmental distractions, supporting their child with understanding and planning their work, assistance with time management, exercise, and regular breaks from learning [Socio-economic status was not uniquely associated with HLD in the current study. This finding is consistent with an earlier study of children and adolescents , but conResults of the current study support the idea that in addition to supporting children with ADHD, it is important that parents are assisted with home learning supports and strategies in adapting to the challenge of facilitating and supporting learning from home . Poor chSupplementary home learning supports for parents of children with ADHD may include more regular direct contact with teachers and school support staff, with the aim of promoting child engagement. Moreover, strategies previously deemed effective by classroom teachers could be discussed with parents, with many children with ADHD having lost access to the additional learning supports they previously received , 13. ChiWhile there are data available detailing strategies parents have found helpful during home learning and recommendations for parent-teacher collaboration e.g. , 52, 53,Findings of the current study also support the notion that enhanced home learning models are needed, particularly for students with differing learning needs, including children with ADHD. With online learning environments forecast to have an increasing place in our educational systems into the future , 58, oppN = 1528; aged 3–19 years) with ADHD attending paediatric services revealed similar characteristics, with the exception of higher levels of comorbid depression and anxiety in the current sample [Findings from the current study should be interpreted in the context of several limitations. The availability of parent-reported data only may be a limitation, given possible reporting discrepancies with children’s perceptions . Future t sample . TherefoTo our knowledge, this represents one of the first Australian studies of home learning experiences among children with ADHD and their parents during the COVID-19 pandemic with a focus on anxiety. It documents the numerous challenges faced by children with ADHD during a time of rapid change and provides preliminary evidence of the need for adequate and timely supports from schools, policymakers, and healthcare services as impacts of the pandemic continue to evolve and longer-term effects become more evident. This is underscored by the fact that many children with ADHD already experienced challenges at school prior to the COVID-19 pandemic. Supports need to be multi-faceted and tailored to the specific needs of children with ADHD, their parents, and their teaching communities.n = 122) with ADHD in Australia during COVID-19 social restrictions, and the role of anxiety in understanding HLD. We found that anxiety symptom severity, but not pre-existing anxiety disorder status, was robustly associated with HLD, before and after adjusting for a range of other clinical factors. ADHD-I symptom severity was the only other variable uniquely associated with HLD. This suggests that strategies to support anxiety and ADHD-I symptoms may be helpful for children with ADHD during home learning. The results reinforce the recommendation that pre-pandemic ADHD symptom supports are continued during the pandemic, and that anxiety symptoms are identified and supported. Children and adolescents with ADHD, and their families, may benefit from additional strategies and supports during and beyond periods of home learning.The COVID-19 pandemic has impacted children and adolescents around the world, particularly those with pre-existing conditions, including attention-deficit/hyperactivity disorder (ADHD) and anxiety. This is one of the first studies to examine home learning experiences in children and adolescents Below is the link to the electronic supplementary material.


To understand whether genetic risk for attention-deficit/hyperactivity disorder (ADHD) is associated with the course of the disorder across childhood and into young adulthood.Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a population-based birth cohort of 2,232 twins. ADHD was assessed at ages 5, 7, 10, and 12 with mother- and teacher-reports and at age 18 with self-report. Polygenic risk scores (PRSs) were created using a genome-wide association study of ADHD case status. Associations with PRS were examined at multiple points in childhood and longitudinally from early childhood to adolescence. We investigated ADHD PRS and course to young adulthood, as reflected by ADHD remission, persistence, and late onset.Participants with higher ADHD PRSs had increased risk for meeting ADHD diagnostic criteria (odds ratios ranging from 1.17 at age 10 to 1.54 at age 12) and for elevated symptoms at ages 5, 7, 10, and 12. Higher PRS was longitudinally associated with more hyperactivity/impulsivity (incidence rate ratio = 1.18) and inattention (incidence rate ratio = 1.14) from age 5 to age 12. In young adulthood, participants with persistent ADHD exhibited the highest PRS (mean PRS = 0.37), followed by participants with remission (mean PRS = 0.21); both groups had higher PRS than controls (mean PRS = −0.03), but did not significantly differ from one another. Participants with late-onset ADHD did not show elevated PRS for ADHD, depression, alcohol dependence, or marijuana use disorder.Genetic risk scores derived from case-control genome-wide association studies may have relevance not only for incidence of mental health disorders, but also for understanding the longitudinal course of mental health disorders. Late-onset ADHD occurs when people meet ADHD criteria only after the In the current study, we investigated associations between ADHD genetic risk, as captured by the PRS, and ADHD course in a population-based longitudinal cohort. First, we examined how genetic risk was associated with ADHD diagnosis and symptoms in childhood at multiple ages ranging from early childhood (age 5) to early adolescence (age 12), from the perspective of different informants (mothers and teachers), and across symptom domains (hyperactivity/impulsivity and inattention). Second, we examined the longitudinal course of hyperactivity/impulsivity and inattention across childhood to assess whether ADHD PRS was associated with level of, and change in, ADHD symptoms across development. Third, we extended analyses to young adulthood to examine whether ADHD PRS was associated with persistence, remission, and late onset of ADHD from childhood to age 18. Fourth, we investigated whether genetic risk for other mental health disorders commonly comorbid with ADHD  were associated with ADHD course, either through contributing to persistence or influencing risk for late-onset ADHD.2 = 0.86, d.f. = 2, p = .65), age 5 IQ , or rates of childhood ADHD . With parents’ permission, questionnaires were mailed to the children’s teachers, who returned questionnaires for 94% of children at age 5 years, 93% of those followed to age 7 years, 90% of those followed to age 10 years, and 83% of those followed to age 12 years. The Joint South London and Maudsley and the Institute of Psychiatry Research Ethics Committee approved each phase of the study. Parents gave written informed consent, and twins gave assent between 5 and 12 years of age and then written informed consent at age 18.Participants were members of the Environmental Risk (E-Risk) Longitudinal Twin Study, a birth cohort of 2,232 British children drawn from a larger birth register of twins born in England and Wales in 1994–1995.DSM-IV diagnostic criteria.We ascertained childhood ADHD diagnoses on the basis of mother- and teacher-reports of 18 symptoms (9 symptoms of inattention and 9 symptoms of hyperactivity/impulsivity) derived from DSM-5 criteria.p < .001).We ascertained ADHD diagnosis at age 18 based on private structured interviews with participants regarding 18 symptoms of inattention and hyperactivity/impulsivity according to ,As reported previously,https://mathgen.stats.ox.ac.uk/impute/impute_v2.html)http://www.ncbi.nlm.nih.gov/SNP/)We used Infinium OmniExpress-24 v1.1 BeadChip arrays  to assay common single nucleotide polymorphism (SNP) variation in the genomes of cohort members. We imputed additional SNPs using IMPUTE2 version 2.3.1 software , then weighted SNPs by effect estimate. To control for possible population stratification, we conducted a principal component analysis of our SNP database using PLINK 1.931Polygenic scoring was conducted following the method described by DudbridgeWe first tested whether ADHD PRS was associated with ADHD diagnosis at ages 5, 7, 10, and 12 using logistic regressions. We assessed whether ADHD PRS was associated with an increasing number of ADHD diagnoses across childhood using multinomial logistic regression. We then examined the correlation between ADHD PRS and a dimensional measure of total ADHD, hyperactivity/impulsivity, and inattention symptoms as reported by mothers and teachers separately at ages 5, 7, 10, and 12.Second, we used longitudinal growth models to examine associations between ADHD PRS and hyperactivity/impulsivity and inattention symptom course (separately) across childhood at ages 5, 7, 10, and 12. Because the distribution of ADHD symptoms was highly skewed, we used negative binomial regressions with a multilevel modeling approach in STATAThird, we examined ADHD course from childhood to young adulthood using multinomial logistic regression to assess whether ADHD PRS was associated with a persistent, remitted, and late-onset course compared with participants who never had ADHD. We tested whether participants with a persistent course had a higher burden of common genetic variants associated with ADHD risk. Additionally, we assessed whether the participants with late-onset ADHD showed similarly elevated PRSs to participants with childhood ADHD to clarify whether late-onset ADHD is genetically similar to childhood ADHD.Fourth, we repeated these multinomial logistic regressions with PRSs for depression, alcohol dependence, and marijuana use disorder. We investigated whether a higher genetic burden of mental health disorders may be associated with ADHD persistence. We additionally assessed whether late-onset ADHD showed higher genetic risk for these other disorders, possibly suggesting late-onset ADHD may be accounted for by symptoms of other common mental health disorders misidentified as ADHD.Analyses were corrected for nonindependence of twin observations using the sandwich variance estimator in STATA.Children with a higher ADHD PRS were at increased risk of meeting ADHD diagnostic criteria at ages 5, 7, 10, and 12 . At age Higher ADHD PRS was also associated with a higher number of ADHD symptoms at ages 5, 7, 10, and 12 . AssociaOverall symptoms of hyperactivity/impulsivity and inattention declined from early childhood to adolescence. Despite this general decline, children with higher ADHD PRSs showed higher levels of hyperactivity/impulsivity symptoms across childhood  comparedt = 0.91, d.f. = 1,837, p = .37). Participants in the late-onset ADHD group did not show increased ADHD PRS compared with participants who never had ADHD.We extended our analyses of ADHD course to young adulthood to examine the associations of ADHD PRS with the remission, persistence, and late onset of ADHD by age 18 . The perb = 0.17, 95% CI ); participants with late-onset ADHD showed no elevation in PRSs for alcohol dependence . Persistence and remission of ADHD may be influenced by other genetic factors not reflected in the current GWAS that focuses on case-control status. Longitudinal twin studies suggest different genetic influences on level of ADHD symptoms in early childhood and change in symptoms to age 16.While most elevated in the persistent ADHD group, the ADHD PRS did not significantly distinguish participants whose ADHD would persist from participants who remitted. This is consistent with findings from a United Kingdom cohort in which ADHD PRSs of participants with high mother-reported ADHD symptoms at age 7 and age 17 were higher than PRSs of controls, but did not significantly differ from the PRSs of participants who had high ADHD symptoms at age 7 only.We did not identify a similar profile of genetic risk in the late-onset and childhood-onset ADHD groups. Rather, the ADHD PRS was not elevated among participants with late-onset ADHD. Despite this group meeting full ADHD symptom and impairment criteria at age 18, the PRSs in this group were more similar to non-ADHD controls than participants with remitted or persistent ADHD. Two studies that examined ADHD polygenic risk in adult-onsetOur findings add new evidence to support late-onset ADHD having a different underlying genetic composition from childhood-onset ADHD. On one hand, if late-onset ADHD reflects fundamentally the same disorder as childhood-onset ADHD, with the exception that it was undetected in childhood, we would expect these ADHD courses to exhibit a similar genetic risk. On the other hand, if late-onset ADHD does not directly develop from childhood-onset ADHD, it is sensible that a PRS derived from a GWAS largely consisting of cases from childhood clinical populationsADHD PRS was associated with more ADHD symptoms at each age, supporting the idea that genetic influence occurs across the dimension of ADHD symptoms in the population. Studies have found that ADHD symptoms tend to decline overall in the population from early to later childhood,Separately examining hyperactivity/impulsivity and inattention symptoms showed that the association with ADHD PRS was slightly stronger for hyperactivity/impulsivity symptoms than for inattention symptoms. These findings are similar to a study of a clinical ADHD population that found a larger difference in levels of hyperactivity symptoms than inattention symptoms between high and low PRS groups.We did not find that participants in the persistent ADHD group showed elevated genetic risk for depression, alcohol dependence, or marijuana use disorder, indicating that genetic risk for these disorders commonly comorbid with ADHD did not significantly contribute to ADHD persistence to young adulthood. Similarly, participants with remitted ADHD did not differ from controls or participants with persistent ADHD on these PRSs, suggesting that lower genetic risk for these disorders did not promote ADHD remission. Furthermore, the late-onset ADHD group did not show elevated genetic risk for these other mental health disorders. While this does not rule out that late-onset ADHD may represent other disorders manifesting with symptoms that mimic ADHD, it does suggest that this group does not share the same genetic risk as cases of depression, alcohol dependence, or marijuana use disorder that are included in the GWASs for these disorders.This study has several strengths including measurement of ADHD diagnosis as well as hyperactivity/impulsivity and inattention symptoms at multiple ages spanning early childhood to young adulthood in a representative population-based cohort. However, our results must be considered in light of some limitations. First, ADHD diagnoses at age 18 were based on self-reports. However, prior work in this cohort found that co-informant reports of ADHD symptoms at age 18 corroborated self-reports, and participants with self-reported late-onset ADHD had significantly more co-informant–rated symptoms than participants without ADHD.Higher ADHD PRS was associated not only with risk for ADHD diagnosis and elevated symptom levels across childhood but also with a modestly increased risk of ADHD persistence to young adulthood. Yet, ADHD PRS did not differentiate between persistent and remitted ADHD. While higher PRSs among participants with persistent ADHD are suggestive of a higher genetic load in this group, currently ADHD PRS would not be useful in a clinical setting to predict, at an individual level, which child will have persistent ADHD up to young adulthood. However, GWASs of ADHD continue to expand in sample size and diversity of study populations across age, ethnicity, and recruitment from nonclinical settings. This offers the opportunity to further subgroup the ADHD population by different phenotypic presentations and developmental courses, thereby increasing possibilities to identify genetic factors specific to persistence, remission, and late onset. Additionally, further research can investigate how genetic risk may combine with environmental factors to impact the course of ADHD over development. While genes do not change over the life span, the effects of genes on health and behavior are not static and can impact development differentially over time. Quantifying genetic risk through PRS approaches can help us better understand, and someday perhaps predict, the course of mental health disorders over the life span.


Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric conditions. Many studies have shown that exposure to low-dose bisphenol-A (BPA) can contribute to ADHD. The relationship between ADHD and composite resin is still unclear. We designed a nested case–control study to investigate the relationship between ADHD and composite resin restorations among children from the Taiwan’s National Health Insurance Research Database. We included 85,503 people whose birth years were between 1998 and 2005 and who received resin restoration from January 2000 to December 2008. A 1:2 matched control sample without ADHD was randomly selected from the database by propensity score matching based on birth year and sex. We identified 4984 individuals as ADHD patients. The average diagnostic age of ADHD was 7.45 years old. The patients who received composite resin restorations had higher risk of ADHD than those who had never received them (aOR (adjusted odds ratio) = 1.25; 95% CI  = 1.13–1.38). Males had a higher risk of ADHD . Taken together, this nested case–control study demonstrated a positive association between ADHD and dental care via composite resin restoration in Taiwanese children. Prospective clinical studies of the relationship between ADHD and composite resin are warranted. Attention deficit hyperactivity disorder (ADHD), characterized by developmentally inappropriate levels of hyperactivity, impulsivity, and inattention, is one of the most common childhood psychiatric conditions. Children are often diagnosed with ADHD during preschool years following symptoms such as frequent fidgeting or squirmy behaviors, an inability to follow instructions, and high distractibility. The consequences of ADHD can persist through adulthood if left untreated or uncontrolled. About 6.7% prevalence of ADHD was reported by US National Health Interview Survey from 1997 to 2000 .BPA is widely used to make polycarbonate plastics such as those in hard plastic baby, water bottles, and epoxy resins for dental sealants/resin-based composites. BPA is a kind of endocrine-disrupting chemical, which may affect brain development and increase the impairment of social communication in children . Dental Up to now, there has been no study examining the impact of dental care via composite resin restoration for ADHD. The aim of this study was to investigate the possible relationship between composite resin restoration and ADHD among children. Therefore, we designed a nested case–control study from the Taiwan’s National Health Insurance Research Database (NHIRD).The Longitudinal Health Insurance Database (LHID) 2010, a part of Taiwan’s NHIRD, was used for this study. Almost all of the Taiwanese population was enrolled in this compulsory National Health Insurance program. The LHID 2010 collected registration information and dental and medical data and contains 1 million beneficiaries randomly sampled from the 2010 registry of beneficiaries in the NHIRD. This study was approved by the Chung Shan Medical University Hospital Ethics Review Board. This report complies with STROBE  guidelines for the observational studies.Subjects of the study were children from the LHID 2010 whose birth years were between 1998 and 2005 and who received operative dentistry (OD) treatment between January 2000 and December 2008. The codes 89,004, 89,005, 89,008, 89,009, 89,010, 89,012, 89,104, 89,105, 89,108, 89,109, 89,110, and 89,112 for OD treatment indicate composite resin restoration. Patients were followed from the first date for composite resin restoration until 5 years after the date OD treatment was received .The diagnosis of ADHD is according to ICD-9 codes 314.00, 314.01, and 314.9. Only two or more repeated diagnoses of ADHD in one year during 2005–2013 were considered to ensure accurate diagnostic criteria. The date on which each patient was first diagnosed with ADHD was defined as the index date. Matched controls (1:2) were randomly selected from the LHID 2010 by using propensity score matching based on both birth year and sex. Psychiatric comorbidities including autism, mental retardation, and developmental delay were assessed as the confounding factors in this study.t-test for continuous variables and the chi-squared test for categorical variables. Conditional logistic regression was used to estimate crude and adjusted odds ratios (ORs) with a 95% confidence interval (CI) for the case group compared with the control group. In multivariate analysis, adjustments were made for age and sex.All data analysis was performed using SAS 9.3 . Statistical analyses of demographic characteristics and socioeconomic status of study subjects were performed using Student’s p < 0.001).The characteristics and socioeconomic status of study subjects with and without ADHD are presented in The odds ratio for the number of composite resin restorations of those with a diagnosis of ADHD is shown in To the best of our knowledge, this nested case–control study first demonstrated the association between the composite resin restoration and ADHD among children. Males had a higher risk of ADHD. There was an increasing pattern in the prevalence of ADHD in Taiwan from 2000–2011 . The femDespite the heritability factors of ADHD, environmental toxins may also affect childhood neurobehavioral outcomes such as BPA. As an endocrine disruptor, BPA may affect dopamine concentration at the dopaminergic neuron terminals and functionally impair dopamine receptors in ADHD patients . When doResin-based composite resin and dental sealants are the most commonly used materials in caries treatment and prevention, especially in children. Many studies have shown that BPA was detected after using resin-based composite for dental caries restoration ,16,17,18In this study, we also evaluated the number of composite resin restoration and the time interval from the first composite resin restoration to the index date. There is no acceleration in ADHD patients where a higher number of composite resin restorations was present. However, the results show that the longer the duration of the composite resin restorations, the greater the risk of ADHD. The reason for this is not quite clear. Composite resin may wear out due to chewing, leading to BPA release into oral environments gradually. Taken together, further detailed studies need to evaluate the duration, number, size, and tooth surface of composite resin restorations in the pathophysiology of ADHD.The possible confounders and other predictors of ADHD included a low birthweight, maternal smoking, alcohol/drug use, low birthweight, prematurity, toxic exposure, diet, and social/family environment . In thisThere are still some limitations in this study. First, there are multiple exposure sources of the human intake of BPA, including the atmosphere, water, effluent, food, drinking water, and dust . HoweverOur study demonstrated a positive association between composite restorations and ADHD among children. To focus on environmental toxins, dentists need to evaluate the potential harmful effects of composite-resin-based filling materials. During dental cavity restoration, exposure to unpolymerized dental resin materials must be controlled and limited to prevent the release of BPA after restoration. The development of a BPA-free composite resin as an alternative is encouraged. While BPA can directly contribute to ADHD, we should point out that dental composite resin is not the only route of BPA exposure in humans. Therefore, further studies are needed to confirm the causal relationship between dental care via composite resin restorations and ADHD among children.There has hitherto been no report on the relationship between dental care via composite resin restorations and ADHD. Our findings demonstrated a positive association between composite resin restorations and ADHD among children. These associations were stronger in males than in females. Since composite resin remains a source of BPA exposure, other alternatives for restorative materials are suggested. Further studies are required to clarify the causal relationship between composite resin restorations and ADHD among children.


Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder, estimated to affect 5–7% of children and adolescents worldwide [–3, thougIncreased recognition and treatment of ADHD in adult prisoners has several potential benefits, beyond improvements in subjective well-being. Firstly, for many patients, receiving a diagnosis of ADHD may be validating . It coulEfforts to improve outcomes for prisoners' mental health and reduce violence and offending are welcome. However, there are several reasons for caution toward the emergent focus on ADHD, and several gaps in the evidence base that need to be addressed. Below, I outline these in turn, offering suggestions for a measured and empirical approach to the condition within holistic formulation and management in prison psychiatry settings.Until recently, estimates of prevalence of ADHD in incarcerated populations varied so widely—from 4 to 72% —as to reThis meta-analysis also revealed wide geographical variation in estimates, from 6.6% in Brazil  to 65.2%Overall, existing studies of prevalence ADHD in prisons continue to show considerable variation, even where more detailed assessments and stricter application of criteria are applied. Furthermore, receiving a diagnosis of ADHD does not necessarily equate to clinically relevant symptomatology. Together, this suggests ongoing caution is warranted in estimating the clinical impact of ADHD in any given prison population, and the need for ongoing rigorous assessments at national and local levels. As other authors have highlighted, inflated estimates of ADHD in prisons also risks stigmatizing individuals with ADHD in the general population as excessively prone to criminal behavior .A major shift in focus toward assessing and treating ADHD in prison risks a disproportionate approach to prison healthcare. Other mental disorders are very common in prisoners , with muIn this context, resources must be used judiciously, and proportionate to clinical need, in keeping with both standard procedures for allocation of community resources and the equivalence principle for prison healthcare . HoweverExcessive focus on ADHD may lead to misattribution of problematic behaviors. The large majority of individuals with ADHD do not offend . In thosDespite this, a recurring theme in existing literature is the attribution of antisocial behavior in prisoners to ADHD. For instance, one editorial suggests that ADHD is “a major causal risk factor for the development of criminal behavior” . Anotherdue to ADHD.Likewise, aggression is not a diagnostic feature of ADHD. DSM-5 criteria for ADHD specify impulsive behaviors such as interrupting, blurting out answers, and difficulty waiting one's turn—not aggression or violence . In contIn particular, to properly disentangle the relative contributions of ADHD and ASPD to violence and aggression in prisoners, there is a need for studies comparing those with ADHD and comorbid ASPD (ADHD+ASPD) to those with ADHD-only, and ideally, also those with ASPD-only, and healthy controls with neither condition. No such study has been carried out in adult prisoners. One study in a Scottish prison  showed tWhile expert guidelines state that the treatment of adults with ADHD should follow a multimodal approach, including psychoeducation and cognitive behavior therapy , 16, medn = 15 in treatment and placebo groups) and for a very short blinded observation period of 5 weeks , lack of cost-benefit analysis for interventions, and insufficient risk: benefit considerations in prescribing guidelines. To bridge these gaps, ongoing studies using robust assessment protocols are required to get a more accurate and granular understanding of rates on ADHD in specific prison populations. Randomized controls trials are required to support use of medication for ADHD as a first-line treatment. Importantly, given the prevalence of other mental disorders with direct links to self-harm, suicide, and violence, well-intentioned initiatives should not be allowed to create a disproportionate and misguided focus on ADHD as a primary problem in prison mental healthcare. Until a better standard of evidence exists, its status is more appropriately considered as under ongoing review.The author confirms being the sole contributor of this work and has approved it for publication.The author declares 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.


Young adults exhibit greater sensitivity than adults to nicotine reinforcement, and Attention Deficit Hyperactivity Disorder (ADHD) increases the risk for early-onset smoking. We investigated the correlation between ADHD Self-Report Scale (ASRS) scores and smoking, evaluated the prevalence of ADHD symptomatology (not diagnoses) in smokers and non-smokers and its comorbidity with benzodiazepine and gambling addictions. A total of 389 young adults from 14 schools in Northern Italy fill out a survey and the Adult ADHD Self-Report Scale (ASRS). A total of 15.2% of subjects tested positive at the ASRS, which correlated with smoking; moreover, smokers had twice the probability of testing positive at the ASRS. ADHD symptomatology, especially when comorbid with tobacco abuse, is an important condition to monitor because early nicotine exposure could be a gateway for other addictive behaviors. Attention Deficit Hyperactivity Disorder (ADHD) is a neuropsychiatric disease that literature indicates to be among the most prevalent disorders in children . StudiesIn these last few years, the conceptualization of the development of ADHD has changed. While this neuropsychiatric disorder was once thought to disappear with adolescence, long-term controlled follow-up studies have shown otherwise, indicating that the persistence of the disorder continues into adolescence in three quarters of cases and into adulthood for 50% of cases ,5. SpeciThe discovery of the persistence of ADHD in adolescence and adulthood has progressively oriented the interest of researchers to study its implications in the development of different forms of psychological distress. Today we know that comorbidity between ADHD and other disorders is particularly frequent, especially for internalizing conditions (13–15%), such as anxiety and depressive disorders, and externalizing disorders 43–93%), such as oppositional-defiant and conduct disorders . Among t3%, such SUD is a psychiatric disorder with implications in healthcare, lost workplace productivity, crime and other social problems . ApproxiSeveral studies recognize ADHD as one of the predisposing factors for the development of SUDs. In a recent meta-analysis, for example, van Emmerik and associates  showed tA high rate of ADHD symptoms was found among heroin-dependent patients, particularly those affected by the most severe forms of addiction. These individuals had higher rates of unemployment, other co-morbid mental health conditions, and were heavy tobacco smokers .Among the various substances that are abused, tobacco is the one most associated with ADHD . The tobIt is well described that ADHD symptomatology increases the risk for earlier tobacco smoking initiation, from occasional to regular smoking, to developing more severe nicotine addiction and having more failed quit attempts ,27,28,29Nicotine withdrawal severity is a predictor of smoking maintenance and relapse. In ADHD smokers, this process appears augmented . SeveralThe neurobiological bases of ADHD have often been called into question in explaining the predisposition of this increased sensitivity to nicotine that was found in several studies. This particular process could be explained with an alteration in dopamine and other catecholaminergic functions in the brain regions and neuro-transmitter systems that are also modulated by both chronic and acute nicotine administration ,35. The The predisposition to use cigarettes found in young adult populations with ADHD acquired relevance not only for the adverse effects related to smoking; several studies indicate that the use of cigarettes during early adolescence often precedes the use of illicit substances during late adolescence , represeFor these reasons, our study has three main objectives: (1) to observe the prevalence and correlation between ADHD and tobacco use; (2) to evaluate the risk of positive ADHD screening in young adult smokers and non-smokers; (3) to evaluate other possible addiction comorbidities, such as benzodiazepine (BDZ) addiction, alcohol addiction and gambling disorder (GD).We expect a higher prevalence of smokers with a positive ADHD screening questionnaire and a higher odds ratio in the same class, in line with the evidence currently present in literature ,43, as wThe sample comprised 389 persons aged between 18 and 22 years old who were enrolled in 14 schools in Northern Italy; of these, 9 schools were located in Mantua and 5 in Verona.Approval for the research was obtained from the Human Research Approval Committee (CARU) of the University of Verona .An anonymous and self-administered questionnaire composed by ad hoc questions was used. It was composed of 17 multiple-choice questions and 6 open questions, for a total of 23 questions.The survey was presented and distributed in classrooms by psychologists from January to June 2019. The time needed to complete it was about 15 min; participants filled out the survey by themselves using paper and pencil. Participation in the survey was voluntary and without remuneration; each young adult could have suspended the compilation at any time without providing any explanation.k (0.76) and very high specificity (99.5%) and total classification accuracy (97.9%) [The survey included questions regarding socio-demographical data, alcohol consumption, the use of benzodiazepines (BDZ) and gambling behavior. The survey areas were: sex, family relationships, licit and illicit drug use , and gambling behavior. Moreover, the survey included the Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Part A , which c (97.9%) . The ASR (97.9%) .p-value < 0.05.Descriptive statistics were performed using percentages for categorical variables and a mean and standard deviation for quantitative variables. Pearson’s chi-square test was used to evaluate the association between demographic characteristics, habits and adult ADHD symptoms in bivariate analyses. Multivariable logistic regression models were performed to assess the association between adult ADHD symptoms (<4 points vs. ≥4 points) and subjects’ habits such as smoking and benzodiazepine use. Specifically, we evaluated smoking as: daily smokers and smokers for at least one year (yes/no), number of daily cigarettes (none/1–10/>10), THC smokers in the last 12 months (yes/no) and benzodiazepine users . As covariates, we included in the model: sex, age, parents separated/divorced (yes/no), number of working family members (<2/2/>2), foreign father (yes/no), school , other habits such as alcohol unit consumption (none/≤2/>2) and gambling . These associations were evaluated using odds ratios (OR) and 95% confidence intervals (CI). Statistical analyses were performed with STATA 16  and statistical significance was set at Participants in this study were 389 young adults, 63.5% of which were male. The mean age in the sample was 18.4 ± 0.6 years (range 18–22 years). Daily smokers were 105 (27%) and 80% of them smoked between 1 and 10 cigarettes every day. Young adults who smoked for at least one year were 92 (23.6%), and 119 (30.6%) used THC in the preceding 12 months. Of the subjects, 349 (89.7%) drank alcohol and 210 (54.4%) consumed two or more alcoholic units in the preceding year. Young adults who used BDZ in a lifetime period were 28 (7.2%) and 4.1% used BDZs more than one time. This study also showed that 112 (28.9%) participants presented a gambling behavior for two or more times in the last year .p = 0.064  subjects had positive results (≥4). No associations in the bivariate analyses were found about the demographic characteristics of the subjects, although 32.2% of those scoring positive on the questionnaire had separated or divorced parents, vs. 21.2% in those scoring negative,  = 0.064 .Multilevel regressions  confirmeADHD is one of the most prevalent neuropsychiatric disorders , but it Several studies show that ADHD increases the likelihood of illicit drug use  and of tOur study shows the correlation between ADHD symptomatology and tobacco use in young adult populations that also emerged in several other studies ,50,51. SIn the current state of empirical research, the reason for which such a correlation is present has not yet been clarified. Among the hypotheses that have currently received greater support is one that views the use of cigarettes as a form of self-medication in the presence of ADHD symptoms ,56, espeAlthough there is currently a lack of studies that can explain the predisposing effects of ADHD symptomatology in the development of SUDs , the posThe nicotine gateway theory is presented by several studies that point out how nicotine exposure in early adolescence in various rodent models increases: (a) the acquisition and intake of nicotine, alcohol, cocaine and methamphetamine; (b) the co-use of nicotine and alcohol; (c) the rewarding effects of nicotine, cocaine, methamphetamine and opioids .It is important to explain that drugs of abuse  influence different neurotransmitter systems. They all exert their reinforcing effects via the mesolimbic system, which is a dopaminergic pathway that connects the Ventral Tegmental Area (VTA) to the Nucleus Accumbens (NAcc) ,62.This pathway’s protection, functions and development are influenced by GABA, glutamate, serotonin and acetylcholine ,65. MotiOur study observed an off-label consumption of BDZs in the young adult population. Treatment of ADHD symptoms is therefore crucial in parallel with the treatment of drug addiction. The use of sleep medications is common in patients with ADHD starting from their childhood; up to 22% of children suffering from ADHD use hypnotic drugs, with no clear evidence for the safety and benefits of long-term use .In our study, there was no significant correlation between BDZ consumption and ADHD symptoms. The reason for this lack of significance could reside in the insufficiency of the sample. It is, however, reasonable to suppose that nicotine use could expose young adults to a major risk of developing a BDZ addiction or problematic use, due to the influence that BDZs exert on the level of GABAergic transmission. Finally, our study explained that there is no correlation between smoking and GD. Future research could examine this aspect of considering environmental data besides the absence or presence of gambling behavior.This study presents several limitations; the first one is the fact that using only a screening test of ADHD (ASRS) makes it impossible to clearly diagnose this pathology. Future studies should include the adult Connors self-report screening scale (CAARS-SV), which allows to determine the type of ADHD with a quantitative estimation of Inattentive symptoms, Hyperactive/impulsive symptoms and a total ADHD index . We undeThis paper confirms the relationship between tobacco abuse and ADHD symptomatology that was observed in other studies. Nicotine addiction is often considered a “minor” addiction problem by specialists , but this substance can create strong links with other substances . BDZ misuse and addiction in adolescents is not debated in the scientific community, but this phenomenon is making its way in this specific population. In our study, it was impossible to establish the relationship between screening ADHD symptomatology, nicotine and BDZ use, and neither to assess nicotine addiction severity, but future studies could explore this specific area using a bigger sample size.


Personality factors, such as the Dark Tetrad personality factors  relate to greater online trolling. Other personality factors, such as the Big Five Personality factors, honesty–humility and negative social potency, may also play a role in cyberbullying, which is an aggressive behavior similar to trolling. The purpose of this study was to predict Facebook trolling behavior based on personality factors. A total of 139 participants completed a survey on their online behavior and personality factors. Online trolling behavior positively correlated with sadism, psychopathy and Machiavellianism, and negatively correlated with agreeableness, conscientiousness and honesty–humility. A hierarchical linear regression showed that sadism, Machiavellianism and negative social potency were the only unique predictors of online trolling behavior. Trolling was unrelated to the frequency of Facebook use and the frequency of commenting. Enjoyment of trolling fully mediated the relationship between Machiavellianism and the trolling behavior. The results thus suggested that Facebook trolling behaviors may be motivated by enjoying the manipulation of others. Trolling can be defined as a deviant, malicious or antisocial online behavior ,2 with mTrolling has been studied separately within two personality frameworks: The Dark Tetrad and the Big Five . The DarThe Big Five personality framework includes extraversion, agreeableness, conscientiousness, neuroticism and openness . These tIn addition to the Dark Tetrad and the Big Five personality traits, another factor from the HEXACO Personality Inventory, honesty–humility, might be justified . This isIn addition to personality traits, social factors also explain trolling behavior, as trolls crave recognition from others to feel successful . Social The purpose of this study was to predict Facebook trolling behavior based on personality factors. Previous studies have shown that the Dark Tetrad personality traits help explain trolling ,19 and tr = 0.35, with acceptable statistical power (1 − β) = 0.80), a sample size of N = 46 (one-sided) was required [To determine the required sample size, an a priori power analysis was conducted. Based on previous research , a probarequired ,37. A total of 147 participants participated in an online survey in May 2018. Eight participants failed to respond correctly to three data quality monitoring questions and were, therefore, removed from the data. Out of the 139 participants left, 17 (12.2%) were male, 119 (85.6%) were female and 3 (2.2%) were non-binary. Participant age varied, as 35 participants (25.2%) were under 25 years old, 72 (51.8%) were 25 to 34 years of age, 17 (12.2%) were 35 to 44 years of age, 6 (4.3%) were 45 to 54 years of age, and 9 (6.4%) were older than 54 years old. Participants were recruited through Facebook using a snowball sample where participants were asked to share the survey with their friends on Facebook. The inclusion criteria for the study were being at least 18 years old and to have a Facebook account. Informed consent was obtained from each subject. Participants were informed of their rights as research participants, that their participation was voluntary, their responses strictly confidential, that they did not need to answer all questions, and could leave the survey at any time if they so wished. No reward was offered for participation. The APA ethical principles and code of conduct guided our research and we followed the principles of the Declaration of Helsinki.The survey included demographic questions (age and gender). In addition, the following measures were used: The Global Assessment of Facebook Trolling. To assess participants’ Facebook trolling behavior, the Global Assessment of Facebook Trolling (GAFT) was used . ParticiThe Dirty Dozen. Machiavellianism, narcissism and psychopathy were measured with The Dirty Dozen, a 12 item self-report questionnaire . StatemeThe Short Sadistic Impulse Scale. The Short Sadistic Impulse Scale (SSIS) was used to measure sadistic inclination . ParticiSocial Rewards Questionnaire. Participants’ negative social potency was measured using the Social Rewards Questionnaire (SRQ) . ParticiHEXACO Personality Inventory Revised. The HEXACO Personality Inventory Revised (HEXACO-PI-R) was used to assess honesty–humility, emotionality, extraversion, agreeableness, conscientiousness and openness . StatemeImpression management. The short form of the impression management subscale of the Balanced Inventory of Desirable Responding was used to assess participants “deliberate self-presentation”  (p. 37).Facebook activities. In the section on Facebook use, we asked participants “How many hours per day do you spend on Facebook?”, and if participants posted comments on Facebook, and if so, for how many hours per day did they spend posting comments on Facebook. Additionally, participants rated their enjoyment of the following activities on Facebook—debating, chatting, trolling, and making friends—on a five-point scale from 1  to 5 (very enjoyable) . SPSS, version 26 , and Mplus, version 6.12 , were used to perform the analyses. We performed a descriptive statistical analysis for all personality variables using mean, standard deviation, and Cronbach’s alpha. To examine the relationships between trolling behavior and the personality measures, Pearson correlation and multiple linear regression were used. In all analyses, we ascertained that the assumptions were met. The minimum alpha level for significance was set at α = 0.05. The path analysis was performed with 5000 bootstrapped samples and the fit of the path model was good  . p > 0.05). Trolling was also negatively associated with honesty–humility, agreeableness and conscientiousness as predicted, but also negatively associated with extraversion. Negative social potency had a positive relationship with trolling. There was no gender difference in participants’ Facebook trolling behavior, t(145) = 0.90, p = 0.37. Mean scores, standard deviations, reliability coefficients and correlation coefficients for the personality variables and Facebook trolling behaviors are reported in To test whether the HEXACO personality traits predicted Facebook trolling behavior, in addition to the Dark Tetrad personality traits and negative social potency, we ran a hierarchical linear regression analysis see . The indƒ2 = 0.10) was small, and large for Model 2 (ƒ2 = 0.38), Model 3 (ƒ2 = 0.43) and Model 4 (ƒ2 = 0.52). At each step in the regression, apart from the last one, there was a significant improvement in the model fit. This implies that the Dark Tetrad and negative social potency improved the prediction of Facebook trolling behavior. The HEXACO personality variables did not, with the exception of conscientiousness, significantly predict Facebook trolling behavior when controlling for previously added variables. For these variables, multicollinearity was not a concern, as tolerance scores were higher than 0.4, VIF scores were below 2.2 and correlations between variables were not strong enough to cause issues with multicollinearity (above 0.80) ,43. AccoCorrelation coefficients for Facebook trolling behaviors, the Dark Tetrad and enjoyment of Facebook activities are displayed in p = 0.04). The other factors were connected with trolling behavior , but not with the enjoyment of trolling. Given that self-reported enjoyment of trolling was connected with both trolling and personality factors, we tested whether enjoyment acted as a mediator between personality variables and trolling behavior. Using structural equation modeling, we constructed a path model with the factors previously identified as most important for trolling  as exogenous variables, trolling enjoyment as a mediator and trolling behavior as the endogenous variable. We found that the relationship previously identified between Machiavellianism and trolling behavior was fully mediated through trolling enjoyment (standardized coefficient for indirect effect = 0.08, This study examined the association between the Dark Tetrad personality factors, the HEXACO traits, negative social potency and Facebook trolling behaviors. In addition, the aim was to study whether the HEXACO traits predicted trolling when the Dark Tetrad and negative social potency were controlled for. Finally, we examined the relationship between these personality and social factors, not just with Facebook trolling behavior, but also with enjoyment of various online activities. In line with our hypotheses, Machiavellianism, psychopathy and sadism positively correlated with Facebook trolling behavior, where sadism was the strongest predictor. This is consistent with previous studies on trolling ,19 and cUnexpectedly, the relationship between Facebook trolling behaviors and extraversion was negative. Other scholars have speculated whether trolling and extraversion may have a positive relationship ,45,46, dSadism, Machiavellianism and negative social potency relate to greater trolling behavior and conscientiousness to less trolling behavior, when controlling for other personality factors. This is in line with previous studies, where sadism was a unique predictor of trolling behaviors ,19 and cIn order to better understand the motivation of those who troll, we asked participants what kinds of activities on Facebook they enjoyed taking part in. Commenting frequency was not connected with trolling behavior, contrary to previous work , suggestIn these analyses, there were no differences by gender, which is inconsistent with previous research on trolling  and cybeSome limitations of the current study include the use of a small sample with an uneven gender distribution, which may have impacted the results ,54. The Future research should focus on exploring some of the mechanisms leading from these personality factors to bullying behaviors, such as through empathy. Attempting to boost protective individual factors could act as trolling prevention. In this context, a further examination of the HEXACO subscales in relation to trolling could prove fruitful. Alternatively, engaging in other forms of prevention and intervention could also be effective. For example, interventions where peers intervene in person to stop trolling behavior are promising , as wellThe results of the current study suggested that personality factors may play a role in explaining trolling behavior, but that personality also intersects with other important factors, such as social rewards and enjoyment of trolling. Interventions to decrease trolling could, therefore, target specific factors, such as decreasing troll enjoyment by blocking trolls from websites or discouraging other users from engaging with the trolls. Decreasing the power that trolls have only becomes more important with time, as online spaces represent an ever-growing part of the lives of the general public. This could also mean that as general users become more internet savvy, trolls could be stopped earlier than before, by being reported to moderators on the websites in question.


Children with attention deficit/hyperactivity disorder (ADHD) are vulnerable to traumatic injuries. Parents of children with ADHD experience undesirable impacts more frequently than parents of children without ADHD. The aim of this study was to evaluate whether traumatic injuries are more prevalent in parents of children with ADHD than in parents of children without ADHD. We compared the prevalence of traumatic injuries between parents of children with and without ADHD by using data from the Taiwan Maternal and Child Health Database from 2004 to 2017. The Cox proportional-hazards regression model was used to examine differences in burn injury, fracture, and traumatic brain injury between parents of children with and without ADHD after adjustment for age, urbanicity, and income level. In total, 81,401 fathers and 87,549 mothers who had at least one offspring with ADHD and 1,646,100 fathers and 1,730,941 mothers with no offspring with ADHD were included in the analysis. The results indicated that both fathers and mothers of children with ADHD had higher risks of burn injury, fracture, and traumatic brain injury than fathers and mothers of children without ADHD. Mothers of children with ADHD had higher risks for all kinds of traumatic events than fathers of children with ADHD. Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder characterized by inattentiveness, hyperactivity, and impulsivity ,2. The pCompared with healthy peers, children with ADHD are more prone to accidental injury and trauma ,15, whicAlthough the association between ADHD and traumatic injuries in children had been explicated, the impact of children’s ADHD on their parents warrants further study. A review of twin studies revealed that the heritability of ADHD ranges from 77% to 88% ; howeverParents of children with ADHD experience undesirable impacts more frequently than parents of children without ADHD. In comparison with parents of children without ADHD, parents of children with ADHD reported lower self-efficacy to help their children, felt less welcome and supported by their children’s schools and teachers, and perceived less time and energy for involvement in their children’s academic lives and social interaction . FamilieWe used the Taiwan Maternal and Child Health Database (TMCHD) to investigate the risk of traumatic injuries in parents of children with ADHD. This study examined the risk of traumatic injuries in parents of children with ADHD. The results of this study may provide knowledge to develop service programs to enhance parental health. We hypothesized that parents who had children with ADHD were more likely to experience traumatic injuries than those who had no children with ADHD.Our study consisted of liveborn children with complete information about the gestational age at birth and identity of both parents in the TMCHD from 2004 to 2017. The data include 99.78% of all births in Taiwan since 2004 . TMCHD dInternational Classification of Disease, 9th revision, Clinical Modification [ICD-9-CM] code: 314 and 10th revision [ICD-10] code: F90) or one inpatient diagnosis of ADHD within the study period , they were identified as having a diagnosis of ADHD.In this study, the children’s ADHD status was the exposure. If the children received more than three outpatient diagnoses of ADHD , urbanicity , and low-income level. The urbanicity was stratified into seven levels from 1 (urbanized cities) to 7  based on the development level of each area . We cateFor descriptive statistics, frequency with proportion and mean with standard deviation (SD) are reported for categorical variables and continuous variables, respectively. To determine the risk of traumatic injuries in parents whose children did and did not have the diagnosis of ADHD, we used the Cox proportional-hazards regression model with time-on-study as the time scale, with adjustment for age, urbanicity, low-income level, and competing risk of death. Hazard ratios (HRs) with 95% confidence intervals (CIs) were used to quantify the risk and statistical significance of traumatic injuries, respectively. Parents of children without ADHD served as the reference. An HR value greater than 1 suggested that the risk of traumatic injuries is higher in parents of children with ADHD compared with parents of children without ADHD. If the CI of the HR included the null value of 1, there was no significant difference in the risk of traumatic injuries between parents of children with and without ADHD. We further compared the risks of traumatic injuries between fathers and mothers using the difference of two hazard ratios divided by the square root of the sum of the two squared standard errors .2 = 39.29, p < 0.001), fracture , and traumatic brain injury . For mothers of children with and without ADHD, the proportions of traumatic injuries were as follows: burn injury , fracture , and traumatic brain injury .p < 0.001).The results of the current study confirmed the hypothesis that parents of children with ADHD were more likely to experience traumatic injuries than those of children without ADHD. In addition, mothers had greater risks of traumatic injuries than fathers when having children with ADHD. To our knowledge, this is the first study to examine the risks of traumatic injuries for both fathers and mothers of children with ADHD worldwide. The fathers and mothers of children with ADHD had higher risks of burns, fractures, and traumatic brain injury than those of children without ADHD. The current study benefited from the establishment of the healthcare database in Taiwan. The pairs of data for parents and children were derived from the TMCHD , which wSeveral reasons may account for the higher risk of traumatic injuries in parents of children with ADHD. First, ADHD is a highly heritable neurodevelopmental disorder. A review revealed that the estimated heritability of ADHD is as high as 71–90% . A behavSecond, the undiagnosed ADHD in adulthood may increase the risk of traumatic injuries in parents. Several factors contribute to the underdiagnosis. First, medical record keeping started in 2004 at the TMCHD  and pareThird, although little evidence exists on children with ADHD being violent toward their parents, studies have shown that adults with a history of ADHD are more likely to perpetrate violence to intimate partners than controls ,42. HypeLast, studies have revealed that a high proportion of parents having children with ADHD experience depression  and anxiSeveral limitations of the study must be addressed. First, as a retrospective cohort study, the possibility of missing records for detailed clinical variables limited the presentation of outcome. Second, for a naturalistic observation, confounding factors cannot be controlled to the same extent as that in a clinical trial. However, naturalistic studies could include individuals more representative of real-world clinical settings. Third, individuals included had undergone treatment so that they could be identified in the TMCHD; however, those who did not seek medical help for ADHD or traumatic injuries were not included into the study.This study revealed that parents who had at least one child with ADHD were at a higher risk of burn injuries, fractures, and traumatic brain injury compared with those without a child affected by ADHD; moreover, mothers were at a higher risk than fathers for all types of traumatic events. The current study implicates the importance to be aware of the increased risks of traumatic injury among parents of children with ADHD. Proper education about accident prevention and management may be helpful to the parents of children with ADHD. Given that knowledge is fundamental to act, it is essential to educate the parents of children with ADHD the increased risk of traumatic injuries they may have. It is also to help the parents to look back upon their life experiences and detect the histories of encountering traumatic injuries. Detecting the association of inattention, impulsivity, and psychological burden on parenting with the occurrences of traumatic injuries should help the parents to raise alertness of and develop prevention strategies for the possibility of traumatic injuries. The need for behavioral and pharmacological intervention in parents of children with ADHD should be evaluated, especially in the parents with undiagnosed ADHD or subthreshold ADHD symptoms. It deserves further prospective studies with longer follow-up period to explore whether undiagnosed ADHD, care burden of parents, and children’s aggressive behaviors contribute to the increased risks of traumatic injuries in parents of children with ADHD.


Background: Attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood and causes adverse effects on social functioning. The present study aimed to widely investigate the predictors, particularly childhood intelligence quotient (IQ) and family environment factors, on adult clinical and academic outcomes in boys with ADHD.Methods: A total of 101 boys with ADHD in a Chinese Han ADHD cohort were followed up 7–10 years later. Baseline ADHD symptoms were evaluated using the parent version of the ADHD Rating Scale-IV (ADHD-RS-IV) and the Chinese version of the Conners' Parent Rating Scale-Revised (CPRS-48). The intelligence of the child was tested by the China-Wechsler Intelligence Scale for Children (C-WISC), and family function was assessed by the Family Environment Scale-Chinese Edition (FES-CV). Adult ADHD persistence was defined using DSM-IV criteria for ADHD, and academic outcome fell into two categories: higher academic level group (studying in senior middle school or above) and lower academic level group .Results: Stepwise multiple logistic regression analysis revealed that the father's character, impulsive–hyperactive index as measured by the CPRS-48, and intellectual–cultural index as measured by the FES-CV independently predicted clinical outcomes in adults, with an AUC of 0.770 . The corresponding sensitivity and specificity were 0.743 and 0.727, respectively. The father's education level, family economic level, and verbal IQ (VIQ) on the C-WISC independently predicted adult academic outcomes, with an AUC of 0.870 . The corresponding sensitivity and specificity were 0.813 and 0.783, respectively.Conclusion: Initial ADHD symptom severity and IQ, father's character and education level, and family atmosphere and function affect adult clinical and academic outcomes. Addressing these areas early may help to improve the prognosis of ADHD into adulthood. Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent childhood-onset neurodevelopmental disorders and is characterized by symptoms of hyperactivity, impulsivity, and inattention . It affeMany studies have indicated that the childhood intelligence quotient (IQ) may be an important predictor of adult ADHD persistence. A 2-year longitudinal study demonstrated that childhood IQ could predict ADHD persistence , which wMoving beyond IQ, the predictive indicators of family factors, such as family economic status, character and education level of parents, parental rearing patterns, parental relationship and health status of parents, especially maternal psychopathology and psychosocial adversity, have been reported in previous studies , 18–20. Therefore, our present study focused on using the FES-CV to investigate family environmental factors and using the parent version of the ADHD Rating Scale-IV (ADHD-RS-IV), Chinese version of the Conners' Parent Rating Scale-Revised (CPRS-48), and China-Wechsler Intelligence Scale for Children (C-WISC) to evaluate ADHD symptoms and IQ (VIQ and PIQ) in boys with ADHD. Furthermore, we followed this Chinese Han ADHD cohort and aimed to provide a comprehensive investigation of the predictors of adult clinical and academic outcomes. We hypothesized that hostile family environmental factors and poor VIQ or PIQ might have a predictive role on adult ADHD outcome, but VIQ and PIQ may have different effects.All participants were recruited from the Child Psychology Outpatient Department of the Third Affiliated Hospital of Soochow University, China from June 2009 to June 2013. Participants were originally included when they met the following criteria: (1) had been unanimously diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) alongside the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) by at least two experienced psychiatrists; a third psychiatrist appeared in cases of dissent between the first two psychiatrists; (2) boy aged 6–12 years, Han Chinese; (3) full-scale IQ (FSIQ) >70; and (4) first visit to the hospital and never received drugs for ADHD. Patients were excluded if they were diagnosed with schizophrenia, mood disorder, autism spectrum disorder, or physical and neurological disease.A total of 154 boys with ADHD completed the evaluation and were originally involved in the study, including 34 (33.66%) ADHD inattentive type (ADHD-I), 2 (1.98%) ADHD hyperactive-impulsive type (ADHD-HI), and 65 (64.36%) ADHD combined type (ADHD-C) subjects at baseline. The researchers did not interfere with the treatment given by the psychiatrist. They were all contacted to participate in the follow-up after they were 18 years of age (ranging from 18.01 to 23.80 years) from June 2019 to June 2020. The procedure was carried out in accordance with the latest version of the Declaration of Helsinki. This study was approved by the local Medical Ethics Committee of the Third Affiliated Hospital of Soochow University and was registered in the China Clinical Trial Registration Center: ChiCTR1800015877. Guardians of all subjects provided signed informed consent prior to the performance of any procedures related to this study.A self-designed questionnaire was used to collect demographic and clinical data of the participants and their parents, including age at diagnosis, family economic status, parental educational level, child and parental character, maternal health during pregnancy, only child or not, birth and delivery status, and family history. The age at diagnosis, maternal health during pregnancy, and birth and delivery status were recorded based on medical information. Family economic status was defined as the total monthly household income level, measured on a categorical scale of 1–3  . CharactADHD symptoms were evaluated using the parent version of the ADHD Rating Scale-IV (ADHD-RS-IV), which is a valid and widely utilized measurement tool used in school-age children with ADHD. The ADHD-RS-IV consists of 18 items corresponding to DSM-IV criteria for ADHD and is based on a four-point scale. Each symptom is scored based on how often it occurs . The score yielded by this instrument ranges from 0 (symptoms “never” occur) to 54  . The totT-scores within a mean ± standard deviation (SD) of 50 ± 10. The Chinese version of the CPRS-48 works well in evaluating symptoms and behaviors in children with ADHD, with the homogeneity reliability of Cronbach's α, the correlation of the Spearman-brown split-half, and the retest reliability of the total score being 0.932, 0.900, and 0.594, respectively  was also used to evaluate symptoms and behaviors in boys with ADHD , which iectively . In the The intelligence of the child was tested by the China-Wechsler Intelligence Scale for Children (C-WISC), which was revised by Gong and Cai at Hunan Medical University. The C-WISC consists of 11 individual tests that include six verbal tests  and five performance tests . Based on individual testing, vocabulary scores (V), procedure scores (P), and full scores (F) were obtained. Furthermore, the VIQ, PIQ, and full intelligence quotient (FIQ) were calculated progressively . All evaWe used the Family Environment Scale-Chinese Edition (FES-CV) for family environmental factor investigation, which included 90 items on 10 dimensions: cohesion, expressiveness, conflict, independence, achievement, intellectual–cultural, active–recreational, moral–religious, organization, and control. The interpretation of each item on the FES-CV is detailed in the previous literature . Each itThe DSM-IV was used for the Diagnostic Interview for ADHD in adults by trained researchers at a follow-up time point, and the clinical outcomes were defined in the following three categories: (a) subjects meeting full DSM-IV criteria for ADHD, (b) subjects meeting partial criteria for ADHD , and (c) subjects not meeting the DSM-IV criteria for ADHD at all. We further divided the adult subjects into two groups: the symptomatic persistence group (a and b) and the symptomatic relief group (c) .t-tests (homoscedasticity), t′-tests (homoscedasticity uneven), or chi-squared tests were used to compare the differences between groups as appropriate. Bonferroni corrections were used in scale comparisons between groups for multiple tests. Third, the variables that were statistically significant (p < 0.05) in the group comparison  were then entered into the stepwise logistic regression analysis (forward selection), with p-value criteria of 0.01 and 0.05 for entry and removal, respectively, and clinical or academic outcomes as the dependent variables. Finally, receiver operating characteristic (ROC) curves were used to assess the predictive effect of variables on outcomes. All tests were two-sided, and a p-value of 0.05 was used as the threshold for statistical significance.The Statistical Package for the Social Sciences (SPSS) version 23.0 was used for data analysis. First, we report the demographic data and clinical and academic outcomes of the subjects. Second, Student's t = 0.575, p = 0.566) or follow-up interval  between the symptomatic persistence group and the symptomatic relief group. However, our results showed that the symptomatic relief group had a better academic outcome than the symptomatic persistence group . Furthermore, the baseline demographic and clinical information of the follow-up group was similar to that of the drop-out group , except for the significant difference in the control index on the FES-CV .In the present study, only 35 of 101 (34.65%) boys with ADHD achieved symptomatic relief in early adulthood. There were no significant differences in age at follow-up . However, the symptomatic persistence group had a higher incidence of oppositional defiant disorder than the symptomatic relief group . The fathers in the symptomatic persistence group tended to be more introverted than those in the symptomatic relief group . For the rating scale, the symptomatic persistence group had higher subscale scores on impulsive–hyperactive  and ADHD index  on the CPRS-48 and lower subscale scores on intellectual–cultural  and active–recreational index  on the FES-CV compared to the symptomatic relief group. Only the difference on the intellectual–cultural index endured after Bonferroni correction (p = 0.026). There were no other differences on the CPRS-48, FES-CV, ADHD-RS-IV, or C-WISC between the two groups at baseline .p < 0.05), a stepwise multiple logistic regression analysis was used to determine the independent predictive factors for symptomatic persistence in boys with ADHD. As shown in p < 0.001, 95% CI = 0.678–0.863). The corresponding sensitivity and specificity were 0.743 and 0.727, respectively  or follow-up interval  between the higher and lower academic groups.Of the 101 follow-up boys with ADHD, only 32 (31.68%) entered senior middle school (at an average age of 15.54 ± 0.32 years), and the remaining 69 boys finished junior high school or studied in vocational secondary school. There were no differences in age at follow-up . The father's character varied significantly between the two academic level groups , and the family economic level was higher in the higher academic level group than in the lower academic level group . There were no baseline significant differences in age at diagnosis, ADHD subtypes, incidence of oppositional defiant disorder, only child or not, character of the child and mother, maternal health during pregnancy, birth and delivery status, family history, and treatment or not between the higher and lower academic level groups. Regarding the baseline intelligence of the boys with ADHD, our results indicated that the higher academic level group had better baseline VIQ , PIQ , and FIQ  evaluated by the C-WISC compared to the lower academic level group.As shown in t = 2.007, p = 0.047) but a higher intellectual–cultural  and active–recreational index score  on the FES-CV at baseline compared to the lower academic level group. There were no differences in other indices on the FES-CV and ADHD-RS-IV between the two groups .In addition, the higher academic level group had a lower control index score (p < 0.05), a stepwise multiple logistic regression analysis was used to determine the independent predictors for adult academic outcomes in boys with ADHD. Our results revealed that the father's education level , family economic level , and VIQ on the C-WISC  could independently predict adult academic outcome . The corresponding sensitivity and specificity were 0.813 and 0.783, respectively . The corresponding sensitivity and specificity were 0.743 and 0.727, respectively. Furthermore, we found that the father's education level, family economic level, and VIQ could independently predict adult academic outcome, with an AUC of 0.870 . The corresponding sensitivity and specificity were 0.813 and 0.783, respectively.The present study investigated childhood factors that predict the risk of symptomatic persistence and academic outcome of boys with ADHD into adulthood. In our follow-up investigation of 101 boys with ADHD, 65.35% continued to meet full or partial DSM-IV criteria for ADHD when they were adults, and only 31.68% of them entered senior high school. Our results indicated that the father's character, impulsive–hyperactive symptoms evaluated by the CPRS-48, and intellectual–cultural index in the family  could predict the persistence of ADHD in adulthood, with an AUC of 0.770 (Family characteristics have a profound impact on the experiences and life trajectories of offspring, playing an important role in emotional and behavioral development during childhood . Thus, tParental education attainment and family economic level are also important family factors and were significantly associated with the growth of children. Low education and family income could influence material conditions, parenting skills, social development, or stress and thereby influence children's mental health and learning . Early sIn the present study, we found that the intellectual–cultural and active–recreational indices on the FES-CV were associated with clinical and academic outcomes. Furthermore, the intellectual–cultural index could independently predict adult symptomatic persistence in boys with ADHD. Early literature indicated that a poor family atmosphere and function exacerbate the severity of ADHD and its prognosis , 47. AmpMost previous studies demonstrated that higher IQ had protective effects on functional impairment in children with ADHD, including educational attainment, occupational rank, and social and occupational adjustment , 15. In Strong evidence supports that the severity of childhood ADHD symptoms as reported by parents was a strong predictor of ADHD outcome at follow-up , 30. OurIn the present study, we used parent-reported ADHD symptoms, rather than self-reported symptoms, which made our results more reliable because ample evidence supports that young individuals tend to report fewer symptoms and that self-reported ADHD symptoms were poorly differentiated by objective measures , 53. HowIn summary, our cohort study indicated that only 34.65% of boys with ADHD achieved symptomatic relief in early adulthood, and only 31.68% of them entered senior middle school. More importantly, we demonstrated the predictive value of the father's character trait and education level, children's VIQ, and impulsive–hyperactive as well as family economic level and intellectual–cultural function on adult clinical and academic outcomes in boys with ADHD. Although there is a long journey in clinical practice to develop appropriate interventions and improve the prognosis of children with ADHD, our finding represents an incremental increase in this knowledge to some extent.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 Third Affiliated Hospital of Soochow University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.YR, HF, and XK conceptualized and designed the study. YR, GP, JC, and SW diagnosed patients and completed the screening assessments. XF and YR analyzed the data, performed the statistical analysis, and wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.