Data analysis, based on a descriptive and structuring procedure to determine the structure of lived experience characterized by the central axes of experience, produced two axes: (1) The process of methylphenidate prescription, highlighting how this prescription was motivated from the exterior, experienced as passive by the adolescents and required commitment from the CAPs; and (2) the perceived effects of methylphenidate treatment, in three domains: at school, in relationships and in the sense of self. Findings raised both the issues of the epistemic position and social representation of the adolescents about ADHD and methylphenidate within this specific French context, and the self-awareness and perception of the adolescents with ADHD. We conclude that these two issues need to be regularly addressed by the CAPs prescribing methylphenidate to avoid epistemic injustice and prevent the harmful effects of stigmatization.Many studies have demonstrated the short-term efficacy and tolerability of methylphenidate treatment adolescents with attention deficit hyperactivity disorder (ADHD). Qualitative literature on this matter focused on school outcomes, long-term side effects, family conflicts, personality changes and stigmatization. Yet, no qualitative study has crossed the perspectives of child and adolescent psychiatrists (CAPs) prescribing methylphenidate and adolescents with ADHD. This French qualitative study followed the five stages IPSE—Inductive Process to analyze the Structure of lived Experience-approach. Fifteen adolescents with ADHD and 11 CAPs were interviewed. Data collection by  Poor outcomes have been described, especially in the absence of treatment, including poor quality of life, substance use disorders, accidental injuries, educational underachievement, unemployment, difficulties socializing, delinquency, suicide, and premature death3. ADHD is one of the most researched disorders in psychiatry in many fields3 including research about genetic causes, environmental correlates, neuropsychological and cognitive processes, and co-occurrence with other psychiatric disorders5, but also social sciences research focusing on the epistemic validity of ADHD and on the ethical and sociological implications of its treatment6.Attention deficit hyperactivity disorder (ADHD) is characterized by the presence of developmentally inappropriate levels of hyperactive-impulsive and/or inattentive symptoms for at least 6 months in different settings and that impair various aspects of the patient's life3. Community prevalence has been estimated between 2 and 7%7. In their meta-regression analysis pooling data from 135 original studies, Polanczyck et al.8 found that neither the geographical location nor the year of study were associated with variability in the estimation of the prevalence. However, a large cohort study conducted in Israel reported an increase in the ADHD prevalence rate from 6.6 to 14.4% between 2005 and 20149, while in France, one study has estimated the prevalence of ADHD for French children aged 6–12 at from 3.5 to 5.6%10 and, a more recent one11, using data from French health care insurance reimbursements for methylphenidate prescription, estimated the prevalence rate of ADHD for French children aged 6–11 at only 0.3%. ADHD epidemiology is a controversial question12, especially in France. Commenting on the study of Ponnou and Haliday10, Ramus and Peyre13 pointed out its methodological flaws, especially the fact that “in France, methylphenidate is not the first-intention treatment for ADHD.” Indeed, the French guidelines, from the Haute Autorité de Santé  state that for children and adolescents “in the first instance, non-pharmacological interventions should be implemented, combining psychological, educational and social measures according to the child's needs. If these measures are insufficient, medication may be initiated (…) and must be integrated into a personalized approach for each child, reevaluated every month and prescribed in addition to non-pharmacological interventions.”14.It is the most frequent neurodevelopmental disorder in childrenMethylphenidate (MPH) is the only medication available today that is indicated as pharmacological treatment of ADHD14. Prescribing rules are strict, only psychiatrists, child and adolescent psychiatrists (CAPs), neurologists, and pediatricians are allowed to diagnose ADHD (or to confirm the pre-diagnosis of first-lines doctors), to initiate such treatment and make the annual renewal. Other renewals, every 28 days can be done by any physician14. In France, access to such specialists is limited, especially for CAPs and in some rural or poor areas, resulting a delay in diagnosing and treating ADHD. Moreover, assessment is quite heterogenous among French CAPs, gradually (1) a sole clinical assessment, (2) the extra use of functional subjective scales completed by parents and teachers, mainly the ADHD RS15 and the Conners16, and (3) neuropsychological assessments including a cognitive evaluation and attentional tests such as the Test of everyday attention for children (TEA-Ch). Many non-pharmacological treatments  are still not widely available. Five methylphenidate drugs are available in France . Since its initial marketing authorization in 1996, consumption—initially low—has grown significantly and constantly17, with a major acceleration in sales in 2004, concomitant with the introduction of the extended-release drug forms. The consumption among adolescent increased by 21.5% between 2012 and 2014, French adolescents the latter year accounted for about 40% of the persons receiving this treatment. Methylphenidate use nonetheless remains relatively low in France compared to other developed countries17. This echoes a lack of consensus regarding how to consider and approach ADHD in France with different opinions and views, not only in the French society18 but also among French mental health professionals. As a matter of fact, there is an important heterogeneity of practice among French CAPs for using the concept of ADHD and using methylphenidate as a treatment.In France, 3. A comprehensive network meta-analysis of 133 double-blind RCTs demonstrated its short-term efficacy versus placebo and showed that it was the only drug with better acceptability than placebo19. Systematic reviews have shown that psychostimulant treatment is often associated with better outcomes in adolescence: better academic performance and social relationships and fewer accidents20. There are however some concerns about side effects of medications—including appetite suppression, sleep issues, and impact on growth with extended treatment21—as well as a lack of evidence about its long-term efficacy.Many randomized controlled trials have shown the short-term efficacy and tolerability of methylphenidate for ADHD22. ADHD also acts a risk factor for the emergence of many disorders during adolescence, especially substance use and mood disorders23. ADHD during adolescence is a major predictor of an array of physical, mental, work, and financial problems in adulthood24. Furthermore, specific issues related with adolescence—identity construction, intersubjective and social relations—collide with ADHD. Several qualitative studies have emphasized that adolescents experience and understand ADHD through the core aspects of self , identity development, agency, and social connectedness28. Some social factors, such as social acceptance, have showed some protective effects on academic functioning on adolescents with ADHD29. A metasynthesis of 11 qualitative studies exploring the lived experience of adolescents diagnosed with ADHD found similar themes—societal pressure, sense of self—but also maturational shift from passive to active and feelings about medication30. Indeed, specific issues have been described regarding the use of stimulants among adolescents with ADHD. Buitelaar31 argued that therapeutic strategies in adolescents with ADHD are merely the same as the one for children and are not targeting specific aspects that make “adolescents special and vulnerable, such as poor insight into own functioning and poor decision making”. Poor medication adherence31, treatment discontinuation32 and misuse33 of methylphenidate among adolescents with ADHD have been reported.Adolescence is a complex developmental period with identity and relational turmoil that can impact both clinical aspects of ADHD and treatment. The course of ADHD varies highly through adolescence with different trajectories being modelized in the literature from age-related improvement—more for hyperactivity-impulsivity symptoms than attention deficit—to worsening symptoms37, their families41 healthcare professionals—both first-line and specialists42 and teachers39, through individual interviews or focus groups. The findings report some positive outcomes—fewer problems at home and at school, reduction of disruptive behavior, improvement of peer relationships39—and some negative experiences with methylphenidate use, such as side effects36, changes in sense of self37 and stigma—yet more related with the ADHD symptoms than the medication use37. Several studies address how difficult the decision to use medication was for the parents40 while Leslie et al.41 described different patterns in which parents first either chose non-pharmacological treatment or rapidly engaged in the medication use. Two studies reported, among adolescents and parents, the progressive autonomy and transfer of responsibility for managing medication34. The issue of continuation or cessation of treatment, along with breaks through planned holidays—was the focus of three qualitative studies among healthcare professionals42, reporting how some patients could manage to stop the treatment, while other “felt the need to restart”39.There is already a consistent qualitative literature exploring the views about methylphenidate treatment for adolescents with ADHD, coming mostly from Western English-speaking countries and collecting data from adolescents or young adults with ADHDTo our knowledge, no qualitative study has yet examined this specific topic in France.The aim of our study was therefore to explore the lived experience of methylphenidate use among French adolescents with ADHD and child and adolescent psychiatrists (CAPs) and to cross the perspectives of these two groups so to develop original insights.43. IPSE is informed by a descriptive phenomenological approach and relies on an inductive process that probes in depth the lived experience of patients and healthcare professionals and analyzes the structure of their experiences. Five stages, described below, structure the research process. The report of this study adheres to the COREQ guidelines44 ((i)approved by the "Conseil pour l'évaluation ethique des recherches en santé Université Paris-Déscartes" . All adolescents and their parents provided written informed consent before inclusion in the study.(ii)44—and regulations, that is in accordance with the declaration of Helsinki regarding the principles for medical research involving human subjects.performed with relevant guidelines—COREQThis exploratory qualitative study used the Inductive Process to analyze the Structure of lived Experience (IPSE) approachelines44 . All proOur research group included four psychiatrists, each with different experience regarding ADHD and methylphenidate prescriptions: one has never prescribed methylphenidate, one prescribes it occasionally, and two specialists in ADHD, prescribing it regularly. The group also included two psychiatric trainees, a psychologist, and a medical doctor from another specialty, all trained in qualitative methods. For heuristic purposes—that is, to enable to discover new unknown elements and to produce original findings—the group’s members were highly diverse, especially in their knowledge, age, and backgrounds. The group worked continuously on reflexivity during open discussions among themselves.Two members of the group reviewed the qualitative and quantitative literature systematically, to confirm the study's relevance and originality. They verified that no qualitative study of this specific topic and explicitly crossing the perspectives of adolescents and CAPs had been conducted. To ensure that the other group members could remain inductive and open to novelty, they had access to this review only after they had completed the data analysis.43 and to include participants who might enrich and add something new to previous findings. We thus used a purposive sampling strategy with maximum variation45, that is to select adolescents who differed by sex, age, family status, duration of disease and methylphenidate treatment, and outcomes of care; and to select CAPs who differed by sex, age, frequency of methylphenidate prescription, and work setting. Researchers identified potential participants whom they considered likely to provide the most information. In practice, after presenting the study design and inclusion criteria during an initial meeting, the research group had regular exchanges with the physicians, during the data collection period, in both child-adolescent psychiatry departments in which recruitment took place so to ensure a variation of those criteria and a variety of exemplary situations. Thus, the physicians helped us to identify adolescents that had relevant and original information to provide.The research group defined the inclusion and exclusion criteria Table  intended46—here based on the criteria described by the authors: “the quality of dialogue” during the interview, “the aim of the study” and the “sample specificity”, that is “the specificity of experiences, knowledge, or properties among the participants included in the sample”46. For both subgroups, inclusion of new participants continued until the analysis of new material no longer yielded new findings; that is, data collection and analysis were complete when the research group considered that the axes of experience obtained provided a sufficient explanatory framework for the data collected47.Sample size was not defined in advance but was determined by data saturation according to the principles of “information power”Patient recruitment took place in two child-adolescent psychiatry departments in the Paris suburbs during face-to-face encounters; they had catchment areas with distinctively different socioeconomic profiles. CAPs were recruited in both public hospitals and private practice, from the networks of both departments through emails and telephone.open-ended approach48, structured by areas of exploration , and one female psychologist (EM), all public health researchers (introduced as such to the research participants) trained in qualitative methods. Interviewers did not have any contact with the participants prior to the study. They conducted semi-structured interviews using an on Table  collecti43. The IPSE analytic process is a rigorous procedure that relies on an inductive, phenomenological method43. In practice, the analysis had two stages: one stage of independent work by the three researchers, aided by Nvivo software, and the other by the group as a whole, pooling the data collectively. In the individual procedure, the three qualitative researchers independently and simultaneously conducted a systematic descriptive analysis to convey each participant’s experience. This involved for each interview: (1) listening to the recorded interview twice and reading it three times; (2) exploring the experience word by word, that is, cutting up the entire text into descriptive units; (3) regrouping the descriptive units into categories. These stages are carried out with the help of QSR NVivo 12 software. During the group process, the three researchers met regularly with the other group members, who had familiarized themselves with the data by listening to and reading all the interviews as many times as necessary. These two-hour meetings began after the analysis of five interviews. The first set was intended to conduct the structuring phase, that is, to regroup the categories into axes of experience, constructed such that each could be linked to its subjacent categories, and then to determine the structure of lived experience characterized by the central axes. The second set of meetings covered the practical phase, the process of triangulation with the data in the literature that made it possible to identify the original aspects of the results and to suggest potential practical implications of the finding to improve care.The analytic procedure followed the IPSE approachWe used several criteria to ensure the rigor of the analysis and the trustworthiness of the results: triangulation, attention to negative cases, reflexivity within the group process, and feedback from "subjects of the experience” by presenting the results to a group of adolescents with ADHD and treated with methylphenidate (N = 5) and a group of CAPs who had experience using methylphenidate to treat adolescents with ADHD (N = 5). They all recognized their own experience in the structure we proposed.Reflexivity—the researchers’ reflection of their role in the study and its effects on their findings at every step of the research process—was worked on constantly in the group, during open discussions between the researchers. To address the diversity of reflexive positions within the group, two questions were asked to each member: (i) “What are your preconceptions and my beliefs about the phenomenon under study and the research question? “And (ii) “What are your expectations regarding this study?”. All the members listed and shared with the group their preconceptions and beliefs about both ADHD and methylphenidate treatment, as well as their personal motives to be part of this research and what they were expecting to find or achieve.The study included 15 adolescents (4 girls and 11 boys) and 11 CAPs specialized in treating adolescents for a total of 26 participants. No one approached refused to participate.Table Data analysis produced a common structure of lived experience based on two central axes of experience: 1) the process of methylphenidate prescription, and (2) the perceived effects of methylphenidate  I was a child, children they are joyful and have fun, no?”Adolescents and CAPs reported that the process leading to methylphenidate treatment originated with the identification of problems in the exterior world—in the family or in a school setting—but that the adolescents did not appear to perceive internally.A11 “So I started Concerta in year 7 (7th grade) because they said I had trouble getting myself to start working, problems of organization.”School problems concerned schoolwork—difficulties in learning and in concentration, poor grades—as well as inappropriate behavior in school. Some adolescents experienced painfully the fact of “being bad at school” and reported being portrayed as “dumb” (A2) or “stupid” (A4) by their peers and even their teachers.A10 “My mother always wanted me to do my homework, extra homework, or extra exercises, and I didn't want to, so it created problems at home… The ambiance at home was not good.”The family problems concerned conflicts around school results and schoolwork, or relationship problems with the parents or siblings.A8 “the teachers said there was something wrong with me … they said I had a little problem and that there was a medication that might help”.The adolescents reported that their parents, and sometimes their teachers, attributed all the problems to ADHD and leading to the search for professional help, sometimes directly for a methylphenidate prescription.A4 “I didn’t know what it was to be hyperactive. I thought I was just a normal child who had stronger adrenaline.”Most of the adolescents did not recognize themselves in this process and mentioned a discrepancy between their perception of their problems and the attribution to a disorder. They did not consider these "problems" to be pathologies, but rather perceived them as part of their identity. They described themselves as "normal" (A5) and used expressions such as "head in the clouds" (A2) and "scatterbrained"(A1). Only some adolescents retrospectively recognized an abnormal aspect to their experience, but only in comparison with other children.P9: Parents especially can’t stand it anymore, it's 'it's unbearable, give him a good dose’.The CAPs all reported that this request came from families or school based on externalized problems. Some CAPs underlined the parents' exhaustion or their high demands of the child.P6 “the school sent an ultimatum: if it's not treated rapidly, he'll have to repeat the year.”Others recognized the need to respond to a demand expressed above all by the school.A15″ I was passive. … my parents, they are really very stubborn. They profoundly believe that if there's a medication to take, you buy it, and you take it.”The adolescents described themselves as passive in the decisions related to the start of medical treatment. They said they "obeyed" (A2) or "complied with" (A14) the decisions of adults in general and of their parents in particular.A5 “At the beginning I didn't want to take it (…) my father told me, "try it and then you'll see yourself if you want it’. I saw it was really not bad at all, I continued taking it … not so much for my grades. OK for my parents it's for my grades, for me it helped me in my everyday life,”Some had initially refused the treatment, because that would have confirmed the abnormal nature of their behavior. Once they tried the treatment, most were convinced of its interest but for reasons different from those of their parents.passive prescription situations, where parents had "almost dictated the Ritalin prescription to me (P2)." Some mentioned an erosion of their medical role, reduced to the sole act of writing the prescription. They also perceived the passivity of the teen, who seem to them to be led by his or her parents and who had no requests of his or her own.P8 “They were truly led here by their parents. If you asked them, they had no reason to be here”.The CAPs also reported some P10 “because inevitably when you think it's indicated, you push a little to prescribe it.”The CAPs reported few situations where the family was not convinced that a treatment by methylphenidate was necessary. The CAPs explained that they didn’t hesitate to be more insistent and directive, especially when they were sure the adolescent would benefit from this treatment.choosing a camp within the discipline of child and adolescent psychiatry, and supporting "the theoretical point of view" (P8) that ADHD is a neurodevelopmental disorder.The CAPs reported the current situation in France regarding the lack of consensus between psychiatrists about to the use of methylphenidate and the views about ADHD. Prescribing methylphenidate meant also taking a personal "activist" stance (P1), P7 “I prescribe medication for children who are ill. I do not prescribe drugs for children to have the best grades in school, it's an ethical question.”They were aware that some people (both from the society and the discipline) could consider their prescription as “biological empowerment” and highlighted their medical professionalism and ethics.Adolescents and CAPs principally reported effects on the outside world—school, but also relationships and, to a lesser extent, on the adolescents themselves.A14 “(Do you take the medication on the weekend too?) Only when I have to work”The adolescents reported first of all numerous changes related to school: better attention and concentration in class, faster note-taking, better quality writing, and a greater capacity to work. They insisted principally on two points: increased autonomy and better performance at school. These numerous benefits at school led the adolescents to consider the drug as a tool for their schoolwork, adapting their intake solely according to this variable.A2: “I don't think I'll take it for my whole life, but today I think that without it I would not necessarily manage to meet the objectives I've set for myself.”Many adolescents saw in this drug a guarantee of their academic and professional success. They associated their academic and future professional objectives with continuation of this treatment.I don't know if it’s doping or not … the person still has to make an effort … without the work, it wouldn't accomplish anything. It's not going to make someone intelligent.”A8: “Finally, they asked themselves about the doping nature of the product.P7: “he's different so society, school, don't tolerate him; so we make it possible for him to be tolerated.”Some psychiatrists also reported questions by their patients about whether the drug's stimulant effect could be perceived as doping or cheating. They would answer that this treatment compensate for a disability and liberate the potential. All the CAPs questioned mentioned the effects at school, principally grades, as one of the principal markers of therapeutic success. Methylphenidate allowed to meet the school system's demands so school would tolerate their patient's behavior. Some also reported having to meet a demand for academic performance.A2: “I noted that I was fighting less, I was becoming more friendly with people”.The adolescents reported improvements in their relationships: easier and less conflictual interactions with better integration in peer groups or calming of family conflicts.A15 “I noticed that it was cutting off my relationships with others.”Nonetheless, the adolescents also described some negative effects on relationships, in particular a loss of spontaneity and paying more attention to others' judgments. Several even reported an experience of no longer associating with their peers, of becoming isolated.P7 “the teachers also have a representation, and as a result they say to themselves, no it's not that he doesn't care about anything, in fact, he's different.”The CAPs raised the question of the effects on relationships through the prism of the calming of family conflicts or of its effects on schooling; they argue that the medication improves the relationships with teachers.A9: “Before, I was extremely dreamy, that is, I always had a story in my head, that I was inventing, like that … but that was before.”The adolescents identified either an increase or a decrease in their appetite that they associated explicitly with the treatment, with some worried about their growth, both height and weight. They also mentioned sleep problems frequently, especially insomnia. They also described a change in their thoughts, which they experienced as less intrusive, and in their imaginative life and their daydreams, which they perceived as less intense.A14: “I don't know if it's a medication or a form of torture, except for tests at school (…), the feeling of malaise that I can feel sometimes, it's torture … I'm someone who is well connected to my feelings, but it reconfigures me.”Some also observed moderation of their emotional expression. Few described their inability to perceive their emotions and reported experiences of ennui, and loss of both desire and pleasure. Some adolescents mentioned their impression that the treatment masked who they really were, that they no longer recognized themselves.P6 “It's to optimize their own abilities, but it's not going to affect their temperament or their personality”.Some CAPs said that they warn the patients that the treatment is going to modify their behaviors but not their personality. Most of the CAPs reported considering the adolescents' subjectivity and addressing with them the medication's effects on them personally, especially around the themes of self-esteem, self-control, and freedom.P7: That's where it gets a little complicated; they see that they are working better in school, and nonetheless they feel that things are not ok and that they are no longer themselves.The prescribers nonetheless remain more focused on the objective markers of the therapeutic effect than of the changes of adolescents’ sense of self, in choosing to target the elements identified by neuropsychological tests and by using terms such as "correct” ,” “compensate” , “optimize” ,” or “boost” (P3). Finally, several CAPs mentioned "contradictory" effects associating an improvement of external functions, but a subjective deterioration reported by the teen.This qualitative study explored the lived experience of methylphenidate use among French adolescents with ADHD and CAPs.39, are reported here by both the French adolescents and CAPs. Our findings also reported negative experiences with methylphenidate use, already described in the qualitative literature, that is the side effects36, and the changes in sense of self37 but also some negative effects on their peer relationships related with these changes in sense of self, with few adolescents even experiencing social isolation.Many of our findings were already reported by the qualitative literature from English-spoken countries. Positive outcomes, such as improvement of both family and peer relationships and better academic performance described in several studies50 has already described how both ADHD diagnosis and treatment impact the self-concept and self-understanding of adolescents, leading for example to negative self-attributions, while Charach et al.34 have reported how methylphenidate can negatively affect the adolescent's sense of self, especially due to the product's rapid effect.The issues of both the sense of self of adolescents with ADHD and how it is modified by methylphenidate is particularly emphasized in our findings. Singh51. One relevant finding in our qualitative study is in line with this feeling of separation between the self and the outside world: The French adolescents in our sample didn’t, initially, neither recognize nor accept the diagnosis of ADHD. Only externalized behaviors and the perception of others made it possible to diagnose ADHD and led to methylphenidate treatment. Some studies have demonstrated that adolescents with ADHD can have a weak self-awareness of their disorder, inaccurate perceptions of their symptoms and a low level of agency52. They often display a positive illusory bias, with positive ideas about their skills and competence, despite their difficulties53. Yet, in our study, the adolescents were aware of their externalized (ab)normal behaviors but did not consider them as pathological, as signs or symptoms of a medical condition. Moreover, some adolescents in our sample considered ADHD to be an external attribution, and other raised the issue of methylphenidate as a doping drug. We can question whether the issue is at a self-awareness and agency level or more related with social representations of ADHD in France. The adolescents of our sample were in fact mirroring a critical epistemic position denying the existence of ADHD as a biomedical entity and denouncing both the medicalization of social (ab)normal behaviors and the risk of biological empowerment54; while the French CAPs prescribing methylphenidate considered this prescription as the proof of their affiliation to another epistemic position—naturalistic—stating the well-established existence of ADHD as a neurodevelopmental disorder54. There is a substantial French literature about the reception and implementation of the concept of ADHD in France. Even if the current tendency is to integrate different models so to have a multidimensional understanding of ADHD, Bader and Mazet55 underlined how the French child and adolescent psychiatry culture—influenced by psychoanalytical theories, focusing on intrapsychic factors and relational dimensions, as well as on the symbolic aspects of symptoms—have shown some reticence and resistance against the implementation and use of ADHD concept since the second half of the twentieth century. Several French scholars, from medical and social sciences, have been denouncing a “scandalous” disorder56 or a “false epidemy”57. Moreover, a recent study has found major distortions of scientific consensus (95.5%) between 45 French medical theses dedicated to ADHD published between 1990 and 2018 concerning the etiology, diagnostic and therapeutic strategies58, the authors pointing the ideology presiding over physicians' social representations of ADHD. French CAPs prescribing methylphenidate to adolescents with ADHD should take into consideration this specific context and explore with each adolescent what are his or her representations of both ADHD and methylphenidate before initiating such treatment.A metasynthesis exploring adolescents' lived experience of ADHD found behaviors, emotions, and thoughts experienced as "things that exist outside themselves, as aspects not related to their will and intentions but rather to the ADHD (…) this experience may create a feeling of separation between the self and one’s own behaviors, thoughts, and emotions”59. Public’s uncertainty concerning the validity of an ADHD diagnosis, public’s skepticism toward ADHD medication and disclosure of diagnostic status as well as medication status of the individual with ADHD have been identified as variables contributing to stigma in ADHD60. The stigmatization affects teens substantially, adding with supplementary psychological distress and increasing the risk of at-risk behaviors, substance abuse, and the loss of social support61. Our findings suggest that during their encounters with their CAPs, the adolescents in our sample could not express fully neither their self/inner experience , nor their interpretations, social representations, or epistemic positions (hermeneutic injustice). These adolescents might be victims here of epistemic injustice62, a mechanism that amplifies their stigmatization and its harmful effects. Even more, the way that the adolescents in our sample resign themselves to the passive acceptance of this treatment echoes the cognitive bias of the labeling effect: as if some adolescents finished by conforming themselves to the exterior (and normative) gaze upon them and have integrated it into their self-concept, thus biasing their judgment of their future activities.Moreover, there is also a substantial literature about the stigmatization of adolescents with ADHD. Persons with ADHD are at high risk to face stigma, prejudices, and discriminationOur findings suggest that French CAPs prescribing methylphenidate to adolescents should address, before initiating and during the treatment, both the issues of the adolescents' own perceptions and awareness of their ADHD symptoms and their social representations and epistemic positions toward both ADHD and methylphenidate. Addressing such issues, we think, could prevent potential epistemic injustice and the amplification of stigmatization through self-stigma  process.63. Fourth, we found no difference in the lived experience of the four adolescents who were diagnosed and started treatment only during adolescence (after the age of 12 years) compared with those diagnosed at a younger age, yet further research focusing on late diagnosis (among older adolescents and young adults) could be of interest to explore and compare aspects of our results especially regarding identity and interiority. Finally, in our study design we sought to recruit only CAPs prescribing methylphenidate, so to cross the perspectives with the adolescents treated with it. However, the practices of French CAPs vary strongly both in their acceptance of the concept of ADHD and in their use of psychostimulants as treatment. Further research should explore this diversity of thoughts and practice among French child and adolescent psychiatrists.This qualitative study has some limitations that must be considered. First, it took place in France, and caution is required in transposing our findings to other places because, as discussed above, fondings are embedded in the French sociocultural context, in general, and within the French system of child and adolescent psychiatry, in particular. Second, the population of adolescents was recruited in specialized departments of child and adolescent psychiatry, and all the psychiatrists specialized in children and adolescents. Our results therefore do not apply to adolescents receiving this treatment in other contexts of care or specialties . Third, subgroup analysis of adolescent boys and girls did not reveal any differences between them in relation to these results, although gender differences in both the phenomenology of ADHD and treatment effects have been described in the literature64.These results of this study directly question both the roles of the self-perceptions and epistemic positions of the adolescent with ADHD in the clinical evaluation and decision-making concerning the prescription for methylphenidate. Treatment decisions should be based on external aspects but the adolescent's sensitive experience and perception plus his or her own interpretation and social representations of ADHD should be discussed during the consultations. And what about the adolescent's consent? We consider that it is impossible to be satisfied with the adolescent's passive acceptance or secondary adherence based only on exterior and normative appearances. Adolescents with psychiatric disorders should be given opportunities to be the agents of their own management and changeSupplementary Information.


Within both groups the Behavior Rating Inventory of Executive Function-Adult (BRIEF-A) Global Executive Function Composite score (GEC) and the Beck Anxiety Inventory (BAI) were moderately correlated. Further, within the study group correlations were found between the BRIEF-A-GEC and the Sensory Responsiveness Questionnaire (SRQ)-Aversive scores , and between the BRIEF-A Behavioral-Rating-Index and the parental self-efficacy scores . Within the control group, negative correlations were found between the BRIEF-A-GEC and SRQ-Hedonic scores . Conclusion: Self-efficacy, executive-functions, high sensory responsiveness and anxiety traits are interwoven and may impact parental co-regulation ability.Background: Attention deficit hyperactivity disorder (ADHD) is a complex neurological condition interfering with family relationships and co-regulation capabilities. Therefore, exploring factors underpinning parental co-regulation ability is crucial for future fostering relationships in families of children with ADHD. Objective: This preliminary study aims to characterize and compare the executive-functions, anxiety, self-efficacy, and sensory modulation in mothers of children with and without ADHD. Method: Mothers of children with (study group) and without  ADHD completed online self-reports, measuring executive-functions; parental self-efficacy; anxiety; and sensory modulation. Results: The study group (N = 40) had lower self-efficacy compared to the control group (N = 27;  Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders diagnosed in childhood , being cNot surprisingly, parenting a child with ADHD is considered highly stressful and demanding ,13. MoreParental capabilities for regulating the behaviors of children with ADHD largely derive from their EFs ,31. EFs Parental self-efficacy, a parent’s belief in his/her ability to successfully perform the parenting role , has beeCo-regulation challenges, particularly in parents of children with ADHD, are also impacted by sensory modulation dysfunction (SMD). Modulating the sensory input, the ability to respond to sensory stimuli adaptively and sufficiently, is a critical neurobehavioral process allowing the environment and surroundings to be comprehended, which is fundamental for the enablement of sufficient responses to encountered sensory stimuli ,55. SMD,Taken together, this preliminary study aimed to characterize and compare EF, self-efficacy, anxiety, and sensory modulation in mothers of children with and without ADHD. Deepening the understanding of parental characteristics and predispositions may have far-reaching implications for fostering healthy relationships, specifically co-regulation within families with children diagnosed with ADHD.This preliminary study was a cross-sectional study carried out via an online survey that was distributed through social media networks. This study was approved by the Institutional Ethics Committee (#0002738-1), and all the anonymous participants consented to participation online before completing the survey.Mothers of children with and without ADHD were invited to participate in the study, since mothers are considered the primary care provider .Inclusion criteria stipulated mothers of children ages 6–12 with or without ADHD and with no other diagnosis.The Behavior Rating Inventory of Executive Function—Adult Version (BRIEF-A)  is a stato what extent are you satisfied with your child-rearing skills?) or statements . Using a 6-point response scale , the total score is calculated as the sum of all item scores ranging from 5 to 90, where higher scores represent a greater level of parental self-efficacy. Factor analysis yielded four factors that accounted for 18.5% of the variance in the ability of a mother to set limits for her child. Construct validity via the known group procedure as well as and internal consistency of α = 0.88 have been reported [The Parental Self-Efficacy Questionnaire  is a stareported .The Beck Anxiety Inventory (BAI)  is a widI am bothered by the way new clothes feel; I am bothered by background humming noises , and responders are required to rate the intensity of their responses. Using a 5-point Likert scale ranging from 1  to 5 (very much), the SRQ-IS provides 2 scale scores: SRQ-Aversive (32 items), representing high sensory responsiveness, and SRQ-Hedonic (26 items), representing low sensory responsiveness, where higher scores indicate higher/lower sensory responsiveness, respectively. Internal consistency indicated a high Cronbach’s alpha , as well as criterion and construct validity [The Sensory Responsiveness Questionnaire—Intensity Scale (SRQ–IS)  is a stavalidity .A demographic and behavioral questionnaire was developed for this current study, inquiring about mothers’ age, marital status, education, socioeconomic status, and their children’s age and grade. In addition, mothers were requested to rate their child’s performance on homework preparation and social functioning using a 10-point scale ranging from 1 (significant difficulties) to 10 (no difficulties). Additionally, their child’s social, behavioral, and organizational difficulties were queried.An online survey was distributed through social media to mothers using the Qualtrics platform, in one questionnaire sequence which took approximately 15–20 min to complete.p < 0.05 was set for all tests. The magnitude of group differences was assessed by calculating Cohen’s d-effect size as small (0.1), medium (0.3), or large (0.5) [Using IBM SPSS Statistics version 24, descriptive statistics were used to describe the sample and variables. The Shapiro–Wilks test was used to test for normality. Group differences were tested for using independent-samples t-tests or chi-square tests for categorical variables. Within each group, correlations were assessed between all variables using Spearman correlations. Correlations were considered low (ranging from 0.25 to 0.49), moderate 0.5 to 0.75), or high (>0.76) . A significance level of , or highp > 0.05) were found between groups in terms of age, education level, marital status, socioeconomic status, or their child’s age  age 40.9 (5.6) years)—henceforth called the study group—and without ADHD  age 42.5 (5.0) years)—henceforth called the control group—participated in this study. No statistically significant differences . Further, the groups differed in the SRQ-Hedonic score; the study group reported statistically significantly higher scores, showing a moderate effect size. No statistically significant group differences were found in the BRIEF-A (on the GEC and both indexes BRI and MI), SRQ-Aversive scale, or the BAI see .Within the study group: The BRIEF-A indexes were moderately correlated with the BAI scores; higher scores (lower EF) were found to be significantly correlated with elevated anxiety. In addition, the BRIEF-A indexes and the SRQ-Aversive score were found to be moderately correlated. Thus, lower EFs (higher scores) were significantly correlated with higher sensory responsiveness .Within the control group: The BRIEF-A indexes were moderately correlated with the BAI scores; higher scores (lower EF) were found to be significantly correlated with elevated anxiety. The BRIEF-A indexes were negatively correlated with the SRQ-Hedonic scale; thus, lower scores (better EF) were found to be significantly correlated with higher SRQ-Hedonic scores (low sensory responsiveness). The BRIEF-A BRI index was negatively correlated with the Parental Self-Efficacy scores; thus, lower scores (better EF) were significantly correlated with a higher perception of parental self-efficacy .Statistically significant group differences were found in children’s homework preparation and social abilities, as well as in their behavioral, emotional, and organizational skills difficulty . MothersThis preliminary study aimed to explore EFs, self-efficacy, anxiety, and sensory modulation in mothers of children with ADHD, attempting to better understand factors affecting their co-regulation abilities ,50,76,77The abovementioned challenges may yield familial strains, elevated stress, and reduced parental competency, as previously reported ,83. As pThis study did not find significant differences in executive functions, anxiety, or sensory-aversive responses between mothers of children with and without ADHD. Further, amongst mothers of both groups, executive functions and anxiety traits were linked, demonstrating that lower executive function abilities are related to elevated anxiety traits, indicating in both groups that deficiencies in abilities such as initiation, working memory, and planning and monitoring task regulation are linked to increased anxiety. It may be suggested that inefficient executive functions to master daily activities induces elevated stress in mothers’ day-to-day interactions with their children . In turnover-responsiveness is linked to reduced EF abilities. Interestingly, in the control group (mothers of children without ADHD), we found that higher sensory under-responsiveness is linked to higher EF abilities. This is the first study reporting these ties among mothers of children with ADHD, which may support previous reports demonstrating that adults with specific difficulties  and reduced executive function abilities also exhibited sensory modulation difficulties and compromised self-regulation capabilities [Among mothers of children with ADHD, we found that higher sensory bilities ,87,88. Cbilities ,90,91,92bilities . Findingbilities . While pbilities ,93,94, sbilities ,96.Appropriately managing ADHD symptoms utilizing EF strategies and self-regulation in children with ADHD emphasizes the need for parental intervention. The current clinical practice guidelines for the treatment of children ages 6–12 with ADHD include the use of medications along with parent training and/or behavioral intervention, preferably both . FurtherThis study had several limitations. As a preliminary study, we used a small sample size comprising mothers only. In addition, data on past or present treatments or counseling, despite being common, were not requested and thus might influence the findings. Increasing the sample size and widening the scope to include both parental views and previous interventions may yield a better understanding of family dynamics. Further, this study overlooked mothers’ own ADHD diagnosis as well as personality traits, psychiatric conditions, and major life events, which may have affected the findings. To deepen the understanding of EFs in mothers of children with ADHD, future studies ought to consider those confounding factors. In addition, in the current study, the nature and source of children’s ADHD were not investigated, which may limit the understanding of ADHD manifestation and its implications. Future studies should identify the source, type, severity of the ADHD diagnosis and comorbidities, and the level of difficulties caused by ADHD in boys vs. girls. This will allow a better understanding of the mothering of children with ADHD.Mothers of children with ADHD demonstrate lower self-efficacy and lower sensory responsiveness. Further, in mothers of children with ADHD, less sufficient EF abilities were linked to higher sensory responsiveness, anxiety, and lower parental self-efficacy. Thus, self-efficacy, executive functions, high sensory responsiveness, and anxiety are uniquely interwoven in mothers of children with ADHD and may interfere with family relationships. These should be addressed to broaden research and clinical perspectives targeting co-regulation in families with children with ADHD.


There are animal models associating dopamine dysfunction with behavioral impairments that model attention deficit hyperactivity disorder (ADHD). Erythropoietin (EPO) has trophic effects on dopaminergic neurons.The aim of this study was to examine the Erythropoietin (EPO) plasma levels and determine whether there was any correlation between plasma EPO levels and clinical characteristics of Attention-Deficit/Hyperactivity Disorder(ADHD).Plasma EPO levels were measured in 78 drug naïve children with ADHD and in 81 healthy children. The severity of ADHD symptoms was determined by scores on the Korean ADHD Rating Scale (K-ARS) in children and healthy controls.The ADHD group consisted of 64 boys and 14 girls, and the healthy control group of 31 boys and 50 girls. The median plasma EPO levels in ADHD children was 12.9 mIU/mL, whereas it was 12.0 mIU/mL in the healthy controls. This difference was not statistically significant. Participants in the highest tertiles of plasma EPO had a 1.49 times higher risk of ADHD than those in the lowest tertile, and those in the second highest tertile had a 2.39 times higher risk of ADHD than those in the lowest tertile. Plasma EPO levels correlated positively with some K-ARS scores, including hyperactivity-impulsivity score and total score. The significant difference in hyperactivity-impulsivity score comparing participants in the second highest with those in the lowest tertile. total K-ARS score was significantly higher in the second highest tertile of plasma EPO compared to those in the lowest tertile.These findings suggest that plasma EPO levels were related to some ADHD symptoms, which could be used in the monitoring of the disorder. Further studies are required to clearly understand the source and role of EPO in ADHD.None Declared


N = 2311 adults age 50 and older, of European-ancestry, with blood-based epigenetic and genetic data. The ADHD-PGS was calculated from a prior genomewide meta-analysis. Epigenome-wide DNA methylation levels that index biological aging and earlier age of mortality were quantified by a blood-based biomarker called GrimAge. We used a structural equation modeling approach to test associations with single and multi-mediation effects of behavioral and contextual indicators on GrimAge, adjusted for covariates.Shortened lifespans are associated with having Attention Deficit Hyperactivity Disorder (ADHD), which is likely mediated by related behavioral and sociodemographic factors that are also associated with accelerated physiological aging. Such factors include exhibiting more depressive symptoms, more cigarette smoking, higher body mass index, lower educational attainment, lower income in adulthood, and more challenges with cognitive processes compared to the general population. A higher polygenic score for ADHD (ADHD-PGS) is associated with having more characteristic features of ADHD. The degree to which (1) the ADHD-PGS associates with an epigenetic biomarker developed to predict accelerated aging and earlier mortality is unknown, as are whether (2) an association would be mediated by behavioral and sociodemographic correlates of ADHD, or (3) an association would be mediated first by educational attainment, then by behavioral and sociodemographic correlates. We evaluated these relationships in a population-based sample from the US Health and Retirement Study, among The ADHD-PGS was significantly and directly associated with GrimAge when adjusting for covariates. In single mediation models, the effect of the ADHD-PGS on GrimAge was partially mediated via smoking, depressive symptoms, and education. In multi-mediation models, the effect of the ADHD-PGS on GrimAge was mediated first through education, then smoking, depressive symptoms, BMI, and income.Findings have implications for geroscience research in elucidating lifecourse pathways through which ADHD genetic burden and symptoms can alter risks for accelerated aging and shortened lifespans, when indexed by an epigenetic biomarker. More education appears to play a central role in attenuating negative effects on epigenetic aging from behavioral and sociodemographic risk factors related to ADHD. We discuss implications for the potential behavioral and sociodemographic mediators that may attenuate negative biological system effects.The online version contains supplementary material available at 10.1186/s13148-023-01484-y. GrimAge, show associations with having more disability, disease co-morbidities, and shorter survival time compared to the same chronologically-aged peers [GrimAge can improve our understanding of pathways through which risk for earlier mortality is elevated for those with ADHD. This may be useful for clinical and geroscience researchers [Biological aging has recently been measured through epigenetic age scores, which quantify the degree of methylation marks across one’s epigenome. Higher scores for one score in particular, called ed peers . Also ased peers –8. ADHD ed peers . In turned peers , 13–17. ed peers . Assessiearchers , 20 in aIn larger population-based studies, it is often impossible to obtain clinical assessments for diagnoses of ADHD on respondents , 22. AddThere are several genetic variants that have been consistently associated with ADHD, yet the underlying molecular genetics are not fully understood , 27. OveIndividuals with any of the behavioral and sociodemographic characteristics commonly associated with ADHD carry a twofold greater risk for earlier death in childhood compared to the general population . A recenWhen evaluating health outcomes with aging, including cognitive outcomes, mental health and age at mortality, one factor that is consistently protective against worse outcomes is more educational attainment –42. IndiUse of the epigenome has become a promising method for indexing accelerated biological aging when the degree of methylation marks is quantified into indices previously shown to predict lifespan, healthspan or physiological dysfunction , 46–51. GrimAge clock are strongly associated with earlier physiological and functional declines . GrimAge has demonstrated stronger relationships with all-cause mortality [GrimAge has been shown to be a stronger predictor of mortality than the Horvath clock, with effects that are independent of genetic influences [GrimAge may be better suited for indexing accelerated aging and risk for earlier mortality related to specific health risks related with ADHD.Methylation at specific regions has also been consistently associated with multiple environmental factors and behaviors, for example, environmental pollution , 58, tobortality  and aginortality . Recentlfluences . Thus, aGrimAge. Second, we evaluate the hypothesis that health behaviors and sociodemographic correlates believed to be on the etiological pathway from ADHD to reduced life expectancy are similarly on the etiological pathway from the ADHD-PGS to older epigenetic age. Third, we test the hypothesis that the effects of the ADHD-PGS on GrimAge are initially mediated through educational attainment, then through the other factors. Findings from this study have the potential to identify life-course pathways through which the ADHD-PGS and related symptoms associate with earlier mortality and could identify potential targets that attenuate biological system effects.Given the consistency of research on the relationships between features of ADHD and risk for earlier mortality , 5, 7, 8Health and Retirement Study (HRS), a nationally representative sample of households of older Americans (aged 51 + years) in the USA. Data collection for the HRS began in 1992 and continues to be collected bianually [n = 2311 had complete data on all other variables and created the analytic sample.The sample was drawn from the ianually . The HRSianually . For theianually , who parminfi package in R, with removal of suboptimal samples or sex mismatched samples thereby yielding 836,660 methylation probes. Epigenetic age as measured by GrimAge was calculated by HRS [DNA methylation was assessed using the Infinium Methylation EPIC BeadChip . Preprocessing and quality control were completed using the d by HRS . As descd by HRS , the clod by HRS , 47, 63.n = 55,374 from 20,183 cases and 35,191 controls) [Genotyping was performed by the National Institutes of Health (NIH) Center for Inherited Disease Research  using the Illumina Human Omni2.5-Quad BeadChip , with coverage of nearly 2.5 million single nucleotide polymorphisms (SNPs). All quality control checks and imputation procedures were implemented by the HRS with details provided elsewhere , 70. Relontrols) , 73, thiFor cigarette smoking, the National Cancer Institute definition of smoking pack-years was calculated as an indicator of lifetime smoking, as a multiplicand of smoking duration in years and average cigarettes per day, then divided by 20. Variables used for coding pack-years included age of start, age of stop, and cigarettes smoked per day extracted from HRS 1992–2016 core wave files. In the case of a missing start age, the mean start age was used, calculated for each gender and 10-year birth cohort . In the case of missing cigarettes smoked per day, the mean was used, calculated for each gender, 10-year birth cohort, and stratified by current/former smoking status. In the case of missing stop age, the mean stop age was used, calculated for each gender and 10-year birth cohort for former smokers.Depressive symptoms were assessed using a modified version of the well-known Center for Epidemiologic Studies-Depression (CES-D) inventory , 75 at b2). A continuous composite score for cognitive functioning was used, calculated as a sum score (range 0 to 27) with a higher score indicating fewer challenges with cognitive processes, including domains of episodic memory, working memory, sustained attention, and orientation [Body Mass Index (BMI), cognition, and income variables were coded from the HRS baseline wave for each respondent, or the subsequent wave to study entry if baseline data were missing. A continuous variable was used for BMI, calculated as kilograms of weight divided by height in meters squared ; recommendations in HRS quality control evaluations show sufficient coverage of population substructure problems when using 6–7 PCs [Other study covariates included self-identified gender  that was verified genetically, chronological age in years, and the top six eigenvalues from principal component (PC) analysis of genotyped data to account for differences in population substructure , 80. Six 6–7 PCs ; and thaFirst, ordinary least-squares (OLS) regression models were constructed to evaluate the association between the ADHD-PGS and epigenetic age, adjusted for age, gender, and six ancestry principal components (PCs). Second, structural equation models (SEMs) were used to test indirect effects of the ADHD-PGS and epigenetic age through smoking pack-years, depressive symptoms, BMI, education, cognition and income with all mediators together. Covariances were added between all predictors. Third, multi-mediational SEMs were constructed to test whether there were indirect effects of the ADHD-PGS through education to influence all other mediators and GrimAge. All SEMs were adjusted for age and gender. Because in SEMs, PCs contributed 0 variance to the model, they were not included in SEMs. OLS models were constructed using SAS  and SEMsn = 2311 for this study.We examined direct and indirect effects of each model and used common model fit indices to evaluate goodness of fit: root-mean square error of approximation (RMSEA), Tucker–Lewis Index (TLI), Comparative Fit Index (CFI), and Chi-square values to evaluate the best fitting model and p-value threshold of 0.05 for evaluating significance of path estimates. Generally, lower RMSEA values from 0.01, 0.05, 0.08 to 0.10 indicate the model has excellent, good, acceptable, and poor fit to the data, respectively , 84; in r = 0.83), we ran all analyses adjusted for chronological age. Thus, we report all results using GrimAge scaled in units of years, and unstandardized coefficients to interpret effects in years of GrimAge.Because chronological age showed high correlation with epigenetic age . Each additional chronological year of age was associated with a 0.76 year older GrimAge . Men had a 3.43 year higher GrimAge  compared to women. All variables accounted for 74.85% of the variation in GrimAge, with 4.82% of the variation accounted for by gender, ADHD-PGS and ancestral principal components. The ADHD-PGS alone accounted for 0.29% of the variation in epigenetic age. Bivariate correlations among variables are provided in the Additional file As shown in Table p = 0.56; details provided in the Additional file Because a prior study  found noχ2(42) = 5159.42, p < 0.0001, RMSEA = 0.036, CFI = 0.998, TLI = 0.976). In this model, the ADHD-PGS directly associated with GrimAge, with each additional SD of the PGS associating with almost a quarter year older GrimAge . Smoking, depressive symptoms, and education mediated 51.7% of the effect of the ADHD-PGS on GrimAge as described below.To test hypothesis 2, the model predicting GrimAge was constructed with all mediators in the model, as depicted in Fig. b = 0.13, p < 0.001), depressive symptoms , and education , as shown by the blue shaded boxes in Fig. b = 0.009, p = 0.14), cognition , or income . Thus, mediational hypothesis 2 was partially supported.Indirect paths from the ADHD-PGS to GrimAge were significant through smoking , which in turn, predicted older epigenetic age . Similarly, higher ADHD-PGS was positively associated with depressive symptoms , which in turn, predicted older epigenetic age . The ADHD-PGS was not related to BMI , but BMI significantly predicted older epigenetic age . Higher ADHD-PGS significantly and inversely associated with more educational attainment  which, in turn, predicted younger GrimAge . Higher ADHD-PGS significantly and inversely associated with higher cognitive scores , but cognitive scores did not predict GrimAge . Lastly, higher ADHD-PGS significantly and inversely associated with higher income , which, in turn, significantly predicted younger GrimAge . Additional paths added for model fit and for covariates are provided in the Additional file All variables in the model accounted for 78.8% of the variation in GrimAge. This included direct effects, depicted in Fig. χ2(42) = 5159.42, p < 0.0001, RMSEA = 0.030, CFI = 0.998, TLI = 0.983) with a similar or slightly better fit than the single mediation model as indicated by the RMSEA and TLI. In this model, as shown in Table b = 0.22, p < 0.01) as was the percentage of effect being mediated, 51.6%. The effect of the ADHD-PGS through education to GrimAge was secondarily mediated through smoking , depressive symptoms , BMI , and income , but not via cognition . Thus, hypothesis 3 was partially supported.To test hypothesis 3, multi-mediational models were constructed, as shown in Fig. χ22 = 5159.b = −0.27, p < 0.0001) and cognition , and positively predicted depressive symptoms  and smoking , but did not predict BMI , or income . Significantly and directly related to older GrimAge were smoking , depressive symptoms , BMI , less education , less income , but not cognition . Notably, there was a significant direct effect from education to GrimAge ; with each additional year of education attained, there was a fifth of a year decrease in GrimAge.The ADHD-PGS, mediators, and covariates explained 80.5% of the variation in GrimAge. Direct effects from the ADHD-PGS include that it inversely predicted education  proportionally similar, but in opposite direction to the total indirect effect of education on GrimAge . As shown in Table b = 0.06, p < 0.0001), via smoking , and via depressive symptoms , whereas non-significant paths were via BMI , via cognition , and via income . As shown by blue shaded boxes in Fig. b = −0.13, p < 0.0001), via depressive symptoms , via BMI , and via income , but not via cognition . Additional paths added for model fit and for covariates are provided in the Additional file Overall, the total indirect effect of the ADHD-PGS on GrimAge was  or when including only those in the lowest and highest quartiles of the polygenic score.Because it is also possible that an ADHD-PGS underlies cognitive challenges that would likely affect years of schooling pursued, we conducted analyses to assess whether the results found could be due to a differential effect of education among the lowest and highest quartiles of the ADHD polygenic score. We constructed linear regression models to include an interaction term (ADHD-PGS*education), adjusted for the ADHD-PGS, education and covariates, and did not find evidence for the interaction (In this study, we evaluated whether an epigenetic marker for accelerated biological aging and earlier mortality was associated with ADHD genetic burden, and whether the association was mediated by hallmark behavioral and sociodemographic factors related to ADHD. We evaluated these mechanisms in a population-based sample, that includes adults over age 50, in which a polygenic score for ADHD represents a continuum of risk for having characteristic features of ADHD. Older biological age was indexed by a blood-based epigenetic biomarker called GrimAge, which has been associated with more disease co-morbidities and all-cause mortality. We found that the relationships with the epigenetic biomarker are partially mediated through educational attainment, lifetime smoking pack-years, and depressive symptoms, but not BMI, cognitive function or household income. Furthermore, there was evidence for pathways of effect in which the ADHD-PGS associated with lower educational attainment, which in turn associated with more smoking, depressive symptoms, higher BMI, and lower adult income to significantly affect GrimAge. While a higher ADHD-PGS increased epigenetic age, more education mitigated that effect, partially through behavioral and sociodemographic mediators. This implies that more educational attainment can mitigate negative outcomes related to damaging health and sociodemographic circumstances related to ADHD. Additionally, this epigenetic biomarker can be useful for indexing the effects of ADHD genetic burden and behavioral correlates of ADHD on multi-morbidity and lifespan.We found that ADHD genetic burden is associated with GrimAge directly, with some of the effect mediated through behavioral and sociodemographic correlates. The direct relationship is likely attributable to both overlapping genetic and environmental influences. The extent to which DNA methylation is under the control of genetics specific to ADHD is largely unknown . An analIt is well-known that genetics are not a lone predictor of ADHD or its features because a multitude of environmental components likely contribute, including early life exposures and contexts involved, but etiological pathways are poorly understood . EmerginLess smoking, fewer depressive symptoms, lower BMI, and higher adulthood socioeconomic status were important for mitigating faster epigenetic aging and risk for earlier mortality due to ADHD genetic burden. The public health burden of any one of these health conditions at any age is substantial , 91, yetWhat is most striking from our findings is that there is a primary mediating role of educational attainment and thus, points to the potential role it can play in mitigating adverse behaviors, lifestyle factors, accelerated aging and earlier mortality. Our results indicate that greater educational attainment could nullify the direct effect of ADHD genetic burden on GrimAge. However, there are good reasons that individuals with ADHD and related features do not pursue higher education, stemming from learning and behavioral challenges and often the lack of educational supports. Educational outcomes have also been linked to neurocognitive functioning across multiple domains, in which there tend to be deficits or delays in development among those with ADHD , 95. ThuDespite the strength of this study with the indexing of epigenetic age in older adulthood and mediating sociodemographic and behavioral pathways, we acknowledge several limitations. This study represents a snapshot in older age, for those at different levels of polygenic indices for ADHD who have survived to older adulthood. The sample was older at the outset than those typically assessed for features of ADHD, so it is unknown how such symptoms may attenuate in adulthood. It is also unknown how behavioral variables, including medication use, may have changed throughout the lifecourse and what effects they would have in accounting for the ADHD-PGS to epigenetic age relationship.A prior evaluation of age patterns has shown that log odds for mortality due to ADHD increase in the age ranges of 46–64 [Another limitation is not considering gene-by-environment effects when there is likely a dynamic interplay occurring between genetic regions encompassed within the polygenic score and sociodemographic or behavioral factors. There is also a limitation of temporality because DNA methylation changes may occur earlier in life, with prior evidence showing for example that early life stress experiences can alter methylation levels , 97. TheAdditionally, we do not look at onset of co-morbidities, such as age of onset of disease, which can differentially affect mortality risk. All measures for this study were taken in middle to later adulthood, so it is unknown how behaviors from earlier life affect the relationship between a polygenic score for ADHD and epigenetic age. However, a strength of this study is assessing a marker of the biological clock and aging real-time in a naturally aging sample. Because the sample is drawn from a population-based study, recruitment was not based on disease status or genetic risk, and thus, results give us a representation of today’s middle to older aged adults across a range of both DNA methylation levels and ADHD genetic burden.For geroscience research, we expand on the current knowledge to show that this blood-based index of epigenetic age can be used to evaluate the degree to which risk for earlier mortality differs based on mediating factors related to ADHD genetic burden. Research to identify links between ADHD and epigenetics is in the very early stages  overall.Additional file 1. Supplementary Tables and Material.


To investigate the longitudinal associations between COVID-19 induced stress (related to COVID-19 restrictions/changes), attention-deficit/hyperactivity disorder (ADHD) symptoms, oppositional symptoms, and mental health outcomes  in children with ADHD during the COVID-19 pandemic.Parents of 140 Australian children with ADHD (aged 5–17 years) completed an online survey in May 2020 during stay-at-home restrictions and 12-months later.p = .007) and hyperactivity/impulsivity symptoms  at 12-months, after accounting for covariates . Despite some indication of associations between baseline COVID-19 stress and 12-month oppositional symptoms and negative affect, these were attenuated when adjusting for baseline symptoms.Baseline COVID-19 stress was associated with increased total ADHD symptom severity (β = .21, The study provides initial evidence of the medium-term impacts of pandemic-related stress for children with ADHD. Prior to the COVID-19 pandemic, studies have reported that children with attention-deficit/hyperactivity disorder (ADHD) experience greater overall perceived stress compared to children without ADHD , and thaThe COVID-19 pandemic is a recent and chronic global health emergency and stressor that may be impacting negatively on the adjustment of children with ADHD. The first COVID-19 case in Australia was recorded in January 2020 and led to a nationwide lockdown from March to May 2020 . As was The pandemic has been a major life stressor in Australia and internationally, including fear of contracting the COVID-19 virus, as well as stress potentially arising from government enforced social distancing restrictions, significant lifestyle constraints, and changes to social connections with family and friends. Pandemic-related stressors such as these have led to a 25% increase in anxiety and depression worldwide, according to a report by the The uncertainties and changes that have arisen as a result of the pandemic have also been stressful for many children, and this stress may be acted out through increased challenging behaviors  or anxieStudies specifically focusing on children with ADHD during the pandemic have reported increased ADHD symptoms , irritabA cross-sectional study by The current study examined the same cohort with longitudinal data to investigate whether COVID-19 stress experienced in the early stages of the pandemic was prospectively associated with ADHD symptom severity, oppositional symptoms, and domains of mental health including negative affect, anxiety, depression, and irritability 12-months later. It was hypothesized that increased levels of COVID-19 stress at baseline would be associated with greater frequency and severity of ADHD, oppositional, and mental health symptoms 12-months later, after accounting for child age, gender, ADHD medication use, neighborhood socio-economic status, and baseline symptoms.This study used two waves of data (baseline and 12-month follow-up) from the ADHD COVID-19 study, which is a longitudinal study surveying parents of Australian children with ADHD during the COVID-19 pandemic. The study was approved by the Deakin University Health Faculty Ethics Committee (HEAG-H 60_2020).Participants were recruited in May 2020 through ADHD organizations, social media, and ADHD parent support groups. Parents and primary caregivers (>18 years old) living in Australia with a child aged 5 to 17 years who had been diagnosed with ADHD were eligible to participate. Of 221 participants recruited at baseline, 207 remained in the study and were invited by email to take part in a 12-month follow-up survey in May 2021. The survey was completed online through Research Electronic Data Capture REDCap; , 2019. Tnot at all to 5 = very extremely), where higher scores indicated greater stress. The Life Changes domain of the CRISIS has demonstrated good internal reliability (ω = .73–.77) and high consistency between US and UK samples (r = .91–.99) using parent report , with higher scores indicating increased symptom severity. The inattention and hyperactivity/impulsivity subscales were also combined to provide an ADHD symptom severity total score. The SNAP-IV has previously demonstrated excellent internal reliability for parent ratings  except for happy versus sad and enjoying activities, which were reverse scored. A total score was calculated, with higher scores indicating more negative mood states. Cronbach’s alpha showed very good internal reliability within the sample at 12 months, α = .82.Ten items from the Mood States domain of the CRISIS were used at baseline and 12 months for parents to report their child’s mood from the circumplex model of affect, including worry, happy versus sad, enjoying usual activities, anxiety, fatigue, irritability, fidgety or restless, difficulty to concentrate or focus, loneliness, and negative thoughts. Scores were measured on a 5-point Likert Scale for each mood state (1 = not true to 2 = true). Higher scores indicated greater symptoms of depression. The SMFQ showed excellent internal reliability within the sample at 12 months, α = .90.Parents reported on their child’s depressive symptoms using the Short Mood and Feelings Questionnaire (SMFQ) at baseline and 12 months. The SMFQ is a reliable 13-item measure , with higher scores indicating greater symptoms of anxiety. The original SCAS has shown excellent reliability . Higher scores indicated greater irritability. The ARI has been validated for parent-report in a clinical sample longitudinally, including a percentage of children with ADHD  was used at baseline and 12 months to measure parent-reported chronic irritability symptoms on seven items using a 3-point Likert Scale , primary language spoken at home, Aboriginal or Torres Strait Islander status, high school completion, number of children in the home, child age, and child gender. Information regarding the child’s ADHD medication use, and diagnosis or treatment of any co-occurring internalizing (anxiety and depression) or externalizing  conditions were assessed at baseline and the 12-month follow-up. The Socio-Economic Indexes for Areas SEIFA;  was calct-tests and chi-square tests for independence examined any differences in child age, neighborhood socio-economic status, child gender, and state of residence between those included and excluded from the analyses. Descriptive statistics were used to summarize the demographic and individual characteristics of the sample, as well as the range and average responses for the outcomes of interest.To be included in the analyses, participants were required to have data available on COVID-19 stress at baseline, and at least one outcome of interest at the 12-month follow-up. Independent samples q = 0.0125 as the threshold for significance  and 12-month ADHD symptom severity , oppositional symptoms, negative affect, anxiety, depression, and irritability (dependent variables) at 12 months. Two sets of adjusted analyses for each domain were also undertaken. First, adjusted linear regression analyses were conducted to account for covariates—ADHD medication use, child age, gender, and neighborhood socio-economic status. Second, adjusted analyses were re-run to account for baseline symptoms of the dependent variable of interest and covariates. Due to the number of statistical comparisons, a False Discovery Rate (FDR) correction was used for both sets of adjusted analyses using ificance . IBM SPSSupplemental Figure 1); with 140 responses eligible for analysis. There was no significant difference between the age of children included in the analyses  and excluded , t(203) = 0.05, p = .961, 95% confidence interval (CI) , or neighborhood socio-economic status between those included  and excluded , t(201) = −1.01, p = .316, 95% CI . There was no significant effect of gender distribution χ2  = 0.14, p = .706, 2  = 5.47, p = .485, Seventy percent of invited participants completed the 12-month survey .As shown in Supplemental Table 2. In the unadjusted models, baseline COVID-19 stress was significantly associated with increased 12-month ADHD symptom severity , and more specifically, increased hyperactivity/impulsivity symptoms , and negative affect  at 12 months (see Bivariate correlations between the variables of interest can be found in p = .001) and hyperactivity/impulsivity symptoms  at 12 months. While associations were also shown between COVID-19 stress and increased oppositional symptoms , and negative affect , these findings did not survive FDR correction (see p = .007) and hyperactivity/impulsivity symptoms  at 12 months (see Supplemental Table 3.When adjusting for covariates, baseline COVID-19 stress remained significantly associated with increased ADHD symptom severity (β = .26, tion see . When adnths see . Both asThis study aimed to investigate the longitudinal associations between children’s COVID-19 stress and ADHD symptom severity, oppositional symptoms, negative affect, anxiety, depression, and irritability in Australian children aged 5 to 17 years with ADHD at two-time points during the pandemic. The hypothesis was partially supported, as COVID-19 stress reported in the early months of the pandemic was significantly associated with greater ADHD symptom severity, hyperactivity/impulsivity symptoms, oppositional symptoms, and increased negative affect 12 months later after accounting for covariates. COVID-19 stress also continued to be associated with greater ADHD symptom severity, specifically hyperactivity/impulsivity symptoms when accounting for baseline symptoms.The significant association shown between baseline COVID-19 stress and 12-month ADHD symptom severity is consistent with pre-pandemic research indicating associations between stress and exacerbated ADHD symptom severity across time in childhood and adolescence . The resHowever, there were differences between specific ADHD symptoms. While baseline COVID-19 stress was associated with symptoms of hyperactivity/impulsivity at 12 months, there was no significant association with inattention symptoms, despite previous research indicating a deterioration in focus and attention in children with ADHD during the early stages of the pandemic . These fThere was also some evidence of a prospective association between COVID-19 stress in the early months of the pandemic and greater negative affect 12 months later, albeit not in other domains of mental health such as anxiety and depression. Again, however, this association did not hold after FDR correction for multiple comparisons, so should be interpreted with caution and requires further research. These findings were unexpected given the associations identified between stress and aspects of mental health such as anxiety, depression, and irritability for children with ADHD prior to , and durThere are several clinical implications stemming from this study. For clinicians working with children with ADHD, it is important to enquire about, and acknowledge, the various causes of stress relating to the pandemic and the impacts this may have on children’s symptoms. While general clinical guidance has suggested that children with ADHD should continue to be supported in accessing and monitoring medication use during the pandemic , they maThe results of this study should be interpreted in the context of some limitations. First, we only examined baseline levels of COVID-19 stress. It is unknown how COVID-19 stress changed over the 12-month period given that many parts of Australia experienced additional lockdowns and restrictions after the baseline survey. Furthermore, parent reports may be influenced by their own stress and worries due to the pandemic. Future research should consider gaining children’s perspectives during the pandemic to assess any discrepancies between parent and child reports. Moreover, no control group was used in the study, so it is unknown whether these results are specific to children with ADHD. However, based on previous findings , it is lThe study also had multiple strengths. First, the retention of participants was relatively high across the 12 months. Second, the study controlled for additional factors such as ADHD medication use, socio-economic indicators, and baseline symptoms. This allowed the impact of COVID-19 stress to be assessed independently from other factors known to influence ADHD, oppositional, and mental health symptoms. This addressed a common limitation of previous studies focusing on ADHD during the pandemic .Since the 12-month survey, multiple parts of Australia have experienced additional lockdowns and a return to remote learning. New South Wales and Victoria experienced a rise in case numbers in July and August 2021, prompting extended lockdowns in these states. During this time, Melbourne, Victoria became the most locked-down city in the world . The numIn conclusion, baseline COVID-19 stress was associated with increased ADHD symptom severity 12 months later, specifically hyperactivity/impulsivity symptoms, in children aged 5 to 17 years with ADHD. These long-term associations were independent of baseline symptoms and other demographic factors, co-occurring conditions, and ADHD medication use. Children with ADHD and their families may require additional support to cope with ongoing COVID-19 stress as the pandemic continues. Future research should continue to investigate the longer-term impacts of the COVID-19 pandemic, and the influence of stress on the mental health of children with ADHD over time.Click here for additional data file.Supplemental material, sj-docx-1-jad-10.1177_10870547231168334 for Longitudinal Associations Between COVID-19 Stress and the Mental Health of Children With ADHD by Ainsley Summerton, Susannah T. Bellows, Elizabeth M. Westrupp, Mark A. Stokes, David Coghill, Mark A. Bellgrove, Delyse Hutchinson, Stephen P. Becker, Glenn Melvin, Jon Quach, Daryl Efron, Argyris Stringaris, Christel M. Middeldorp, Tobias Banaschewski and Emma Sciberras in Journal of Attention Disorders


BackgroundTeachers are pivotal in integrating children with attention deficit hyperactivity disorder (ADHD) into academic and social contexts. Their comprehension of and attitudes toward ADHD significantly influence the inclusion of these children. This study was conducted to assess teachers' knowledge, attitudes, and perceptions about ADHD and its treatment within a representative sample from Turkey.MethodsAn online self-administered questionnaire was formulated to gauge teachers’ knowledge, attitudes, and perceptions related to ADHD and its treatment.ResultsOf the respondents, 57.7% accurately identified that ADHD is more commonly present in boys. Furthermore, a majority of teachers (60.8%) correctly answered the question related to the comorbidity of ADHD and learning disabilities. However, 20.3% of teachers believed that ADHD medications were addictive, with 9.7% expressing reluctance to use such treatment for their children if needed.ConclusionThe results highlight the need for revising the current training curricula for novice teachers and providing additional training for experienced teachers. Such initiatives should aim to rectify any negative perceptions and attitudes toward ADHD held by teachers. Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder typically emerging during childhood. Epidemiological data suggest it affects an estimated 5% to 11% of individuals aged 18 years and under, with a higher prevalence observed among males compared to females . AdditioChildren with ADHD in classroom environmentsClassroom settings present a unique set of challenges for children with ADHD, as they necessitate behaviors that inherently oppose ADHD's key symptoms. Prior research has revealed that ADHD children frequently encounter numerous school-related difficulties attributable to hyperactivity, inattention, and impulsivity, which are hallmark symptoms of the disorder. Interestingly, gender-specific variations in symptom manifestation may be observed. For example, boys predominantly exhibit externalized symptoms such as hyperactivity and impulsivity, whereas girls tend to display more internalized symptoms, including inattention, diminished self-esteem, and depression .Academic performance of children with ADHD often suffers, resulting in grade retention or even school suspension. Their unique symptom profiles frequently lead to diverse problematic behaviors in the school context. Children with predominantly impulsive symptoms may, for instance, disrupt class by interjecting without permission or engaging other students at inappropriate times. Conversely, those with primarily inattentive symptoms might struggle to adhere to instructions and rules, maintain focus on tasks, or accomplish assigned work. Hyperactive children typically find it challenging to remain seated, avoid playing with unrelated objects during tasks , cease chair-rocking, or halt repetitive hand or foot tapping . HoweverGiven ADHD's symptomatic nature, it is expected that associated behaviors would impact peer relationships in school environments. Children with ADHD may exhibit controlling, disruptive, and aggressive behaviors, likely leading to negative perceptions among their peers. Consequently, these children may find themselves ostracized from peer-group play activities. Furthermore, children with ADHD might struggle to accurately interpret social cues, thereby responding inappropriately. A study by Gresham et al.  revealedADHD and teachersEducating students diagnosed with ADHD can present significant challenges for teachers. These educators often encounter difficulties in their professional capacities, such as managing the unique behavioral, attentional, and learning needs of these students. Manifestations of ADHD such as constant fidgeting, abruptly leaving their seat, interrupting discussions, and causing class-wide disruptions can lead to feelings of frustration for the educators . The chaThe role of educators in relation to ADHD is multifaceted and of considerable importance. Initially, teachers often play a crucial role in the early identification of ADHD. The diagnosis process of this condition does not rely on a single test; instead, it depends on an extensive review of the child's history and behavioral observations across multiple contexts, which frequently include ADHD symptom checklists rated by parents and teachers . Given tTeachers’ perceptions, attitudes, and knowledge concerning ADHDTeachers play a pivotal role in both the identification and management of ADHD. However, their effectiveness in these roles can be significantly influenced by a range of factors, including their understanding and perception of ADHD. Teachers who lack accurate knowledge or harbor misconceptions about ADHD may fail to recognize or utilize evidence-based interventions and accommodations designed to support students with ADHD in the classroom. In contrast, teachers who possess a more comprehensive understanding and display a positive attitude toward ADHD are generally more inclined to employ effective strategies. These strategies not only aid children with ADHD in their academic achievement but also alleviate their symptoms. Previous studies have underscored a significant correlation between a teacher's knowledge of ADHD and their confidence in effectively teaching children with ADHD, fostering an inclusive classroom environment, and managing disruptive behaviors ,12. HoweTeachers' attitudes toward ADHD may also diverge, ranging from positive to negative, and are likely to be shaped by their perceived teaching efficacy and expectations. Additionally, attitudes can differ depending on various factors such as the age, gender, severity of symptoms, and academic performance of the children with ADHD. Interestingly, classroom exposure to ADHD may contribute to teachers' knowledge of the disorder. Sciutto et al.  reportedThe present studyIn the context of academic and social inclusion for children with ADHD, the role of teachers proves to be vital. Their knowledge and attitudes toward ADHD significantly contribute to fostering an inclusive environment for these children. Globally, substantial research has been conducted to understand teachers' knowledge and attitudes toward students with ADHD. However, there is a knowledge gap in the context of Turkish teachers that has been attempted to be filled by a limited number of studies . This gaA version of this paper was presented at the 32nd National Congress of Child and Adolescent Psychiatry, Istanbul, Türkiye, 2023.Participants and procedureAn online self-administered questionnaire, modeled after prior surveys exploring teachers’ knowledge, attitudes, and perceptions about ADHD , was devInitially, participants were asked, “What do you believe is the prevalence of ADHD?” to gauge their perceptions about the prevalence of ADHD. This was followed by assessing their general knowledge about ADHD through responses to five statements. An option for “I have no idea” was incorporated to diminish the chances of guesswork, thereby enhancing the probability that the responses truly reflected the respondents’ knowledge . The thiApproval for the study was granted by the Provincial Education Directorate. The online survey was distributed among schools in Silifke, a district situated along the Mediterranean coast in Turkey, during a brief sampling period . Silifke boasts 117 educational institutions , employing approximately 2,300 teachers during the study period. Prior to initiating the survey, an online consent form detailing the data collection procedure and study objectives was provided. Assurance was given that participation was anonymous and voluntary. After perusing the information sheet and giving consent, willing participants gained access to the survey. Ethical approval was granted by the Toros University Scientific Research and Publication Ethics Committee , with the study adhering to the principles outlined in the Helsinki Declaration.Statistical analysisThe data were analyzed utilizing SPSS Version 28.0 . Descriptive statistics are presented as means (standard deviation) and percentages (%). The findings were subsequently depicted in tables and graphs.The online survey was completed by 227 teachers, approximately 10% of the educators employed in Silifke. The mean age of the teachers was 42.30 years (SD = 7.90), with 17.2% possessing a tenure of 10 years or less. Of the total, 23.3% (n = 53) had undergone ADHD-specific training, and 59.5% had taught students diagnosed with ADHD. Detailed demographic information is provided in Table Upon being queried about the prevalence of ADHD, 42.3% of teachers estimated it to fall between 5% and 10%  accurately identified a higher prevalence of ADHD in boys. Moreover, 60.8% correctly recognized the comorbidity of ADHD and learning disabilities. Conversely, a minor proportion believed ADHD was not a consequence of parental attitudes (18.5%) or that inattention and hyperactivity/impulsivity did not necessarily co-occur (41.4%). Table In response to the question “Are medications used for treating ADHD addictive?” 20.3% of respondents confirmed, whereas 58.1% expressed uncertainty  are known to coexist. Prior research indicates that children with ADHD are more prone to initiate alcohol abuse than their counterparts, and individuals diagnosed with ADHD are likely to engage in the use of alcohol and other substances at an earlier age . SeveralAccording to only 18.5% of participants, the assertion that “ADHD is a result of parental attitudes” is misguided. The precise causes and risk factors for ADHD are not yet fully understood, though recent studies have underscored the significant influence of genetic factors in the development of ADHD . MoreoveThe present study revealed that a significant majority (60.8%) of teachers recognized learning disabilities more frequently in children with ADHD compared to their peers. However, diagnosing ADHD remains a complex task due to the existence of multiple conditions that share symptomology with ADHD. For example, academic underachievement, a typical outcome for children with ADHD, is also observed in children with other disorders such as learning disabilities and intellectual disabilities. Interestingly, prior research indicates that 30-50% of children with ADHD concurrently exhibit a specific learning disability . This coEarly childhood is when many children begin to show signs of ADHD, but a subset remains undiagnosed until adulthood. It is essential to recognize that ADHD can manifest in several forms: predominantly inattentive, predominantly hyperactive/impulsive, and the combined type . Boys wiThis study sought to elucidate the understanding, attitudes, and perceptions of ADHD and its treatment among a cohort of teachers, marking the first such effort focusing on educators in Turkey’s rural regions. Nevertheless, the study’s findings and interpretations must be viewed within the context of its constraints. First, this study did not employ a validated questionnaire to assess teachers’ knowledge of ADHD. Instead, a custom five-item questionnaire was curated, zeroing in on aspects pertinent to clinical practice and those potentially disruptive to the diagnostic or therapeutic process. To enhance interpretability, descriptive analyses were undertaken at the item level, allowing for individual discussion of each item. Secondly, the generalizability of the findings may be somewhat limited. The study involved teachers in rural areas; the sample size and response rate were modest. Thirdly, the cross-sectional nature of the study prevented the tracking of changes in teachers’ knowledge and perceptions of ADHD over time. Lastly, the study did not probe the timing of ADHD-related training reported by some teachers, making it impossible to assess the continuity of their knowledge on the subject.This study's findings offer significant insights into teachers’ understanding, attitudes, and perceptions of ADHD. It was observed that teachers exhibit gaps in their ADHD knowledge in certain areas, underscoring the necessity for expanded training. This research also implies that it is crucial to revisit the existing curriculum of teacher training for newcomers and ongoing professional development programs for experienced educators. These programs should aim not only to broaden their knowledge but also to alleviate their negative perceptions and attitudes toward ADHD. Importantly, fostering teachers' comprehension and acceptance of the nature of ADHD can enhance learning efficacy for students with ADHD, potentially boosting their school attendance and educational engagement. While the importance of training programs is undeniable, their repeated reinforcement at regular intervals is of paramount importance.