Mycobacterium tuberculosis. In mycobacteria, dormancy is controlled by the response regulator DevR, which responds to conditions of hypoxia. Here, we show that OsdR of Streptomyces coelicolor recognizes the same regulatory element and controls a regulon that consists of genes involved in the control of stress and development. Only the core regulon in the direct vicinity of dosR and osdR is conserved between M. tuberculosis and S. coelicolor, respectively. Thus, we show how the system has diverged from allowing escape from the host defense system by mycobacteria to the control of sporulation by complex multicellular streptomycetes. This provides novel insights into how bacterial growth and development are coordinated with the environmental conditions.Dormancy is a state of growth cessation that allows bacteria to escape the host defense system and antibiotic challenge. Understanding the mechanisms that control dormancy is of key importance for the treatment of latent infections, such as those from  Mycobacterium tuberculosis, allowing this pathogen to escape the host defense system. Here, we show that OsdR (SCO0204) of the soil bacterium Streptomyces coelicolor is a functional orthologue of DevR. OsdR, when activated by the sensory kinase OsdK (SCO0203), binds upstream of the DevR-controlled dormancy genes devR, hspX, and Rv3134c of M. tuberculosis. In silico analysis of the S. coelicolor genome combined with in vitro DNA binding studies identified many binding sites in the genomic region around osdR itself and upstream of stress-related genes. This binding correlated well with transcriptomic responses, with deregulation of developmental genes and genes related to stress and hypoxia in the osdR mutant. A peak in osdR transcription in the wild-type strain at the onset of aerial growth correlated with major changes in global gene expression. Taken together, our data reveal the existence of a dormancy-related regulon in streptomycetes which plays an important role in the transcriptional control of stress- and development-related genes.Two-component regulatory systems allow bacteria to respond adequately to changes in their environment. In response to a given stimulus, a sensory kinase activates its cognate response regulator via reversible phosphorylation. The response regulator DevR activates a state of dormancy under hypoxia in IMPORTANCE Dormancy is a state of growth cessation that allows bacteria to escape the host defense system and antibiotic challenge. Understanding the mechanisms that control dormancy is of key importance for the treatment of latent infections, such as those from Mycobacterium tuberculosis. In mycobacteria, dormancy is controlled by the response regulator DevR, which responds to conditions of hypoxia. Here, we show that OsdR of Streptomyces coelicolor recognizes the same regulatory element and controls a regulon that consists of genes involved in the control of stress and development. Only the core regulon in the direct vicinity of dosR and osdR is conserved between M. tuberculosis and S. coelicolor, respectively. Thus, we show how the system has diverged from allowing escape from the host defense system by mycobacteria to the control of sporulation by complex multicellular streptomycetes. This provides novel insights into how bacterial growth and development are coordinated with the environmental conditions. Complex natural habitats of bacteria call for rapid response systems to ensure adaption to often-changing environmental conditions. One prevalent mechanism that bacteria such as streptomycetes use to couple environmental stimuli to adaptive responses consists of a sensor kinase (SK) and a cognate response regulator (RR), which act as a two-component signal transduction system (TCS)  1, 2). , 2. 1, 2Streptomyces a rare example of a multicellular prokaryote  and induces a regulon controlled by the response regulator DevR , which consists of some 50 genes, including universal stress proteins (USPs), nitroreductases , redox proteins, and heat shock proteins . The locus tags SCO0203 and SCO0204 were named osdK and osdR, respectively, to highlight their function in response to oxygen availability, stress, and development.In this work, we suggest that the TCS pair SCO0203/SCO0204 regulates a dormancy-related response in osdR-osdK operon. OsdK has 41% and 42% amino acid identity (57% amino acid similarity) with DevS and DosT, respectively (see M. tuberculosis (SCO0203 (OsdK) and SCO0204 (OsdR) form a two-component regulatory system  and are rculosis . Indeed,rculosis , 16, 15/rculosis . The intrculosis . OsdR anrculosis  and S2, rculosis .10.1128/mSystems.00014-16.6Figure S1 Streptomyces and Mycobacterium orthologues. The secondary-structure prediction was based on the crystal structure of DevR (PDB accession number 3C3W) and is shown on top. Conserved residues are shown in red, and boxes denote conservative substitutions. An upward arrow indicates residues involved in interactions with DNA; blue arrows indicate residues contacting nucleotide bases, and red arrows indicate residues making DNA phosphate oxygen contacts. Abbreviations: M. tuber, M. tuberculosis; Mmarin, Mycobacterium marinum; Msmeg, Mycobacterium smegmatis; Mvanba, Mycobacterium vanbaalenii; Shygro, Streptomyces hygroscopicus; Sscab, Streptomyces scabies; Scoeli, S. coelicolor; Sviola, Streptomyces violaceoruber; Ssirex, Streptomyces sp. strain Sirex. For accession numbers, see Materials and Methods. Download Figure S1, TIF file, 1 MB.Sequence alignment of the DNA binding domain of DevR with Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mSystems.00014-16.7Figure S2 M. tuberculosis (A) and OsdR with DevR of M. tuberculosis and NarL of Pseudomonas aeruginosa (B) were created with ClustalW (digits indicate the amino acid number). The different protein domains are indicated in italic. Amino acids conserved in at least 80% of the sequences are shaded . Important amino acids of DosT and DevS are indicated beneath and above the alignment, respectively. GAF, GAF domain; DHp, dimerization and histidine phosphotransfer domain; CA, C-terminal catalytic and ATP binding domain; REC, receiver domain; HTH_LuxR, helix-turn-helix LuxR domain; ♦, phosphorylation site; ○, RR activation; #, H-bond network from iron to the surface; *, hydrophobic space surrounding a heme; ~, contact with a propionate group heme; ●, ligand binding; ▲, surface crevice; ≈, heme binding; ■, cavity next to a ligand binding pocket. Download Figure S2, TIF file, 2.4 MB.Alignment of SCO0203 (OsdK) and SCO0204 (OsdR). Multiple alignments of OsdK with DevS and DosT of Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the S. coelicolor OsdR could bind to the recognition site of M. tuberculosis DevR, electrophoretic mobility shift assays (EMSAs) were performed. His6-tagged OsdK and OsdR were purified, and the sensory kinase OsdK was autophosphorylated using 32P-radiolabeled ATP and then used to transphosphorylate OsdR , and hspX, which encodes a latency-related heat shock protein. As negative controls, DNA fragments of the upstream region of dasR of S. coelicolor and AT-rich DNA from Escherichia coli were used. OsdR bound with low affinity to the DNA fragment encompassing the dasR promoter region, while no binding was seen when AT-rich E. coli control DNA was used . The reaction mixtures were run on 3.5% acrylamide gels in 0.5× Tris-borate-EDTA (TBE) buffer. Gels were dried and then subjected to autoradiography for analysis. Download Figure S3, TIF file, 0.1 MB.Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the osdR orthologues from 12 Streptomyces species for possible similar cis-acting regulatory elements using MEME , centered on the predicted binding site, was used as a probe  had no effect on OsdR binding (We then designed four mutant 50-mer probes containing single mutations (designated 50a and 50b), a double mutation (50ab), or a quintuple mutation (50x) of the most conserved nucleotides of the binding site. In line with the predicted importance of the conserved nucleotide positions in the consensus sequence , nucleot binding . Taken tuspA, osdR, SCO2637 (for a serine protease), and SCO2967 (for a carboxypeptidase), and the intergenic regions between the divergent genes SCO0207 and SCO0208 (for another USP domain protein and pyruvate phosphate dikinase), SCO5978 and SCO5979 , and SCO6040 and SCO6041 (for a lipoprotein and a protoporphyrinogen oxidase). All the predicted binding sites were bound by OsdR, with most probes fully bound by OsdR~P (at 1 µM), except SCO2637, which was bound with 2-fold-lower affinity .Next we tested DNA binding by OsdR to predicted targets using EMSAs of PCR-amplified DNA probes . These waffinity . This suS. coelicolor strain M512 and the M512 osdR mutant derivative GSTC6. Promoter-probe vectors harboring the upstream regions of uspA (SCO0200), osdR, and SCO0207 were introduced into S. coelicolor M512 and the mutant GSTC6, and the promoter activity was analyzed, with as a control the empty vector or the vector with the whiG promoter, which is transcribed constitutively . While the empty vector did not show activity and whiG transcription was not affected by the deletion of osdR, PSCO0200, PSCO0204, and PSCO0207 were all active in M512 but poorly or not expressed in the mutant  in the nonpigmented e mutant , stronglosdR null mutants GSTC2 and GSTC3 as well as M145 ΔosdK (GSTC1) and M145 ΔosdRK (GSTC4) on MS medium indicated earlier formation of mycelial hyphae in the osdR mutants and accelerated sporulation and enhanced production of the gray spore pigment  agar plates overlaid with cellophane discs. Biomass was harvested at time points corresponding to vegetative growth (24 h), the onset of aerial growth (30 h), aerial growth (36 h), early sporulation (42 h), and sporulation (54 h) in the parental S. coelicolor M145. RNA from two independent biological replicate experiments was subsequently used as a template for cDNA synthesis/Cy3-dCTP labeling and subsequently hybridized onto oligonucleotide-based S. coelicolor whole-genome DNA microarrays . By rank product analysis, a list of genes whose levels of expression were statistically significantly different was obtained at a percentage of false positives (PFP) of <0.01. With the additional cutoff of a minimum 2-fold change in the levels of transcription between the wild type and mutant, a list of over 800 genes whose transcription was significantly altered in the osdR null mutant was obtained . Of these, SCO0167, SCO0172, SCO0181, and SCO0200 (uspA) were all downregulated at one or more time points in the mutant (S. coelicolor has three different nitrate reductases (Nar1 to -3) for anaerobic respiration, each active at different stages of development , dnaK, hspR, groEL1, groEL2, groES, genes encoding the proteasome (SCO1643 to SCO1644), and several cold shock genes. Zinc-related genes like those of the gene cluster for the zincophore coelibactin, were downregulated at all time points except 36 h, at which time levels of transcription were comparable between wild-type and osdR mutant cells , vegetative/aerial growth (30 h), aerial growth/early sporulation (42 h), and sporulation (54 h). Only genes with a PFP value of less than 0.010 and a fold change (ΔosdR expression/M145 expression) of more than 2.0 are presented. The levels of the fold changes are indicated with colors, as represented by the scale bar. Download Figure S4, TIF file, 0.3 MB.Heat maps of genes related to zinc import (A), sulfur metabolism and thiol homeostasis (B), and nitrogen metabolism (C) that are significantly differentially expressed between the Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the osdR at most time points, while early-developmental (bld) genes were downregulated at the same time points , development , stress management, etc.  as the internal standard, and RNA obtained from mycelia of M145 grown for 24 h was used to normalize the results between the different qPCR runs. Similar trends in expression profiles were observed in both sets of transcript analyses  in the osdR mutant together with the binding of OsdR to the upstream regulatory element strongly suggests that uspA transcription is transactivated by OsdR. ssgB (SCO1541) transcription was higher in the mutant, which corresponds well with the accelerated development and enhanced spore pigmentation of GSTC2 .To corroborate the microarray data, reverse transcription-quantitative PCR (qPCR) analysis was performed on independent RNA samples isolated from the mycelia of fe cycle . Downregof GSTC2 . The tra10.1128/mSystems.00014-16.10Figure S5 osdR mutant. RNA was isolated for microarray analysis (left) and RT-qPCR (right) profiling from independent cultures grown on MM with 1% mannitol during vegetative growth (24 h), vegetative/aerial growth (30 h), aerial growth (36 h), aerial growth/early sporulation (42 h), and sporulation (54 h). The expression profiles of the wild type (black circles) and the osdR mutant (gray triangles) over time in the microarray data (left) and the RT-qPCR data (right) were compared. Genes of interest tested were SCO2637, SCO3323 (bldN), and SCO5321 (whiE). Download Figure S5, TIF file, 0.3 MB.Microarray and RT-qPCR expression profiles of genes deregulated in the Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the ssgB or within the whiE cluster, EMSAs showed specific binding by phosphorylated OsdR to ssgB and to the intergenic region between genes SCO5320 and SCO5321 .The two-component regulatory system (TCS) formed by OsdK (SCO0203) and OsdR (SCO0204) shows significant sequence similarity to the dormancy TCS in rculosis . In thisin silico predictions and in vitro validation by EMSAs indicate that around 50 genes or gene clusters are controlled directly by OsdR. Analysis of the transcriptional changes in the osdR null mutant by global transcription profiling revealed the deregulation of numerous stress-related genes, including numerous stress-related genes in the region around osdR. A distinctive pattern of deregulation of developmental genes was evident, with upregulation of sporulation genes  and downregulation of genes involved in early development , which corresponds well to the observed accelerated development of osdR mutants. The transcriptional data suggest that OsdR controls a hinge point in development. This is perhaps best illustrated by the divergent transcription of the chp genes in the osdR mutant. It has previously been shown that the chpCEH genes are expressed earlier than the other chp genes and also that the ChpCEH proteins are sufficient to form the characteristic chaplin layer on the outside the aerial hyphae and spores and to support aerial growth. BldN was previously shown to control all of the chp genes .In liquid-grown cultures, where he clump ), and on dormant . Sporulaiability  supportsosdR null mutant are noteworthy, and while the results need to be worked out further, they may have major implications for the control of the switch from early- to late-developmental growth. Interestingly, such a clear transition in the global transcriptional profile of S. coelicolor has been reported previously, during growth in a fermentor. Distinctive sharp increases and decreases in the transcription of many genes were observed at this time point, and importantly, this includes several genes of the OsdR regulon, namely, genes in the nitrate reductase cluster adjacent to osdR (SCO0212-SCO0220), bldN, the bldN-controlled chp genes, and several other developmental genes  M145 was the parent for the osdK (GSTC1), osdR (GSTC2 and GSTC3), and osdRK (GSTC4) null mutants. S. coelicolor M512  was theeriments . Preparaeriments . R5 medieriments  for the 10.1128/mSystems.00014-16.1Table S1 Table S1, PDF file, 0.4 MB.Bacterial strain, plasmids, and constructs. Download Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the aacC4 , construct pGWS377, which carries only the flanking regions, was used for homologous recombination. Construct pGWS380 was designed for the construction of an in-frame osdRK double mutant  by combining the upstream region of osdR (obtained from pGWS377) and the downstream region of osdK (obtained from pGWS378). GSTC6 (M512 ΔosdR) was created for promoter probing purposes using the same approach as for the S. coelicolor M145 osdR mutant.Details for all plasmids and mutants are presented in aacC4 . PCRs weaacC4  with the10.1128/mSystems.00014-16.2Table S2 Table S2, PDF file, 0.5 MB.Oligonucleotides. Download Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mSystems.00014-16.3Table S3 Table S3, PDF file, 0.3 MB.Position weight matrix for the OsdR binding site. Download Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mSystems.00014-16.4Table S4 Table S4, PDF file, 0.1 MB.Overview of microarray results. Download Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mSystems.00014-16.5Table S5 Table S5, PDF file, 0.8 MB.Overview of genes deregulated at 36 h. Download Copyright © 2016 Urem et al.2016Urem et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 6-tagged OsdR and OsdK were overexpressed from plasmids pET0203 and pET0204 in E. coli BL21(DE3) (HisL21(DE3) . The plaL21(DE3) .In vitro autophosphorylation of 30 pmol of OsdK was performed with 32P-radiolabeled ATP as described previously (In vitro phosphorylation of OsdR for electrophoretic mobility shift assays (EMSAs) was achieved using the phosphor donor acetyl phosphate (AcP) as described previously , SCO0200, osdR, and SCO0207.Promoter probing experiments were performed using the eviously . The nonand redD . When re pIJ2587 , the RED control . The proS. coelicolor M145 (wild-type strain) and its osdR mutant GSTC2 by harvesting biomass from cellophane disks on MM with 1% mannitol after 24, 30, 36, 42, and 54 h of growth. Total RNA was isolated as described previously (RNA was isolated from eviously .http://www.surrey.ac.uk/fhms/microarrays/Downloads/Protocols/index.htm). Together with Cy5-dCTP-labeled S. coelicolor M145 genomic DNA as the common reference, the samples were hybridized onto 44,000 60-mer oligonucleotide microarray slides (http://www.r-project.org) using Limma (version 2.5.0) . The RNA was reverse transcribed into cDNA using Cy3-dCTP (y slides . The flun 2.5.0) , 88. Rann 2.5.0)  and Rankn 2.5.0)  was applrpsI (SCO4735) as an internal control. Each reaction mixture was tested in triplicate and for normalization between different plates, with the 24-h wild-type sample as the reference. An average of all three measurements was used to calculate normalized expression.For RT-qPCR analysis, cDNA was generated using the iScript Advanced cDNA synthesis kit (Bio-Rad Laboratories). RT-qPCRs were performed on 200 ng RNA with the iTaq universal SYBR green supermix (Bio-Rad Laboratories), using Streptomyces filaments and spores was performed as described previously . The GenBank nucleotide sequence accession number of M. tuberculosis DosT is P9WGK0, and that of DevS it is NP_217648. The microarray expression data have been deposited in ArrayExpress (with the accession number


ADHD symptom trajectories were assessed as well as medication, global functioning, disability, health-related quality of life, and alcohol and drug consumption at follow-up. Ninety percent of those diagnosed were initially treated pharmacologically and half of them discontinued treatment. One-third reported remission, defined as not fulfilling any ADHD subtype and a GAF-value last year ≥ 70, which was not affected by comorbidity at baseline. Current medication was not associated with remission. Subjects evaluated and first diagnosed with ADHD as adults are functionally improved at follow-up 6 years later despite a high percentage of psychiatric comorbidity at baseline. Half dropped out of medication, and there was no difference in ADHD remission between subjects with on-going medication at follow-up or subjects without medication, although current medication was related to a higher degree of self-reported global improvement.There are very few studies on the long-term outcome in subjects diagnosed with ADHD as adults. The objective of the present study was to assess this and relate the outcome to whether there was current medication or not and to other potential predictors of favourable outcome. A prospective clinical cohort of adults diagnosed with ADHD according to DSM-IV criteria was followed-up on an average of 6 years after first evaluation ( A diagnosis of attention-deficit/hyperactivity disorder (ADHD) requires an onset of symptoms in early life and is estimated to affect about 5% of children . AlthougA subgroup of persons diagnosed with ADHD is first diagnosed in adulthood. This group is in many respects different from that diagnosed in childhood . These dThe prevailing treatment strategy in ADHD is based on central stimulants. An abundance of studies have shown that such medication in children and adolescents is successful with respect to symptom reduction . SimilarAs the aim of treatment is to achieve long-term symptom reduction, studies that report outcome after years of treatment are necessary. In the present study a well-defined cohort of subjects first diagnosed with ADHD as adults was assessed with respect to long-term outcome. This was also related to whether there was current medication or not and to other potential predictors of favourable outcome.In 2002, a special out-patient clinic for referral of adult subjects with suspected diagnoses of ADHD, autism spectrum disorders and Tourette syndrome was opened at Uppsala University Hospital. It was powered with a multidisciplinary team with senior psychiatrists, clinical psychologists, social workers and occupational therapists. The work was built on a stable structural diagnostic routine to enable follow-up for quality assurance and research purposes. Out of 233 subjects who were consecutively referred to a team led by senior psychiatrist D.E. between April 2002 and October 2010, 168 (78 women and 90 men) fulfilled diagnostic criteria of adult ADHD and were included in this study. See also Fig. The current follow-up was conducted between March and August 2013. Written informed consent was obtained from all included subjects. A questionnaire was distributed and later supplemented by an interview performed by a research nurse with extensive experience of handling subjects with ADHD. The study was approved by the Uppsala Regional Ethics and performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.All included subjects were originally evaluated by a multidisciplinary team and diagnosed by the senior psychiatrist. The diagnostic procedure aimed at establishing best estimate diagnoses . As repoCurrent psychiatric comorbidity was evaluated by the Structured Clinical Interview for DSM-IV axis I disorders (SCID I) . CriteriAll subjects were subject to physical examination including basic neurologic status, as well as routine laboratory testing including screening for illegal drugs.The treatment protocol was individualised for each patient and based on a multimodal approach containing both pharmacological and a non-pharmacological measures.Current symptoms and treatment history were assessed on average of 77 months after baseline and performed in two steps.First, questionnaires were sent to the included subjects with questions about current symptoms of ADHD using a self-report version of the semi-structured interview utilized at baseline. Current functioning was assessed by a self-report version of the global assessment of functioning scale (GAF) . PotentiSecond, after return of the questionnaires there was a telephone interview covering demographics as well as details of their past and current medical condition. The interview mainly functioned to validate that the patients have understood the questionnaires, and to give practical support to fill in the questionnaires. Twenty-nine participants were given such support.Subjects’ own information regarding previous medication periods was validated against data in their patient files if available. In case of contradictory data, we choose to rely on patient file data. Slightly less than half of the subjects, 57 subjects; 46%, were on current medication, while 67 subjects were not. Mono-therapy was reported by all but three participants; methylphenidate in 46 subjects and amphetamine in eight subjects. Three subjects (5%) were treated with methylphenidate and atomoxetine in combination. A vast majority (84%) reported adherence to treatment on a daily basis. Fifty-five of those medicated had discontinued their medication and 12 (10%) were never treated. The 55 who had discontinued medication had been free of drugs for 41 ± 27 months; range 1–108, and 49 out of those had been free of drugs for a year or more at follow-up. In only two subjects the reason for discontinuation was the person’s own perceived clinical improvement.Non-pharmacological measures included psychoeducation (received by 41%), social and similar support (34%), vocational support (44%) and psychological therapy (55%), either in a group or individualised. Any non-pharmacological intervention was given to 80% of the subjects.The primary outcome measure was “remission”, which was defined as not fulfilling any ADHD subtype and a GAF-value of ≥ 70 during the last year.U test was used for analysis of group differences; otherwise the t test was performed for continuous data.Dichotomous data were analysed using Chi-square test statistics or Fisher’s exact test when applicable. Kolmogorov–Smirnov’s test was used to test for normality. When appropriate Mann–Whitney The strategy was to assess potential predictors of remission in stepwise binary logistic regression analyses, where variables which were significant in simple regressions should be included in a final model. Values are given as mean ± SD, or median with range within brackets. All statistical analyses were performed using IBM SPSS Statistics, version 23.Out of the 168 eligible subjects, 124 (74%) could be included for follow-up , worked full/part time or were studying (p < 0.05).There was no baseline difference between the 124 participants and the 44 non-participants with respect to age, sex, ADHD subtype, ADHD-score, axis I or axis II comorbidity, autism spectrum disorders or education level (data not shown). However, participants more often lived alone . Any use of drugs other than alcohol was reported in 7% of those in remission and 17% in those who were not; totally 14%. Risk scores for potential drug-related problems [p = 0.16).There was no difference in mean alcohol consumption, as measured by AUDIT scores and drug use as assessed by DUDIT scores. Scores above limits for harmful drinking  were, hoproblems  was repoAlthough those who had current medication did not report better on longitudinal assessments of their ADHD trajectories they reported significantly better on the CGI-I scale than those who had no medication Table . There wAll baseline variables recorded in Table The first main finding is that one-third of the subjects first diagnosed with ADHD as adults went into remission during an observation time of on average 6 years. This result relates well to findings in two recent similar studies. Karam et al.  describeThe second finding is that, despite a high percentage of psychiatric comorbidity at baseline, adult ADHD in general seems to have a favourable long-term outcome judged from the GAF scores at follow-up. These scores were similar to values previously reported from the general population . FurtherThe third main finding was that the remission rate and the ADHD scores were similar in those who were on current treatment with central stimulants and in those who were not treated. This observation adds to the present literature as there is currently no accepted evidence based on longitudinal assessments which suggests that there are long-term benefits from such medication in those first diagnosed with ADHD as adults . ActuallThe fourth main finding was that half of the subjects treated with central stimulants had discontinued treatment at follow-up which is similar to data reported from previous long-term studies , 40. ActEven though those who were currently on medication did not report better ADHD scores or Sheehan disability scores, they still reported higher improvement measured by CGI-I. This discrepancy may suggest that there are medication-related improvements which are not adequately reflected in the symptom-specific ADHD-screening profile but still sensed by the subjects. It is also possible that the subjects’ ratings contain a placebo-related mechanism in those who are compliant with the medication and pursue treatment over time. Finally, clinically not discerned individual differences may affect both a possible response to, and a tendency to discontinue medication , 47.It is noteworthy that no baseline factors predicted outcome 6 years after being first diagnosed with ADHD in adulthood. This stands in contrast to previous studies which indicate that psychiatric comorbidity at baseline was related to poorer outcome after on average 4.5 years , and alsAn issue is that the primary outcome variable differs between studies. It has been recommended that clinical research in ADHD should use “remission” as the primary outcome , thus, tThe clinical implications are that half of adults diagnosed with ADHD, and subsequently pharmacologically treated, had discontinued medication after a mean period of 6 years. On-going medication at follow-up was related to improvement of variables beyond core ADHD symptomatology such as global improvement and increased quality of life. As the study is small, although with a long follow-up time, it is difficult to draw detailed conclusions from subgroups in a trustworthy manner. In a broader context, the study support the notion that this group of patients constitutes a clinical challenge where each person requires individually designed support containing a multitude of approaches, and where medication is only one. The observation that half of the patients terminate medication after some time and where the termination is not related to improved symptoms of ADHD, points to a structural weakness in ability to motivate and support patients . AwaitinFirst, this study did not evaluate on-going psychiatric comorbidity at follow-up. There was, however, no difference in the number of comorbidities at baseline between those that remitted and those that did not, or in those that continued and those who discontinued their medication. Furthermore, in a prior study those in remission did not have more remission from comorbidities at follow-up than those being non-remitters . Second,This paper presents one of the longest naturalistic outcome studies of clinical subjects diagnosed with ADHD in adulthood. It is characterized by a very low attrition rate and almost three-fourth of the cohort was assessed after a mean of 6 years, which is substantially more than in previous prospective studies which present with dropout rates as high as 50–66% , 40. All


Prenatal smoking exposure has been associated with attention-deficit/hyperactivity disorder (ADHD). ADHD is commonly associated with a wide spectrum of psychiatric comorbidity. The association between smoking and neuropsychiatric comorbidity of ADHD has remained understudied. The aim of this study is to examine the association between prenatal exposure to maternal smoking and offspring ADHD, and test whether the smoking-ADHD associations are stronger when ADHD is accompanied by other lifetime neuropsychiatric comorbidities.n = 10,132), matched with four controls  on date of birth, sex and residence in Finland.The study is based on a nested case-control design and includes all Finnish singletons born between 1991 and 2005 and diagnosed with ADHD by 2011 . Compared to the only ADHD cases, subjects with comorbid conduct disorder or oppositional defiant disorder had a significantly stronger association with smoking exposure .Prenatal smoking represents an important risk factor for the ADHD comorbid with CD/ODD. Further research on the association between prenatal smoking exposure and neuropsychiatric comorbidity of ADHD is needed considering the increased risk among these subjects of an overall poor health outcome as compared to only ADHD. In particular, studies utilizing biomarkers or including subjects with neuropsychiatric conditions with and without comorbid ADHD are needed.The online version of this article (doi:10.1186/s12888-016-1007-2) contains supplementary material, which is available to authorized users. Among ADHD cases, comorbid diagnosis of autism spectrum disorders (ASD) are found in 10–33 % [conduct disorder (CD) in 16–18 % [learning and coordination disorders in 15–46 % [and mental retardation in 4–8 % [Attention-deficit/hyperactivity disorder (ADHD) is estimated to have a worldwide prevalence of 5 % . The dis 10–33 % , 5, cond 16–18 % , learnin 15–46 %  and mentBoth genetic and environmental risk factors contribute to the development of ADHD . MaternaPsychiatric comorbidity complicates the assessment of ADHD  and mighThis is a nationwide register study based on a nested case–control design. The sampling frame included all 900 603 liveborn children in Finland between January 1, 1991 and December 31, 2005. We utilized data from record linkages of three national registers: the Finnish Hospital Discharge Register (FHDR), Finnish Medical Birth Register (FMBR) and Finnish Central Population Register. The cases and controls were identified from the FHDR and the Finnish Central Population Register, respectively. Linkage was achieved by personal identity codes (PIC), which are assigned to all Finnish citizens and residents by the Central Population Register since 1971.The FMBR, founded in 1987 contains standardized data on the perinatal period for all live births, and stillbirths with birth weight of at least 500 g or gestational age of at least 22 weeks in Finland. The FHDR includes medical diagnoses made in the Finnish public health care system. The register covers all inpatient wards, in both somatic and psychiatric hospitals, local health centres, military wards, prison hospitals, and private hospitals. Since 1998, it has also covered outpatient care in public specialized hospitals. In Finland, diagnostic classification is based on the International Classification of Diseases (ICD); ICD-8 (WHO 1967) from 1969 to 1986, ICD-9 (WHO 1977) from 1987 to 1995 and ICD-10 (WHO 1992) from 1996 onwards. This register was used in order to identify cases of ADHD and of co-morbid conditions and parental psychiatric history. The Finnish Central Population Register is a digital national archive containing basic information on Finnish citizens and permanent residents. It is maintained by the Population Register Centre and local register offices. Individual data recorded in the system includes name, personal identity code (PIC), address, citizenship, native language, family relations, date of birth, date of death, emigration/immigration, and other information. The linkage between the registers was made using the PIC, which is unchanged throughout the lifespan.The cases consisted of all Finnish singletons (citizens or permanent residents) born between January 1, 1991 and December 31, 2005 and who were diagnosed with ADHD (ICD-10: F90.X or ICD-9: 314.X) by December 31, 2011 while treated in Finnish public special health care after the age of 2 years. Among 10,409 total cases, information on maternal smoking during pregnancy was available for 10,132, which represent the cases for this study.The controls with CD/ODD were not included in the dataset because the clinical features of CD/ODD and ADHD overlap and these disorders are difficult to differentiate from one another [The case and control identifications were based on hospital diagnoses, and structured diagnostic interviews were not conducted to fully confirm whether the control group is entirely free of ADHD. In order to reduce this possibility, these controls were not included. The cases were identified from the FHDR and the controls were identified from the Finnish Central Population Register according to above-named criteria.For every case, we identified four controls matched by sex, date of birth (+/- 30 days) and place of birth, excluding any diagnosis of ADHD or conduct disorders resulting in 40,141 subjects. Among them, maternal smoking status during pregnancy was available on 38,811 subjects who were eventually included in this study. Study subjects with severe or profound mental retardation were excluded from both the case and control groups because it is difficult to assess the symptoms of attentional and hyperkinetic disorders among these subjects.  another . The casInformation on maternal smoking during pregnancy was obtained from the FMBR. These were ascertained by maternity clinic nurses during routine prenatal visits during the second trimester of pregnancy and documented in health records. Maternal smoking during pregnancy was classified as: non-smokers, smoking only during the first trimester and smoking after first trimester.and gestational age. Covariates were classified as represented in Tables gestational age were obtained from the FMBR.The covariates used in the analyses were: maternal and paternal psychiatric history, maternal history of any substance use, maternal and paternal age at birth of offspring, maternal and paternal immigrant status, maternal socioeconomic status (SES), birth weight for gestational age, Apgar scores at 1 min, number of previous births A father was defined as having a “psychiatric history” if he had been diagnosed with any mental health disorder based on the classification of ICD-8 from year 1969 to 1986 (291-308), ICD-9 from year 1987 to 1995 (291-316) or ICD-10 from year 1996 onwards . Maternal psychopathology was defined correspondingly with the exception of separating “history of substance use history” and “any other psychiatric history” as independent covariates. These were separated because maternal diagnosis of substance use might be an indicator of teratogenic risk factors and thus it differs from paternal substance use diagnosis and other maternal diagnoses. A mother was defined as having a “history of substance use disorder” if she had been diagnosed accordingly based on the classification of ICD-8 from year 1969 to 1986 , ICD-9 from year 1987 to 1995  or ICD-10 from year 1996 onwards (F10-19). Data on parental psychiatric diagnoses were obtained from the FHDR.The lifetime comorbid psychiatric diagnoses of the subjects were obtained from the FHDR according to ICD-10 (F10-F99) similar to that used in the case identification 2011. Only those psychiatric conditions with onset typically during early childhood and with high rates of comorbidity with ADHD were included in the study. These conditions were mental retardation (F70–F79), pervasive developmental disorders, including autism spectrum disorders (ASD) (F84); Tourette syndrome (F95.2); conduct disorders, including oppositional defiant disorder (CD/ODD)  and learning and coordination disorders (F80–F83). The corresponding comorbid psychiatric conditions were classified into five groups.Seventy-six percentof the ADHD cases had at least one comorbid diagnosis. Learning and coordination disorder was the most common comorbid diagnostic group (48.1 %). The other most common comorbid diagnoses were: CD/ODD (28.1 %), anxiety disorders (13.6 %), autism spectrum disorders (11.9 %), depression  and mental retardation (3.7 %). The psychiatric comorbid patterns of the sample have been reported recently in more detail [These findings were in general consistent with previous studies [The overlap between the observed comorbidities is shown in Additional file e detail . These f studies . The ovegroup 48. %. The oBecause these comorbidities showed significant overlap each case was assigned to only one comorbid group in a hierarchical manner in the following order: first mental retardation; second ASD; third Tourette syndrome; fourth CD/ODD and fifth learning and coordination disorders. For example, if a case was diagnosed with both mild mental retardation and Tourette syndrome, she/he would be assigned to the group of mental retardation. If the case had none of the previous conditions, he/she would be classified into group six, “ADHD without comorbidities”. As listed in Table χ2 -test. The primary outcome variable was an ADHD diagnosis (no/yes). Conditional logistic regression models were used to examine the association between maternal smoking and ADHD with odds ratios (OR) and 95 % confidence intervals (CI).Multivariable analyses were conducted initially to test the significance of association between covariates and maternal smoking among controls as well as between covariates and ADHD diagnosis using Pearson’s p <0.05.The unadjusted model was used to evaluate the association between maternal smoking and the outcome in the entire sample. Maternal smoking was classified first as a dichotomous variable and then as a categorical variable by timing during gestation (no smoking /during first trimester only/after first trimester). The multivariable logistic regression model was used to evaluate the associations adjusting for covariates. In this comparison the reference group were the controls. Statistical significance (2-tailed) was judged at p < 0.1. The interaction term between ADHD with each comorbidity versus “ADHD without comorbidity” was assessed to compare the magnitude of ORs for smoking during pregnancy. In addition, differences in the magnitude of the ORs for ADHD between smoking only during the first trimester and smoking after the first trimester were tested correspondingly.Subsequently, we compared the relationships between maternal smoking and odds for ADHD alone and with each comorbid condition. Finally, we compared the relationships between maternal smoking and each ADHD-comorbid group with the “ADHD without comorbidities”. In the multivariable regression model adjustment was made for covariates with associations between both smoking and the outcome covariates at Statistical analyses were performed with SAS statistical software .and gestational age were associated with both maternal smoking during pregnancy among the controls and ADHD and were included as covariates in the analyses . Among the cases, 2.2 % of mothers smoked only during the first trimester and 28.1 % after the first trimester. Among controls, the corresponding figures were 1.6 % and 13.7 %. There were increased odds for ADHD associated with maternal smoking after first trimester  as well as smoking only during the first trimester . There were significant differences in the magnitude of the odds for ADHD between smoking only during the first trimester and smoking after first trimester (p < 0.001). The difference in odds for ADHD between smoking during pregnancy and during the first trimester only was statistically significant (p < 0.001).As shown in Table p < 0.001) and the lowest with learning disorders . In addition with other confounders the results were adjusted first with weight for gestational age , second with gestational age (OR 1.61 95 % CI 1.45–1.78) and third with neither . The results were similar in all three models for all comorbid categories.The associations between maternal smoking during pregnancy and odds of ADHD with each comorbid condition are shown in the Table p < 0.001). The association between smoking and comorbid CD/ODD was significantly stronger compared to the respective associations for each of the other ADHD-comorbid diagnostic groups in unadjusted models. In the adjusted model only the groups of ADHD subjects with comorbid Tourette syndrome and mental retardation did not differ significantly from the group with ADHD and CD/ODD.As shown in Table The present study has several findings which add to the evidence of a complex association between exposure to smoking during pregnancy and later ADHD with comorbid conditions. First, prenatal smoking exposure was associated with increased risk of ADHD with comorbid neuropsychiatric disorders. Second, comparing each of the co-morbid groups with the control group, the strongest association was found with ADHD comorbid with CD/ODD. Third, the group with ADHD and CD/ODD was the only group showing a statistically significant association with smoking compared to the group of ADHD without comorbidities. To our knowledge, this is the first study to report these associations in a large nationwide sample.The association between maternal smoking during pregnancy and, offspring ADHD and, specifically CD/ODD status has several possible explanations. First, exposure to smoking during pregnancy might have direct intrauterine effects mediated by nicotine contributing to risk for ADHD and CD/ODD. Nicotine has been shown to transfer across the placenta to the fetus . Also, nThe association between prenatal smoking exposure and offspring ADHD in general was in line with previous similar studies reporting findings of ORs ranging between 1.5 and 2.4 , 10. TheSixth, common internalizing disorders, such as anxiety and depression, were not included in the analysis. Anxiety and depression may have onset at adolescence or adulthood whereas the included disorders typically have an onset at childhood. Including these disorders in the utilized hierarchical model would have been complicated. However, exclusion of internalizing comorbidities is not expected to affect the conclusions drawn from our results.The present study is based on a large nationwide sample, and the analyses were adjusted with several confounders. However, there are limitations that need to be considered while interpreting the findings. First, the subjects include only the ADHD cases referred to specialized mental health services and assumingly these represent mainly the patients with the most severe symptoms of ADHD. The healthcare services in Finland are universal and publicly funded; children are exempted from the generally low patient fees. Because of this the number of severe ADHD cases missing due to lack of access to health services is expected to be small. Second, the maternal smoking status was based on a self-report. Previous studies have shown that pregnant mothers under-report their smoking. Actually, between 7 and 22 % of the self-reported non-smokers were smokers according to the blood and urine cotinine levels , 39. ThiThe study supports previous findings of association between smoking during pregnancy and offspring ADHD. In future studies utilization of biological markers of smoking such as cotinine levels would confirm the present results. The children with the combination of ADHD and CD/ODD show more tendency to develop mood disorders  and late


Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood disorder with international prevalence estimates of 5 % in childhood, yet significant evidence exists that far fewer children receive ADHD services. In many countries, ADHD is assessed and diagnosed in specialist mental health or neuro-developmental paediatric clinics, to which referral by General (Family) Practitioners (GPs) is required. In such ‘gatekeeper’ settings, where GPs act as a filter to diagnosis and treatment, GPs may either not recognise potential ADHD cases, or may be reluctant to refer. This study systematically reviews the literature regarding GPs’ views of ADHD in such settings.A search of nine major databases was conducted, with wide search parameters; 3776 records were initially retrieved. Studies were included if they were from settings where GPs are typically gatekeepers to ADHD services; if they addressed GPs’ ADHD attitudes and knowledge; if methods were clearly described; and if results for GPs were reported separately from those of other health professionals.Recognition rate; ADHD controversy ; Causes of ADHD; GPs and ADHD diagnosis; GPs and ADHD treatment; GP ADHD training and sources of information; and Age, sex differences in knowledge and attitudes.Few studies specifically addressed GP attitudes to ADHD. Only 11 papers (10 studies), spanning 2000–2010, met inclusion criteria, predominantly from the UK, Europe and Australia. As studies varied methodologically, findings are reported as a thematic narrative, under the following themes: Across times and settings, GPs practising in first-contact gatekeeper settings had mixed and often unhelpful attitudes regarding the validity of ADHD as a construct, the role of medication and how parenting contributed to presentation. A paucity of training was identified, alongside a reluctance of GPs to become involved in shared care practice. If access to services is to be improved for possible ADHD cases, there needs to be a focused and collaborative approach to training.The online version of this article (doi:10.1186/s12875-016-0516-x) contains supplementary material, which is available to authorized users. Attention-deficit hyperactivity disorder (ADHD) is a common behavioural disorder of childhood, characterised by over-activity, impulsivity and inattention, and is recognised to cause significant personal, academic and social functioning. Marked variation exists in cited prevalence rates, which range from as high as 26 % , 2 to loIn general, identifying mental health difficulties in children and young people is a challenge in primary care . ReviewsWithin a context of generally poor recognition of children’s mental health difficulties in primary care, ADHD may present additional challenges, as it remains a socially contested diagnosis, and the subject of on-going debate in popular media as well as in medical professions. Regarding the appropriateness of psychotropic prescribing for children, both reasoned concerns as well as more critical views are found , 17–19. aetiology of ADHD and the relationship of neurobiology to symptoms remain poorly understood, leaving the field open to multiple interpretations [treatment continues to be actively debated, as evidenced by the recent Cochrane meta-analysis of methylphenidate (MPH) effectiveness in childhood ADHD and the subsequent published debate [For example, despite extensive research, the etations , 21. Furd debate –25. In sd debate , 27, thed debate . In manyd debate , 25.service structures, in many countries, GPs in primary care are service ‘gatekeepers’: for many conditions, including ADHD, they do not diagnose or initiate treatment but rather refer to relevant specialists. In such settings, patients and their families are precluded or discouraged from consulting specialists directly without GP referral – examples are 19 countries in Europe, Canada, Australia and New Zealand [In addition to debates over aetiology and treatment, further features of the medical/social context that may affect ADHD diagnosis, referral and treatment are medical service structures and ADHD treatment guidelines. Regarding  Zealand –31. This Zealand . ‘Gateke Zealand  generate Zealand , 32, 33, Zealand –33. This Zealand  but, as Recommendations in guidelines, regarding who may diagnose ADHD and initiate treatment, further underscore GPs’ gatekeeper role. Reviews of guidelines , 35 noteIn sum, GPs in gatekeeper settings are charged with identifying children with suspected ADHD and referring them to specialist secondary services, but they do not engage with diagnosis or initiate treatment. Unlike many other psychiatric diagnoses, the nature of ADHD and its optimal treatment, despite being agreed by most psychiatrists and across the world in national treatment guidelines, is disputed by other professionals and questioned in the media , 18, 36;The systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines . The seageneral (family), physician  and attention deficit hyperactivity disorder . The search yielded 3776 studies. Duplicates were removed and two researchers independently reviewed 3023 titles and abstracts according to the inclusion and exclusion criteria listed below.The primary search in abstracts included three main terms and their variations: Studies of GPs’ attitudes/knowledge regarding ADHD in children and/or adolescentsIf more than one profession is studied, GP findings are reported separatelyStudies in countries where GPs are first-contact gatekeepersPublished in or after 1994, when DSM-IV was publishedPublished prior to January 2015English languagePublished in peer-reviewed publicationsBooks, chapters and book reviews; clinician review notes, case studies, clinical practice guidelines or recommendations; opinion pieces and commentaries;Studies of ADHD prevalence; medication adherence; ADHD-related physical health in primary care; adult ADHD; and studies making only passing reference to ADHD;Studies of first-contact paediatricians or child and adolescent psychiatrists, whose training, knowledge and recognition are likely to differ substantially from GPsn = 1136); studies of ADHD measures or medication efficacy (n = 557); or studies where ADHD was included with other general mental health difficulties, but not reported on separately (n = 250). At full-text review, 41 studies were examined and 30 were excluded ; Causes of ADHD; GPs and ADHD diagnosis; GPs and ADHD treatment; GP ADHD training and sources of information; and Age, sex differences in knowledge and attitudes.Themes were An ADHD screening study in the UK and GP self-reports in Australia and Canada suggested that GPs under-recognition of ADHD. In the UK (2002) only 1 in 10 children who screened positive for pervasive hyperactivity using the SDQ in a community sample were in contact with mental health services, even though 74 % of screened children had seen the GP in the previous year and GP hyperactivity recognition inevitably led to referral. In Australia (2002), GPs saw over 550 children aged 4–16 annually yet reported identifying just 1–5 ADHD cases in any given year, suggesting a recognition rate of under 1 %. In Canada (2005), 20 % GPs said they saw no children in whom they would consider ADHD; this compared to only 6 % who stated they saw no children in whom they would consider mood disorders, suggesting GPs recognised ADHD less frequently than other mental health difficulties in children, even though prevalence data indicate ADHD is more common.In surveys and focus groups in the UK, Australia and Iran 2000–2010), GPs typically expressed mixed feelings and scepticism about ADHD and about medicalising childhood behaviour, as well as concern about stigma. In the most recent study , 1 in 5 GPs believed ADHD was ‘not a serious problem’ that did not need to be managed and over 8 out of 10 GPs believed children with ADHD ‘misbehave primarily because they don’t want to obey rules and do their assignments. In Australia and the UK, GPs cited ADHD over-diagnosis and discussed overmedication, medicalisation of misbehaviour and suspicion about medicating children. GPs in London  particularly felt that ADHD was controversial, potentially stigmatising and disadvantageous; it was considered a ‘fashionable’ diagnosis (2005), and referrals were characterised as a risk avoidance strategy (2008). Interviews in the UK (2000) identified three stances: strong anti-labelling; sceptical and reluctant to medicalise; or ADHD diagnosis viewed as facilitating parental understanding and school supports, but not something GPs wished to deal with. The UK studies also illuminated the concept of parent blame , 43 % GPs felt stimulants were suitable first-line treatments, but 17 % said they were always inappropriate; in Iran (2010), 75 % agreed ADHD can be managed with medication, but 52 % of GPs believed only severe cases should receive it. In the UK (2005), most GPs stressed a combination approach to treatment .Most studies did not report on ADHD-specific GP training. Of those that did, just 6 % GPs in the UK and 10 % in Iran had received this. GPs in all qualitative studies frequently cited their lack of ADHD training and knowledge. Qualitative studies in Australia (2003) and the UK  indicated that GPs relied on media as a source of ADHD information, as did about a quarter of GPs in surveys . All studies concluded that GP training in ADHD was needed.Finally, just a few studies reported analyses of attitudes and knowledge by GP age or gender and there was no pattern of findings. Male GPs reported significantly higher comfort and skill in Canada, whereas female GPs did so in Finland  have found that only small proportions of children with ADHD receive treatment –8. As GPRecognition rate; ADHD controversy ; Causes of ADHD; GPs and ADHD diagnosis; GPs and ADHD treatment; GP ADHD training and sources of information; and Age, sex differences in knowledge and attitudes.The systematic review of papers found surprisingly few studies of this topic, 11 studies (12 papers). Although diverse in focus, settings, time and measures, the studies were found to have explored common topics of Strikingly, across this diverse set of studies, GPs’ views regarding causes, treatment and their role in ADHD were found to have many similarities and to reflect recent studies of other professionals, such as teachers, that highlight persistent of misconceptions about ADHD and its management . As GPs The presence of such views raises concern about GPs’ role in recognising ADHD in countries where they control children’s access to services. This is supported by UK research of the pathway to ADHD care, which indicates that children with hyperactivity, but without additional behaviour problems, are likely to go unrecognised by the GP unless the parent requests referral . It is fThe finding that GPs are reluctant to be involved in active ADHD care also raises questions about policy recommendations for shared care between mental health services and primary care such as the UK NICE Recommendations . For exast century. Several studies were of large, randomly selected samples with very good response rates (52–76 %) and a combination of quantitative and qualitative studies enables both depth and breadth to be accessed. At the same time however it should be noted that only a limited number of studies was identified and some were opportunistic surveys. The use of different questionnaires in each study means that caution should be employed when drawing conclusions about attitudes across these studies, and direct comparisons of proportions of GPs holding certain views across settings and times are not possible.This review benefited from a systematic, wide-ranging search and is the first examination, to our knowledge, of international GP/FP attitudes to ADHD in jurisdictions where GPs are gatekeepers to ADHD services. It captures views across four continents in the first decade of the 21Furthermore, a skew towards the earlier part of the decade means that many studies report attitudes that are over a decade old. The limited range of studies (and paucity of recent findings) is surprising and suggests an urgent need for updated and more wide-ranging research in this field: it is possible that GPs’ views may have changed and may be influenced by the growing literature supporting biological contributions to ADHD , 21. OneIndeed the possible role of stigma in GPs’ ADHD recognition and referral process is another aspect of ADHD that is worthy of further exploration. Stigma is substantially under-investigated regarding ADHD,  surprisiGP education is one strategy to improve knowledge and self-efficacy regarding mental health in general in children and adults, and ADHD in particular, and can assist with appropriate referral to services –62. As nHowever, it should be noted that training and increased knowledge alone may not be enough to affect GPs’ behaviour, , 63. Sikcertainty about their clinical findings  but also a sense of urgency about taking this action [Notably, Canadian GPs, who had received autism education, only raised a concern with parents regarding possible symptoms of a child’s autism if linked with personal s action . This fis action , 13 and s action  indicatecurrent ADHD attitudes and knowledge is highlighted once again.In relation to services, in settings where national or professional ADHD guidelines require secondary services to diagnose and initiate treatment, they often also  recommend the involvement of GPs in shared care models . This waThis review identifies knowledge gaps among GPs regarding ADHD in many jurisdictions where they operate as gatekeepers to ADHD care. Despite the limited number of studies found, their geographic breadth indicates that mixed (and often unhelpful) attitudes regarding the construct of ADHD are internationally widespread, even among medically trained clinicians, in these gatekeeper settings. Combined with prevalence studies and investigations of pathways to care, the findings suggests that education about ADHD is required not only for GPs but for all groups in the care pathway, including parents, teachers and the public, to enable parental concerns to be correctly identified and managed, and to ensure appropriate access to specialist services. This training might address barriers to parents’ perceptions of problems and to expression of concerns regarding possible ADHD in primary care consultations. It would also be valuable to work with GPs, to ensure that they are alert to relevant concerns and symptoms, and have adequate training and supports to respond accordingly.


Contrary to Diagnostic and Statistical Manual of Mental Disorders (DSM-5), fifth edition, some studies indicate that ADHD-inattentive presentation (ADHD-I) is a distinct diagnostic disorder and not an ADHD presentation.In this study, 12 ADHD-combined presentation (ADHD-C), 10 ADHD-I, and 13 controls were enrolled and their resting state EEG recorded. Following this, a graph theoretical analysis was performed and functional integration and segregation of brain network was calculated.The results show that clustering coefficient of theta band was significantly different among three groups and significant differences were observed in theta global efficiency between controls and ADHD-C. Regarding the alpha band, a lower clustering coefficient was observed in control subjects. In the beta band, clustering coefficient was significantly different between the control and children with ADHD-C and also between ADHD-I and ADHD-C. The clustering coefficient, in the subjects with ADHD-C, demonstrated a rapid decline and was significantly lower than the subjects with ADHD-I and control.Decreased clustering, in high thresholds, may be associated with hyperactivity while increased segregation in low thresholds with inattentiveness. A different functional network occurs in the ADHD-C brain that is consistent with several studies that have reported ADHD-I as a distinct disorder. The preDespite conventional categorization of ADHD presentations, some studies suggest that ADHD-I is a distinct diagnostic disorder and not a presentation of ADHD . BarkleyNeurophysiological studies have shown that pathophysiology of ADHD is associated with several abnormalities in cortical and subcortical regions  and variThe functional and structural connectivity of complex networks are investigated using graph theoretical analysis. Several recent studies have demonstrated that graph theoretical analysis is a reliable approach to determine functional or structural brain connectivity abnormalities in various neurological, psychiatric, and cognitive disorders . In 1998Small world topology has been identified in many functional and structural brain connectivity networks , and altThe current study is the first study to identify a functional difference in ADHD presentations using graph theoretical analysis. EEG coherence in different frequency bands  among electrode pairs was used to determine edges and clustering coefficients, characteristic path lengths and the clustering coefficient for ADHD-I, ADHD-C, and control groups. Finally, the topological properties of the brain networks were demonstrated and the functional differences among three groups were characterized.2.2.1.Thirty-five right-handed children aged between 7 and 11 years participated in the experiment 12 ADHD-C , 10 ADHD-I  and 13 controls . Children with ADHD were all recruited from Hamrah Child and Adolescent Multidisciplinary Neuropsychiatric Center, Tabriz, Iran. None of the children in the study had ever been treated with methylphenidate or had a history of treatment with neuromodulation devices such as neurofeedback or transcranial direct current stimulation. Full diagnostic criteria for the ADHD combined and inattentive participants for ADHD-C and ADHD-I were implemented, respectively. The diagnosis was based on DSM-5 criteria.For all participants, the child behavior checklist  was comp2.2.For EEG recording, we used a Mitsar® amplifier with 21 channels and WinEEG® software. EEG was sampled at 250 Hz with a filtered online 0.1–40 Hz band pass. EEG was recorded using a 19 channel Electrocap® according to the 10–20 international system. All electrodes were referenced to linked earlobes, and the ground was placed on AFZ. Electrode impedance was maintained below 10 kΩ.1 and the EEG coherence of 5 frequency bands; theta (4.5–7 Hz), alpha (7.5–12 Hz), beta1 (12–15 Hz), beta2 (15–17.5 Hz) and beta3 (18–25 Hz) among all electrode pairs  were obtained.EEG signals were recorded for 5 minutes in eye open condition and at least 90 seconds of artifact free signal was selected for processing. Visual signal selection and then automatic rejection  was used for artifact rejection. Each epoch was also visually appraised by an independent expert. EEG data were processed offline by Neuro-guide software2.3.A 19×19 binary adjacent matrix was formed as a functional network for each participant. Previous findings have suggested that coherence can be used to characterize the pathophysiological changes in ADHD . TherefoWhere C(w) is the Fourier transform of cross correlation coefficients between two electrodes . Binary i is obtained by counting the number of edges in the subgraph of i neighbors. Locally, the clustering coefficient is measured as the ratio between the number of actual edges and the maximum possible number of edges in the subgraph of neighbors of i  that is identified by averaging on all shortest paths. In a 19×19 binary adjacent matrix, there are 171 shortest paths between all pairs of nodes in the network and their average is the characteristic path length of the network . Rapid i2 . To investigate differences between group pairs, a post hoc analysis (Tukey) was applied. In various thresholds of frequency bands, clustering coefficient and global efficiency were calculated and related graphs as a function of thresholds were determined. In each band, the R among these graphs were obtained by Matlab software.3.3. 1.Regarding the theta frequency band, the clustering coefficient was significantly different among three groups . In loweClustering coefficients as a function of different thresholds are shown in 3. 2.In the alpha frequency band, a lower clustering coefficient was observed in control subjects compared to either of the ADHD presentations (T<0.5). In addition, a rapid decline in ADHD-C was observed in T>0.5 . The cor3. 3.A significant difference in the beta1 frequency band was observed between the control group and children with ADHD-C in lower thresholds (T<0.4) and between ADHD-I and control subjects in 0.35<T<0.46. As in alpha and theta bands, a rapid decline in ADHD-C was observed in T>0.4 . The R b3. 4.In the beta2 frequency band clustering coefficient, a significant difference was observed between the ADHD-C and control groups in T<0.38 while ADHD-C had a higher C than both ADHD-I and control groups . Regardi3. 5.In the beta3 frequency band, the clustering coefficients of ADHD-I and ADHD-C were significantly different from the control group at lower thresholds. In addition, there was no significant correlation between the clustering coefficient graphs . Despite4.The current study is the first to investigate functional connectivity differences between two ADHD presentations (ADHD-I and ADHD-C) and control subjects. We demonstrated that the functional connectivity in ADHD presentations is different from control subjects  and 7. HSeveral studies suggest that stimulus assessment  and LongEvidently a greater theta coherence reported in children with ADHD may be associated with hyperactivity . In agreAlpha waves have also been investigated in several ADHD studies . These sA reduced beta power has been repeatedly reported in ADHD children . In the The presence of clusters or modules in functional networks denotes a segregated neural processing . The abiThe small world brain function has been demonstrated in previous studies . A smallOverall, an impaired segregation in higher thresholds was observed in children with ADHD-C . This new finding indicates a brain functional change in the ADHD-C presentation that was completely different from the ADHD-I presentation. This suggests that various neuronal activities may be involved in different ADHD-presentations. The current finding is consistent with previous studies that introduce ADHD-I as a distinct disorder .A significant correlation of clustering coefficients at certain thresholds was observed between ADHD-I group and controls . However, there was not a considerable correlation between ADHD-C and the control group . The results demonstrated that in ADHDC, there was a rapid reduction at high thresholds while this reduction was much slower in children with ADHD-I and controls. Therefore, in ADHD-C, the functional segregation was significantly reduced at higher thresholds which may be correlated with impairment in the neural network . We suggOverall, ADHD presentations demonstrated an increased segregation in low thresholds that were correlated to increased local modularity and may be related to inattention. It shows a different functional network in the brains of ADHD-C subjects which was consistent with several studies that introduce ADHD-I as a distinct disorder . We suggOur findings are the first to show a significant difference in functional brain networks between children with ADHD-C and ADHD-I. However, further studies with greater number of participants is required to replicate our results and assumptions.


Dopamine dysfunction is known to be associated with attention deficit hyperactivity disorder (ADHD). Dopamine D4 receptor gene (DRD4) is one of the important genes in this pathway. This study intended to investigate the variable number of tandem repeats (VNTR) in exon 3 of the DRD4 gene in Iranian children and adolescents. In this study, 130 children with ADHD, aged 6–14 years, and 130 healthy children, within the same age range, were enrolled. All children were selected from northwest of Iran which have Caucasian ethnic background and are of a Turkic ethnic group. VNTR polymorphisms of the DRD4 gene were evaluated by PCR using exon 3-specific primers followed by agarose gel electrophoresis.p = 0.004; X2 = 17.39; df = 5). The least percentage of repetition alleles in both groups was 2R. The Hardy-Weinberg principle and Chi-square test showed a significant difference in 4-repetition (4R) alleles between the ADHD (76.2%) and control (53.8%) groups ( There is a significant correlation between the 4R alleles of DRD4 and ADHD in the northwest of Iran. ADHD is a common childhood psychiatric disorder that is associated with the symptoms of sustained hyperactivity, impulsiveness, and inattentiveness. The worldwide prevalence is 4–8% in school-aged children, which may persist during adolescence and adulthood in 50–80% of cases . A compaADHD is a heterogeneous neurobehavioral disorder with multifactorial etiology, leading to neural pathway alternations . The pheDiagnosing ADHD is currently based on clinical similarities, like other psychiatric conditions. The diverse phenotype results in diagnostic challenges , 7 that The length of exon III varies between 2 and 11 repeats of a similar 48-bp VNTR, presented by D4.2 to D4.11 . TypicalThere are evidences supporting significant relationship between 7-repeat alleles of DRD4 exon III polymorphism and ADHD –19. On tThe present study was conducted in a child and adolescent psychiatry clinic of Tabriz University of Medical Sciences. The procedure was approved by the regional ethical committee and written informed consent was obtained from parents of participated children and adolescents.The inclusion criteria were children and adolescent, aged 6–18 years, diagnosed with ADHD, based on clinical interviews conducted by a children and adolescent psychiatrist.The exclusion criteria were concurrent psychiatric disorder, epilepsy, a serious medical condition or history of severe trauma, and any degree of intellectual disability. ADHD cases with comorbid ODD and/or CD were excluded.n = 130) in specialized psychiatric clinic were included by a child and adolescent psychiatrist. In this study, ADHD diagnosis was carried out through a semistructured diagnostic interview based on DSM-IV-IR criteria.This study was conducted in northwest of Iran. The populations living in these areas have Caucasian ethnic background and are of a Turkic ethnic group. Children diagnosed with ADHD (n = 130), who were introduced for adenotonsillectomy procedure, within the same age range, were taken as the controls. These children were diagnosed to have no psychiatric condition by the same diagnostic procedure as children with ADHD. An informed written consent was obtained from all parents.A group of children . This tool was to identify ADHD and possible comorbid psychiatric conditions as well as choosing controls .The diagnostic procedure was completed through interview with child and the parents. The test-retest and interrater reliability of the Persian version is reported to be 0.81 and 0.69 . 5′-GGTCTGCGGTGGAGTCTG-3′  (Forward) 5′-GCGACTACGTGGTCTACT-3′  (Reverse)In his process, 2 mL peripheral blood samples were prepared and genomic DNA was extracted from it, using QIAamp DNA kit according to the manufacturer's instruction. The extracted DNA was quality-checked by using a NanoDrop device within the range of 260–280 nm. The genotyping of DRD4 exon III was carried out by polymerase chain reaction with the following primer sequences:μL reaction mixture containing 50 ng genomic DNA, using Ampliqon Master Mix (Denmark), 1 mL from each primer, and 0.2 μLTaq DNA polymerase, according to temperature plan in Amplification by PCR was performed in 20 p < 0.05 was considered significant.Data from counting the gene products in each sample was fed to SPSS21. Data are expressed as number and percentage, and the obtained mean values are investigated, using the Chi-square test. In this study, One hundred and thirty children diagnosed with ADHD and 130 children with no psychiatric diagnosis were enrolled. Mean age of children in the two groups was not significantly different. However, there were more males in the ADHD group (83% in the ADHD versus 61% control group). The role of a first-degree family relationship was present in many samples. Descendants of a cousin marriage accounted for the majority of children with ADHD . As the p = 0.004; X2 = 17.39; df = 5). There was no significant between-groups difference in other repetitions. The 2R genotype had the lowest prevalence.ADHD is a prevalent neurobehavioral disorder starting during childhood . AccordiIn the present study, the DRD4 gene was observed in all Iranian participants (ADHD and controls) within the range of 2R to 7R alleles. The dominant alleles in our study were 4R, 5R, and 6R, among which the 4R allele had the highest prevalence. The between-groups difference was significant only in 4R allele. Results of the present study are consistent with those of Bidwell et al. . Cheuk eThough these studies were in line with the present study considering 4R as an indicator of ADHD, studies on other populations, specifically White Europeans and Americans showed a greater role of 7R alleles in the development of ADHD . In contAnother meta-analysis study showed a significant difference in the relationship of ADHD and DRD4 7R in people of European-Caucasian and South American descent versus people of Middle Eastern Populations . Leung eAccording to demographic and ethnicity studies, it can be concluded that phylogenetics can be studied by investigating the polymorphism of genes in specific diseases. As it is seen, 4R is more prevalent in Asians than White Caucasians and Europeans . High prHowever, there are studies that refuse the relationship of 7R alleles with ADHD. Carrasco et al. reports a negative relationship between 7R alleles and ADHD in a study conducted on a Chilean population . BrookesThe most obvious explanation for dissimilarity of reported results is differences of the study samples. However diagnostic procedure and methodological differences should also be accounted. The importance of a conclusion is not restricted to facilitating the diagnostic procedure but also might lead to preparing a precise treatment plan for each individual. Functional differences in the DRD4 intracellular signaling system have been studied for the 48-bp repeat alleles, and studies show that the 7R allele may be less sensitive to endogenous dopamine and mediates a blunted response to dopamine . If resuIt can be stated that the 4R allele carriers, which appear frequently in the ADHD patients in the northwest of Iran, may have a better prognosis than the carrier 7R, which in other populations have been linked to ADHD. In other words, the 4R allele repeats in DRD4 gene can be considered as a prognostic diagnosis in ADHD disorder in this area of Iran.In contrast to the results of studies conducted on White Europeans and Americans, in which 7R was the genetic indicator of ADHD, our study showed 4R as the variant of this disorder in northwest of Iran.


If we were to turn the ADHD clock back to the 1980s, we would find a story that, from a global perspective, could perhaps be titled Those crazy Americans: There they go again.DSM III, and for the next 15 years or so the use of this diagnosis and prescribing of stimulants to school-age youth was mostly an American affair, looked upon with considerable skepticism by psychiatrists and physicians in Europe and other parts of the world. In 1995 the US Drug Enforcement Agency reported that the US “produces and consumes five times more methylphenidate than the rest of the world combined”, which the agency saw as a rather dubious achievement.The diagnosis back then was brand new, one that the American Psychiatric Association had created in 1980 when it published And so it seemed 25 years ago: psychiatrists and physicians in other countries weren’t about to follow this latest American practice and start seeing their children through the ADHD lens. Perhaps, I remember thinking, the US medical community could learn from the rest of the world, and this would put a brake on the ADHD train.But here we are in 2017, and ADHD has become a global disorder: 5% of school-age children are said to “have” ADHD, and the prescribing of stimulants to children and youth has risen in countries around the world. This globalization effort has marched forward under the biological banner. The condition is said to be highly heritable (and thus a genetic disorder), and brain scans tell of how brain volumes differ in ADHD children compared to “normal” youth. Thus we have an important question to ask: Is the ADHD phenomenon a story of scientific progress, or the successful exportation of an American fad?To raise this question is not to say that there are not children who have behavioral problems characterized by inattention or “hyperactivity” or that there are not children who are floundering in school and need help. The question is whether societal beliefs about ADHD are grounded in a good understanding of the relevant science and whether the use of the diagnosis and the prescribing of medications has proven helpful to children who may be struggling in this way.The International Journal of Qualitative Studies on Health and Well-being is devoted to “challenging the ADHD consensus”, which provides a much-needed forum for critiques of the common wisdom. The first thing that readers may notice is that the eight articles reflect the globalization of ADHD. They tell of media coverage of ADHD in France and Australia; of youth in Chile and European countries so diagnosed; and of academic researchers in the UK, the Netherlands and elsewhere investigating the phenomenon.This issue of The globalization of ADHD relies on the telling of a story to the public, and in an analysis of media reports in France, a society usually portrayed as resistant to this “medicalization of childhood”, Ponnou and Gonon report that whereas newspapers and other print media have often provided fairly nuanced coverage of ADHD, giving space to psychosocial explanations for ADHD behaviors, television shows—where most Europeans get their news these days—have mostly presented the biomedical narrative. When such programs were aired, parental requests for the ADHD diagnosis rose.Meanwhile, Harwood and her research colleagues’ study of the selling of ADHD in Australia reveal how media reports of ADHD employed the language of “heroic struggles, criminals and scientific breakthrough”. Science was on the march; the medication provided a “lubricant for learning” and yet parents, in their desperate bid to find help for their children, had to fight against “bad” doctors who refused to take the ADHD diagnosis seriously. This was a framework that told of a valiant fight for good, and with such stories forming the public understanding of ADHD, the prescribing of stimulants to children in Australia, at least for a time, surpassed the rate in the original ADHD hotspot, the USA.The globalization of ADHD has also involved the “educating” of professionals—teachers, nurses, physicians, and other mental health workers—and the article of Meerman and co-authors documents how this instruction might best be described as scientifically illiterate. To cite just one example, the biomedical narrative tells of how brain scans show an abnormality in brain volumes in ADHD children. But of course such research involves calculating “average” brain volumes from youth diagnosed with ADHD compared to “normal” controls, which means that a scatterplot of individual brain volumes would show many in the ADHD cohort as “perfectly normal” and many in the “normal” cohort with abnormally “small” volumes.The fact that “most children with ADHD behavior have ‘normal’ brains” is one of six facts that Meerman, Batstra, Grietens, and Frances argue that teachers and other mental health professionals “need to know”. The remarkable thing is that so many mental health professionals would be surprised to learn of this basic information.One fact that is noted in several of the articles, and is almost unbearably sad, is that studies have regularly failed to find that ADHD medications provide a long-term benefit. The studies have not found that the drug treatment reduces delinquency rates, or improves school performance, or improves any other markers of success. In the absence of such benefits, we are left chalking up the long-term harms that can come with regular stimulant use. Regardless of whether ADHD is “real” or simply a diagnostic construct, we should want to see that the treatment helps school-age children grow up and thrive. Given that research hasn’t shown that to be so, what is the rationale for long-term stimulant use?This question is of particular relevance given that we known there are psychosocial interventions that can help such children. Timimi tells of the success of a Relational Awareness Programme that involves “prioritizing building relationships over controlling behavior (symptoms)” and helps parents and teachers move “away from emotional energy reinforcing negatives and toward reinforcing positives”. My guess is that if you asked 100 random adults in society to assess the likely effectiveness of these two therapies, stimulants or fostering relationships, that helped build a child’s emotional resilience, nearly all would pick the latter. But the globalization of ADHD has not proceeded with that menu of options put before society.In debates over ADHD, we often fail to hear from the children so diagnosed and medicated. What does it do to their inner world? How does the diagnosis affect their sense of self? How do they navigate their new status in the world as an ADHD child? Rojas Navarro and Vrecko, Helle-Valle et al., and Salomonsson tell of investigations into the child’s world, and given the stereotype of ADHD children as difficult and prone to outbursts, these articles all remind us, in one way or another, of how resilient, caring, and frightened they may be. Which is to say, they remind us of children struggling to make their way in a challenging world, who could use help of a non-medical kind.Journalist and author of Anatomy of an Epidemic Madinamerica.comand founder of