Genome-wide association (GWA) studies have shown that many different genetic variants cumulatively contribute to the risk of psychiatric disorders. It has also been demonstrated that various parent-of-origin effects (POE) may differentially influence the risk of these disorders. Together, these observations have provided important new possibilities to uncover the genetic underpinnings of such complex phenotypes. As POE so far have received little attention in neuropsychiatric disorders, there is still much progress to be made. Here, we mainly focus on the new and emerging role of POE in attention-deficit hyperactivity disorder (ADHD). We review the current evidence that POE play an imperative role in vulnerability to ADHD and related disorders. We also discuss how POE can be assessed using statistical genetics tools, expanding the resources of modern psychiatric genetics. We propose that better comprehension and inspection of POE may offer new insight into the molecular basis of ADHD and related phenotypes, as well as the potential for preventive and therapeutic interventions. Genome-wide association (GWA) studies have demonstrated that many different genetic variants cumulatively contribute to the risk of psychiatric disorders. The GWA approach has been particularly successful in schizophrenia, where over 108 susceptibility loci have been identified , 3.Even with considerable research efforts being directed towards understanding the etiology of ADHD and clearly identifying a wide range of risk factors, genome-wide studies have, so far, failed to identify robustly associated genes. The majority of candidate genes studied to date confer only a small risk for ADHD, often refer to co-occurring conditions and they lack consistent replication . Apart fPOE is a collective term referring to situations in which mothers and fathers do not contribute equally to the development of a phenotype in their offspring . There aGenomic imprinting is the occurrence of monoallelic expression of only one of the two alleles, dictated by parental origin . Such diSNAP25 [HTR1B [SLC6A4 [BDNF [DDC [GNAL [TPH2, DRD4, DRD5 [SLC6A3 [FAS and PDLIM1 genes [Imprinting has already been implicated in psychiatric health , 14, witSNAP25 , HTR1B [5 [HTR1B –30, SLC6 [SLC6A4 , 32, BDNA4 [BDNF , DDC [34DC [GNAL , TPH2, DD4, DRD5  and SLC6 [SLC6A3 , 36. TheM1 genes . In compM1 genes .SLC6A3, that has been suggested to be imprinted, highlights several methylation-prone features of its sequence, including over 90 satellite repeats in its body and high cytosine/guanine density in its promoter region [DNA methylation patterns have also been studied in ADHD, mainly in previously nominated candidate genes. A recent study of dopamine transporter gene r region . A longir region . NonetheParent-of-origin effects are often interpreted as evidence of imprinting. However, there are additional mechanisms that can lead to differential impact of parents  on their offspring. At birth, the phenotype of a new-born may have already been strongly affected by the intrauterine milieu . The intMaternal genetic variants with a strong impact on fetal development have been studied in clinical genetics, where they have been termed “teratogenic alleles”. By similar mechanisms, the risk of psychiatric disorders in the offspring may also be influenced by maternal genes . For insTPH1 mutations resulting in impaired maternal serotonin production may have long-term consequences for brain-development and increase the risk of ADHD-related symptoms in their offspring [However, in practice it is difficult to sort out exactly how maternally or paternally inherited alleles would impact the developing fetus’ response to intrauterine environment (epistasis and gene × environment interaction). Maternally derived hormonal factors are known to influence prenatal growth and development. For instance, animal studies have shown that maternally derived serotonin can influence embryonic development. In ADHD, it was shown that maternal ffspring . Similarffspring . A similffspring .Mitochondrial DNA and the non-pseudoautosomal region of Y chromosome (which is only transmitted from father to son) are the two particular cases of POE. Classical mitochondrial diseases are characterized by maternal inheritance as well as muscular and neurological dysfunction. Similarly, polymorphisms in mitochondrial DNA have been also associated with neuropsychiatric conditions, such as schizophrenia, bipolar disorder, major depressive disorder and autism –50. The TTR gene [Apart from being maternally inherited, mitochondrial DNA may also exert its parent-of-origin effect through modification of penetrance of nuclear genome. Such a phenomenon has been described in a case of a familial neuropathy caused by mutations in the autosomal TTR gene , 57.MAOA is encoded on the X chromosome, plays vital role in the metabolism of neurotransmitters and its dysfunctions have been implicated in several neuropsychiatric conditions, including ADHD [The non-pseudoautosomal region of the Y chromosome is exclusively transmitted from father to son . Animal ing ADHD . Thus, YBehavioral changes linked to sex chromosomes can also be observed in Turner’s and Klinefelter’s syndromes, with abnormal behavioral/cognitive phenotypes depending on parental origin of X chromosome. Different levels of autistic symptoms have been reported between Klinefelter’s patients with additional maternal or paternal X chromosome , while pGWA studies have contributed to a substantial advancement of human genetic knowledge during the past decade, but these data can so far only explain a fraction of the estimated heritability of complex disorders. In addition, associations detected in case/control design may originate from genetic mechanisms other than those functioning in cases, but rather from their confounders, such as maternal genotype effects, imprinting and/or maternal-fetal interactions , 6. Imponull hypothesis examined the hypothesis tested by TDT itself is that of random meiotic selection of a parental allele for transmission to an offspring, but in POE it is the equality of paternal and maternal transmissions; (2) non-independence of observations the TDT statistics assumes that observed transmissions are independent (under Mendel’s second law), meaning the TDT-based parental transmission comparison may not be valid because of the statistical dependence between maternal and paternal transmissions in triads with two heterozygous parents or because of the possible prenatal maternal effect occurring together with genetic association in triads with homozygote parents [bias due to missing data POE detection by TDT-based approach may introduce likely bias when incomplete trios are utilized  and (4) confounding effects TDT-based method to study POE is sensitive to a possible confounding impact of maternal effects on non-equivalence of parental transmissions [One aspect of POE, the examination of which has been attempted the most, is imprinting, or non-equivalence, of parental alleles. To date, all studies of POE in ADHD have applied transmission disequilibrium test (TDT) based approaches to identify biased transmission of parental alleles , 33. In  parents , 66; (3)missions , 67, as missions , 69 or hmissions .One method to account for both maternal effects and non-equivalence of parental alleles is the application of a log-linear modeling in trio data, that can be implemented in a number of softwares  , 73–75. To date, log-linear modeling has not been applied to analyze POE in ADHD.Apart from the family-based TDT approach, the parental origin of a genetic polymorphism may also be assessed in a sample of unrelated individuals by comparing phenotypic variance of a quantitative trait in a heterozygous genotype group to that of a homozygous group . This teAnother approach that can utilize unrelated individuals to examine POE is Mendelian randomization (MR), an alternative method to investigate the causal nature of early life events  on disorders developed later in life. MR applies genetic variants to infer about the effect of a non-genetic risk factor  on a disease outcome . Genetic variants employed in MR must be associated with the disorder in question, serving as a proxy for it. The alleles of such variants can then be used to divide a population into groups that differ systematically only in the presence of the examined disorder. Since the association between these variants and a disorder is not generally confounded by behavioral or environmental exposures, such design provides a causal estimate that is free from confounding, analogous to randomized controlled trials . MR was The role of POE in the development of ADHD is alluring, and we have only just begun to explore these phenomena. The phenotypes, that have already been shown to be influenced by POE, suggest that these effects may have important impact on the development of neuropsychiatric conditions, including ADHD. Nonetheless, the exploration of POE in ADHD has been limited to mostly candidate gene studies, with no consistent findings thus far. Genome-wide analyses of POE mechanisms are also lacking in ADHD, as there has only been published a single genome-wide parent-of-origin effect study on ADHD, performed on a relatively under-powered sample of 846 trios .As the genetic association is largely conceptualized by loci with two equivalent alleles, most GWA studies of ADHD and related neuropsychiatric phenotypes have not implemented POE. Instead, genetic studies of POE in ADHD have been utilizing family-based TDT-like statistics to examine mostly just candidate genes. However, such approach may result in outcomes that are difficult to interpret as this test cannot provide clear distinction between maternal effects and non-equivalence of parental transmissions (imprinting). This may affect the formation of new hypotheses about molecular mechanisms of ADHD and the design of follow up functional studies. A presumption of imprinting would prompt the examination of epigenetic mechanisms in affected offsprings, while that of maternal effect would drive the evaluation of maternal genome and environment (including intrauterine environment). Thus, psychiatric genetics may benefit from the implementation of alternative statistical methods (e.g. LRT) to detect POE as the number, the impact and the function of genes with parent-of-origin effects in ADHD remains an important open question.While improving statistical methods to examine POE in neuropsychiatric conditions will advance our odds of uncovering such effects, it is worth mentioning that sample size is a critical factor as well. Collecting trio data is challenging and, in many instances, recruited trios are incomplete, with missing parental genotypes adding to the difficulties of achieving adequate sample sizes. This is of particular concern in recruitment of trios with late-onset neuropsychiatric conditions , where parental genotypes may not be attainable. Recently, the formation of the international psychiatric genetics consortium (PGC) provided a platform for a much needed boost in assembling large enough samples, which led to identification of a number of genome-wide significant association loci for neuropsychiatric disorders , 82. NonResearch into POE of neuropsychiatric disorders is still in its methodological infancy and has not yet produced genome-wide significant and replicable results. The development and application of modern statistical approaches to examine the genetics of ADHD beyond simple association can yield novel insights into the genetic architecture of this disorder. Considering POE as a source of phenotypic variation can reveal a “hidden” heritable component that remains unrecognized in traditional association studies of complex traits. In addition, POE could add to the incomplete monozygotic twin concordance often observed for ADHD behavior , the pheIn conclusion, better comprehension and inspection of POE may offer new possibilities of gaining insight into the molecular basis of ADHD and related phenotypes, as well as the potential for preventive and therapeutic interventions.


Earlier menarche is related to subsequent breast cancer risk, yet international differences in the age and tempo of other pubertal milestones and their relationships with body mass index (BMI) are not firmly established in populations at differing risk for breast cancer. We compared age and tempo of adrenarche, thelarche, pubarche, and menarche in a migrant study of Bangladeshi girls to the United Kingdom (UK) and assessed whether differences by migration were explained by differences in BMI.n =168), British-Bangladeshi (n =174) and white British (n =54) girls, aged 5 to 16 years. Interviewer-administered questionnaires obtained pubertal staging; height and weight were measured. Salivary dehydroepiandrosterone-sulfate concentrations >400 pg/ml defined adrenarche. Median ages of pubertal milestones and hazard ratios (HR) with 95% confidence intervals (CI) were estimated from Weibull survival models.Included were groups of Bangladeshi (P-trend = 0.70) nor at menarche  differed across groups. In contrast, median age at thelarche  occurred earlier among girls living in the UK. Compared with Bangladeshi girls, HRs (95% CI) for earlier thelarche were 1.6 (1.1 to 2.4) for British-Bangladeshi girls and 2.6 (1.5 to 4.4) for white British girls (P-trend <0.01), but were attenuated after adjustment for BMI (British-Bangladeshi = 1.1 (0.7 to 1.8), white British = 1.7(1.0 to 3.1); P-trend =0.20).In all three groups, adrenarche occurred earliest, followed by thelarche, pubarche, and finally menarche. Neither median age at adrenarche  contains supplementary material, which is available to authorized users. Menarche is one of the longest known and well-established early-life risk factors for breast cancer . HoweverThere have been numerous studies of international differences in age at menarche , but no Healthy girls aged 5 to 16 years were recruited from two settings: 1) 10 schools in London, England from September 2009 until December 2010, and 2) 7 schools in Sylhet Town, Bangladesh from January 2011 until April 2011. Selecting schools as the recruitment sites provided a central location for data collection. London schools were chosen in an area in which there would be a high percentage of immigrants from Sylhet, Bangladesh. White British girls were recruited from the same schools as British-Bangladeshi girls. In Sylhet Town, we identified semi-private/semi-government schools, which were likely to have pupils from families who had relatives living in the UK and were of the same socioeconomic status as those families that had emigrated.The ABBY Project received ethical permission from the Department of Anthropology, Durham University Ethics Committee and the Sylhet MAG Osmani Medical College. The Office of Human Research Subjects at the National Cancer Institute issued an Institutional Review Board exemption based on the existing approvals. Parents provided written informed consent granting their daughters, who provided written informed assent, permission to partake in the interview.n = 411) were classified based on birthplace, parents’ birthplace and self-reported ethnicity. The three study groups were: Bangladeshi (B) (n = 168), British-Bangladeshi (BB) (n = 174) and white British (WB) (n = 54). An ordinal variable called the residency scale was created based on the number of individual/ancestral generations resided in the UK. Bangladeshi girls  were born and resided in Bangladesh with no ancestral generations who lived in the UK; second generation British-Bangladeshi girls  were born and resided in the UK with one ancestral generation who lived in the UK, and white British girls  were born and resided in the UK with at least two ancestral generations who lived in the UK. This scale was created to test for a trend according to increasing exposure to the UK growth environment, a surrogate measure for a range of environmental exposures, including an obeseogenic diet and/or endocrine disruptors.Participants  when it occurred. Thelarche and pubarche were assessed by self-report using a modified version of the pubertal development scale (PDS) and were defined as the PDS equivalent to Tanner Stage 2 ,9]. We . We 9]. Saliva samples were collected at the time of interview (between 09:00 and 16:00 hours) for measurement of dehydroepiandrosterone-sulfate (DHEAS) levels. Samples were collected in 5-ml polystyrene tubes using gum base  as a stimulant. Collection tubes were placed immediately in a cooler with ice until transported to the field laboratory in either Bangladesh or London. The samples were stored in −20°C freezers, and then couriered on ice to the Durham Ecology and Endocrinology Laboratory. A total of 377 saliva samples were analysed by one researcher (GC) using a commercially available salivary DHEAS enzyme-linked immunosorbent assay purchased from Salimetrics . The reproducibility of the assay was assessed by two pooled quality-control samples in each batch. The total (within- and between-batch) coefficients of variation were <20%. The lower and upper limits of detection were 43 pg/ml and 16,000 pg/ml, respectively. Adrenarche is clinically defined when DHEAS levels exceed 40 to 50 μg/dl in serum ,11] and and11] a2).Height and weight were measured by two researchers in the UK using standardised techniques , and onez-scores and categorised them into quartiles. BMI z-scores were compared to reference UK growth-curves to determine nutritional status, reported as the percentage of girls who were clinically underweight, normal weight, overweight, or obese ..z-scoresThe key feature of the pubertal data is that the precise age at onset of each pubertal milestone was not known for individual girls. That is, girls were right-censored if they had not reached the milestone and girls who reached the milestone at some unknown age in the past were left-censored. This is an example of current-status data . Becausez-scores. To determine if the ages of adrenarche, thelarche, pubarche, and menarche were associated with BMI among all girls, HRs for the association between the onset of each pubertal milestone and BMI z-score quartiles were also estimated. To account for possible diurnal variation in DHEAS production, we also adjusted for the time of saliva collection, but this did not change the results (data not shown).From the Weibull models, we derived two types of estimates to assess pubertal age: median age and hazard ratio (HR). The median age at each pubertal milestone is the corresponding age at which 50% of the girls in each group were predicted to have reached that milestone. Tests for trend were performed according to the residency scale. The HR reflects the risk of reaching a milestone at a given age, meaning that a higher ratio indicates an earlier age at onset for the milestone. HRs for the association between ages of adrenarche, thelarche, pubarche, and menarche with residency scale were estimated both unadjusted and adjusted for BMI P <0.05.The order of puberty was assessed by comparing the median age of each milestone within each population. Juvenile, pubertal, and sexual development tempo , as did pubarche . In contrast, there was no trend across groups for adrenarche  nor menarche .Median age at thelarche occurred earlier with increasing residency in the UK . This overall trend of reaching thelarche earlier with increasing residency scale remained after adjustment for BMI, but was no longer statistically significant (Table P-trend = 0.20). In white British girls, BMI explained 83% of the proportion of risk of reaching thelarche earlier than Bangladeshi girls; in British-Bangladeshi girls, BMI explained 56% of the proportion of risk of reaching thelarche earlier than Bangladeshi girls. The HRs (95% CI) for reaching pubarche were 1.5  for British-Bangladeshi girls and 2.0  for white British girls compared with Bangladeshi girls (Table P-trend <0.001). Reaching pubarche earlier with increasing residency scale remained after adjustment for BMI (Table P-trend = 0.02).Compared with Bangladeshi girls, HRs (95% CI) for reaching thelarche were 1.6 1.1, 2.4) for British-Bangladeshi girls and 2.6  for white British girls (Table .4 for Brz-score in the fourth quartile (Q) compared with the first . The median age of thelarche occurred about two years earlier among girls in both the third and fourth quartiles of BMI z-scores when compared with girls in the first two quartiles . The median age of menarche occurred earlier with increasing BMI z-scores, but the trend did not reach statistical significance .For all girls, BMI was associated with the age of adrenarche, thelarche and menarche, but not pubarche. The median age at adrenarche was about one year earlier among girls with a BMI The order of sexual development was similar across Bangladeshi, British-Bangladeshi, and white British girls and proceeded in the following order: adrenarche, thelarche, pubarche, and menarche Figure . Only 10P <0.001). However, the tempo of puberty  was slower for girls living in the UK . The tempo of sexual development  was approximately five years among all groups, . The interval between thelarche and pubarche was approximately two years in all groups .The tempo of juvenility  was more rapid for girls living in the UK  and ethnicity (Bangladeshi versus White). British-Bangladeshi girls begin and progress through puberty earlier and slower than girls living in Bangladesh, but not as early or slowly as white British girls. The differences in pubertal development were partly, but not entirely, explained by higher BMI among white British and British-Bangladeshi girls versus Bangladeshi girls, suggesting that nutritional and other environmental factors associated with the UK growth environment are associated with early, but prolonged, pubertal development.th century ,,, which,  century ,22] tha thath ce century ,23],. BM. BM34]. This study supports a model whereby most sexual development starts with adrenarche and then proceeds from thelarche to pubarche to menarche. In contrast, other studies have previously distinguished girls that progress through puberty along the thelarche pathway from those that progress through an adrenarche pathway . Our stuA slower pubertal tempo, but faster juvenile tempo, was associated with increasing residency in the UK growth environment in our data. An earlier onset of thelarche, but slower progression through puberty, has also been observed over time within the US and Western Europe ,38]. Gi. Gi38]. et al. (2008) suggest) did not change the overall observed pattern of results. It has also been demonstrated that white adolescents overestimate their pubertal stage more often than non-white adolescents; however within the same Bangladeshi ethnic group, we observed earlier breast development in those living in the UK compared with those living in Bangladesh. Interestingly, there are cultural markers of thelarche within both Bangladeshi populations [There are limitations that need to be considered when interpreting the findings reported here. First, the comparison of age at menarche across groups was limited by the small sample size in the older white British girls, which resulted in some instability in estimates. However, the consistency in median ages between status quo and recalled methods, suggests that our approach is robust. Secondly, while our cross-sectional findings should be reproduced in longitudinal studies, the migrant study design enabled us to compare migrants of the same ethnicity, in terms of two generations, with girls living in both the “home” and “host” country. Finally, we assessed pubertal staging using self-reported PDS because clinical examinations are not a viable method in a school setting. Although there can be low concordance between findings from physical examination and those from the PDS , anotherulations  so it isOur findings suggest that the growth environment might account for the ethnic differences in pubertal age and tempo seen across and within international populations. Bangladeshi girls who grew up in the UK progressed through puberty earlier, but more slowly, than girls who grew up in Sylhet, Bangladesh. BMI explained some, but not all, of these differences in pubertal age. Other environmental factors such as psychosocial stress and endocrine disrupting chemicals may also affect the age and tempo of pubertal milestones. When the tempo between adrenarche, thelarche and menarche are considered together and compared across Bangladeshi, migrant British-Bangladeshi, and white British girls, a clear and provocative pattern emerges: there is a longer period of androgen exposure in populations at low risk, equal periods of androgen and oestrogen exposure in populations at intermediate risk and a prolonged period of oestrogen exposure in populations at high risk. These findings support the inclusion of age of thelarche, a potentially new risk factor, in future breast cancer studies.


The symptom profile and neuropsychological functioning of individuals with Attention Deficit/Hyperactivity Disorder (ADHD), change as they enter adolescence. It is unclear whether variation in brain structure and function parallels these changes, and also whether deviations from typical brain development trajectories are associated with differential outcomes. This paper describes the Neuroimaging of the Children’s Attention Project (NICAP), a comprehensive longitudinal multimodal neuroimaging study. Primary aims are to determine how brain structure and function change with age in ADHD, and whether different trajectories of brain development are associated with variations in outcomes including diagnostic persistence, and academic, cognitive, social and mental health outcomes.NICAP is a multimodal neuroimaging study in a community-based cohort of children with and without ADHD. Approximately 100 children with ADHD and 100 typically developing controls will be scanned at a mean age of 10 years  and will be re-scanned at two 18-month intervals (ages 11.5 and 13 years respectively). Assessments include a structured diagnostic interview, parent and teacher questionnaires, direct child cognitive/executive functioning assessment and magnetic resonance imaging (MRI). MRI acquisition techniques, collected at a single site, have been selected to provide optimized information concerning structural and functional brain development.This study will allow us to address the primary aims by describing the neurobiological development of ADHD and elucidating brain features associated with differential clinical/behavioral outcomes. NICAP data will also be explored to assess the impact of sex, ADHD presentation, ADHD severity, comorbidities and medication use on brain development trajectories. Establishing which brain regions are associated with differential clinical outcomes, may allow us to improve predictions about the course of ADHD. Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood, affecting 5 % of school-age children . ADHD haThe Children’s Attention Project (CAP)  is an AuThis paper describes the Neuroimaging of the Children’s Attention Project (NICAP). This extension to CAP involves comprehensive longitudinal multimodal neuroimaging to determine how brain structure and function change over developmental stages in ADHD, and whether deviations from typical trajectories of brain development are associated with differential outcomes, such as the persistence or remission of ADHD symptoms and academic, cognitive, social and mental health outcomes. This paper describes the rationale, design and methodology of the neuroimaging protocol for NICAP.As individuals enter adolescence, the presentation of some ADHD symptoms and neuropsychological functioning appears to change –12. InatNumerous cross-sectional studies have examined brain differences between individuals with and without ADHD. Functional imaging studies have highlighted several abnormalities in individuals with ADHD, particularly in the prefrontal cortex and striatum  and the parietal cortex –19. StruWhile ADHD symptoms vary considerably with age and neuroimaging abnormalities have been described in children with ADHD, it is unclear whether the changes in brain structure and function parallel symptom changes. It is also unknown whether deviations from typical trajectories of brain development are associated with differential outcomes, such as the persistence or remission of ADHD symptoms and academic, cognitive, social and mental health outcomes. A recent meta-analysis , identifNICAP will collect single site, multimodal neuroimaging on a high-resolution 3 Tesla scanner to link neurobiological structure and function to academic, cognitive, social, and mental health outcomes. We will assess children with and without ADHD as they progress through puberty at mean ages 10, 11.5 and 13 years. This design will enable us to map trajectories in brain growth and how they differ between typically developing children and those with ADHD. We will be able to ascertain whether such changes are reflected in ADHD symptomatology and functional abilities.The primary aims are to 1) Describe how brain structure  and function (resting state connectivity) change across late childhood to early adolescence (brain growth trajectories) for children with and without ADHD; and 2) Examine whether differences in trajectories of brain structure and function reflect differential outcomes for children with ADHD and non-ADHD controls. Outcomes to be assessed include the persistence of ADHD, ADHD symptom severity and functional outcomes .Secondary aims will explore the impact of sex, ADHD presentation, ADHD severity, comorbidities and medication use on brain growth trajectories.NICAP is single site, multimodal neuroimaging study in a community-based cohort of children with and without ADHD conducted longitudinally over a 5-year period. Baseline, 18 and 36 month follow-ups will be conducted between 2014 and 2018. The study is funded by the Australian National Medical Health and Research Council . Ethics approval was granted by the Royal Children’s Hospital Human Research Ethics Committee, Melbourne (#34071).N = 6098) in their second year of formal schooling. Surveys were distributed across 43 socio-economically diverse Melbourne primary schools. Children screened positive as potential ADHD cases  and a matched sample of those screened negative (both parent and teacher ADHD indices were <75th percentile for boys and <80th percentile for girls) received a parent face-to-face diagnostic interview to confirm diagnostic status. Baseline data were collected between 2011 and 2012, for a sample of 179 children with confirmed ADHD and 212 confirmed non-ADHD controls aged 7 years. Participants were followed up at two 18 month intervals at ages 8.5 and 10 years.Participants for NICAP are recruited from the CAP. The CAP cohort and methods have been described previously . BrieflyRecruitment for NICAP participation coincides with the CAP 36 month data collection (age 10 years). Parents provide additional written informed consent for the NICAP study. Approximately 100 ADHD and 100 typically developing controls will be recruited for NICAP baseline assessment. Two follow-up assessments will occur at 18-month intervals when participants are aged 11.5 and 13 years.Our sample size is primarily based on the feasibility of recruitment from the pre-existing CAP cohort. Based on recruitment of equal numbers of controls to ADHD cases, with a participation rate of 65 %, accounting for exclusions due to MRI incompatibility , and an estimated attrition of 5 % at each timepoint, we expect ~100, 95 and 90 participants per group at timepoints 1, 2 and 3 respectively. It is difficult to estimate with precision the power this will provide for detecting group differences in trajectories of development. However, a study of the sample size required in longitudinal MRI studies of brain volume in adults  suggestsAt each data collection time-point participating families will attend a 3.5 h assessment session at The Royal Children’s Hospital, Melbourne, Australia. Assessment sessions involve a structured diagnostic interview, parent questionnaire, child cognitive assessment and MRI scanning. Saliva samples will also be collected for future research questions around genetics and pubertal hormones. With parent consent, questionnaires will be sent to the child’s classroom teacher.Measures are summarized in Table NIMH Diagnostic Interview Schedule for Children-IV [ldren-IV : At baseQuestionnaires assess several domains covering a range of predictors and outcome variables. Key measures are described below and summarized in Table The Pubertal Development Scale (PDS)  is a parThe Tanner Sexual Maturation Scale (SMS) is a parent-reported measure used to assess the child’s pubertal stage. It comprises drawings of five progressive stages of pubertal development of secondary sexual characteristics, from stage 1 (pre-adolescent) through to stage 5 (adult appearance). For males, five drawings combining pubic hair and genital development are presented. For females, breast development and pubic hair development are presented in different drawings. Tanner staging has historically been considered the gold standard for puberty measurement .NICAP includes direct assessments of working memory, inhibition, sustained attention, cognitive flexibility, spatial attention and visuo-motor integration. The first four tasks are computer-based, enabling measurement of properties such as reaction time.The Stop Signal Task assesses response inhibition . SubjectThe Sustained Attention to Response Task (SART) is a measure of sustained attention . The fixThe Spatial N-Back is a widely used measure of working memory that requires flexible updating capabilities. This includes a spatial 1-back and 2-back version. The 1-back requires maintaining and updating one location at a time, whereas the more difficult 2-back requires maintaining and updating two locations.The Set Shifting task assesses cognitive flexibility. Two target pictures are presented that vary along two dimensions . Participants are cued with a letter to respond to the target pictures, according to one dimension.The Landmark Task is a paper-based task measuring spatial attention . ParticiThe Grooved Pegboard test  is a timed motor test to assess complex visual-motor coordination for both the dominant and non-dominant hand. Participants place grooved pegs into a pegboard unit in an ordered pattern of 25 holes, requiring the participant to match the groove of the peg with the groove of the board.Children complete a 30 min training session in a mock MRI scanner which reproduces the physical environment of the real scanner including sound recording of the scanner noises. This familiarizes participants to the MRI environment, lowers anxiety and provides practice at keeping still during the scanning session.Neuroimaging data are collected from a single-site on a research-dedicated 3-Tesla Siemens TIM Trio MRI scanner  at the Murdoch Childrens Research Institute, The Royal Children’s Hospital, Melbourne. Using a 32-channel head coil, the multimodal MRI acquisition techniques have been selected to provide advanced information concerning the structural and functional development of the brain and regional development of specific structures. The neuroimaging protocol comprises structural and functional sequences lasting approximately 45mins. See Fig. A modified multi-echo magnetization prepared rapid gradient-echo (MEMPRAGE) sequence, incorporating navigator based prospective motion correction, will be acquired to provide T1-weighted anatomical images , 40. TheWe also employ Siemens in-scanner motion correction (MoCo) in which the field-of-view/slice positioning is updated in real time to accommodate for motion during the acquisition. This reduces motion artifact and dramatically improves image quality. This is particularly important in this population of children with attentional and hyperactivity difficulties, as motion artifact is a large challenge.Additional morphometric information is obtained by employing the T2-SPACE (Sampling Perfection with Application optimized Contrast with flip angle Evolution) protocol to provide T2-weighted anatomical images. Together, the MEMPRAGE and T2-SPACE provides T1-weighted and T2-weighted volumes providing optimal sensitivity for tracking subtle changes in cortical morphometry.2 + interleaved b = 0 s/mm2) with an anterior-posterior phase encoding direction. Standard and reverse phase encoded blipped image with no diffusion weighting (Blip Up and Blip Down) are also acquired to correct for magnetic susceptibility-induced distortions related to the EPI acquisitions [Diffusion-weighted images (DWI) are acquired to probe white matter microstructure. Multi-band accelerated EPI sequences protocol, developed by the Centre for Magnetic Resonance Research , are acquired in order to accelerate DWI volume coverage allowing multiple shell acquisition. Three shells are acquired using this protocol  images are acquired to measure spontaneous intrinsic correlated neural activity while subjects are at rest, enabling detection of functional connectivity between brain regions. rs-fMRI has longitudinal reliability and reproducibility in children , has theThe rs-fMRI processing pipeline begins with realignment of EPI volumes to correct for participant movement. Volumes are then aligned to the participant’s structural images, which are segmented into different tissue classes. Removal of physiological noise and other nuisance variables is then performed using a component-based approach. Signal from white matter and cerebrospinal fluid is used to estimate noise of non-neuronal origin . This noise is then removed from regions of interest, along with the contribution of realignment parameters and movement outliers.QSM provides a quantitative and spatially specific image contrast, which is differentially sensitive to myelin and iron content . The novQuality control procedures are important at a number of steps. Regarding MRI motion artifacts, several steps are taken in order to minimize movement during the scanning and to assess the data quality afterwards. The mock scanner session prior to the scan is vital to assist participants be aware of movements and become comfortable in the scanner environment. During all scans except for the rs-fMRI participants watch a movie of their choice distracting them from the scanning environment. During scanning, movement is monitored and participants are reminded to keep still when necessary. Poor images due to motion are repeated if time permits. At the scanner level, scanner stability is monitored weekly with the standard functional Brain Imaging Research Network (FBIRN) QA protocol. In addition, T1 and T2 are performed to examine signal-to-noise and image uniformity.Research staff and students who conduct the assessments are trained to a high level of competence in the scanning and assessment procedures, and are observed for the first two assessments. Written standard operation procedures were developed for standardized assessments, cognitive testing, mock scan and saliva collection. Fortnightly supervision meetings take place with a registered clinical psychologist (ES) in order to maintain consistency across cognitive and diagnostic assessments.This research will provide the ability to map trajectories of brain structure and function onto a comprehensive set of functional outcome domains encompassing academic, cognitive, social, and mental health functioning. Developing a large database of multimodal MRI sequences with ongoing clinical and cognitive/behavioral measures in a demographically diverse sample will enable the detection of subtle, yet important, differences in brain developmental trajectories in children with ADHD compared to non-ADHD peers.Identifying objective neural markers of outcomes in ADHD, and potential modifiable predictors of outcomes will be an important innovation and will contribute substantially to improving the prognosis of children with ADHD. Establishing which brain regions are associated with positive clinical outcomes will help improve predictions about the course of ADHD. The advantage of a large community sample is the opportunity to examine neurobiological development across the continuum of severity, as well as in healthy controls.A better understanding of the developmental links between brain changes and outcomes also has important implications for children with developmental and mental health problems broader than ADHD. The identification of neurodevelopmental changes associated with functional outcomes will open the possibility for future studies to test targeted interventions leading to improved long-term outcomes.


Attention-deficit/hyperactivity disorder (ADHD) can be viewed as the extreme end of traits in the general population. Epidemiological and twin studies suggest that ADHD frequently co-occurs with and shares genetic susceptibility with autism spectrum disorder (ASD) and ASD-related traits. The aims of this study were to determine whether a composite of common molecular genetic variants, previously found to be associated with clinically diagnosed ADHD, predicts ADHD and ASD-related traits in the general population.N = 8229) based on a discovery case-control genome-wide association study of childhood ADHD. Regression analyses were used to assess whether polygenic scores predicted ADHD traits and ASD-related measures  in the ALSPAC sample. Polygenic scores were also compared in boys and girls endorsing any (rating ≥1) ADHD item (n = 3623).Polygenic risk scores were calculated in the Avon Longitudinal Study of Parents and Children (ALSPAC) population sample . Polygenic risk for ADHD was also negatively associated with pragmatic language abilities (p = .037) but not with social cognition (p = .43). In children with a rating ≥1 for ADHD traits, girls had a higher polygenic score than boys (p = .003).Polygenic risk for ADHD showed a positive association with ADHD traits (hyperactive-impulsive, These findings provide molecular genetic evidence that risk alleles for the categorical disorder of ADHD influence hyperactive-impulsive and attentional traits in the general population. The results further suggest that common genetic variation that contributes to ADHD diagnosis may also influence ASD-related traits, which at their extreme are a characteristic feature of ASD. Attention-deficit/hyperactivity disorder (ADHD) is a highly heritable neurodevelopmental disorder characterized by early-onset, developmentally inappropriate inattentive, hyperactive, and impulsive behaviors It has become clear in more recent years that the boundaries between different neurodevelopmental and psychiatric disorders are not clear-cut, as exemplified by the observed clinical and genetic overlap between ADHD and other disorders. Rates of co-occurrence are especially high for ADHD and autism spectrum disorder (ASD), another highly heritable neurodevelopmental disorder, characterized by social communication and interaction deficits as well as restrictive and repetitive behaviors n = 452) differ from control subjects (n = 5081) on the basis of a polygenic risk score, an aggregate score of thousands of common alleles of very small effect that together form an index of genetic risk for ADHD Previous research has suggested that children with a clinical diagnosis of ADHD  residing in Avon, England, with expected delivery dates of April 1, 1991–December 31, 1992. An additional 713 eligible children whose mothers did not enroll during pregnancy were enrolled after age 7, resulting in a total sample of 14,701 of children alive at age 1 year. Full data (phenotypic and genotypic) were available for up to 5661 children, depending on the outcome variables. Children with >30% missing items on any outcome variable were excluded from analyses of that variable. The study website  contains details of all available data. Ethical approval for the study was obtained from the ALSPAC Ethics and Law Committee and local research ethics committees.The Avon Longitudinal Study of Parents and Children (ALSPAC) is a large, well-characterized longitudinal data set Data on ADHD traits were collected when participants were ~7 years, 7 months old, using the parent Development and Well-Being Assessment (DAWBA) Social communication traits were assessed using the Social and Communication Disorders Checklist (SCDC) The SCDC was assessed at the same time as the DAWBA ADHD measures. Parents were asked to judge how much 12 descriptions applied to their child’s behavior. The responses were coded as follows: 0 for “not true,” 1 for “quite/sometimes true,” and 2 for “very/often true.” A total SCDC score was calculated by summing these responses (with a possible range of 0–24).An abridged version of the CCC was used to assess language abilities at ~9 years, 7 months of age. Parents were asked to rate whether statements about their child were “certainly true,” “somewhat true,” or “not true,” which were coded as 0, 1, and 2. The following subscales were summed to generate a pragmatic language abilities score: inappropriate initiation, coherence, stereotyped conversation, conversational context, and conversational rapport. Subscale scores were based on six to eight items each. The pragmatic language total score was obtained for children with data available for each subscale. Because the CCC measures language abilities, lower scores suggest pragmatic language deficits.Information on DSM-IV ADHD diagnoses is available based on the DAWBA at ~7 years of age. Data on ASD diagnoses are available based on clinical records, using a clinician’s diagnosis of ASD After quality control (QC), genome-wide data for 500,527 single nucleotide polymorphisms (SNPs) were available for 8229 of the children, of whom 4213 (51.2%) were boys. Details of QC procedures are provided in n = 727) and population control subjects (n = 5081) was used to define risk alleles. This clinical sample was selected as the primary discovery sample because it is similar to the ALSPAC general population in ethnicity and underwent similar diagnostic assessment procedures. The ascertainment of DNA samples, QC procedures, and GWAS results were described in detail previously p < .5 were considered risk alleles.The analytic method described by the International Schizophrenia Consortium http://pngu.mgh.harvard.edu/~purcell/plink/p < .5) in the discovery ADHD GWAS and used those to calculate a polygenic score for each individual in ALSPAC using PLINK z score transformations.Full details are available in t test. Girls and boys were also compared. Analyses were conducted on the 8229 ALSPAC children with full genetic data available after all QC.In the ALSPAC sample, children with ADHD or ASD diagnoses were compared with each other and with the remainder of the sample on ADHD, SCDC, and CCC traits, using Student As a result of a strongly negatively skewed distribution of the CCC pragmatic language data, variables were transformed (ln x + 1) and linear regression analyses were performed to test for association with ADHD polygenic score. The ADHD and SCDC traits were highly positively skewed, contained an excess of zero values, and could not be transformed to normality see . These dp value for each ZINB model compared with a null model, which included gender but not polygenic score. The ZINB analyses were performed using Mplus version 7  The ZINB model consists of two submodels that allow for a distribution with an inflated number of individuals with values of zero: 1) logistic regression model of an unobserved dichotomous outcome to predict who has a score = 0 and who has a score >0 and 2) negative binomial model of the continuous outcome in individuals having a score ≥0. Likelihood ratio tests were used to determine an overall R2 in the full model compared with the null model. Given the non-independence of the outcome variables, all results are interpreted using a significance threshold of p < .05. Given that previous analysis of polygenic scores for ADHD in a clinical sample of children with ADHD showed that girls had higher polygenic scores than boys t test was used to test whether polygenic scores in children rating positive for any (rating ≥1) ADHD trait in the target sample were significantly higher in girls than in boys.For each association test, the amount of variance explained was calculated as the difference of Nagelkerke pseudo-Where significant associations were observed, secondary analyses were run to determine whether the same associations could be detected for traits at a later time point . Replication was sought using a second ADHD GWAS discovery sample—the Psychiatric Genomics Consortium n = 5585), children with a diagnosis of ADHD (n = 105), children with a diagnosis of ASD (n = 35) or children with both ADHD and ASD (n = 8). Of the children with a diagnosis of ADHD, 7.1% also had a diagnosis of ASD; of the children with ASD, 36.4% also had ADHD. This overlap was greater than would be expected by chance .t = 13.03, p < .001; inattentive, t = 13.12, p < .001). Children with ASD had lower levels of inattentive traits than children with ADHD  but did not differ significantly in terms of hyperactive-impulsive traits .As expected, ADHD traits were higher in children with a diagnosis of ASD than in children without ADHD or ASD  and lower CCC pragmatic language scores  than children without ADHD or ASD but had lower SCDC scores  and higher pragmatic language ability scores  than children with ASD. The ADHD and social communication outcomes were moderately correlated  and SCDC  and higher CCC pragmatic language ability scores .Children with a diagnosis of ADHD had significantly higher SCDC scores (rrelated . CompareN = 8229). Among children with any ADHD traits , girls had a higher polygenic score than boys . This finding is not attributable to an overall population difference on polygenic score by gender . Gender was included as a covariate in all further analyses.The ADHD polygenic scores were based on 49,595 SNPs and were normally distributed in the ALSPAC sample , hyperactive-impulsive traits , and inattentive traits . The ZINB models indicate that the association signal comes from the zero-inflated part (part 1) of the model for all ADHD outcomes.Results of associations of ADHD polygenic score with the ADHD and social communication outcomes are shown in n = 2038), children with low levels of ADHD , and children with moderate-to-high levels of ADHD . Analysis of variance showed a significant group difference , and post hoc tests revealed that children with no ADHD traits had a lower mean polygenic score than children with ADHD scores of 1–11 (p = .022) and children with scores ≥12 (p = .037). The difference between the two other groups was not significant (p = .80).To explore further the contribution of polygenic scores to ADHD trait levels in subjects with nonzero scores, the population was split into three arbitrary groups, based on increasing trait score: children who scored 0 (p = .037). Exploration of whether findings were attributable to specific CCC subscales showed association with lower scores on the “inappropriate initiation” and “conversational context” subscales  but not with “coherence,” “stereotyped conversation,” and “conversational rapport” . No association was found between polygenic score and SCDC total score (p > .05).The ADHD polygenic scores showed a significant association with lower CCC pragmatic language scores  for all models was very small, although this estimate does not reflect the true magnitude of the genetic overlap because it is highly sensitive to sample size Structural equation modeling with ADHD and pragmatic language as correlated outcomes confirmed that both constructs are independently predicted by polygenic score . The amon ≥ 5495) for total ADHD traits  and hyperactive-impulsive traits , with weak association with inattentive traits  (n = 3316), girls had a higher polygenic score than boys .The observed association between polygenic score and ADHD (at ~7.5 years of age) could also be seen at the later time point  . Among cp > .05) but did show an association at age 10 with total ADHD traits  and hyperactive-impulsive traits , with weak association with inattentive traits  (p = .017) but showed no association with the CCC “inappropriate initiation” subscale .Polygenic scores based on the second discovery sample  = .055) . Polygent = 1.80, p = .071, Cohen’s d = .060). At age 10, girls had significantly higher polygenic scores than boys .In children with ADHD trait scores ≥1 at age 7, there was a trend for girls to have a higher polygenic score than boys, calculated using this second discovery sample  ADHD, predicted both low levels and high levels of ADHD traits in the general population. The ZINB analysis suggested that the association signal between polygenic score and ADHD traits originates from the zero-inflated part of the model . This result might be due to greater power at the lower end of ADHD traits, as progressively fewer children have higher levels of ADHD traits.Consistent with previous literature in clinical and general population samples Results of the genetic analysis also suggest that risk alleles for ADHD may contribute to phenotypic traits in the general population, beyond core ADHD features. Polygenic risk scores previously found to be associated with diagnosis of ADHD were also nominally associated with pragmatic language abilities in the general population but not with social cognition traits, as indexed by SCDC scores.Secondary exploratory analyses suggested that the association of ADHD polygenic risk with pragmatic language score was driven by scores on the “inappropriate initiation” and “conversational context” subscales of the CCC. Some items in the “inappropriate initiation” subscale may tap into impulsive ADHD behaviors , but items in the “conversational context” subscale  have no apparent link with ADHD features. Overall, the findings suggest that risk variants for ADHD may have pleiotropic effects on closely related but conceptually different neurodevelopmental traits in the general population. These findings also support findings from a twin study, in which ADHD traits at age 8 shared genetic effects and were most associated with ASD communication difficulties, rather than ASD social difficulties or stereotyped behaviors One possible advantage of the primary discovery ADHD sample used to derive risk alleles, over the replication sample, is its similarity to the ALSPAC cohort in terms of ancestry and geography, but nevertheless the sample was relatively small Although we found an association between ADHD polygenic score and pragmatic language abilities, there was no association with social cognition, as measured by the SCDC. A more recent collaborative cross-phenotype analysis suggested that common GWAS variants do not contribute to the overlap in diagnoses of ADHD and ASD As expected, boys in the ALSPAC cohort had higher ADHD trait scores than girls A limitation of this study was that although the SCDC and CCC measures of social cognition and pragmatic language are predictive of a clinical diagnosis of ASD in the sample Because the ALSPAC cohort is longitudinal, the sample is affected by attrition. Previous studies have determined that predictors of attrition include socioeconomic and pregnancy factors as well as presence of behavioral difficulties, including ADHD, in the study child n = 54) of cases overlapped in both discovery samples. Although p < .5 is frequently used as a threshold for calculating polygenic scores p value thresholds for calculating polygenic scores demonstrated that observed effects are consistent across various thresholds (As a result of the relatively small ADHD GWAS discovery sample sizes, power to detect susceptibility variants is low, and aggregate scores based on GWAS are likely to be based on a poor signal-to-noise ratio resholds .In summary polygenic risk previously found to be associated with clinical ADHD diagnosis predicted inattentive and hyperactive-impulsive traits in a general population sample. This study also indicates that common genetic variants associated with ADHD may be associated with pragmatic language ability in the general population, a trait measure that is distinct from the core deficits of ADHD. The approach of testing genetic risks that contribute to dimensions that cut across diagnostic categories, rather than using DSM diagnoses, is in line with the Research Domain Criteria framework


Bartonella infections are widespread and highly prevalent in rodents. Several rodent-associated Bartonella species have been related to human diseases. Recently, Bartonella species was reported as the etiology of a human case in the country of Georgia (Caucasus). However, information on Bartonella in rodents in Georgia is absent. Rodent hearts were collected from Georgia to investigate the presence and diversity of Bartonella species. Bartonella bacteria were cultured from 37.2% (16/43) of rodents examined, while Bartonella DNA was detected in 41.2% (28/68) of rodents by polymerase chain reaction targeting citrate synthase (gltA) gene. Sequences of gltA showed that rodents in this region harbored multiple Bartonella strains, including Bartonella elizabethae, Bartonella tribocorum, Bartonella grahamii, and an unknown genogroup. The first three Bartonella species, known to be rat-associated and human cases linked, were commonly observed in wood mice  (5/8 positive with B. elizabethae and B. tribocorum) and social voles  (4/6 positive with B. grahamii and B. elizabethae) in this study. The frequent distribution of these Bartonella species suggests that they may contribute to unidentified clinical infections. The unknown genogroup was observed in 24 Bartonella isolates and/or DNA extracts from heart tissues, all of which were obtained from Libyan jirds (Meriones libycus). Further characterization of the bacterial cultures based on sequence analysis of four additional genes  supported that the jird-associated Bartonella strains comprise a distinct monophyletic clade. The impact of this bacterium on wildlife and human health needs to be determined. Bartonella are small, fastidious, and slow-growing Gram-negative aerobic rods. They parasitize erythrocytes and endothelial cells of a wide range of mammalsBartonella species have been associated with emerging diseases, involving a broad spectrum of clinical syndromes from self-limited cat-scratch disease (CSD) to potentially fatal diseases, such as endocarditis.13Bacteria of the genus Bartonella infections have been extensively studied in rodents of numerous species from various regions across the world, which demonstrated the very widespread and high prevalence of Bartonella species.Bartonella species have been described and at least five of them—Bartonella elizabethae, Bartonella tribocorum, Bartonella grahamii, Bartonella vinsonii subsp. arupensis, and Bartonella washoensis have been implicated as causative agents of human infections.Bartonella species usually are host specific. For example, B. elizabethae and B. tribocorum are specific to Rattus rats,B. washoensis is specific to squirrels of family Sciuridae.Bartonella species that could be pathogenic to humans. The close relation between rodents and humans throughout the world makes the study of rodent-borne Bartonella essential to determine the extent to which rodents may serve as sources of human infections. Although Bartonella infections are widely distributed and highly prevalent in rodents of different geographic regions, these bacteria have yet to be identified in rodents from Caucasus, including the country of Georgia. Diagnostics of infections in humans caused by Bartonella species are still limited in this country. However, a recent investigation of a human case with lymphadenopathy manifested as typical CSD in the country of Georgia has indicated that the agent was a Bartonella strain.B. tribocorum and B. elizabethae rather than Bartonella henselae, the common agent of CSD, and the strain was identical to those frequently found in commensal rats in Israel.Bartonella species in rodents in this region, considering a possibility that these species likely contribute to undiagnosed clinical human cases. The objectives of this study were to evaluate the presence of Bartonella species in rodents from Georgia and to investigate the genetic diversity of recovered Bartonella strains.Libyan jirds (Meriones libycus) and six as social voles . Only eight rodents were sampled in Gardabani and all were identified as wood mice . The collected rodent hearts were kept at −20°C until sent to U.S. CDC's laboratory in Fort Collins, CO, for testing.Rodents were trapped within two field sites in May 2010. The first site is located in Dedoplistskaro municipality of Kakheti, the eastern region of Georgia bordering with Azerbaijan; the second site is located in Gardabani municipality of Kvemo Karli, the southeastern region of Georgia bordering with Azerbaijan and Armenia. Captured animals were identified morphologically to species, weighed, sexed, and dissected to collect hearts under sterile conditions. Of 60 rodents collected in Dedoplistskaro, 54 were identified as ® Gold homogenizer  following heart protocol provided by the manufacturer. The homogenates (100 μL) were then plated on heart infusion agar supplemented with 10% rabbit blood and incubated in an aerobic condition with 5% CO2 at 35°C for up to 4 weeks. Plates were monitored for bacterial growth twice a week after initial plating. Bacterial colonies were presumptively identified as probable Bartonella species based on their morphological characteristics. A single colony from each plate was picked and streaked onto secondary agar plates for another 4–5 days of incubation under the same condition. If colonies on the same plate looked different, a single colony for each appearance is subcultured separately. Pure cultures were harvested in 10% glycerol.Rodent hearts (∼50 mg) were homogenized in 200 μL brain heart infusion broth supplemented with amphotericin B  using Bullet BlenderBartonella cultures were confirmed by polymerase chain reaction (PCR) amplifying a 378-bp fragment in the citrate synthase (gltA) gene using Bartonella-specific primers BhCS781.p and BhCS1137.n.gltA that incorporates the region amplified by primers BhCS781.p and BhCS1137.n used for Bartonella cultures. All conditions were the same as the first PCR assay but using the following parameters: initial denaturing at 94°C for 2 minutes; 38 cycles of 94°C for 30 seconds, 48°C for 30 seconds, and 72°C for 2 minutes; and ending with 72°C for 7 minutes.Direct PCR was performed on DNA extracted from the remaining heart homogenates using QIAamp DNA Mini Kit  following the tissue protocol provided by the manufacturer. Primers CS443FBartonella gltA–positive PCR products from both PCR assays were purified with the QIAquick PCR Purification Kit  according to the manufacturer's instructions and sequenced in both directions using an Applied Biosystems Model 3130 Genetic Analyzer . Sequencing reactions were carried out in a C1000 Touch Thermal Cycler using the same primers as the initial PCR assays at a concentration of 1.6 μM. Cycle parameters for the sequencing reactions were 96°C for 1 minute, followed by 24 cycles of 96°C for 10 seconds, 50°C for 5 seconds, and 60°C for 4 minutes.gltA sequences were analyzed using Lasergene sequence analysis software Version 12  to determine consensus of sequences for the amplified region of the gltA. The Clustal W program within MegAlign of Lasergene was used to align and compare homology of Bartonella gltA sequences obtained from all samples in this study among themselves and with other known Bartonella species or genotypes available in the public domain for an initial Bartonella species identification. The neighbor-joining method by Kimura's two-parameter distance method and bootstrap calculation was carried out with 1,000 replicates. Newly identified variants from this study were submitted to GenBank and assigned with unique accession numbers (KT327027–KT327033).The resulting gltA sequences identification, the novel Bartonella strains isolated from L. jird (n = 12) were further analyzed using four additional genes, including cell division (ftsZ), nicotinamide adenine dinucleotide dehydrogenase gamma-subunit (nuoG), RNA polymerase beta subunit (rpoB), and transfer-messenger RNA (ssrA), following the protocols published elsewhere.gltA to compare the homology between the isolates and described Bartonella species and genotypes. Newly identified variants for each gene were deposited in GenBank with accession numbers KT327034–KT327035 (ftsZ), KT327036–KT327037 (nuoG), KT327038–KT327039 (ssrA), and KT327040–KT327041 (rpoB).Comparing multiple genes can greatly increase a discriminatory power in genetic analysis of bacterial population.This research was conducted in compliance with the Animal Welfare Act and other Federal statutes and regulations related to animals and experiments involving animals and adheres to principles stated in the Guide for the Care and Use of Laboratory Animals, National Research Council Publication (1996 edition). All procedures involving animals were conducted under animal use protocols approved by the Institutional Animal Care and Use Committees of the National Center for Disease Control and Public Health, Tbilisi, Georgia.L. jirds and 6 social voles) were overgrown by fast growing non-Bartonella microorganisms which meant no conclusion could be made whether these organs were infected. From the other 43 remaining heart samples, which consisted of 8 wood mice and 35 L. jirds, Bartonella cultures were obtained from 16 individuals, including 4 wood mice and 12 jirds , with 50% (4/8) in wood mice and 34.3% (12/35) in L. jirds. All of the obtained isolates were further analyzed by sequencing.Among the samples taken from 68 rodent hearts and cultured individually on agar plates, 25 .Molecular detection by PCR for all 68 rodents identified that 28 rodent hearts were positive for al voles . OverallgltA amplicons for all 17 isolates showed that the Bartonella strains circulating among the investigated rodents belonged to multiple groups, including B. elizabethae, B. tribocorum, and an unknown genogroup (B. elizabethae (two isolates) or B. tribocorum (three isolates). The two isolates obtained from the same wood mouse each belonged to B. elizabethae and B. tribocorum. The strain of B. tribocorum was close to the variant FJ577651 previously reported in Israel ratsL. jirds were identical or close to each other and belong to 2 closely related variants (95.6% similarity). One variant (GenBank accession number KT327027) was the dominant and was identified in 11 of the 12 isolates, whereas another variant (GenBank accession number KT327028) was found only in one isolate. Both of the two jird-associated variants were similar to several variants reported from JapanGerbillus nanus), Lesser Egyptian jerboa (Jaculus jaculus), Greater Egyptian jerboa , fat-tailed gerbil (Pachyuromys duprasi), and bushy-tailed jird , and fleas (Synosterrnus leopatrae) collected from Anderson's gerbil , with similarities ranging from 94.6% to 97.6%.Bartonella species or genotypes  or B. tribocorum (N = 1); the sequences obtained from four social voles belonged to B. grahamii with one exception for which the sequence belonged to B. elizabethae. Of the 22 Bartonella-positive L. jirds, 18 sequences belonged to the same novel genogroup identified in the cultures obtained from the same rodent species in this study, with the majority (16/18) being identical to the variant KT327027 (the dominant one), and the other 2 being identical to the variant KT327028. The last four Bartonella-positive L. jirds belonged to B. elizabethae  was at borderline proposed for definition of bacterial species,Bartonella species.L. jirds, dwarf gerbil, Lesser Egyptian jerboa, Greater Egyptian jerboa, fat-tailed gerbil, and bushy-tailed jird all belong to the gerbil subfamily. The results of multi-locus sequence typing analyses based on sequences of five genes  support the opinion that the strains associated with gerbils form a single unique genogroup. Although some bacteria belonging to this group were reported from Japan,Bartonella-positive individuals among L. jirds observed in Georgia suggested that L. jirds likely serve as the major host for this Bartonella lineage. More investigations are warranted to determine the impact of this bacterium on wildlife and humans.The majority of the examined


Executive functions (EFs) is an umbrella term for various cognitive processes controlled by a complex neural activity, which allow the production of different types of behaviors seeking to achieve specific objectives, one of them being inhibitory control. There is a wide consensus that clinical and behavioral alterations associated with EF, such as inhibitory control, are present in various neuropsychiatric disorders. This paper reviews the research literature on the relationship between executive dysfunction, frontal-subcortical neural circuit changes, and the psychopathological processes associated with attention deficit hyperactivity disorder (ADHD) and post-traumatic stress disorder (PTSD). A revision on the role of frontal-subcortical neural circuits and their presumable abnormal functioning and the high frequency of neuropsychiatric symptoms could explain the difficulties with putting effector mechanisms into action, giving individuals the necessary tools to act efficiently in their environment. Although, neuronal substrate data about ADHD and PTSD has been reported in the literature, it is isolated. Therefore, this review highlights the overlapping of neural substrates in the symptomatology of ADHD and PTSD disorders concerning EFs, especially in the inhibitory component. Thus, the changes related to impaired EF that accompany disorders like ADHD and PTSD could be explained by disturbances that have a direct or indirect impact on the functioning of these loops. Initially, the theoretical model of EF according to current neuropsychology will be presented, focusing on the inhibitory component. In a second stage, this component will be analyzed for each of the disorders of interest, considering the clinical aspects, the etiology and the neurobiological basis. Additionally, commonalities between the two neuropsychiatric conditions will be taken into consideration from the perspectives of cognitive and emotional inhibition. Finally, the implications and future prospects for research and interventions in the area will be outlined, with the intention of contributing scientific reference information that encompasses the knowledge and understanding of executive dysfunction and its relationship with these treated disorders. Executive functions (EFs), also known as executive control or cognitive control, are a complex set of interrelated cognitive processes controlled by its top–down nature  and mediIn the historical background, it has been found that although the term “EFs” was coined by Lezak, it was Luria – his direct predecessor – who first described it, even without mentioning it directly. He proposed a brain functioning model based on clinical findings, which consists of three functional units: (1) motivation arousal (reticular and limbic systems); (2) acquisition, processing, and storage of information ; and (3) programming, monitoring, and verification of behavior  temporal [event-related brain potentials (ERPs)] and spatiotemporal [magnetoencephalography (MEG)] resolutions show functional differences in the PFC and striatum in patients with ADHD compared to controls, indicating the existence of dysfunction in the frontostriatal network, which could explain the changes observed in processes such as response inhibition. Furthermore, they showed a decrease in gray matter in the frontal right turn and the rotation of the right posterior cingulate, and in the middle left white matter .Electroencephalogram studies show the existence of a relationship between clinical symptoms of ADHD and characteristics of brain activity, reporting the presence of increased theta activity in the EEG .The genetic mechanisms of ADHD are polygenic and this study focused on those related to dopamine, a gene involved in ADHD that could be the D2 receptor gene located on chromosome 11  Biomarker analysis and its future use in the monitoring of each pathology. Genetic and neurophysiological evidence can be integrated into the study of brain hemodynamics using fMRI, PET and SPECT techniques, for example, as well as EEG by monitoring spontaneous and induced electrical activity. Thus, we could better understand the physiological and cognitive mechanisms underlying these pathologic entities, generating new possibilities for clinical and experimental settings. (2) Use of neuropsychological assessment and neuroimaging in order to map the brain. It is vital to develop studies that record biological activity while simultaneously making assessments via cognitive tests . It would be more appropriate to combine traditional and ecological neuropsychological tools in order to obtain more reliable results. (3) Comorbidity and monitoring of the disorder. Given the explanations outlined in this review regarding the increased chance of individuals diagnosed with ADHD suffering from PTSD, is it possible to argue that ADHD worsens the outcome of PTSD, and can we therefore propose a comorbidity? If yes, this could be included in future diagnostic manuals to show the interaction between the two pathologies. Thus, it would contribute not only to the understanding and diagnosis of both diseases, but also to its monitoring at both the clinical and research levels.Finally, it should be expected that the inclusion of technological tools in the diagnostic and intervention stage will allow better recreation of the scenarios of daily life, thus increasing understanding of rarely addressed cognitive and emotional strategies that are important in shaping ADHD and PTSD.LM, EP, CS, MT, CT conceptualized and designed the work. LM, EP, CS drafted the work. LM, EP, CS, MT, CT critically revised and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The aim of this study was to evaluate symptom persistence in attention-deficit/hyperactivity disorder (ADHD), the development of comorbidities, and psychostimulant usage patterns. Follow-up studies were conducted in 37 patients with ADHD and 22 healthy controls, aged 10 and 18, 4 years after their first assessment. The ADHD was rated as persistent if participants met all DSM-IV criteria for syndromic or sub-threshold persistence, or had functional impairments . Of the 37 ADHD patients we reevaluated, 75% had persistent symptoms, and psychiatric comorbidities with additional functional impairments and academic problems were more common than in controls. These follow-up findings show a high comorbidity associated with ADHD and support the importance of evaluation and treatment for ADHD and comorbidities throughout life. Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental condition characterized by age-inappropriate levels of inattention, hyperactivity, and impulsivity , and it Although ADHD is a neurodevelopmental disorder, hyperactivity–impulsivity symptoms declined with increasing age, but inattention symptoms did not –9, and mMoreover, ADHD is frequently associated with psychiatric comorbidities, such as anxiety disorders (30–40%), , 14, andThus, the persistence of ADHD symptoms is a risk factor for a number of adverse outcomes in adolescence and adulthood, especially when there are comorbidities. It is associated with continuing social, educational, occupational, interpersonal difficulties, substance use disorders, driving difficulties and accidents, and delinquency problems , 16–18. There have been several follow-up studies of children documenting the persistence of ADHD into adolescence and adulthood , 19–34. Thus, a prospective longitudinal follow-up study was designed to (a) investigate ADHD symptom persistence and full remission over these 4 years and to (b) track comorbidities and psychostimulant use.The project was approved by the Research Ethics Committee of UNIFESP-HSP (protocol # 1616/06). All patients, healthy controls, and their families were informed of the procedures involved. Those who agreed to participate signed an informed consent form.The baseline sample was selected from January 2007 to December 2007. This sample included children and adolescents with ADHD, visiting the Interdisciplinary Neuropsychological Child Care Center (NANI), Department of Psychobiology, UNIFESP. NANI is an outpatient facility specialized in interdisciplinary research on diagnosing neurodevelopmental disorders, delivering care, researching and teaching, specialized in ADHD. The sample at baseline consisted of 38 patients , diagnosed with ADHD at a mean age of 8.7 years (SD = 2.3). The healthy subjects were matched to the ADHD patients for gender, age, level of education, and type of school attended . Their mean age was 8.8 years (SD = 1.8).The inclusion criteria were as follows: (1) a full diagnosis of ADHD according to DSM-IV, (2) no comorbid mental disorders, (3) no history of psychostimulant medication use or any other medication that might interfere with cortisol secretion, (4) no history of a serious medical illness, and (5) an IQ score higher than 75 points. These strict criteria were responsible for the small number of participants.At follow-up, 4 years later, 37 patients (30 boys and 7 girls) and 22 healthy subjects (15 boys and 7 girls) were included. Their ages ranged from 10 to 18. They were contacted by mail, e-mail, telephone, or through their school. In the ADHD group, there was a loss of one patient for failure to locate. The control group lost 16 children and adolescents, 8 for failure to locate and 8 because the family refused to participate in the research.The diagnosis of ADHD was based on the application of a Brazilian version of the SNAP-IV  and the Child Behavior Checklist (CBCL). The SNAP-IV is a questionnaire consisting of symptoms from the Diagnostic and Statistical Manual – Fourth Edition – DSM-IV  that hasBehavioral and comorbidity symptoms were reassessed using the CBCL questionnaire. The CBCL has been widely used for screening comorbidity disorders in samples of patients with ADHD –43.Symptom persistence was defined based on the concepts proposed by Biederman et al. , 29: (a)t-tests. The analysis of qualitative variables in independent samples used the chi-squared test. For data collected longitudinally (including the number of symptoms from the DSM-IV), involving paired samples, the Split-Plot ANOVA for repeated measures, and Student’s t-test for paired samples were used. For all tests, a significance level of 5% was established.Statistical Package for the Social Sciences (SPSS) version 20.0 was used for all statistical analyses. The data were analyzed using descriptive statistical procedures for analyzing and testing hypotheses according to the nature of the variables  and the sample type (independent or paired). The normality analysis in the samples distribution was performed using Kolmorov–Smirnov test. For samples with normal distribution, parametric tests were adopted. The analysis of quantitative variables, involving the comparison of independent samples, used one-way ANOVA and Student’s p = 0.86). Thirty-one (83.8%) boys and 7 (16.2%) girls were in the ADHD group, whereas 15 (68.2%) boys and 7 (31.8%) girls were in the clinical control group. Male to female ratio in the ADHD group was 4/1. The loss of the healthy subjects was due to an inability to located them (N = 8) or to family members’ refusal to participate (N = 8).Thirty-seven out of the 38 previous ADHD-diagnosed patients were evaluated in the follow-up study. The mean age of the adolescents was 13.1 (SD = 2.5) for the remittent ones and 12.4 (SD = 2.1) for the persistent patients in the ADHD group, and 12 (SD = 1.9) in the clinical control group. There were no significant age differences between the two groups (N = 14) had at least one grade-level repetition during their school progression and 22 patients had received warnings of possible problems/suspensions/expulsions school, in the previous year before the follow-up. One was arrested and was in a prison for teenagers for stealing and the use of psychoactive substances for the third time at the time of data collection.Of the 37 patients, 22 (59%) had experienced suspension and/or expulsion during the previous school year. In the ADHD group, only seven were treated with methylphenidate. Almost half of our sample, 47% (Twenty-eight out the 37 ADHD patients at follow-up showed symptom persistence (75%) and 9 (25%) showed full remission. Symptom persistence was as follows: 13 (46.4%) fulfilled all diagnostic criteria (syndromic persistence), 10 (35.7%) fulfilled sub-threshold criteria symptoms (symptomatic persistence), and 5 (17.8%) had functional impairments .The descriptive data of the participants and the characteristics of the ADHD group regarding the persistence or absence of symptoms are shown in Table In the sample, 33.1% (13/37) had none of the investigated comorbidities, 13.5% (5) had at least one comorbid disorder, and 51.3% (19) had 2 or more disorders. In the persistent ADHD group, only 18% (5/28) did not have comorbidities.n = 19), CD 70% (n = 19), and affective problems, such as dysthymia (DD) and major depressive episodes (MDD) 74% (n = 20) compared with controls. Remitted patients did not differ from controls . Five of the seven patients were of the most favored social class and possibly had easier access to medical services and medication purchase. Despite substantial evidence supporting the efficacy of stimulant medication for children with (ADHD), adherence to stimulant treatment is often suboptimal . Many chThere are limitations to this study. The first is the relatively small sample size, occasioned by the strict inclusion criteria. A second limitation is the gender distribution with few girls, making it difficult to generalize the results. However, the predominance of boys in the sample is consistent with previous studies and in the general population. A third limitation is represented by the sample loss in the control group in the 4-year follow-up.Our results are relative to a population with potentially more severe ADHD (because they searched for treatment) and may not correspond with what happens with individuals with ADHD who do not seek treatment. The current analyses suggest that a small number of children with ADHD attain complete remission and the persistence of symptoms might be associated with more psychiatric comorbidities. This can indicate that the comorbid disorder is also persistent, and should encourage clinicians to carefully monitor comorbidities in children with ADHD and to be attentive to the residual manifestations of the symptoms of this disease over time. The results could suggest that a lack of effective pharmacological and psychosocial interventions and early diagnosis could aggravate the core symptoms of ADHD, leading to persistence of symptoms and the development of comorbidities, especially with ODD/CD. However, small number of children and adolescents with ADHD were treated effectively throughout the course of the disorder , and theThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Aims and method To measure compliance with National Institute for Health and Care Excellence (NICE) recommendations in two adult attention-deficit hyperactivity disorder (ADHD) clinics and to guide further service development. We audited the case notes of 150 patients referred to adult ADHD clinics in East Anglia in 2010-2011 against NICE standards using an adapted version of the ADHD audit support tool.Results We found good compliance with NICE standards for diagnosis, assessment and pharmacological treatment of adult ADHD. There was a failure in smooth transitional arrangements from child and adolescent mental health to adult ADHD services. Comprehensive treatment programmes addressing psychological, behavioural, educational and occupational needs were not well developed. Deficiencies were observed in conducting recommended physical examinations. Substance use was prevalent in almost half of ADHD patients.Clinical implications Greater attention is needed in delivering better transitional arrangements and comprehensive treatment programmes for adult ADHD. More structured training with emphasis on ADHD-specific psychological interventions, physical examination and treatment of complex cases, especially with comorbid substance misuse, should be offered to clinicians. Symptoms of ADHD persist into adulthood and 10-20% of children with a diagnosis of ADHD still meet diagnostic criteria in adulthood.The Adult ADHD Research Clinic in Cambridge (with a satellite clinic in Peterborough) is a joint venture between the Department of Psychiatry at the University of Cambridge and Cambridgeshire and Peterborough NHS Foundation Trust (CPFT); this tertiary referral centre provided a diagnostic and treatment advice service for East Anglia until it was temporarily suspended in August 2011. In January 2013, a new National Health Service (NHS)-funded adult ADHD service was started by CPFT. Adult ADHD clinics of the Hertfordshire Partnership NHS Foundation Trust (HPFT) are part of secondary mental health services for adults in Hertfordshire providing comprehensive assessment, diagnosis and treatment. Patients stabilised with drug therapy are referred back to their respective general practitioner (GP) through a shared care agreement.The study was conducted to measure compliance of current practice in two adult ADHD centres with recommendations in the NICE guideline and to further inform service development.4 The percentage of patients was calculated for whom selected relevant NICE standards were met. As a part of the audit, data on patterns of substance use in the ADHD population were also collected. The project had formal approval from both participating trusts.We audited the case notes of 150 patients who were referred to our adult ADHD clinics in Cambridgeshire and Hertfordshire in 2010–2011 against NICE standards using an adapted version of the ADHD (adult) audit support tool.n = 100, HPFT n = 50).There were a total of 150 ADHD adult patients selected consecutively for this audit from the two trusts (CPFT n = 46) was in regular employment, with 51 patients in the unemployed category; the rest were in education (n = 41). Employment status was unknown for 12 patients. Fifty-seven ADHD patients had a forensic history.The study sample  was predThere was failure in transition to adult ADHD services in 34 out of 53 (64%) cases known to child and adolescent mental health services (CAMHS) with an established ADHD diagnosis . The rea6 across both trusts (89% at CPFT and 100% at HPFT) and assessing psychosocial impairment along with patients’ needs, physical health history and coexisting conditions.Good compliance was observed in using (and documenting) diagnostic criteria (DSM-IV and/or ICD-10)Drug treatment was the first line of treatment recommended for 80% (80/100) of the patients at CPFT and 94% (47/50) at HPFT. In HPFT, methylphenidate was the first drug tried in 79% (37/47) of cases and there was 100% compliance in initiation and titration of the methylphenidate and monitoring of side-effects. Before starting the drug treatment, a full mental health and social assessment was carried out for all patients. However, a full physical assessment prior to drug treatment was performed only in 11% of cases (5/47); some physical examination was carried out in 72% (34/47). Risk assessment for substance misuse and drug diversion was performed in the majority of cases . Of the patients taking methylphenidate, 10% (4/47) received routine blood tests. Antipsychotic use was observed in 3% of patients (5/150); none of these patients carried a diagnosis of psychotic disorder; one patient suffered with a comorbid tic disorder and indication of antipsychotic use in four other patients was not documented in case notes.A medical or family history of serious cardiac disease, a history of sudden death in young family members or abnormal findings on cardiac examination was reported in only 7 patients, but an electrocardiogram (ECG) recording was performed for 14 patients.A comprehensive treatment programme including drug treatment and addressing patients’ psychological, behavioural, educational or occupational needs was recommended by CPFT for 95% of adults with ADHD. However, drug treatment formed a part of comprehensive treatment programme in only 25% (12/47) of adults receiving treatment in HPFT, where a diagnostic and treatment service is established.Group or individual cognitive–behavioural therapy (CBT) to address the person’s functional impairment was consideredn = 9) and opiate dependence (n = 1).Almost half of the sample diagnosed with ADHD used illicit or licit substances . Alcohol  and nicotine  were the most commonly used drugs. Patients also used caffeine ; cocaine ; cannabis ; amphetamine ; ecstasy ; hallucinogens  and heroin . All adults with ADHD and comorbid substance use received treatment by clinicians with expertise in both ADHD and substance misuse management (HPFT) or were referred to the drug and alcohol team with a recommendation for starting ADHD drug treatment after the substance misuse management (CPFT). Overall, 85% (57/67) of patients using substances were offered drug treatment for ADHD and 15% (10/67) were referred or signposted to the drugs and alcohol team for treatment of alcohol dependence .Organisational support in terms of training programmes covering diagnosis and management was present at both trusts. Local shared care arrangement between primary and secondary care was present at HPFT only. Under the shared care arrangement, a range of responsibilities from drug prescription to physical health monitoring and annual reviews is transferred when the specialist and the GP agree that the patient’s condition is reasonably predictable and the treatment regime has been specified. If the GP is not confident about undertaking this role, then they are under no obligation to do so. In such an event, the totalOverall, this first audit of adult ADHD services in East Anglia established good compliance with NICE guidance for assessment and treatment. This confirms that the implementation of NICE guideline recommendations for adults with ADHD is feasible and should therefore be rolled out and evaluated on a broader scale.7 found that neurodevelopmental disorders such as ADHD did not come under the eligibility criteria for transfer from CAMHS to adult mental health services. These young people are either retained at CAHMS or referred to GPs or voluntary organisations. For patients with a childhood diagnosis of ADHD there should be a clear transitional arrangement that takes into account the fact that adolescents are the most critical group of patients and that lack of treatment during the transitional period typically results in increased morbidity in adulthood.8 Clear communication and transitional pathways between specialist adult ADHD services, CAMHS, community paediatricians and GPs are essential to ensure continuity of care for individuals with ADHD from adolescence to adulthood. Currently, HPFT has a policy and CPFT is developing a transitional pathway, with the aim of improving transitional arrangements.There was a failure in smooth transitional arrangements from CAMHS to adult ADHD services. Different reasons were quoted for non-transition in some cases, but for most patients the reasons were not known. The 2010 TRACK study, which looked into the transition policies, procedures and outcomes in Greater London,2 In our study good compliance was observed in using (and documenting) diagnostic criteria (DSM-IV and/or ICD-10) and assessing psychosocial impairment. A full mental and social assessment prior to starting the ADHD drug was carried out, but deficiencies were observed in conducting (or delegating) recommended physical examination. Interestingly, there was an overuse of ECG investigations. Such discrepancy in practice can be overcome by structured training on adult ADHD with emphasis on physical examination and the use of ECG. This can be complimented by filing a physical examination checklist in the patient file and developing a local protocol for the indication of ECG use in adult ADHD patients with a history (or family history) of cardiovascular problems.NICE has explicitly expressed the need for full mental health and social assessment and full history and physical examination prior to the drug treatment.9 Although good evidence of the effects of psychotherapy in adulthood is sparse,10 new research supports the use of CBT programmes in adults with ADHD.13 In the UK, the Young–Bramham Programme11 provides an integrated approach for understanding ADHD, adjusting modules to the diagnosis and developing skills to cope with symptoms and associated impairments. The programme offers techniques based on psychoeducation, motivational interviewing, cognitive remediation and CBT.11Drug treatment was the first line of treatment in the majority of cases. However, attention is needed in delivering more comprehensive treatment programmes addressing psychological, behavioural, educational and occupational needs. Adult ADHD patients are commonly referred to existing psychological services embedded in local community mental health teams or Improving Access to Psychological Therapies (IAPT) services, which have limited expertise in managing ADHD symptoms and associated impairments. The main issues that affect adults with ADHD include poor skills in prioritising and organising workloads in the workplace and home environment, occupational and educational underachievement, poor interpersonal and social skills and low self-esteem.2 The finding highlights the need for more effort in educating clinicians about safety and effectiveness of antipsychotics in ADHD. More comprehensive treatment programmes that address psychological, behavioural, educational and occupational needs should be established and encouraged through the development of local ADHD support groups and in partnership with the voluntary sector. These include anger management, occupational therapy, ADHD life coaching, inter-agency liaison and working with voluntary sector providing employment support and counselling services.Use of antipsychotics was seen in 3% (5/150) of patients referred for ADHD assessment, despite the fact that NICE has ruled out the use of antipsychotic drugs in treatment of core symptoms of ADHD.15 Factors such as novelty-seeking personality traits, increased impulsivity, self-medication for ADHD symptoms16 and comorbid disorders such as conduct disorder17 and bipolar disorder18 increase the risk of developing substance use disorder in this population. Adults with ADHD are more likely to be past or current users of substances and use these substances in greater amounts. They are also more likely to receive treatment for previous alcohol and drug use disorders.19Several longitudinal studies of children and adolescents with ADHD have demonstrated an increased risk of developing substance use disorder compared with matched controls.20 discuss treatment studies in this area and provide a treatment algorithm to guide clinicians in the management of adult ADHD comorbid with different forms and severities of substance use disorders.In our sample, substance use was prevalent in almost half (45%) of the ADHD patients. Patients with substance use disorder were appropriately referred to the addiction team and/or managed by clinicians with expertise in treating both ADHD and substance misuse as per the NICE guideline. It is important that mental health professionals receive appropriate training in assessment and management of ADHD with comorbid substance use disorder. Magon & Müllerwww.rcpsych.ac.uk/pomh). The baseline audit on prescribing for ADHD was concluded and results published in a report in September 2013; the report is not available externally, but more information can be obtained by contacting POMH atpomh-uk@rcpsych.ac.uk. The QIP project will generate UK-wide data on prescribing for adults with ADHD and help to identify gaps in service provision.The national Prescribing Observatory for Mental Health (POMH-UK) launched a new Quality Improvement Programme (QIP) in 2013 focusing on prescribing for ADHD in children, adolescents and adults (