Low birth weight (LBW) is a serious public health problem in low- and middle-income countries and a leading cause of death in the first month of life. In India, about 18% of children are born with LBW (<2500 grams) in 2015–16. In this study, we aim to examine the influence of maternal factors and socio-demographic covariates on LBW in Indian children.Data were drawn from the fourth round of the National Family Health Survey (NFHS-4), conducted in 2015–16. A cross-sectional study was designed using a stratified two-stage sampling technique. Cross-tabulation, Pearson’s chi-squared test, and multivariate logistic regression analyses were employed to assess the impact of maternal factors and other covariates on children’s LBW.Of total participants , 17.5% of children were found to be born with LBW. The study revealed that women who had prior experience of stillbirth  and any sign of pregnancy complications  were more likely to have LBW children, even after adjusting for a range of covariates. Maternal food diversity was found to a protective factor against children’s LBW. Women with underweight and anemic condition were associated with an increased likelihood of LBW children. Regarding maternity care, women who attended ≥4 ANC visits , took iron tablets/syrup during pregnancy , and delivered in a public health facility  were less likely to have LBW babies. Besides, various socio-demographic factors such as place of residence, caste, religion, education, wealth quintile, and geographical region were significantly associated with LBW of children.Interventions are needed for adequate ANC utilization, improvement in public facility-based delivery, providing iron supplementation, and uptake of balanced energy-protein diet among pregnant mothers. Besides, special attention should be given to the socio-economically disadvantaged women to address adverse pregnancy and birth outcomes including LBW. The first weight of newborns, usually taken just after birth is called birth weight. The World Health Organization (WHO) defines low birth weight (LBW) as weight at birth below 2500 grams or 5.5 pounds regardless of gestational age . LBW canIn 2015, the incidence of LBW is found to be highest in South Asia (27%) than any other region in the world. The prevalence of LBW is almost stagnant in all regions of the world between 2000 and 2015 ,4. AlthoInfants with LBW are more likely to suffer from stunted growth. It affects children’s schooling outcomes, productivity, and cognitive development. It is also associated with increased risks of infections, childhood illnesses, long-term physical and mental disorders, and other chronic diseases in later part of life ,8.Previous research has documented that LBW of children is determined by a complex interplay of biological, socioeconomic, obstetric, maternity care during pregnancy, nutrition, and environmental factors –13. For It is understood from prior evidence that the occurrence of LBW is largely determined by reproductive behaviors, food consumption, nutritional status, provisioning of maternity care during pregnancy, access to healthcare services, and socio-economic status of the mother. Among all the factors identified from past research, maternal factors are found to be the most important determinants of LBW. We conceptualize that LBW of children is influenced by a set of key maternal factors. Moreover, there are several underlying background factors  that would determine the LBW of children through these proximate maternal factors .Although there is a plethora of research on various factors of LBW in children, less attention has given to the factors related to maternal characteristics, especially in Indian context. Our study contributes to significant evidence in the growing body of research on proximate maternal determinants of LBW in children that would be useful to design policies and programs to combat the high incidence of LBW children. Therefore, we aim to investigate the influence of key maternal factors and underlying socio-demographic factors on LBW among Indian children, using a large-scale nationally representative cross-sectional sample survey.Data were drawn from the fourth round of the National Family Health Survey (NFHS-4), conducted in 2015–16. The NFHS-4 is a large-scale nationally representative sample survey, carried out across all Indian states and union territories (UTs) under the stewardship of the Ministry of Health and Family Welfare (MoHFW), Government of India, and the International Institute for Population Sciences (IIPS), Mumbai. The data collection was completed for 601,509 households, 699,686 women aged 15–49 years with a response rate of 97%, and 112,122 men aged 15–54 years with a response rate of 92%. The primary objective of this survey was to provide updated and reliable information on fertility, family planning, maternal and child healthcare, childhood immunization, infant and child mortality, nutrition, HIV/AIDS-related knowledge and attitudes, women empowerment, and domestic violence against women. A stratified two-stage sampling technique was adopted for the collection of data. In the first stage, clusters were selected using probability proportional to the cluster size. In the second stage, 22 households from each cluster were selected with an equal opportunity systematic selection from the household listing. A detailed description of the sampling design and survey procedure is provided in the national report of NFHS-4 [The NFHS-4 provides information about 259,627 children born to women aged 15–49 years in the past five years preceding the survey. To avoid recall bias, this study was limited to the most recent births in the past five years . Among them, 37,306 children were not weighed at birth and 5830 respondents were refused to answer about children’s birth weight. Therefore, the final analytical sample was limited to 147,762 most recent births in the past five years preceding the survey .The low birth weight of children is considered as the outcome variable in this study. The birth weight of children was categorized as <2500 grams (low birth weight) and ≥2500 grams . The information on the birth weight was collected either from mothers’ recall or a written record of health cards. Children were coded as ‘1’ if they had less than 2500 grams of the birth weight; otherwise, they were coded as ‘0’.In this study, we aim to examine the impact of key maternal factors on LBW in children. Furthermore, we controlled a wide range of socio-demographic factors as to understand how covariates alter the influence of maternal factors in determining LBW in children. The selection of these variables is based on past research on LBW conducted in India and other developing countries. The key maternal factors are grouped into two broad categories: (a) mother-related factors and (b) health care factors.Concerning mother-related factors, we considered reproductive health, food consumption, and nutritional status of the mother in the analysis. It is understood from the previous literature that these maternal factors are prominent determinants of children’s LBW. Mother-related factors include history of pregnancy termination , any sign of pregnancy complications (no/yes), maternal food diversity index (low/medium/high), maternal BMI , and maternal anemia (not anemic/anemic).2). We used WHO cut-off points to classify the BMI of mothers as three groups: <18.5 kg/m2 (underweight), 18.5–24.9 kg/m2  and ≥25.0 kg/m2 (overweight/obese). Anemia is a measure of the amount of hemoglobin present in the blood or red cell count in the blood. If women recorded hemoglobin level below 11.0 grams/decilitre (<12.0 grams/decilitre for pregnant women) were considered as anemic. Hemoglobin levels also adjusted for cigarette smoking and altitude in enumeration areas that were above 1,000 meters.Food diversity index was measured from the eating frequency of nine food items that were asked to the mothers: milk or curd, pulses or bean, dark green leafy vegetables, fruits, eggs, fish, chicken or meat, fried food, and aerated drinks. The survey responses were recorded as daily, weekly, occasionally, and never for each food item. The distribution of study participants by the consumption of food items can be found in In regard to health care factors, our study included both the demand-side and supply-side factors of maternal health care. These factors are the number of ANC visits (none/1–3/≥4), uptake of iron tablets/syrup during pregnancy (no/yes), place of delivery (home/public facility/private facility), and distance to health facility (no problem/big problem/not a big problem).Demographic and socio-economic factors were considered as covariates in this study. The selection of these factors is based on previous studies conducted on LBW in India and other countries. Demographic factors include women’s age  and age at marriage (<18 and ≥18 years). Furthermore, socioeconomic factors include the place of residence , caste , religion , birth order , maternal education , wealth quintile , and region .p values and it was set at p<0.05. All the statistical analyses were performed using STATA version 12.1 .Univariate statistics, bivariate, and multivariate logistic regression were carried out for the analyses of data in this study. Descriptive statistics were performed to show the distribution of study participants. Bivariate analyses were carried out to understand the nature of the association between predictors and the outcome variable. The test of association was performed using Pearson’s chi-squared statistic. The sample weight was used to estimate the percentages. Furthermore, a series of three binary logistic regression models were employed to assess maternal factors associated with children’s LBW. The first model assessed the influence of mother-related factors on LBW of children. In the second model, health care factors were progressively included. Finally, demographic and socio-economic factors were incorporated into a single model to determine the impact of maternal factors on children’s LBW independent of other covariates. We checked for multicollinearity between independent variables before performing the multivariate logistic regression. In this study, multicollinearity was tested at two stages. In the first stage, a correlation matrix was developed based on nine food items, which have been used for the construction of food diversity index, to examine whether these food items were highly correlated with each other or not . In the https://dhsprogram.com/data/available-datasets.cfm.The ethical approval of the National Family Health Survey (NFHS-4) was obtained from the ethics review board of the International Institute for Population Sciences (IIPS), Mumbai, India. This survey was also reviewed and approved by ICF International Review Board (IRB). Informed written consent for participation in this survey was obtained from the respondents during the survey. Each individual's approval was sought, and then only the interview was conducted. The NFHS-4 is an anonymous publicly available dataset with no identifiable information of the survey participants and accessible upon a granted request from the Demographic and Health Surveys (DHS) Program at Of the total respondents  about 17.5% of children were born with LBW. The majority of women had no history of pregnancy termination (88.8%) and no signs of pregnancy complications (58%). About two-thirds of respondents (63.8%) had a medium level of diversity in their meals. Nearly one in every four women (22.7%) was underweight and over half of them (55.6%) were anemic. About 60% of women had received ≥4 ANC visits. An overwhelming majority of women took iron tablets or syrup during pregnancy (84.7%) and delivered in either public or private health facilities (93.1%). A considerable proportion of women reported either no problem (36.3%) or not a big problem (34.7%) regarding distance to the health facility. Regarding socio-demographic characteristics, over half of the women (55.9%) belonged to age 25–34, and more than one in every three women (36.2%) married before they reached 18 years. Most of the respondents lived in rural areas (66.8%), belonged to other backward classes (45.1%), and affiliated to Hindu religion (80.2%). Over half of the women (52.2%) had a secondary level of education. Participants were almost equally distributed across household wealth quintiles. The highest proportion of respondents resided in the east region (23.7%), followed by the south (22.6%), and central (20.9%) regions of the country .The occurrence of LBW was found to be higher among women who had a history of pregnancy termination  and any sign of pregnancy complications (17.8%) as compared to their counterparts. Mothers who had low diversity in diet considerably had a higher incidence of LBW babies (20.4%) than those mothers who had medium (17.5%) or high (15.8%) diversity in their meals. Furthermore, women experiencing underweight (21.3%) and anemia (17.8%) were more likely to have LBW children compared to their counterparts. The incidence of LBW babies was lower among women who attended ≥4 ANC visits (16.6%), took iron tablets or syrup during pregnancy (17%), and delivered in a health institution . Respondents who faced difficulties regarding distance to the health facility had a higher prevalence of LBW children .The prevalence of LBW decreased with the increase of the age of women in which women aged 15–24 years had a higher proportion of LBW babies than those women aged 35 years or older (19% vs. 17.3%). A higher percentage of mothers had LBW children who married before 18 years compared with those who married at 18 years or later (18.6% vs. 16.9%). The incidence of LBW decreased with the increase of maternal educational level. The prevalence of LBW was 6.3% lower among higher educated women as compared to women who had no formal education (13.3% vs. 19.6%). The occurrence of LBW also had a decreasing trend from bottom to upper quintiles of household wealth where the percentage of LBW was 5.5% lower in the richest quintile than the poorest household. Children’s LBW was common among those who lived in rural areas (17.9%), belonged to scheduled caste (18.4%) and scheduled tribe (19.5%) and Hindus (17.8%). The prevalence of LBW also varied across geographical regions. The highest incidence of LBW was found in the north region (20%), followed by the central (19.5%) and west (18.5%) regions .The results of binary logistic regression for assessing the impact of maternal factors on LBW in children are presented in Regarding demographic factors, women ages 25–34  were less likely to have LBW babies as compared to women ages 15–24 years. Participants living in rural areas were less likely to have LBW babies  as compared to their urban counterparts. Concerning caste and religion groups, scheduled tribe  and Muslim  children had a lower risk of LBW in the adjusted analysis. The probability of LBW children reduced with higher-order birth. Maternal education was found to be a protective factor against children’s LBW occurrence. Compared to women who had no education, women with secondary  and higher education  were less likely to have LBW babies. Women from the richest quintile had reduced odds of LBW babies  as compared to women from the poorest quintile. The geographical region also had a significant influence on the incidence of LBW babies. The results revealed that children resided in the central , east , northeast , west , and south  regions were less likely to experience LBW as compared to children from the northern region of the country.India has initiated several reproductive healthcare programs for the improvement of maternal and newborn health status. Despite these efforts, a high proportion of children are born with LBW, leading to an alarming rate of child mortality in the country. We used a sub-sample of the NFHS-4 data where about 17.5% of children are found to be born with LBW, which is similar to the reported prevalence of LBW (18%) that was estimated from all living children under the age of five years in India . HoweverThe findings of this study indicate that maternal factors are significantly associated with LBW of children. Concerning reproductive indicators, women’s prior history of stillbirth and complications during pregnancy increased the likelihood of having LBW children by 20% and 8%, respectively. Adverse reproductive health of mothers may result in restricted fetus growth. Evidence has found that the risk of LBW deepens when pregnancy occurs within 6 months of previous birth . A possiA noteworthy finding in this study is that the food diversity of women had a significant impact on the birth weight of infants. The likelihood of LBW decreased with an increasing level of food diversity. This result is in accordance with the findings from Ghana where mothers who consumed diversified and nutritious foods were less likely to have LBW babies . SimilarSeveral demographic  and socio-economic characteristics  were significantly associated with LBW of children. Among socio-demographic factors, maternal education and household wealth status were found to be protective factors against LBW of children. The odds of having LBW decreased with an increasing level of maternal education. This finding is in line with several previous studies conducted in India and other developing countries ,17,22,23The findings of this study should be considered in light of some limitations. The information regarding the birth weight of children was collected either from a written record or mother’s recall. Therefore, birth weight information from the mother’s recall is prone to recall bias and social desirability. Nonetheless, to minimize the recall bias in the study, we restricted our sample for the most recent birth of women in the past five years preceding the survey. Moreover, there is a large number of missing cases in birth weight data because many children were not weighed at birth, or respondents were refused to answer. We could not assess the causal relationship between the outcome variable and predictors due to the cross-sectional nature of the study design. This study could not assess potential factors mediating the association between maternal characteristics and LBW in children. Future research is needed using longitudinal data to understand the mechanism behind the high occurrence of LBW children in India. Despite these limitations, this study provides important insights on maternal factors associated with LBW in children, which may be useful for policymaking to reduce the incidence of LBW in Indian context.The findings of this study indicate that several maternal factors are significantly associated with the occurrence of LBW babies. Interventions are needed for adequate ANC utilization, improvement in public facility-based delivery, iron supplementation to reduce anemia, and the intake of balanced energy-protein diet among pregnant mothers. Policymakers and stakeholders are also suggested to design effective policies and programs to address the poor reproductive health of women that would further help to reduce the risk of LBW babies. Additional efforts should be taken among socio-economically vulnerable groups of women to address adverse pregnancy and birth outcomes including LBW.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


The World Health Assembly (WHA) developed six global nutrition targets that focus on child and maternal nutrition. The progress made by individual countries is available as a yearly global nutrition report. However, reporting the national progress might mask important sub-national differences. This study aimed to measure the progress of the 11 regions of Ethiopia towards achieving the 2025 WHA targets using average annual reduction rates (AARR).Ethiopia is off-track in meeting the five global nutrition targets studied. The national AARR of stunting is 2.3 against a target of 5.3, for wasting the current AARR is 3.1 against a target of 5.3. The AARR of non-exclusive breastfeeding was 2.1 close to the target of 2.7. Anemia in women of reproductive age increased across all the regions of Ethiopia. The majority of Ethiopian regions were on track to achieving the overweight and exclusive breastfeeding targets by 2025. There is an urgent need to address anemia in Ethiopian women of reproductive age because its prevalence has been increasing. Secondly, the progress to reduce wasting and stunting in children under-5 has not been enough and more work needs to be done if Ethiopia is to achieve the 2025 targets. Malnutrition is a preventable cause of death in almost half of children under 5 in developing countries . The impMany countries have made commitments towards achieving the 2025 Global Nutrition Goals and Ethiopia is one of these countries. The reports coming out of the Global Tracking Tool website show that Ethiopia is off-track in meeting five of the goals and there is inadequate data to measure the progress made in low birth weight. The prevalence of stunting and wasting in Ethiopia is above the average for a developing country . The 201The progress a country makes in achieving the 2025 is available as the annual Global Nutrition Report and online here . This reThe progress towards the global nutrition targets is classified into three categories based on the WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring (TEAM) recommendations. This classification compares a country’s required AARR to achieve the target with its current AARR. If the current AARR is greater than the required AARR, the progress is on track; otherwise, it is off track. Moreover, progress has further been classified into off track with some progress and off track with no progress or worsening Table . The accData from the publicly available reports of the nationally-representative demographic health surveys (DHS) available after 2011 were used –12. BecaMonitoring the prevalence of not exclusively breastfeed (NEBF) children to track target 5 is recommended as it makes it easier to see the AARR rate and measure progress  NEBF is t/Pt + n)/n; where Pt is the starting prevalence (baseline), Pt + n is the final prevalence, and n is the number of years between the two data points. All statistical analyses were carried out using the R Studio version 3.4.2.The AARR is given by the following formula , 14 AARRThe national level of stunting has shown a downward trend decreasing from 44.4% in 2011 to 36.8% in 2019 (Table Nationally, Ethiopia is off track in the five out of the six WHA’s global nutrition goals Table . The AARThis study aimed to measure how the different Ethiopian regions were progressing towards achieving the global nutrition goals of 2025. No progress has been made in reducing anemia and overweight prevalence. The national level of stunting levels has been decreasing at AARR of 2.35 (Table Wasting in children under 2 years old increases the risk of overweight later in life and breastfeeding reduces the risk . This inOnly 31 countries out of 194 were on track for achieving the exclusive breastfeeding target in 2018 . AlthougThe results of this study show that Ethiopia is off-track in meeting the WHA Global Nutrition Targets. Nationally, there has been some progress made in reducing stunting, wasting and exclusive breastfeeding targets whereas there was no progress made in achieving the overweight and anemia targets. The subnational analysis reveals that the capital Addis Ababa is the only region on track to achieve 40% reduction of stunting by 2025. Moreover, most of the regions are on track to achieve the exclusive breastfeeding by 2025. Gambela and Somali regions are not making any progress in reducing wasting levels and there hasn’t been any progress made in reducing anemia levels as a whole. The national anemia levels in women of reproductive age need an urgent attention. Despite making some progress no Ethiopian region is on track to reduce achieve the wasting target.This study has some limitations. Firstly, the more data points are available between the baseline and the current rate the better the predictions. However, nationally representative data for anemia and exclusive breastfeeding were available for two data points in 2011 and 2016 and this might not reflect the current situation and the interpretation of these two reduction rates must consider this. Secondly, this study assumes that the current reduction rates do not change and the predictions whether the targets would be achieved are based on this assumption.Additional file 1. This is an excel table showing the data used in this study and its analysis.


High-throughput sequencing analysis was carried out to investigate microbial community evolution, and the results showed that the relative abundance of ammonia-oxidizing bacteria (AOB) in the SMBR increased from 0.1% without pre-treatment to 1.78% with the pre-treatment of MC.A high concentration of suspended solids (SS) in swine wastewater reduces the efficiency of the biological treatment process. The current study developed a short-cut combined magnetic coagulation (MC)–sequence batch membrane bioreactor (SMBR) process to treat swine wastewater. Compared with the single SMBR process, the combined process successfully achieved similarly high removal efficiencies of chemical oxygen demand (COD), total nitrogen (TN), ammonium nitrogen ( According to the Bulletin of the Second National Census of Pollution Sources in China, announced in June 2020, the livestock industry is the main source of water pollutants discharged in the agricultural industry, i.e., chemical oxygen demand (COD), S) 1117–437 mg/L .,33.NH4+-The short-cut combined MC–SMBR process in Stage II could effectively remove COD, TN, and Compared with a single SMBR process, the combined MC–SMBR process can greatly enhance the solid–liquid separation efficiency and achieve a better removal performance of COD, The variation of nitrogen compounds within a cycle at the different stages of the SMBR showed similar behavior, as shown in The real-time control strategy was used in the SMBR, in which the “ammonia valley point” on the pH curve was used to judge the end of the ammonia oxidation process to timely stop the aeration. Hence, the nitrification reaction stopped during the ammonia oxidation stage to reach a high NAR. When the ncreased ,35.The total cycle time of all stages was different, i.e., Stage I was 240 min, Stage II was 230 min, and Stage III was 205 min. Therefore, the footprint of the SMBR was reduced by 4% and 14% in Stage II and Stage III, respectively, compared with that in Stage I. As shown in Bacteroidetes (18.89–72.35%), Proteobacteria (6.43–36.25%), Patescibacteria (11.25–19.33%), Firmicutes (4.21–16.40%), Chloroflexi (0.54–14.72%), and Actinobacteria (0.83–11.42%). Compared with Stage I, the abundance of Bacteroidetes and Firmicutes increased during Stage II and Stage III, whereas the abundance of Proteobacteria, Chloroflexi, and Patescibacteria decreased. Bacteroidetes was the most abundant phylum and has the ability to metabolize the EPS generated by nitrifiers and secondary metabolites produced by biomass decay [Proteobacteria phylum was correlated with Nitrosomonas, with high abundances in the SMBR [Chloroflexi was involved in organic matter degradation, such as polysaccharides [The microbial communities of activated sludge in the SMBR during Stage I , Stage II , and Stage III  were investigated using a high-throughput sequencing analysis. The relative taxonomic abundances of the microbial communities at a phylum level are shown in ria 6.43–.25%, Patthe SMBR ,38. Chlocharides . The maiNitrosomonas was detected as the AOB, whereas Nitrolance and Nitrospira were the NOB. According to the ammonia valley, the relative abundance of AOB in the SMBR was only 0.1% in Stage I due to the control of the oxic phase. After combining with the MC process, the relative abundance of AOB was increased to 1.78%, with a higher growth rate. The reason was that the MC pre-treatment reduced the organic carbon in the influent, which was beneficial for the growth of autotrophic bacteria, such as AOB and NOB. Besides, the reasonable aeration time of the SMBR was conducive to the elimination of NOB.The genus-level distributions, abundances, and changes in the AOB and NOB reads during the different stages are shown in A redundancy analysis (RDA) was conducted to reveal the species distributions in the samples along with controlling parameters at the genus level . Sludge 3·d)), and the HRT was shortened by 14% (from 5.0 d to 4.3 d) with the introduction of the MC process. Besides, the relative abundance of AOB in the SMBR increased from 0.1% in Stage I to 1.78% in Stage III, which is beneficial for improving AOB activity in the SMBR due to the removal of SS and organic matter by the MC pre-treatment. Considering the economic, technical, and performance factors, the MC in Stage II with dosages of PAC, PAM, and magnetic seeds of 0.5 g/L, 2 mg/L, and 1 g/L, respectively, was more suitable for swine wastewater pre-treatment.The short-cut combined MC–SMBR process was successfully developed to treat the swine wastewater, and its removal efficiencies were 99.0%, 97.6%, 96.0%, and 69.1% for


To assess General Practitioner (GP) and pediatrician adherence to clinical practice guidelines (CPGs) for diagnosis, treatment and management of attention deficit hyperactivity disorder (ADHD).Medical records for 306 children aged ≤15 years from 46 GP clinics and 20 pediatric practices in Australia were reviewed against 34 indicators derived from CPG recommendations. At indicator level, adherence was estimated as the percentage of indicators with ‘Yes’ or ‘No’ responses for adherence, which were scored ‘Yes’. This was done separately for GPs, pediatricians and overall; and weighted to adjust for sampling processes.Adherence with guidelines was high at 83.6% (95% CI: 77.7–88.5) with pediatricians  higher than GPs . Appropriate assessment for children presenting with signs or symptoms of ADHD was undertaken with 95.2% adherence (95% CI: 76.6–99.9), however ongoing reviews for children with ADHD prescribed stimulant medication was markedly lower for both pediatricians  and GPs .Adherence to CPGs for ADHD by pediatricians was generally high. Adherence by GPs was lower across most domains; timely recognition of medication side effects is a particular area for improvement. Attention deficit hyperactivity disorder (ADHD) is the most common mental disorder during childhood, affecting over seven percent of Australian children aged 4 to 17 years . It can For children with ADHD, early diagnosis and evidence-based treatment improves the chances for positive long-term outcomes , 5. ClinDespite the availability of CPGs, considerable variation is reported to exist in the diagnostic evaluation and treatment of ADHD –9. This The largest published Australian study examining guideline adherence in the diagnosis of ADHD found self-reported assessment by pediatricians to be largely consistent with best practice, but noted lower rates of comorbidity identification for internalising, externalising and sleep problems in comparison to parent report. However, this study was limited by its reliance on self-report survey data, exclusive focus on diagnostic indicators, participation from a small group of self-selected pediatricians (n = 24) and non-inclusion of general practitioners (GPs), who can also be involved in the care of children with ADHD.In Australia, unlike many other countries, while GPs are the ‘gate keepers’ to referral, responsible for identifying children with suspected ADHD and referring them to specialist services, they can also play an important role in the ongoing management of ADHD . The impGiven the serious short- and long-term consequences of ADHD, monitoring and evaluation of adherence to clinical guidelines is important to track changes and identify where improvements are needed . CurrentThe CTK methods have been described in detail elsewhere , 29. HerWe modified and applied the RAND-UCLA method to develop indicators . For theResearchers with experience in clinical indicator development  extracted CPG recommendations, collated expert feedback and revised the content, structure, and format of each indicator between review rounds. From the four CPGs, 43 recommendations were extracted and considered for inclusion . RecommeThese 26 initial draft recommendations were subjected to a three-round modified Delphi “internal review” by four clinicians involved in the study (one GP and three pediatricians) followed by further reviews and modifications by four pediatricians, two psychologists, two psychiatrists, and a GP external to the project  , 37. EacCTK targeted 400 medical records for ADHD and 6,000 for the 16 other conditions. Without adjustment for the design effect, a minimum of 400 visits per condition was sought to obtain national estimates with 95% Confidence Interval (CI) and precision of +/- 5% at condition level, conservatively assuming only one eligible indicator per visit. If any of the 6,400 medical records targeted and sampled contained an occasion of care for ADHD, indicator adherence was assessed. Further details on sample size and methods are provided elsewhere  and addiData were collected by eight experienced pediatric nurses (“surveyors”), trained to assess eligibility for indicator assessment and adherence to CPGs. Surveyors undertook criterion-based medical record reviews using an electronic data collection tool. They had access to extensive instructions and definitions to assist with making their decisions, including what constituted a comorbid illness. Surveyors were also instructed to not make assumptions and to rely on only the information provided in the patient’s medical record , Women’s and Children’s Health Network of South Australia Human Research Ethics Committee (HREC/14/WCHN/68), the Sydney Children’s Health Network Human Research Ethics Committee (HREC/14/SCHN/113) and the Children’s Health Queensland Human Research Ethics Committee (HREC/14/QRCH/91), and site-specific approvals from 34 sites. Ethics approvals included reporting by healthcare setting for condition-level data. Australian human research ethics committees can waive requirements for patient consent for external access to medical records if the study entails minimal risk to facilities, clinicians, and patients; all relevant bodies provided this waiver. The study was protected from litigation by gaining statutory immunity as a quality assurance activity from the Federal Minister for Health under Part VC of the Australian Health Insurance Act 1973. Further details are reported elsewhere .In total, 306 children had one or more occasions of care eligible for assessment for ADHD. Almost half the children were aged nine years or older, with three-quarters male . There wAs previously reported , averageChildren with ADHD prescribed stimulant medication (methylphenidate and dexamphetamine sulphate) had the treatment duration and signals for stopping documented prior to prescription.”) to 100% for pediatricians for several indicators ”; 95% CI: 94.5–100).The assessed adherence of four bundles is shown in In our study, Australian children with eligible assessments for ADHD received appropriate care for an average of 83.6% (95% CI: 77.7–88.5) of indicators, which was high relative to the average across the 17 conditions from the CTK study  . Indeed,Highest adherence was recorded for indicators that addressed assessment and short-term management of ADHD. Overall guideline adherence for Bundle A assessing components of appropriate ADHD assessment was 95.2% (95% CI: 76.6–99.9) and for Bundle B appraising whether children newly diagnosed with ADHD met DSM-IV criteria was 95.2% (95% CI: 88.3–98.7). The overall high rate of adherence to guidelines for the initial assessment, diagnosis and short-term management of ADHD suggests that, in general, these aspects of guidelines are relatively accessible, known, and feasible to implement in routine clinical practice. Further, these findings are broadly consistent with previous UK research examining healthcare professionals’ attitudes towards implementing the NICE ADHD guidelines  in cliniOur results suggest that Australian clinicians are following recommendations to use stimulants ahead of other medications ADHD19) with estimated adherence rates of 76.0% for GPs (95% CI: 91.8–86.9) and 97.6% for pediatricians . Our data is in agreement with research from Australia , 44 and  with estAlthough studies comparing healthcare professionals in their adherence to ADHD guidelines are limited, two studies from the USA reported that pediatricians were more likely to follow ADHD identification and management guidelines than family physicians  , 20. In A previous Australian survey of 207 approved stimulant prescribers from NSW reported that pediatricians effectively monitor patients if prescribed stimulant medication, including physical assessments of weight, blood pressure and height in over 80% of cases . In contOverall, the findings of this study suggest there is scope for improved monitoring, particularly with documenting heart rate, blood pressure and weight for children on ADHD medication. Some interventions which have been trialled to increase guideline adherence for ADHD diagnosis and management include computerised decision aids in primary practices in the USA , 50. A cThe main strength of the study is that a multi-stage representative sample was taken, covering Australian states containing 60% of Australia’s children, and as such is likely generalisable to much of the unsampled population. Rather than self-report, an audit of medical records allowed an assessment of real-world practice. The audits themselves were carried out by experienced pediatric Registered Nurses who had undergone extensive training for the task. The whole medical record was available to the surveyors and guideline compliance data were collected for the two-year study period of interest (2012–2013); this means longer-term follow-up care for ADHD was not examined.As to weaknesses, the study used documentation to assess actual practice; i.e., assuming that the action was not done if it was not documented. This may have affected results for some indicators where activities were not as readily documented . However, we argue that medical record documentation is a fundamental aspect of clinical practice and essential for delivering high quality and safe care to a population of patients . We noteThe study was able to examine care delivered by both GPs and community pediatricians in three states in Australia, which cover 60% of the Australian pediatric population. Other specialist groups such as mental health teams, allied health professionals, psychiatrists, and neurologists were not sampled. There is limited information in Australia on the proportion of children with ADHD seen by these practitioners. Data from the Young Minds Survey provides a breakdown of service use by children with any mental health condition, and the majority present to GPs and pediatricians .However, our study is limited by self-selection bias, with sampled GPs and pediatricians possibly more confident in their practice and record keeping, which could lead to an overestimation of adherence. Moreover, the generalisability of the pediatrician findings is limited to children who could access and afford to see a pediatricians, as most pediatricians in Australia charge more than the Medicare schedule fee and require up-front full or gap payment . While we targeted a minimum of 400 medical records, we were only able to identify 306 records through our sampling, leading to wider than expected confidence intervals around our estimates of adherence for many indicators and settings.Finally, we acknowledge that our ADHD sample was predominantly male ; reflecting representative population-based studies showing that the male to-female ratio of ADHD is approximately 3:1 . Some reTo our knowledge, this is the largest cross-sectional survey of pediatric medical care for ADHD in Australia. Our methodology provides valuable baseline data on the appropriateness of care for children with ADHD, which is necessary for benchmarking purposes and the targeting and evaluation of national initiatives for specific gaps identified in this care, to be assessed by future studies. With the exception of baseline assessment and routine monitoring of heart rate and blood pressure, adherence to CPGs for ADHD by pediatricians treating patients in Australia is high. Adherence to CPGs for ADHD by GPs is lower across most domains; further research is needed to understand the reasons for GP divergence from CPGs. Timely recognition of medication side effects may be a particular area for improvement, particularly monitoring and documentation of this in medical records.S1 AppendixTable of 34 medical record audit indicator questions.(DOCX)Click here for additional data file.S2 AppendixDetails the selected methods specifically relevant to ADHD.(DOCX)Click here for additional data file.S3 AppendixExcerpt from the Surveyor manual.(DOCX)Click here for additional data file.


Surfactant tolerance in the presence of mono and divalent reservoir ions, as well as the solubility of surfactant in high salinity and low salinity brine, are the two major requirements for any surfactant that is subjected to oilfield application. Herein, six poly(ethylene oxide) zwitterionic surfactants having different ionic headgroups and hydrophobic tail were synthesized for oilfield applications. They were characterized by various instrumental techniques (Fourier-transform infrared spectroscopy (FTIR), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-ToF-MS), Nuclear Magnetic Resonance (NMR)) and the combination of these techniques allowed for us to deduce the structure. All of the surfactants revealed prominent solubility in high salinity and low salinity brine due to the presence of ethoxy units between the aromatic ring and amide group. The surfactant samples were oven aged for 90 days at reservoir temperature and a clear solution implies their excellent aqueous stability. Rendering to thermal gravimetric results, decomposition of surfactants was found to occur around 300 °C, which is higher than the reservoir temperature (≥90 °C). It was observed that the hydrophilic headgroup has no significant impact on the critical micelle concentration and other surface properties. However, the hydrophobic tail bearing benzene ring significantly alters the critical micelle concentration and other surface properties. Surfactants (surface active agents) are extensively applied in various oilfield applications, such as drilling fluid, well stimulation, filter cake removal, swelling inhibitor, corrosion prevention, fracturing, and enhanced oil recovery ,5,6,7,8.Surfactant adsorption on the reservoir rocks is a big challenge that requires broad studies before the application of surfactant in a specific reservoir. For instance, negatively charged anionic surfactants are avoided in carbonate reservoirs and the positively charged cationic surfactants are avoided in sandstone because of adsorption issues. Zwitterionic surfactants belong to the class of surfactants that is composed of both positive and negative charges, and these charges neutralize each other under the normal environment. In comparison with zwitterionic surfactants, anionic and cationic surfactants exhibit lower heat stability and lower salt tolerance due to headgroup interactions, which makes zwitterionic surfactants more suitable for oilfield applications . N-erucamidopropyl-N,N-dimethyl ammonium) propane sulfonate} exhibit viscoelastic properties and meet the requirements of hydraulic fracturing operation  attached with the phenyl ring. The peak at δ 3.21 ppm could be related to two methyl units of positively charged ammonium head [N+(CH3)2]. The signals of the ethoxy group appeared as an overlapped peak at δ 3.60–3.69 ppm. The doublet peaks at δ 6.82 ppm were linked with the two aromatic protons of phenyl ring [2 × (CH)] at meta position with respect to the tertiary butyl group. Similarly, doublet peaks at δ 7.26 ppm could be linked with the next two aromatic protons of phenyl ring [2 × (CH)] at the ortho position with respect to the tertiary butyl group. The broad singlet peak at δ 8.02 ppm could be assigned to an amide group [NH(CO)]. The chemical structures of all the synthesized zwitterionic surfactants  and corresponding intermediates were identified using MALDI-ToF-MS, NMR, and FTIR. We described the structure identification of TEAC here as an example. Rendering the proton NMR data of TEAC , the intCH3)3] attached to the phenyl ring. The peak at δ 34.0 ppm was assigned to a quaternary carbon of tertiary butyl [C(CH3)3] connected with the phenyl ring. The peak at δ 51.0 ppm was related to two methyl units of positively charged ammonium head [-N+(CH3)2]. The signals that were observed at δ 62.2 ppm and δ 64.5 ppm were referred to two methylene units of positively charged ammonium head [(CH2)2-N+(CH3)2]. The overlapped signals of methylene units of the ethoxy group were detected at δ 67.3–70.6 ppm. The signals at δ 114.0 ppm referred to two methine carbons of phenyl ring [2 × (CH)] at meta position with respect to the tertiary butyl group. Similarly, the peak at δ 126.1 ppm was linked with the next two methine carbons of phenyl ring [2 × (CH)] at the ortho position with respect to the tertiary butyl group. The peak at δ 143.5 ppm was assigned to a quaternary carbon of phenyl ring [C-C-(CH3)3] that was directly bonded with the tertiary butyl group. Likewise, the peak at δ 156.3 ppm was associated with the quaternary carbon of phenyl ring [C-O-CH2-CH2-] that was directly bonded with the ethoxy group. Two peaks detected at δ 168.1 ppm and δ 172.5 ppm were linked with the carbonyl carbon of acetate [CH2COO] and carbonyl carbon of amide [CH2CONH], respectively. Rendering to carbon-13 NMR data of TEAC , the str−1 related to NH stretch. Two adsorption signals at 2959 cm−1 and 2872 cm−1 are allocated to the CH3 and CH2 stretching regions, respectively. The strong signals at 1625 cm−1 were assigned to the carbonyl stretch. The adsorption signals at 1460 cm−1 may refer to CH2 bend. The ethoxy groups were detected by the adsorption signals at 1106 cm−1 [Rendering to the FTIR spectra of TEAC , strong 106 cm−1 . m/z 527.33 can be assigned to an exact molecular mass of TEAC containing 4 ethoxy units (n = 4). The following peaks before and after the major peak are the distribution of ethoxy units with the mass difference of m/z 44, which is a molecular mass of one ethoxy unit. For example, the peak of m/z 439.28 is assigned to a molecular mass of TEAC containing two ethoxy units (n = 2) and the peak of m/z 483.31 is referred to as a molecular mass of TEAC having three ethoxy units (n = 3). Similarly, the signals of m/z 571.36 are assigned to a molecular mass of TEAC with five ethoxy units (n = 5) and the peak of m/z 615.39 is referred to as a molecular mass of TEAC having six ethoxy units (n = 6). Generally, the NMR and FTIR techniques are sufficient for identifying the chemical structure of the surfactant. However, for high molecular weight surfactants containing the distribution of ethoxy units, the combination of an additional method, such as MALDI-ToF-MS, is suitable for achieving insight into the chemical structure of surfactant. According to MALDI-ToF-MS of TEAC , Table 4Overall, the NMR, FTIR, and MALDI-ToF-MS data appeared to be in agreement with the suggested structure of TEAC. The detailed structural characterization data is available in The tolerance of surfactant in mono and divalent reservoir ions, and the solubility of surfactant in a normal and high saline environment, are the two major requirements for any surfactant subjected to oilfield application. The synthesized zwitterionic surfactants  showed good solubility in low salinity and high salinity brine due to the presence of ethoxy units between the aromatic ring and positively charged ammonium head . The enhDuring the oilfield application, the solution of a surfactant is injected into the reservoir and remains there in a non-ambient environment for several days. Therefore, thermal studies of the synthesized surfactant are important for identifying the efficiency of the surfactant in a harsh environment. The thermal degradation behavior for TEAC, TEAS, TEAH, NEAS, NEAC, and NEAH was performed by TGA. Rendering to TGA isotherm , the inicmc) increased with an increase in salinity. The data that are given in The fundamental surface/interface properties of the synthesized surfactants were measured while using the Du Noüy ring method, as outlined in max) and minimum area per molecule (minA). The parameter minA represents the area that is occupied by a surfactant molecule at the air/solution interface. A higher minA value indicates that a single molecule will occupy more space at the interface and the number of molecules will be lesser at the interface and vice versa. These properties were determined using Equations (1) and (2):The tendency of these synthesized surfactants to be adsorbed at the air-water interface was determined using maximum surface excess . Surfactants with a longer tail  exhibited lower гmax values when compared to the corresponding surfactant having a shorter tail . Similarly, surfactants with a longer tail  showed high minA values as compared to the surfactants containing a shorter tail .Here, dγ/dlnC represents the gradient below cmc, o number . The add−1) in 1M NaCl. Moreover, a reduction in CMC was also observed by using high salinity brine. On the other hand, γcmc increased by increasing the hydrophobic tail length, which emphasized that the surface properties primarily depend on the hydrophobic tail rather than hydrophobic headgroup. The synthesized zwitterionic surfactants exhibited superior surface and thermal properties and could be a suitable candidate in harsh reservoir conditions.We demonstrated the influence of ionic headgroup and hydrophobic tail containing a benzene ring on the thermal and the surface properties of the synthesized poly(ethylene oxide) zwitterionic surfactants. The surfactants revealed prominent solubility in low salinity and high salinity brine and the oven aged samples of surfactants for 90 days at reservoir temperature showed no phase separation and/or precipitation, which confirm their excellent aqueous stability. TGA data revealed a higher degradation temperature than the actual reservoir temperature (90 °C) and the nature of the hydrophilic head and hydrophobic tail showed little effect on the thermal properties of the surfactants. It was established that the impact of various headgroups was not very obvious on CMC and other surface properties of the surfactants. However, the variation of the hydrophobic tail significantly alters the CMC and other surface properties. For instance, the CMC values reduced considerably by increasing the length of the hydrophobic tail in both normal as well as high saline water and NEAC exhibited lowest CMC (0.0507 mmol L


FAPDs are not more common among obese children compared with healthy controls at a community level. Obese children may have been overrepresented in previous studies which were done at a clinical level due to comorbidities and a more severe phenotype that makes them more likely to consult. Nutritional status is not a useful predictor for the occurrence of FAPDs in children in the general population.Functional abdominal pain disorders (FAPD) are the most common chronic pain conditions in pediatric gastroenterology. They account for 50% of all pediatric gastroenterology clinic visits. The pathophysiology of FAPDs is poorly understood, but there is growing understanding of the role of food and the patient’s nutritional state in both their treatment and prognosis. Clinic-based studies have shown a higher prevalence of FAPDs, and worse prognosis among obese children with FAPDs. We aimed to assess the nutritional status of children with FAPD to determine if there is increased prevalence of FAPDs in obese or underweight patients. We conducted a cross sectional study of schoolchildren in Colombia. We enrolled 1030 patients from five schools and screened them for FAPDs using Rome IV criteria. Data on weight, height, abdominal circumference and BMI were collected for each child. Cases (FAPDs) were compared with a control group of enrolled children who did not meet diagnostic criteria for any functional gastrointestinal disorders (FGID). We diagnosed 58 (5.8%) children with FAPDs based on Rome IV criteria. When we compared to participants who were not diagnosed with FGIDs by screening, there was no statistically significant difference in children who were obese (OR 0.34 CI: 0.03–1.34,  Functional abdominal pain disorders (FAPD) are among the most common types of chronic pain disorders in children . FAPDs aThe pathophysiology of FAPDs remains poorly understood. Multiple factors seem to be involved. Among those factors, food and nutritional status are thought to play a role in triggering symptoms and influencing their prognosis . MultiplWe conducted a community-based cross-sectional study to assess the relationship between nutritional status and FAPDs in schoolchildren in Colombia. The study has the potential to advance our understanding of the “true” relationship between FAPDs and nutritional state by overcoming some of the limitations of previous studies.We sent invitation letters to the homes of all children aged 10–18 years from 5 schools in Cali, Colombia. Participants were screened for FAPDs using Rome IV criteria. Children who met criteria for FD, IBS, FAP—NOS and abdominal migraine were considered cases and those without any functional gastrointestinal disorder (FGID) served as controls. Patients with organic gastrointestinal disease or disease affecting growth were excluded from the study.A member of the research team performed anthropometric measurements on all participants including weight, height and abdominal circumference measurements. Body height (centimeters) was measured from the soles of the participant’s feet to the top of head. Body weight (kilograms) was measured with an electronic scale. Abdominal circumference (centimeters) was measured at level of the umbilicus. Body mass index (BMI) was calculated as weight in kilograms divided by the square of the height in meters.Anthropometric measurements were adjusted for age and sex. Children were classified as overweight when BMI was between +1 and +2 standard deviations and obese when BMI was above +2 standard deviations according to sex-specific World Health Organization (WHO) growth chart. Children were designated as underweight when the BMI was between −2 and −3 standard deviations and severe underweight when BMI was below −3 standard deviations according to the WHO growth chart. Abdominal obesity was defined as abdominal circumference >90% for age and sex on WHO growth chart.p-values < 0.05 were considered significant.Data are presented as mean or percentages when appropriate. Anthropometric measurements are provided as age- and sex-specific. Standard deviations were calculated. To describe the distribution of variables, exploratory analysis was performed for all the variables. For the continuous variables, we obtained the central tendency and dispersion measurements. For categorical variables, we obtained frequencies and proportions. We estimated the proportion of children with its corresponding 95% confidence interval (CI); and the descriptive measurements with their corresponding standard deviations and ranges. To evaluate risk factors, a univariate analysis was initially performed between each of the exposure variables of interest and the effect variable. Odds ratios (OR) were calculated and 95% CI was included. Fisher’s exact test was used to compare the proportions of normal/abnormal nutritional state between the groups of children with and without FAPDs. All study procedures were approved by the Institutional Review Board of the University of Valle (HUV 024-2019), and parental informed consent was obtained for all participants.We invited 1297 school children to participate. Eighty percent (1152/1297) accepted our invitation. One hundred and twenty-two (9.7%) children were excluded due to pre-existing medical conditions as outlined above. Thus, 1030 schoolchildren ages 10–18 years old (mean 13.9 (+/−1.9) years) completed the study, 531 (51.6%) girls and 499 (48.4%) boys .Seven hundred and thirteen children (69.2%) were normal weight. Ninety-five children (9.2%) were obese, 198 (19.2%) were overweight, 19 (1.8%) were underweight and 5 (0.5%) children were severely malnourished. Thirty-seven (3.7%) children were diagnosed with abdominal obesity .p = 0.000) and least likely to be white race  than the control group.We diagnosed 58 (5.8%) children with FAPDs based on Rome IV criteria, p = 0.124), overweight , abdominal obesity   . We alsoThis is the first study to compare the nutritional status of children with FAPDs with healthy controls at a community level. Our study found no significant difference in the nutritional status between schoolchildren diagnosed with FAPD by Rome IV criteria and healthy controls in the community. This study reinforces the Rome IV criteria by showing that FAPDs are rarely associated with “red flag” symptoms such as weight loss, underweight or short stature.While food is thought to play a role in triggering FAPDs , it is uOur findings seem to contradict the results of previous studies based at a medical clinic level that found an increased prevalence of FAPDs in obese children . HoweverNevertheless, we cannot ignore the results of previous studies that found obese patients presenting to clinics were more likely to have FAPDs , and thaThe strengths of our study include its large sample size and design that allowed us to assess the true difference between the diseased group and controls. Questionnaires were given at the school level to facilitate completion and reduce selection bias. Members of the research team conducted all measures to enhance the accuracy of results.Our study is not without limitations. First, the results of this study may not be generalizable to other populations. We only measured weight, height and abdominal girth and calculated the BMI. BMI is widely used as an indicator of nutritional status ; howeverOur study suggests that the prevalence of FAPDs is similar in obese children and healthy controls at a community level. Nutritional status is not a useful predictor for the occurrence of FAPD in children in the general population. Obese children may be overrepresented in previous studies conducted at the clinical level due to higher rate of comorbidities and a more severe phenotype. Future research should confirm our findings and investigate the role of obesity in the development of more severe FAPDs and the use of weight control measures to mitigate these effects.


More specifically, the MOXO-dCPT has four stages, which differ in their combinations of ecological visual and auditory dynamic distractors. By exploring the participants’ performance in each of the stages, we were able to show that: (a) ADHD patients spend significantly more time gazing at irrelevant areas of interest (AOIs) compared to healthy controls; (b) visual distractors are particularly effective in impacting ADHD patients’ eye movements, suggesting their enhanced utility in diagnostic procedures; (c) combining gaze direction data and conventional CPT indices enhances group prediction, compared to the sole use of conventional indices. Overall, the findings indicate the utility of eye tracker-integrated CPTs and their enhanced diagnostic precision. They also suggest that the use of attention-grabbing visual distractors may be a promising path for the evolution of existing CPTs by shortening their duration and enhancing diagnostic precision.Clinical decision-making may be enhanced when combining psychophysiological sensors with computerized neuropsychological tests. The current study explored the utility of integrating an eye tracker with a commercially available continuous performance test (CPT), the MOXO-dCPT. As part of the study, the performance of adult attention-deficit/hyperactivity disorder (ADHD) patients and healthy controls ( Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is characterized by a “persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development” . Though The current diagnostic procedure regarding ADHD is based on a clinical evaluation by a qualified clinician. As it is a multifaceted disorder, this usually entails collecting data from different sources, including clinical psychiatric interviews with both the individual and informant/s that may provide additional non-overlapping information . ScreenFindings are mixed regarding the ability of CPTs to support clinical decision-making . CPTEye movement research has flourished since links between cognitive processes and eye movements were first described . Eye movThe MOXO-dCPT has garnered significant research attention, mainly because it is based on an online platform and does not require the acquisition of special equipment . Thereby, they offer unique opportunities to enhance our theoretical understanding of ADHD and, consequently, to enhance the utility of CPTs. For example, while inattention seems to be partially independent of modality , response inhibition seems to be modality-specific . InteresThe current study explored these possibilities using a two-pronged approach. First, we divided the visual environment of the MOXO-dCPT into two regions . We then assessed the allocation of attention by ADHD patients and healthy controls while they performed the MOXO-dCPT. We hypothesized that compared to healthy controls, ADHD patients would gaze for longer durations outside the screen area , which is irrelevant for success in the task. We also hypothesized that combining an eye movement measure with the conventional MOXO-dCPT indices would enhance the CPT’s diagnostic precision . Second, we investigated the impact of distractor types  on ADHD patients’ performance in the CPT. This was done with a practical purpose in mind. More specifically, if similar or better utility will be found in the first stages of the CPT, later stages can be discarded without decreasing the CPT’s discrimination capacity . Finally, we aimed to establish cutoffs for diagnosing ADHD based on the findings. These were meant to serve future validation studies that may, with time, pave the way for the integration of the MOXO-dCPT in daily clinical practice.N = 85), partially overlapping with those included in Berger, et al. [Adult ADHD patients and healthy controls participated in the study. They were undergraduate students who participated in the study for academic credit. An ADHD diagnosis (314.0x) based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria  was man, et al.  and Lev,, et al. . EthicalThe task consisted of eight blocks, each comprising 59 trials . In each trial, a stimulus card (target/non-target) was presented in the screen center, followed by a blank screen see . ParticiAn EyeLink 1000 eye tracker  was selected for its high spatial and temporal accuracy  and due The participants underwent the SCID-5-RV and then filled out a demographic/health questionnaire, the adult ADHD self-report scale (ASRS), and the Wender Utah rating scale (WURS) short form. The ASRS ,48 incluFour types of responses were recorded while the participants performed the MOXO-dCPT: (a) Attention: Correct responses during stimulus presentation or the inter-stimulus interval (ISI) following it. (b) Timeliness: Correct responses only during the time in which the target stimulus was present on the screen. (c) Impulsivity: Commission errors during the time in which a non-target stimulus was presented. (d) Hyperactivity: Commission errors that were not coded as impulsive. These included multiple keystrokes in response to a target stimulus, for example. Four indices were then created, expressing the participant’s percentage of responses in each of the response categories out of the maximum possible during the task.The participants’ field of view (FOV) was divided into two areas see : (a) Tast-tests and chi-square analyses . Welch’s unequal variance t-test was used when the assumption of group’s homogeneity of variance was not met [p < 0.05 marking statistical significance. The study’s dataset is available from the authors upon request.The groups were compared in demographic and clinical variables see  using in not met . All anat-test and the conventional MOXO-dCPT indices using a multivariate analysis of variance (MANOVA) with a between-subjects factor of group  for the ANOVAs  [d: small effect = 0.2–0.5; moderate effect = 0.5–0.8; large effect > 0.8. Partial eta-squared (η2p): Small effect = 0.01; moderate effect = 0.06; large effect = 0.14.ADHD patients and controls were compared in the eye movement distractibility scale using an independent-samples roup see . We calcs ANOVA) . To enabs ANOVA) ,54. CoheThe classification accuracies of the eye movement distractibility scale and conventional MOXO-dCPT measures were assessed using a receiver operating characteristic (ROC) curve see . An ROC r > 0.08 criterion used as a multicollinearity indicator. Second, multicollinearity was further assessed using the variance inflation factor criterion . Note tgroup (ADHD/controls) as a between-subjects factor and type of distractor  as a within-subjects factor. Note in this regard that a repeated-measures two-way ANOVA was chosen because each participant performed the four stages of the MOXO-dCPT which differ in the type of distractor they employ . A line chart was produced  in the MOXO-dCPT the eye movement distractibility scale best differentiated the groups see . The anauced see  to repret-test and a MANOVA ” , presentp < 0.01), while no significant group differences were found in demographic variables. See As expected, ADHD patients had significantly higher total scores in the WURS 25-items, and ASRS  compared to healthy controls (p < 0.01). There were also significant group differences in conventional MOXO-dCPT indices, L = 0.70, F = 4.81, p = 0.02. Post hoc analyses indicated that ADHD patients performed significantly worse than controls in the timeliness and impulsivity indices . See There was a significant group difference with a large effect size in the eye movement distractibility scale; ADHD patients spent more time gazing at the distractibility AOI than controls (p < 0.001), while that of the attention, timeliness, hyperactivity, and impulsivity indices were poor . See ROC curve analyses indicated acceptable discriminative capacity of the eye movement distractibility scale , correctly classifying 69.8% ADHD patients and 71.4% controls. The stage 2 model, which added the eye movement distractibility scale to the predictors, significantly predicted group membership, p < 0.01. The model correctly classified 64.3% ADHD patients and 67.4% controls. Out of the predictors, only the eye movement distractibility scale and the impulsivity index significantly contributed to group prediction . Notably, the addition of the scale significantly contributed to group membership prediction beyond that of the conventional indices , p = 0.02. See All correlations between the predictors in the logistic regression were <0.08 and had VIF values <4, suggesting that multicollinearity likely did not impact the logistic regression’s findings. The first regression model significantly predicted group membership (group (ADHD/controls) and type of distractor  main effects, as well as a significant group X type of distractor interaction (ps < 0.01). Bonferroni multiple-comparison post hoc analyses yielded significant group differences during the visual and combined visual–auditory distractors stages , while the group differences in the no distractors and auditory distractors stages were not significant . Notably, the effect size in the visual distractors stage (Cohen’s d = 1.11) was larger than that of the combined distractors stage (Cohen’s d = 0.94). See The repeated-measures ANOVA yielded significant t-test reanalysis for solely the visual distractors stage yielded similar results as found for the analysis of the full CPT, namely a significant group difference with an even higher effect size (Cohen’s d = 1.11). The MANOVA’s reanalysis showed no significant group differences in the MOXO-dCPT indices F = 2.234, p = 0.07. The ROC reanalysis for the visual distractors stage indicated acceptable discriminative capacity of the eye movement distractibility scale . Regarding the indices, only the timeliness index showed significant, though poor, discriminative capacity . All other indices showed poor discriminative capacities . See The independent-samples p = 0.06), while correctly classifying 55.8% ADHD patients and 61.9% controls. The second regression model, which also included the eye movement distractibility scale, significantly predicted group membership, p < 0.01. The second model correctly classified 69.8% ADHD patients and 69.1% controls. Notably, the eye movement distractibility scale significantly contributed to group prediction over the first model, p < 0.01. Out of five predictors, only the eye movement distractibility scale’s coefficient contributed significantly to group prediction, p < 0.01. See Multicollinearity was not indicated by the preliminary analysis for the logistic regression that focused on the visual distractors stage. The first regression model  did not significantly predict group membership . As evident in The current study assessed the utility of integrating an eye tracker with the MOXO-dCPT, a commercially available CPT. As only the center of the screen displayed the stimuli relevant for success in the task , gazing outside this AOI was counterproductive and could only impair performance. Therefore, the gaze direction measures were optimally suited to assess the distractibility and response inhibition deficits that are key characteristics of ADHD, in an intuitive and face-valid manner . This clThis sensitivity of the eye movement measures to detect subtle response inhibition deficits was further capitalized upon in the current study by assessing the differential utility of the MOXO-dCPT’s distractors. The MOXO-dCPT is unique in utilizing different types of “real-world” dynamic distractors to magnify cognitive impairment that may otherwise evade detection. The analyses of the MOXO-dCPT stages indicated that visual distractors  had the strongest discriminative capacity. During this stage, the groups significantly differed in the eye movement distractibility scale and it had stronger discriminative capacity than each of the conventional indices (AUC = 0.775). This was mirrored in the scale’s cutoffs, which could be set to enhance either sensitivity or specificity. The former was useful when screening for ADHD, while the latter had utility when false positives should be minimized . For example, 88.4% of the ADHD patients spent 10.8% or more of their time gazing at the distractibility AOI, making the cutoff useful for screening purposes. On the other extreme, spending 39.4% or more gazing at the distractibility AOI was associated with perfect specificity , though sensitivity was poor (23.3%). The interested reader can find cutoffs that either prioritize specificity  or sensitivity  for the eye movement distractibility scale in the The discrimination capacity of the visual distractors stage was closely followed by that of the combined distractors stage, suggesting that visual distractors drive these group differences. This mirrors earlier findings regarding the differential utility of distractors in the MOXO-dCPT ,39. For The current study’s strengths include the use of a face-valid gaze direction measure which is particularly appropriate for exploring the inattention and response inhibition deficits of ADHD patients. The MOXO-dCPT’s ecological distractors in this regard are particularly attractive for such an eye tracker-CPT integration. Limitations of the current study include: (a) The MOXO-dCPT does not randomize the stages, possibly confounding the distractor type and order of stages. This, for example, may have led to the enhanced utility of the visual distractors stage as compared to the combined distractors stage . Future studies may consider collaborating with the MOXO-dCPT publishers to create a version of the CPT in which the stages are randomized. Thus, this version will differ from that used in clinical practice, which should be acknowledged. (b) The sample size of the current study did not allow a comparison between ADHD subtypes . This is unfortunate, as these subtypes may differ in their cognitive profile . CompariThe current study assessed the utility of an eye tracker-integrated CPT, while analyzing each stage of the MOXO-dCPT . ADHD patients were found to spend more time gazing outside the task area compared to healthy controls, and this was particularly notable when visual distractors were utilized. The MOXO-dCPT’s ecological distractors therefore impact the performance of ADHD patients in the task and they have difficulty in suppressing spontaneous eye movements towards such distractors. These findings have both practical and theoretical implications. They suggest that the discriminative capacity of the MOXO-dCPT, and perhaps other CPTs, may be enhanced and clinical decision-making improved by integrating data derived from conventional indices and eye movement measures. They also indicate that the MOXO-dCPT may be shortened with implications regarding the cost and time of evaluating those with ADHD or suspected to have the disorder. From a theoretical perspective, the enhanced utility of the visual distractors adds to the accumulating literature on distinctions between visual and auditory stimuli in CPTs, possibly enhancing our ability to theoretically drive the development of CPTs. The overall findings nicely align with the rapidly expanding research of biomarkers in psychiatry and the growing efforts to enhance diagnostic precision in the field ,75. CPTs


DRD4 and/or 5-HTTLPR genotypes herein. Three-wave longitudinal data of 1860 adolescents  from the general population and clinic-referred cohort of TRacking Adolescents’ Individual Lives Survey were used. Using a multigroup Random Intercept Cross-Lagged Panel Model, we tested between-person  and within-person  associations across ADHD symptoms, family and school climate, and the extent to which these depended on genotype. Findings indicated no influence of genotype. Results did show significant between-person differences , indicating that higher stable levels of ADHD symptoms were associated with a less favorable family and school climate. Regarding within-person causal processes, ADHD symptoms predicted a less favorable family climate in early adolescence , while ADHD symptoms predicted a more favorable family climate in the later phase of adolescence , a finding which we explain by normative developmental changes during adolescence. Overall, this study showed that negative associations between ADHD symptoms and both family and school climate are largely explained by stable between-person differences. We recommend applying the Random Intercept Cross-Lagged Path Model to developmental data to tease stable associations and change processes apart.We examined bidirectional relations between attention-deficit/hyperactivity disorder (ADHD) symptoms and family and school climate, and the possible role of The online version of this article (10.1007/s00787-019-01424-3) contains supplementary material, which is available to authorized users. Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed disorders of childhood . AlthougThe school environment another important environmental factor that may be related to ADHD symptoms over time, has received little research attention, despite the fact that adolescents spent substantial amounts of time at school. In general, it is well known that classroom quality is influential in reducing ADHD symptoms by behavioral school interventions , but it DRD4) is proposed as one of the genetic susceptibility variants . Furthermore, within-person correlations at time 1 between the four different constructs were modelled, representing the extent to which within-person deviations from the expected score in one construct at time 1 was associated with the within-person deviations from the expected score of the other three constructs at time 1. Finally, correlated residuals at time 2 and time 3 , model the extent to which within-person fluctuations in one construct are associated with within-person fluctuations in one of the other three constructs at the same time point  to examine the extent to which there was variance at the between-person and within-person level. Figure lanation , 44. TheDRD4 and 5-HTTLPR genotype are displayed in Supplementary Table r values ranging from .69 to .81, all p values < .001), as were correlations among family climate , but they were small-to-moderate for school climate , for all variants of the DRD4 and 5-HTTLPR genotype. Of note, the correlations between ADHD symptoms and school climate at all time points were small , whereas ADHD symptoms and family climate were more strongly correlated . There were no significant gene–environment correlations .The characteristics of the study sample are shown in Table The ICC for ADHD symptoms was .737 indicating that 73.7% of the variance in the three measures of ADHD symptoms over time is explained by differences between persons  over time. The remaining variance of 26.3% is explained by fluctuations within a person . The ICCs for family climate, school climate, and covariate ADHD medication were .508, .285, and .690, respectively.DRD4 genotype After it was demonstrated that there were no relations between family and school climate , we constrained these relations to zero, and subsequently performed model selection of which the first step was aimed at model simplification  = 91.981, CFI = 1.000, RMSEA = .000 (.000–.016)] and are presented in Supplementary Figure 1.5-HTTLPR genotype In analyzing 5-HTTLPR genotype differences between ADHD symptoms and both family and school climate, we applied the same procedure as when examining moderation of the DRD4 genotype. Table χ2(3) = 346.84, p < .001]. We, therefore, freely estimated the stability paths, whereas other all ADHD medication paths were constrained over time  = 0.07, p = .78] when the stability paths of family climate were variant instead of invariant over time. Therefore, stability path of school climate were subsequently constrained to be equal over time. Comparable with the DRD4 genotype model, we did not find moderation of the 5-HTTLPR genotype across all constructs at both the between-person and within-person level. In Supplementary Figure 2, the results of the within-person differences of this final model are presented, showing good model fit . Table χ2 = 346.84Overall model Since we did not find moderation of the DRD4 and 5-HTTLPR genotypes, results on the associations between ADHD symptoms and the family and school climate are shown for the total sample. Figure n = 1863) with good model fit . At the between-person level, there were small-to-moderate correlations between the stable traits of ADHD symptoms with family climate  and school climate . Thus, higher levels of ADHD symptoms across the three measurement waves coincide with less favorable family and school climates (and lower levels of ADHD symptoms with more favorable family and school climates). Family and school climate were positively correlated . Results further indicate a substantial stable association of ADHD medication with ADHD symptoms  and a less favorable family climate .After the stable ‘trait-variance’ of ADHD symptoms, family climate, school climate, and medication use were partialled out of the model, we found small-to-large within-person changes over time. First, all within-person stability paths of school and family climate were significant and invariant over time. However, the within-person stability paths of ADHD symptoms were not equal over time, since betas were larger from T1 to T2 than from T2 to T3. This suggests that as adolescents grow older, they are approaching their expected score. Second, there was a small positive correlation between ADHD symptoms and family climate at T1. This was about half as strong as the stable between-person differences suggesting that most of the variance in the data can be accounted for by trait-like rather than state-like associations . Third, the correlated changes between ADHD symptoms and family climate were differentiated between T2 and T3. The significantly correlated residuals at T2 showed that the within-person fluctuations in ADHD symptoms was associated with the within-person fluctuations in family climate. This finding indicates that when an individual’s level of ADHD symptoms increases between two adjacent measurements, the individual’s family climate becomes less favorable (or vice versa). Note that this is a correlation between dynamic errors; they are not due to the change in either study variable from 2 years earlier, nor by medication use which is part of the model, but rather by an un-modelled time-variant third factor. This association represented by the correlated change was absent at T3. Finally, the within-person cross-lagged paths of ADHD symptoms in predicting the family climate were different across time. When an individual scored higher than expected on ADHD symptoms at T1, the same individual scored lower on family climate at T2. However, the opposite pattern was found between T2 and T3, where an individual with a higher than expected score on ADHD symptoms at T2 predicted a more favorable family climate at T3. However, changes in family climate had no lagged effects on changes in ADHD symptoms over time.DRD4 and 5-HTTLPR across adolescence  in a large pooled population and clinic-referred sample. We did not find genetic moderation by the DRD4 or 5-HTTLPR genotype, neither at the between-person nor the within-person level. Independent from the DRD4 and 5-HTTLPR genotype, we found important trait associations  between ADHD and the family and school climate which indicated that adolescents with higher stable ADHD symptom levels lived in a less favorable family climate, and experienced a less favorable school climate across adolescence. Moreover, our results suggest causal effects between ADHD symptoms and the family climate . That is, ADHD symptoms at age 11 predicted a less favorable family climate at the age of 13.5, while ADHD symptoms at age 13.5 predicted a more favorable family climate at age 16. No evidence was found for family climate altering ADHD symptoms over time, nor for change processes between ADHD and school climate at the within-person level.The current study examined whether bidirectional associations between ADHD symptoms and the family and school climate were moderated by the plasticity genes Using an advanced methodological approach that separates between-person differences from within-person processes, we found that ADHD symptoms and family climate were predominantly associated at the between-person level  compared to the within-person level. The link between ADHD symptoms and a less favorable family climate is consistent with previous literature , 12, 63,The second important finding related to processes over time is that we did not find evidence for possible causal effects of family climate on ADHD symptoms. That is, worsening of family climate did not increase ADHD symptoms or, conversely, improvement in family climate did not lead to reductions in ADHD symptoms. This contrasts with the suggestion of Johnston and Mash  that negOur finding of higher stable ADHD symptoms correlated with a less positive school climate across adolescence at the between-person level is in line with previous studies documenting an association between a good school climate and fewer student- and teacher reported internalizing and externalizing problems  in pressDRD4 7-repeat or being homozygous for the S-allele of the 5-HTTLPR were not more responsive to the family or school environment in a ‘for better and worse’ manner. Thus, our study found no support for the differential susceptibility hypothesis. Previous studies on differential susceptibility have focused mostly on differences between individuals rather than the processes of change as they take place within the lives of an individual , and have not applied the RI-CLPM model which separates these two levels. Thus, in so far as our data would show support for differential susceptibility, based on the literature we did expect this to become apparent at the between- subject level, while potential effects at the within-subject level would be novel. We had hoped that our developmental perspective would elucidate conflicting results especially about the ‘risk’ variant of the DRD4 genotype ),genotype –39. The genotype , which mDRD4 and 5-HTTLPR genotypes across adolescent development. Some limitations should be taken into account when interpreting the current findings. First, assessment of the family climate as reported by parents does not necessarily inform us how adolescents themselves experienced the family climate. Another disadvantage of relying on parent reports of the family climate is that method variance may in part explain the associations with ADHD symptom levels . However, it has been found that parent-reports of the home environment are well in line with child-reports [A strength of this study was the use of a large, longitudinal dataset and the application of an advanced methodological approach that separates between-person  and within-person  associations, providing clear evidence for links between ADHD symptoms and both family and school climate independent from the -reports . NeverthDRD4 and 5-HTTLPR genotype; thus, no evidence for differential susceptibility to the environment was found. To the extent that our findings on change processes may seem, unexpected, it is important to repeat that the existing knowledge base is confounded by stable associations between ADHD symptoms and family climate which have not been partialled out in previous studies. We recommend replication of our study applying the RI-CLPM to tease stable associations and change processes apart.Our study provides support that adolescents with ADHD symptoms and a less favorable family and school climate are tightly interwoven, as shown by stable between-person differences across adolescence. Moreover, within-person changes over time point to a causal role of ADHD symptoms on the family climate. These effects were independent from both the Supplementary material 1 (DOCX 228 kb)Below is the link to the electronic supplementary material.


While several studies have reported various cognitive impairments in children with attention‐deficit/hyperactivity disorder, the neuropsychological profiles of adults with this disorder are understudied. Here, the intelligence and memory functions of adults with attention‐deficit/hyperactivity disorder without intellectual disability were evaluated.The Wechsler Adult Intelligence Scale—Third Edition and Wechsler Memory Scale—Revised were administered to 30 adults with attention‐deficit/hyperactivity disorder whose full‐scale intelligence quotients were >85. Diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders‐IV criteria. Conners' Adult ADHD Rating Scales—Self‐Report—screening version and the Autism Spectrum Quotient were also evaluated.In the Wechsler Adult Intelligence Scale—Third Edition, the verbal intelligence quotient was significantly higher than the performance intelligence quotient and the verbal comprehension score was the highest among the secondary indices. In the Wechsler Memory Scale—Revised, the visual memory score was the highest measure. Although the verbal intelligence quotient had no correlation with any Wechsler Memory Scale—Revised measures, the performance intelligence quotient was significantly correlated with the visual memory and attention scores of the Wechsler Memory Scale—Revised. Conners' Adult ADHD Rating Scales hyperactive‐impulsive score was significantly correlated with the verbal intelligence quotient, whereas the inattention score was not correlated with any measures of the Wechsler Adult Intelligence Scale—Third Edition or Wechsler Memory Scale—Revised.The results suggest that while adults with normal‐intelligence attention‐deficit/hyperactivity disorder have comparatively high verbal comprehension and social knowledge, their ability of information processing and visual‐motor coordination are relatively weak. The Wechsler Adult Intelligence Scale—Third Edition (WAIS‐III) and Wechsler Memory Scale—Revised (WMS‐R) of 30 adults with attention‐deficit/hyperactivity disorder (ADHD) were examined. The verbal intelligence quotient was significantly higher than the performance intelligence quotient in the WAIS‐III and the performance intelligence quotient was significantly correlated with the visual memory and attention scores of the WMS‐R. Adults with ADHD have comparatively high verbal comprehension and social knowledge, while their information processing ability and visual‐motor coordination are relatively weak. While it was formerly believed that childhood ADHD recedes in adulthood, recent research has found that ADHD symptoms persist well into adulthood.Previous studies have indicated that children with ADHD show significant dysfunction in a wide range of neuropsychological domains, including executive function.Thus, in this study, we investigated the intelligence, memory function, and symptoms of adults with ADHD without intellectual disability. The Wechsler Adult Intelligence Scale—Third Edition (WAIS‐III), a standard psychological test for evaluating intelligence,2We administered the WAIS‐III and WMS‐R to 30 adults with ADHD . The subjects were recruited at the outpatient clinic of Showa University East Hospital or Showa University Karasuyama Hospital. Only those with an ADHD diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)‐IV criteria and Conners' Adult ADHD Diagnostic Interview for DSM‐IV™SPSS 22.0J (IBM Corp.) was used for all statistical analyses. The means with standard deviations were calculated for the WAIS‐III, WMS‐R, AQ, and CAARS. The paired t test was used to calculate the VIQ‐PIQ difference of the WAIS‐III. One‐way repeated‐measures analysis of variance was used to compare the secondary indices of the WAIS‐III and each measurement of the WMS‐R; post hoc pairwise comparisons were performed with Bonferroni correction. Pearson's product‐moment correlation coefficients were calculated among the measurements of the WAIS‐III and WMS‐R as well as among the measurements of clinical symptoms and the WAIS‐III and WMS‐R. The significance level was set at 0.05, except for the correlations, at which 0.01 was set to count for the possible type I error.3t(29) = 2.855, P < .01). Concerning the secondary indices, significant within‐participants effects were found (F(2.42) = 4.723, P < .01, ηp2 = 0.14) with post hoc pairwise comparisons, revealing that the score of verbal comprehension (VC) was significantly higher than that of working memory . All measurements of the WMS‐R were also within the normal range. The within‐participants effects were also significant (F(2.21) = 6.654, P < .01, ηp2 = 0.187) with the pairwise comparison resulting in the score of visual memory being significantly higher than that of verbal memory (P < .01), general memory (P < .01), and delayed memory (P < .05).Table r(29) = 0.606, P < .001) and attention (r(29) = 0.588, P < .01). The full‐scale intelligence quotient (FIQ) only had a significant correlation with attention (r(29) = 0.512, P < .01).Pearson's product‐moment correlation coefficients were calculated between the IQ values of the WAIS‐III and WMS‐R Table . VIQ hadr(29) = −0.466, P < .01).Table 4To our knowledge, this is the first study to simultaneously examine the profiles of the WAIS‐III and WMS‐R in adults with ADHD. Although the intelligence level of the participants in the present study was within the normal range, VIQ was significantly higher than PIQ. This result is consistent with previous findings in children and adults with ADHDThe mean score of visual memory was highest among the measurements of the WMS‐R, although the memory function of the participants was within the normal range, as was their WAIS‐III scores. Relatively lower verbal, general, and delayed memory may be caused by the symptoms of ADHD, as these three scores showed negative, although nonsignificant, correlations with the CAARS‐IA score. Moreover, these results correspond to the difficulties in daily life individuals with ADHD often face, such as trouble concentrating on tasks and being forgetful of completing tasks. The heterogeneity or imbalance of functions reflected in the scores of the WAIS‐III and WMS‐R may affect the daily and social life of individuals with ADHD.For the CAARS scores, the IA subscale score was higher than the HI subscale score, indicating the predominance of inattention symptoms. This matches with previous findings that inattention symptoms largely remain in adulthoodRegarding the association between clinical symptoms and neuropsychological measurements, verbal function impairment was most closely related to ADHD symptoms as the CAARS HI score showed negative correlations with VIQ. Previous neurophysiological and neuroimaging studies have indicated decreased prefrontal function in individuals with ADHD,Contrary to our expectation, the WMS‐R measurements of the participants were within the normal range. However, as Quinlan et alSeveral limitations of our study must be considered. First, only 30 participants were included, limiting the statistical power of the study. Second, we did not include normal controls as comparison. Third, possible effects of medication were not considered. At the time of our assessment, 10 of the 30 participants were on either methylphenidate or atomoxetine. Fourth, only subjective measurements of self‐rating scales were used to assess symptoms, lacking objective clinician rating scales.This study highlights the uneven intelligence and memory profiles of adults with ADHD with possible relation to symptoms. Further studies that determine the association of daily functioning and medication regimens with objective measures of symptoms are to be planned.The authors declare no conflict of interest.MH was critically involved in the analysis of the data and wrote the first draft of the manuscript. WH contributed to the interpretation of the data and the writing of the manuscript. AI was critically involved in the study design and analysis of the data and contributed to the interpretation of the data and the writing of the manuscript. YO and OT were involved in the subject recruitment process and the clinical diagnostic assessments. All authors contributed to and approved the final manuscript.The study protocol has been approved by the suitably constituted Research Ethical Committee of the Showa University School of Medicine (No. 793), and it conforms to the provisions of the Declaration of Helsinki.All participants provided written consent to the study after a full explanation of the study procedures.