While the association between adult Attention Deficit/Hyperactivity Disorder (A-ADHD) and Substance Use Disorders (SUDs) has been widely explored, less attention has been dedicated to the various substance use variants. In a previous paper, we identified two variants: type 1  and type 2 (use of cannabinoids). In this study, we compared demographic, clinical and symptomatologic features between Dual Disorder A-ADHD (DD/A-ADHD) patients according to our substance use typology, and A-ADHD without DD (NDD/A-ADHD) ones. NDD patients were more frequently diagnosed as belonging to inattentive ADHD subtype compared with type 1 DD/A-ADHD patients, but not with respect to type 2 DD/ADHD. NDD/A-ADHD patients showed less severe symptoms of hyperactivity/impulsivity than DD/A-ADHD type 1, but not type 2. Type 1 and type 2 patients shared the feature of displaying higher impulsiveness than NDD/A-ADHD ones. General psychopathology scores were more severe in type 2 DD/ADHD patients, whereas type 1 patients showed greater similarity to NDD/A-ADHD. Legal problems were more strongly represented in type 1 than in type 2 patients or NDD/A-ADHD ones. Our results suggest that type 1 and type 2 substance use differ in their effects on A-ADHD patients—an outcome that brings with it different likely implications in dealing with the diagnostic and therapeutic processes. Attention Deficit Hyperactivity Disorder (ADHD), which was originally identified as a childhood neuropsychiatric illness, is now known to endure into adulthood in about two-thirds of these patients, with adult prevalence rates estimated to be close to the 3–5% range. Even if it has been defined as “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development” ) , in adulIn a previous study with a sample of 72 patients entering treatment, we identified two patterns of substance use: the first (type 1) centered on the recourse to stimulants/alcohol, and the second (type 2) on the use of cannabinoids (THC). Type 1 DD/A-ADHD was found to occur in significantly younger people, who had to cope with more legal problems than type 2 ones. The two patterns were similar in terms of ADHD-specific symptomatology and its severity at treatment entry. No differences were found with the other scales assessed, except for lower scores in answering the Morningness-Eveningness Questionnaire (MEQ) in type 1 DD/A-ADHD patients. We concluded that, at treatment entry, the presence of different comorbid SUD variants did not affect ADHD-specific symptomatology or the severity of DD/A-ADHD .The aim of the current study was to assess the influence of type 1 and type 2 substance use on the A-ADHD clinical picture by comparing the demographic, clinical, and functional features of patients—those with and without a DD/A-ADHD.This was an observational, cross-sectional, non-interventional, retrospective study based on data derived from two Italian psychiatric databases. Patients were recruited from the ADHD Outpatient Clinic of the University of Pisa and from the ADHD Outpatient Clinic of La Sapienza University in Rome. We merged the data, as the two clinics adopted the same sample selection, assessment methods and assessment of clinical features. This study was based on a single evaluation of adult patients admitted between 2016 and 2019. All the patients recruited in the study were evaluated through a clinical interview, self-report questionnaires and scales by residents of the Department of Clinical and Experimental Medicine, School of Psychiatry of the University of Pisa, and by residents of the Psychiatric Unit of La Sapienza University, in Rome, Italy, with at least 2 years of experience in the adult ADHD field, and under the supervision of senior psychiatrists active in the ADHD research group. Patients with schizophrenia spectrum disorders according to DSM-5 criteria were excluded from the clinical sample.The study was conducted according to the World Medical Association Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. Both the consent form and the experimental procedures were approved by the ethics committee of the University of Pisa , in accordance with internationally accepted criteria for ethical research.p = 0.506) and sex  were homogenous between the three groups being compared. Legal problems were self-reported and included crimes for drug possession or sale, burglary or stealing, aggression or violence related or unrelated to drugs, and driving crimes.Out of 183 patients selected, 166 entered the study; five patients were excluded due to schizophrenia comorbidity, and 12 refused to participate due to personal reasons. Among the 166 patients recruited, 113 (68.04%) were males, and 53 (32.0%) were females, mean age 28.30 ± 10.7 ; of these, 85 were substance non-users (NDD/A-ADHD), 56 (65.9%) males and 29 (34.1%) females, mean age 28.99 ± 11.5; a total of 81 patients, comprising 57 (70.4%) males and 24 (29.6%) females, mean age 27.58 ± 9.8, were also affected by a Substance Use Disorder . Both conditions were diagnosed according to the DSM-5 criteria. Using our methodology, [In addition to the application of DSM-5 criteria, ADHD diagnosis was further assessed by means of the Adult ADHD Self-Report Scale (ASRS) for screening purposes  and confThe Conners’ Adult ADHD Rating Scales–Observer: Short Version (CAARS-O:S) was completed by a close relative of the patient. This made the quantification of ADHD symptoms and the ADHD Index possible; high scores obtained on the ADHD Index suggest clinically significant levels of ADHD symptoms .Difficulties in the Emotion Regulation Scale (DERS) is a 36-item self-evaluation scale comprising six subdomains of emotional regulation . Answers range from 1  to 5 , and higher total scores recorded in answering DERS reflect greater difficulties in regulating emotions .The Structured Clinical Interview for Axis I Disorders (SCID-I) was used for the assessment of other psychiatric disorders, according to DSM-5 procedures.The Barratt impulsiveness scale (BIS-11) is a 30-item questionnaire used for the assessment of impulsiveness, which is factorialized into three second-order domains named “Attentional”, “Motor” and “Non-planning” impulsivity .For each patient, the clinician completed the 18-item version of the Brief Psychiatric Rating Scale (BPRS-18)—a tool commonly used to assess general psychopathology. The BPRS explores symptoms typically grouped into five subscales: Anxiety-Depression, Anergia/negative factor, Thought Disturbance, Activation, Hostility-Suspiciousness and Total Psychopathology Severity ,24.The Reactivity Intensity Polarity Stability Questionnaire (RIPoSt-40) is a self-report questionnaire comprising 40 items that are used to measure Emotional Dysregulation (ED), which can be further subdivided into four subscales known as “Emotional Impulsivity”, “Positive Emotionality”, “Negative Emotionality” and “Affective Instability” .The World Health Organization Disability Assessment Schedule (WHODAS 2.0), developed directly by the WHO, is a 36-item self-administered questionnaire that is used to explore functioning and disability in major life domains .The 19-item Morningness–Eveningness Questionnaire (MEQ) was used to assess patients’ chronotype: a total score of 41 or below is interpreted as indicating an “evening chronotype”, whereas a score of 59 or above is considered to mark out a “morning chronotype” .We clustered our patients in different typologies of substance of use by adopting the following procedure. We scaled the use of each substance by defining four ordinal levels: 0 = no lifetime use; 1 = past use (at least six months of abstinence); 2 = current (during the previous 6 months) use; 3 = both past and current use. An exploratory factorial analysis was performed on the substances investigated  in ADHD patients, in order to identify possible composite dimensions. The initial factors were extracted by means of principal component analysis (PCA-type 2) and then rotated according to Varimax criteria in order to achieve a simple structure. The criterion used to select the number of factors was an eigenvalue >1. Items loading with absolute values >0.40 were used to describe the factors. This procedure makes it possible to minimize the correlations between the factors, thus allowing their optimization as classificatory tools for each subject. The factor scores were then standardized as z-scores to facilitate the comparison of scores occurring among the factorial measures. All the subjects were then grouped into different subtypes on the basis of the highest z-scores obtained for each factor. This procedure gave the opportunity to classify groups of subjects on the basis of the most statistically abnormal substance use cluster. In this way, it became possible to resolve the problem of identifying a cut-off for the inclusion of patients in different identified clusters. In this specific case, to be able to cluster patients in groups, we used correlations between the substances used.The three groups  were compared for sociodemographic, clinical and functional characteristics by means of the chi-square test for categorical variables (with z-test contrasts and Bonferroni’s correction), and one-way analysis of variance for continuous variables, a posteriori contrasts according to the Scheffé’s procedure.p < 0.05 level.All analyses were carried out using the statistical package of SPSS (version 25.0). Since this is an exploratory study, statistical tests were considered significant at the Using DIVA 2.0, NDD patients were found to have been more frequently diagnosed with the inattentive ADHD subtype than type 1 DD/A-ADHD patients, but not with respect to type 2 DD/A-ADHD ones.No differences were found by comparing difficulties in emotion regulation (DERS) or in its severity (RIPoSt-40); the degree of disability was very similar between the groups.On symptoms of impulsiveness (BIS-11), type 1 and type 2 patients displayed greater impulsiveness than NDD/A-ADHD ones. General psychopathology (BPRS) scores were more severe in type 2 DD/A-ADHD patients, whereas type 1 showed similarities with NDD/A-ADHD patients.The presence of other psychiatric comorbidities was not statistically different among the three groups.In summary, DD/A-ADHD showed greater impulsivity than their peers without DD; more specifically, type 1 and type 2 patients showed the same degree of impulsivity. Type 2 showed more general psychopathology (BPRS) than type 1, while their NDD/A-ADHD peers, interestingly, showed the same degree of psychopathological severity. Type 1, but not type 2 patients, were more hyperactive/impulsive and less often diagnosed as belonging to the inattentive A-ADHD type. Type 1 also showed more frequent legal problems.On the topic of legal problems, our patients—more specifically, those abusing stimulants and/or alcohol—confirmed data appearing in the literature that show a higher frequency of violent behaviors, together with antisocial and illicit forms of conduct among people with SUD and ADHD . Again, Regarding our results, general psychopathology could help us discern the effects of different substances on patients with ADHD. Cannabinoid users had a more severe psychopathology, while displaying more activation, hostility, suspiciousness and thought disturbances . In the Even if the association of SUD and ADHD has been widely studied in the literature, few authors have ever examined the role played by specific substances in affecting psychopathological domains. A recent study of ADHD patients seeking treatment for a SUD  showed a higher addiction severity in cannabis use groups, with similar ADHD features found between different groups . To the When using the BIS scale to differentiate between two diverse typologies of substance abuse, the results are unsatisfactory. Both groups show similar, higher scores of impulsiveness compared with NDD/A-ADHD patients. This finding may suggest that, regardless of the substance of abuse, illicit drugs always have a negative impact on the behavior of ADHD patients by enhancing impulsive behavior and loss of self-control. Alternatively, it may be that ADHD patients with higher impulsivity levels at baseline (in youth) are at more risk of developing SUD ,35.Our data raise the hypothesis of a distinctive form of substance use in a real-world population of A-ADHD . Users oTHC acts on the cannabinoid receptors within the brain that are usually responsible for producing affective feelings of well-being, euphoria, reduction of anxiety, cognitive, somatic and sensory effects, such as memory lapses, difficulty in concentration, time distortion, and increased sensitivity to external and internal stimuli . THC is Cocaine, with its prodopaminergic effects, might mask several symptoms of ADHD, and may thus constitute a confounding factor for the correct recognition of the underlying disorder and the definition of a valid strategy for treating a Dual Disorder patient. On the other hand, when impulsivity is indeed present, it becomes necessary to exclude the possibility that it may be due to the SUD. If this is the case, it is important to treat the substance use, and not only the impulsivity, with psychiatric medications. We suggested a hierarchic approach, in which treatment of impulsiveness due to SUD should come first ,51. WhenTo our knowledge, our study is the first to analyze patterns of substance use among DD A-ADHD patients and their relationship with the psychopathological outcomes. Although our results are preliminary, and require further research, they may give an important contribution for the evaluation of DD patients with ADHD and their treatment.Several limitations have to be addressed. First of all, the sample size was not big enough to generalize our findings. All the patients evaluated were never diagnosed or treated for ADHD before adulthood and presented with a severe clinical picture. To confirm our data, a wider sample should be enrolled. The second limitation is the self-assessment of several features, such as impulsivity, Emotional Dysregulation and overall functioning, which may lead to reporting biases. Finally, our sample did not include patients treated exclusively at the “addiction units”; this is especially true for opioid addicts who, indeed, were minimally represented in our sample. In Italy, psychiatric units and addiction units work independently, resulting in poor communication between the two. These sample selection biases limit the generalization of our data.Testing the type 1 and type 2 substance modality of use is a useful tool for studying the symptomatological variants of A-ADHD. These variants may be related to the different concepts of craving that are experienced by individuals with a DD/A-ADHD, adding different possible implications in the task of responding to the diagnostic and therapeutic processes.


Attention deficit hyperactivity disorder (ADHD) is a highly prevalent disorder in young adult prisoners. This audit aimed to identify how many residents are prescribed medication treatment for ADHD in HMP Elmley and whether those seen by the prison psychiatrists have been managed in line with NICE guidelines. We also audited waiting times and time to follow-up appointments. This was done with the overall aim to identify potential areas for development.We performed a spot audit of all residents in HMP Elmley who were prescribed ADHD medication on 4th November 2019, using their electronic patient records. Appointments with the psychiatrists were then subdivided into initial assessments and follow-up appointments for the purpose of analysis. Performance was measured against NICE Guideline [NG87]: Attention deficit hyperactivity disorder: diagnosis and management. We also calculated the waiting times for initial appointment and follow-up appointment.We found that 33 of residents were on ADHD medication at the time of the audit, approximately 3% of the prison population. 64% of those had a pre-existing diagnosis and 36% had been given a new diagnosis at HMP Elmley. Of those newly diagnosed 100% had undergone a Diagnostic Interview for Adults in ADHD (DIVA) assessment for diagnosis.Baseline physical health checks had been performed in 68% of patients prior to starting medication and a cardiovascular examination had occurred in 9%. At follow-up 100% of patients had their physical observations and weight checked and their symptoms reviewed.91% of patients were started on methylphenidate or lisdexamfetamine as first line treatment, with the rest started on atomoxetine and the reason for this documented.100% patients were offered general psychological support.There was a mean 22 day wait for an initial appointment (range 0-65) and a mean 20 day wait from starting medication to a psychiatric follow-up appointment (range 8-37)The number of residents treated for ADHD in HMP Elmley is relatively low (3%) compared to the estimated prevalence in prison population.The key areas for improvement are in baseline cardiovascular examinations and physical health evaluations. The waiting time between initial psychiatric appointment and follow-up is another area where improvement is needed and this will form the basis of a quality improvement project.Future steps include setting up a specific ADHD clinic with an allocated nurse practitioner to support, producing a template for ADHD assessments and follow-ups, producing a local policy on ADHD and developing specific resources for ADHD psychoeducation.


The results demonstrated a faster response time in neurotypical children compared to ASD and ADHD children, with ADHD participants performing better than ASD participants on the same task. The overall accuracy parameter between the ADHD and ASD groups did not significantly differ.Recognizing a person’s identity is a fundamental social ability; facial expressions, in particular, are extremely important in social cognition. Individuals affected by autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) display impairment in the recognition of emotions and, consequently, in recognizing expressions related to emotions, and even their identity. The aim of our study was to compare the performance of participants with ADHD, ASD, and typical development (TD) with regard to both accuracy and speed in the morphing task and to determine whether the use of pictures of digitized cartoon faces could significantly facilitate the process of emotion recognition in ASD patients (particularly for disgust). This study investigated the emotion recognition process through the use of dynamic pictures (human faces vs. cartoon faces) created with the morphing technique in three pediatric populations (7–12 years old): ADHD patients, ASD patients, and an age-matched control sample (TD). The Chi-square test was used to compare response latency and accuracy between the three groups in order to determine if there were statistically significant differences ( Faces are complex stimuli that convey social and affective information; recognizing a person’s identity is a fundamental social ability . In factThis is one of the reasons that the practical and clinical applications of automatic emotion recognition have been extensively tested and validated in some neurodevelopmental disorders ,5,6, parFacial expression recognition involves dynamic and multimodal phenomena. Facial transformation from a neutral expression sends complex signals, which are converted into emotions . The praASD is known to be associated with difficulties in using facial expressions to convey emotions and deficits in emotional reciprocity ,15,16,17ADHD is a neurodevelopmental disorder characterized by attention deficit, hyperactivity, and impulsivity ) . A numbeChildren with ADHD are less accepted and often rejected by their peers ,36,37. TThe recognition of facial expression involves dynamic and multimodal phenomena. The transformation of the face from a neutral expression sends complex signals, which are converted into emotions ,41,42,43The morphing task has been used since 2001 to evaluate children with ADHD and ASD , and it We aimed to investigate the performance of ADHD, ASD, and TD participants with regard to both accuracy and speed in the morphing task and to determine whether the use of dynamic pictures representing cartoon faces could significantly facilitate the process of recognizing emotions in ASD participants.We hypothesized that children with ADHD would respond faster than ASD participants due to their executive and attention deficits , which iOur study aimed to provide a watershed in the understanding of the emotion recognition process. While many studies have investigated this process in ADHD and ASD populations, comparative studies between the two clinical populations are scarce and results have been conflicting, especially when conducted using tasks with dynamic images (representing cartoon faces). Therefore, we used dynamic images of cartoon faces in emotion recognition, with the perspective of using the morphing task as a tool to enhance the expression recognition process at the rehabilitation level.Sixty-two children in the age range 7–12 years were recruited and assigned to one of three groups: (1) an ADHD combined type (ADHD-C) group; (2) an ASD group; and (3) an age-matched control group.All children and parents recruited for the first two groups were referred to the Department of Human Neurosciences at Policlinico Umberto I clinic in Rome for a follow-up evaluation, which included recruitment to our study between May and September 2019. The 21 children in the ADHD group and the 20 children in the ASD group were included after meeting the DSM-5 diagnostic criteria for ADHD-C or ASD, respectively , and aftAll participants were evaluated using a morphing task. The morphing technique is an image processing technique commonly used to metamorphosize from one image to another .In our study, 24 videoclips with neutral faces gradually developed basic emotions . Videoclips were built using FantaMorph , a software used to create morphing images and sophisticated animation effects, including the transformation of the images used.It should be emphasized that the group of complex emotions  was excluded since these emotions imply the attribution of a cognitive state as well as an emotion and are more dependent on context and culture . They caThese videoclips were split into two conditions to compare emotion recognition in human and cartoon faces. These two conditions were chosen on the basis of studies carried out by Jusyte in 2017  and BrosDuring the training session, participants watched two videoclips in which a neutral expression turned into a sad or happy expression in order to introduce children to the task. All children passed the initial trial and were then admitted to the experiment.In the first condition, we presented greyscale images representing 12 young adults, six females and six males, selected from the Cohn-Kanade database ,57. We rIn the second condition, we used colored pictures showing cartoon faces of six females and six males. These images were included in the Facial Expression Research Group Database (FERG-DB) . They weParticipants and their parents were informed about the study procedures and all parents provided written informed consent to participate. The administration room, which was the same for the two clinical groups, was located within the school for the control group. The room had a table with a notebook and two chairs (one for the participant and one for the doctor) and no distracting elements such as posters, billboards, or games.In the training session, participants were instructed by the child neuropsychiatrist to press a button on the keyboard as soon as a face corresponding to the lexical label appeared on the screen.Each videoclip lasted 7 s and included 60 frames. We recorded answers and response latency on the appropriate answer sheet. In both conditions, videoclips were presented in the same random order obtained by pseudo-randomization for each child. The experiment was conducted using a Microsoft Office PowerPoint presentation , shown on a computer with a 10-inch screen and at a distance of 50 cm.2) was performed to investigate potential relationships between the number of errors  and the six emotions in the two conditions (human and cartoon faces);The Chi-square test  was used to investigate group differences with regard to response latency (speed in seconds).For statistical analysis, SPSS 19 software  was used. In order to compare the performance obtained by ADHD, ASD, and TD participants with regard to both accuracy and speed on the morphing task, we performed the following analyses:The clinical participants were 20 children with ADHD combined type (ADHD-C) in the age range 7–12 years old , 21 children with ASD in the age range 7–12 years old , and 21 children in the control group (TD) in the age range 7–12 years old . Demographic characteristics are reported in p < 0.05; p < 0.01) in the recognition of basic emotions. In condition 1 (human faces), ASD children exhibited a significantly higher error frequency as compared to TD participants when they were asked to recognize disgusted faces . With regard to surprise, the ADHD group exhibited the highest error frequency compared to the other two groups .The Chi-square test was used to compare response accuracy between the three groups in order to determine if there were statistically significant differences . With regard to disgust, the ADHD group had the highest percentage of errors .In condition 2 (cartoon faces), we found a significant difference in error frequency distribution relative to the emotion of sadness between the ADHD group and the other two groups . In condition 2 (cartoon faces), the percentage of error in identifying the emotion of disgust was higher in the ADHD group relative to the ASD group , and the error frequency for sadness was higher in the ADHD group .We compared the response accuracy for the aforementioned emotions between the two clinical groups (ADHD and ASD). The results were similar to those obtained in the previous phases of this study. In particular, in condition 1 (human faces) we found no significant differences between the ADHD and ASD groups in identifying the emotion of disgust, while the error frequency distribution for surprise was significantly higher in the ADHD group . The ADHD and TD groups tended to confuse fear and the facial expression of sadness more frequently than the ASD group, while the ASD group more often confused fear and surprise compared to the other two groups . In condition 2, the ADHD group more frequently confused disgust and anger as compared with the TD group, which confused these emotions less frequently .In condition 1, the emotion disgust was more frequently confused with anger in both clinical groups compared to the control group . To report these results, we report the name of the emotion followed by M  or F  to indicate the gender of the stimulus presented. In the post hoc comparison in condition 1 (In order to explore the presence of significant differences between the three groups regarding response latency (parameter speed in seconds), we conducted a multivariate analysis of variance (MANOVA). Wilks’ multivariate Lambda test suggested the existence of statistically relevant differences in response latency between the three groups  of ADHD and ASD individuals in response to dynamic emotional images in a morphing task. When compared to the ASD and ADHD groups, children with TD performed better in terms of speed, while the ADHD group performed better than the ASD group. In terms of accuracy, there was no significant difference between the ADHD and ASD groups.The findings in our analysis confirm previous studies that found a deficit in the emotion recognition process in subjects with ASD and ADHD. Our study shows that the poor performance of the ASD group, particularly for the emotion disgust, is consistent with literature data, especially in regard to Lozier’s meta-analysis . Meta-anSpecifically, in condition 1 (human faces), the emotion disgust was least recognized by the ASD group, while the emotion surprise was least recognized by the ADHD group. In condition 2 (cartoon faces), the highest error frequency was shown for the emotions sadness and disgust, in both cases by the ADHD group vs. the TD and ASD groups.These results suggest that digital faces/cartoons may facilitate recognition for participants in these groups. The ASD group made fewer mistakes recognizing disgust, one of the hardest emotions to perceive, in condition 2. This facilitation suggests that the ASD group may be able to use atypical strategies to recognize emotions. This hypothesis originated from previous studies ,57,58,59A qualitative observation showed that in our sample there was a lower error rate in cartoon emotion recognition than in human faces. Happiness is the easiest emotion to recognize. Disgust and fear, especially in condition 1, were the most difficult to recognize. This is consistent with literature stating that fear is easier to perceive than recognize. Of the six basic emotions, fear may be defined as the one that conveys the strongest multisensorial signals. These signals, such as environmental threats, may play an important role in decoding emotions .Disgust, after fear, was the most difficult emotion to identify, and was recognized better in the oldest neurotypical participants (similar to fear). Conversely, in ASD, the recognition deficit increased with age, especially for disgust, fear, and sadness . The varMajor latency in emotion recognition for both clinical groups;Greater emotion recognition error rate compared to the control group;Tendency to confuse some emotions .In brief, the difficulty in complex emotion recognition in these participants was evident by:We hypothesized that there would be an emotion recognition deficit in children with ASD and ADHD compared to the control TD group when using a dynamic stimulus, such as the morphing test. Overall, a faster response time was detected in the group of children with TD compared to the ASD and ADHD groups. The ADHD group, in turn, had a faster response time than the ASD group. Regarding the accuracy of the overall performance, the ADHD and ASD groups did not show a significant difference, and mostly seemed to be superimposable, while the performance of the TD group was qualitatively better. Our data confirm previous studies in the literature. The advantages of the morphing technique have been proven by evidence. Dynamic stimuli may somehow facilitate the emotion recognition process in both groups because a “dynamic picture” impersonalizes human interactions in a more realistic way. In everyday life, facial expressions are rarely transmitted and decoded as static snapshots of internal states . DynamicConsidering the remarkable facilitation and improved response to dynamic pictures, we hypothesize that the morphing technique could be a valuable aid to reinforce the bases of mind theory and may support the improvement of social reciprocity in ADHD  and ASD Several studies have been performed in order to better understand the utility of computer-based interventions (CBIs) in teaching social and emotional skills to subjects with ASD ,68.Ramdoss et al. , in a syConsistent with these studies, the findings of the present study evidenced the possibility that the morphing task might be a way to simplify emotion recognition in these populations, allowing them to understand the internal states of others, enhance their empathy, and, hypothetically, reduce their gaps in social relationships. In our study, this improvement occurred above all for disgust. However, it can be hypothesized that an improvement for other emotions could be achieved by perfecting the videos through the contextualization of cartoon faces.This study has some limitations. First, the clinical sample included children of a specific age (7–12 years old). Extending the sample from preschool to adulthood would allow the emotion recognition process to be evaluated throughout life and would allow the accuracy and response latency to be associated with age in these populations, as Richoz showed for the normotypical population [Second, the visual attention parameter (using eye tracking or configurable face processing skills) was not assessed, and consequently the differences in face perception could represent a bias of the study.Third, all participants included in the study had a pure diagnosis of ASD or ADHD; none had an overlap of the two diagnoses. In addition, all participants had an FISQ of 85 or more. While there is no evidence that these factors influenced the results obtained, we cannot rule out this possibility.Fourth, the images used in condition 1 were grayscale images of young adults. This could represent a bias with respect to the use of color cartoon images in condition 2. In fact, it has been suggested in the literature, despite the scarcity of studies, that the use of color images of child and adolescent faces may represent a more realistic confirmation of the ability to recognize emotions in the pediatric population.Additional aspects of interest may be represented by functional Magnetic Resonance Imaging (MRI) studies and the activation of specific brain structures during the emotion recognition process through dynamic tasks  and eye-This study demonstrates that emotion recognition was facilitated through the use of cartoon faces in ASD and ADHD populations, and that the quality of emotion recognition was comparable between ASD and ADHD participants. This is the first study to compare facial recognition in participants with ADHD, ASD, and TD using a morphing task.The findings of this study may have clinical implications in the planning of alternative strategies for rehabilitation settings for children with neurodevelopmental disabilities. The theoretical implications include a better understanding of the maturational changes underlying social skill deficits. We believe that the morphing task has proven to be useful in behavioral investigations and that its use in a more natural or ecological assessment setting is promising. Finally, these results are important for future research evaluating the emotion recognition process as a therapy goal and the morphing task as a rehabilitation tool in order to improve the social and empathy skills of children with ASD and ADHD.


The use of rye in poultry diets is associated with impairments in poultry performance due to the increased content of non-starch polysaccharides (NSPs). The performance of the body also depends on its health status, which can be reflected in structural changes of organs and systems. The gastrointestinal tract is the primary site of possible interaction between various nutrients, so changes in nutrition may be reflected in intestinal morphology. New hybrid rye varieties have been developed with a lower content of NSPs. Xylanase supplementation attenuates the negative effects of NSPs on poultry performance. The current study evaluated the inclusion of modern hybrid rye and xylanase supplementation on the absorptive surface of the small intestine of broilers. The results of the current study showed that the inclusion of modern hybrid rye to a corn–wheat-based diet improved the absorptive surface of the small intestine of broilers, regardless of xylanase supplementation.p < 0.05), and ileal mucosa thickness and crypt width (p < 0.05). Xylanase supplementation attenuated the effects of rye in the duodenum and ileum and decreased the villi height and villus-to-crypt ratio in the jejunum (p < 0.05). Rye and xylanase had no effect on the spatial distribution of claudin 3 and ZO-1 protein, but xylanase supplementation reduced the amount of claudin 3 in the duodenum and jejunum (p < 0.05). The findings of this study indicate that 20% inclusion of modern hybrid rye to the diets of broilers improved the structure of the duodenum and ileum, but these effects were attenuated by xylanase supplementation.The current study investigated the effects of the inclusion of modern hybrid rye (Brasetto variety) to a corn–wheat-based diet, with or without xylanase, on the absorptive surface of the small intestine of broilers. A total of 224 one-day-old male Ross 308 broiler chicks were randomly divided into four experimental groups with seven replicate cages of eight birds/replicate. A 2 × 2 factorial study design was used, with rye inclusion (0% or 20%) and xylanase supplementation (0 or 200 mg/kg of feed) as factors. Inclusion of rye increased duodenal and ileal crypt depth, villi height, the villus-to-crypt ratio and absorption surface area ( Secale cereale) is resistant to fungal diseases, has a high tolerance to low temperatures, droughts and irregular soil pH and has a high production yield [Corn is the most common energy source used in the diets of intensively reared poultry ,2. Howevon yield . Nonetheon yield ,5,6 due on yield . The limon yield ,9,10.To attenuate the deleterious effects of NSPs, poultry feeds are routinely supplemented with exogenous xylanases, which hydrolyze the complex carbohydrates (NSPs) present in cereal cell walls and consequently decrease digesta viscosity and release nutrients which can then be utilized by the animal ,11. The 2 total floor space in the cage (length × width × height = 120 × 65 × 50 cm), in an environmentally controlled room in the poultry house. During the study, the temperature in the experimental facility was maintained from 32 °C at 1 d of age to 21 °C at 21 d of age and later, relative humidity cycled from 50 to 60%, air exchange was 1 m3/1 kg of body weight gain (BWG)/1 h and concentrations of CO2 and NH3 were maintained below 2000 and 20 ppm, respectively. Each cage was equipped with four nipple-cup drinkers and a trough feeder along the front of the cage. Water and feed were supplied ad libitum. Feed was supplemented ad libitum as follows: starter (1 to 21 D), and grower-finisher (22 to 42 D) feeding phases. This study is part of a larger project on modern cereals in poultry and livestock farming. It provides new and additional data and analysis from the perspective of structural changes in the broiler digestive system from previously reported studies ,11. A coNutrient requirements of broilers were met or exceeded, according to poultry feeding standards, by formulated isonitrogenous and isoenergetic experimental diets . The conThe hybrid winter rye cv. Brasetto was used as a partial replacement of corn in the diet. In order to improve the high NSP levels within the rye, xylanase Ronozyme WX  with a minimum xylanase activity of 1000 FXU/g was used as a supplement to the diet. As previously stated, the chemical composition of the rye grain included 9.23% of crude protein, 0.81% of crude fat, 1.46% of crude fiber and 1.51% of crude ash .http://rsb.info.nih.gov/ij/index.html, accessed on 20 November 2020).At the end of the experiment, birds were weighed, and seven representative birds (one per replicate cage with body weight close to the average) from each group were slaughtered by decapitation after electrical stunning, following a 12-h fast. During the necropsy, two 20-mm-long samples of the duodenum (2 cm after stomach), jejunum (from 50% of intestine length) and ileum (2 cm before ceca), were collected and processed for standard histology, as previously described ,22. The Immunohistochemical staining was performed on the tissue slices according to a previously described protocol . Heat-ing for 10 min. The supernatant was then collected. The protein content was determined using the Bradford method [Tissue samples obtained from relevant segments, adjacent to the above-mentioned histology samples of the small intestine, were collected from every sacrificed chicken and were used for Western-Blot analysis, as previously described previously . Brieflyd method . Samplesd method  to deterp < 0.05). The sample size was calculated for a two-sided test with an α of 0.05 and power at 0.8, with an effect size of 1.63 [Data were analyzed by 2-way ANOVA using the GLM procedure of Statistica 13 . The model included diet and xylanase and their interactions as fixed effects. The replicate cage served as the experimental unit. Tukey’s test was used to compare differences between means when the model was declared significant ( of 1.63 .Results from the histomorphometry measurements are presented in p < 0.001) and villi height  were increased in the duodenum of broilers receiving rye or xylanase, or both rye and xylanase in the feed compared to broilers not receiving rye and xylanase in the feed. In both cases, the effect of rye was attenuated by xylanase (p < 0.001). The absorption surface area was increased in broilers receiving rye in the feed , and the villus-to-crypt ratio was increased in broilers receiving rye  or xylanase  compared to birds without rye and xylanase in the feed. In addition, in both these cases, the effect of rye was attenuated by xylanase, especially with respect to the villi-to-crypt ratio (p < 0.001). There was no response to feed with rye or xylanase or both in other parameters such as serous membrane thickness, outer and inner muscle layer, submucosa and lamina muscularis mucosa (p > 0.05). It was shown that the main effect of the addition of xylanase was a reduction in the thickness of the inner muscle layer by 16%. Although there were no differences between groups for serosa and mucosa thickness, the interaction of rye and xylanase still existed, and xylanase attenuated the response of these individual duodenal elements to rye in the feed  increase of jejunal crypts depth compared to groups with xylanase supplementation and without rye or xylanase, whereas 9% (p < 0.001) increase compared to broilers receiving 20% rye in the feed. Unlike in the duodenum, xylanase stimulated deepening of crypts when the feed contained rye. Villi height and villus-to-crypt ratio were reduced by 10% (p = 0.002) and 15% (p < 0.001), respectively, in broilers receiving rye and xylanase in the feed compared to broilers without rye or xylanase in the feed. The observed effect could be strengthened by additive impact of rye, since these two parameters were lowered by 4 and 5% respectively by the main effect of rye content (p = 0.026), villi width by 20% (p = 0.019) and villus-to-crypt ratio by 7% (p = 0.009), compared to broilers without xylanase in the feed. The thickness of the serosa, outer and inner muscle layer, submucosa, lamina muscularis mucosa, mucosa, crypt width and absorption surface area were not affected by the rye inclusion or xylanase supplementation (p > 0.05). Although rye, xylanase, or both had no effect on mucosal thickness compared with broilers not receiving rye or xylanase in the feed, xylanase exacerbated the lowering effect of rye.Jejunal histomorphometry parameters are presented in  content . The addp = 0.004), crypt width by 10% (p < 0.001) and depth by 19% (p < 0.001), villi height by 13% (p < 0.001), absorption surface area by 23% (p < 0.001) and villous to crypt ratio by 12% (p = 0.020) compared to feed without this cereal and xylanase. Xylanase addition to the broiler feed increased the crypt depth by 19% (p < 0.001), villi height by 13% (p = 0.006) and villi width by 15% (p = 0.009) compared to the broilers receiving feed without rye and xylanase. The effect of rye inclusion depended on the addition of xylanase in all the parameters mentioned above. Xylanase attenuated the response of the intestinal mucosa, crypts and intestinal villi to rye. The absorption surface area and the ratio of villous to crypt, increased by rye inclusion, were also decreased by xylanase. Only crypt depth was stimulated by both rye inclusion and xylanase addition but without additive effect in broilers receiving rye and xylanase in the feed  proteins was performed through microscopic observation of the small intestine epithelium of the duodenum, jejunum and ileum. The immune reactions with antibodies in the examined parts of the digestive tract were similar in all treatment groups. The reactions were continuous, and claudin 3 and ZO-1 were observed on the pericellular borders of the epithelium cells. The spatial distribution of the proteins assessed was normal, without any signs of epithelial gaps. There were no visible differences in the intensity of protein expression between treatment groups .p = 0.037), feed with rye (0.79) (p = 0.002) and feed without rye and xylanase (0.80) (p = 0.002) (p = 0.036). Lower amounts of the ZO-1 protein were also detected in the duodenal epithelium of broilers receiving xylanase in the feed (0.78) compared to broilers receiving feed with 20% rye inclusion (0.84) (p = 0.028) (p < 0.001 for both comparisons) (p = 0.010) and broilers receiving rye and xylanase (1.04) (p = 0.004)  compared to broilers receiving feed with rye and xylanase (0.76) (= 0.002) c. Rye no= 0.028) b. The amarisons) b. The am= 0.004) c. There = 0.004) d.The current study investigated the effects of the inclusion of modern hybrid rye (Brasetto variety) to a corn–wheat-based diet, with or without xylanase supplementation, on the absorptive surface of the small intestine of broilers. Previous studies have shown that the use of rye, as an alternative energy source in poultry diets, has been associated with increased viscosity of the digesta and thus poor digestibility and absorption of ingested nutrients . Rye incThe small intestine is the primary site for the digestion and absorption of ingested nutrients ,31. SomeIn the current study, both the rye inclusion and the xylanase supplementation affected the morphology of the small intestine, with the duodenum and ileum being the most affected, followed by the jejunum. The inclusion of rye in the broiler’s diet had a more pronounced effect on the small intestine histomorphometry compared to the xylanase supplementation. The enzyme-induced changes in villus height, crypt depth and villus height-to-crypt depth ratio in the small intestine of broilers in the current study contrast with previous findings. Wu et al. 2004) observed no significant effects of xylanase supplementation on the villus height, crypt depth and villus height-to-crypt depth ratio in the duodenum, jejunum and ileum of broilers fed a wheat-based diet supplemented with xylanase (1000 XU/kg diet), for a period of 21 days . Similar observedDietary inclusion of the new hybrid Brasetto rye significantly increased the duodenal crypt depth and villus-to-crypt ratio, as well as the ileal villus height of the broilers in the current study. Since the duodenum is the primary site for nutrient absorption , it woulIn addition to its digestive and absorptive functions, the intestine also serves as an important barrier against the external environment, preventing the entry of toxins, food antigens and harmful microorganisms ,48,49. IThe present study has its limitation since physiological approach and methods would provide greater insight into the effects of rye and xylanase on the nutrient absorption rate and would allow the establishment of intestinal barrier permeability and integrity in the context of rye and xylanase interaction. It would also be an interesting approach to study different doses of xylanase considering the present findings on the effects of the rye and xylanase interaction. The present study, however, indicates that modern hybrid rye varieties can be used as a safe energy source for broiler chickens from the standpoint of structural integrity and small intestinal function.In conclusion, the current study showed that modern hybrid rye of the Brasetto variety can be added to corn–wheat-based diets for broiler chickens, as an alternative energy source, without adversely affecting small intestine morphology. In fact, dietary rye inclusion has the potential to improve the structure of the small intestine and to increase the absorptive surface, but xylanase supplementation attenuates these effects.


According to the WHO, low birth weight (LBW) affects 15–20% of newborns worldwide. In Mexico, there are no national, state, nor municipal estimates that inform the country’s situation over time. The purpose of this study was to estimate the incidence of LBW at the national, state, and municipal levels from 2008 to 2017, and to estimate the LBW incidence based on maternal sociodemographic characteristics, prenatal care and marginalization indexes at the national level using open national data. We used spatial data analysis to georeferenced LBW incidence at the three levels of geographical disaggregation studied. At the national level, the incidence of LBW increased progressively from 6.2% (2008) to 7.1% (2017), and the country’s capital represented the area with the highest incidence. Southeastern and central states reported the highest LBW regional incidence. At the municipal level, the number of municipalities with an incidence of LBW ≥8% increased in both male and female newborns. The incidence of LBW was higher as the marginalization indexes increases. The results from this study may assist in the identification of vulnerable groups and the development of public health programs and policies with an intersectoral approach that improves maternal and child nutrition. The World Health Organization (WHO) defines low birth weight (LBW) as weight at birth less than 2500 grams (g) (5.5 pounds) . LBW is Globally, more than 20 million newborns are LBW infants, which represents 15–20% of all births annually . NeverthIn 2012, the WHO established a comprehensive implementation plan on maternal, infant, and young child nutrition that includes among its six global nutrition targets, a 30% reduction in LBW by 2025 . Mexico,Mexico is a country in the southern part of North America that is constituted by 32 states. Each state is comprised of municipalities; the country has 2,469 in total. Mexico City is the country’s capital and is constituted by sixteen territorial demarcations . In 2008Despite the NOM-007-SSA2-1993, there are no national nor systemic reports that estimate and monitor LBW incidence or prevalence. Few studies have calculated LBW prevalence in regional hospitals with a small sample size and a short period analyzed (i.e. one year) –18. In 2The purposes of this study are: (1) to estimate the incidence of LBW in Mexico at the national, state, and municipal level between 2008 to 2017; (2) to estimate the incidence of LBW based on maternal sociodemographic characteristics, prenatal care, and marginalization indexes at the national level; and (3) to georeferenced the data obtained using spatial analysis. This study would provide a further understanding of the Mexican situation with LBW and assist in the development and implementation of strategies to reach the global nutrition target of a 30% reduction in LBW by 2025.This study used a descriptive retrospective design to estimate the incidence of LBW in Mexico from 2008–2017 using national administrative open-access datasets. This period was selected because it represents, up to the development of this research project, the most recent data available. We accessed the datasets and extracted the data that met the inclusion criteria . We excluded data from newborns with missing birth weight and sex.Birth certificates data were accessed from the SINAC website . The cerMexican population census is conducted every 10 years. We used the 2010 Census report to obtain marginalization indexes and area of residence at the municipality, state, and national levels. This information was used across the studied period (2008–2017) . Based oThe INEGI developed an open-access national Geostatistical Framework represented by polygons that constitute the spatial limits of all country’s geographic units . The geoFor categorical variables  proportions were calculated; for continuous variables  means and standard deviations (SD) were estimated. Birth weight data that laid ± 3 SD from the mean were considered outliers and removed from the analysis.LBW incidence was estimated by dividing the total number of newborns with LBW by the total number of births that occurred per year at each geographic level: municipal, state and national.®.LBW incidences were compared from 2008 to 2017 by estimating the relative risks (RR) using Poisson regression models with Bootstrap estimations with one thousand repetitions to identify statistically significant changes. In these models, we tested the possible interaction between newborns’ sex and year to identify if the change in LBW incidence was differential according to sex. Derived from the interactions, models stratified by sex were carried out, at the national and state level. For all calculations, the statistical significance level was set at 0.05 alpha level except for interaction in which it was 0.1. All analyses were performed using Stata Software 13To distinguish LBW incidence based on maternal sociodemographic, prenatal care and marginalization index, the total newborns with LBW per category were divided by the total number of births that occurred in the same category. The marginalization index and area of residency were imputed from the 2010 Census and used throughout the study period.® and merged using the country’s geographic coding system to conduct the spatial data analysis and to create the maps. QGIS® is a free, open-source, software of geographic information system that includes tools for spatial data analysis [To georeferenced the incidence of LBW we performed spatial data analysis. The Geostatistical Framework dataset from INEGI and the dataset including LBW incidence were imported into QGISanalysis .A total of 21,146,302 birth records from 2008 to 2017 were identified. We excluded 1,247,874 observations with missing birth weight data (5.9%) and 244 observations with gestational age <21. In addition, we excluded 20,639 data  due to missing information about newborn sex. By excluding this data, outliers were also excluded. We retained for analysis 19,877,545 birth records, 51% of them corresponded to male newborns and 49% to female newborns. Most of the births occurred in a health institution (98.25%) while only 1.31% occurred in a household, 0.04% in public roads, 0.39% in a place other than the public road or home and 0.01% did not specify.Regarding maternal and newborn’ characteristics from 2008 to 2017, the distribution of maternal age and parity was similar in both periods. In 2017, a higher level of maternal education, an increased of Seguro Popular coverage of 28.2 percentage points (pp) and an increase of 1.4 pp of prenatal care access was observed when compared with 2008. Regarding newborn characteristics, these were similar in both years .During the study period, it was observed that birth weight distribution showed a displacement to the left for both males and females from 2008 to 2017 . In femaAt the national level, a constant increase in the LBW incidence between the years 2008 and 2017 was observed in males and females . In 2008At the national level, there was a statistically significant increase of 1.0 and 0.8 pp for females and males, respectively, from 2008 to 2017 (p<0.0001 in both cases) . At the The change in LBW incidence from 2008 to 2017 was 13% in males and 17% in females (p<0.0001 for both cases) . This chLBW incidence at the municipal level reflects important disparities . In the LBW incidence in both females and males increased from 2008 to 2017 regardless of maternal characteristics , except th and 8th week of pregnancy [To our knowledge, this is the first study that reports the incidence and trends of LBW in Mexico, at the national, state and municipality levels. The results from this study are relevant for tracking the progress towards reducing this public health concern in the country as well as identifying high-risk groups to design and target interventions. The incidence of LBW in Mexico, at the national level, progressively increased from 6.2% in 2008 to 7.1% in 2017. At the state level, Mexico City reported the highest incidence followed by Southeastern and Central states ; however, the states with the highest increase are located in the North of the country . At the municipal level, there is no clear geographic pattern observed in the incidence of LBW. Municipalities with incidences ≥8% were distributed throughout the country. We observed that the incidence of LBW was higher in urban areas, in places with low indices of marginalization, and among mothers ≥35 years old and without prenatal care. Similarly, other studies have identified that high maternal age and inadequate prenatal care are associated with LBW , 28. Desregnancy , by 2012regnancy .Seguro Popular is a public health insurance that covers a wide range of services without co-pays for its affiliates . It was The Mexican incidence of LBW was similar to the incidence reported for Latin America (8.7%) by WHO . The incAccording to UNICEF estimations , a reducMexican states with the highest incidences of LBW are located in Southeastern and Central Mexico. These regions are characterized by higher rates of poverty  and highMexico City and localities with very low marginalized index and higher rates of LBW incidence deserve special attention, it seems contradictory that places with better living conditions have higher incidences of LBW. In the case of Mexico City, although it has a lower marginalization index  comparedIt is important to notice that in some municipalities the incidence of LBW was higher than 50%. In most of these, the number of recorded births ranged from 1 to 9 births. This situation caused the estimated incidences of LBW to be very high but reflects the reality of these municipalities . It is iImportant limitations need to be considered when analyzing the results from this study. The databases we use may not cover all the births that occurred in the country. In Mexico, it is estimated that 89.3% of births occur in hospitals, 3.8% in homes, and approximately 6% of births occur in unspecified places. It is not possible to know if all births occurring outside hospitals are registered in SINAC. In addition, errors in measurement and recording of birth weight, as well as, the misclassification between live births and stillbirths, are also inherent limitations to the data we used. The localities with the highest vulnerability are those that could have a higher under-registration of births and therefore the incidences of LBW that we reported could be underestimating this public health problem.Another important limitation is the lack of maternal anthropometric data (e.g. height and Body Mass Index) and other variables such as the altitude, complications during pregnancy and type of delivery that can be related to LBW.Despite these limitations, the results of this study represent the first effort to systematize the LBW statistics at different levels of geographic disaggregation. It is critical to invest in a report system that keeps track of this important health indicator, this implies investing both in the infrastructure and in the training of the personnel who participate in the measurements, recording and systematization of this indicator. The results from this study may assist government entities, researchers and stakeholders in the design and implementation of appropriate interventions, community-based programs, and public policies that aim to improving maternal and child health indicators. The regionalization at state and municipal levels of LBW incidence allowed us to identify the most vulnerable areas in the country and analyze the maternal and sociodemographic characteristics that may be related to LBW incidence. The spatial data analysis is an important tool that facilitates the visualization of the states and municipalities more affected.Mexico faces a complex situation to meet the goals proposed by the WHO for 2025. Future studies should aim to identify the determinants of health associated with LBW, to design and implement community-based programs and public policies targeted to reverse the trend and achieve the goals proposed by the WHO in the World Nutrition Goals 2025.S1 Table(PDF)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.


In this paper the authors reported finding a statistically significant higher incidence of children with lower urinary tract symptoms (LUTS) having an association with ADHD when compared to those with LUTS without ADHD . Theirs But it is also consistent with the concerns that inherently exist in studies that report on associations between different medical conditions or symptom groups . When a While the MTA-SNAP-IV is considered valuable for assessing ADHD symptom severity and plays a supporting role in the diagnostic process, it is generally considered by most clinicians in that field to not be the sole arbiter for that diagnosis and the same could be said for the DVSS questionnaire, particularly when there are no LUTS absolutely specific for any LUTC and there are many LUTS that are common in a variety of LUTCs making relying on questionnaire type instruments alone of limited value , 4. A goWhile the literature is replete with specific objective diagnostic criteria for ADHD and its various subtypes, this is not so as regards LUTS where symptoms, sometimes bolstered by uroflow pattern appearance, are often the sole arbiters of the presumed underlying LUTC diagnosis. In that vein, included below are references that may help to better illustrate what is meant by using objective diagnostic criteria for parsing out which common LUTC is being treated even though these are by no means the only objective paradigms that can be used nor do they conform 100% with current ICCS recommended terminology.Another problem area is that while most clinicians agree in principle that treatment should be multidisciplinary, it has been my observation that it has become increasingly prevalent that the specialty that drives the bus so to speak as to how these children are managed is the specialty to which the patient first sought care, or for whatever reason was deferred to, and that can be either Urology, Colorectal/GI or Psychiatry and can potentially have a negative effect on how quickly the child's various issues are resolved if not addressed simultaneously early on.For those practices fortunate to be located in a center where a more centralized, multidisciplinary approach to care is feasible as in the case of these authors, there is not only adequate resources to provide all the care services needed but real potential to more scientifically investigate the true nature of these associations. In just such a setting there is also the opportunity if one were so inclined, to initiate carefully constructed investigational studies to more clearly identify whether any particular type of ADHD is the underlying etiology responsible for any specific LUT condition or are they more simply associations that act as an impediment to achieving a successful therapeutic response. If this line is pursued it will hopefully provide not only insight into the true nature of the ADHD-LUT Dysfunction association, but also lead to more refined treatment recommendations.In the end one cannot over emphasize the importance for all clinicians who treat these children, regardless of their practice setting, to remain aware of the frequent associations between ADHD and both Bowel and Bladder disorders which if left unrecognized and addressed, can seriously undermine the optimization of patient care and that the focusing of treatment on one particular condition at the expense of the other is generally not helpful. And finally, when reporting one's results in the literature on the nature of those associations and treatment outcomes, it is best served when the reported disorders are clearly and objectively defined, that treatments be carefully applied in the order of greatest clinical need to better discern which was responsible for response and that statistically significant improvements be paired with truly meaningful clinical improvements as well. This is not to acknowledge that sometimes the exact etiologic cause of a given disorder cannot be readily proven or that often multimodal therapy is needed for optimal response, only that the further away from scientific methods of proof and the more one relies on associations drawn from inference and data that can be subjectively influenced, the more the likely the take home message will remain muddled, not clarified.


N = 45) and TD children (N = 49) on a baseline aDMTS task and sequentially adapted the aDMTS task so that correct choice behavior was rewarded with a more potent reinforcer (reward manipulation) or with sample-specific (and hence response-specific) reinforcers . At baseline, children with ADHD performed significantly worse than TD children. Both manipulations  improved performance in the ADHD group, resulting in a similar level of performance to the TD group. Increasing the reward value or the response-specificity of reinforcement enhances Conditional Discrimination Learning in children with ADHD. These behavioral techniques may be effective in promoting the learning of adaptive behavioral choices in children with ADHD.When children with ADHD are presented with behavioral choices, they struggle more than Typically Developing [TD] children to take into account contextual information necessary for making adaptive choices. The challenge presented by this type of behavioral decision making can be operationalized as a Conditional Discrimination Learning [CDL] task. We previously showed that CDL is impaired in children with ADHD. The present study explores whether this impairment can be remediated by increasing reward for correct responding or by reinforcing correct conditional choice behavior with situationally specific outcomes . An arbitrary Delayed Matching-To-Sample [aDMTS] procedure was used, in which children had to learn to select the correct response given the sample stimulus presented (CDL). We compared children with ADHD ( ADHD is marked by elevated levels of inattention, hyperactivity and impulsiveness that are inconsistent with a child’s developmental stage  has been shown capable of normalizing the on-task performance of children with ADHD compared to TD children, including the amelioration of performance deficits linked to executive impairments  in children with ADHD , irrespective of the response, or the standard Common Outcomes [CO] procedure where only one outcome is used to signal correct responding across trials  as in a DO procedure, is to our knowledge not specifically being taught in behavioral management programs  reinforcers  and/or primary reinforcers  and/or introducing differential outcomes (remediation 2) would ameliorate deficits in CDL performance, under conditions of delay, observed in children with ADHD compared to TD children. Within differential outcomes, we also assessed the importance of the degree of response-specificity of reinforcement; i.e., is there a difference in the effectiveness of response specific secondary reinforcer compared to response specific primary and secondary reinforcement.Immediately before the start of the current study, all children had performed a series of CDL tasks with increasing delays to determine the delay at which their performance tapered off  or to secondary and primary reinforcement  and 55 typically developing children participated in the study. Six participants  were subsequently excluded due to an error in administration; i.e., an incorrect delay was selected from the baseline aDMTS tasks for use in the reward, nDO and DO tasks. The children, aged 8 to 12 years, were recruited through the clinical networks of the authors (ADHD group) and local schools (TD group). Study inclusion criteria were: (a) an estimated IQ score ≥ 80, based on the short form of the Dutch version of the Wechsler Intelligence Scale for Children [WISC-III-NL] (b) absence of any sensory, neurological or motor disorder or a clinical diagnosis of Autism Spectrum Disorder (as indicated by parents) (c) absence of a clinical diagnosis of Conduct Disorder [CD] as assessed by the CD section of the Disruptive Behavior Disorders module of the Diagnostic Interview Schedule for Children, Parent Version , Oppositional Defiant Disorder [ODD] section (≤ 95.2nd percentile) and CD section (≤ 95.2nd percentile) of the Disruptive Behavior Disorder Rating Scale  to 3 (very much). Raw scores  were transformed to norm scores ranging between 10  and 19 . Adequate psychometric properties are reported for a Flemish sample; internal consistencies for the Inattention (α = 0.90), Hyperactivity/Impulsivity (α = 0.87), ODD (α = 0.88) and CD subscales (α = 0.66)  associations through a feedback-based trial-and-error procedure; correct responses were followed by a smiley face, incorrect responses were followed by a red cross. To increase the level of difficulty, a third choice stimulus C3 was added on all trials. In order for participants to become acquainted with the task, a training phase was presented prior to the first CDL task.In phase 1, initial CDL performance was assessed through repeated arbitrary Delayed Matching-To-Sample [aDMTS] tasks, as reported in De Meyer et al. .1 In eac1 or S2) and the position of the choice stimuli  was determined randomly for each trial (12 options) and a different set of stimuli was used for each delay. The correct sample-choice association was determined in advance and not counterbalanced. With increasing delay between the sample and choice stimuli, a drop in learning performance is consistently observed, typically attributed to an increased memory load  , , whereas correctly choosing C2 after presentation of S2 resulted in a different outcome O2 (a yellow smiley)  accumulated towards candy and O2 (yellow smiley) towards a toy. At the beginning of the task, participants were informed about the change in reward outcome: For every yellow smiley you will earn yellow points and for every blue smiley you will earn blue points. At the end, you can exchange all the yellow points for toys and all the blue points for candy. The more yellow points you earn, the higher the chance you have at earning toys. The more blue points you earn, the higher the chance you have at earning candy. The other half of the children in each group received secondary DO only. They were told that secondary reinforcers accumulate towards non-differential primary reinforcers (both types of smileys earn candy and toy rewards); For every blue smiley you will earn blue points and for every yellow smiley you will earn yellow points. At the end, you can exchange all the blue points and all the yellow points together for toys and candy. The more points you earn, the higher the chance you have at earning candy and toys  were varied between participants, stratified for gender, age, and group. All children performed both the nDO and DO tasks (within-subjects). The nature of the DO task (primary and secondary DO or secondary DO only) was manipulated between subjects. In the DO aDMTS task, correctly choosing CFor every smiley you will earn a point. At the end, you can exchange all the points for candy or toys. The more points you earn, the higher the chance you have at candy or toys. To control for reward level across conditions  and the potential influence on their motivation, upon completing the 24 trials in the nDO task, children were rewarded with both toys and candy (explained as being a consequence of their outstanding performance) but unrelated to their actual performance . For each participant, this metric was calculated for 1) the baseline task  the aDMTS task from Phase 2 (increased reward); and 3) the two aDMTS tasks from Phase 3 (nDO and DO).In all tasks, CDL performance was measured as baseline; for full results, see De Meyer et al., Before participating in the study, separate information letters were given to parents and children, and informed consent was obtained from both parents. While parents completed the structured interview (ADHD group only) and questionnaires (DBDRS and demographic questionnaire), children performed the experimental tasks in a distraction-free room. All participants completed the basic aDMTS task immediately before the tasks described here . The authors confirm that the study was conducted in line with the ethical standards of the institutional research committee and with the 1975 declaration of Helsinki and its 2008 amendment.χ2 = 4.62, p = 0.032) with an uneven distribution of boys (N = 31) and girls (N = 14) in the ADHD group compared with the control group  = 10.89, p = 0.001, ηp2 = 0.106. Neither IQ nor gender were included as covariates in the analysis as neither variable correlated with any of the outcome variables.Review of the distribution of the outcome variables detected some extreme values (outliers) and high skewness and kurtosis for all outcome variables (unrelated to group), indicating non-normal distributions. Therefore, data was subjected to an arcsine transformation, as is recommended when outcome variables are percentages ; moderate  and large   when the DO manipulation involved secondary reinforcement only versus primary and secondary reinforcement. Post-hoc analyses, independent-samples ) Cohen, , 1992.χ2 (2) = 5.75, p = 0.056. For the majority of children with ADHD and all TD children, a delay of 16 s was selected ; for the remaining children in the ADHD group, an 8-s (n = 3) or 0-s (n = 2) delay was selected.The distribution of the individually determined delays, selected on the basis of performance in the baseline tasks, was not significantly different between the groups, F = 6.97, p = 0.010, ηp2 = 0.070 and group, F = 9.45, p = 0.003, ηp2 = 0.093, and a significant condition by group interaction,5F = 4.60, p = 0.035, ηp2 = 0.048; adding a monetary reward had a larger impact on the CDL performance of children with ADHD compared to TD children p = 0.002, d = 0.69, but not following the addition of a monetary reward, t(92) = 1.56, p = 0.122, d = 0.32. Paired-samples t-tests showed that the difference in CDL performance between the baseline task and the monetary reward task performance was significant for children with ADHD, t(44) = -2.85, p = 0.007, d = 0.43 but not for TD children, t(48) = -0.44, p = 0.666, d = 0.06.The first 2 (group: ADHD vs TD) × 2 (condition: baseline vs monetary reward) repeated measures ANOVA yielded statistically significant main effects for condition, F = 10.87, p = 0.001, ηp2 = 0.106, but not condition, F = 0.19, p = 0.665, ηp2 = 0.002. The group x condition interaction was significant, F = 5.37, p = 0.023, ηp2 = 0.055  = -1.46, p = 0.152, d = 0.23 (TD) and t(44) = 1.79, p = 0.081, d = 0.26 (ADHD), however for children with ADHD, compared to TD children, the percentage of correct choices was significantly lower under nDO, t(92) = 3.57, p = 0.001, d = 0.74, but not under DO, t(70.88)p = 0.063, d = 0.39. The order in which the conditions were presented did not influence the results when included as a covariate.The effect of DO versus nDO was compared between groups in a 2  × 2  repeated measures ANOVA.see Fig. , Table 2F = 3.56, p = 0.062, ηp2 = 0.038, or condition effect, F = 0.23, p = 0.636, ηp2 = 0.003, nor a group by condition interaction F = 0.11, p = 0.740, ηp2 = 0.001  × 2  factorial ANOVA was run. Results showed that there was no significant group, F1, 0 = 3.56,Children with ADHD experience difficulty in using feedback to adapt their behavior in the presence of delays . Here we evaluated the ability of different reinforcement manipulations to improve performance on a CDL task. Specifically, we tested the effects of increasing reinforcer size and the introduction of Differential Outcomes (i.e. response-specific reward outcomes). Within DO, we explored whether response-specific primary and secondary reinforcement was superior to response-specific secondary reinforcement only.Contrary to our prediction that increasing reward size or value would have a positive effect on CDL performance under conditions of delay in both groups, we found a significant improvement in performance, i.e., a higher percentage of correct responses compared with baseline conditions, in the ADHD group only. Under increased reward conditions, the performance of the ADHD and TD group was no longer significantly different, suggesting a normalization of performance for the ADHD children.Similarly, adding a specific reward outcome to sample-choice associations, i.e., DO, improved performance on the delayed CDL task in children with ADHD only. Although a significant difference in performance was found between the groups when using non-differential outcomes, under DO reward conditions the difference between the ADHD group and the TD group was no longer significant. Again, this suggests that adding DO may normalize CDL performance in children with ADHD. Further, we predicted that manipulating the nature of the reward within DO would affect performance. The data do not support this hypothesis, i.e., primary and secondary DO performance did not differ from performance under secondary DO only, for either group.The observation of improved CDL performance through reward maximalization is in accordance with earlier findings that indicate beneficial effects of reward optimization on deficits in Executive Functioning [EF] performance in ADHD , DO did appear to “normalize” performance in the ADHD group, i.e., they performed more similarly to TD children on CDL. One explanation for the effect of a DO procedure on aDMTS performance is that it allows for the associative activation of a prospective memory representation upon presentation of the sample stimulus that primes correct choice behavior. This extra memory representation might have helped to counter possible short-term or working memory deficits that could impair aDMTS CDL performance in children with ADHD.Improvement of CDL performance through a monetary reward involves an increase in reward value, which might have served to remediate an underlying memory (short-term or working) deficit. The impact of DO on CDL performance might likewise be mediated by an effect on memory; the nDO and DO conditions did not differ in reward An alternative explanation for increased performance on the CDL task through increased reward or DO centers on their emotional-motivational effects , with children being promised candy and a toy in each .t(93) = -1.74, p = 0.086, argue against a simple task training effect. The current design did not allow us to control for the contextual effect of being rewarded with a monetary reward before the DO-nDO conditions, as the monetary reward condition was always presented first, after which DO and nDO were presented in counterbalanced order. Therefore, we cannot strictly rule out that delivering a large monetary reward ahead of the DO/nDO tasks differentially affected performance of the ADHD and TD groups. Another possible limitation relates to the stimuli used in the aDMTS task. Over the four aDMTS tasks , the set of stimuli used was fixed and not counterbalanced. Therefore, performance differences between aDMTS manipulations might, in principle, be due to stimuli-specific characteristics. However, considerable care was taken to establish stimulus sets of equal difficulty. In addition, it is possible that the task instructions influenced reward expectations differently for the DO and nDO conditions, favoring the DO condition. Although this effect was not evident in the performance of TD children  we cannot rule out an ADHD specific differential effect. Finally, due the between-subjects manipulation of DO (primary and secondary versus secondary DO only), groups were rather small, reducing power to detect significant differences between those two forms of DO.The current study comes with some caveats. To begin with, we did not succeed in collecting teacher ratings to confirm the ADHD diagnosis for all participants due to practical constraints  and therefore cannot confirm the cross situational severity of symptoms, considered a core diagnostic criterion in the diagnosis of ADHD. While acknowledging this limitation, most of the children who entered the study had been previously assessed and diagnosed through the KU Leuven university hospital, by means of multi-method, multi-informant assessments where also cross-situational severity was taken into account. Over the course of the study .and for playing nicely with siblings)  is less feasible in real-life situations compared to the relatively simple implementation of DO. In the present study, DO was as effective as a high value of reward in increasing CDL performance in children with ADHD, and the implementation of DO in token economy programs can be relatively easy .In conclusion, the present research provides initial evidence that deficits in delayed conditional discrimination learning in ADHD on a DMTS task can be attenuated by enhanced reward and DO manipulations. Our results have potential implications for the refinement of behavioral interventions for children with ADHD. These findings can, for example inspire adaptations to existing token economies in ADHD, and further testing of these adapted “differential outcomes” token economies versus “non-differential” token economies on proximal daily life outcomes in micro-trails Below is the link to the electronic supplementary material.


Background: Autism spectrum disorder (ASD) often co-exists with attention deficit/hyperactivity disorder (ADHD), which may aggravate functional impairment. However, it is unclear how comorbid ADHD symptoms influence the adaptive behavior and social interaction deficits of children with ASD.Methods: The study enrolled 340 children (ranging from 2 to 14 years) with ASD, with comorbid ASD and ADHD, or with typical development (TD). A psychological evaluation involving adaptive behavior and social function was conducted using the Vineland Adaptive Behavior Scale, Second Edition (VABS-II) and the Social Responsiveness Scale (SRS).Results: There was a high prevalence of ADHD symptoms (46.6%) in children with ASD, and children with ASD + ADHD presented the worse profile of ASD symptoms. The ASD + ADHD group had higher scores on VABS and lower scores on SRS in comparison with the ASD alone group and TD group. The regression analysis revealed that ASD symptoms and ADHD symptoms were significantly associated with greater impairments in adaptive behavior and social function. The ADHD symptoms were responsible for an additional 0.8% of the variance in adaptive behavior, and 9.5% of the variance in social function.Conclusions: More severe ASD symptoms and greater impairment in adaptive function and social ability were found in children with ASD and comorbid ADHD, highlighting the need to identify ADHD comorbidities early on in children with ASD and to reduce their negative impact on functioning. Autism spectrum disorders (ASD) are behaviorally defined as neurodevelopmental disabilities, which are characterized by deficits in reciprocal social interaction and communication as well as by restricted, repetitive patterns of behavior or interests , 2. ReceDiagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) in 2013, clinicians are able to make a diagnosis of ADHD in the context of ASD. This has led to increasing interest in the overlap of the clinical presentations of ASD and ADHD symptoms. Epidemiological studies have identified that the comorbidity rate of ADHD in ASD ranges from 14 to 70% in different countries  had ever received an ADHD diagnosis . Accordi.4% had eountries . To dateountries –14.Adaptive behavior and social function are the most important measures in evaluating functioning in ASD. Adaptive behavior refers to the ability to perform the daily activities required for individual and social sufficiency , and is Therefore, this study aims at clarifying the effect of ADHD symptoms in the context of ASD on adaptive behaviors and social function, and to analyze the independent effects of the ADHD symptoms on functional impairment in ASD children. We hypothesized that the children and adolescents with comorbid ASD and ADHD may exhibit more severe autism symptomatology, lower adaptive skills, and poor social function. Here, the present study recruited a case-control sample of children and adolescents (2–14 years old) with confirmed ASD, ASD with ADHD, and TD. This study would provide a more comprehensive understanding of the functional impairments in ASD with comorbid ADHD, and offer basic evidence for the development of personalized treatment training programs for individuals with ASD comorbidities.This cross-sectional study included 340 children, ranging from 2 to 14 years, who were consecutively recruited from the general public and the Child Developmental and Behavior Center of Harbin Medical University, Harbin, China. Diagnosis of ASD and/or ADHD was based on two independent specialist clinicians from our research team using the diagnostic criteria specified in DSM-5. The current gold standard for ASD diagnosis is based on clinical observation, substantiated by standardized testing of the patient with the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS). Diagnoses of ADHD were also confirmed by using the Vanderbilt ADHD Parent Rating Scale (VADPRS). Exclusion criteria included (1) neurodevelopmental disorders of known etiology , (2) significant sensory or motor impairment, and (3) serious chronic diseases. The neurodevelopmental histories and mental states of the typical development (TD) group were also evaluated and confirmed by neuropediatric specialists. The sample description and scores on primary measures were showed in All participants recruited for the purpose of the research received oral feedback and a written summary of the results of evaluation without any payment. Caregivers provided written informed consent and children provided assent if possible. The procedures related to this study were approved by the Institutional Review Board of Harbin Medical University.In this study, all psychologists or trainees involved in administering the measurement protocols had established research reliability. Participants were evaluated using the ADI-R, ADOS, VAPRS, Vineland Adaptive Behavior Scale; Second Edition (VABS-II), Social Responsiveness Scale (SRS), Childhood Autism Rating Scale (CARS), Autism Behavior Checklist (ABC) and a cognitive assessment. Due to applicability, cooperativity and compliance from patients and their guardians, some cases did not complete all above examinations. Multiple assessments were available for many cases in this corpus. However, only the most recent assessment was retained for each case.The ADI-R  is a semThe ADOS  is an inThe Childhood Autism Rating Scale (CARS)  was use The ABC  was fillThe VADPRS was scored using the National Institute for Children s Health Quality s criteria, and consists of 45 statements on children s behaviors, 9 of which correspond with behaviors included in the Diagnostic and Statistical Manual of Mental Disorders for the predominately inattentive subtype of ADHD and 9 to the hyperactive/impulsive subtype. Higher scores reflect more severe of problem behavior of children with ADHD. This questionnaire had good reliability and validity , 27, andThe VABS-II, is a measure of adaptive behavior based on parent interview with validity and reliability from birth to adulthood, and commonly incorporated in assessments for ASD. The VABS yields domain scores in the areas of communication, daily living skills, socialization, and motor skills, as well as an overall adaptive behavior composite. Lower scores indicated greater impairment of adaptive behavior. The VABS-II has demonstrated strong reliability and validity . In the The SRS  is a 65-M = 100 and SD = 15. In this study, we use the full scale IQ as an indicator of IQ.The Wechsler Preschool and Primary Scales of Intelligence  or Wechst-tests or one-way analyses of variance (ANOVA), followed by post-hoc Welch two-sample t-test and Least-significant (LSD). To non-normal distribution of data, multiple comparisons among three groups were conducted by Kruskal-Wallis H test and differences between two groups were assessed by Mann-Whitney U-test for post-hoc analysis. Pearson's chi-squared test was used to compare gender composition between groups. Linear regression model with enter method (VABS and SRS) as outcome variable was conducted to test the associations of potential explanatory variables. The demographics  as covariates were entered into the first block, followed by ASD diagnosis in the second block and ADHD diagnosis in the third block. The model R2 is reported as interpretation of the meaning of such individual coefficients is limited by multicollinearity. Significance level was set at p < 0.05 (two-tailed). SPSS Version 21.0  was used for all statistical analyses.Comparisons between groups were examined, as appropriate, by means of independent samples F = 0.149; p = 0.862 and χ2 = 4.533; p = 0.104). However, IQ was significantly different among the groups , and the post-hoc analyses showed that IQ was significantly lower in the ASD + ADHD group, compared with the TD group (p < 0.001) and the ASD group (p < 0.013). Meanwhile, there was significantly lower IQ in the ASD group, compared with the TD group (p < 0.001).Overall, the 340 children in our study included 293 boys and 47 girls with a mean age of 5.85 ± 2.65 years: 134 children with ASD (ASD group), 117 children with ASD and ADHD (ASD + ADHD group) and 89 with typical development (TD group). The ADHD comorbidity rate was 46.6% in the children with ASD. As shown in t = −3.052; p = 0.003), ADOS , and ABC . However, the scores for the CARS were not significantly different between the two groups  (The ASD + ADHD group had higher scores than the ASD group in the ADI-R (= 0.694) .2 = 84.932; p < 0.001), Daily living skills , Socialization , Motor skills , and the Composite scale   . The posTD group .F = 15.872; p < 0.001), social cognition , reciprocal social interaction , social motivation , autistic mannerisms , and SRS total scale   . Subsequs domain .2 value increased by 0.8% , which was statistically significant. The ASD diagnosis  and ADHD diagnosis  were negatively correlated with the VABS-II score. For the SRS, when the ASD diagnosis variable was added alone (model 2), it explained 9.6% of the variance in the SRS scores; when the ADHD diagnosis variable was further added (model 3), the R2 value increased by 9.5% , which was statistically significant. The ASD diagnosis  and ADHD diagnosis  were significantly positively correlated with the SRS score.After controlling for demographic confounders , for VABS-II, when the ASD diagnosis variable was added (model 2), 7.3% of the variance was explained by ASD diagnosis; when the ADHD diagnosis variable was further added (model 3), the RIn this population-based case-control study, we found a high prevalence of ADHD symptoms (46.6%) in children with ASD. Children with ASD + ADHD exhibited more severe ASD traits, and a greater degree of weakness in adaptive profile and social function. Moreover, ADHD symptoms could aggravate the impairment of adaptive behavior and social function in individuals with ASD.Previous research , 33 has In extrapolating from the current data, children with ASD + ADHD had worse performance in adaptive behaviors than children with only ASD and children with TD, which were noted in the communication, daily living skills, socialization and motor skills subdomains, and in the VABS composite. The findings of the present study were in line with previous reports and provide supportive evidence that ADHD symptoms have an impact on adaptive behaviors , 34. AvnA large-scale population-based study demonstrated that ASD symptoms explained 18% of the variance in adaptive behavior, while the same variables were responsible for 14% of the variance in social function . This stOne potential explanation for the findings is that symptoms of comorbidity will confuse the diagnosis of ASD, so that when ASD is diagnosed, the symptoms are more severe and the function is more impaired than in other children of the same age. For example, a study from the National Survey of Children's Health found that ~20% of 1,500 U.S. children aged 2–17 years with parent-reported ASD were initially given a diagnosis of ADHD, and were diagnosed with ASD three years later than children without ADHD concerns , compareIn addition, it is well-known that the SRS and VABS assessment outcomes are affected by the individual characteristics of children, such as age, gender and cognitive level . The EurThere are some limitations to the current research. First, we did not enroll children with only ADHD in the analysis, and the study could have benefited from comparisons with the ADHD population. Second, there is a selection bias in our research. On the one hand, all participants involved in this study were from Heilongjiang Province, on the other hand, fewer older children are recruited, so it is difficult to extrapolate the results to the general population. Finally, whether the children with ASD and ADHD received medical treatment for ADHD was not taken into account. For a more detailed understanding of the changes of adaptive function and social function in ASD, a longitudinal study is needed to explore further the differentiated executive strategies required in the interventions designed for children with ASD and ADHD.In summary, our results indicate that, for individuals with ASD who are diagnosed with ADHD, the characteristics of the comorbidity made their ASD symptoms more severe, and exacerbated their deficits in adaptive function and social ability. In light of the these findings, it is important to identify ADHD comorbidities early on in children with ASD, and to explore effective medical and behavioral interventions to reduce the impact of ADHD symptoms, thereby hopefully leading to improved functioning.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Harbin Medical University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.MZ and CS conceived and designed the research. YL, LW, SX, SP, and JZ performed clinical assessment. YL analyzed the data and wrote the paper. CS and MZ contributed reagents, materials, and analysis tools. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.