Intellectual Disabilities (ID) and Attention Deficit Hyperactivity Disorder (ADHD) are recognized psychological vulnerabilities in police interviews and court proceedings in England and Wales. The aims of this study were to investigate: (a) the prevalence of ID and/or ADHD among suspects detained at a large London metropolitan police station and their relationship with conduct disorder (CD), (b) the impact of their condition on police staff resources, (c) the effectiveness of current custody assessment tools in identifying psychological vulnerabilities, and (d) the use of ‘Appropriate Adults’ in interviews.A total of 200 individuals in a police custody suite were interviewed and screened for ID, ADHD (current symptoms) and CD.The screening rates for these three disorders were 6.7%, 23.5% and 76.3%, respectively. ADHD contributed significantly to increased requests being made of staff after controlling for CD and duration of time in custody. This is a novel finding. Reading and writing difficulties and mental health problems were often identified from the custody risk assessment tools, but they were not used effectively to inform on the need for the use of an Appropriate Adult. The frequency with which Appropriate Adults were provided to support detainees in police interviews (4.2%) remains almost identical to that found in a similar study conducted 20 years previously.The current findings suggest that in spite of reforms recently made in custodial settings, procedures may not have had the anticipated impact of improving safeguards for vulnerable suspects. Detainees with ID and ADHD require an Appropriate Adult during police interviews and other formal custody procedures, which they commonly do not currently receive. The findings of the current study suggest this may be due, in large part, to the ineffective use of risk-assessment tools and healthcare professionals, which represent missed opportunities to identify such vulnerabilities. The widely publicized Bradley report  raised cet al. [Concerns about the identification of vulnerabilities of suspects in police custody, and suggested amendments to provisions for these, were raised in the early 1990s in studies for the Royal Commission on Criminal Justice ,3. This et al.  relied oet al. ). These et al. ,6.A broader evaluation of difficulties by the Royal Commission found that 35% of detainees had “problems which might interfere with their functioning or coping ability during police interviewing”   and its The focus of the previous consultation reports ,3,15 hasCompared with a general population rate of 5.9 to 7.1% for childhood ADHD  and 2.5%There is conflicting evidence from research as to the influence of each disorder on forensic outcomes. A follow-up study of childhood psychiatric inpatients (n = 541) reported that those with childhood Conduct Disorder (CD) or CD with combined hyperkinetic disorder were at significantly greater risk for adult delinquency, whereas those without CD were no more likely to commit future crime than those with any other psychiatric disorder . In contPACE and its accompanying Codes of Practice  do not aThe updated Code C of the PACE Codes of Practice  stipulatThe study was conducted with a group of individuals who were arrested and detained in a police custody suite in South London, where the Bradley recommendations were being implemented, in order to address the following hypotheses. (H1) rates of ID and ADHD in people presenting in police custody will be higher than reported for the general population. (H2) significant comorbidity will be found among ID, ADHD and CD ,40. (H3)In addition to the above hypotheses, exploratory analysis was conducted to investigate whether the police Custody Record risk assessment screening tool and/or HCP contact in police custody, successfully identified vulnerable individuals leading to an increased use of Appropriate Adults during police interviews.The sample comprised 200 individuals in custody at a police station in South East London. The mean age of the group was 27.5 years , most being male . Ethnic background was taken from the Custody Record for 194 participants, of whom 95 were classified as white (49.0%), 85 black (43.8%), 13 mixed race (6.7%) and 1 Asian (0.5%). The participants were in custody for a range of alleged offenses (information available for 191 participants) including property , violence , criminal damage , public disturbance , drug-related , driving , sexual  and other offenses , the ‘other’ category mainly included a warrant or breach of court restrictions/bail. All individuals were assessed by custody staff during a routine intake procedure for capacity to participate in the study. This included an evaluation of alcohol and drug intoxication or withdrawal, serious mental health problems, severe communication/comprehension problems and risk of violence to the researcher. These individuals were identified during routine intake procedures carried out by custody officers with every detainee. This resulted in a small number of exclusions due to either intoxication and/or risk of violence to the researcher, but the exact number of exclusions was not specifically recorded. There were no exclusions due to serious communication/comprehension problems and/or serious mental health problems.In order to determine the sample size required to estimate the prevalence of ID and ADHD in this population with good precision we used the following formula provided by Daniel , and madP = expected prevalence or proportion , and d = precision .where n = sample size, Z = Z statistic for a level of confidence, As recommended, we used a standard 95% confidence level for both calculations for which the Z statistic is 1.96.d should be half of P; therefore, the d value used for the ID calculation was 0.04 (4% expressed as a proportion of one). The estimated number of participants required was 164.With regard to prevalence of ID, we based our calculation on an expected prevalence rate of 7.5% reported by Jackson  in probad figure used was 0.05 (5% expressed as a proportion of one)”. The estimated number of participants required was 215.With regard to prevalence of ADHD, we based our calculation on an expected prevalence rate of 19% found in a recent UK study in probation services . This raet al. [The two estimated sample sizes are different mainly due to the different values of precision and expected prevalence used in the calculations, as described by Naing et al. .These self-report screens each comprise 18 items relating to Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) classified symptoms of inattention, hyperactivity and impulsivity. On each screen, nine items relate to problems of hyperactivity/impulsivity and nine to inattention. Each item is rated on a four-point scale: ‘never or rarely’ (0), ‘sometimes’ (1), ‘often’ (2) and ‘very often’ (3). The individual is asked to rate items for their behavior in childhood and over the past six months (current/adulthood). The Barkley scales offer a total symptom count for the inattentive domain and the hyperactive/impulsive domain (0 to 9 for each) and the cut-off criteria applied were: (i) six or more ADHD symptoms in either domain for retrospective childhood ratings; plus (ii) four or more ADHD symptoms from either domain for ‘current’ ADHD ratings.The Barkley scales also include an assessment of impairment asking participants to rate, on a four-point scale , the functional impact of endorsed ADHD symptoms. Impact is assessed for 10 domains, including home life, work or occupation, social interactions, community activities, educational activities, dating or marital relationships, money management, driving, leisure or recreational activities and management of daily responsibilities. The Barkley Current Symptom Scale has been reported to have 75% sensitivity and 61% specificity on the Inattention scale and 69% sensitivity and 39% specificity for the Hyperactivity/Impulsivity scale . Little This semi-structured clinical interview was used to classify the diagnostic status of the sample. The interview systematically evaluates each of the 18 DSM-IV ADHD symptom items (9 each in the domains of attention and hyperactivity/impulsivity) for both current  and childhood symptoms. The DIVA also includes additional questions to establish impairment from ADHD symptoms (impairment criteria), in two or more settings (pervasiveness criteria) and the age of onset of symptoms (age of onset criteria). The DSM-IV recommendation is that, for a positive diagnosis, six items must be endorsed in the same (or both) domain(s) for current and childhood symptoms. However, a distinction is made in the literature between ‘syndromatic’ and ‘symptomatic’ ADHD, with the latter requiring endorsement of fewer current symptoms  . This idThis questionnaire rates an individual based on seven items tapping intellectual skills  and functional skills . A higher score (range 0 to 7) indicates lower likelihood of intellectual disability and scores can be converted to a percentage score to be compared with the cut-off percentage, as described in the manual. The LDSQ has been reported to have good convergent validity when compared with full-scale IQ scores ,50, withThis six-item self-report screen asks individuals to rate frequency of adolescent conduct behaviors on a four-point scale. Possible scores range from 6 to 24 with a higher score indicating greater presence of conduct disorder symptoms. The OADP-CDS has been shown to have good internal consistency, test-re-test reliability and good screening efficiency for detecting lifetime CD. As recommended, cut-off scores of 10 or higher for males and 8 or higher for females were used to indicate presence of CD . In the A review of the Custody Record was conducted in order to extract relevant information to test the hypotheses of the present study. Data were collected relating to: (1) police procedures and provisions . (2) duration of time the detainee had spent in custody . (3) requests made while in custody; this was the number of times each participant requested food/drink, legal contact , family contact, or made some other request . Information pertaining to these requests was found to be recorded routinely using similar wording across the small number of staff responsible for responding to a buzzer pressed by a detainee. There were no record reviews completed where this information was not available.This tool is a standard assessment that is routinely administered to all detainees presenting at the custody suite reception. It is documented within the Custody Record. The tool consists of categorical data in the form of Yes/No answers for questions pertaining to alcohol and substance use, medical and/or mental health needs, ability to read and write, and additional needs while in custody. Four questions completed by the Custody Officer and seven of the detainee-report questions were thought to be theoretically relevant to exploring whether the screening tool successfully identified vulnerable individuals.Following ethical approval by the King’s College London Psychiatry, Nursing and Midwifery subcommittee (reference PNM/10/11-116), participants were recruited at the custody suite over a 12-week period in 2011. All detainees deemed suitable by custody staff were approached by a researcher with a member of staff. They were invited to take part in a study investigating factors that might be associated with behavior in custody. Those who were interested in participating were taken to a consultation room off the main custody area where the research assistant provided an information sheet and a verbal explanation of the study, and the participant had the opportunity to ask any questions. Those who reported difficulties reading the information sheet, or those who did not wish to do so, had the information sheet verbally read to them with opportunities to ask questions and clarify details as required. No individuals reported specific problems understanding the material when it was verbally presented to them. Participants who then wished to take part provided their written consent and completed the questionnaires. Around one-third of participants completed the questionnaires verbally with the researcher due to self-reported difficulties with reading. Following the completion of the participant measures, the researcher completed the record review. Ten participants consented to complete questionnaires but did not give consent for researchers to examine their Custody Record. With regard to the questionnaires, there was some missing data due to some detainees not wishing to complete some of the measures. The precise number completed on each screening measure is reported in the Results section.Of the 195 participants who completed the LDSQ, 13 (6.7%) screened positive for intellectual disability  screened positive for ADHD in childhood and 46 (23.5%) for current symptoms with the largest subgroups being combined (14.8%) and hyperactive/impulsive (6.6%)  screened positive for childhood CD (see Table Of those who screened positive for ADHD (n = 46), 44 (95.7%) completed the CD screen, all of whom screened positive for CD, and 6 (13%) had co-morbid ID. Table Table P < .001). Results indicated significant positive correlations between the number of requests made and childhood CD , childhood ADHD , current ADHD symptoms , ADHD impairment , but not for ID .In order to investigate the relationship of CD, ADHD and ID with requests made for staff time while in custody, one-tailed partial correlations were conducted between symptoms (continuous screening scores) and the number of requests made to staff while in custody. The duration of time between the individual being detained and the time of their record review was recorded and controlled for, as longer time would have afforded greater opportunity to make requests  were noted to have been seen by a HCP. Of these individuals, the current study identified that 7 people screened positive for ID and 24 screened positive for current ADHD. However, only two (28.6%) and one (4.2%) had an Appropriate Adult, respectively.Out of 166 individuals interviewed by police while in custody, 7 (4.2%) were provided with an Appropriate Adult. Two of these suspects screened positive for ID and one for ADHD. Of the remaining 159, 35 (22.0%) screened positive for current ADHD and 9 (5.7%) screened positive for ID.The findings in this study mostly support our hypotheses. The prevalence rates of ID and ADHD were both higher than those reported in the general population from normative  data. With regard to ADHD, rates were marginally higher for childhood symptoms during a period of civil unrest, which suggests that rates of ADHD in custody may be influenced by local and situational factors for young detainees. As expected, there were high rates of co-morbidity, especially between ADHD and CD, which are known to occur together at a higher rate than chance . We founOur results indicate that ADHD and CD symptoms predicted consumption of staff time, with ADHD symptoms driving requests of staff time after controlling for CD and duration of time spent in custody. One possible explanation for this is that those who are symptomatic for ADHD have increased behavioral disinhibition  where iThe exploratory analysis found that the implementation of improved assessment procedures had not increased the rate of the use of Appropriate Adults beyond that reported 20 years previously. Indeed, only two of the detainees screening positive for ID and one for ADHD had been provided with an Appropriate Adult. This represents a serious flaw in the current risk assessment process, especially given the recent initiative of HCPs being present at police custody suites.et al. study [The indicated rate of ID in the current study 6.7%) is consistent with previous findings  and suggl. study , but it l. study . Researc% is consl. study ,56-58. Tl. study . The saml. study . In the Although every individual brought into custody completed a risk-assessment (completed by themselves and by a Custody Officer), and almost half (44.7%) of this sample were interviewed by a HCP, very few were identified as having difficulties that merited the need for an Appropriate Adult. This under-identification has been recognized as one of the main barriers to providing adequate support . NevertDisappointingly, of those detainees interviewed by police only 4.2% were provided with an Appropriate Adult and this figure is almost identical to the 4.3% reported over 20 years previously in the Royal Commission study [The findings should be considered in light of some particular strengths and limitations of the study. Although only representing one large Metropolitan Police station, the findings are likely to generalize to other police stations , but somet al. [Other than the prevalence data for ADHD using a clinical diagnostic methodology, all other analyses were conducted based on a sample obtained from screening rates of ADHD, CD and ID. Hence, diagnostic rates cannot be estimated for CD and ID as the number of false positive and false negative identifications are unknown. In clinical practice, for example, a diagnosis of ID would require assessment of both cognitive and adaptive functioning, and an assessment of childhood onset. Secondly, the screening and diagnostic data were based on self-reported information. This was a necessary methodological limitation as the high turnover of detainees in the custody suite and the short periods of time they generally spend in custody limited the opportunity for obtaining supplementary informant information. Nevertheless, adults with ADHD have been found to be reliable in reporting attention problems . There wet al.  found thet al. .Finally, the focus of the current study has been on identifying vulnerabilities considered relevant to police custody procedures in relation to safeguards and reliability of police interviews. However, a further benefit of thorough screening procedures would be to signpost individuals who may require more detailed assessments for support within designated external services.In summary, ID and ADHD are recognized vulnerabilities for navigating the criminal justice system, particularly early on during interviews and court proceedings. As predicted, these difficulties are more common in a police custody setting than in the general population, yet are largely unrecognized. Identification of these potential vulnerabilities does not appear to have improved greatly with the introduction of the current risk-assessment tools. The self-report version provided a more accurate predictor in the current study than the Custody Officers’ evaluation, although this seems to be disregarded as it does not appear to be routinely used to inform needs in custody. In turn, this resulted in a substantial number of individuals who self-reported literacy and/or mental health problems not being provided with the supportive mechanisms that they may be entitled to during the police interview process. What is clear is that Custody Officers and HPC staff need to develop greater awareness about the mental health and/or intellectual vulnerabilities presenting in police detainees, including their screening and management. This knowledge and information is essential to safeguard the police interview process through the implementation of effective systems to determine the provision of Appropriate Adults.ADHD: Attention Deficit Hyperactivity Disorder; CD: Conduct disorder; CJS: Criminal Justice System; DIVA: Diagnostic Interview for ADHD in Adults; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders-IV; HCPs: Healthcare practitioners; ID: Intellectual disabilities; LDSQ: Learning Disability Screening Questionnaire; OADP-CDS: Oregon Adolescent Depression Project - Conduct Disorder Screen; PACE: Police and Criminal Evidence Act.SY has been a consultant for Janssen-Cilag, Eli-Lilly and Shire; has given educational talks at meetings sponsored by Janssen-Cilag, Shire and Flynn-Pharma, Novatis, Eli-Lilly; and has received research grants from the National Institute of Health Research, Janssen-Cilag, Eli-Lilly and Shire. SY was a member of the NICE guideline development group for ADHD. GG has received speakers’ fees and travel honoraria from Janssen, Eli-Lilly and Shire. EG and OS have no disclosures.All authors have contributed to data analysis and producing drafts of this article through electronic discussions and face-to-face meetings. The final manuscript was read and approved by all authors. EG and OS were the Research Assistants who conducted the data collection.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/11/248/prepub


Response inhibition, an important domain of executive function (EF), involves the ability to suppress irrelevant or interfering information and impulses. Previous studies have shown impairment of response inhibition in high functioning autism (HFA) and attention deficit hyperactivity disorder (ADHD), but more recent findings have been inconsistent. To date, almost no studies have been conducted using functional imaging techniques to directly compare inhibitory control between children with HFA and those with ADHD.Nineteen children with HFA, 16 age- and intelligence quotient (IQ)-matched children with ADHD, and 16 typically developing (TD) children were imaged using functional near-infrared spectroscopy (NIRS) while performing Go/No-go and Stroop tasks.Compared with the TD group, children in both the HFA and ADHD groups took more time to respond during the No-go blocks, with reaction time longest for HFA and shortest for TD. Children in the HFA and ADHD groups also made a greater number of reaction errors in the No-go blocks than those in the TD group. During the Stroop task, there were no significant differences between these three groups in reaction time and omission errors. Both the HFA and ADHD groups showed a higher level of inactivation in the right prefrontal cortex (PFC) during the No-go blocks, relative to the TD group. However, no significant differences were found between groups in the levels of oxyhemoglobin concentration in the PFC during the Stroop task.Functional brain imaging using NIRS showed reduced activation in the right PFC in children with HFA or ADHD during an inhibition task, indicating that inhibitory dysfunction is a shared feature of both HFA and ADHD. Autism is a disorder characterized by impairments in social interaction and communication, and a markedly restricted repertoire of social activities and interests . Many studies have indicated that individuals with autism exhibit an impairment of executive function (EF). Response inhibition, an important domain of EF, reflects the ability to suppress irrelevant or interfering information or impulses. Mosconi Clinical observations indicate that autism and attention deficit-hyperactivity disorder (ADHD) share many similar symptoms, including inattention, hyperactivity, and poor self-control. Several studies have suggested that inhibitory dysfunction is a key neurophysiological defect of ADHD A number of groups have directly compared response inhibition between ADHD and autism groups. However, these studies have often yielded conflicting results. For instance, Ozonoff and Jensen Casey Besides, according to the weak central coherence hypothesis of Frith (1989) concerning the abnormal performance of individuals with autism on tasks that involve both local processing and global processing Functional near-infrared spectroscopy (NIRS) is an optical method for measuring changes in brain oxygenation. NIRS is noninvasive, easy to operate and conduct repeat scans, and provides data with a high temporal resolution. Thus, NIRS may be a useful approach for assessing brain function in children with developmental disorders, particularly when combined with neuropsychological tests.Further investigation of phenotypic overlap between ADHD and autism at the behavioral and neurocognitive levels are needed for the identification of endophenotypes across diagnostic categories. The current study has attempted to compare the performances of children with autism and ADHD in tasks requiring response inhibition, as well as use NIRS to investigate any differences between these two disorders in the functioning of the prefrontal cortex during response inhibition tasks.Nineteen boys with high functioning autism (HFA) (IQ≥80) and 16 boys with ADHD, recruited from the Child Mental Health Research Center of Nanjing Brain Hospital, were compared with 16 typically developing (TD) children recruited from the local community. Participants were group-matched for age, gender, full-scale IQ and handedness. All participants were right-handed, and the range of ages was 8–14 years old see . IndividThe Go/No-go task was a block design task comprised of two Go and two No-go blocks. Blocks were presented alternately with a 30 s resting phase. Each block included 20 trials, and in total, 80 trials were given, of which 25% were No-go (inhibition) trials. Each trial was displayed for 500 ms, with a 1000 ms inter-stimulus interval. In No-go blocks, participants were required to make a response to the letter “O”, and withhold their response when the letter “X” presented. All stimuli had the same occurrence probability of 0.5. In Go blocks, the letters “A” and “B” were shown instead of letters “O” and “X”. Participants were instructed to respond to each letter as quickly as possible, following a fixation cross. The whole experiment lasted 240 s, and the correct reaction times (RT) omission errors and commission errors (responding to a No-go) were recorded.The Stroop task was composed of two conditions, and each condition was presented twice, alternately, with a 30 s resting phase. Each block included 10 sets of stimuli, and every trial was displayed for 500 ms, with a 2500 ms inter-stimulus interval. Participants were alternately shown the letter “X” in one of four colors , and black Chinese characters whose meanings represented the four colors described above, in neutral blocks. Participants were required to distinguish whether the meaning that the Chinese character represented was consistent with the color of the letter “X”, and to respond accurately, as quickly as possible.In incongruent blocks, participants were alternately shown black Chinese characters whose meanings represented one of four colors , and Chinese characters printed in those four colors. As in the neutral task, participants were instructed to make an immediate and accurate response while distinguishing whether the colored character was of the same color as described by the meaning of the black character.The total experiment time was 240 s, and performance was measured using the correct reaction times and reaction errors in incongruent blocks.A 16-channel NIRS system (JH-NIRS-BR-05), developed by Huazhong University of Science and Technology, was used to measure the relative changes in oxygenated hemoglobin (oxy-Hb). This system used near infrared light at three wavelengths . In the current study, the relative concentrations of oxy-Hb were recorded at 16 measurement points in an area of 1.875×2.2 cm over the bilateral prefrontal cortex see . The samt-tests. All statistical analyses were conducted using SPSS 16.0 for Windows software, and P<0.05 was regarded as statistically significant.In order to improve the signal-to-noise ratio, NIRS data were filtered with a digital bandpass set between 0.0005 and 0.02 Hz. To compensate for drift over time, a baseline correction of oxy-Hb (5 s preceding the task) was carried out, in which the mean value of the baseline was calculated and subtracted from each time point during the baseline and activation phase F = 3.47, P = 0.04), whereas there was no significant difference between the HFA and ADHD groups in the number of commission errors (P>0.05). There were significant differences between the three groups in the reaction times during the No-go blocks . The results of t-test showed that both the ADHD and HFA groups had a longer reaction time during the inhibition task (P<0.05) comparing to the TD group. For the number of the omission errors, neither the HFA nor ADHD group made more than the TD group did (P>0.05). However, during the Go blocks there were no significant differences among the three groups in the reaction time .The behavioral data for all subjects undertaking the Go/No-go task were considered suitable for analysis since that the error rate was not higher than 30%, as shown in F = 0.88, P = 0.42) and in the reaction time  during the incongruent blocks. In addition, there were no significant differences between the HFA group and TD group in both the reaction errors  and reaction time during incongruent blocks . Furthermore, the children with ADHD performed as well as the TD children during the incongruent blocks . Meanwhile, compared with the ADHD group, the HFA group did not made more errors in the Stroop task   see .−4±34×.1410−4 a.u. vs. 0.52×10−4±37.58×10−4 a.u.; t = 2.75, P = 0.009). Furthermore, there was a significant difference in the oxy-Hb concentration in the right prefrontal cortex between the ADHD and TD groups . However, there were no significant differences between groups in the oxy-Hb concentrations in the other three regions of the prefrontal cortex (P>0.05). Moreover, as shown in −4±28.53×10−4 a.u. vs. −36.47×10−4±33.01×10−4a.u.; t = 2.62, P = 0.01). However, there were no significant differences between HFA group and TD group in the oxy-Hb concentrations in the prefrontal cortex (P>0.05)Analysis of the data using t-tests showed that the oxy-Hb concentration of the right prefrontal cortex in the HFA group was lower than that in the TD group during No-go blocks (−32.88×10ADHD and autism are both highly heritable neurodevelopmental disorders. There is evidence that both these conditions co-exist with a high frequency: specifically, 20–50% of children with ADHD meet the criteria for autism, while 30–80% of children with autism meet the criteria for ADHD From the behavioral perspective, our data are suggestive of a dysfunction in response inhibition both in the HFA group and in the ADHD group. Compared with the TD group, children in both the HFA and ADHD groups needed more time to make a response during a No-go blocks. In addition, their difficulty might be specific to the No-go blocks, as during Go blocks no significant difference was found between each two groups. Furthermore, children in both these groups made more errors than those in the TD group during the No-go blocks. These data demonstrate that impairment of response inhibition exists in both HFA and ADHD, and this finding is in agreement with that of Christ However, during the Stroop task, no significant differences in error number were noted in our study between the HFA and TD children, or between the ADHD and TD children. These deferential results obtained from the Go/No-go and Stroop tasks support the viewpoint of Casey From our study, we found that both reaction time and oxy-Hb level in the right prefrontal lobe are highest in the HFA group, and lowest in the TD group. Imaging studies have found that inhibitory function is correlated with the level of activation of the right prefrontal lobe Although Schroeter et al. Some limitations of this study are worth noting. First, the present study included a rather small sample size, and further research is needed to increase the sample size and strengthen the conclusions drawn. Second, because NIRS is unable detect the activities of deep sub-cortical structures where near-infrared light cannot reach, combination studies with other imaging methods are needed to further investigate possible relationships between the activity of the prefrontal cortex and the responses to stimuli.


B. henselae, B. clarridgeiae, B. vinsonii subsp. berkhoffii and B. bovis. Overall seroprevalence was 47.4% in dogs (n = 97), 40.4% in jackals (n = 57) and 12.8% in red foxes (n = 39). Bartonella species DNA was amplified from whole blood and representative strains were sequenced. DNA of a new Bartonella species similar to but distinct from B. bovis, was amplified from 37.1% of the dogs and 12.3% of the jackals. B. vinsonii subsp. berkhoffii was also amplified from one jackal and no Bartonella DNA was amplified from foxes. Adjusting for age, the odds of dogs being Bartonella PCR positive were 11.94 times higher than for wild canids (95% CI: 4.55–31.35), suggesting their role as reservoir for this new Bartonella species. This study reports on the prevalence of Bartonella species in domestic and wild canids of Iraq and provides the first detection of Bartonella in jackals. We propose Candidatus Bartonella merieuxii for this new Bartonella species. Most of the Bartonella species identified in sick dogs are also pathogenic for humans. Therefore, seroprevalence in Iraqi dog owners and bacteremia in Iraqi people with unexplained fever or culture negative endocarditis requires further investigation as well as in United States military personnel who were stationed in Iraq. Finally, it will also be essential to test any dog brought back from Iraq to the USA for presence of Bartonella bacteremia to prevent any accidental introduction of a new Bartonella species to the New World.Bartonellae are emerging vector-borne pathogens infecting erythrocytes and endothelial cells of various domestic and wild mammals. Blood samples were collected from domestic and wild canids in Iraq under the United States Army zoonotic disease surveillance program. Serology was performed using an indirect immunofluorescent antibody test for  B. henselae, B. clarridgeiae, B. vinsonii subsp. berkhoffii and B. bovis. Overall seroprevalence was 47% in dogs (n = 97), 40% in jackals (n = 57) and 13% in red foxes (n = 39). Bartonella species DNA was amplified from whole blood and representative strains were sequenced. DNA of Candidatus Bartonella merieuxii, a new Bartonella species similar to but distinct from B. bovis, was amplified from 37% of the dogs and 12% of the jackals. B. vinsonii subsp. berkhoffii was also amplified from one jackal and no Bartonella DNA was amplified from foxes. Dogs were more likely to be Bartonella PCR positive than wild jackals and foxes, suggesting the role of dogs as reservoir for this new Bartonella species. As most Bartonella species isolated or detected in dogs are also infecting humans, it will be important to test Iraqi people, especially from Baghdad, and American veterans who served in Iraq for the presence of infection by Candidatus Bartonella merieuxii.Bartonellae are emerging vector-borne pathogens infecting erythrocytes and endothelial cells of various domestic and wild mammals. Blood samples were collected from domestic and wild canids in Iraq under the United States Army zoonotic disease surveillance program. Serology was performed using an indirect immunofluorescent antibody test for  Bartonella are fastidious, hemotropic, gram negative, rods that have an affinity for the erythrocytes, endothelial cells and macrophages of their hosts Lutzomyia verrucarum) for B. bacilliformis, the cat flea  for B. henselae, and the human body louse (Pediculus humanis corporis) for B. quintanaBartonella to bank voles and gerbils  by Ctenophthalmus nobilis fleas and to jirds (Meriones crassus) by Xenopsylla ramesis has also been established Bartonella DNA has been detected in ticks and biting flies as well B. birtlesii by Ixodes ricinusThese bacteria are primarily arthropod-borne Bartonella and many Candidatus species have been identified in a wide range of domestic and wild animals More than 25 species/subspecies of Bartonella infections in humans is quite broad Bartonella species B. henselae and B. quintana cause severe systemic diseases in immunocompromised patients, such as bacillary angiomatosis and bacillary peliosis Bartonella infections are an important cause of culture-negative endocarditis in humans Bartonella infections include prolonged fever of unknown origin with or without lymphadenopathy Bartonella spp. The clinical spectrum of Bartonella species, most of which are zoonotic, have been isolated or detected by PCR amplification and DNA sequencing from dogs, including B. vinsonii subsp. berkhoffii, B. henselae, B. clarridgeiae, B. rochalimae, B. quintana, B. koehlerae, B. elizabethae, B. vinsonii subsp. arupensis, B. taylorii, B. volans-like, B. bovis and B. bovis-like Bartonella sp. strain designated as strain HMD [GenBank accession number EF614393], which is phylogenetically similar, but distinct from B. bovisBartonella spp. are very similar to the clinical and pathologic abnormalities seen in humans, the findings in this manuscript may prove to be of comparative medical importance Bartonella species is still unclear Bartonella infection has never been reported in Iraq. Therefore, the objective of the present study was to investigate the presence of Bartonella spp. by PCR amplification and to assess seroprevalence of B. henselae, B. clarridgeiae, B. vinsonii subsp. berkhoffii and B. bovis in domestic and wild canids of Iraq.Several Canis familiaris), 57 (29.5%) jackals (Canis aureus) and 39 (20.2%) red foxes (Vulpes vulpes) located on several United States military bases throughout Iraq. Categorical age, sex, and location data was also collected with samples, when possible.Whole blood samples (1.5–2 ml) were collected between February and December 2008 under the US Army feral animal control and zoonotic disease surveillance program from the saphenous or jugular veins in EDTA tubes from 193 canids, including 97 (50.3%) stray dogs  Animal Use and Care Committee  in accordance with the Guide for the Care and Use of Laboratory Animals of the National Institutes of Health. The blood samples were frozen and shipped to the UCD School of Veterinary Medicine. In a pilot study on 40 dogs, 10 jackals and 35 foxes , either major bacterial contamination or lack of isolation of B. henselae H1 (ATCC 49882) and U4 (UC Davis), B. clarridgeiae (ATCC51734), B. vinsonii subsp. berkhoffii genotype I (ATCC 51672) and B. bovis (strain 91-4T: CIP 106692T and CCUG 43828T) were tested on the serum or blood supernatant samples, using an indirect immune-fluorescent-antibody assay (IFA) as previously described B. vinsonii subsp. berkhoffii and B. bovis), 1∶2800 (B. henselae H1 and U4) and 1∶3600 (B. clarridgeiae). For each well, 20 µl of the conjugates were added to the respective slides. The intensity of the fluorescence was graded subjectively by two independent masked readers, with sample fluorescence graded ≥2 at the 1∶64 dilution reported as positive.Presence of antibodies against gltA gene was then performed for all samples gltA gene were BhCS.781p 5′- and BhCS.1137n 5′, as previously described gltA gene was amplified and then verified by gel electrophoresis. The amplified product was then digested with restriction endonucleases TaqI , HhaI, MseI and DdeI . Banding patterns were compared with 19 standard strains of Bartonella, including B. henselae and B. clarridgeiae, B. koehlerae and Bartonella ruminant strains.The DNA was extracted as previously described rpoB gene gltA gene sequence for the HMD strain had not been previously performed, DNA from strain HMD was submitted by one of the authors (EB), and after PCR testing with the appropriate primers, was submitted for sequencing . Amplified products from the gltA gene, rpoB gene, and the ITS region were sequenced in both directions and consensus sequences were compared. The sequence alignments obtained in this study were also referenced against those of other known Bartonella species deposited in the GenBank/EMBL/DDBJ database using BLAST [gltA, rpoB and ITS spacer sequences to identify genetic variants. A phylogenetic tree was constructed from concatenated sequences of gltA, rpoB and ITS from representative Bartonella isolates, including ruminant-associated Bartonella species, by using neighbor-joining methods. Nucleotide substitution rates were calculated by Kimura's two-parameter distance model, as previously described Two representative DNA products from the dog and jackal groups were further analyzed by PCR of the 16S-23S rRNA intergenic spacer region (ITS) ng BLAST . The CluBartonella prevalence data generated from diagnostic tests and binomial proportion confidence intervals (CI) were calculated using Wald and Fisher's exact methods where appropriate in OpenEpi, version 2.3.1 . All variables were initially screened using univariate logistic regression to check for statistically significant associations with serology and PCR outcomes. Due to quasi-complete separation of PCR data, species and location variables were reclassified in biologically meaningful groups prior to univariate analysis. Using forward stepwise selection methods, categorical variables were retained in separate multivariate logistic regression models for PCR and IFA. Variables that induced changes >10% in the β-coefficients of covariates after inclusion in the model were considered to be potential confounders, and evaluated along with biological reasoning and prior knowledge. Likelihood ratio tests comparing models with and without two-way interaction terms were used to determine presence of effect measure modification. All logistic regression models and resulting adjusted odds ratios with 95% CI were generated in SAS, version 9.3 .gltA PCR product from the four enzyme digestions indicated similar banding patterns for all 36 dogs (data not shown). Banding pattern was similar to B. clarridgeiae using TaqI, HhaI and MseI. However, DdeI allowed differentiating these strains from B. clarridgeiae. A representative dog “strain” (F059) was chosen for further genetic analysis. Sequencing of the gltA gene fragment showed that the closest related Bartonella species were respectively B. bovis, B. schoenbuchensis, B. melophagi, B. chomelii and B. capreoli [gltA sequence of the HMD strain was deposited in GenBank under the number JX073031. Sequencing of the 16S-23S ITS spacer region indicated that DNA of “strain” F059 was 100% identical to the previously reported HMD strain Bartonella species [rpoB sequences, DNA of “strain” F059 was also 100% identical to strain HMD and with the closest related species being B. bovis and other ruminant Bartonella species [Most of the dogs  were captured in Baghdad and surrounding suburbs . The other dogs were from locations classified as North Iraq (n = 15), West Iraq (n = 3) or South Iraq (n = 2). Forty-three (57.3%) of the 75 dogs for which sex was reported (missing from 22 dogs) were male. Age was not recorded for 27 animals, with 60 (85.7%) of the 70 dogs classified as adults. Thirty-six dogs  were PCR positive . RFLP ancapreoli . The par species . For the species gltA and rpoB genes and the 16S-23S ITS indicted that all strains clustered together and aligned most closely to B. bovis  or North Iraq . Within Baghdad and its suburbs, 57.14% (20/35) of the dogs from Inner Baghdad, 40% (6/15) from Outer Baghdad and 14.8% (4/27) from North Baghdad were PCR positive. Of the male dogs, 46.5% (20/43) were PCR positive compared to 46.8% (15/32) of the females. Only 10% (1/10) of the young dogs compared to 53.3% (32/60) of the adults were PCR positive.A phylogenetic tree of the concatenated sequences of the B. bovis . HoweverBartonella antigen [B. bovis, specifically.Overall, 47.4% of the dogs  were seropositive to at least one  antigen . Among t antigen . Of the Bartonella, including one young male from North Iraq infected with B. vinsonii subsp. berkhoffii [Of the 57 jackals sampled, 55.6% (30/54) were collected from North Baghdad, 18.5% (10/54) from Outer Baghdad, 16.7% (9/54) from North Iraq, and 9.3% (5/54) from West Iraq . The sex ratio of the sampled jackals was 83% (44/53) male and 17% (9/53) female . Age was recorded dichotomously for 51 jackals, with 74.5% (38/51) classified as adults and 25.5% (13/51) as young. Seven jackals  were PCR positive for rkhoffii . The othgltA gene sequence aligned most closely with B. bovis and the other ruminant Bartonella species [B. schoenbuchensis and the other ruminant Bartonella species. For the rpoB sequences, DNA amplification from jackal F040 was 100% identical to strain HMD and aligned most closely with B. bovis and the other ruminant Bartonella species [DNA of a representative jackal “strain” (F040) was chosen for genetic analysis. The  species . The 16S species .Bartonella antigen [Bartonella sp. strain HMD adult male from North Baghdad. All six other jackals were IFA positive for the four Bartonella antigens. Of the 17 seropositive jackals that were PCR negative, 70.6% (12/17) were seropositive for the four antigens tested.Overall, 40.4%  of the jackals were seropositive for at least one  antigen . Of the Bartonella PCR positive [Blood samples were collected from 39 red foxes, comprised of 21 from West Iraq, 15 from Baghdad (four from Inner and 11 from Outer Baghdad) and three from North Iraq. There were 20 male and 19 female foxes, including 29 adults and 10 young individuals. None of the fox samples were positive . SeropreBartonella PCR positive were 11.94 times higher than of wild canids (95% CI: 4.55–31.35). Adjusting for species, the odds of adult canids being PCR positive were 5.62 times higher than young canids (95% CI: 1.19–26.59). The age-adjusted odds of dogs being Bartonella seropositive were 8.71 times higher than for foxes (95% CI: 3.03–25.01). Similarly, age-adjusted odds of jackals being Bartonella seropositive were 5.64 times higher than of foxes (95% CI: 1.87–17.07).Species, sex, age and location data were collected for most of the canids and submitted to a univariate analysis  and 8. ABartonella species in domestic and wild canids of Iraq and provides the first detection of Bartonella in jackals. Dogs and jackals were frequently infected with a new Bartonella species similar to strain HMD, initially described from dogs in southern Italy and Greece This study reports on the prevalence of B. bovis clearly suggest that the “strains” infecting dogs belong to a new Bartonella species. We propose Candidatus Bartonella merieuxii for this new species. B. vinsonii subsp. berkhoffii, a common Bartonella species isolated from dogs B. rochalimae was not detected from any of the canids, which is especially interesting as red foxes have been found to be infected by this Bartonella species in Israel and Europe Candidatus B. merieuxii infection in dogs than in wild canids, domestic dogs may represent a major reservoir of this new species in Iraq. Because this new species is genetically related to B. bovis, we sought to investigate the seroprevalence of B. bovis in these canids in addition to the antigens usually used for canids in our laboratory. Most (86%) dogs and jackals that were PCR positive were also seropositive for B. bovis and for the three other antigens. The lowest seroprevalence observed was for B. clarridgeiae and B. vinsonii subsp. berkhoffii, suggesting that these Bartonella species may be found less frequently in Iraqi canids as compared to other parts of the world.Based on the criteria suggested by La Scola et al. Bartonella species in animals of the tropics, Middle East, and some African nations Bartonella bacteremia in stray dogs was 31.3% (60/192) The high seroprevalence in stray dogs and jackals correlates with previously reported studies on seroprevalence of B. henselae and B. clarridgeiae, especially in human sera Bartonella species was due to cross-reactions or to co-infection or sequential infection to different Bartonella spp. over an extended time period. Given the relatively small sample sizes of some canid groups and locations, larger studies will be important to strengthen our findings.Cross-reactivity is known to occur between Bartonella spp. in dogs. The current hypothesis on the mode of transmission of B. vinsonii subsp. berkhoffii involves ticks, because seropositive dogs were also frequently seropositive for other known tick-borne pathogens B. quintana, B. quintana DNA has been amplified from both fleas and ticks, providing support for being possible Bartonella vectors Candidatus Bartonella merieuxii was detected in Rhipicephalus sanguineus ticks, as DNA was amplified from three tick pools including one pool from salivary glands from female ticks and one gut content pool collected two dogs PCR positive for Candidatus B. merieuxii Bartonella species. Unfortunately, information on the presence of ectoparasites was not available and no quantitative measure of the fleas and ticks was reported. Given the high prevalence of Bartonella spp. reported in dogs and to a lesser extent in jackals, studies to detect Bartonella spp. DNA in arthropods in Iraq are warranted.To date, no vector has been proven as the source of infection for any B. henselae and B. clarridgeiae. Symptomatic bacteremic dogs are often seronegative and frequently manifest similar pathology and disease manifestations as reported in human patients Bartonella species identified in sick dogs are also pathogenic for humans Bartonella quintana, for instance, causes a high percentage of endocarditis in people and has been associated with endocarditis in dogs Bartonella bacteremia in veterans with unexplained fever, lymphadenopathy, or culture negative endocarditis. Finally, it will also be essential to test any dog brought back from Iraq to the USA for presence of Bartonella bacteremia to prevent any accidental introduction of a new Bartonella species to the New World.In humans, clinical diagnosis of atypical CSD and bacteremia associated with other emerging clinical manifestations of bartonellosis is difficult Bartonella species or subspecies. As a reservoir, persistent infection in dogs has been documented in association with B. vinsonii subsp. berkhoffii, B. henselae and B. koehleraeB. henselae to people B. vinsonii subsp. berkhoffii or B. henselae from dogs to veterinarians Bartonella sp. to facilitate additional genetic characterization and the development and validation of Bartonella species specific serologic assays. In addition, attempts at isolation from sick soldiers deployed in Iraq would seem reasonable.In the context of zoontic bartonellosis, the dog appears to serve as both a sentinel and a reservoir for human infections. As a sentinel, infection in both dogs and humans (most often cases of endocarditis) has now been documented for eight Bartonella infection was detected in domestic dogs and wild canids in different areas of Iraq. Our findings identify a potential role for dogs as a major reservoir of a new and potentially zoonotic Bartonella species.In summary, presence of Bartonella merieuxii , allowed him to build many bridges between physicians and veterinarians in the field of zoonoses. DNA of this species has been amplified and sequenced from dogs and wild canids  in the old world.


Olefin metathesis has emerged as a powerful tool in organic synthesis. The activating effect of an allylic hydroxy group in metathesis has been known for more than 10 years, and many organic chemists have taken advantage of this positive influence for efficient synthesis of natural products. Recently, the discovery of the rate enhancement by allyl sulfides in aqueous cross-metathesis has allowed the first examples of such a reaction on proteins. This led to a new benchmark in substrate complexity for cross-metathesis and expanded the potential of olefin metathesis for other applications in chemical biology. The enhanced reactivity of allyl sulfide, along with earlier reports of a similar effect by allylic hydroxy groups, suggests that allyl chalcogens generally play an important role in modulating the rate of olefin metathesis. In this review, we discuss the effect of allylic chalcogens in olefin metathesis and highlight its most recent applications in synthetic chemistry and protein modifications. In some cases, metathesis is even compatible with amine and sulfur containing building blocks. Together with its high stability in various media and excellent chemoselectivity, olefin metathesis has been used on peptide substrates for various applications in chemical biology [Olefin metathesis is one of the most useful chemical transformations for forming carbon–carbon bonds in organic synthesis  1–4]. T–4. T1–4] biology –8. The d biology –13 and o biology –15, revi biology , has ena biology –18.The outcome of olefin metathesis is sensitive to multiple factors, such as the nature of the catalyst, steric crowding around the alkene and the directing effects of nearby heteroatoms. These factors are of great importance, especially when optimizing reaction conditions for delicate natural product synthesis or protein modification. Interestingly, the activating effect of allylic heteroatoms, such as oxygen and sulfur in olefin substrates, has been observed in many examples and was found to play an important role for effective olefin metathesis in synthesis. These reports suggest that allylic chalcogens can modulate the rate of olefin metathesis, and their effects appear to be a general phenomenon in metathesis chemistry.In this review, we collect these reports and discuss the activating effect of allylic chalcogens, such as oxygen, sulfur and selenium, as well as their relative reactivity in olefin metathesis. The applications of the allylic chalcogen effect in protein modifications via olefin metathesis and the associated principles of cross-metathesis (CM) partner selection for reliable and efficient reaction on proteins are also highlighted.tert-butylethylene, containing a fully substituted allylic center, was reported to be almost inert to reaction with catalyst 1 . Th. Th24]. ereomers . The obsreferred . This in19 was synthesized by the CM reaction between diene 16 and methyl acrylate with very high yield [17 which has a conformation unfavorable for RCM. The open chain intermediate 17 favors CM, while RCM of 16, must proceed via unfavorable higher energy conformations such as 18a, generated by breaking hydrogen-bonding in 17, and/or highly strained intermediate 18b, if the reaction was to occur  and sulfide derivatives, S-butenyl and S-pentenyl cysteine , failed to work under identical conditions in aqueous media (23) and allyl dibenzylamine (24), but the allyl sulfide analogue 22 remained the most reactive substrate in aqueous media  and 45% , respectively , required the more reactive allyl selenide protein tag for the CM to proceed efficiently. Reactive allyl sulfides such as 39 were unsuitable as CM partners for the protein substrate since they led predominantly to self-metathesis. The allyl amine derivative 38 was unreactive in metathesis with proteins possibly due to an electron-deficient or sterically-demanding nature. Taking these factors into consideration, effective functionalization of proteins by CM (>95% conversion) was achieved with 9 different substrates including biochemically important molecules such as GlcNAc, mannose and N-acetylamine, which could serve as effective mimics of post-translational protein modifications .These studies suggest that an unhindered allyl sulfide or selenide protein tag is a requirement for most effective CM. Allyl and hexenyl ethers were found to be the most compatible CM partners for allyl sulfide or selenide containing proteins. The more challenging alkene substrates, such as the ones containing electron-deficient Since the early work by Hoye on secondary allylic alcohols  and late


The aim of this study was to investigate the compromised developmental trajectory of the functional connectivity among resting-state-related functional networks (RSFNs) in medication-naïve children with attention-deficit/hyperactivity disorder (ADHD).Using both independent component analysis and dual regression, subject-specific time courses of 12 RSFNs were extracted from both 20 medication-naïve children with ADHD, and 20 age and gender-matched control children showing typical development (TDC). Both partial correlation coefficients among the 12 RSFNs and a resting-state resource allocation index (rsRAI) of the salience network (SN) were entered into multiple linear regression analysis to investigate the compromised, age-related change in medication-naïve ADHD children. Finally, correlation analyses were performed between the compromised RSFN connections showing significant group-by-age interaction and rsRAI of SN or clinical variables.Medication-naïve ADHD subjects failed to show age-related increment of functional connectivity in both rsRAI of SN and two RSFN connections, SN-Sensory/motor and posterior default mode/precuneus network (pDMN/prec) – anterior DMN. Lower SN-Sensory/motor connectivity was related with higher scores on the ADHD Rating Scale, and with poor scores on the continuous performance test. The pDMN/prec-aDMN connectivity was positively related with rsRAI of SN.Our results suggest that medication-naïve ADHD subjects may have delayed maturation of the two functional connections, SN-Sensory/Motor and aDMN-pDMN/prec. Interventions that enhance the functional connectivity of these two connections may merit attention as potential therapeutic or preventive options in both ADHD and TDC. Abnormalities beyond the fronto-striatal circuit in attention-deficit/hyperactivity disorder (ADHD) subjects have been consistently reported in recent neuroimaging studies. Brain abnormalities have been found not only in the frontal-striatal circuitry In developing children, however, age is an important factor to consider when exploring the brain as a network system. A recent study reported that cortical thinning across age was found in bilateral hemisphere of both ADHD and healthy subjects, when comparing children to young adults To explore the brain as a network system in developing children, there are some considerations for constructing functional networks, such as the selection and the number of regions of interest (ROI), and the method for measuring functional connectivity. One method is the selection of ROIs derived from either anatomical parcellation in each subject, or from use of anatomical atlases. While this method can show the characteristics of large-scale networks of the brain system, the lack of functional meaning of anatomy-based ROIs is the most critical disadvantage. In the present study, the method for choosing ROIs was the extraction of macro-scale functional networks with a data reduction method such as independent component analysis (ICA), a multivariate method. The method using ICA can reduce brain imaging data, without any significant data loss, into several or tens of macro-scale functional networks which can better reflect functionality than do anatomical-atlas-based approaches. If ICA is performed with low number of dimensions, a brain network can be represented, and be understood, with the interactions among a small number of the functional ROIs. Here, using low dimension ICA-dual regression analysis for resting-state fMRI data from medication-naïve ADHD subjects, we delineated subject-specific functional networks and their time courses. Then, partial correlation was used to measure functional connectivity, which controls the effect of other connections on a specific connection, among the resting-state functional networks (RSFNs).For the theory-driven test, our approach considering interactions among all networks in brain can provide less biased results than the previous method without considering them In sum, previous studies have suggested that brain abnormalities in those with ADHD are not only in the fronto-striatal circuit, but also involve interaction among whole brain functional networks, the salience network (SN) in particular, including dACC, AI and PPC, CEN, and DMN. The altered interaction among SN, CEN, and DMN may be related with attentional lapses in ADHD. Also, the developmental properties may influence the aberrant interactions among functional networks. However, to the best of our knowledge, no study has dealt with considerations of the aspects of development of macro-scale whole brain systems, especially using such as functional ROI selection, connectivity measures, rsRAI and developmental properties; simultaneously, in medication-naïve ADHD children.We test following hypotheses. First, medication-naïve ADHD have the aberrant development of specific functional connections in whole brain network consisting of several or tens of RSFNs. The aberrant connectivities may relate with behavioral and cognitive measures. Secondly, based on the theory from previous studies, rsRAI of SN also shows the aberrant development in medication-naïve ADHD children. Finally, there are the association of the aberrant development of functional connections and rsRAI showing significant age by group interaction, implicating underlying mechanism in ADHD brain network.We recruited psychotropic medication-naïve children with ADHD, aged 6 to 16 years, by advertisements targeting children who visit the child and adolescent psychiatric clinic in St. Mary’s Hospital . Typically-developing control children (TDC) were also recruited by advertisements targeting children who were between 6–16 years of age, and who had no history of psychiatric disorder. The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition - DSM-IV) criteria on structured diagnostic interview (Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Life time Version-Korean Version) were used for diagnosis. All subjects were right-handed and had full-scale Intelligence Quotients above 70. Subjects were also required to be free from any neurological disease or insult, developmental disorders including pervasive developmental disorders or mental retardation, and medical disorders that could affect brain development. Subjects were excluded who had any history of substance abuse, any recent substance use, psychotropic medication, head trauma, significant fetal exposure to alcohol or drugs, and perinatal or neonatal complications. Subjects were excluded with claustrophobia, irremovable metal materials, or poor cooperation with the MRI scanning procedure. The Catholic University of Korea – Daejeon, St. Mary’s Hospital Institutional Review Board approved all procedures. The purpose of the study was explained to subjects and parents, who gave their written informed consent. All parents provided demographic information . The numADHD and other psychiatric comorbidities were determined based on the Korean Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL), a semi-structured diagnostic instrument. The reliability and validity of the K-SADS-PL has been previously determined For assessment of ADHD symptoms, inattentiveness and hyperactivity were evaluated by both parents and psychiatrists based on the Korean version of the ADHD rating scale (K-ARS). The severity of ADHD symptoms were assessed with the ADHD Rating Scale (ARS) which was introduced by Dupaul and his colleagues Assessment of neurocognitive functions has also been done. A computerized, continuous performance test (CPT) 3; imaging matrix: 64×64; field-of-view (FOV): 240×240 mm2, number of slices: 27; 210 volumes. Subjects were instructed to keep their eyes closed and not to think of anything particular during fMR scans. A T1-weighted anatomical image was also acquired using a magnetization-prepared, gradient-echo sequence . The head was stabilized with cushions and taped to help minimize movement.Using a 1.5 T Philips scanner at Daejeon St. Mary’s Hospital, fMRI imaging was acquired with a BOLD-sensitive echo-planar gradient-echo (EPI) sequence with the following imaging parameters: repetition time (TR): 2000 ms; echo time (TE): 35 ms; flip angle (FA): 70°; spatial resolution: 3.4375×3.4375×5 mmhttp://www.fmrib.ox.ac.uk/fsl/feat5/index). The first five scans were discarded to account for T1 saturation effects. The remaining 205 images were spatially realigned using rigid-body transformation and were subjected to slice-timing correction. Next, a brain mask from the first fMR data volume was created to eliminate signals outside of the brain, for each subject. Then, a temporal band-pass filter (0.01 Hz<f <0.1) was applied to effectively remove signal drift and to get a resting-state-related signal. Spatial smoothing using a Gaussian kernel of full-width at half-maximum 6 mm was performed to reduce noise without reducing valid activation. The serial correlations were removed to make the statistics valid and maximally efficient. Finally, corresponding fMRI volumes were registered with corresponding 3D high-resolution structural images that had been co-registered to the Montreal Neurological Institute (MNI) T1 template using FLIRT (FMRIB’s Linear Image Registration Tool) of FSL. The fMR volumes were transferred into the MNI space with 4-mm isotropic resolution.The fMRI data were processed and analyzed with the MELODIC (Multivariate Exploratory Linear Optimized Decomposition into Independent Components) module of the FSL software  in the population of all subjects were identified using MELODIC. This involves: (i) using a standard (subject×space×time) ICA decomposition of the temporally concatenated Functional connectivity analyses were performed using time courses of the 12 RSFNs of each subject, which were acquired with dual regression. Results from a functional connectivity study using simulated fMRI data showed that partial correlation (PC) analysis was more reliable than cross correlation (CC) analysis http://stat.ethz.ch/R-manual/R-patched/library/stats/html/lm.html). The linear regression model proposed was:As brain development is very active from age 7 to 16, the functional connectivity should also be actively changing during childhood and adolescence http://cran.r-project.org/web/packages/MASS/index.html). If the model selected by bidirectional elimination approach was the best model, FDR was recalculated with the p-value of the selected model. In each model, both normal distribution and skewedness were tested with the Shapiro-Wilk normality test. The confidence interval of each parameter was calculated using bootstrapping with ‘boot’ of ‘R package’ because the sample size (n = 40) was small in the present study. To compare the slope of the group-by-age interaction after having adjusted other factors, multiple linear regression analysis was performed on each group and the slope for each group was displayed using added-variable  plot An alternative connectivity analysis is the network-based statistics NBS , which is known as a method for coarse sampling resolution  as was present in this study. Although the NBS is a nonparametric statistical test and defines clusters using the graph theoretical concept of connected component, it has the disadvantage that it identifies two separate pairwise connections (B–A and B–C) as one cluster (A–B–C). In a recent ADHD study using NBS, for example, altered intrinsic connectivity in many regions such as orbitofrontal-temporal-occipital and fronto-amygdala-occipital network clusters, was reported . Thus, if the developmental property is confined to a certain functional connection, our approach might be more suitable than NBS to detect it. Permutation method is another option for functional neuroimaging data which are used for inference when the null distribution is not known For the correction for multiple comparisons (66 pairs), false discovery rate (FDR) was performed for each main effect or interaction separately, at a statistical threshold level of q <0.05. To confirm whether our proposed model is apt or not, the model was selected using the bidirectional elimination approach for each surviving RSFN pair. Then, the proposed model was compared with the selected model by bidirectional elimination approach and with the non-interaction model (FC ∼ group+IQ+gender+age). If there was no significant difference, the simpler model was chosen as the best model. All multiple linear regression analyses were performed using ‘MASS 7.3’ of ‘R package’  including the anterior insula (AI) and anterior cingulate cortex (ACC), plays a critical role in switching between the DMN and the CEN . SN may allocate brain resources to either CEN or DMN depending on internal and external situations. Terminology of ‘resource allocation’ having been used when overactivation of brain regions was also linked to the modulation of intrinsic activity of DMN SN-CEN and FCSN-DMN indicate differences in partial correlation coefficients between SN and CEN; and SN and DMN, respectively. Four rsRAIs were calculated . High rsRAI may represent the status for getting ready to cope with external stimuli in resting-state and may be related to a low possibility of attentional lapses. We hypothesized that resource allocation by SN may have developmental properties in TDC which may not be shown in medication-naïve ADHD children. To test our hypothesis, age-by-group interaction was investigated for each rsRAI using multiple linear regression analysis.Here, FCThe functional connection among RSFNs may be related to various phenotypes of ADHD regarding behavior and cognitive ability. Here, using ‘Spearman’s rank order partial correlation analyses’, we explored the relationship between functional connectivity of RSFN pairs, or rsRAI, showing a significant group-by-age interaction and clinical variables after controlling out the effect of age, IQ and gender; at the level of P<0.05. The relationship between IQ and functional connections of RSFN pairs was also explored with the effect of age and gender controlled out at the level of P<0.05.Twenty medication-naïve children with ADHD (mean age 10.2±2.7) and 20 age and gender (M:F = 16∶4) matched TDC (mean age 10.6±2.5) were included in this analysis. The two groups did not differ in age, height, weight, paternal or maternal education levels, but the ADHD-group showed lower scores on the Full Scale IQ Score than the TDC group, and significantly higher scores than TDC groups of the ADHD Symptom Rating Score . The proposed model was, however, better fitted than non-interaction one . In this proposed model, there was a significant age-by-group interaction in Sensory/motor-SN :There was no significant effect on the multiple linear regression analysis of each group. In the functional connectivity between the Sensory/motor network and SN, the slope gradually increased by getting older in TDC group, but decreased in the ADHD group -A. This In the functional connectivity between pDMN/prec and aDMN, the selected model using the bidirectional elimination approach better fitted the data than the proposed model  and also better than the non-interaction model . The selected model was:In this selected model, there were significant main effects on intercept, group, and IQ, as well as age, by group interaction in the aDMN-pDMN/prec connection after correction for multiple comparisons . In the Medication-naïve ADHD subjects failed to show the age-related increment of rsRAIs in bilateral CEN-SN-pDMN/prec connections , which was shown in the TDC group. The bilateral rsRAIs survived after Bonferroni correction at the level of P<0.0125 (0.05/4). See . No age-Partial correlation analysis with age and IQ controlled out at the level of P<0.05, showed that the rsRAI of right CEN-SN-pDMN/prec was positively related with aDMN-pDMN/prec , not SN-Sensory/motor , connectivity across all subjects . This poAfter controlling for age, IQ and gender effects, the age-related decline of functional connectivity in Sensory/motor – SN was associated with the increased K-ARS total , inattention  and hyperactivity  scoresacross all participants. It was also associated with increased omission  and commission errors  in CPT, and with decreased backward  and total  T-scores in the Finger window test across all participants. There were no significant relationships in each group.The increased functional connectivity in pDMN/prec – aDMN was associated with increased verbal  and total IQ  across all subjects; when both age and gender were controlled. This relationship was also found in both the ADHD  and TDC  groups. In the ADHD group, the decreased functional connectivity in pDMN/prec – aDMN was associated with lower body weight  and with shorter height  indicating a delay in physical development.This resting-state fMR study provides an opportunity to identify aberrant developmental trajectories of two RSFN connections: the SN-Sensory/Motor and aDMN-pDMN/prec connections in medication-naïve ADHD children. The SN-Sensory/Motor connection was associated with behavioral or cognitive symptoms. The aDMN-pDMN/prec connection was associated with body weight, height and IQ. Additionally, these abnormalities were related with deficits in the development of resource allocation by the SN in medication-naïve ADHD children. To the best of our knowledge, this is the first report of the aberrant development of resource allocation by SN, and of its relationship with aberrant development of the inter-DMN connectivity in medication-naïve ADHD children.Although the cellular basis of the altered developmental trajectory of the functional connection between specific RSFNs has yet to be established, the delayed or failed development of the between-RSFN connections in medication-naïve ADHD children may be attributed to the slower maturation of the brain network system including neuronal synaptic pruning In a narrow sense, the SN includes dACC, AI and PPC. However, it is also named the cingulo-opercular network. The cingulo-opercular network is thus a variant name of the SN, which anchored by the AI and ACC. The ventral attentional network includes the temporo-parietal junction, the supra-marginal gyrus, frontal operculum and AI Menon et al. (2010) proposed a model of dynamic bottom-up and top-down interaction underlying attentional control. According to their model, first, deviant stimulus detected by primary sensory areas is transmitted to AI and ACC. Second, AI and ACC generate a ‘top-down’ control signal which is transmitted to the primary sensory area and other neocortical regions including the dorsolateral prefrontal cortex, temporo-parietal area and premotor cortex. Third, the neocortical regions respond to the attentional shift. Finally, the ACC facilitates response selection and motor response. Thus, functional connection between SN and sensory/motor networks reflects both attentional and motor responses to significant stimuli.In the present study, the functional connection between SN and sensory/motor network declined in medication-naïve ADHD subjects across age, while it increased in the TDC subjects. Furthermore, the decreased functional connection was associated with increased behavioral symptom scores, especially with inattentive symptoms, and with poorer visual cognitive abilities such as the finger-window-backward task representing visual working memory ability and omission/commission errors of visual CPT across all subjects. In a study using regions of interest in key nodes of the SN, CEN, and DMN; the functional connectivity of the right fronto-insular cortex with the ACC, right dorsolateral prefrontal cortex, and posterior cingulate cortex; were greater in adults than children a priori ROIs which was measured with simple Pearson correlation analysis in patients having medication Medication-naïve ADHD subjects also failed to show age-related increment in the functional connection between pDMN/prec and anterior DMN. The decreased functional connection between posterior and anterior DMNs was associated with decreased IQ across all subjects, as well as in each group. The anterior and posterior DMNs integrate into a cohesive, interconnected network during development In the regression analyses, to investigate age-related changes of functional connectivity between pDMN/prec and anterior DMN, there were significant main effects of intercept, group, age, and IQ; as well as group-by-age interaction . In the As we predicted, medication-naïve ADHD children failed to show age-related increment of rsRAI in bilateral CEN-SN-pDMN/prec; which was found in the TDC group . In a prThe response to treatment can modulate the developmental trajectory of an ADHD brain. The remitted ADHD, in contrast to persistent ADHD, showed a less-steep slope of age-related thinning of the cerebral cortex, especially in the medial prefrontal/cingulate and dorsolateral prefrontal cortex IQ is one of main aspects of brain function which can affect aDMN-pDMN/prec connection. When the multiple linear regression analysis was performed for each group, the main effect on IQ was significant in both groups. We also found a positive relationship between IQ and this connectivity across all subjects, as well as in each group. Thus, our results suggest that those with higher IQ have stronger aDMN-pDMN/prec connection in both groups. In further study, an IQ-matched sample may be needed.In addition, we should comment on several limitations in the present study. First, age-related development of functional connectivity could have a nonlinear trajectory. Unfortunately, the nonlinear trajectory issue was not able to be investigated because of research funding constraints for large sample size for neuroimaging studies. Second, our results could be affected by heterogeneity in terms of gender or ADHD subtypes. Third, the number of ROIs delineated by ICA can vary according to user decisions about dimensionality. In this study, we used the best-fit result provided by MELODIC in FSL. Although our approach with relatively low dimensionality (12 by 12 interactions) focused on the demonstration of brain status as the interaction among large scale RSFNs, ICA analysis with high dimensionality may be helpful to investigate within-network information. These limitations should be considered in further large-sample studies of medication-naïve ADHD subjects. The false discovery rate used in the present study may not be the best option to correct for multiple comparisons.In summary, this resting state fMRI study to investigate developmental differences in functional connectivity among RSFNs, has shown that medication-naïve ADHD may have delayed the maturation of the two functional connections, SN-Sensory/Motor and aDMN-pDMN/prec. Interventions that enhance the functional connectivity of these two connections may get attention as potential therapeutic or preventive options both for ADHD, and for typically-developing children exposed to a highly competitive environment.Figure S1Artifactual components.(DOCX)Click here for additional data file.Figure S2RSFNs from separate ICA for each group. Spatial correlation coefficients between corresponding RSFNs from each group from RSFN1 to RSFN12∶0.67, 0.81, 0.47, 0.77. 0.70, 0.73, 0.72, 0.73, 0.81, 0.68, 0.79, 0.65.(DOCX)Click here for additional data file.Table S1Resting state related independent components (RSFNs). N: network; S: system; DMN: default mode network; SMA: supplementary motor area; Inf: inferior; Sup: superior; C: cortex; G: gyrus; L: left; R: right; B: bilateral.(DOCX)Click here for additional data file.Table S2Functional connectivity among RSFNs: mean correlation coefficients.aStatistically significant age by group interaction at q <0.05. Right upper side: Healthy TDC group; Left lower side: ADHD group. From left-upper to right-lower part: RSFN1: Frontal; RSFN2: Sensory/motor; RSFN3: Salience ; RSFN4: Right central executive (rCEN); RSFN5: Left central executive network (lCEN); RSFN6: Dorsal attentional (dAtt); RSFN7: V1; RSFN8: V1/V2; RSFN9: Extrastriate; RSFN10: a temporooccipital part of posterior DMN (pDMN/TO); RSFN11: a precuneus part of Posterior default mode (pDMN/prec); RSFN12: Anterior default mode (aDMN). Age by group interaction after the correction for multiple comparison using FDR: RSFN 2– RSFN 3 pair ; RSFN 11– RSFN 12 pair .(DOCX)Click here for additional data file.Table S3The number of subjects across age ranges. Two-side fisher’s exact test.(DOCX)Click here for additional data file.


We used insurance claims of a nationally representative population-based cohort to assess the longitudinal treated prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) in children, adolescents and adults.Participants were identified from among National Health Insurance enrollees in Taiwan from 1999 to 2005. We identified study subjects who had at least one service claim during these years with a principal diagnosis of ADHD. A total of 6,173 patients were recorded in the treated ADHD cohort during the 6-year study.p = .001). An increase in the treated incidence rate of ADHD, from 44.67 per 100,000 in 2000 to 81.20 per 100,000 in 2005, was also observed (p = .013). However, the treated prevalence of ADHD was still lower than that of the community data in Taiwan. The peak treated prevalence of ADHD was at age 7–12 years for both males and females, and the peak treated incidence of ADHD was at age 0–6 for females and age 7–12 for males. Overall, the treated incidence and prevalence rates dropped abruptly after age 13–18 (both p<.001) for males and females (p<.001 for both). Male vs. female ratios of treated prevalence and incidence were both above 1 before age 25–30 years, but below 1 thereafter.There was a significant increase in the treated prevalence rate of ADHD during the study period, from 64.65 per 100,000 in 2000 to 145.40 per 100,000 in 2005 (Although an increasing number of people with ADHD sought treatment during 1999–2005 in Taiwan, the treated prevalence of ADHD was still lower than that of the community data. The treated incidence and prevalence of ADHD fell dramatically after age 13–18. However, more women than men sought treatment in adulthood. There may be under-diagnosis and under-treatment of ADHD, especially among females and adults. Attention-deficit/hyperactivity disorder (ADHD) is characterized by behavioral symptoms of inattention, hyperactivity, and impulsivity across the life cycle and is associated with considerable morbidity and disability ADHD impacts several domains of the lives of those who suffer from its symptoms, their family, and society In this study, the medical claims data were retrieved from the Taiwan’s National Health Insurance Research Database (NHIRD). The confidentiality of individuals was protected using encrypted personal identification to avoid the possibility of the ethical violations related to the data. Exemption was obtained from the institutional review board of Chi Mei Medical Center. The study sample was taken from the database of medical claims, including outpatient (ambulatory) care, hospital inpatient care, dental services, and prescription drugs provided by the National Health Research Institutes (NHRI) in Taiwan for use in related healthcare service studies. The Longitudinal Health Insurance Database 2005 is a sub-dataset of the NHIRD that contains all claims data (from 1996 to 2011) of one million beneficiaries who were randomly selected in 2005. The data consists of outpatient (ambulatory) care and inpatient care records and the registration files of the Taiwan NHIRD; as many as 93.1% of the residents of Taiwan in 1999 and 99.2% in 2009 were enrolled in the national health insurance system. There were no statistically significant differences in age and sex between the sample group and all enrollees.Using the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic criteria In Taiwan, most of ADHD patients are diagnosed and treated by psychiatrists. They are diagnosed through clinical interview, scale assessment, and neuropsychological test (e.g. attention ability) in either outpatient or inpatient care. The physicians register the diagnosis code of the patient to the national health insurance system according to the ICD-9-CM diagnostic criteria. The treatment is pharmacotherapy mostly, but may also include nonpharmacological and multimodal management for adjuvant therapy, such as psychoeducation, counseling, behavioral intervention, and family therapy.Study subjects described above were defined as the prevalent cases from 1999 to 2005. The treated prevalence of ADHD from 1999 to 2005 was also calculated. The treated prevalence of ADHD was calculated with the number of total study subjects at the beginning of each year as the denominator and the number of prevalent cases of ADHD in each year as the numerator.The study subjects who were defined as having ADHD during the year and had not been defined as having ADHD during the previous years were defined as incident cases. The treated incidence of ADHD for each year was calculated from 1999 to 2005. The denominator was the person-years that were contributed by the study subjects. The study subjects who were alive at the end of the year contributed one person-year to the denominator. The study subjects who died during the year contributed one-half person-year to the denominator. The numerator was the number of incident cases.We obtained the information on age and sex directly from the Bureau of National Health Insurance (BNHI)’s insured file. Age was categorized into one of 8 groups comprising every 6 years from 0 to 48 years , and older than 49 years. The trend analyses of years were tested by linear regression using overall 6-year treated incidence and prevalence of ADHD. The Chow test The SAS statistical package SAS System for Windows, version 9.3.1  was used to perform the analyses in this study.A total of 6,173 patients were enrolled in the treated  ADHD cohort during the 6-year study.p = .001). Increasing trends were found for both males  and females . There was a trend toward an increase in the incidence rate of treated ADHD, from 44.67 per 100,000 in 2000 to 81.20 per 100,000 in 2005 , although there was a decrease in 2003. The treated prevalence and incidence rates of ADHD were both higher in males than in females for every calendar year. However, decreasing trends were noticed for the male-to-female ratio of treated incidence and prevalence during 2000–2005, ranging from 3.98 to 2.95 and 4.97 to 3.85, respectively  for both males and females (both p<.001) using Chow test. The treated prevalence rate also dropped abruptly after age 16–18 years , for both males and females (both p<.001)  .The overall male-to-female ratios of the treated prevalence and incidence of ADHD were 3.85 and 2.95, respectively. Male-to-female ratios of treated prevalence ranged from 1.46 to 5.52 before age 25–30 years, but fell below 1 thereafter. Male-to-female ratios of treated incidence ranged from 1.46 to 3.47 before age 25–30 years, but fell below 1 thereafter .Our study is among the few that have examined healthcare-seeking ADHD patients across their lifespan, with a long observation period and a large sample of a general population, using data from Taiwan’s NHIRD. We designed a study to evaluate the annual incidence and prevalence of pharmacologically-treated ADHD in healthcare-seeking children, adolescents, and adults among a nationally representative general population in Taiwan for the period 1999 to 2005.Overall, prevalence of treated ADHD increased during 2000–2005 from 64.65 per 100,000 to 145.40 per 100,000 patients. An increase in the treated incidence rate of ADHD was also observed, from 44.67 per 100,000 to 81.20 per 100,000. These findings are in line with figures reported in the literature, which show an increase in the prevalence of ADHD treatment during the past decade in the UK The results of this study suggest an increase in the prevalence and incidence of treated ADHD in Taiwan throughout the study period; however, the highest treated prevalence figure reported  is below those reported in Germany (50 per 1000) Our data showed that the peak treated prevalence of ADHD was at age 7–12 years for both males and females. These findings are in line with figures reported in Western countries, including Germany There may be several explanations for the under-treatment of ADHD patients in their adulthood. In Taiwan, Ritalin (methylphenidate) is the only stimulant that has been included in the benefit package of the National Health Insurance program for use in the treatment of ADHD in adults The present study has demonstrated that although the prevalence and incidence rates of treated ADHD were both higher in male patients for every calendar year, decreasing trends were noted for the male-to-female ratio throughout the study period, for both treated incidence and prevalence. These findings are in line with figures reported in the literature, which showed prevalence and incidence rates of drug prescribing were both consistently higher among boys than girls, although the greatest increases over time were observed in female patients The general impression that male ADHD are much more likely to be clinically diagnosed and treated is mostly based on studies among children and adolescents This study has some limitations, however. The ADHD diagnoses used in the study were from administrative claims data reported by physicians, which may not be as precise as diagnoses made by structured interview with specific diagnostic criteria. Still another limitation of this study is that the sample size of adult patients was relatively small. Despite these considerations, the present study has important implications for practice and research. Our study is one of the few to explore longitudinal trends in the treated prevalence and incidence of healthcare-seeking ADHD patients across the lifespan, using nationwide datasets. The use of a nationwide population-based database such as this has advantages, such as (1) the large sample size; (2) preventing selection bias in recruiting study subjects; (3) avoiding the recall bias of patients when filling out questionnaires; (4) it may be more representative of the real world, i.e., allowing us to understand what is actually happening under the general conditions of clinical practice. This study has added to the existing body of knowledge on age and gender effects on the epidemiology of treated ADHD in clinical settings, in particular to the ADHD healthcare-seeking figures in adulthood.Epidemiologic data from Taiwan’s NHIRD in current study showed that although increasing numbers of people with ADHD had sought treatment during 1999–2005 in Taiwan, the treated prevalence of ADHD was still lower than in community data. The unique findings of this study were that there may be an under-diagnosis and under-treatment of ADHD, especially among females and adults. Nevertheless, more women than men sought treatment in their adulthood. This study has added to the existing body of knowledge on age and gender effects on the epidemiology of treated ADHD in clinical settings, in particular to the ADHD healthcare-seeking figures in adulthood. Furthermore epidemiologic studies can clarify whether the patterns of ADHD diagnosis and treatment in community and clinical settings is appropriate. Population-based epidemiologic studies may shed important new light on how we understand ADHD, as well as its natural history, treatment, and consequences.