The heterostructure was prepared using in situ solvothermal and calcination methods. BOC/BOI exhibits a 3D hierarchical structure constructed with thin nano-platelets. The photocatalytic performance of the BOC/BOI photocatalyst demonstrated that the degradation efficiencies of RhB and BPA were 97% and 92% after light illumination within 90 and 30 min, respectively. In comparison, bare BOC and BOI efficiencies were only 20% and 10% for RhB dye, respectively, and 2.3% and 37% for BPA aqueous pollutants, respectively. Moreover, radical trapping measurements indicated that •O2− and •OH radicals played prominent roles in RhB and BPA degradation into mineralization. Analysis of band structures and photochemical redox reactions of BOC/BOI revealed a Z-scheme charge transfer between BOC and BOI by an internal electric field formed at the interface. Therefore, the highly improved photocatalytic performance of the BOC/BOI heterostructure is attributed to the synergetic effects of large surface area, high visible-light absorption, and the enhanced separation and transport of photo-excited electron–hole pairs induced by the hierarchical and Z-scheme heterojunction of the BOC/BOI.In this study, we report the synthesis of a 3-dimensional (3D) hierarchical Bi As water pollutants have become an increasingly severe threat to life in this industrialized society, removing hazardous pollutants is currently a major social challenge. The pollutants mostly included in water are hazardous organic dyes and phenolic compounds. Rhodamine-B (RhB) is a common water-soluble organic dye used widely in various industry fields. Since it is classified as carcinogenic and neurotoxic, it poses health risks to humans . Thus, iTo solve these issues, photocatalysis has attracted substantial attention due to environmental friendliness and its use of freely available solar light ,7,8. The2/Bi2WO6, g-C3N4/WO3, CdS/Bi3O4Cl, etc. [3O4Cl (BOC) and Bi5O7I (BOI) are photochemically stable and have suitable bandgaps of 2.60 eV and 3.01 eV for visible-light absorption, respectively [•O2−) and hydroxyl (•OH) radicals, respectively, which are beneficial for the degradation of organic pollutants [The Z-scheme heterojunction photocatalyst has attracted extensive attention due to the direct transfer and spatial separation of photogenerated charge carriers between two photocatalysts, and maintaining its high redox ability of both surfaces . VariousCl, etc. ,14,15, hCl, etc. , easy adCl, etc. , formatiCl, etc. , and posCl, etc. . In partectively ,23. Furtllutants .12O17Cl2 Z-scheme composite by the in situ growth of BOC on the surface of Bi12O17Cl2 for high photodegradation efficiency under visible light [3N4 heterostructure to remove antibiotics, dye, and heavy metal from water under visible light [3N4 nanosheets interface.Therefore, various Z-scheme heterostructures of the other group semiconductors combined with BOC or BOI have been developed for photocatalytic applications. For instance, Zhou et al. prepared a series of BOI/MIL-53(Fe) nanocomposites . The welle light . In anotle light . The higMeanwhile, the morphology of the photocatalyst strongly affects the photocatalytic performance. Therefore, various morphologies, such as zero-dimensional (0D) nanodots , 1D nanoIn this study, we prepared a Z-scheme BOC/BOI heterojunction photocatalyst with a 3D-hierarchical morphology for enhancement in the photocatalytic degradation of RhB and BPA. The heterojunction was fabricated using an in situ two-step solvothermal-calcination method. Morphological characterizations show that BOC/BOI has a 3D-hierarchical structure constructed with thin nano-flakes. Analysis of energy-band structures of BOC/BOI heterojunction proves that the generation of an internal electric field directed from BOI to BOC facilitates Z-scheme charge transfer between BOC and BOI. Thus, the BOC/BOI demonstrated a higher reaction rate and degradation efficiency than the bare BOC and BOI during RhB and BPA degradation. Furthermore, the degradation pathway was suggested by identifying the mineralization and reaction intermediates using liquid chromatography–mass spectroscopy. The excellent performances of the BOC/BOI heterostructure are attributed to more active sites induced by its unique 3D hierarchical morphology and the enhancement of the separation of photogenerated electrons and holes through the Z-scheme transfer process. This research presents that the Z-scheme BOC/BOI heterojunction with a 3D-hierarchical structure is a suitable photocatalyst for the degradation of environmental pollutants.3)3·5H2O, 99%), potassium chloride , potassium iodide , ethylene glycol ((CH2OH)2, 99%), 1-Vinyl-2-Pyrrolidone (PVP) ((C6H9NO), 99%), Rhodamine-B , Bisphenol-A , dimethylformamide (DMF), nitro-blue tetrazolium (NBT), terephthalic acid (TA) and 1,4-benzoquinone (BQ)  were purchased from Sigma Aldrich Inc. . ethanol  and isopropyl alcohol (IPA)  were purchased from DAEJUN Co., Ltd. . All reagents were used without any further purification.Bismuth nitrate pentahydrate (Bi(NO3)3·5H2O (4.5 mmol) was dissolved in 15 mL of ethylene glycol (EG). The mixture was then sonicated and stirred vigorously for 30 min. In Step (b), the PVP (10 mmol) was dissolved in 10 mL of EG, which was then sonicated and stirred vigorously for 30 min. In Step (c), the PVP solution (prepared in Step (b)) was added dropwise into the Bi(NO3)3·5H2O solution (prepared in Step (a)) and stirred for 15 min at 400 rpm. Next, in Step (d), various molar ratios of potassium chloride (KCl) and potassium iodide (KI) were dissolved in 10 mL of EG by stirring for 30 min. In Step (e), the KCl:KI solution was added dropwise into the Bi(NO3)3·5H2O solution (prepared in Step (c)) under continuous stirring. In Step (f), the mixture was then transferred to a 50 mL Teflon-lined autoclave and sealed. Next, the autoclave was heated at 160 °C for 12 h and cooled naturally to room temperature. After that, the raw BOC/BiOI composite powder was isolated from the EG solution using centrifugation at a speed of 8000 rpm for 10 min and washed with distilled (DI) water and ethanol. The washed BOC/BiOI powder was then dried overnight at 60 °C and put into alumina crucibles. The powder was calcinated in a muffle furnace at 450 °C for 1 h with a ramp rate of 5 °C/min. As a result, the targeted BOC/BOI composites were prepared. The samples with various molar ratios of 1:1, 1:2, 1:3.3, and 1:4.6 of KCl and KI were synthesized, and these were respectively denoted as BOC/BOI-1, BOC/BOI-2, BOC/BOI-3, and BOC/BOI-4. In addition, for comparison, bare BOC and BOI samples were prepared with a similar method as the one used for BOC/BOI. For the preparation of bare BOC and BOI, KCl and KI were added relative to the molar ratio of Bi in Bi(NO3)3·5H2O solution, such as Bi:Cl with 3:1 and Bi:I with 1:1.An in situ two-step solvothermal method was used to prepare the BOC/BOI heterojunction, as shown in Structural analysis of the prepared samples was conducted using X-ray powder diffractometer (XRD) with Cu-Kα as an X-ray source (wavelength of 1.5409 Å) operated at a scan rate of 5°/min in the diffraction angle (2θ) range from 10° to 80°. The crystalline phase was characterized through Micro-Raman spectroscopy measurement , equipped with a green laser source (wavelength of 532 nm and power of 6 mW). The morphology and elemental compositions were examined using a field emission scanning electron microscope (SEM)  equipped with an Energy-dispersive X-ray spectroscope (EDX). A UV-visible spectrophotometer  equipped with a 60 mm integrating sphere was used to investigate the optical properties, including the diffuse reflectance spectrum and optical bandgap. X-ray photoemission spectroscopy (XPS)  with a Monochromatic Al Kα X-ray source was used to examine the chemical composition of samples. The collected XPS data were calibrated with a non-oxygenated carbon peak that originated at 284.8 eV ,31. The 2)  equipped with a UV-IR cutoff filter (420 nm > λ > 780 nm). RhB dye and BPA colorless pollutants were used to evaluate the degradation efficiency of the synthesized photocatalysts. The pollutant aqueous solution in a double wall jacket beaker (80 cm2 surface area) connected with a water chiller was kept perpendicular to the light source at a distance of 30 cm. Each photocatalyst with 10 mg and 40 mg was used to degrade 40 mL of RhB dye (17 ppm) and BPA colorless pollutant (15 ppm), respectively. Initially, the RhB and BPA solution was stirred for 60 min and 30 min, respectively, under the dark condition to attain adsorption-desorption equilibrium of the photocatalysts. Next, after a specific time interval, a 2 mL solution was taken from each solution, which was then centrifuged for 3 min at 3000 rpm to separate the solution from the photocatalyst. The absorbance spectrum of the separated solution was determined using a UV-visible spectrophotometer, which established the rate of degradation to light irradiation time. Radical trapping experiments were conducted to determine the radical’s dominant species involved in the photocatalytic decomposition of RhB. IPA, BQ, and KI of 2 mmol were used as trapping reagents to determine the active species such as •O2−, •OH radicals and holes, respectively. NBT (0.025 mmol) was used as an indicator to determine the amount of •O2− radical. We also employed a liquid chromatography–mass spectrometry (LC–MS) system , installed with a column  for the degradation pathway and reaction intermediates investigation.The photocatalytic characteristics of the samples were determined using a visible light source with a 300 W Xenon lamp (1000 W/m2SO4 (50 mL) was used as an electrolyte. A clean fluorine-doped tin oxide (FTO) glass was employed as a substrate of the working electrode. The working electrode was prepared from the slurry, which was made by dispersing the photocatalyst (0.1 mg) in DMF (1 mL), then sonicated for an hour. The slurry was coated over the FTO by a drop-casting technique and dried at 160 °C for 1 h before being used as a working electrode.The electrochemical impedance spectroscopy (EIS) analysis was conducted on a three-electrode workstation . The Pt-spiral wire and standard calomel were used as counter and reference electrodes, respectively. An aqueous solution of 0.5 M NaThe structural phases of the BOC, BOI, and BOC/BOI-3 were analyzed using XRD patterns, as shown in −1 corresponds to A1g vibration originating from the stretching mode of the Bi-Cl bond [−1 to 627.3 cm−1 correspond to the Bi-O bond vibration [−1 indicates E1g vibration due to the internal stretching mode of Bi-I [−1 and 591.8 cm−1 are related to Bi-O bonding, which are generated due to the oxygen-rich environment in BOI [−1 in the BOC/BOI-3 composite is blue-shifted and red-shifted compared to BOI and BOC, respectively. These shifts indicate that BOI and BOC in the BOC/BOI-3 composites are strongly interconnected due to the interfacial interaction between oxygen and bismuth atoms.The structural characteristics of the BOC, BOI, and BOC/BOI-3 were further analyzed using Raman measurements, as shown in -Cl bond , while tibration . For BOI of Bi-I . The higt in BOI ,39. FurtTo investigate the morphology and microstructure of the synthesized samples, FESEM and TEM measurements were performed. The microstructure of the BOC/BOI heterojunction was investigated using HRTEM. 5/2 and Bi 4f7/2, which are attributed to the Bi-O bonding  is less electronegative than chlorine (Cl), it is easy for I to leave electrons. Theoretically, when I donate electrons, the concentration of the outer shell’s electron decreases, resulting in a reduced shielding effect and corresponding to an increase in the binding energy of the inner electrons. As a result, the corresponding XPS peaks shift toward a high binding energy. Therefore, this high energy shift indicates the electron density migration from BOI to BOC in the BOC/BOI-3 heterojunction. The vice versa effect is responsible for the shift of the BOC peaks to lower binding energies.o) of RhB dye solution over BOC/BOI composites is substantially higher than that of pure BOC and BOI. Specifically, the BOC/BOI-3 and BOC/BOI-2 composites completely decomposed RhB dye solution within 160 and 220 min, respectively. The temporal absorption spectra of RhB dye solution with BOC/BOI-3 show a gradual decrease in absorbance intensity with irradiation time  ,tion (1) . The obtle light . The deg•O2−, •OH, and h+, respectively. −1 (no scavenger) to 0.008, 0.007, and 0.005 min−1 with IPA, BQ, and KI, respectively. Thus, the results indicate that •OH, •O2− radical, and h+ can be generated during RhB degradation [Next, radical trapping analysis was conducted to explore the active radicals generated in the BOC/BOI-3 sample during RhB degradation, as shown in radation .•O2− radical. To directly investigate the •O2− radical, the temporal absorption spectra of NBT with UV light were obtained in the presence of the BOC, BOI, and BOC/BOI-3 samples, as shown in •O2− radicals during the transformation from NBT to Formazan [•O2− radicals (•O2− and NBT (4:1 in molar ratio)  , the amoectively b.2 radical attack on the bonding between benzene and chromophore, and further degraded into smaller m/ɀ intermediates with the m/ɀ value of 254, 251 and then to m/ɀ 194 and finally convert to m/ɀ = 130 on the cleavage of the chromophore. In 2 and H2O.Finally, we performed LC–MS to elucidate the reaction intermediates, photocatalytic degradation pathway, and mineralization process of RhB and BPA over BOC/BOI-3 sample, as shown in −1 range [We further conducted the recycling experiments to evaluate the photocatlytic reusability and stability of BOC/BOI-3 heterojunction photocatalyst, as illustrated in −1 range .−-h+ pairs in BOC, BOI, and BOC/BOI-3, as shown in −-h+ pairs in the BOC/BOI-3 sample. Furthermore, we adapted time-resolved photoluminescence spectroscopy (TRPL) to estimate the lifetime of the excited charge carriers (avg) of BOC/BOI-3 (8.80 ns) are longer than that of the BOC (7.42 ns) and BOI (7.91 ns). The longer τavg indicates that the recombination rate of the photogenerated charge carriers is reduced. Thus, the BOC/BOI composite led to more efficient separation of electron–hole pairs. We also measured the transient photocurrent response of the samples to examine the separation efficiency of the photo-excited charge carriers, as shown in s) and charge transfer resistance (Rct), in parallel with the constant-phase element (CPE) , Mott–Schottky (MS) plots, and valence band (VB) XPS spectra, as shown in inset of a, where f) of the prepared BOC and BOI samples were obtained using MS analysis, as shown in fb) of the n-type semiconductor represents the Ef level [f vs. normal hydrogen electrode (NHE) scale were calculated using Equation (2) [f of BOC and BOI were found to be −0.401 eV and −0.857 eV vs. NHE, respectively  ; as a reectively a.(2)Efbf level are calculated to be 2.039 V and 1.743 V vs. NHE for BOC and BOI, respectively  XPS measurement was carried out to determine the VB potential for BOC and BOI, as shown in ectively a.CB, EVB, and Eg, denote the CB potential, VB potential and band gap of the sample, respectively. As a result, the calculated CB potentials for BOC and BOI are −0.631 V and 1.327 V vs. NHE, respectively .ectively a. Thus, − and h+ (as shown in the below reactions (4) and (5)). Then, the photo-excited electrons in the CB of BOC will be easily transferred to the VB of BOI due to the IEF at the interface in the heterojunction; this initiates the Z-scheme charge transport of the photo-excited charge carriers in the photocatalytic processes (reaction (6) and in 2O into •OH and hydrogen ions (H+) (reaction (7)) due to the fact that the VB of BOC (2.039 eV) is more positive than +1.99 eV (H2O/•OH vs. NHE). At the same time, the remaining photogenerated electrons in the CB of BOI will reduce the O2 molecules in aqueous solution into highly active •O2− radical (reaction (8)), then the •O2− and •OH− radicals further react with RhB or BPA aqueous solution to degrade it into H2O, CO2, and small molecules (reaction (9)). Moreover, the unique 3D morphology of BOC/BOI-3 will provide more catalytic centers and increase the active sites. Accordingly, BOC/BOI-3 shows enhanced photocatalytic performance for degrading RhB and BPA pollutants.Regarding the analysis of the band structure of the BOC/BOI-3 sample, a possible Z-scheme photocatalytic mechanism for BOC/BOI could be proposed c. Under •O2−, and •OH radicals played a crucial role in RhB and BPA degradation. Through LC–MS results of RhB and BPA during photodegradation, its mineralization and degradation pathway were proposed. Therefore, the excellent photocatalytic performances of BOC/BOI are attributed to its large surface area, visible-light absorption, and low electron–hole recombination, which are due to its unique 3D hierarchical morphology and the direct Z-scheme photocatalytic process. Conclusively, direct Z-scheme BOC/BOI heterostructure is a suitable photocatalyst for use in the photodegradation of environmental pollutants.In this study, a simple solvothermal growth technique was used to synthesize the 3D hierarchical BOC/BOI heterostructure photocatalyst. The heterostructure demonstrated direct Z-scheme photocatalytic behavior in the photocatalytic degradation of RhB and BPA. The 3D hierarchal morphology of BOC/BOI can increase active sites due to its high surface area, and can improve visible-light absorption via multiple reflections inside the sample. XPS and mechanistic studies proved the generation of an internal electric field from BOI to BOC at their interface, which contributed to Z-scheme transport of photogenerated charge carriers in the BOC/BOI heterojunction. Thus, the BOC/BOI sample demonstrated a higher reaction rate and a higher degradation efficiency than the bare BOC and BOI during RhB and BPA degradation. Radical trapping analysis showed that


This systematic scoping review evaluates the multidecade pattern of diagnosis in attention-deficit/hyperactivity disorder in young people using a framework for identifying overdiagnosis for noncancer conditions. Is attention-deficit/hyperactivity disorder (ADHD) overdiagnosed in children and adolescents?In this systematic scoping review of 334 published studies in children and adolescents, convincing evidence was found that ADHD is overdiagnosed in children and adolescents. For individuals with milder symptoms in particular, the harms associated with an ADHD diagnosis may often outweigh the benefits.This finding suggests that high-quality studies on the long-term benefits and harms of diagnosing and treating ADHD for youths with milder or borderline symptoms are needed to inform safe and equitable practice and policy. Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services.To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions.This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality.Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy. However, for increased detection to represent current overdiagnosis rather than previous underdiagnosis of ADHD, we also need evidence that these additional cases do not derive a net benefit from diagnosis . Although the benefits of appropriate diagnosis and treatment of ADHD may be well known,12 harms are less well appreciated. Physical and psychosocial harms  may be experienced directly by the young patients and their family, but economic and opportunity costs are experienced by the wider society.7Overdiagnosis of ADHD could happen because of diagnostic inflationIn this study, we systematically reviewed the literature to identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents. Moreover, we aimed to highlight any existing evidence gaps. We used a 5-question framework for detecting overdiagnosis in noncancer conditions.PRISMA) Extension for Scoping Reviews26 and Joanna Briggs Methodology,27 including the provision of a PRISMA-ScR Checklist. A summary of the methods is given here, and the details are published elsewhere.28Because of the broad research question, we conducted a systematic scoping review that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses  and false-positive diagnosis  are not the focus of this article.Overdiagnosis is defined here as occurring when a person is clinically diagnosed with a condition, but the net effect of the diagnosis is unfavorable.18 All included data were mapped to these 5 questions: (1) Is there potential for increased diagnosis? (2) Has diagnosis actually increased? (3) Are additional cases subclinical or low risk? (4) Have some additional cases been treated? (5) Might harms outweigh benefits of diagnosis (5a) and treatment (5b)  ?Peer-reviewed primary and secondary studies in children and adolescents that were published in English between January 1, 1979, and August 21, 2020, were eligible for inclusion. Studies with mixed-age populations were included if it was possible to extract data from them separately or if most participants were aged 18 years or younger. Given the overwhelming amount of evidence on pharmacological ADHD treatment outcomes, we included systematic reviews and cohort studies only for question 5b. Studies needed to have a clear emphasis on ADHD.Searches were performed on August 21, 2020, in MEDLINE, Embase, PsychINFO, and the Cochrane Library  and another researcher. Any discrepancies were resolved through discussion.After the removal of duplicates and a pilot phase, 2 of us (L.K. and R.S.) independently screened abstracts using the web-based text mining tool Abstrackr (Brown University).32Data were extracted into a standardized template, which was developed through an iterative process , we looked for prevalence variations and other indicators, such as evidence of a spectrum of symptoms. For example, the lack of biological explanations for large prevalence variations among populations or among diagnostic standards would indicate a reservoir of potentially diagnosable disease. To analyze the data on ADHD diagnosis and treatment patterns (questions 2 and 4), we included any studies that provided time-trend data on clinical diagnosis or medication rates.25 We grouped the evidence for this question into 2 categories: studies that reported ADHD severity and studies that reported degree of impairment as a proxy.The question of whether additional diagnoses were predominantly mild cases (question 3) was central to ascertaining whether extra detection represented a net benefit or harm. However, severity of ADHD was not consistently defined or assessed, relying heavily on subjective interpretations.18 In addition, we considered the evidence on benefits and harms across the wider ADHD spectrum.We divided the evidence on benefits and harms (question 5) into outcomes of the diagnosis and outcomes of any subsequent treatment, with a focus on the ratio of benefits to harms specifically for youths with milder ADHD-related behaviors.26Of the 12 267 records retrieved, 334 studies (2.7%) were included. eAppendix 3 in Of the 334 included studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Most studies were published within the past 10 years (n = 217 [65.0%]) and were most commonly from North America (n = 128 [38.3%]), Europe (n = 93 [27.8%]), or Oceania/Asia (n = 35 [10.5%]) .The quality of included studies varied; approximately one-third of the studies were classified as having low (n = 129), moderate (n = 102), or high (n = 103) risk of bias. Studies that provided evidence for question 5 were more likely to be at high risk of bias (n = 69 [45.7%]) .356 A summary of the findings is described here. The full results are provided in eAppendix 6 in 45 equally symptomatic girls were less likely to be diagnosed than boys in 2 studies.55 Eight studies showed decreasing ratios over time, which were indicative of a reservoir of diagnosable ADHD in girls.47A total of 104 studies were included to answer question 1. Large variations in ADHD diagnosis were found between subpopulations in 48 studies. Twenty-five studies provided evidence of variation between the sexes, showing lower diagnosis of ADHD in girls than in boys. Although biological reasons may exist,77 One study did not confirm this finding.78 It was conducted in a low-prevalence setting in which only specialists diagnosed ADHD, suggesting that variation  is much smaller where stricter adherence to diagnostic criteria may occur.Of the 12 included studies that focused on relative age, 11 studies showed that the youngest children in class were more likely to be diagnosed with ADHD than the oldest children.66 However, there is evidence that diagnosis rates increased rapidly .67 Twenty-one studies64 on diagnostic variation by socioeconomic or health insurance status and 8 studies59 on regional variation all demonstrated substantial differences.Youths from various migrant backgrounds were traditionally less likely to be diagnosed with ADHD in 15 studies.93 Twenty-two studies reported a spectrum of ADHD-related behaviors showing that problems existed on a continuum, with ADHD on the extreme end in 7 studies129 and subthreshold behaviors on the other end displayed by a considerable proportion of young people in 8 studies,123 indicating a large reservoir of potentially diagnosable ADHD. This continuum was also described by a higher risk of adverse outcomes with increasing ADHD symptoms from subthreshold symptom levels to severe behaviors in 13 studies.120Eighteen of 20 studies that compared diagnostic prevalence between 2 or more diagnostic criteria described a concurrent increase in potential cases with the broadening of criteria.97 Four of 5 phenotype change studies reported stable or declining ADHD symptoms in the population, making it unlikely that the expansion was associated with an actual increase in ADHD symptoms over time.99Evidence of expanding reservoirs attributed to the medicalization of behavior was found in 3 studies.105 and potential overdiagnosis because of false-positive diagnosis,107 often occurring simultaneously.103Sixteen studies that investigated diagnostic inaccuracies as a reason for variation reported potential underdiagnosis because of false-negative diagnosis144 and 3 observing a plateau in the early 2000s.145 Similar evidence came from studies that measured trends in annual diagnostic incidence149 or lifetime diagnostic prevalence,150 with nearly all of these studies (96.0%) confirming continuously increasing ADHD diagnoses.Of the 45 studies included to answer question 2, 30 studies estimated change in diagnostic prevalence of ADHD over time, with 27 documenting increased trends152Twenty-five studies were included to answer question 3. Five studies reported that only a small proportion of all diagnosed youths displayed severe ADHD behaviors.151 Six studies that confirmed stable or declining ADHD behaviors in youths over several decades supported this finding.99 Correspondingly, 2 studies75 on the relative age effect on ADHD diagnosis reported that the proportion of youngest children in class who received a diagnosis compared with older children had increased in more recent birth cohorts. In contrast, 3 studies138 that reported time trends of parent- or clinician-perceived severity of the disorder showed larger relative increases in more severe cases (which could be associated with a growing tendency to report the same behaviors as more severe).Eleven studies used changes in impairment as a proxy for severity. Eight of these studies confirmed that impairment levels, adverse outcomes, and benefits of medication substantially decreased with the expansion of the group of diagnosed youths.213 identified a plateau or decrease in this trend for preschool-aged children, with 2 studies163 indicating a general declining trend in youths in Germany who received treatment. Annual incident treatment rates were reported to be increasing in 5 studies197 and to be stable or without a clear trend in 4 studies,200 whereas 10 of 11 studies209 reported increasing trends in medication dispensing or sales.Of the 83 studies included to answer question 4, 64 showed an increasing percentage of youths being pharmacologically treated for ADHD. Three studies233 provided information on this group and both reported harms and found that the diagnostic label could have adverse social, psychological, and academic effects when compared with undiagnosed youths with similar behaviors.A total of 31 studies reported the consequences of diagnosis (question 5a). We focused on the benefits and harms for milder cases. Only 2 studies217 accompanied by understanding and sympathy222 as well as decreased guilt, blame, and anger.223 Subsequently, this explanation could increase perceived control, with expectations of solutions,222 enhanced confidence,220 and a sense of belonging.223 Second, enablement was often experienced223 and was characterized by increased support accompanying a diagnosis of ADHD and by an enhanced ability to seek and accept help.223Regarding the general benefits of a diagnosis (across the full spectrum of ADHD cases), 2 main themes emerged. First, in 14 studies, an ADHD diagnosis was shown to create a sense of empowerment for those involved. It provided a biomedical explanation for experienced problems, supporting a sense of legitimacy225 often followed by inaction and stagnation.229 This view can also deflect from other underlying individual, social, or systemic problems,215 which can prompt a self-fulfilling prophecy, wherein the perceived inability to change reduces opportunities235 as well as promotes hopelessness and passiveness.222 This loss of control may be especially high when the diagnosis is used as a step toward coercing young people into correcting arguably problematic behaviors.223 Second, 14 studies reported on stigmatization. The diagnosis can create an identity that enhances prejudice and judgment,240 which are associated with even greater feelings of isolation, exclusion, and shame.225Two themes related to potential harms also emerged. First, in 22 studies, a biomedical view of difficulties was shown to be associated with disempowerment. By providing an excuse for problems, a decrease in responsibility by all involved can occur,299 on treatment efficacy stratified by severity of ADHD behaviors. These studies confirmed substantially greater treatment response in youths with more severe symptoms at baseline and diminished benefits in milder cases. None of the 29 studies that reported on direct harms of treatment differentiated between case severity.348A total of 120 studies reported on the consequences of pharmacological treatment. Forty studies reported on the direct outcomes of pharmacological treatment of ADHD, including 2 studies233 suggested that treatment was only beneficial to academic outcomes in youths with severe symptoms, with 1 study64 reporting a potentially harmful outcome in milder cases. Another study150 found that the benefits of medication in reducing hospital contacts and criminal behavior were smaller in later birth cohorts for whom treatment prevalence was higher (thus likely expanding treatment to milder cases).Of the 85 studies on indirect outcomes of treatment, 3 studies reported on youths with less severe ADHD. Two of these articles295 However, only 3 studies298 reported long-term follow-up beyond active treatment, finding no difference in symptoms between youths who were treated and those who were untreated in later life, and another study296 found no difference in symptoms after a 48-hour washout period. In terms of harms, active treatment was commonly associated with mild and moderate adverse events342 and high discontinuation rates.348 Ten studies mentioned unsatisfactory reporting of harms.346Twenty-four studies that reported the direct outcomes of medication across the spectrum of symptoms supported substantial short-term symptom reduction.256 cardiovascular,274 physical,310 psychological,329 social and emotional,337 and accidents.266 We found evidence of benefits for academic outcomes,255 injuries,263 hospital admissions,259 criminal behavior,333 and quality of life.336 In addition, harmful outcomes were evident for heart rate and cardiovascular events,274 growth308 and weight,308 risk for psychosis and tics,312 and stimulant misuse or poisoning.324 Treatment was associated with reduced physical activity in 2 studies. For suicidal behavior as well as emotional and social impairment, we could not find any favorable or unfavorable patterns.Indirect treatment effects (across the spectrum of ADHD symptoms) were documented for diverse outcomes, including academic,The findings suggest that relatively large symptom reductions through medication translate to modest decreases in functional impairment at best while carrying risks. This ratio is likely worse for youth with milder ADHD in which large symptom reductions are impossible.To our knowledge, this study is the first systematic scoping review on overdiagnosis of ADHD in youths. We found evidence of overdiagnosis and overtreatment of ADHD. We confirmed a large reservoir of diagnosable ADHD, consistently increasing rates of ADHD diagnosis and treatment, and a large proportion of newly detected cases with milder symptoms . Furthermore, we found few studies that assessed symptom severity among extra cases diagnosed through expanded disease definitions as well as the balance of benefits and harms for these individuals, representing a critical evidence gap.4 and may be applicable to other conditions, such as autism.358Our findings have implications for these individuals, who may be harmed by overdiagnosis and the adverse effects of medication during childhood, adolescence, and even adulthood. These findings are also relevant to the growing number of adults being newly diagnosed with ADHD359 and equitable use of health care resources.360Several important research questions emerged during this review. Larger studies need to be conducted to confirm whether the additional ADHD cases now being diagnosed have milder symptoms. Future research is also required to evaluate whether diagnosing and treating milder ADHD cases may carry net harm. To reduce health and educational inequities, resources must be shifted from the overdiagnosis and overtreatment of ADHD to the needs of youths with more severe symptoms and who are more likely to benefit, including those currently underdiagnosed. Our research focused on overdiagnosis, and we did not address the misdiagnosis and underdiagnosis of ADHD. Although they are outside of the scope of this study, misdiagnosis and underdiagnosis are important complementary issues in a broader discussion of the principles of “right” careWe recommend that practitioners, parents, and teachers carefully weigh the potential benefits and harms that can accompany ADHD diagnosis and treatment, especially when identifying youths (or adults) with milder symptoms. For this group, the benefits of diagnosis and treatment may be considerably reduced or outweighed by harms.9 and Thomas et al.25 This approach incorporates the valid need for efficient diagnosis and treatment for severe cases as well as a watch-and-wait approach for borderline cases. It echoes management by active surveillance of low-risk prostate, breast, and thyroid cancers, in which overdiagnosis occurs frequently,361 and it ensures that resources are allocated where they are needed most and will be most valuable.359An option to improve the balance of benefit to harm in practice may be to follow a stepped-diagnosis approach, as described by Batstra et al26 to synthesize a large, heterogeneous set of studies. We undertook a critical appraisal of the included studies32 that allowed us to evaluate the quality of the evidence collected globally over many decades. Previous analyses focused on specific aspects of ADHD overdiagnosis, such as the existence of a relative age effect,72 differences between diagnosis and phenotype trends,21 or outcomes of medication.346 Although they contributed important evidence to the literature, these earlier studies were unable to draw overall conclusions on overdiagnosis of ADHD, which we were able to do.This study has several strengths. The 5-question framework enabled us to undertake a systematic scoping review, in accordance with international standards,This study also has several limitations. First, despite the inclusion of studies from many countries over a long period, these findings may not be applicable to all demographic groups. Given the scope of this study, we restricted the evidence for questions 4 and 5 to pharmacological treatment of ADHD, which is the most common and controversial treatment. Second, this review is limited by the availability and quality of evidence. Although our confidence in the outcomes for questions 2 and 4 is high, many studies included for questions 1, 3, and 5 were at high risk of bias. Third, parents or teachers were often the sole reporters of potentially subjective measures . This lack of self-reported data means that it is unknown whether benefits and harms may have been reported differently by the youths themselves.In this systematic scoping review, we found convincing evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Despite an abundance of research in the field of ADHD, gaps in evidence remain. In particular, high-quality studies on the long-term benefits and harms of diagnosing and treating ADHD in young people with milder symptoms are needed to inform safe and equitable practice and policy.


Objectives: Neurocognitive functions might indicate specific pathways in developing attention deficit hyperactivity disorder (ADHD). We focus on reward-related dysfunctions and analyze whether reward-related inhibitory control (RRIC), approach motivation, and autonomic reactivity to reward-related stimuli are linked to developing ADHD, while accounting for comorbid symptoms of oppositional defiant disorder (ODD), and callous-unemotional (CU) traits.Methods: A sample of 198 preschool children  was re-assessed at age 8 years . ADHD diagnosis was made by clinical interviews. We measured ODD symptoms and CU traits using a multi-informant approach, RRIC  and approach tendency using neuropsychological tasks, and autonomic reactivity via indices of electrodermal activity (EDA).Results: Low RRIC and low autonomic reactivity were uniquely associated with ADHD, while longitudinal and cross-sectional links between approach motivation and ADHD were completely explained by comorbid ODD and CU symptoms.Conclusion: High approach motivation indicated developing ADHD with ODD and CU problems, while low RRIC and low reward-related autonomic reactivity were linked to developing pure ADHD. The results are in line with models on neurocognitive subtypes in externalizing disorders. Attention deficit hyperactivity disorder (ADHD) and oppositional defiant and conduct disorder (ODD/CD) frequently occur together—about 50% of ADHD cases also develop ODD/CD . LongituADHD, ODD/CD and CU traits have been found to be associated with diverse neurocognitive dysfunctions . As thesDysfunctional processing of reward has been found to be prevalent in ADHD and in externalizing disorders. The “trait impulsivity” model, for example, postulates that early emerging impulsivity is a crucial vulnerability factor  and indicative of a developmental pathway from ADHD to ODD and other externalizing disorders such as CD and substance use disorder . The impThere is broad empirical evidence of low reward-related IC (RRIC) and other executive function deficits in children with ADHD as well as those with ODD/CD , 11. LowThere is relatively broad evidence that children with ADHD show cortical arousal deficits. Cognitive deficits of the disorder have been assumed to be caused by difficulties in regulating arousal according to situational demands , 18, 19.It has been shown that low resting-state sympathetic arousal in children with ADHD can be caused by comorbid ODD/CD problems, low anxiety, and psychopathic personality traits , 21. TheBased on the research reviewed above, we examined the following hypotheses: (a) Low RRIC is associated with developing ADHD. This association overlaps with  comorbid ODD symptoms. We do not hypothesize an overlap with CU traits, as this top-down control component of impulsivity might not be impaired in children with CU traits. (b) High reward-related approach behavior is associated with developing ADHD. This association can be explained by ODD symptoms and CU traits, as this bottom-up component of impulsivity can be expected to be common to all three psychopathological domains. (c) Low autonomic reactivity to reward-related stimuli is linked to ADHD. This association overlaps with ODD symptoms and CU traits.t = 0.00) and age of the child, ADHD symptoms, symptoms of anxiety/depression, and oppositional symptoms of the child (t-scores between −1.78 and 0.96).A sample of 198 preschool children  was recruited from childcare facilities. The children were 4–5 years old  at the first assessment wave and 8 years old  at the second wave. Inclusion criteria were: IQ>80, lack of motor and sensory disabilities, lack of chronic physical and mental diseases, no indication of a trauma experienced by the child, and no continuous pharmacological treatment. To determine eligibility, a telephone interview and a screening questionnaire on the ADHD symptoms of the child [FBB-ADHS-V by , see belAt T1, all children were medication naïve. At 8 years (T2), three children were medicated with methylphenidate, and were therefore excluded from the analyses of the 8-years data. Reward-related inhibitory control. RRIC was measured using the Snack-Delay task by Kochanska . In thisApproach motivation. The Stranger-with-Toys (SWT) task  was usedADHD and ODD symptoms of the child. The ADHD scale of the Parental Account of Childhood Symptoms (PACS) interview in the modified preschool version (Pre-PACS)  was condParents completed the ODD rating scale of the questionnaire (FBB-SSV), which has also shown good psychometric properties .Anxiety and depressive symptoms of the child. The Anxious/Depressed scale of the German version of the Child Behavior Checklist (CBCL4-18) by Döpfner et al.  was emplReward-related inhibitory control. At T2, we conducted the Gift-Bag task by Kochanska . In thisApproach motivation. The interview on attractive toys (Int-AT) task adapted from Asendorpf  was condAutonomic reactivity. Arousal level and reactivity of the sympathetic nervous system can be validly measured by indices of the EDA . We analn = 31 (15.7%) received an ADHD research diagnosis. Parents and teachers completed the ADHD questionnaire (FBB-ADHS of DISYPS-III) by Döpfner and Görtz-Dorten  and the teacher  ADHD questionnaire scores were significantly associated with the ADHD diagnosis.ADHD diagnoses. At T2, the ADHD diagnostic module of the Child and Adolescent Psychiatric Interview (CAPA) by Angold et al.  was condz-Dorten . In the ODD symptoms. For the assessment of ODD symptoms, mothers and fathers completed the oppositional symptoms scale  by Döpfner and Görtz-Dorten . TeacherCU traits. CU traits were assessed using the “prosocial behavior” scale of the SDQ and the “callous-unemotional” scale of the Antisocial Process Screening Device (APSD) . MothersFurther control variables. Symptoms of anxiety disorders and depression were assessed by use of the screen interview of the DISYPS-III by Döpfner and Görtz-Dorten . The verCorrelation coefficients among the study variables were calculated for descriptive purposes. In those cases where gender of child was significantly associated with a neuropsychological/physiological predictor variable, we adjusted for gender in all respective analyses.To test the hypotheses on the associations of (a) T1 and T2 RRIC, (b) T1 and T2 approach tendency and (c) T2 electrodermal reactivity with T2 ADHD diagnosis, we conducted logistic regression analyses. In analyses (a) and (b), we adjusted for T1 ADHD symptoms (model 2) to assess whether the predictor variables predict T2 ADHD over and above T1 ADHD symptoms. In all analyses , ODD and CU symptoms were covaried in model 3. For control purposes we additionally adjusted for anxiety/depressive symptoms and the approximated verbal IQ of the child in model 4.In a next step, for the significant predictor-ADHD links, we tested whether ODD and/or CU symptoms significantly explain this link . For this purpose, we partitioned the total predictor-ADHD link (common variance) into the direct link (common variance between predictor and ADHD not explainable by the comorbid dimension) and the indirect link  using ordinary least squares (OLS) regression, and tested these links using the bootstrapping method recommended by Preacher and Hayes . The patConsistent with our hypothesis, the T1 Snack-Delay task and the T2 Gift-Bag task were significantly associated with the T2 ADHD diagnosis , model 1The T1 SWT task and the T2 Int-AT task were significantly associated with the T2 ADHD diagnosis , model 1As expected, children with ADHD showed lower mean SCRs to the questions on the attractiveness of the toys than did the other children , model 1p's < 0.10). Children with high symptoms showed a lower baseline/resting arousal level.For the purpose of comparison, we additionally assessed baseline SCL. As shown in In the present study, it was analyzed whether reward-related dysfunctions and sympathetic arousal are linked to ADHD development, and whether or not these links can be explained by ODD symptoms and CU traits. We found low RRIC, measured at preschool and school age, to be uniquely related to ADHD. Preschool RRIC significantly predicted ADHD development. The association between preschool approach motivation with school-age ADHD was significantly and completely explainable by comorbid ODD symptoms as well as by CU traits. Children with ADHD showed low autonomic responses to reward-related stimuli. This link was unique for ADHD, i.e., could not be explained by symptoms of ODD or CU traits. We discuss these findings in greater detail in the following.We expected that RRIC deficits in ADHD can be explained by comorbid ODD symptoms. Contrary to this expectation, however, we found that the school-age ADHD diagnosis was significantly and uniquely associated with preschool- and school-age low RRIC. The associations could not be explained by comorbid ODD symptoms or CU traits. This result appears to correspond with a recent model on conduct problem development by Waller et al. . In thisCorresponding to our expectations, high approach motivation at preschool and school age was associated with ADHD. Moreover, as expected, ODD symptoms and CU traits significantly and completely explained the link between preschool approach motivation and ADHD. Hence, high approach motivation at preschool age might indicate risk for the development of comorbid ADHD/ODD symptoms/CU traits. Several models have proposed that impulsivity forms the basis of externalizing disorders , 15. BlaIn line with our hypothesis, children with an ADHD diagnosis showed comparably low mean SCRs to the reward-related stimuli at the 8-years assessment. The associations were unique for ADHD. ODD and CU symptoms were not associated with low SCRs. This finding corresponds to the results of Conzelmann et al. , who repOur study has several strengths, including the consideration of neuropsychological and psychophysiological characteristics as well as different psychopathological domains in a longitudinal design; the multi-informant approach  to the assessment of comorbid symptoms; the use of dimensional scores reflecting the expression of comorbid symptoms; and the analysis of a sample with increased ADHD symptoms, allowing for a sensitive and reliable description of ADHD development. A limitation might be seen in the lack of measurement of autonomic reactivity to neutral and negative stimuli. Such a measurement would have facilitated the comparison with previous research. Moreover, in future research, it would be interesting to assess further neuropsychological, biological and psychosocial characteristics and to analyze the role of ADHD symptom presentation  in order to increasingly refine the characterization of the developmental pathways. Due to possible influences on our findings the overlap between RRIC and the concept of delay aversion should be analyzed. As a further limitation of our study, it is not possible to draw any causal inferences from the findings. The reward-processing dysfunctions might constitute intermediate phenotypes involved in the development of the specific psychopathological problems, or may merely be correlates of these problems. In either case, however, an identification of neuropsychological/physiological predictors or indicators of emerging psychopathological pathways can be useful for risk identification and the application of tailored interventions.Taken together, we assessed the development of ADHD while accounting for ODD symptoms and CU traits between preschool and school age. In line with current theorizing, we found that high approach motivation was linked to ADHD with comorbid ODD/CU symptoms. Low reward-related cognitive control (RRIC) and low autonomic reactivity to reward-related stimuli were specific for ADHD and might reflect the arousal regulation dysfunction of the disorder at an early stage of development. Given the scarcity of longitudinal data in this area, our results need to be cross-validated. The neurocognitive variables might constitute age-specific markers of clinically more homogenous pathways.ursula.pauli-pott@med.uni-marburg.de.The datasets presented in this article are not readily available because they are part of a ongoing longitudinal study. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by Ethics Committee of the Faculty of Medicine of the University of Marburg, Marburg, Germany. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.AC, KB, FD, PS, and SS organized the database. UP-P performed the statistical analysis. SS wrote the first draft of the manuscript. SS and UP-P wrote sections of the manuscript. All authors contributed to conception, design of the study, contributed to manuscript revision, read, and approved the submitted version.This work was supported by the German Research Foundation  and the University Hospital Marburg (grant number: 17/2018 MR).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.


Attention deficit hyperactivity disorder is the most common neuropsychological disorder in childhood and adolescence, affecting the basic psychological processes involved in learning, social adaptation and affective adjustment. From previous research, the disorder is linked to problems in different areas of development, with deficiencies in psychological processes leading to the development of the most common characteristics of the disorder such as inattention, excess of activity and lack of inhibitory control. As for the diagnosis, in spite of being a very frequent disorder, there are multiple controversies about which tools are the most suitable for evaluation. One of the most widespread tools in the professional field is behavior inventories such as the Strengths and Difficulties Questionnaires for Parents and Teachers or the ADHD Rating Scale-V. The main disadvantage of these assessment tools is that they do not provide an objective observation. For this reason, there are different studies focused on recording objective measures of the subjects’ movement, since hyperkinesia is one of the most characteristic symptoms of this disorder. In this sense, we have developed an application that, using a Kinect device, is capable of measuring the movement of the different parts of the body of up to six subjects in the classroom, being a natural context for the student. The main objective of this work is twofold, on the one hand, to investigate whether there are correlations between excessive movement and high scores in the inventories for the diagnosis of ADHD, Rating Scale-V and Strengths and Difficulties Questionnaire (SDQ) and, on the other hand, to determine which sections of the body present the most significant mobility in subjects diagnosed with ADHD. Results show that the control group, composed of neurotypical subjects, presents less kinaesthetic activity than the clinical group diagnosed with ADHD. This indicates that the experimental group presents one of the main characteristics of the disorder. In addition, results also show that practically all the measured body parts present significant differences, being higher in the clinical group, highlighting the head as the joint with the highest effect size. Attention Deficit Hyperactivity Disorder (ADHD) is the most common neuropsychological disorder in childhood and adolescence ,2,3. It The diagnosis is mainly based on behavioral symptoms and is made before the age of 12. For a diagnosis to be made, the child must present alterations in at least two environments such as at home, social situations and/or school. Furthermore, these changes cannot be due to the existence of another mental disorder. Cases are usually detected in the school environment due to the learning difficulties that these children present and which often lead to school maladjustment. In addition to academic performance, areas such as emotional adjustment and peer relationships are also affected at this age. If it persists into adulthood, it can lead to low socioeconomic status, difficulties and changes in work and other problems in daily life, especially if the individual does not receive treatment .When regarding the etiology of ADHD, it cannot be assessed from a singular perspective, with scientific literature collecting information from various fields to try to give an explanation to this disorder. From a genetic point of view, the high heritability of the disorder, modulated by the interaction with the environment, has been demonstrated ,9. AccorFrom the follow-up of the research developed on the basis of this last theory, it has been observed that the disorder is linked to problems in different areas of cognitive development, such as working memory , processBased on this previous knowledge, there have been many efforts to try to operationalize, measure and detect deficiencies in the cognitive processes and functions of the executive system involved in ADHD. However, controversy remains about what these neuropsychological variables are and which tools are the most suitable for their evaluation .One of the most widespread tools in the professional field dedicated to diagnosing and intervening with subjects who have ADHD are behavioral inventories. This tool, through a series of questions answered mostly by family and teachers, determines whether the behaviors related to the disorder are present to a sufficient degree to carry out a diagnosis. The most widespread inventories are the Strengths and Difficulties Questionnaires for Parents and Teachers , the ADHTherefore, the main disadvantage that we find in these evaluation systems is that they do not provide an objective observation. Thus, the imprecision of the diagnosis of ADHD based on subjective criteria , coupledTrying to solve these mentioned limitations, the ADHD Movements application has been programmed. This application uses a Kinect device to objectively measure the movement of the subjects without the use of any device on the body. Furthermore, as it is a small device, it can be introduced into the natural environment without being invasive. ADHD Movements detects the visible skeletons and their body sections. The application then draws each of the joints on the screen and records, analyzes and counts the amount of movement and distance traveled by each joint of each subject. More detailed information on the development of this application can be found at . In thisThe main objective of this research is to investigate whether there are correlations between excessive movement and high scores in the inventories for the diagnosis of ADHD, Rating Scale-V and SDQ. In turn, we try to determine which sections of the body present the most significant mobility in those subjects diagnosed with ADHD. To carry out this study, a series of classroom sessions were held. These sessions consisted of a study techniques workshop with boys and girls, where the movement of the different parts of the body was measured during the workshop, using the developed application.Firstly, the project was presented to the Clinical Research Ethics Committee of the General Hospital of Alicante (CEIC-HGUA) for evaluation. After the evaluation, approval was obtained which allowed the selection of the children.The sample of the experimental group was obtained from the Children’s Mental Health Unit (USMI) of the General Hospital of Alicante, taking into account children between 7 and 12 years of age diagnosed with ADHD. The procedure was then explained to the parents and guardians of the children so that they could accept the conditions of the study. Once the legal permits were obtained, several dates of availability for a workshop of study techniques were proposed to each of the families involved.In parallel to the main study, a procedure was carried out to form a sample for a control group. For this purpose, we contacted the public school CEIP Azorín in the town of San Vicente del Raspeig. The sample of the group was made with the same characteristics as the experimental group, in terms of age and gender.Finally, groups of mixed students were created, with a homogeneous number of subjects from the clinical and control groups. All the workshops were given by two speakers, for approximately 45 min, where different cognitive tools were explained to facilitate the learning process. The speakers did not intervene if during the session there was an episode of absent-mindedness on the part of a subject, since the objective was to take movement measurements. Additionally, prior to data collection, the inventories for the diagnosis of ADHD, Rating Scale-V and SDQ, were applied to all participants, in order to verify the presence of symptoms and the degree of appearance in all components of the sample.The sample was composed of 65 children, aged between 7 and 12 years. The children were classified in two groups: Experimental group and control group. The experimental group was composed of 32 children with a clinical diagnosis of ADHD: 24 boys and 8 girls. In turn, of the 32 children, 24 had a diagnosis of ADHD with combined presentation and 8 predominantly inattentive presentation, according to the criteria of the DSM-5 [ADHD Rating Scale V (ADHD RS-V) ,45. ScalStrengths and Difficulties Questionnaire (SDQ) ,50. The  is 0.77 .z) represents the distance to the sensor. From these coordinates it is possible to perform the necessary calculations to detect a movement, movement patterns, gestures, postures, etc. Based on this device, ADHD Movements application has been used. It allows us to know the amount of movement of each joint of all the subjects during each minute of the study techniques workshop.Kinect device. The Kinect device was originally developed for Microsoft’s XBox360 video game console to provide a natural interface that allows interaction using body movement, gestures and voice commands so that users can interact with the console without the need for physical contact with a video game controller. However, due to the characteristics of the device and the possibility of developing their own applications using different libraries (both free and Microsoft’s own) its use has not been limited only to video games. In fact, it has been considered an innovative interface of interaction between people and computers, besides highlighting its simplicity in data acquisition . Kinect For the practical elaboration of the project, we looked for a unique space with specific conditions where the activities could be carried out for all the assistants. The chosen space was a classroom at the University of Alicante that had chairs with a built-in table as it would facilitate the use of the Kinect device since this type of chairs allow a view of the whole body .The different activities carried out in the workshop sessions were organized by age groups, combining 50% of the children from the experimental and control groups. One of the limitations of the Kinect device is the limitation of 6 bodies, therefore, each of the sessions was programmed with a maximum of 6 children and a minimum of 4.Children from the experimental group who were taking some kind of medication were invited to attend a new workshop to “expand and review” the previously explained study techniques. For this particular session, they had to attend without taking the prescribed medication during the previous days to alleviate the symptoms derived from the disorder.The predisposition of all the participating families is to be thanked, since they agreed to all requests and petitions. Therefore, the children in the experimental group were studied on two occasions, that is, two movement measurements were taken; one with the medication and the other without. In order to ensure the capture of the movement of the subjects, and to prevent any type of technological incident, two Kinect devices were used in each of the workshops.t-test was used and the magnitude of the effect sizes of the differences found were tested with a d index (standardized mean differences): Small  was checked . Then, a(d≥0.80) . All datFollowing the objectives established, the results can be found below. Firstly, the differences in means in the hyperactivity subscale of the ADHD RS-V questionnaire are presented, followed by the results obtained for the hyperactivity/inattention subscale of the SDQ questionnaire. Finally, the differences in objective movement recorded by the Kinect device are analyzed from two different perspectives: Experimental group vs. control group, and experimental group with and without taking their usual medication.The results indicate that, after the tutors and parents answers, the subjects of the experimental group present a higher mean score than those of the control group for the hyperactivity subscale.Furthermore, following the criteria proposed by Cohen , the magAfter the analysis of the tutors’ and parents’ answers, the results indicate that the subjects with a diagnosis of ADHD obtain higher average scores on the hyperactivity subscale, than the subjects of the control group.Furthermore, following the criteria proposed by Cohen , the magFirstly, Hereafter, we present the mean scores and the differences of the clinical group in relation to joint movement at two different times, having taken the usual prescribed medication and, the same subjects, without taking the medication that palliates the symptoms of an attention deficit disorder . The datBelow, the results obtained in this study will be discussed, both those most significant and related to our objectives, as well as those less significant and that do not align with the aims of the present study. In order to justify our objectives, the statistical analysis of the collected data was carried out and the results are presented hereafter. Firstly, it is important to highlight the result of the comparison of means between the control group and the experimental group on the hyperactivity subscale of the ADHD RS-V questionnaire and the hyperactivity subscale of the SDQ questionnaire, which detect differences of a high magnitude both in the school context (disorder ,35. On tOf these differences, it is relevant to highlight the head as the joint with the highest size effect ( stimuli ,55,56. IFinally, in line with a recent study investigating the effect of methylphenidate in children with ADHD , which fThis leads us to conclude that, for our sample, there are significant differences in the mean difference for the 17 body parts studied between the control group and the clinical group. These differences are greater in the sections of the body that are more related to the focus of attention on a learning stimulus. In turn, when we compared the frequency of movements of the different body sections in the clinical group with and without medication, we detected that the smallest differences were in the sections that we had previously found wider discrepancies between two groups. This fact leads us to ask ourselves if medication has a lesser effect when controlling excessive movement in the segments of the body that present a greater relationship with attention, which would lead us to understand that psychostimulants improve general body control, but may not be as effective in executive functions, the cognitive substratum of attention control.In view of the results obtained in this research, we consider essential that, through future lines of research, this pilot study be continued by validating the results. Firstly, it would be interesting to focus the effort of mediation and data collection on those anatomical components that can provide us with more information about the ability to focus attention on an auditory or visual stimulus, to be more rigorous in the conception of movement of these components and even to assess different types of movement, linking them either to those derived from the kinesthesia that accompanies the rest of the anatomical components of the subject’s body or to movements that are directly related to the defocusing of attention on the learning stimuli.For this, it will be necessary to overcome the main limitations of the current study, mainly the small number of subjects that make up both the clinical and control groups. While the results obtained are significant, it is difficult to assess them as generalizable to the entire clinical population diagnosed with ADHD. For this tool to become a valid instrument to support the diagnosis, it is important that it has a scale composed of neurotypical population and clinical population, which would allow professionals who use it in educational contexts, to support their observation of data and allow them to guide a diagnosis. Therefore, through future work, we consider essential to collect a sample that will provide more solidity and transference to the obtained results.In addition, we also found as a limitation, having measured a high number of sections of the body of the research subjects, many of these anatomical sections being of little relevance. It would be convenient to focus on those anatomical sections that show significant differences between clinical and control groups. Therefore it would be highly interesting to study the correlation between the control of movement/orientation of the head, neck and right/left shoulder sections of the body, the taking or not of the medication prescribed to alleviate the symptoms of ADHD and the effectiveness in performing tasks that require executive functions.Finally, after collecting a larger sample of subjects, it would be very interesting to determine two experimental groups, one composed of students diagnosed with ADHD with combined predominance and the other with students diagnosed with ADHD with inattentive predominance. From what we have observed in the practical application of the measuring instrument, it is very likely that kinaesthetic patterns could be determined for each diagnostic presentation.


This study examined parent–adolescent agreement on the callous, uncaring, and unemotional dimensions of callous–unemotional (CU) traits and the differences in adolescent-reported and parent-reported CU traits among 126 adolescents with autism spectrum disorder (ASD), 207 adolescents with attention-deficit/hyperactivity disorder (ADHD), and 203 typically developing (TD) adolescents. Adolescent-reported and parent-reported CU traits on the three dimensions of the Inventory of Callous and Unemotional Traits were obtained. The strength of CU traits and the differences between adolescent-reported and parent-reported traits were compared among the three groups using analysis of covariance. Parent–adolescent agreement was examined using intraclass correlation. The results reveal that both adolescent-reported and parent-reported callousness and uncaring traits in the ASD and ADHD groups were significantly stronger than those in the TD group. Parent–adolescent agreement on the uncaring trait was fair across the three groups, whereas that on callousness was poor across all three groups. Parent–adolescent agreement on unemotionality was fair in the TD group but poor in the ADHD and ASD groups. ASD and ADHD groups had significantly greater differences in scores reported by parents and adolescents on the callousness trait than the TD group. The parent–adolescent score differences in the uncaring trait were also larger in the ASD group than in the TD group. Thus, these results support the application of a multi-informant approach in CU trait assessment, especially for adolescents with ASD or ADHD. Callous–unemotional (CU) traits are characterized by feeling none of the values that people share, feeling no remorse, lacking prosocial feelings, and being unemotional . They arASD and ADHD are among the most early neurodevelopmental disorders and cause disabilities in multiple aspects of brain function . ChildreAlthough not as severe as in those with CD, adolescents with ADHD have higher CU traits than those without ADHD . RegardlEnsuring the accuracy of informant data is crucial in survey studies . BecauseNo study has examined the agreement or differences between self- and parent-reported CU traits in adolescents with ASD, those with ADHD, and TD adolescents simultaneously. Such an evaluation can help clinicians and researchers determine whether they should collect information from both adolescents and parents or rely on a sole informant. Executive dysfunction is significantly associated with CU traits, including difficulties with cognitive flexibility, attentional switching, and response reversal ,32,33. EThe measures used to assess CU traits, such as the Inventory of Callous and Unemotional Traits (ICUT)  and the This study examined the levels of parent–adolescent agreement in various dimensions of CU traits and the differences in adolescent-reported and parent-reported CU traits among adolescents with ASD, ADHD, and typical development. We hypothesized that parent–adolescent agreement levels would vary among CU trait dimensions and among the three groups of adolescents. Given that both ASD and ADHD are neurodevelopmental disorders that may make it more difficult for adolescents with ASD and ADHD to be aware of their CU traits, we also hypothesized that the difference between adolescent-reported and parent-reported CU traits among adolescents with ASD and ADHD would be greater than that among TD adolescents.Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [Adolescents with ADHD or ASD were enrolled from three child psychiatry outpatient clinics in Taiwan. The inclusion criteria for adolescents with ADHD were as follows: (1) being aged 11–18 years, (2) having ADHD diagnosed by a certified child psychiatrist according to the fifth edition of the  (DSM-5) , and (3)The child psychiatrists explained the study purposes and procedures to the remaining parent–adolescent dyads and invited them to participate in this study. They were assured that their responses were confidential and that their participation or nonparticipation would not influence their right to receive medical services. Finally, 207 (88.5%) ADHD parent–adolescent dyads and 126 (90%) ASD parent–adolescent dyads agreed to participate in this study.TD adolescents were recruited through online advertising. The inclusion criteria were as follows: (1) being 11–18 years old and (2) having no ADHD, ASD, intellectual disability, major psychiatric disorders, or a history of severe brain injury. A child psychiatrist interviewed the adolescents’ parents to confirm that the adolescents met the inclusion criteria and that the parents had no cognitive deficits that might prevent them from understanding the study purposes and completing the questionnaires. Finally, 203 TD parent–adolescent dyads participated in this study. The protocol was approved by the Institutional Review Board of Kaohsiung Medical University -20150080; date of approval: 5 February 2016).not at all; 1, somewhat true; 2, very true; and 3, definitely true) [The ICUT comprises 24 items that are answered on a 4-point Likert scale to assess how appropriately the items describe the participants  ,46. Thisly true) . Both adThe sociodemographic characteristics of adolescents and their parents recorded in this study were sex and age. Parental duration of education (years) was also recorded.TD adolescents and adolescents with ADHD or ASD and their parents were invited to complete the research questionnaires in the interview rooms of outpatient clinics after written informed consent was obtained from them. Two master’s degree research assistants conducted individual interviews with the adolescents to collect data on self-reported CU traits. The parents also completed the C-ICUT. The parents could approach the research assistants with questionnaire-related queries and for clarification.ANCOVA) after adjustment for sex and age. We examined the level of agreement between adolescent-reported and parent-reported CU traits using a two-way random effects model, consistency, and intraclass correlations (ICCs) among average measures. Negative ICC values were treated as 0 because negative ICC coefficients are not theoretically possible or meaningful [ANCOVA after adjustment for age and sex. Post hoc comparisons were conducted using Shaffer’s correction. A sensitivity analysis was conducted to replicate these comparisons using an age- and sex-matched sample to address possible inappropriate adjustment arising from unequal sample sizes between groups. A two-tailed p value of <0.017 (0.05/3) was considered statistically significant.The data were analyzed using SPSS 20.0 . We examined the normality of the C-ICUT total and subscale scores based on the adjusted Fisher–Pearson standardized moment coefficient of kurtosis and skewness. Kurtosis and skewness greater than ±2 indicated nonnormality . We examaningful . Accordianingful , parent–F = 9.841, p < 0.001) but not in parents’ age . A post hoc comparison indicated that adolescents in the ADHD group were younger than those in the TD and ASD groups. The chi-squared test revealed no significant between-group differences in adolescents’  or parents’ sex distributions . The C-ICUT total and subscale scores were normally distributed, with kurtosis and skewness ranging from −0.136 to 1.154 and −0.508 to 1.738, respectively . We found that adolescent-reported and parent-reported scores on the callousness and uncaring subscales were significantly lower in girls than in boys, and no difference was observed in age (d in age .p = 0.073), which may have been due to the loss of statistical power because of the decrease in sample size after matching.A sensitivity analysis was conducted using the age- and sex-matched sample see . The patThe present study demonstrated that both adolescent-reported and parent-reported scores in the callousness and uncaring subscales in the ASD and ADHD groups were greater than those in the TD group. Adolescents with ASD ,15,16 orThe present study demonstrated that parent–adolescent agreement differed across the three CU traits. Agreement on uncaring was fair across the three groups of adolescents. People with the uncaring trait may exhibit a lack of care for others’ feelings and achievements in performing tasks . People Conversely, parent–adolescent agreement on callousness was poor across all three groups. People with callousness may exhibit a lack of empathy, guilt, or remorse for misdeeds . CompareThe present study indicated that the ASD and ADHD groups had significantly larger differences than the TD group in scores reported by parents and adolescents on callousness. Moreover, the parent–adolescent score differences in the uncaring trait were significantly larger in the ASD group than in the TD group. Conversely, the parent–adolescent score differences in the unemotional trait in the ADHD group were significantly larger than those in the ASD group. Taken together, our results support the notion that CU traits are a heterogeneous group. ASD and ADHD symptoms and parent–adolescent conflicts may increase parents’ difficulties in evaluating adolescents’ CU traits. Researchers should apply a multi-informant approach in CU trait assessment, especially in adolescents with ASD or ADHD.This study had several limitations. First, we recruited participants with ASD or ADHD from outpatient clinic units. Whether the results of this study are generalizable to adolescents with ASD and ADHD who did not visit psychiatric units warrants further study. Second, adolescents’ sex and the presence of comorbid CD and ODD symptoms as well as parental age can predict parent–adolescent agreement on CU traits in adolescents with ADHD ; howeverOur results reveal that both adolescent-reported and parent-reported scores in the callousness and uncaring subscales of CU traits in the ASD and ADHD groups were higher than those in the TD group. Moreover, parent–adolescent agreement on CU traits varied across the three dimensions of CU traits and across groups of adolescents with various psychiatric diagnoses. Clinicians and researchers should consider the heterogeneity of CU traits and seek data from different informants when examining CU traits in adolescents with ASD or ADHD. On the basis of our findings, we recommend using a multi-informant approach for CU trait assessment, especially for adolescents with ASD or ADHD.


Stigmatization represents a major barrier to treatment seeking across mental disorders. Despite this, stigma research on individual mental disorders remains in its infancy. Attention-deficit hyperactivity disorder (ADHD) in adults also represents an under-researched area—being far less studied than its child counterpart. This study examined the current state of public perceptions towards adult ADHD. A simulation group consisting of 105 participants performed the Weiss Functional Impairment Rating Scale (WFIRS) and Conners’ Adult ADHD Rating Scales (CAARS) as though they had ADHD. These scores were compared to a group consisting of 98 individuals with adult ADHD and a group of 117 healthy individuals both groups being instructed to complete the WFIRS and CAARS to the best of their abilities. Simulators were found to overestimate impairments in adult ADHD (to a large effect) in the domains of hyperactivity, DSM-IV hyperactivity-impulsivity, DSM-IV total, work, school, (to a medium effect) in family and social, and  in inattention, impulsivity, DSM-IV inattention, and life skills when compared to the ADHD group, and in all domains (to a large effect) when compared to the control group. Current and retrospective ADHD symptoms were found to be associated with more accurate perceptions in a number of domains. Evidence for the presence of perceptions considered to be stigmatizing was found, with largest effects present in the domains of hyperactivity, impulsivity, impairments at work, school, and engagement in risky behaviour. Stigma, as defined by Goffman (1963), is a characterization of an individual which conveys a social identity that is devalued in a given social context . Stigmatization of mental disorders has and continues to be a primary concern in the field of mental health Link . GulliveStigma as a concept can be divided in many ways, such as public stigma, courtesy stigma, and self-stigma  is a neurodevelopmental disorder characterized by persistent periods of hyperactivity, impulsivity, and inattention that is pervasive across situations and leads to interference in daily functioning  and WFIRS  Participants in the simulation group overestimate the extent of impairments in adult ADHD, particularly in the domains of inattention, hyperactivity, impulsivity, school, family, and risk (2) ADHD knowledge is negatively correlated with perception accuracy, suggesting that greater knowledge of ADHD is associated with more accurate perceptions, and (3) ADHD symptomology is negatively correlated with perception accuracy, suggesting that self-proximity to ADHD symptoms is associated with more accurate perceptions.One-hundred and thirty-seven individuals were considered for inclusion in the study. Ten participants did not meet the diagnostic criteria for a diagnosis of ADHD, and were excluded from the study. A total of 29 participants were excluded from the ADHD sample due to non-credible performance on the Test of Malingered Memory . This sample was gathered in the context of a larger research project, which randomly assigned healthy individuals to one of several groups . This left a total of 222 healthy individuals included in the study  was performed taking GROUP  by AGE (in years), IQ (Multiple Choice Vocabulary Test), YEARS OF EDUCATION, RETROSPECTIVE ADHD SYMPTOMS (WURS-K), CURRENT ADHD SYMPTOMS (ASRS), and ADHD KNOWLEDGE (ADHD Knowledge Questionnaire). A Chi-squared test checked for differences on gender by taking GROUP  on GENDER. Any significant differences were then investigated further by pairwise comparisons using Tukey’s honest significance difference (Tukey’s HSD). Significance level was set to 0.05.Comparisons of group characteristics are presented in Table Intellectual functioning was estimated using the Multiple Choice Vocabulary Test . This questionnaire ascertains the participants’ ADHD symptomology when they were experiencing childhood. It consists of 25 items . The items of the questionnaire measure knowledge across 4 domains: Symptoms (11 items), Diagnosis & Prevalence (10 items), Etiology (6 items), and Treatment (7 items). The combined score from these domains then gives an indication of ADHD specific knowledge. Responses were given as either “true”, “false”, or “do not know”. Sum scores ranged from 0 to 34, with 0 indicating no correct responses, and 34 indicating all responses correct.To ensure symptom validity and acceptable levels of effort, 3 effort measures were used: the TOMM Tombaugh , the GETThe WFIRS-S is a questionnaire aimed at estimating a participant’s ability to function in 7 domains (CADDRA 2017). It is primarily used in the assessment of ADHD for both adults and children. It allows for the assessment of emotional, behavioural, and cognitive functioning in domains clinically relevant to ADHD. The domains are Family (8 items), Work (11 items), School (11 items), Life Skills (12 items), Self-Concept (5 items), Social (9 items), and Risk (14 items), resulting in a total of 70 items. Items are framed as statements (e.g. “having problems with family”) and the participants indicated how closely the statement related to them. Responses are given on a Likert scale ranging from 0 (being “Never or Not at All”) and 3 (being “Very Often or Very Much”), and included the option to choose “not applicable”. The participant’s sum score in a domain was calculated by taking their score on all items in that domain and dividing it by the number of items endorsed in that domain.The Conners’ Adult ADHD Rating Scales is a questionnaire designed to assess the severity of ADHD symptoms in adults . Current and retrospective ADHD symptoms were then assessed using the WURS-K and the ASRS. Participants were asked whether they had a history of psychiatric or neurological diseases or pharmacological treatment. Following this, a short presentation was shown to the simulation group only, outlining the potential benefits of a diagnosis of adult ADHD. This presentation intentionally did not include information regarding the nature of adult ADHD and its symptomology. Participants in the simulation group were instructed to complete the CAARS and WFIRS questionnaires as though they had adult ADHD. To help ensure that they feigned ADHD, they were told that the participant who feigned most convincingly would win a recent tablet personal computer, and overdoing symptoms would decrease their chances of winning. Control group participants were instructed to complete the CAARS and WFIRS questionnaires to the best of their abilities. Both groups were told not to seek help from the examiner. The Effort Scale was then presented to the simulation group to ascertain how much effort they put into feigning ADHD. Upon completion, participants were given a debriefing. Assessment took approximately 30–60 min. The research was conducted in compliance with ethical standards and approved by the local institutional ethical committee.U tests were performed. These compared the pairs of GROUP  by CAARS INATTENTION, CAARS HYPERACTIVITY, CAARS IMPULSIVITY, CAARS SELF-CONCEPT, CAARS DSM-IV INATTENTION, CAARS DSM-IV HYPERACTIVITY-IMPULSIVITY, and CAARS DSM-IV TOTAL. Following this, each pair of GROUP  was then compared on WFIRS FAMILY, WFIRS WORK, WFIRS SCHOOL, WFIRS LIFE SKILLS, WFIRS SELF-CONCEPT, WFIRS SOCIAL, and WFIRS RISK. A Bonferroni adjustment was administered (0.05/7 = 0.007) to account for multiple testing and Cohen’s d was calculated for each comparison to determine the size of the differences between groups. Interpretation of the magnitude of Cohen’s d was in accordance with Cohen (1988), with d < 0.20 representing a negligible effect, 0.20 ≤ d < 0.50 a small effect, 0.50 ≤ d < 0.80 a medium effect, d ≥ 0.80 a large effect.Due to violations of normality and homogeneity of variance, it was decided to use nonparametric tests. All analyses were performed using the statistical software package SPSS 25.0. Five participants were removed from the analysis of the WFIRS scores due to administrative errors. These 5 participants were deemed appropriate for inclusion in all analyses, not including those WFIRS scores. An initial alpha level of 0.05 was set for all analyses, but was adjusted for multiple comparisons if applicable. To examine the difference in CAARS subscales, and the difference in WFIRS subscales, between the ADHD group, the simulation group, and the control group, Mann–Whitney To derive a variable of perception accuracy of the simulation group, the mean CAARS and WFIRS scores of the ADHD patient group were subtracted by the individual scores of the simulation group. These new difference scores  of the WFIRS subscales and CAARS subscales for the simulation group. Given the violations of normality and homogeneity of variance in the data, Spearman’s rho was taken as the nonparametric measure for correlation. Interpretation of the size of the correlation was in accordance to the categorization of Cohen (1988), with Figure U test taking GROUP  by all CAARS variables are given in Table d ≥ 0.8). Simulators had significantly lower scores than the ADHD group on CAARS SELF-CONCEPT to a large negative effect. No significant difference was found between the groups on CAARS INATTENTION, CAARS IMPULSIVITY, or CAARS DSM-IV INATTENTION. Nevertheless, the effect sizes here represented small positive effects (0.20 ≤ d < 0.50) for all except CAARS INATTENTION, which had a negligible negative effect. The simulation group showed significantly higher scores than the ADHD group on WFIRS FAMILY, WFIRS WORK, WFIRS SCHOOL, WFIRS SOCIAL, and WFIRS RISK. These effect sizes represent medium-to-large positive effects (0.50 ≤ d < 0.80). This effect was not found for WFIRS LIFE SKILLS, however, the effect size represented a small positive effect. Simulators had significantly lower scores than the ADHD group on WFIRS SELF-CONCEPT to small negative effect size.The means and standard deviations of each group across the CAARS and WFIRS subscales are seen in Table The ADHD group scored significantly higher than controls on all CAARS and WFIRS subscales. The effect sizes seen here are all considered positive and large CAARS ACCURACY DSM-IV HYPERACTIVITY-IMPULSIVITY, ( +)WFIRS ACCURACY WORK, and a medium negative correlation with ( +)CAARS ACCURACY IMPULSIVITY and ( +)WFIRS ACCURACY SELF-CONCEPT. Retrospective ADHD symptoms were found to have a small negative correlation with ( +)CAARS ACCURACY HYPERACTIVITY, ( +)CAARS ACCURACY SELF-CONCEPT, ( +)CAARS ACCURACY DSM-IV INATTENTION, ( +)CAARS DSM-IV HYPERACTIVITY-IMPULSIVITY, ( +)CAARS ACCURACY DSM-IV TOTAL, ( +)WFIRS ACCURACY FAMILY, ( +)WFIRS ACCURACY WORK, ( +)WFIRS ACCURACY SCHOOL, ( +)WFIRS ACCURACY SELF-CONCEPT, and ( +)WFIRS ACCURACY SOCIAL. For all remaining variables, there were negligible negative correlations.For ADHD knowledge, a small negative correlation was found with ( +)CAARS ACCURACY SELF-CONCEPT, and a small positive correlation with ( +)CAARS ACCURACY DSM-IV TOTAL and ( +)WFIRS ACCURACY SCHOOL. Additionally, except for ( +)CAARS ACCURACY SELF-CONCEPT, ADHD knowledge was found to have a negligible positive correlation with all remaining ( +)CAARS subscales. IQ was found to have a small negative correlation with ( +)CAARS ACCURACY SELF-CONCEPT, a small positive correlation with ( +)CAARS ACCURACY DSM-IV INATTENTION and ( +)WFIRS ACCURACY RISK, and a medium positive correlation with ( +)WFIRS ACCURACY SELF-CONCEPT. In the case of YEARS OF EDUCATION, a small negative correlation was found with ( +)CAARS ACCURACY HYPERACTIVITY and ( +)WFIRS ACCURACY SOCIAL, a small positive correlation with ( +)WFIRS ACCURACY LIFE SKILLS and ( +)WFIRS ACCURACY SELF-CONCEPT, a medium positive correlation with ( +)CAARS ACCURACY SELF-CONCEPT, and a large negative correlation with ( +)CAARS ACCURACY INATTENTION. Age was found to have a small negative correlation with ( +)CAARS ACCURACY INATTENTION and ( +)CAARS IMPULSIVITY, and a small positive correlation with ( +)CAARS ACCURACY SELF-CONCEPT, ( +)WFIRS ACCURACY FAMILY, ( +)WFIRS ACCURACY SELF-CONCEPT, and ( +)WFIRS ACCURACY RISK.The present study sought to examine the state of public perceptions towards adult ADHD in a number of functional domains, and whether ADHD knowledge or proximity to ADHD symptoms contributed to more accurate perceptions towards individuals with adult ADHD. This was done using a method intended to measure perceptions at a covert, rather than overt level. Analysis revealed that the public perception of adult ADHD was largely negative, and it most closely represented public stigma . Significant effects were also found between the simulation group and the control group. However, the effect sizes of these differences were for the majority larger  across the CAARS and WFIRS domains when compared with the differences found between the ADHD group and control group. This is evidenced that the simulators took their role seriously, and supports the internal validity of the study.Simulators showed negative misconceptions as seen by statistically significant overestimation of impairments in adult ADHD on the CAARS and WFIRS subscales. The domains of hyperactivity, DSM-IV hyperactivity-impulsivity, DSM-IV total, work, school, and risk were all overestimated to a significantly large effect when compared to the ADHD group. The domains of family and social were significantly overestimated to a medium effect when compared to the ADHD group. Despite not being statistically significant, the simulation group still overestimated impairments to a small effect in impulsivity and DSM-IV inattention when compared to the ADHD group. Surprisingly, impairments in the domain of self-concept were shown to be significantly underestimated by the simulation group to a large effect in the CAARS, and a small effect size in the WFIRS subscales. Both Figs. These findings are in contrast with the findings of Mueller et al.  which reGiven the domains in which impairment was most overestimated, it seems these estimations by the simulation group may be more aligned with childhood ADHD than adult ADHD . However, evidence of ADHD as displayed by the ADHD Knowledge Questionnaire was not the only type of knowledge posited to potentially improve perception accuracy. It was theorized that proximity to ADHD symptomology (as measured by current and retrospective ADHD symptoms) would lead to more accurate perceptions. The current study found retrospective ADHD symptoms had negligible-small associations with more accurate perceptions on all domains. This trend of greater perception accuracy could be an indication of an association between an individuals’ past experiential proximity to ADHD and an increase in their accuracy in estimating impairments. A similar trend of greater perception accuracy was found for current ADHD symptoms, as evidenced by negligible-small associations with all domains except for inattention, hyperactivity, and self-concept. Taken together, these findings may indicate current and retrospective symptomology in an individual to be an area suitable for further investigation. It should be highlighted that these associations were mostly non-significant and small in size, as such their potential relevance should be considered with caution. However, they do lead to some prospectively valuable directions for future research. Given the greater number of associations of ADHD-related symptomology over ADHD-related knowledge, it seems that rather than theoretical knowledge being associated to more accurate perceptions, it may be the experiences of the individual which holds more influence. Additionally, an individual who has more experience of ADHD symptoms, could potentially have unique insight into the more covert symptoms of ADHD, symptoms which may be harder to convey through theoretical methods. However, these findings should be taken as speculatory, as they are based on associations which were predominantly small and non-significant.This study was not without its limitations. One potential limitation of this study was a lack of representativeness among the ADHD subtypes in the ADHD group. This is not surprising, however, as research has shown the more overt symptoms of hyperactivity/impulsivity tend to dissipate upon adulthood . This number of participants may be considered lacking when trying to generalize the findings to accurately represent populations. This could lead to increased variability within the results, potentially decreasing the external validity of the research. This is not the only benefit of a larger sample size. By increasing the sample size, it becomes more feasible to investigate the effects of descriptive characteristics within the sample, for example, age, gender, and education. Furthermore, clinical characteristics could potentially be explored, such as comorbidities, treatment outcomes, and subtype comparisons. This would allow for many possibilities of interest which could not be considered given the current sample size. As such, future studies should put a greater emphasis on gathering a larger number of participants to ensure that validity is safeguarded.Finally, this study can be seen as limited in its scope of potential scenarios to have simulators feigning. Further studies should examine the aspects of life in which an individual with ADHD may experience stigmatization, for example in education, social settings, housing prospects, healthcare, and employment Lebowitz . StudiesPerceptions indicative of public stigma were demonstrated in the vast majority of domains of interest. Specifically, it was the more overt symptom domains which were found to be misconceived the most: hyperactivity, DSM-IV hyperactivity-impulsivity, DSM-IV total, work, school, and risk. Moreover, as the simulators overestimated the overt symptom impairments the most, it is possible that the conceptualization of ADHD in the public view is dominated by that of childhood ADHD. Additionally, increased knowledge of ADHD was not found to be greatly associated with more accurate estimations of impairments, however, increased current and retrospective symptoms experienced by the participants were found to be associated with more accurate estimations in a number of domains. These associations were small in size, however, and as such should be taken as an area which may lead to interesting future research. It may also open a discussion as to whether it is possible that more experiential knowledge will potentially be more effective at increasing public understanding of adult ADHD than theoretical means.