The following predictors were included in the model: age, hypertension, diabetes mellitus, baseline glomerular filtration rate, 6 min walk test measured at visit 4, BNP values at visit 4, left ventricular ejection fraction levels at visit 4, a total dose of radiotherapy received, and anthracycline cumulative doses. The model’s AUC was 0.72 , evidencing the satisfactory predictive ability of the model; sensitivity 100%  at a specificity of 66.67% ; PPV 54.1% ; PVN 100% . The calibration plot showed satisfactory agreement between predicted and actual chances (p = 0.98). The designed model can be applied in settings lacking speckle tracking echocardiography.The asymptomatic progression of chemotherapy-induced cardiotoxicity poses a significant risk to breast cancer patients. In the present single-center cohort study, a predictive model for evaluating the risk of cardiotoxicity during or by the end of chemotherapy was designed. The risk-prediction nomogram was delineated and assessed. In total, 34 patients out of 120 developed asymptomatic cardiotoxicity (28.3%). Of six explored biomarkers, only B-type natriuretic peptide showed a reliable pattern of incremental increase, revealing statistical significance between cardiotoxicity “+” and “−” groups by visit 4 or by the 9th month of monitoring ( Breast cancer  accounts for 12.5% of all new annual cancer cases worldwide, making it the most common cancer globally .Nonetheless, the number of cancer survivors continues to grow in the United States and other countries, primarily due to improved strategies for early detection and advances in antitumor pharmacological treatment, particularly chemotherapy. However, most cancer survivors must cope with the physical effects of cancer and its treatment, leading to functional and cognitive impairments ,5. It ha2 of anthracyclines, increasing to 16% at 500 mg/m2, 26% at 550 mg/m2, and 48% at 700 mg/m2 . In addition, the following data were subject to be recorded in IRC: presence/absence of CTRCD, if yes—type, form, time of emergence; any other complications during chemotherapy courses; chemotherapy outcomes, including modifications due to CTRCD; interruption due to CTRCD; changes due to non-CTRCD complications; interruption due to non-CTRCD complications; completeness of chemotherapy (%); and death .The research implied five visits, including an initial appointment and then every three months. Data to be collected included general information ; tumor features  data); clinical data ; previous treatment ; the administered chemotherapy ; and cardiac protectors (if prescribed). During the visits, the following data were collected: systolic/diastolic blood pressure (SBP/DBP), 6 WT , selected clinical and biochemical lab tests , echocardiographic data  and speckle tracking data), and biomarkers assays. The values of six conventional biomarkers: cardiac troponin (cTnI), B-type natriuretic peptide (BNP), C-reactive protein (CRP), myeloperoxidase (MPO), galectin-3 , and D-dimer were explored, as stated in the study protocol . All thehttp://osf.io/nykmw/ (accessed on 10 June 2022)]). The patient’s risk scores were stated in this form based on the defined hazard of risks and individual risk levels.According to the 2022 ESC (European Society of Cardiology) Guidelines on cardio-oncology, the stratification of cancer patients by cardiovascular risk groups is one of the crucial steps in their management . During 2 doxorubicin and 600 mg/m2 cyclophosphamide, used on the first day and administered every 21 days for four courses. The AC-T regimen was the same doses of AC during the first four courses, after which T (paclitaxel or docetaxel) was given at 90 mg/m2 for four courses (every 21 days). Trastuzumab (Herceptin) was presented at standard regimen every three weeks for up to 18 courses, with an initial dose of 8 mg/kg and then 6 mg/kg. In addition, a group of patients were administered a mixed regimen of trastuzumab and anthracyclines (HER2-positive cases). As known, administering adjuvant trastuzumab in a week cycle concurrently with an anthracycline-taxane chemotherapy regimen appears to be a preferable option to optimize its favorable effect in improving DFS  and to prevent significantly higher risk for cardiotoxic effects ; PVN 100% . The calibration plot for the model is presented in p-value 0.9793. The calibration plot describes the consistency between the model-predicted probabilities and the observed probabilities of CTRCD“+”, evaluated by the Hosmer–Lemeshow test. The plot showed satisfactory agreement between predicted and observed  chances (p = 0.98).The Hosmer–Lemeshow goodness-of-fit test was performed to evaluate the model calibration. The Chi-Sqr. statistic was 2.0544; df 8; Exploring cardiotoxicity issues gained a great scope following improved therapeutic options in breast cancer patients. Meanwhile, research studying this problem, particularly the issues of cardiotoxicity mitigation or its management in breast cancer survivors, is still limited . As the n 1200, 134 out of 439 BC patients with LVEF data have been classified into CTRCD, which means that CTRCD affected a quarter of all BC patients or even more [n 120, where 98 received anthracycline therapy) detected 34 cases of asymptomatic cardiotoxicity (28.3%).Reportedly, CTRCD occurs in approximately 10% of patients , but theven more . For antven more . In the ven more . Our mixp = 0.038), and the presence of baseline cardiovascular disease . In our cohort, patients who developed CTRCD differed from those without CTRCD by the presence of previously existing diseases: hypertension (p < 0.001), diabetes mellitus (p 0.001), and ischemic heart disease (0.023). According to Kazakhstan researchers, BC mortality was associated with women diagnosed with diabetes (HR 1.2) and arterial hypertension (HR 0.4) [Preconditions underlying CTRCD development are essential to explain the growing incidence of CTRCD. Many researchers highlight the role of clinical factors, particularly pre-existing CV diseases. The role and influence of pre-existing CV diseases on the risk of cardiotoxicity during antineoplastic treatment were stated in the latest ESC Cardio-Oncology Guidelines 2022 . As showp > 0.05) [As known, asymptomatic cardiotoxicity can only be diagnosed via imaging methods, and systematic monitoring is required. Of the two methods of LVD visualization (TTE and speckle tracking), GLS monitoring has been recognized as the best method for detecting asymptomatic cardiotoxicity. One of the main limitations of LVEF is the significant coefficient of variation, which limits its sensitivity for detecting small changes in LV function. In contrast, declines in GLS can occur without substantial changes in LVEF . In the  > 0.05) . Neverth > 0.05) . In our We examined trends in six biomarker performances across CTRCD“+” and “−” groups to select an acceptable indicator of incrementally increasing cardiotoxicity . Only BNP showed a consistent and statistically significant upward trend from visit to visit, particularly in the CTRCD“+” sample. This trend was observed irrespective of the treatment type, though BNP evidenced the highest performance within the anthracycline treatment group in our study. BNPs elevation, irrespective of BNP type, was widely recognized to be associated with cardiotoxicity during anthracycline chemotherapy and may even be more sensitive for predicting cardiotoxicity than echocardiography ,54.Contrary to expectations, cTnI in our study was not a reliable marker despite numerous papers evidencing the high efficacy of troponins in CTRCD. As known, 2020 ESMO consensus recommendations defined subclinical cardiac dysfunction as an absolute decrease from baseline in the GLS of −5% or a relative decrease from baseline in the GLS of −12% or troponins elevation from baseline, highlighting the leading role of troponins . Highly In addition to cTnI, MPO, CRP, D-dimer, and Gal-3 also failed to manifest as reliable predictors of asymptomatic CTRCD in our study, contradicting the reports of other researchers. In studies, MPO was strongly associated with an increased risk of coronary artery disease and acute HF, being a promising biomarker of cancer therapy-related cardiotoxicity in BC patients treated with anthracyclines and trastuzumab ,59,60,61p = 0.98), it has not undergone clinical validation yet. One should consider the model’s predictions as one of the sources of information that should be used in conjunction with other established clinical assessments.We have attempted to design a predictive model based on essential data from patient monitoring that can be applied to assessing the patient’s chance of developing cardiotoxicity during the treatment, particularly before the upcoming follow-up. The model should contribute to the timely modification of chemotherapy to prevent unfavorable outcomes. The model includes imaging, laboratory, and observational clinical data at different stages, as CTRCD risk is a dynamic variable, and the risk changes throughout the care pathway . PresumaWe revealed inverse proportionality between the age and scores in the model. Older patients can receive lower scores than those at younger ages. We suppose this is related to the following circumstances: the model was primarily designed for those who received anthracycline therapy, and younger age at diagnosis is a significant risk factor, at least for pediatric patients on anthracycline therapy . ChineseSome features of this study can be referred to as positive aspects. To our knowledge, we are the first researchers who tried to develop a predictive model that can serve as a practical alternative when advanced echocardiographic methods are unavailable. Despite the limited predictive accuracy, the model has passed internal validation and can be applied with other clinical tools. Second, we provided a direct comparison of six conventional biomarkers used in everyday practice and confirmed the leading role of NPs in subclinical CTRCD diagnosis. We also figured out and demonstrated the need to utilize highly sensitive troponins for early diagnosis of cardiotoxicity.The study had inevitable limitations. First was the substantial heterogeneity of our cohort, where 98 patients received anthracyclines, 12—trastuzumab, and 10—combined treatments. Such inequity significantly limited the chance of in-depth analysis across treatment groups, potentially leading to bias. In addition, we presented data without follow-up, whereas the weight of clinical risk factors can change over time.n 120, and many patients were predisposed to develop CTRCD due to pre-existing CV diseases. The leading role of NPs in subclinical CTRCD diagnosis was confirmed in the research. The predictive model based on essential data from patient monitoring can be applied to assessing the patient’s chance of developing cardiotoxicity in settings lacking speckle tracking, the gold standard of current echocardiography. The presented model requires further research and clinical validation.We detected 28.3% of patients with asymptomatic  CTRCD in the cohort with


To theEditor—We read with great interest Ordaya and colleagues' recent article titled “Let the Cat Out of the Heart,” describing the clinical characteristics of 16 cases of Bartonella endocarditis [Bartonella endocarditis's association with renal failure, embolization, and PR3-ANCA positivity. Publishing case-level data on Bartonella endocarditis is increasingly relevant in light of the 2023 updates to the modified Duke criteria that include Bartonella diagnostics as a major endocarditis criterion [Bartonella henselae as the predominant etiology of Bartonella endocarditis without providing species-level evidence to support this claim. The 16 cases described were diagnosed by Bartonella serologic positivity, with 7 patients confirmed to Bartonella genus level by Bartonella polymerase chain reaction (PCR) on explanted cardiac tissue. Species-specific PCR targets such as 16S rRNA, ribC, rpoB, and gltA genes were not performed [Bartonella species other than B henselae in the introduction, they proceed to focus on B henselae, emphasizing cat exposure and Ctenocephalides flea vectors. “Cat exposure” was reported in 62.5% of the described cases, but the authors failed to define what this exposure meant. Were all “cat exposures” scratches or simply a recollection of a feline in the vicinity? The authors also failed to include important risk factors for Bartonella quintana, such as homelessness, pediculosis, or immigration from a low-income country [B henselae infection without sufficient information to exclude alternative Bartonella species.However, we have concerns that the article, including the witty title, may mislead readers to consider erformed . While t country , 5. ThisBartonella endocarditis may cause reactive Coxiella burnetii serology. Eight of the 16 patients in this study resulted in false-positive C burnetii serology. Analogously, Bartonella serology lacks specificity and cross-reacts between Bartonella species. Bartonella quintana and B henselae commonly cause serologic positivity for the other species, with similar titers [B quintana was a more common cause of Bartonella serologic positivity than B henselae [Bartonella species based on serology.The authors appropriately recognize the limitations of serology, recognizing that r titers . In Manihenselae . One canB quintana infection. However, only HIV and alcohol use were reported in their Table 1; current homelessness, previous homelessness, and shelter exposure were not described. Moreover, it is increasingly recognized that B quintana is endemic to many low-income countries [B quintana infection that was not described here. Last, B quintana has previously been isolated from cats, and human cases of B quintana have occurred after a feline bite [B henselae among endocarditis cases with Bartonella serologic positivity.In the introduction, Ordaya et al appropriately describe homelessness, human immunodeficiency virus (HIV), and alcohol use as risk factors for ountries , 8. Thusine bite , 10. CatBartonella species, Bartonella endocarditis may be caused by either B henselae or B quintana (or another species) and may or may not be linked to a cat.In quantum mechanics, Schrödinger's cat is a thought experiment to demonstrate quantum superposition . In this


There has been little focus on autism and attention-deficit hyperactivity disorder (ADHD) in occupational groups, particularly in high-demand roles such as the police.To describe the characteristics and experiences of UK-based police force employees who are autistic and/or have ADHD, including the benefits and challenges their conditions bring to their occupation, their need for reasonable adjustments, and their co-occurring mental illnesses.An online survey was developed, containing both quantitative and qualitative elements. Survey invitations were disseminated through the National Police Autism Association. The survey was open from 23 April to 23 July 2022.n = 57; 49%) and depression  were both highly prevalent among the participants.A total of 117 participants participated in the survey, including 66 who were autistic and 51 with ADHD. Participants who were autistic and/or had ADHD widely reported both benefits and challenges related to their condition(s) in policing work. Both the autistic and ADHD groups widely reported having requested workplace adjustments related to their condition(s), although these were frequently not made. Anxiety  motivations for taking on this career, (b) rewards of the role, (c) challenges of the job and (d) challenges regarding career progression.Police force employees who are autistic and/or have ADHD reported that their conditions provided both benefits and challenges with respect to policing work, and that they had requested related workplace adjustments, although such adjustments frequently do not take place. Healthcare professionals need to recognise the importance of workplace considerations and advocacy for people who are autistic and/or have ADHD. ADHD similarly appears to be associated with increased risks of mental and physical illness.5 In contrast to autism,6 ADHD is overrepresented within the criminal justice system.7 Furthermore, there is substantial underemployment among adults who are autistic8 and/or have ADHD9 compared with their peers. Demographic factors also influence people's experiences of both conditions, including sex and gender,10 age,12 and whether they have a clinical diagnosis of autism and or ADHD13 .Autism spectrum disorder (hereafter referred to as autism) is described by the DSM-514 their prevalence within the criminal justice system15 and police training interventions in understanding these conditions.16 However, there has been comparatively little research into police employees who are themselves autistic and/or have ADHD, despite these individuals requiring support as well as potentially having abilities that offer significant benefits to police work, such as those relating to pattern recognition,17 detail-focused processing, memory18 and divergent  thinking.19Previous research pertaining to autism and ADHD and the police has largely focused on where members of the public who are autistic and/or have ADHD have had encounters with the police, including their experiences,20 Considering the importance of effective communication in police work, as well as the frequently challenging environments police force employees work in, such difficulties may have a particular impact in this occupational group. By contrast, prior research into the workplace experiences of people with ADHD reported that they expressed concerns about not meeting their perceived potential in the workplace, and inattention symptoms demonstrated a strong association with work-related problems.21 Police work can involve situations where maintenance of attention is critical to the safety of both self and others, so such problems may be more manifest in people with ADHD working in the police force.Research more generally into the workplace experiences of autistic adults describes positive factors, such as self-actualisation, enjoyable interactions with colleagues and clients, and earning money, as well as negative aspects including difficulties communicating with others, poor working conditions and challenges to sensory sensitivities in the workplace.In this study, we conducted an online survey of UK-based police force employees to describe the characteristics and workplace experiences of those who were autistic and/or had ADHD, including the benefits and challenges their conditions bring to their working life, their need for reasonable adjustments and the organisational response to such needs, and rates of co-occurring mental illness. We also conducted subgroup analyses concerning other factors that were likely to influence workplace experiences, including gender, age and length of employment, as well as having a clinical diagnosis of autism and/or ADHD.https://doi.org/10.1192/bjo.2023.508) by three of the authors to ascertain the workplace experiences of police employees who were autistic and/or had ADHD. The survey contained both quantitative and qualitative elements. The survey included questions related to the benefits or challenges of individuals’ autistic and/or ADHD features relating to their policing work, awareness of their colleagues of their diagnosis or diagnoses, how well supported they felt, their own understanding of their needs, their colleagues’ and the general public's understanding of autism and/or ADHD, whether they would recommend a career in police work for an adult who is autistic and/or has ADHD and whether their career had progressed in the way they wanted. Additional sections of the questionnaire related to participants’ basic demographic details, as well as any co-occurring mental and or physical health conditions, and whether they took any medications for such conditions.A survey was developed 24The survey was transferred to an online survey platform,The first page of the online survey comprised a consent form, with a box that the participant ticked to confirm their consent to take part in the study. The survey was available from 23 April 2022 to 23 July 2022.With respect to the positionality of the authors, one of the authors has a clinical diagnosis of ADHD. Three of the authors have first-degree relatives with the conditions under study in this survey, one with an autistic sibling, another with a sibling who is autistic with co-occurring ADHD and another with an autistic child. Two of the authors have clinical experience of working with people who are autistic and/or have ADHD. None of the study authors have personal experience of working in the police force or having close family members working in the police force. The research team developed the study following liaison with a senior member of the NPAA.Ethical approval for the study was obtained from the University of Leicester Ethics Service .P < 0.05. The autistic group was defined as those who responded with ‘yes’ to the item ‘Do you believe that you are autistic and/or have a clinical diagnosis of autism, made by a qualified healthcare professional?’, and the ADHD group was defined as those who responded with ‘yes’ to the equivalent question for ADHD. This approach enabled recognition of adults who self-identified as being autistic and/or having ADHD but lacked a clinical diagnosis. There are barriers to accessing a clinical diagnosis in the UK for both conditions, including a lack of awareness of the conditions among many healthcare professionals, as well as lengthy waiting lists for diagnostic assessment.26 Within the autistic and ADHD groups, subgroup data are reported according to sex , year of birth (<1980 or ≥1980),Quantitative analyses were completed in IBM SPSS version 28. Fisher's exact test was used for significance testing, with the threshold for statistical significance set at 27 Braun and Clarke27 demonstrated that the codebook approach to thematic analysis allows analysts to develop the final codebook as influenced by engagement with the literature and can also be participant-centred through a familiarisation process. Consistent with this approach, we recognised how our questions shaped some of the responses provided given the nature of the survey, but two coders explored the data independently and then mapped the final codebook to ensure researcher agreement and consistency in code and theme labels.The qualitative survey data were explored using a codebook type of thematic analysis, as this allowed for a conflation of deductive coding based on the quantitative findings, and inductive interrogation of text provided by participants.n = 49); ADHD but not autistic (n = 34); both autistic and ADHD (n = 17); and neither autistic nor ADHD (n = 17). In terms of gender,28n = 81; 69%), with 11 participants (9%) not providing data on their age. With respect to ethnicity, most participants reported being of White British or Northern Irish ethnicity , with 8% of participants (n = 9) reporting membership of other ethnic groups and 2% (n = 2) not providing data pertaining to ethnic group membership. More than three-quarters of the participant population joined the police force in 2003 or later . The distributions of ethnicity and year joining the police force were similar in the four groups.A total of 117 individuals participated in the study, taking a mean average of 19 min to complete the survey . The characteristics of the participant population are summarised in Of the participant population, 66 (56%) reported believing themselves to be autistic and/or having a clinical diagnosis of autism made by a qualified healthcare professional, with 44 of these individuals (67% of the autistic subgroup) having a clinical diagnosis. By comparison, 51 (44%) reported believing themselves to have ADHD and/or having a clinical diagnosis of ADHD made by a qualified healthcare professional, with 30 of these participants (59% of the ADHD subgroup) having a clinical diagnosis.With respect to mental health conditions, anxiety-related conditions were highly prevalent, with 57 (49%) participants reporting anxiety and nine (5%) reporting post-traumatic stress disorder. Depression was also highly prevalent, being reported by 40 (34%) participants, with a further three (3%) participants reporting low mood. No participant reported having bipolar disorder or schizophrenia. Many participants reported taking prescribed medications for their mental health, including 38 (32%) taking antidepressants, four (3%) taking anti-anxiety medication, two (2%) taking antipsychotic medication and one (1%) taking a mood stabiliser.n = 8; 7%) and asthma .With respect to physical health conditions, musculoskeletal-related problems were the most prevalent, being reported by 19 (16%) of participants, followed by gastrointestinal conditions (n = 66) is shown in A summary of the findings from autistic participants (n = 43) of participants said ‘yes.’ No significant differences in response were observed between males and females (P = 0.72), in those born prior to 1980 compared with those born during or after 1980 (P = 0.99), or in those who joined the police force prior to 2006 compared with those who joined during or after 2006 (P = 0.16). However, participants with a clinical diagnosis of autism were significantly more likely (P = 0.025) to report their autistic features providing such benefits to them  compared with their peers without a clinical diagnosis (n = 12). Conversely, most participants also reported that their autistic features provided challenges to them with respect to their policing work . Participants who had joined the police force prior to 2006 were significantly more likely to report such challenges relative to their peers who had joined during or after 2006 (P = 0.04).With respect to whether they believed that their autistic features provided benefits to them with respect to policing work, 81%  reported viewing themselves as requiring adjustments to their role at work owing to their autism diagnosis; women were significantly more likely to view themselves as requiring adjustments compared with their male peers (P = 0.03). More than half of participants  reported that they or someone on their behalf had requested adjustments to their role at work owing to their autism diagnosis, with no significant differences between the subgroups under comparison : P = 0.43; year joining the police force (prior to or after 2006): P = 0.80; clinical diagnosis of autism: P = 0.31). In terms of whether requested adjustments were made, 55% of participants (n = 22) reported that this had happened, although those who had joined the police force prior to 2006 were significantly less likely to report adjustments being made (P < 0.001).More than two-thirds of participants (n = 51) are shown in A summary of the findings from participants with ADHD (n = 35) of participants said ‘yes.’ Participants who had joined the police force prior to 2006 were significantly more likely (P = 0.02) to report their ADHD features providing such benefits to them. However, most participants also reported that their ADHD features provided challenges to them with respect to their policing work .With respect to whether they believed that their ADHD features provided benefits to them with respect to policing work, 78%  reported viewing themselves as requiring adjustments to their role at work owing to their ADHD diagnosis; participants with a clinical diagnosis of ADHD were significantly more likely to view themselves as requiring adjustments compared with their peers with a self-diagnosis (P = 0.03). Approximately half of participants  reported that they or someone on their behalf had requested adjustments to their role at work owing to their ADHD diagnosis, with no significant differences between the subgroups under comparison : P = 0.99; year joining the police force (prior to or after 2006): P = 0.35; clinical diagnosis of ADHD: P = 0.07). In terms of whether requested adjustments were made, 35% of participants (n = 8) reported that this had happened, with no significant differences between the same subgroups : P = 0.72; year joining the police force (prior to or after 2006): P = 0.11; clinical diagnosis of ADHD: P = 0.70).Almost three-quarters of participants (n = 57) and depression  were reported. No statistically significant differences were found between the previously described demographic subgroups and either self-reported depression : P = 0.42; year joining the police force (prior to or after 2006): P = 0.33) or anxiety : P = 0.99; year joining the police force (prior to or after 2006): P = 0.71). Furthermore, there were no statistically significant associations between having a clinical diagnosis of autism or ADHD and self-reported depression  or anxiety .29The qualitative coding process led to the generation of four central themes related to the benefits and challenges of being a person who is autistic and/or has ADHD working for the police; while presenting slightly differently in some cases, these were mostly consistent for autism and ADHD. These themes were: (a) motivations for taking on this career, (b) rewards of the role, (c) challenges of the job and (d) challenges of career progression. Working for the police force can be a complex, stressful and demanding career, and thus the characteristics associated with autism and/or ADHD were discussed in relation to this job profile. Notably, the four themes were not represented equally in depth, breadth or meaning; although we report all four themes here, we note that the challenges of working for the police as a person who is autistic and/or has ADHD represented by far the most significant theme. This is consistent with studies of autistic employees’ experiences of the workplace more generally, which have found overwhelmingly negative reports and workplace stress.It kind of just went from there – structure, guarantee of work/pay and (at the time) pretty good benefits.Wanted to do the job as a child. Like structure and discipline.Doing something different every day.Participants reported motivations for a career in the police that in some ways reflected the characteristics associated with their autism and/or ADHD. For example, autistic persons alluded to the value of structure and job security, whereas those with ADHD considered diversity in the role to be a motivation for their choice.Meaningful work – as it works to protect the community, exciting role,I really felt it was a role where I could help people.Many of the participants cited helping others as the primary driver for their career direction; this was the case for both autism and ADHD. They discussed the different ways in which they felt a career in the police would enable them to help other people, and this was posited as important to them and to their day-to-day lives in the job. They wanted work that was meaningful and was exciting, and they wanted to do something where they could help people.Ensuring a thorough investigation in completed (at least on my part) to assist victims of crime.I enjoy knowing that I have done my best for the victim.Knowing I am contributing to a job and helping bring justice to families of victims.The participants in this study were clear that there were rewards within the police force that helped to maintain a drive to undertake the work. Mostly, this related to a narrative of justice, contributing to society and serving victims of crime.A central discourse for the participants involved highlighting their commitment to the victims of crime as they positioned themselves as wanting to do their best to help them.Catching burglars, sex offenders and the most violent people.Catching criminals and putting them before a court.Aligned with justice was a discourse of ensuring that they had a role in managing criminal behaviour and played a central part in ensuring that criminals were no longer able to continue with their unlawful acts, which they constructing as ‘catching criminals’.The participants recognised that to help victims and fulfil the objectives of their policing role, they needed to attend to the criminals and to ensure that these cases reached court.Getting to engage and reassure members of public and being able to deal with lots of different things every day all at once.I feel it stretches me and utilises my skills thoroughly.I see people at their very best and also at their very worst – it's both rewarding and highly challenging, but I love to be challenged and find it a very grounding position to be in.Notably, there was also, for some, an individualistic sense of reward as they reported that the role within the police force brought personal benefits, such as skills development and being challenged.The participants highlighted a range of challenges relating to working for the police, and although some challenges were reported as direct consequences of their autism and/or ADHD, other challenges related more to wider structural, organisational and systemic issues within the public sector. These wider challenges were nonetheless positioned within a neurodevelopmental profile of the individual and thus related to their perceptions of their own condition and how they believed others saw them.Not burning out, my ADHD wears me out severely, so getting sufficient rest mentally from the intensity ADHD in the job brings in my head.Socialising and making friends. I have always struggled with these, particularly with females around my own age.Participants highlighted that there were features of their autism and/or ADHD that they felt had an impact on their daily work lives, particularly in relation to social interactions with other members of the police force.Lack of knowledge around ADHD and my feeling unable to explain this to my previous managers has meant I have deliberately not moved to roles I would like for fear of there being no support for me to learn new skills.I believe I am perceived as being a bit ‘strange’ and it is this that has prevent previous opportunities.Been held back by disclosing autism diagnosis.Here, there were instances where participants recognised their individual limitations or difficulties, as the characteristics of their condition made things more difficult for them. However, there were also challenges caused by the organisational response and the views or behaviour of others. In many cases, they did not disclose their neurodevelopmental condition to their peers or managers because of the risks they considered this to entail, and indeed this was confirmed for some.Being misunderstood, dealing with discrimination and challenged culture.I have then reached a burnout phase in both, leading to a skill drop which caused me to feel pushed out of both roles. Due to the hostile and sexist attitude in both of these areas, any issues make you feel extremely vulnerable.According to the data, challenges of the workplace were thought to result in discrimination and burnout, which can risk poorer mental health outcomes for those individuals.As noted, working for the police can be a stressful and demanding occupation, and these participants recognised that such issues were exacerbated by dealing with discrimination and a hostile and sexist attitude, which could lead to burnout and feelings of vulnerability.Dealing with red tape and constantly jumping through hoops.Dealing with management, the role is emotionally draining and physically demanding but a job like no other, ruined by weak management and poor decision making.The volume of workload is not sustainable and means we give victims a lesser service than I would like, and this caused me stress.Organisational factors were also highlighted as problematic, with both autistic participants and those with ADHD citing problems with workload, bureaucracy (framed as ‘red tape’) and poor leadership.I believe my ADHD has held me backADHD has definitely made it more difficult to progress as my ADHD makes it very difficult to say the right thing to line managers and job specific conversations to aid promotion/transfer to specialised teams.The fundamental message that participants were keen to convey through the qualitative aspect of the questionnaire was the detrimental impact of the neurodevelopmental condition on their career pathway. Many of the participants (both autistic and ADHD) reported that their characteristics had created challenges to promotion and progression. This was related to processes and structures, lack of reasonable adjustments and difficulties in implementation when they were provided, lack of knowledge and understanding by senior leaders, and a range of barriers within the organisation.I have asked for reasonable adjustment in interview it didn't go well. I took a prompt card into an interview with the agreement of HR on the interview was said they thought it was cheating I didn't get the job.The frustration at knowing that I am junior in rank, feel capable of operating at a far higher level but as I am not a networker, am not appreciated, am overlooked I do not get support/encouragement to help me. On top of this the promotion processes are set up in a way which disadvantages me.Especially noteworthy in the responses was that despite reasonable adjustments where they were recognised or asked for, there were still challenges in terms of career progression and promotion.This article reports survey responses from UK-based individuals working for the police force, with a focus on their experiences of being autistic and/or having ADHD while being a police force employee. Participants included those who had clinical diagnoses made by qualified healthcare professionals, in addition to individuals who believed themselves to have the condition(s) but had not received such clinical confirmation.n = 43; 81%). Those participants with a clinical diagnosis of autism were significantly more likely (P = 0.025) to report their autistic features providing benefits. According to the qualitative data, participants tended to be less direct in terms of describing how their autistic characteristics brought benefits to their policing work. However, they did demonstrate a commitment to the fundamental goals of the role, such as helping victims, ensuring social justice and dealing with criminals, and they saw this as a rewarding aspect of their career choice. Some participants believed that they could make a difference to society because of their personal profile. A previous survey of autistic people conducted by Cope and Remington30 similarly described participants reporting a range of strengths they brought to the workplace, including ‘superior creativity, focus, and memory; increased efficiency and personal qualities such as honesty and dedication; and the ability to offer unique autism-specific perspective’.Most autistic participants reported that their autism provided benefits to them with respect to policing work , with those who had joined the police force prior to 2006 being significantly more likely to report these challenges (P = 0.04). The reasons for this difference are unclear; one possible explanation may be that some autistic employees come to realise the full extent of the challenges they experience after prolonged service (e.g. instances where they felt overlooked for promotion). Participants were particularly expressive about how their autistic characteristics underpinned a range of individual, organisational and structural challenges in policing work. Although there are legislative directives that govern organisational responses to health conditions in the workplace, in practice, a range of difficulties can remain. This is in line with the findings of other studies reporting on the need for wholesale changes to reasonable adjustments for autistic people.29 These challenges were reported widely by our participants and were arguably exacerbated by a general reluctance to disclose their identity because of stigma, fears around promotion, other people's perspectives and job opportunities, among other reasons. Arguably, the police force (like many other large organisations) relies on neurotypical ways of structuring and managing workloads and careers, which has important implications for individuals’ mental health and levels of stress. This is important in the context of neurodevelopmental conditions, as those with autism or ADHD are at higher risk of the onset of co-occurring mental health conditions,31 and the challenges faced in the workplace may exacerbate this. For example, Hayward et al32 found that workplace stress had a greater impact on well-being for autistic persons. Although reasonable adjustments may ostensibly be a solution, our participants highlighted how these were failing to fulfil their objectives.However, a similar proportion of participants reported that their autistic features provided challenges to them in their policing work (n = 22) reported that such adjustments had been made. Previous survey findings from autistic adults suggest that there are numerous barriers to having workplace adjustments acted on, including both social  and organisational  barriers.13Of the autistic participants who viewed themselves as requiring workplace adjustments owing to their autism diagnosis, only 55% (n = 51), the majority  of participants believed that their condition provided them with benefits relating to their work, although almost all participants reported experiencing related challenges . Participants with ADHD reported liking the fast pace and diversity of police work, in contrast to the structure and routine preferred by autistic participants. Such findings indicate that neurodevelopmental conditions should be perhaps factored into decisions relating to career and/or role choice, as previously suggested by Nadeau.33 Such considerations will help determine the best fit between an employee and their role, according to the employee's relative abilities and difficulties, coupled with the demands associated with different occupational roles. As Nadeau33 describes, ‘a lifetime of struggling with tasks for which one is ill suited is like a life a life of wearing never wearing shoes that fit’. Thus, although reasonable adjustments should be made in all circumstances, it is likely to be in both employee's and employer's best interests for individuals to work in a role well suited to their relative strengths and difficulties.With respect to participants with ADHD (P = 0.03). There are multiple possible explanations for this. It could be that the clinically diagnosed individuals on average experienced greater workplace challenges resulting from their symptoms, or indeed that individuals experiencing greater difficulties were more likely to pursue a formal diagnosis, possibly viewing this as an important step in getting any required adjustments acted on.13 Of the ADHD participants who had requested adjustments to their role owing to their ADHD diagnosis , only 35% (n = 8) had such requested adjustments made, suggesting that many of the barriers experienced by autistic adults may also exist for their peers with ADHD,13 although there may also be ADHD-specific barriers.Participants with a clinical diagnosis of ADHD were significantly more likely to view themselves as requiring workplace adjustments compared with their self-diagnosed peers (n = 57) and depression , with similarly high prevalence rates reported for those with a clinical diagnosis of autism  and ADHD . Although these rates are higher than those reported in the general population,34 anxiety and depression are both more prevalent among autistic persons35 and persons with ADHD37 who are clinically diagnosed. However, Gullon-Scott and colleagues38 reported significantly higher rates of anxiety and depression among police officers compared with the general population; thus, it appears that police work in general may increase one's risk of such conditions.With respect to co-occurring mental health conditions, the participant population reported high rates of both anxiety  and a substantial proportion of the subgroup with ADHD were also autistic .In summary, when comparing the autistic participants with those with ADHD, the quantitative findings were broadly similar. The majority of participants in both groups reported their conditions providing both benefits and challenges relating to their policing work. Furthermore, the majority of both groups reported needing workplace adjustments, but when such adjustments were requested, they were made only inconsistently for both groups. With respect to the qualitative findings, there did appear to be differences in motivation for a career in policing, with autistic participants expressing an appreciation for structure and routine, whereas those with ADHD reported an appreciation of the energy and fast pace associated with their career choice. However, one must be cautious in the interpretation of such findings, as a substantial proportion of the autistic subgroup had co-occurring ADHD  may have the condition(s) they believe themselves to have, there is uncertainty as to whether they would meet the threshold for clinical diagnosis were they to undergo formal diagnostic assessment. However, it is important to consider the long, often prohibitive waiting times for autism and ADHD clinical assessments in the UK.n = 106) reported being of White British or Northern Irish ethnicity. However, this ethnicity distribution does appear to broadly reflect the overall ethnicity distribution of the wider UK police force, which as of March 2020 comprised a 93% White police officer workforce, with only 7% of officers belonging to Black and minority ethnic groups.43 By comparison, the general UK population consists of 82% White ethnicity and 18% from all other ethnic groups.44Another limitation of this study was the lack of participants from minority ethnic groups, as 91% of participants ; one possible explanation may be that participants with ADHD experiencing a greater level of functional impairment may be more motivated to pursue a clinical diagnosis.Davies and colleagues,Finally, although qualitative data were collected, this was done via the online survey rather than interview; the survey relied on textual responses, which tended to be short. A more in-depth qualitative study conducted using an interview-based approach would provide greater richness of detail and further context regarding the subject matter. Furthermore, the opportunity to talk through the issues could provide a mechanism for exploration of the specific issues that were raised in the responses to the questionnaire.Healthcare professionals, including psychiatrists, psychologists and other professionals, have a central role in the assessment and diagnosis of autism and ADHD. The findings of this survey underline the importance of occupational considerations when working with people with these conditions, as well as advocating with employers for reasonable workplace adjustments to be made and providing ongoing support in the workplace (e.g. by psychologists working closely with police force employees). Furthermore, policing work may confer an additional risk of anxiety and depression among police force employees, and it is important to be particularly mindful of the need to also assess for co-occurring mental illness when conducting assessments for neurodevelopmental conditions.46 This understanding is especially important in the modern world, as organisations are in a position of needing to retain their workforce, and in the current moment there is a greater spotlight on employee well-being and job satisfaction. Thus, the rewards of any role are instrumental in retention and productivity, and adjustments and recognition of equality and diversity characteristics are centralised.The findings reported here suggest that UK-based police force employees who are autistic and/or have ADHD frequently have co-occurring mental illness, predominantly anxiety and depression. The findings will be shared with police force employees and stakeholders, with a view to further developing the workplace environment to be more supportive of staff who are autistic and/or have ADHD. This will involve both making reasonable adjustments for any difficulties such individuals may experience in their policing work and making the most of strengths related to their autism and/or ADHD. Indeed, some authors have recently argued in favour of a positive autism approach that focuses on building on talents in the workplace rather than improving weaknesses.19 Another group of interest for further study would be former police force employees who may have left for reasons related to their neurodevelopmental condition(s). Furthermore, any interventions and/or policy changes to improve the police workplace for employees who are autistic and/or have ADHD should be subjected to rigorous scientific study, to measure their impact as objectively as possible.Further research is required to gain further understanding of the experiences of police force employees who are autistic and/or have ADHD, including those related to specific roles within the organisation, as well as the experiences of those who are also members of ethnic minority groups. In addition, research should consider not just current police force employees who are autistic and/or have ADHD but those who wish to work for the police but have been unsuccessful in their application(s), as autistic adults in particular experience specific barriers to successful recruitment.Surveys such as that used in this study could also provide a framework for studying adults with such conditions in other occupational groups, as there is a general lack of research evidence pertaining to the workplace experiences of adults who are autistic and/or have ADHD. Collecting such data and ensuring that subsequent findings lead to meaningful policy change is essential to achieve the goal whereby many more such individuals will be able to thrive in their workplace.


Attention-deficit/hyperactivity disorder (ADHD) is an established condition with high prevalence and strong negative impact on mental health, academic and socio-economic performance and quality of life not only in children and adolescents, but also in adults –3. AlthoSpeaking of under-diagnosis of ADHD in adults: there are two complex challenges to be faced when diagnosing ADHD in adults for the first time. One is to differentiate the cluster of ADHD symptoms from those of other psychiatric diagnoses that are frequently seen in adults. The other challenge is to reconstruct the presence of ADHD in childhood, as the existence of several ADHD symptoms before the age of 12 years is mandatory to diagnose ADHD as a neurodevelopmental disorder, according to ICD-11 and DSM-5 , 10. ThuEven if there were really such cases of individuals with first-onset of ADHD symptoms in adulthood, this concept seems to apply to a negligible proportion of adults diagnosed with ADHD , 12. NevAs mentioned above, adults who present for a first-time diagnosis of ADHD pose a challenge to clinicians due to poor recall of childhood symptoms , includiIn the absence of a biomarker, until today the retrospective diagnosis of childhood ADHD can only be made by clinical assessment. In particular, a clinical-diagnostic interview to assess the individual’s developmental history and the use of appropriate retrospective rating scales are the main methods for this. In all of these methods, the valid retrieval of necessary information from the reviewer's  long-term memory is essential. Uncertainty regarding the validity of this information addresses a key question in psychiatric diagnostics; moreover, it addresses questions known also in philosophy, psychology and jurisprudence. To what extent can we trust non-experts’ long-term memory regarding specific professional terms, which may additionally be biased by informants’ subjective views and expectations regarding the advantages or disadvantages of such a diagnosis?Developmental history, obtained through a clinical diagnostic interview, is a widely used tool to assess academic performance, social behavior and possible problems from pre-school and primary school times. We have published a pilot study about the importance and usefulness of the developmental history in the diagnosis process, even in significant details, in patients with ADHD older than 12 years. We found that parents of those patients retrospectively already reported problematic behaviors in early and middle childhood . The diaRating scales have been developed to systematically and as validly as possible assess ADHD symptoms in childhood based on informant recall . The short versions of the Wender Utah Rating Scale (WURS), self-rating scales, have gained particular importance in adult psychiatry and were promoted as standard of care, e.g. by the Federal Joint Committee , a public legal entity comprising the four leading umbrella organizations of the self-governing German healthcare system under the statutory supervision of the German Federal Ministry of Health . In contIn many European countries, school reports are available which, unlike subjective recall with the high risk of bias, still reflect the evaluation by teachers at that time unchanged even after decades. School reports are routinely written by teachers at the end of a term. They contain detailed information about academic performance and social behavior-related to symptoms of ADHD, notably inattention. Consequently, clinical guidelines recommend their use for the assessment of childhood ADHD , 22. An Taken together, the management of a key diagnostic issue in the first-time diagnosis of ADHD in adolescents and particularly in adults is currently unsatisfactory, as there is neither a scientific basis nor a certain established guideline in this regard. Presumably, this is part of the explanation for why there is often under-diagnosis but also potentially over-diagnosis of adult ADHD. This may lead to wrong treatment of false-negative or false-positive ADHD diagnoses in certain situations. We suggest that novel ideas and scientific resources should be invested here to bring fresh thinking to this currently overlooked or neglected clinical problem.


The current investigation assessed a) the performance of the FOCUS ADHD mobile health application (App) in increasing pharmacological treatment adherence and improving patients’ knowledge of attention-deficit/hyperactivity disorder (ADHD) and b) the impact of implementing a financial incentive for using the App .In a randomized, blind, parallel-group clinical trial, 73 adults diagnosed with ADHD were allocated into three groups for 3 months: a) Pharmacological treatment as usual (TAU); b) TAU and the App (App Group); and c) TAU and the App + a commercial discount on the purchase of medication prescribed for ADHD treatment (App + Discount Group).There was no significant difference in mean treatment adherence between groups, assessed as a medication possession ratio (MPR). However, the App + Discount Group exhibited greater medication intake registrations compared with the App Group during the initial phase of the trial. The financial discount also produced a 100% App adoption rate. App use did not increase ADHD knowledge, though knowledge scores were high at baseline. The usability and quality of the App were rated favorably.The FOCUS ADHD App achieved a high adoption rate and positive evaluations by users. Use of the App did not increase adherence to treatment as measured by MPR, but, for App users, the addition of a financial incentive to use the App produced an increase in treatment adherence in terms of medication intake registrations. The present results offer encouraging data for combining incentives with mobile digital health solutions to positively impact treatment adherence in ADHD. Attention-deficit/hyperactivity disorder (ADHD) is a chronic condition characterized by inattention, hyperactivity, and impulsivity, affecting approximately 5.3% of children and adolescents globally . ADHD syThe ADHD diagnosis is based on clinical evaluation. As a chronic condition, patients with ADHD should undergo periodic reassessments and receive long-term monitoring . EffectiDespite data showing the efficacy and tolerability of available treatment interventions in clinical trials, less than 20% of adults with ADHD are diagnosed , only 11Treatment adherence is a complex phenomenon that depends on a set of interrelated domains including patient symptomatology, treatment plan, socioeconomic aspects, and the healthcare system itself , 16. ThoNumerous strategies have been evaluated to improve treatment adherence in mental health. The optimization of health services design, involving specialized and/or multidisciplinary management  can imprOther interventions include contingency management strategies . In substance use disorders, the use of contingency strategies has a positive impact on medication adherence, treatment attendance, and treatment goal completion, including completing homework, signing treatment plans, and reducing dysfunctional behavior , 32. ThiAnother promising strategy for increasing treatment adherence in mental health disorders , includiTo date, few studies have been conducted on ADHD evaluating the use of text messages (short message service [SMS]) to send medication reminders as an intervention to improve pharmacological treatment adherence. Two such studies evaluated the impact of SMS messages on promoting timely prescription refills in adult patients undergoing stimulant medication treatment in an experimental  and primThe FOCUS ADHD App was developed to help monitor patients with ADHD in the ADHD outpatient program (PRODAH) of the Federal University of Rio Grande do Sul UFRGS) at the Hospital de Clínicas de Porto Alegre (HCPA), Brazil. Through a Task Manager contained within the App, FOCUS combines multiple features and functionalities to support all aspects of the treatment trajectory for ADHD patients including treatment information registration , patient management support , an option to add a user-customized reward system, and a robust library of psychoeducational contents. Finally, the App allows the integration of a treatment support network that can be shared with family members and health professionals, at the user’s discretion.Although promising, many mHealth solutions lack robust scientific clinical evidence of their efficacy , 40. ThuThe main hypotheses considered for this study were a) the use of the FOCUS ADHD App during pharmacological treatment (App Group) would increase treatment adherence compared with a treatment as usual (TAU) only Control Group; b) providing a significant discount on stimulant medication (25%), combined with the use of the App (App + Discount Group) would increase medication treatment adherence compared with the TAU-only Control Group and the App Group; and c) users of the App (App Group and App + Discount Group) would obtain higher scores on an ADHD knowledge scale compared with the TAU-only Control Group.A three-arm randomized clinical trial was conducted to monitor adult participants with ADHD for 3 months. The participants were recruited through a public call led by the PRODAH-Adult division between June 2021 and October 2022.The participants were evaluated according to the following inclusion criteria: a) fulfill diagnostic criteria for ADHD according to the DSM-5, b) age range between 18 and 45 years of age, c) own a smartphone, d) have a clinical ASRS score at diagnosis of ≥24, e) have at least a high school diploma, and f) accept the use of pharmacological treatment for ADHD. The exclusion criteria for the study were a) participants with any unstable or chronic clinical disease without adequate treatment, as hypertension, heart, kidney, or liver diseases; b) the presence of any significant neurological disease ; and c) the presence of unstable psychiatric comorbidities requiring immediate treatment such as depression with risk of suicide, substance abuse/dependence, anxiety, bipolar disorder, and current or past history of psychosis.Prior to the trial, participants were evaluated by a clinically experienced psychiatrist using the Structured Clinical Interview for DSM-IV and the Mini International Neuropsychiatric Interview. Sociodemographic and medical history information was also collected. Participants answered the ASRS-18 questionnaire version validated in Brazil  for the Supplementary Figure 1).Before starting the trial, participants were given a Baseline clinical evaluation by a psychiatrist with extensive experience with ADHD who confirmed the diagnosis based on a clinical interview and the application of the Portuguese version of the ADHD module of the K-SADS-E adapted for adults . ParticiThe eligible participants were then randomized into three groups by an outside member of the research team who did not participate in their follow-up. Participants randomized to the first group followed pharmacological treatment as usual (TAU-only Control Group). TAU consisted of clinical pharmacotherapy administered by a psychiatrist experienced in the treatment of adult ADHD. The second group, in addition to TAU, used the FOCUS ADHD App (App Group). Participants in the third group followed TAU and used the FOCUS ADHD App (like the App Group), but also received a discount on their medication purchase, conditioned on participating in at least 80% of the planned monthly medication intakes as established by the treatment plan registered in the App (App + Discount Group).Clinical follow-up assessments were conducted by the same psychiatrist who conducted the Baseline clinical evaluation after 4 weeks  and 8 weeks . The clinician performed treatment adjustments, refilled the prescriptions, and evaluated ADHD symptoms using the ASRS scale. A final follow-up was also performed at 12 weeks using electronic self-assessment questionnaires sent to participants.Treatment adherence was monitored through weekly contacts by research assistants with all participants. The instrument used to evaluate adherence to pharmacological treatment was the medication possession rate (MPR) – defined as the average percentage of time (days covered by the medication dosage) a patient has access to treatment according to their treatment plan between two prescriptions. A cutoff of 80% (or a mean MPR of <0.8) was used to indicate low treatment adherence .The knowledge assessment was performed based on an adapted questionnaire  to identParticipants assigned to the two FOCUS ADHD App groups were given instructions concerning App download and registration by the study coordinator. They were also informed about the App functionalities such as the pill reminders, weekly symptoms assessment, the option to invite a support network, and the twice-a-week psychoeducation contents that would be published during the protocol duration. The App + Discount Group was also informed about the incentive eligibility criteria, namely, to register 80% of their medication intakes on the App according to the treatment plan registered on the tool by the user. Once a week, the App database was analyzed to check participants’ adherence to determine eligibility for the discount at the end of the first and second months. If a participant was eligible, instructions were provided explaining how to access a 25% discount from a partner Pharmacy Chain.Participant ratings of App quality were evaluated through the User Version of the Mobile Application Rating Scale (uMARS)  that wasThe final analyzed sample comprised all participants with available data in at least one of the primary outcomes, namely, treatment adherence, knowledge of ADHD, or quality of the App.X2 and Fisher exact tests. The t-Student or U-Mann–Whitney test was applied to compare the effect of the discount incentive on the App + Discount Group compared to the App Group. An ANOVA or Kruskal Wallis test was used to compare the three groups, and post hoc analyses with Holm’s correction were performed for multiple pairwise comparisons. To study the between-subjects factor (Group) and within-subject factor (Time), we performed a repeated measure two-way ANOVA including the interaction term. Finally, we used Spearman’s correlation analysis to evaluate the association between quantitative variables. The threshold for statistically significant effects was set at 5% (p ≤ 0.05).All analyses were performed using JAMOVI software (Version 2.3) . Mean, sp = 0.787). Almost half of the participants were female (49.3%), and more than 80% of the participants indicated their race as white. Most participants were single (64.3%), and 62% had completed higher education. All other sample characteristics and sociodemographic factors did not significantly differ among groups (Supplementary Table 1).Seventy-three participants (Mean age = 35 ± 7 years) were randomized, of which 68 were included in the analysis see . A statiSupplementary Table 2 for all details).Almost all participants had symptoms of ADHD before 12 years of age (98.6%). The most prevalent ADHD presentations were combined (54.8%) and inattentive (38.4%). The most commonly identified comorbid disorder was past Major Depressive Disorder (65.8%). Social Anxiety (12.3%) and Generalized Anxiety Disorder (8.3%) were also prevalent. The three experimental groups did not significantly differ in the prevalence of ADHD presentation or comorbid conditions . There was no statistically significant main effect of Group  and no significant Group X Time interaction .p = 0.606, ES = 0.0176) .All groups had a mean MPR above 100%, and there was no statistically significant difference between groups  see . Even whF = 1.22, p = 0.275, ES = 0.007) and the result was independent of randomized group status   see .Figure 4Forty-nine participants were eligible to use the FOCUS ADHD App see .X2 = 5.35, p = 0.05).Among these 49, 5 (10.2%) did not download the App. All five participants that did not download the App were from the App Group. Thus, the adoption of the App for this group (75%) was significantly lower compared with the App + Discount Group (100%) ; and a significant effect of Time, as App engagement significantly decreased over time . An observed significant Time X Group interaction  demonstrates that the increased medication intake registrations exhibited by the App + Discount Group were significantly greater early in the trial, returning to levels similar to the App Group by the third clinical evaluation (Week 12).Engagement was defined as the number of times (as a %) that users registered their medication intake into the App see . There wRetention is defined as user engagement  being consistent throughout the study . Only four participants, all from the App + Discount Group (16.7%), fulfilled this retention criterion throughout the entire study duration.Supplementary Table 3). There was a trend toward greater ratings of usability in the App + Discount Group  compared to the App Group , but this effect was not significant . Analyzing the results from the uMARS subscales, the “Information Quality” rating received the highest mean score at 3.84 (SD 0.85), followed by Functionality at 3.67 (SD 0.88) and Esthetics at 3.49 (SD 0.66). The only rating variable with a score lower than 3 was Engagement at 2.89 (SD 0.62). Comparing the differences between the groups, the only significantly different subscale score was “Information Quality” in favor of the App + Discount Group .The FOCUS ADHD App received a positive quality evaluation by 25 study participants obtaining a total uMARS score of 3.45 (SD 0.63) out of 5  between participants receiving pharmacological TAU compared to participants who received TAU combined with the use of the FOCUS ADHD mobile health App. Though not consistent with previous studies showing a positive effect of mHealth solutions on treatment adherence –37, we nThough no effect on adherence was observed, it is important to highlight that all groups exhibited an MPR above 100% in our study. These values are much higher than the established cutoff value used to classify participants as adherent and non-adherent in previous studies . One posRegarding the FOCUS ADHD App, we observed a high adoption rate, especially by those receiving a reinforcement for using the App (100% for the App + Discount vs. 75% for the App Group). User engagement has proved to be a key element in determining the effectiveness of digital interventions –48, and Related to the complexities of using MPR as a measure of adherence, it is interesting to consider that our participants’ engagement with the App and their registration of medication intake could be considered a reasonable measure of adherence. The naturalistic nature of the present study prevented us from documenting that these registrations were associated with actual medication intake. That said, the fact that our participants made an effort to get onto the App and registered an intake and confirmed to our research assistants (via weekly contacts) that these registrations were associated with actual medication intakes, provides reasonable evidence that they took the medication. This suggests initial evidence that a financial incentive paired with the FOCUS ADHD App increased medication adherence, at least initially.In terms of retention of App use, no participant continued to register medication intake more than 80% of the time during the entire study in the App Group, while four participants in the App + Discount Group (16.7%) fulfilled this criterion. Though these numbers are low, they are consistent with the available mHealth literature –48, highWhen evaluating ADHD knowledge assessment, no significant differences emerged among groups. However, the average baseline scores for the three groups were already above the adopted cutoff for indicating a good understanding of ADHD, which may have created a ceiling effect where only a small improvement could be observed in all groups. Creating a more interactive educational experience by customizing the available psychoeducational contents with specific patient characteristics or needs could improve the FOCUS ADHD App.When we analyzed the FOCUS ADHD App performance based on the uMARS questionnaire, the total average score of the evaluations from both groups of App users was above 3, a cutoff that has been utilized in previous studies as evidence of a positive evaluation of App quality –52. In pThe literature also highlights the importance of designing and implementing personalized approaches to promote users’ engagement with digital mental health solutions . The FOCAs clinical trials using digital technology continue, it will be important to consider the conditions for optimal implementation in clinical practice , 56. SpeThere are some limitations to consider when evaluating the present results. The sample size was relatively small, and the protocol did not have a digital control group. There were income differences among study groups that were non-significant probably due to the large amount of variability within groups. Although this difference was not statistically significant, income could affect the salience of financial incentives.The current findings demonstrated that the FOCUS ADHD App obtained a high adoption rate and received positive evaluations from its users. In the present study, the use of the App did not increase treatment adherence as measured by MPR. That said, for those using the App, evidence of increased medication intake registrations in the group that received a discount on their medication offers initial evidence supporting the utility of combining financial incentives with mHealth solutions to increase treatment adherence. These data, together with prior evidence showing that App use can increase treatment adherence –37, call