Parents’ knowledge, attitudes, and beliefs about attention-deficit/hyperactivity disorder (ADHD) are crucial in the selection of the treatment strategy and how to care for children with ADHD. However, little is known about parents’ conception in mainland China. A semi-structured questionnaire was used to assess this information with 25 true/false questions regarding ADHD, and other questions investigating the methods of acquiring ADHD-related information, treatment preference, and concerns about ADHD treatment strategy. We found that the average score of all the participants was 17.42 ± 2.69  for the questionnaire on knowledge, attitudes, and beliefs about ADHD. This indicated that the parents had insufficient knowledge of this disease profile. They always accessed specialized information through mobile internet. For the treatment options, the investigated parents chose psychotherapy treatment rather than medications, in that they worried about the side effects of medication and expected to find alternative treatment strategies. The present investigation demonstrated that most parents lack knowledge about ADHD in treatment decision making in China. Medical professionals should provide parents with evidence-based ADHD-related information to help them understand this disease. Attention-deficit/hyperactivity disorder (ADHD), a common childhood mental disorder, is characterized by inattention, hyperactivity, and impulsivity , leadingStudies have found that improving parents’ understanding of ADHD through training can increase compliance, which may help promote the quality of life and long-term prognosis of children with ADHD . SciuttoTherefore, the present study aimed to (a) investigate parents who have children with ADHD regarding their knowledge, attitudes, and beliefs about this disorder, (b) identify the methods of acquiring information about ADHD, and (c) learn parents’ preferences, concerns, and expectations regarding ADHD treatment. Our findings reveal parents’ understanding of ADHD in Zhejiang Province, China, and corresponding educational materials should be provided to these parents in need.This was a cross-sectional, descriptive study. The recruited participants, consisting of only one of the parents having a child diagnosed with ADHD for the first time based on DSM-5 criteria, were interviewed with a revised version of the questionnaire, including demographic characteristics, parental knowledge, attitudes, beliefs, treatment goals and concerns, treatment selection preference, and any related content that parents greatly wanted to know. The contents of parental knowledge, attitudes, and beliefs in the questionnaire were quoted and adapted from the research questionnaires made by Mulholland  and studThe sample consisted of the parents of children with ADHD aged 8 to 16 years. These children were referred to the Children’s Hospital, Zhejiang University School of Medicine, from August 2020 to September 2021. Each primary caregiver of the individual referred to the clinics was included in the study if the child met the inclusion criteria and provided consent. During the period, it was emphasized that the information collected would be confidential and would only be used for analysis to improve the psychoeducation of parent training in ADHD management.The first part collected demographic characteristics, including child gender and age, parent gender, age, and education level. The second part included a 25-item survey that was used to collect data on the knowledge, attitudes, and beliefs of the parents of children with ADHD. It consisted of 25 true/false questions . The third part included three multiple-choice questions that were used to collect the methods of acquiring ADHD-related information, treatment preferences, and concerns about ADHD treatment strategy. The fourth part included two open-ended questions that were used to collect the treatment goals and the relevant information they most wanted to know.This study was a cross-sectional and experimental study. The purpose was to investigate the level of ADHD-related knowledge among the parents of children with ADHD in China. A two-sided test was performed, and the test criterion was set as α = 0.05. The mean ADHD-related knowledge score was 17.15, and the standard deviation was 3.10 in the pilot study. The admissible error was 0.43. The sample size was calculated using the PASS software version 15 (n = 201). Considering that 40% of the participants did not completely finish the questionnaire, the target enrollment of 281 patients was achieved in this study.The variables were input into SPSS 25 for statistical analysis. Descriptive analysis was used to analyze the demographic characteristics, and a chi-square test was used to analyze whether there were differences in the age and educational level of the fathers and mothers. Meanwhile, the distribution of parents’ knowledge, attitudes, and beliefs about ADHD, the percentage of parents who accessed ADHD-related information from different sources, their views on ADHD treatment, and their concerns were descriptively analyzed. At the same time, a chi-square test and Wilcoxon rank-sum test were used to analyze the difference between the mothers and fathers.p values less than a level of significance value of 0.05 were considered statistically significant.For all the analyses, p = 0.180). The main demographic characteristics are shown in A sample of 295 parents of children (n = 295) with ADHD were potentially included in the study. Finally, 210 were recruited. Three-quarters of them were mothers (N = 154). One-half of the parents had an education level of college or above (50% of fathers and 53.9% of mothers). There was no difference between the age and education level of the fathers and mothers (p = 0.849). There was no statistical significance among parents with different educational levels regarding their knowledge, attitudes, and beliefs about ADHD The average score of all the participants was 17.42 ± 2.69 (95% CI: 17.06–17.78)  for the questionnaire on knowledge, attitudes, and beliefs about ADHD. The scores from the mothers were higher than those from the fathers, but the difference did not reach statistical significance , not a manifestation of a child’s curiosity (87.14%), and could not heal itself (81.90%). However, approximately one-third of the parents considered ADHD to be a bad habit and only occurred in childhood.Unfortunately, regarding the topic of the etiology of ADHD, 40.48% of the parents considered ADHD to be caused by sugar intake and food additives, and 70.48% of the parents believed that the wrong method of parenting would be a reason for this disease .In terms of functional impairments, more than three-quarters of the parents thought ADHD lowered the functions of academic achievements (80.95%), peer relationships (84.29%), and interaction with family members (78.57%). More than two-thirds of them knew that children with ADHD were at severe risk of being disciplinary violations (83.81%) and playing truants (73.90%).As regards the treatment strategy, 78.10% of the parents believed ADHD was mainly dependent on drug treatment, and 93.33% believed that children should be parented under the same rules as their normal peers. A total of 82.86% of the parents took the view that excessive punishment increased behavioral problems in ADHD children. Almost all the parents thought children with ADHD needed psychological support, and teachers should understand ADHD and coping methods.p = 0.015), which is shown in Regarding the item of homework, only 27.14% of the parents thought students with ADHD should have less homework, and 42.38% thought they should have more oral homework. However, more than one-third (37.14%) of the parents thought that children with ADHD were more suitable for extra course tutoring. There was no difference between fathers’ and mothers’ views about all the questions in the questionnaire except item 21  for their children, followed by behavioral therapy (43.33%), or by medications (28.10%). Approximately half of the parents were concerned about the side effects of treatment. One-third of the parents expected their children’s attention, behavior, and learning to improve after treatment. In addition, 28% of the parents wanted to learn about the treatment methods or side effects of medications before beginning the treatment. More detailed information is shown in Parents’ perceptions about ADHD are crucial in how to select the next intervention strategy after diagnosis, which greatly influence the long-term treatment outcomes ,20. StudThis study revealed that the knowledge and beliefs about ADHD were insufficient  in parents who had a child with ADHD, these children were diagnosed as ADHD for the first time. These results were consistent with the findings of Amiri et al. , which sOur survey indicated that many participants had incorrect beliefs about the nature of ADHD. Approximately one-third of the parents considered ADHD as a bad habit and considered ADHD to occur only in childhood, which was also drawn in one study in Iran . With thWe also found that most parents had misunderstandings about the causes of ADHD. It is worth noting that two-thirds of the parents believed that the wrong method of education had caused this disease, which was consistent with the research by Ghanizadeh et al. . AttribuMost parents believed that teachers should be aware of ADHD and know the management in this study. The teachers of children with ADHD are important in the process of evaluation, treatment, and follow-up of the disease. One interview with parents with ADHD children about ADHD management also found that those parents frequently raised the point that school and teacher support was necessary for ADHD management in America . A randoThere are several functional impairments of ADHD, including low academic performance, violation of discipline, poor peer relationships, and emotional dysregulation. Appropriate requirements for them could benefit the outcomes. However, our study found that few parents thought that students with ADHD should have less homework and needed more oral homework. This showed that parents usually do not know that lowering the quantity of homework for children with ADHD is better, nor do they know which way of learning is more suitable for ADHD students. Emotional dysregulation and poor peer relationships should be addressed, as they would exacerbate the symptoms of ADHD and contribute to more severe functional impairments of ADHD . More thIn total, the knowledge, attitudes, and beliefs toward ADHD were similar between fathers and mothers in the present study. However, the rate of the included mothers was higher than that of the fathers, which was consistent with a study in Mexico ,41 and mWith respect to the treatment strategy, although three-quarters of the parents believed ADHD was mainly dependent on pharmacological treatment, the first treatment option was psychological support, followed by behavioral modification and medications. However, there were more parents who believe that medications can control ADHD in Iran . Most guThe methods of acquiring information about ADHD for most parents were via the internet using smartphones. They rarely used professional books or academic websites as resources for ADHD knowledge. Similar results were also found in other studies in South Africa and America ,28. WithAs we hypothesized, the main content that parents wanted to know was the treatment-related information that was basically regarding the parents’ concerns. In one study in America, parents worried about side effects and long-term adverse effects and thought that medication should be their last resort . AnotherThis study had some limitations. Our cross-sectional study could not determine whether improving parents’ knowledge, attitudes, and beliefs about ADHD could improve patients’ outcomes, which can be investigated in a future longitudinal cohort. The participants in this study were the parents of children with ADHD, and the results of the study might not be representative of the views of other non-diagnosed ADHD patients. Moreover, there may be significant differences between the parents of these newly diagnosed children with ADHD and those already in the treatment and management stages of the disorder. Of course, our study focused on the parents of children with ADHD diagnosed for the first time. Therefore, the parents of children with ADHD have limited views on ADHD. Our sample size was also limited, which might result in bias and could not provide a more convincing conclusion. In addition, the perceptual credibility obtained by various information sources was not effectively detected; this information helps to optimize the priority information sources of psychological intervention education resources, but this study can be used as a starting point and provide some relevant data in mainland China.Our study revealed that a large gap still exists between evidence-based knowledge and the opinions of parents with children diagnosed with ADHD for the first time. Quite a few parents in the present research had an insufficient understanding of the symptoms, etiology, nature, treatment, and prognosis of ADHD. Parents preferred psychotherapy and wanted to know more information on treatment. Therefore, medical professionals should provide parents with evidence-based ADHD-related information in parent training and establish official WeChat accounts or reputable websites to answer the concerns of parents. The present results should be taken into account when planning education materials for parents with children with ADHD.


Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurodevelopmental condition, affecting around 5-7% of school-aged childrenThe study by Yang et al.Do the findings by Yang and colleagues imply that children should be systematically screened via PRS to detect those who will likely develop ADHD and increased STU? The simple answer is no. Technically, PRS are defined by the weighted sum of the risk alleles which are associated with a disorder based on data from available Genome Wide Associations Study (GWAS). Currently, due to small effect sizes, ADHD PRS cannot accurately predict individual outcome. In other terms, most of those with high scores on the currently available ADHD PRS will not develop ADHD because “the signal is too weak”So, where does the value of the study by Yang et al. lie? I believe it is in the understanding of the links between ADHD symptoms and STU at different levels, and in the implications for treatment development. By using a multimodal approach with a cross-sectional as well as longitudinal approach, the authors were able to build and test a comprehensive, coherent model linking ADHD and increased STU, spanning from genes to behaviour via brain measures (estimated white matter integrity). In turn, this points to possible intervention strategies. Indeed, there may be several reasons underlying the link between ADHD and STU. For instance, increased STU might stem from the behavioural impulsivity of individuals with ADHD, or increased STU could contribute ADHD symptoms, in particular inattention. However, the study by Yang et al. suggests that both ADHD and long STU share common genetic underpinning and are characterised by possible dysfunctions in white matter tracts related to visual functions. This may result in impaired executive control of visual functions, with enhanced sensitivity to and distractibility by visual stimuli leading to increased STU.If replicated in other studies, the findings by Yang et al., would provide a compelling rationale to assess interventions aimed at restoring or improving these impaired visual functions. To date, the paradigm “gene dysfunction leading to brain imaging alterations, in turn underpinning behavioural manifestations” has not led to relevant innovations in the care of children with ADHD. For instance, meta-analytic evidenceSC declares honoraria and reimbursement for travel and accommodation expenses for lectures from the following non-profit associations: Association for Child and Adolescent Central Health (ACAMH), Canadian ADHD Alliance Resource (CADDRA), British Association of Pharmacology (BAP), and from Healthcare Convention for educational activity on ADHD.


This study reports that children exposed to 2,3,7,8-tetra-chlorodibenzo-p-dioxin (TCDD), the major toxin in Agent Orange, from the breast milk of mothers residing near the former Da Nang US air base in Vietnam may have specific alterations in higher brain functions, resulting in social and communication deficits, including autism spectrum disorder (ASD). After the age of 8 years, girls with high TCDD showed increased attention deficit hyperactivity disorder (ADHD)-like behaviors and altered mirror neuron activity, which is often observed in children with ASD. However, no significant relationship between autistic traits and toxic equivalency values of polychlorinated dibenzodioxins and polychlorinated dibenzofurans (TEQ-PCDD/Fs) was found in these children. Notably, boys with high levels of TEQ-PCDD/Fs showed poor language and motor development in the first 3 years of life, although boys with high TCDD levels did not. However, at 8 years of age, boys with high TCDD showed reading learning difficulties, a neurodevelopmental disorder. These findings suggest that perinatal TCDD exposure impacts social–emotional cognitive functions, leading to sex-specific neurodevelopmental disorders—learning difficulty in boys and ADHD in girls. Future studies with a greater number of children exposed to high levels of TCDD are necessary to estimate the threshold values for neurodevelopmental effects. Da Nang Air Base, located in central Vietnam, is a former U.S. air base contaminated with dioxins from the use of Agent Orange and other herbicides containing 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) during the Vietnam War. We previously measured levels of 17 polychlorinated dibenzodioxins and polychlorinated dibenzofuran (PCDD/F) congeners in the breast milk of mothers residing nearby Da Nang Air Base and found these to be three- to four-fold higher than those in the breast milk of mothers living in unsprayed areas  andMarazziti et al. (2012)  reviewedIn an in vitro study, Hwang et al. (2016)  reportedTaken together, and compared to other PCDD congeners, TCDD might have more specific AhR-dependent toxicity to induce mitochondrial dysfunction, which is involved in the pathophysiology of neurodevelopmental disorders, such as ASD and ADHD, observed in children from the Da Nang cohort. Further studies are required to clarify the differences in neurotoxic effects between TCDD and other PCDD/Fs congeners and their mechanisms in the future.Perinatal TCDD exposure affects social–emotional cognitive functions, leading to neurodevelopmental disorders. However, the effects are sex-specific: primarily LD in boys and predominantly ADHD in girls. PCDD/F congeners other than TCDD may specifically impact neurodevelopment in boys. The estimated threshold values for TCDD may also differ between the sexes. Further studies on children, including those with high TCDD exposure, are necessary to clarify the sex and age-specific neurodevelopmental effects of these dioxins.


Shared care by general practitioners (GPs) would deliver more timely care, closer to home, however GPs indicated the need for interprofessional training support. This study describes the use of Project ECHOA retrospective pre/post-knowledge and self-efficacy survey across twenty-seven aspects of ADHD management was administered, using a seven-point Likert scale.Significant improvement (p < 0.001) in provider self-efficacy was demonstrated across all tested domains.Use of the ECHO model™ by an interprofessional team of paediatric specialists achieved an increase in GP knowledge and self-efficacy in the local management of children and young people with complex healthcare needs. Learnings indicate viability to expand the application of the ECHO model™ to address fragmentation for other priority populations across the Australian healthcare and human service sector landscape.Use of the ECHO model™ to support and train GPs was successful. Integration of care was achieved through strengthened partnerships between content and context experts, and the ECHO model™’s case-based learning methodology. Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition affecting 5–7% of Australian children and accounts for 20% of paediatric outpatient encounters nationally 2. This rA previous study of GP attitudes around ADHD management found that GPs do not feel equipped to manage ADHD . GP pres33®  pilot to support GPs to manage children and adolescents with ADHD [® is a virtual hub-and-spoke model of collaborative, case-based learning, delivered via regular videoconferences. The ECHO model™ has been used extensively around the world to create virtual knowledge networks, or communities of practice, by incorporating learning strategies informed by theoretical frameworks including Social Cognitive Theory, Situated Learning Theory, and Community of Practice Theory [9® connects a multidisciplinary ‘hub’ team of specialists, to ‘spoke’ primary care providers, to collaboratively discuss de-identified patient cases during regular videoconferences. The model has proven to be an effective training method for a range of complex conditions internationally [To address this need for training and multidisciplinary input, Children’s Health Queensland Hospital and Health Service (CHQ) introduced a Project ECHOith ADHD 7. ECHO® e Theory 910. ECHOtionally .The ECHO model™ adopts a core learner-centric approach to the virtual hub-and-spoke education, based on a key principle of “all teach and all learn” . Special1210151617In January 2016, the then Queensland Minister for Health and Minister for Ambulance Services commissioned a $35 million-dollar Integrated Care Innovation Fund (ICIF) . PHN org® hub at CHQ, based in South Brisbane, and to launch and evaluate the pilot focussed on ADHD. The grant term also committed that CHQ would work in partnership with two local PHNs throughout the grant term (2016–2018) to raise awareness and promote the ADHD ECHO® pilot to primary care audiences.The CHQ research team applied and was successful in obtaining an ICIF grant to pilot the ECHO model™ for the first time in Queensland to support GPs with ADHD management . The bas® model™’s case-based learning methodology.The aim of this study was to investigate whether the use of the ECHO model™ to support and train GPs was successful through a self-efficacy survey. The change in the integration of care was assessed based on GPs perceptions of the established partnerships between content and context experts, and the ECHOThis study was approved by the Children’s Health Queensland Hospital and Health Service Human Research Ethics Committees (Ref: HREC/17/QRCH/67).® hub as a collaborative model of education and case-based discussions to allow paediatric experts to share knowledge with GPs and other healthcare professionals in the primary care sector. Education was delivered via a series of weekly videoconference sessions from April 2017 with a panel of experts located at a central ‘hub’ site, while providers remained in their local setting. CHQ leveraged the virtual nature of the ECHO model™ to support primary healthcare providers in urban, regional, rural, and remote settings to better manage patients with an ADHD diagnosis and complex healthcare needs. In each of these geographic settings, access to specialist services was limited. In this project, the ECHO® series were targeted at empowering GPs to better manage children with ADHD.CHQ established a Project ECHOThe CHQ project team consisted of a General Practice Liaison Officer, Project Manager, and General Paediatrician – with each key staff member responsible for aspects of the planning and implementation of the pilot. A crucial step in the initial planning phase involved sending the project team to complete the ECHO Institute™’s Immersion training at the University of New Mexico, USA. Immersion training is compulsory for prospective hub organisations to become licensed to use the ECHO model™ and provided the team with extensive training in the ECHO model™.® series in Queensland based on a literature review, example curricula from another ECHO® hub site delivering an ADHD ECHO® Network, and through consultation with ADHD subject matter experts. Subsequently, a multidisciplinary panel of experts was identified and engaged to facilitate the ADHD ECHO® Network over several cohort cycles known as series. Stakeholder engagement was maintained throughout the implementation through project governance meetings and targeted promotional activities on social media. Project staff networked effectively to engage new stakeholders and panellist expertise where necessary throughout the implementation period.The project team worked to gain and maintain organisational support and buy-in from key executive leaders in Queensland. Stakeholders, including representatives from CHQ, PHNs, the Department of Health’s Clinical Excellence Queensland (CEQ), GPs, and a consumer representative, were engaged to form a project steering committee that was responsible for key decision-making throughout the pilot. This governance forum oversaw and endorsed all aspects of the pilot throughout the implementation phase. The project team designed a locally-responsive curriculum for the first paediatric pilot ECHO® Network series were delivered in line with the Queensland school term calendar. GPs interested in learning more about ADHD were recruited to join the ADHD ECHO® Network, through marketing support provided by the Queensland PHNs. There was no requirement for the GPs to have previous experience managing patients with ADHD. In addition to GPs, participation was open to GP registrars, psychologists, nurses, and paediatric trainees. Feedback was collected from various stakeholders and participants, allowing for adjustments and improvements throughout implementation.The project team utilised a variety of methods to market the training and recruit participants. Back-to-back ADHD ECHO® session commenced with a brief didactic presentation by a hub panellist on an aspect of ADHD management identified in the curriculum. Following this, participants presented de-identified cases to peers and the hub panel as a virtual team. Throughout the didactic and case presentation components of the ECHO® session, all participants had the opportunity for raising questions for clarification and offering evidence-based recommendations. The ADHD ECHO® panel was made up by a developmental paediatrician, psychologist, senior guidance officer, general paediatrician, and parent representative. The parent representative, recruited through ADHD Australia, brought rich insight and lived experience raising four children with ADHD and other behavioural health needs [® Network sessions into their local patient management. Participants were encouraged to re-present their patients at subsequent ECHO® sessions if required for further advice and support.Cohorts of up to 20 participants joined weekly, 90-minute videoconferences for 10-week cohorts throughout 2017–2018. Each ECHOth needs 22. Parti® Network were accredited by the Royal Australian College of General Practitioners (RACGP) and/or Australian College of Rural and Remote Medicine (ACRRM). The CPD points were offered to GPs who completed the pre-disposing activity, attended a minimum of six ECHO® sessions, and completed the evaluation including retrospective pre/post-ECHO® self-efficacy survey. Other professional disciplines that participated in the ECHO® sessions were able to self-report the CPD activity to their relevant professional bodies and were provided with attendance transcripts for evidence.Continuing Professional Development (CPD) points for attending the ADHD ECHO® self-efficacy survey (Appendix 1) across twenty-seven aspects of ADHD management including symptom monitoring, prescription of stimulants, assessment and management of co-morbidities, and referral to allied health and school support services [1523252627Following each of the five 10-week series, all participants were invited to complete the retrospective pre/post-ECHOices 152325262728.® hub was successfully established, five ADHD ECHO® Network series were delivered to a total of 65 primary care providers, including 43 GPs. During the study period, 31 out of 43 GP participants from five of the ADHD ECHO® Network cohorts  responded to the retrospective pre/post- ECHO® self-efficacy survey. Data were analysed using Stata 15.1 software [® sessions to meet the RACGP and ACCRM CPD awarding requirements. Other respondents who did not meet the minimum of attending six ECHO® sessions were excluded from this data set.Once CHQ’s ECHOsoftware . The Lik® survey responses in all surveyed domains  in the pre/post-ECHO domains . Importa®-trained GPs to manage patients in the primary care setting to determine if impacts on patient outcomes and cost-effectiveness of using the ECHO model™ in the Australian context are similar to international experiences [33This data provided evidence that the innovation improved GPs’ capacity and confidence to manage children with ADHD in primary care. In addition, the research team acknowledged that there were challenges experienced by the project team in sustaining rates of GP participation throughout the pilot. Anecdotally, these challenges were in part attributable to the funding instrument whereby the federal government funds a fee-for-service model in the Australian primary care setting which discourages GPs from participating in learning opportunities during income generating business hours 3132. Fut31eriences 3334.Did the innovation result in improved GP knowledge and confidence in the diagnosis and management of children with ADHD?GP participants rated their own self-efficacy across 27 dimensions related to the management of children with ADHD 152325262728.252627® Network responses in line with guidance from the ECHO Institute™, University of New Mexico Health Sciences Center. This was to reduce the risk of biasing in pre-ECHO® self-efficacy responses if completed prior to attending the sessions, whereby participants may score their knowledge and confidence higher pre-ECHO®, despite generally “not knowing what they don’t know”. Strong improvements were seen in participant self-efficacy across all 27 dimensions. On average, self-efficacy scores increased from 2.6 to 5.4 on a seven-point scale.The survey was completed retrospectively for collecting both pre- and post-ECHOThe strongest improvements in GP self-efficacy were observed in responses to:®: 1.6, post-ECHO®: 5.1);Switch from short acting to long-acting stimulants ;Use the Vanderbilt questionnaire to monitor symptoms of a child with ADHD ;Prescribe stimulants to children with ADHD ;Serve as a ‘local consultant’ within your clinic or community for ADHD questions .Discuss with families what educational support is available for children with ADHD ;Monitor blood pressure in children with ADHD taking stimulant medication (6.2);Know when a referral back to a paediatrician may be required (6.1);Refer a child to a school guidance officer (5.9);Screen for side effects of stimulant medication in children with ADHD (5.8).® Network. The study provides proof of concept that the ECHO™ model can be used to empower and support GPs in ADHD management, and that a virtual shared-care model could feasibly be implemented. Increased virtual shared-care of young people with ADHD could potentially ameliorate the rising demand for paediatric outpatient ADHD care [This study is the first to examine changes in Australian GP self-efficacy in the management of paediatric ADHD, after participating in an ECHODHD care 35, and fLimitations of the study included both the potential for recall and response bias due to the retrospective and self-reporting nature of survey responses, and the small number of survey responses. The researchers also acknowledge that the GPs who participated in this study were volunteers, and there was no comparison group, so desirability bias cannot be excluded.®-trained GPs, with outcomes of patients receiving ‘usual care’ in paediatric outpatient department settings. Research into the longer-term cost-effectiveness of GP training via ECHO® in Australia is also required.Future research should be conducted to determine if the increased self-efficacy observed in this study is sustained long-term. These results also warrant further research comparing health outcomes and consumer satisfaction with care of patients who are cared for by ECHO® pilot presents a compelling example to system managers at state and federal levels, of an innovative way to virtually share care for patients with complex healthcare needs across the primary-secondary-tertiary continuum and beyond geographic boundaries.This research demonstrates scalable learnings that can support the GP workforce through wider use of the ECHO model™ being replicated in a variety of different topic areas and across other professional, sectoral, and geographic jurisdictions. The ADHD ECHO® Network. Some barriers were structural, relating to external factors that would be difficult to resolve. Others were internal, relating to some of the prescriptive aspects of the ECHO model™ and session structure, and the potential mismatch with the Australian primary care funding model.The researchers acknowledge the inherent limitations within the intervention design to sustain ongoing participation of GP participants in the ADHD ECHO® Network sessions are mandated to always be free, GPs can also be eligible to receive CPD points for participation in any accredited ECHO® Network. If a GP presents a patient case in any ECHO® Network session, they can self-determine their eligibility to claim a case-conferencing item number under the Medicare Benefits Scheme. This would only serve to partially remunerate the GPs lost income-generating time at ECHO® Network sessions in which they presented a patient case from their own practice for advice and support. Despite these characteristics of the ECHO® Network intervention, it remains unclear whether the provision of CPD points alone would remain a sufficient incentive to attract and retain a solid, steady flow of GPs to enrol in the ECHO® Network longer-term.While spoke participation in all ECHO® Network. Participation required a one-hour per week commitment over 10 weeks at a specified time to be eligible for the maximum CPD points. ECHO® Network participation during business hours would typically result in a GP losing revenue, due to the fee-for-service funding model and many GPs not having a salary retainer. This was seen as unattractive for many potential GP participants, and unacceptable for some.The prescribed nature of the ECHO model™’s virtual delivery method and regular timeframe constrained the number of GPs able and willing to participate in the ADHD ECHO® Network to the target population of participants was yet to be identified. The associated workload for the project team in registering and onboarding GPs was identified as resource intensive and future planning to streamline this should be investigated.The Australian landscape of CPD provision is competitive, with a variety of options constantly marketed to GPs by professional colleges for upskilling, was also identified as a barrier to uptake. Several strategies were explored, however a highly effective method of marketing the ADHD ECHO® Networks after the ADHD ECHO® pilot, there is also growing evidence that this method of learning appeals to a wide array of other professional groups.It is hypothesised that as the ECHO model™’s use in Australia expands, its reputation as a well-known, high-quality option for primary care professional development will increase. This would complement and offset some of the project team’s efforts during the pilot to gain GP participant enrolments. Based on enrolments across the variety of CHQ’s ECHO® Network pilot, CHQ employees who had ECHO® panellist roles were funded through the ICIF grant to enable the backfilling of their usual roles. This was to ensure continuity of frontline services while this pilot was being tested.For the initial ADHD ECHO® Network pilot, the project team relied on in-kind support from a variety of internal and external colleagues to fulfill panellist roles. Organisational incentives to serve as panellists were utilised such as professional networking and knowledge-sharing with new colleagues at spoke sites to attract content experts from across CHQ and other specialist partner agencies. This was generally straightforward and sustainable as organisational role descriptions commonly required more senior staff to commit to providing education and training as a core responsibility. The sustainability of this aspect of the ECHO model™ in particular for external staff with subject matter expertise needs to be considered.However, in subsequent series beyond the grant term of the ADHD ECHO® Network pilot, it was discovered that even when the innovation was successful in improving the confidence and capacity of GPs to manage children with behavioural conditions such as ADHD, there were cultural barriers to changing engrained practice with the potential to prevent and/or reduce the bottleneck service burden of the HHS. Historically, GPs in Queensland have tended not to use the prescribing delegations they have to treat children with ADHD.Over the course of the ADHD ECHO® Network series regarding their GP colleagues.While a residual culture of hospital staff not trusting GPs in the community enough to discharge patients to their care remains, positive changes were reported amongst the paediatric specialists involved in the delivery the ADHD ECHO® innovation may achieve an increase in paediatricians’ discharge of ADHD patients to general practice following diagnosis and initiation of treatment. GPs who were interviewed reported that participating in the ADHD ECHO® Network series resulted in improvements in their self-efficacy and capacity to manage ADHD patients without needing to refer to a paediatrician.This research provides evidence to suggest the Project ECHO® Network series would be seen over time and warrants further research over a longer-term period. This was confirmed by the GPs surveyed who reported that participation in the ADHD ECHO® Network series might decrease the future chance of needing to refer patients to a paediatrician. As a result of their participation in the ADHD ECHO® Network, some GPs reported that they developed collegial relationships with the paediatric panellists and other GP spoke participants, such that if faced with a difficult patient, the GP was inclined to first contact one of those now-known colleagues for advice before deciding to refer to a hospital outpatient service. A reduction in health service utilisation and costs due to improved local capacity for ADHD management in primary care would therefore be feasible but would require longer term data to validate. Consideration of similar benefits across state and federally-funded health systems should be explored where the ECHO model™ could be applied to enable more virtual shared care solutions to system pressures.It is likely that a significant reduction in new referrals from GPs who had completed the ADHD ECHOIt takes time to achieve genuine culture change and reduce historical/hierarchical/professional barriers;® Networks, despite the international evidence linking the ECHO model™ of virtual shared care to improved outcomes;Primary care fee-for-service funding models inhibit the GP workforce from engaging in ECHO® Networks can improve GP knowledge and self-efficacy;Participation in ECHOThe use of the ECHO model™ in Australia can successfully integrate care.The aim of this study was to investigate whether the use of the ECHO model™ to support and train GPs was successful through a self-efficacy survey. The change in the integration of care was assessed based on GPs perceptions of the established partnerships between content and context experts, and the ECHO model™’s case-based learning methodology.This study found that the use of the ECHO model™ to support and train GPs in managing children with ADHD was successful. The improved integration of care was achieved through strengthened partnerships between content and context experts, and the ECHO model™’s case-based learning methodology.


Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are commonly comorbid with allergic and autoimmune diseases in children. The aim of the current study was to investigate the association between children’s and first-degree relatives’  allergic and autoimmune diseases and children’s ASD and ADHD. We enrolled participants from Taiwan’s Maternal and Child Health Database. We used the Cox regression model to examine the associations of familial, siblings’ and children’s allergic and autoimmune diseases with children’s ASD and/or ADHD. In total, we included 1,386,260 children in the current study. We found the significant association between familial allergic or autoimmune disease and development of ASD or ADHD among children. We also identified the predominant impact of familial aggregation on the above associations. The associations between some parental diagnoses of autoimmune or allergic diseases in children’s ASD and/or ADHD were stronger in mothers than those in fathers. Early assessment of the possibility of ASD and ADHD is required for children who have a parent with an allergic or autoimmune disease. Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are both neurodevelopmental disorders . ResearcResearchers have become increasingly interested in the effects of immunological diseases, such as allergic and autoimmune diseases, on the development of ASD and ADHD. Research suggested that children with ADHD or ASD have an increased risk of allergic comorbidities . MoreoveAlthough previous studies have explored the link between immunological diseases and ASD and ADHD, no conclusion has been reached regarding the effects of parental allergic and autoimmune diseases on the development of ASD and ADHD in their children. A population-based study in Canada indicated that children born to mothers with SLE had an increased risk of ASD . AnotherThe current study derived data from Taiwan’s National Health Insurance Research Database (TNHIRD). Information in TNHIRD is based on the National Health Insurance Program, with 99.99% coverage of Taiwan’s population. The TNHIRD has a different dataset to store information, including registry for beneficiaries, ambulatory care claims, inpatient claims, prescriptions dispensed at pharmacies, registry for medical facilities, and registry for board-certified specialists . AccordiWe used the Taiwan’s Maternal and Child Health Database (TMCHD), one of datasets from TNHIRD, for the period from 2004 to 2016. TMCHD is a specific dataset, which was designed to examine the family study by further integration of information about newborn information  since 2004 in Taiwan. The TMCHD contains records on 99.78% of all births nationwide in Taiwan since 2004 . We furtThe inclusion criteria of the current study were that all of the living born children and their parents did not have missing information on their identity in the TMCHD. We recruited children who were 5 years old or older in 2016 because children aged 5 years or older may develop sufficient symptoms to permit reliable ASD and ADHD diagnoses, and every child had a minimum follow-up period of 1 year (to 2017). In Taiwan, children can enter the kindergarten at two years old; teachers have enough time to observe children’s behaviors for clarifying symptoms of ASD or ADHD. Therefore, it is suitable to set 5 years old as one of the inclusion criteria. Moreover, the mean age of first diagnosis of ADHD was 7.7 years in Taiwan , and theInternational Classification of Disease, Ninth Revision (ICD-9) and Tenth Revision (ICD-10), which were the diagnoses system of TMCHD and TNHIRD. The details are listed in The exposure in the current study was the three allergic diseases  and four autoimmune diseases  of children or their first-degree relatives . The reason to choose these diseases was that these diseases are relatively common allergic and autoimmune diseases based on our preliminary analysis. If participants received one inpatient or at least two outpatient diagnoses of these autoimmune disease or allergic diseases during the research period , they were identified as having any allergic or autoimmune disease  or more than two outpatient diagnoses given by psychiatrists within the study period. The covariates in this study were sociodemographic characteristics, namely parental age of delivery and child’s sex.To examine the associations of familial, siblings’ and children’s allergic and autoimmune diseases with children’s ASD and ADHD, we used the Cox regression model. In these models, children’s and familial  allergic and autoimmune diseases were treated as predictors, whereas children’s ASD and ADHD were treated as the outcome. We adjusted for child and relative’s year of birth and familial clustering using the robust variance. We followed the analysis based on Hegvik et al. .We used hazard ratios (HRs) with 95% confidence intervals (CIs) to quantify ASD or ADHD risks and their levels of statistical significance. An HR > 1 suggested that the risk of ASD or ADHD was higher in children in the comparison group than in the reference group. The CI of the including a null value of 1 implied that the risk of ASD or ADHD did not reach statistically significant difference.We also examined whether higher number of affected relatives  in family associated with a higher incidence of ASD and/or ADHD, we participants into three groups: (1) no family member has allergic or autoimmune diseases, (2) only one family member  had allergic or autoimmune diseases, and (3) two family members had allergic or autoimmune diseases. We did not consider the group of within-individual, mother and father all had allergic or autoimmune diseases because such is an extremely rare case.Finally, to further examine whether these familial associations of allergic and autoimmune diseases with ASD and/or ADHD were different between mothers and fathers. We used a moderation analysis with the inclusion of interaction between parents and exposure , and the estimate of the interaction represents a differential effect between mothers and fathers . In thisIn total, we included 1,386,260 children in the current study. Among them, 661,957 (47.8%) children were boys and 724,303 children were girls (52.2%), and 78,307 children have at least one full sibling, with 351,192 of sibling pairs and 14,576 having one half-sibling. The average age of children was 9.7 years. The incidence of ASD and ADHD for these children was 1.0% and 5.1%, respectively. The demographics and disease status are presented in In Finally, the The current study demonstrated the significant association between familial allergic or autoimmune disease and development of ASD or ADHD among children. Furthermore, we also identified the predominant impact of familial aggregation on the associations between familial allergic/autoimmune diseases and development of ADHD or ASD among children. In advance, the associations between some parental diagnosis of autoimmune or allergic diseases in children’s ASD and/or ADHD was stronger in mothers than those in fathers, indicating the predominant effect with mothers. We found that any allergic disease from full sibling was significantly associated with children’s ASD and/or ADHD. However, the significance was not identified within individual disease. This may be due to the limited cases of groups with full sibling, and it will compromise the statistical power, resulting in the insignificance. Similarly, it can also explain the insignificance of adjusted odds ratio for two or three family members have disease in the column of ADHD in the The present study extends the application of the previous population-based study, demonstrating that ADHD and autoimmune diseases may co-aggregate among biological relatives, indicating that the relationship between ADHD and autoimmune diseases may be partially explained by shared genetic factors . Our stuSeveral reasons may explain the influence of parental immunologic diseases on the development of children’s neurodevelopmental disorders. First, allergic and autoimmune diseases have high heritability, implying an increased risk of allergic and autoimmune diseases in the children of parents with such diseases. A family history of immunological diseases is a key risk factor for allergic diseases . GeneticSecond, the derailment of the dopaminergic system may be associated with immune diseases. Dopamine receptors have been found to be expressed in immune cells, contributing to immune-inflammatory diseases . DysreguSeveral limitations of this study should be noted. First, the nature of the retrospective cohort study limited the interpretation of the outcome due to the possibility of unmeasured variables. For instance, the effect of pharmacological treatment for allergic and autoimmune diseases on the development of neurodevelopmental diseases remains unknown. Second, the intertwined biomedical mechanisms of allergic and autoimmune diseases render subgroup analyses of either allergic or autoimmune disease influences individually difficult. Third, because the TMCHD was established since 2004 and by the end of this study , we can only include children born during this period. As a result, the age coverage of our child participants was limited to, at most, 13 years old. Furthermore, it is not easy to identify more than two generations in a dataset started in only 13 years. Therefore, our familial aggregation study design was limited to first-degree relatives but not to expand to second-degree or third-degree relatives. Fourth, due to the limitation of database, no further data of genetic information were available to clarify the association between familial autoimmune or allergic diseases and ASD or ADHD among children. Further genetic studies may be helpful to clarify the etiologies of this association. Finally, the TMCHD could not identify participants who did not seek medical help for ASD, ADHD, or allergic or autoimmune diseases. As TMCHD is a database with high coverage of the Taiwanese population , this efThe current study determined the influences of familial and children’s allergic and autoimmune diseases on the risks of ASD and/or ADHD among children. We also manifested the influence of familial aggregation in the association between parental allergic and autoimmune diseases on their children to develop ASD or ADHD. Physicians should pay attention to the possibility of comorbid ASD and ADHD among children with allergic or autoimmune diseases, especially among children with family histories of allergic or autoimmune diseases. Further study to investigate the biological mechanism underlying the association between immunological diseases, ASD, and/or ADHD is warranted.


Approximately 48–54% of children with attention-deficit/hyperactivity disorder (ADHD) have impairing difficulties with emotion regulation, and these difficulties are not ameliorated by first-line ADHD treatments. Working memory and inhibitory control represent promising intervention targets given their functional, if not causal, links with ADHD-related emotion dysregulation.M = 10.22, SD = 1.43; 76% White/non-Hispanic; 29 girls).This preregistered randomized controlled trial tested whether two digital therapeutic training protocols that have been previously shown to improve working memory  and inhibitory control (Inhibitory Control Training [ICT]) can improve emotion regulation in a sample of 94 children with ADHD aged 8–13 years , at 1–2 months after completing treatment , and at 2–4-months follow-up . Contrary to our hypotheses, the CET and ICT groups demonstrated equivalent reductions in emotion dysregulation and maintenance of effects. Exploratory analyses revealed that results were robust to control for informant expectancies, ADHD medication status/changes, in-person vs. at-home treatment, child age, and time from treatment completion to post-treatment ratings.Results of Bayesian mixed model ANOVAs indicated both treatment groups demonstrated significant decreases in emotion dysregulation relative to pre-treatment at immediate post-treatment (parent report; To determine whether working memory and inhibitory control are causally linked with ADHD-related emotion dysregulation, future studies should include active control conditions that do not train executive functions prior to making decisions about the clinical utility of CET/ICT for the treatment of emotion dysregulation in ADHD.https://clinicaltrials.gov/], identifier [NCT03324464].[ Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by impairing symptoms of inattention, hyperactivity, and impulsivity . ADHD afd = 0.80–0.95; ],Given the established links among working memory, inhibitory control, and emotion regulation, there has been increased interest in the extent to which training these executive functions can improve emotion regulation in various populations. For example, training working memory using emotional/affective stimuli has improved emotion regulation in samples of neurotypical adults –44 as weBoth working memory and potentially inhibitory control may be functionally related to emotion regulation difficulties in children with ADHD , 10, butFor children with ADHD, evaluating the efficacy of executive function training protocols is further complicated by target misspecification and related issues of first-generation protocols that significantly limit their potential to produce downstream effects on behavior and functioning . SpTo address these limitations, our group created two translational, evidence-based, digital therapeutic treatments that include gaming elements , 34, 58.Given that CET and ICT (a) effectively improve working memory and inhibitory control processes, respectively, that are linked with ADHD-related emotion dysregulation; and (b) have been shown previously to produce clinically meaningful improvements in other behavioral and functional domains for children with ADHD , 26, 59,n = 73; 77.7%) completed three visits during the pre-treatment evaluation, lasting approximately 3.5 h each. These children also completed testing sessions at mid-treatment, post-treatment, and 2–4 months follow up. Four treatment cases were lost to follow-up from March to June 2020 as the study was shut down due to COVID-19. Procedures were adjusted when the study resumed in June 2020 to minimize face-to-face contact, including reducing the pre-treatment battery to a single 4-h testing session that included the use of face masks and social distancing for participants and study team members . Additionally, weekly treatment sessions that occurred in the clinic prior to the shutdown were conducted via telehealth for all children beginning in June 2020, and in-clinic mid/post/follow-up child testing was discontinued. Treatment delivery format  was probed as a covariate as described below. Parents (pre/mid/post/2–4 months follow-up) and teachers (pre/post) completed measures at each time point according to the original protocol. Teacher questionnaires were sent during the post-treatment session and were completed by teachers approximately 1–2 months post-treatment  from the Southeastern US, consecutively referred to a university-based research clinic through community resources. Psychoeducational evaluations were provided to caregivers. IRB approval was obtained/maintained; all parents/children gave informed consent/assent. Child race/ethnicity was mixed, with 71 (75.5%) White/Non-Hispanic, 11 (11.7%) Black/African American, 7 (7.4%) Hispanic/Latino, and 5 (5.3%) multi-racial/ethnic children. All participants spoke English.As shown in https://osf.io/abwms.All families completed a comprehensive evaluation that included detailed semi-structured clinical interviewing  and agen = 16 were eligible but declined participation, and n = 2 were excluded due to average or better performance on all pretreatment working memory tests, resulting in a total treated sample of 94 (83.9% of eligible cases). No inhibitory control thresholds were set as specified in our NIMH grant. Children with ADHD that did vs. did not participate in the treatment phase of the study did not differ on age, sex, SES, race/ethnicity, IQ, medication status, ADHD presentation, and the presence of common comorbidities . Untreated children with ADHD did not differ from treated children with ADHD on parent-reported emotion dysregulation (p = 0.21–0.27), but they had moderately higher teacher-reported emotion dysregulation  than the children with ADHD who participated in the treatment phase of the study. Children that were not randomized to CET or ICT were not followed past the pre-treatment evaluation.As shown in the CONSORT diagram , a totalChildren were excluded from the larger study for gross neurological, sensory, or motor impairment; seizure disorder, psychosis, or intellectual disability; or non-stimulant medications that could not be withheld for testing.As detailed in Kofler et al. , identicCentral executive training and ICT each contain nine games, with each game created to train various functions/modalities of their respective targeted executive function. Both treatments include an automated token economy in which children receive virtual “tickets” for successful responses during games, completing games, and completing the daily “mission mode” to facilitate increased engagement in the task and reinforcement of training targets. Tickets were exchanged for tangible prizes that children collected during weekly in-office sessions or intermittently throughout treatment if they participated via telehealth due to COVID-19. The daily “mission mode” consists of three games that the child has not recently played that are selected by the software and must be completed prior to having access to all nine games, and it is designed to ensure appropriate breadth of training. Please see Kofler et al.  and KoflThe computerized CET protocol focused on improving children’s working memory , 34. CETThe computerized ICT protocol focused on improving the “action restraint” and “action cancelation” components of inhibitory control . ICT wasEmotional Self-Control and Negative Emotionality. The emotional self-control subscale assesses children’s skill at regulating their emotions and affect in response to changes in the environment , and the negative emotionality subscale assesses children’s tendency to respond in an overly negative way to routine and novel environmental stimuli . These subscales were selected as the primary emotion regulation outcomes given their relative rigor according to an extensive review of all available emotion regulation measures . Higher raw scores indicate more difficulties with emotion regulation.The BASC-3  containsmeasures . Psychom86–0.88; ]. The emAn additional measure of emotion regulation was added to the study protocol in March 2018 given emerging data linking emotion regulation with the executive functions targeted by our protocols as described above. The Emotion Dysregulation Inventory (EDI)  assessesEmotion Regulation Checklist (ERC) was administered instead of the EDI at pre-treatment for the first 62 participants. The EDI was administered at all other time points. The ERC (r = 0.44–0.79), and the ability to differentiate between groups of children at-risk vs. not at-risk for emotional problems  teachers were told that the child was participating in an intervention . The pop-values) were supplemented with Bayes Factors as recommended (10 is the Bayes Factor (BF) indicating how much more likely the alternative hypothesis (H1) is relative to the null hypothesis (H0). Values >3.0 are considered moderate support for the alternative hypothesis , and is reported when the evidence favors the null hypothesis . We refer to findings of BF10 >3 as significant evidence for an effect , and findings of BF01 >3 as significant evidence against an effect . Both p-values and Bayes Factors are reported. We refer to effects as “marginally significant” when results indicate p < 0.05 but BF10 < 3.0 .Traditional null hypothesis significance tests  and academic outcomes are reported in Kofler et al. , all manipulations, and all measures in the study.Best practice guidelines for cognitive training studies were closely followed as detailed in r et al.  and Singr et al. , respectr et al. : , but thTaken together, results of this double-blind randomized controlled trial were consistent in documenting significant improvements in emotion regulation for children with ADHD that persist at least 2–4 months after treatment termination and are not likely artifacts of any assessed threats to validity. If results of the current study are consistent with future studies including an additional control treatment that targets a mechanism that would not be expected to affect emotion regulation, it would appear likely that working memory and inhibitory control are potentially functionally linked with emotion regulation difficulties in ADHD, consistent with prior experimental evidence in ADHD and non-ADHD samples , 41. At https://osf.io/86fwu/.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: Open Science Framework (OSF) The studies involving human participants were reviewed and approved by the Florida State University Human Subjects Committee. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the minor(s)’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.NG was the lead investigator for analysis and interpretation of the data and drafting of the work. MK was the principal investigator for funding acquisition and had a supporting role in revision of the manuscript. All authors made substantial contributions to the conception of the work, revision of the manuscript, and the acquisition of data for the work, and provided approval for publication of the content.


Controversy around the association between celiac disease (CeD) and attention deficit hyperactive disorder (ADHD) was addressed by a systematic review in 2015, ultimately showing no association. Since 2015, there have been several studies showing an association between celiac disease and attention deficit hyperactive disorder. This is an updated systematic review. Background: Most experts agree on the recommendation to not screen as part of the standard of care for ADHD in persons with CeD or vice versa. Simultaneously, they propose that untreated patients with CeD and neurological symptoms such as chronic fatigue, inattention, pain, and headache could be predisposed to ADHD-like behavior, namely inattention . The inattentive subtype of ADHD that encompasses the symptoms of inattention is phenotypically heterogeneous, as it includes the clinical construct of sluggish cognitive tempo (SCT). SCT symptoms overlap with the neurological manifestations of CeD. Methods: A systematic search (PRISMA) of PubMed, Google Scholar, EMBASE, Web of Science, Stanford Lane, SCOPUS, and Ovid was conducted for articles up to 21 February 2022. Of these, 23 studies met the criteria. Results: Out of the 23 studies, 13 showed a positive association between ADHD and CeD. Most studies that showed a positive association had been published in the last five years. Inconsistencies in the results remain due to the heterogeneous methodology used, specifically for ADHD and the outcome questionnaires, as well as a lack of reporting on ADHD subtypes. Conclusion: There is an association between ADHD and celiac disease. The current methodological limitations will be lessened if we examine the subtypes of ADHD. In chilophrenia . Meanwhiophrenia .CeD can occur in healthy persons (silent CeD) or later in life in persons with positive gluten-sensitive autoantibodies but a normal to minimally abnormal mucosa upon intestinal biopsy  . This peADHD is a neurodevelopment condition diagnosed by the International Classification of Disease (ICD) criteria. Depending on the study year, professionals have used either ICD-9 or ICD-10. The difference between years of study is relevant when we consider the subtypes of ADHD. In the ICD-10, the ADHD subtypes have separate codes, namely, inattentive (F90.0), hyperactive (F90.1), combined (F90.2), other (F90.8), and unspecified (F90.9)—whereas the ICD-9 has only three codes: combined (314.1), inattentive (314.00), and residual (314.8). These limitations have been discussed in previous studies ,17. AlthThe symptoms associated with SCT are characterized by a pattern of inconsistent alertness and orientation, confusion, physical under-activity, daydreaming, and lack of mental alertness. Prior studies have found SCT to be associated with poor/abnormal neurocognitive performance, even when controlling for other ADHD symptoms ,23. GiveA past systematic review of eight studies on the association of ADHD and CeD concluded that there was no association . OverallThis review was conducted following the PRISMA reporting guidelines .We conducted a literature search (see The inclusion criteria were as follows: (1) search terms of ADHD and CeD ; (2) ages less than 18 years (including three studies with a range of ages and reported data that included subjects below 18 years). In addition, we considered the past study’s limitations/strengths and the reference list of the included studies to find other relevant articles. Only articles in English were reviewed. Posters from conferences were reviewed, and attempts were made to access unpublished manuscripts, but the authors did not have the data ready. There were no ineligible studies.The exclusion criteria were: (1) studies that included the above search terms but did not narrow the diet intervention to gluten only; (2) studies that included other related diagnoses  and did not report the results that included the search terms; and (3) review articles that did not contain data that established an association between ADHD and CeD.A total of 52 titles and abstracts were retrieved and screened. Full-text articles were read to evaluate the inclusion or exclusion criteria for purposes of association. In all, 23 met both the inclusion and exclusion criteria. Out of these 23 studies, 8 had been reported in the previous review .The outcome measures were the reported association of the two conditions. Data extraction included: (1) the mean age and range; (2) the assessment process to validate CeD and ADHD; (3) the study design; (4) the sample size; and (5) the reported association.n = 12), DSM-5 (n = 1), ICD-9 (n = 5), and ICD-10 (n = 6), and some (n = 3) did not report any criteria. The method of assessment of ADHD and its symptomatology varied and ranged from using standardized methods to historical data or a neurological/psychiatric examination (see n = 6) or examining the ADHD (n = 8) and CeD (n = 9) population via medical database/registry/chart reviews. All of the studies used serological markers for CeD when ADHD was the target population.The studies diagnosed ADHD using DSM-IV  improved ADHD symptoms in most patients ,31. NeurThe studies did not report subtype differences in the association between CeD with ADHD, a majority did not look at subtypes. In examining the evidence of dietary interventions in the subtypes of ADHD in the autistic population, the hyperactive (HYP) subtype showed a downward decline with a sustained decrease that lasted up to 12 months, while the IN subtype showed an improvement at 8 and 12 months ,48,49. CThis systematic review indicated an association between ADHD and CeD. Ongoing methodological limitations have contributed to meaningful recommendations. Although the criteria used for diagnoses of CeD were closely followed, diagnosis of ADHD using ICD criteria was identified as a limitation, as it may have allowed for the inclusion of misdiagnoses and diagnoses ,18. ThisIn terms of diagnostic validity, there is currently not enough evidence to describe the subtype of SCT in diagnostic terms due to poor negative predictive power toward an ADHD diagnosis . AlthougThis review supported previous evidence where ADHD symptoms were present prior to the diagnoses of CeD, as seen in atypical CeD . In a poSince the prevalence of celiac serology is higher in ADHD children than in the general population , all of For more complex genetic connections, the predisposing factor for CeD is the HLA-DQ2 and -DQ8 haplotypes ,54,55. TIt has been shown that environmental (as opposed to genetic) factors are more relevant for the SCT type versus the HYP and IN subtypes of ADHD. This was seen in a twin study, where individual differences in the SCT subtype were mostly explained by non-shared environmental factors, while genetic factors mostly influenced the variability in the HYP and IN subtypes. This finding indicates that, when we disregard SCT, it may cause greater ADHD heterogeneity and diminished diagnostic clarity among children belonging to the ADHD inattentive group .The prevalence of celiac disease varies with sex, age, and location . Gender-The limitations of this review are: (1) there was no comparison of the articles used for the review to minimize bias as there was one author, and one could infer unconscious bias; (2) the SCT is a well-known subtype of ADHD, but it cannot be measured if we use the ICD criteria, and most of the standardized questionnaires are standardized in a white population ; (3) theThere was an association found between ADHD and celiac disease, which contrasts with the previous review. This review highlighted the need to examine the subtypes of ADHD, specifically the inattentive type. There may be a behavioral phenotype of ADHD that responds to a gluten-free diet. This is consistent with earlier studies and supports the screening of ADHD patients for celiac disease. It also supported the previous review’s recommendation for clinicians to assess a broad range of physical symptoms in addition to typical neuropsychiatric symptoms when evaluating patients with ADHD.


Attention-deficit hyperactivity disorder (ADHD) has been linked to “unhealthy” food consumption, but the studies in this area are insufficient. The aim of this study is to investigate the relationship between ADHD/related symptoms and processed meat products and snack consumption.This study was conducted on 390 children aged between 6 and 17 with 169 ADHD  and 221 healthy controls . Food consumption was evaluated by a modified food frequency questionnaire, including 18 food containing processed meat products and snacks. ADHD symptoms were evaluated by the teacher and parent Turgay DSM-IV-Based Child and Adolescent Disruptive Behavioral Disorders Screening and Rating Scale  and Conners’ Rating Scale .Children with ADHD consumed more processed meat products, milk-based desserts, and chocolate-sweets than controls (p<0.05). A positive correlation was observed between the ADHD symptom scores and the consumption amount of all snacks, the amount of chocolate-sweets consumption, the frequency of consumption of sujuk, chocolate, jelly beans, sweets, cakes, and chocolate spread (p<0.05).Children with ADHD consume more foods rich in saturated fat and sugar than their healthy peers. Processed food consumption of children with ADHD may be associated with ADHD symptoms. Children with ADHD consume more processed meat products and snacks than healthy peers.Children with ADHD are at risk for unhealthy nutrition.Consuming processed foods is positively correlated with the presence of ADHD symptoms.Attention-deficit and hyperactivity disorder (ADHD) is one of the most common psychiatric diseases worldwide, affecting 5–12% of children. ADHD is a neurodevelopmental disorder characterized by inattention, distraction, restless excessive activity, impulsivity, and other deficiencies of executive functions [The role of nutrition in the etiology of ADHD is a topic under investigation. Although many studies have been conducted on nutrients and their components, the results are inconsistent with each other. Common findings in studies investigating the relationship between diet models and ADHD has been associated with unhealthy dietary models (rich in saturated fat-refined sugar and poor in vegetables and fruits) . In a stADHD diagnostic criteria include symptoms such as forgetfulness and losing something easily . StudiesImpulsivity symptoms are among the core diagnostic symptoms of ADHD . WesternThis work was planned as a case–control study to comparing the consumption of processed meat products and snacks with and without ADHD.All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The study protocol was approved by the University of Health Sciences Hamidiye Scientific Research Ethics Committee (project/decision no: 19/16).The present study was a case–control study.The questionnaires for the case group were conducted by a dietitian face to face. In the control group, the questionnaires were delivered to parents through teachers. The questionnaires from the parents were checked and filled in again by the dietitian with the children. The demographic characteristics of the child and family, frequency, and quantity of consumption of 18 foods, including processed meat products and snacks, were questioned in both groups. The family and the teacher were asked to fill the scales used to evaluate the ADHD findings of the case group, and the forms were taken 1 month later.The recruitment and data collection were ongoing from October 2018 to May 2019. The case group of the study was conducted in the child and adolescent psychiatry clinic in Istanbul. The control group from primary, middle, and high schools in Istanbul were included in the study.The case group was included in 169 ADHD children aged 6–17-year old. The inclusion criteria were as follows (1) normal intelligence based on either a Wechsler Intelligence Scale for Children-full-scale intelligence quotient  score above 80 or the average/above average academic performance documented with the last year’s final school grades , (2) evaluation by a child and adolescent psychiatry clinic for behavioral/learning problems, (3) ADHD diagnosis and subtype according to the DSM-V by a structured psychiatric interview.In the control group, the questionnaire was conducted on 400 healthy children aged 6–17 years, and 221 people who completed the questionnaires were included in the study. The parents were asked in writing, “Does your child have any psychiatric disorder?” and children with any psychiatric condition were not included in the study.Written consent was obtained from parents.www.e-picos.com,” NY, New York.To predict that the unhealthy nutrition rate in those with ADHD+ may have a minimum difference of 5% more than the unhealthy nutrition rate in those with ADHD; to be able to determine statistically significant with at most 5% Type I error margin and at least 80% power, it has been determined as a minimum sample size of 400. The determination of the sample size was calculated using the program “ A questionnaire containing processed meat products and ready-to-eat snacks were used. Among the foods consumed, attention was paid to whether they were homemade or not, and the foods that were bought ready-to-eat were questioned. The foods and groupings that are questioned while consuming food are listed below:Sujuk, salami, sausage, pastrami: Processed meat productsChocolate spread, sweets, jellybeans, chocolate, chewing gum: Chocolate-sweetsDessert, pastry, cake, biscuit: Bakery productsPudding, fruit yogurt, ice cream: Sugary and dairy productsChips, cracker: Salty snacksParticipants’ processed meat products and snack consumption, using a modified food frequency questionnaire form with 18 food, were questioned as “every day,” “once a week,” “2–3 days a week,” “3–4 days a week,” “5–6 days a week,” “2–3 days a month,” “once a month.” The frequency of food consumption was questioned along with the amount consumed, and the amount and frequency of these consumptions were determined. Foods with a consumption frequency of every day, 2–3 days a week, 3–4 days a week, and 5–6 days a week were labeled as “very often” and foods with a consumption frequency of once a week, 2–3 days a month, once a month, and the ones that have no consumption at all were labeled as “Very seldom or none.”Food consumption amounts were taken by asking the various sizes of food sold in the market , by showing photos, or by kitchen measurements . Daily consumption amounts were calculated for each food according to the frequency of consumption. The amounts of foods were calculated in grams. The daily consumption of foods has not been evaluated on a product basis. Instead, the total amount of food consumption into classified food groups was calculated . By collecting all snacks, the total daily snack consumption amount was calculated.These scales are frequently used in behavior assessment. Based on the observations of the parents, the CPRS includes 48 questions used in the behavioral assessment of their children. Based on teachers “classroom observations, the CTRS consists of 28 questions used in students” behavioral evaluation .It is a scale developed according to DSM-IV criteria . There awww.e-picos.com,” NY, New York. The relationships between the variables were examined with the Spearman correlation coefficient and binary regression analyses. The tests were determined in the 95% confidence interval, and the significance level was p<0.05.The Statistical Package for the Social Sciences version 17.0 was used for statistical evaluation of the data. To control the confoundings, hospitals and schools in the same neighborhood were preferred so that the income levels and living standards of the groups were similar to each other. To check that the questionnaire was conducted properly, questionnaires with meaningless or opposite answers were not evaluated. Similarly, sloppy questionnaires with the same answer to all questions were not taken into consideration. The arithmetic mean and standard deviation values of the data obtained from individuals were calculated. Nominal variables are given using frequency and percentages. Descriptive findings were presented as mean and standard deviation for continuous data. Independent sample t-Test was used for the average comparison between binary groups. Chi-square tests were used to compare the classified data. Chi square test was calculated using another program “ Since the symptom scales of the case group were obtained from parents and teachers, 169 forms were distributed to them, 94 participants returned the CTRS form, 75 returned the CPRS form, 86 returned the teacher T-DSM-IV-S, and 73 participants returned the parent T-DSM-IV-S. As a result, demographic characteristics and food records were analyzed with 169 data from the case group and 221 from the control group. Besides, the relationships between symptom scales and food consumption in the case group were analyzed for children whose scales could be reached .The demographic features of the ADHD and control groups are shown in It was determined that most of the mothers (61.4%) had primary education, the rest had high school (24.8%) and university (13.4%) education, and the education level of fathers was slightly higher than mothers. The education level of the mothers of children with ADHD is higher than that of the control group (p<0.05).The ADHD group is classified according to the time of diagnosis and treatment. The percentage of receiving treatment for ADHD patients is 32% for 0–29 days, 27% for 1–5 months, and 41% for 6 months and above.The frequency of food consumption was evaluated between the two groups . PastramThe amount of processed meat products, bakery products, sugary and dairy products, chocolate-sweets, salty snacks, and all snacks consumption was compared . The aveBinary regression was analyzed to determine the effect of age, gender, and parents’ education on food consumption . The ageThe relationships between total scores and food intakes were examined with the Spearman correlation test in children with ADHD . A positSince ADHD is the most common neurodevelopmental disorder of childhood , studiesWestern-style diet, where processed meats are consumed more, has been associated with ADHD . In our Instant food, which is described as “junk food,” is snacks that are high in energy density and poor in terms of nutrients . It can Various hypotheses regarding the unhealthy diet of patients with ADHD have been proposed. First of all, it is the impulsivity and inattention components of ADHD that can be effective in an unhealthy diet. Easy and cheap access to fatty and sugary food in the markets is one of the important factors affecting the selection of these foods. People with high levels of impulsivity often have difficulty in resisting conditions that are offered to them and, are more sensitive to rewards . GuerrieParents’ attitudes should be taken into consideration when interpreting children’s unhealthy food liabilities in ADHD. Studies report strong correlations between parental behavior and children’s food consumption . GeneticParenting a child with ADHD is a tiring, time-consuming, and emotional process that involves feelings of guilt and hopelessness at different stages of life. The daily life of a parent with ADHD is full of plans to overcome daily challenges with his child and be prepared for these challenges . StudiesOur results can partially be generalized. Because foods are produced generally in similar ways. Ingredients in processed foods are nearly the same. ADHD symptoms are also the same all over the world. Hence, it is expected that the relation of consumption of processed foods and ADHD can be similar also in other populations.The parents in the control group were unable to participate in oral interviews. The parents’ written information was considered.Failure to take the scales used to evaluate ADHD symptoms from all participants.In both groups, it was not questioned whether the parents had a diagnosis of ADHD. This situation can be a potential confounding factor because of food choice, accessibility and consumption. Like this factor, some other variables that can cause ADHD were not evaluated in the study.In our research, processed meat products and snack consumption were found to be higher than healthy peers. Foods were found to be associated with the total ADHD score.This study shows that children with ADHD are at risk for unhealthy nutrition. Children with ADHD should be under more observation in terms of nutrition than healthy children. It should be particularly recommended that both healthy children and children with ADHD reduce the consumption of this type of unhealthy food. Research is needed to show a clear mechanism for the causes of these results.