Therefore, they would be more affected by their environmental experience, either for good or bad. Under supportive environmental conditions, such at-risk individuals might actually outperform their non-vulnerable peers, suggesting that these individual factors might be considered susceptibility factors rather than risk factors. Little is known regarding the positive effect of the environment in the ADHD literature, but it has been demonstrated in cognitive functions that are closely associated with ADHD, such as executive functions (EF). We review this literature and examine the extant empirical support for sensitivity to aspects of the home environment and parenting in the case of ADHD and EF. Moreover, we review factors that could help identify the specific aspects of the home environment and parenting that these children might be more susceptible to. Such knowledge could be valuable when designing preventive interventions and identifying those children that are especially sensitive and could benefit from such interventions. Recommendations for future studies are discussed as well.Although the evidence for the genetic basis of attention-deficit/hyperactivity disorder (ADHD) is strong, environmental factors, such as the quality of parenting or the home environment, may moderate such genetic liability. The plausible negative effect of a low-quality home environment and negative parenting on child outcomes is well-established; however, the positive effect of a high-quality environment and positive parenting remained largely uninvestigated. Due to the presence of genetic, temperamental, or physiological factors, children who were traditionally considered  Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder, among the most commonly diagnosed disorders during childhood, with an estimated worldwide prevalence of 5.9% of school-age children , 2 and arisk, who also experience a low-quality home environment, would be at higher risk to manifest the disorder’s symptoms, compared to individuals who are not at such risk , and b. environmental factors (including parenting and home environment), for which the involvement in ADHD might be moderated by the child’s individual factors. Following the literature, we also use the term “familial risk for ADHD,” which refers to the existence of parental ADHD symptoms, which might increase the risk both ironment .risk factors for ADHD and the phenotypic manifestation of ADHD symptoms might be indirect, through the development of deficits in cognitive domains. We focus on deficits in EF as an example of such an indirect relation . Finally, in Section “Discussion,” we discuss the general implications of sensitivity to the environment in the context of ADHD, the current limitations in the extant research in this field, and discuss future research directions.This review consists of four sections. In Section “Introduction,” we discuss the general idea of sensitivity to the environment and review empirical evidence supporting this idea regarding general developmental outcomes. In Section “Sensitivity to environmental factors in attention-deficit/hyperactivity disorder,” we discuss sensitivity to the environment in the case of ADHD. Specifically, we review individual factors  that were found to be related to ADHD and have been traditionally referred to as risk factors for ADHD. We then review evidence suggesting their role as susceptibility factors that moderate the effects of the environment on ADHD symptomatology. In Section “The role of sensitivity to the environment in the development of executive functions,” we discuss the possibility that the relation between The general idea that children vary in their sensitivity to environmental settings or parenting practices is a cornerstone in the field of developmental psychology. This idea has been largely supported by empirical evidence that repeatedly demonstrated interactions between child characteristics and their rearing environment, in the prediction of a wide range of developmental outcomes, such as externalizing behaviors, substance abuse, internalizing problems, disorganized attachment, prosocial behaviors, self-regulation, and more –32.Interactions between child characteristics and aspects of the rearing environment have been mainly interpreted according to several theoretical frameworks, including the diathesis-stress model , the difAccording to the diathesis-stress model , some inHowever, an environment can also be positive and supportive. The differential susceptibility model  proposesFollowing the differential susceptibility model, the vantage sensitivity model  was devePluess  suggesteFrom an empirical point of view, one of the main difficulties in distinguishing between these models is that their empirical testing is heavily dependent on the specific range of the environmental quality that was considered , 34, as As mentioned above, in this review, we focus on the role of sensitivity to parenting and aspects of the home environment in the development of ADHD. Sensitivity to negative aspects of the home environment, as reflected in the diathesis-stress model, has already been reviewed elsewhere  and therDespite the range limitations described above, several meta-analyses included studies that used varied susceptibility factors , a variety of environmental aspects (that together reflect a full range from negative to positive environments), and a large range of outcomes, supported the idea of sensitivity to the environment, and specifically suggested a pattern of differential susceptibility; meaning that sensitivity to the environment was demonstrated for better and for worse , 30, 31.More recent findings also supported sensitivity to the environment in predicting internalizing and externalizing problems , 40, 41,Such inconsistency in the pattern of sensitivity to the environment between the results of Jaekel et al.  and WindAs detailed above, the concept of sensitivity to the environment has been well-demonstrated in relation to several aspects of child adjustment, including externalizing and internalizing disorders , 40, 41.ADHD is one of the most common behavioral disorders in childhood , and it Individuals with ADHD are also at risk for secondary mental health problems; indeed, comorbidities with other psychopathologies are frequent, especially externalization problems such as oppositional defiant disorder (ODD) and conduct disorder, internalizing problems such as mood and anxiety disorders, and specific learning disorders , 61, 62.All these aspects emphasize the importance of early detection of children at risk to develop ADHD and early implementation of intervention programs. Potentially, such programs could moderate the developmental course of ADHD and lead to a decrease in the likelihood of ADHD diagnosis and persistence rates, as well as diminishing or even preventing long-term outcomes that are associated with ADHD. An early preventive approach is important because serious difficulties and negative outcomes may persist despite the decline of symptomatology in adolescence and adulthood . The desIn this section, we discuss individual factors  that have been traditionally referred to as risk factors for ADHD , 72; eviMultiple genetic factors and their interactions with environmental factors play a substantial role in the etiology of ADHD , 6, 73. A more advanced approach was used by genome-wide association studies, which scan the entire genome. Such studies showed that the genetic risk for ADHD is due to the polygenic effects of numerous common and rare DNA variants. Each variant explained a very small proportion of the variance of ADHD and their combination increases the risk for ADHD; together these variants explained approximately one-third of ADHD heritability , 80. TheAnother individual risk factor that has been studied in relation to ADHD is child temperament. Temperament refers to innate individual differences in behavioral tendencies and style, which appear early in life and remain relatively stable during development , 84; it Researchers have suggested that at extreme levels, certain temperament dimensions may act as markers of risk for ADHD –90. In gImportantly, genetic risk for ADHD and aspects of child temperament are not exclusive risk factors. For example, Martel et al.’s have recently found a mediational pathway from polygenic risk for ADHD, through temperamental EC, to inattention symptoms among adolescents . HoweverEnvironmental factors were estimated to account for 10–40% of the variance of ADHD through their direct effect or gene-environment interactions . The envIt should also be considered that child ADHD may be bi-directionally related to the family environment –110. ForThe existence of sensitivity to aspects of parenting and home environment in ADHD has been supported by several studies including studies that used the candidate genes approach , 117–120The negative effect of aspects of the parenting and home environment on children at risk for ADHD has been supported by several studies that used environmental aspects such as low SES, low parental education, and psychological adversity, supporting a diathesis-stress model , 118–121Although all the findings in this section supported the diathesis-stress model , 118–122Much less is known regarding such sensitivity to positive aspects of the environment in the case of ADHD. In this section, we discuss evidence from studies that tested a broader range of the home environment or tested the plausible role of positive parenting or home environment on the development of ADHD. An overview of these studies can be found in Elmore et al.’s found that the 5HTTLPR genotype moderated the relation between positive and negative aspects of the home environment  and inattention symptoms. Specifically, susceptible youth  who experienced high cohesion showed decreased inattention symptoms, compared to non-susceptible youth; but, susceptible youth who experienced high conflict showed increased inattention symptoms, supporting a differential susceptibility pattern .In a study that was conducted on a sample of preschoolers who were not raised by their biological parents, consistent findings regarding the positive effects of caregiving on the development of ADHD symptoms in children emerged. Susceptible children according to their 5HTTLPR genotype  who experienced less intrusive caregiving demonstrated fewer ADHD symptoms, even after controlling for age at placement or duration of institutionalization, but those susceptible children who experienced more intrusive caregiving demonstrated the highest ADHD symptoms. This pattern was consistent with a differential susceptibility model , althoug1 Li and Lee used a sample of 6–9 year-old-boys and found that negative aspects of parenting predicted child inattention symptoms, but only among boys with high-activity MAO-A genotype, supporting sensitivity to negative aspects of the environment. However, this genotype did not moderate the association between positive parenting and child symptomatology , were associated with increased ADHD only among children who carried the 9/10 allele of the DAT1. Negative parenting behaviors were positively associated with ADHD only among children who carried the 9/9 allele . These rmatology . Therefo2 Specifically, high reactive children whose mothers had high levels of conscientiousness showed the lowest levels of impulsivity, even compared to low reactive children. However, high reactive children whose mothers had lower conscientiousness showed the highest levels of impulsivity, suggesting a pattern of differential susceptibility ; whereas children at high risk are those who are usually found to be more susceptible to their environment. However, temperamental susceptibility in both studies was based only on one domain, and since not all individuals with ADHD show deficits in this area  have been extensively demonstrated in a subgroup of individuals with ADHD –134. EF risk for ADHD, through the development of deficits in cognitive domains, and then to the phenotypic manifestation of ADHD symptoms. For these reasons, it is important to examine the plausible role of sensitivity to positive aspects of the environment regarding cognitive outcomes, that may play a role in the development of ADHD, for example, aspects of EF. Testing the involvement of intermediates may also expand our understanding of how genetic or temperamental sensitivity works , therefore, it is more complex to test and interpret the specific sensitivity pattern  in the case of ADHD symptoms. Still, despite the different patterns, it seems plausible that sensitivity to the environment exists in the developmental pathways leading directly, or indirectly, through cognitive deficits in the EF domain, to ADHD; and this could help identify children who could benefit most from early intervention programs.The factors that were found to indicate sensitivity to the environment have been quite consistent across studies. Mainly, variations of candidate genes , aspects of temperament , parental ADHD symptoms, and neonatal brain volume, were all found to moderate the relation between environmental factors and the developmental outcomes of ADHD and EF.The parenting and home environment aspects tested in the reviewed papers demonstrated a variety of domains, including the mother’s personality and caregiving behaviors , 143, faFurthermore, the developmental nature of ADHD, as well as its early onset, may help identify early markers that may foresee its development. The possibility that certain early markers may provide a hallmark for the prediction of a particular outcome in the future, or reflects sensitivity to the environment, raises an important question regarding the specificity of such a prediction. Namely, given that one can properly identify certain markers of susceptibility in early childhood, how informative can this information be to the prediction of a particular outcome and not another? Aspects of temperamental reactivity and self-regulation have been found to predict other developmental outcomes, such as externalizing and internalizing problems , 150. Sirisk for ADHD may actually reflect sensitivity to the environment.The ability to identify such markers may be improved in several ways; for example, by assessing the combination of different temperament markers instead of focusing only on a specific temperamental domain. Such an approach was used, for example, by Willoughby et al., who found that an elevated level of risk for ADHD was predicted by the temperament profiles of (1) high fear, high anger, and low self-regulation; (2) low fear and low self-regulation; and (3) moderated by anger and moderated activity ; HoweverIn the context of identifying genetic risk, one of the main limitations of the reviewed genetic studies is that the risk for ADHD was mostly evaluated by specific candidate genes , 123. ADIt should also be considered that all studies that were included in this review were correlative. Although environmental factors may moderate the genetic or temperamental risk for ADHD and alter developmental pathways, they may also be passive markers of certain developmental pathways and not active determinants of these pathways . Indeed,To fully test the plausibility of sensitivity to the environment and its practical and therapeutic implications, several aspects should be addressed in future studies. First, potential susceptibility factors should be more broadly assessed; for example, by polygenic risk, several temperamental aspects or temperamental profiles, family history of ADHD—and even the combination of these factors. Second, the assessment of the home environment and parental variables should also be broader; a broader assessment would enable future studies to determine which children are sensitive to which aspects of their environment. Early identification of susceptible children and implementation of interventions that target specific aspects that children may be especially sensitive to, and therefore may benefit most from, may help achieve a better developmental outcome, both in the cognitive domain and in the reduction of their symptomatology. Third, indirect relations should be considered, as cognitive functioning may mediate the relation between the susceptibility factors and the outcome of ADHD symptoms . The addTE undertook the review under the supervision of AB. TE wrote the first draft of the manuscript. Both authors developed the initial idea for this review, contributed to the article, and have approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Evidence is lacking on how to understand the reasons for variations, both in prevalence of ADHD and ADHD medication prescribing patterns in children and adolescents, within Region Skåne. These variations are not in line with current national clinical guidelines and seem to have increased over time. This qualitative interview study illuminates pediatric psychiatrists’ attitudes toward ADHD and their experiences of prescribing ADHD medication. Eleven pediatric psychiatrists described the complex interplay of variables that they experienced while assessing a child, which had influence on their decision to prescribe medication. Being part of a local unit’s culture influenced how ADHD medications were prescribed. They wished that the assessment of the child’s symptoms was consistent with guidelines in every unit but noted that such alignment was not implemented. They pointed out that an ADHD diagnosis is dependent on the surrounding’s motivation and capacity to adapt to the present state of the child. The participants described how they balanced clinical guidelines with demands from the family, as well as from society at large. Their personal attitudes and clinical experiences towards diagnosing and prescribing medications to children with ADHD influenced their decisions. The study adds information about how attitudes may lead to variation in diagnostics and therapy. Attention deficit hyperactivity disorder (ADHD) affects about 5–6 percent of all Swedish children and is characterized by impaired attention, impulsiveness, and hyperactivity . These sOver the last decades, the numbers of children and families seeking psychiatric health care have increased substantially in many countries ,12 and tPreliminary results highlighted significant differences in the prevalence rates of children with ADHD between the four pediatric psychiatric clinics in Region Skåne, with some clinics in line with national numbers whilst others are far below. The preliminary results also indicated that for those diagnosed with ADHD, less ADHD medication was prescribed per patient at the clinics with low ADHD prevalence. These differences indicate a variation in adherence to current guidelines and seem to increase over time . Previous research suggests that several reasons might add to this, including the prescribing physicians’ attitudes . These dIt is essential to find out what the variations in diagnosing and prescribing patterns are motivated by in order to promote equal health-care utilization. The aim of this study was to investigate the attitudes and experiences of diagnosing and prescribing medication for ADHD among senior consultants in pediatric psychiatry.The study is based on a qualitative design with semi-structured interviews analyzed with interpretative content analysis on a latent level . This stThe study was conducted at CAMHS in Region Skåne in southern Sweden. CAMHS Skåne comprises of four clinics and covers a catchment area of about 300,000 children and adolescents up to the age of 18 years. CAMHS Skåne consists of 23 outpatient units, with four tertiary out-patient units for children with psychosis, bipolarity, post-traumatic stress disorder, eating disorder and gender dysphoria. The four large cities in the region have day care units. The only emergency unit is located in Malmö and consists of a pediatric psychiatric emergency room and two inpatient units with 21 beds in total.All 36 senior consultants at the CAMHS in Region Skåne, excepting for those involved in this study, were invited to take part. Thirteen consultants agreed to take part, all of them employed at outpatient units, and eleven interviews were conducted. Five of the participating consultants were men and six women, with specialist experience of between two and 17 years (mean seven years). All of them frequently met children with ADHD in their daily practice.All interviews were performed by DS between September and December 2021. Due to the coronavirus pandemic, the interviews were conducted online via Zoom. The interview length varied between 33 and 48 min (median 38 min). The interviews were recorded with a voice recorder. The interviewer gave open questions based on the variations in assessment and prescription pattern within the region, following a semi-structured interview guide with follow-up probing questions. At the end, the participants were asked if they had any final comments.The recorded interviews were transcribed verbatim and analyzed by latent content analysis  by DS anThe study was approved by the Swedish Ethical Review Authority . After the participants had read the study information, they verbally agreed to the informed consent in the voice recording. All participants were to some extent colleagues with the interviewer DS, although none were mentors, supervisors or in other positions of potential hierarchical power. Only DS and KL read the interviews, and only DS knew who participated.The analysis revealed three themes with underlying sub-themes  illuminaThe first theme illuminates the complex interplay of variables that the clinicians experienced, with those present with them in the room, while assessing a child. These factors were described as influencing their decision to prescribe medication on the same day, to wait a while or not prescribe at all.The clinicians discussed the fundamental challenge of defining normal function, how it is connected to a child’s maturity over time and depending on the surrounding circumstances. They acknowledged that their own attitude around normality influenced how they as clinicians weighed a prescription of ADHD medication versus trying other interventions. They argued that the predominant culture, to some extent, defines normal function and whether the criterion for a diagnosis is met, along with how those definitions have changed over the last decades. They expressed that although their view of psychiatry stems from biology they cannot sidestep the reality that pediatric psychiatry is highly influenced by political and cultural trends. They highlighted that a child’s functioning versus demands in their environment, to some extent builds the neuropsychiatric field, since there are no blood samples or other objective tests to verify ADHD. They felt pressure to prescribe medicine as politicians had stated that “all children should be able to pass their final exams”. (I3)“Should one really prescribe medicine to a child that manages in school, will get grades in all subjects and will be able to get a good future, just because this child could be able to get an even better future?” (I8)The clinicians underpinned the complexity of defining a child’s functioning to be above or below cutoff for an ADHD diagnosis, and that it could be risky to simplify the process. An example was given regarding a child presenting a clinical picture of ADHD, that later turned out to be suffering from a prolonged, complex crisis reaction.“My experience is that trauma often is diagnosed later on, when a child diagnosed with ADHD is treated according to guidelines, but nothing helps, has had treatment for 2 years and is about to be discharged. Then it may turn out that this child has been sexually abused for years”. (18)The clinicians highlighted the importance of being aware of the continuous development of a child’s functioning and skill acquisition, and how it unfolds over time. They reflected on the fact that a child’s expressed emotions were sometimes, in psychiatry, viewed as symptoms of ADHD, instead of seeing them as individual emotional responses to the surrounding circumstances. Clinicians asked themselves if ADHD perhaps can be seen as immaturity in relation to the environment’s demands and they referred to the fact that many adults no longer reach the criteria for an ADHD diagnosis.The clinicians spoke of diagnosing ADHD as a first step towards deciding whether to prescribe medication or not. The clinicians experienced that it had become easier over time for parents to demand an ADHD assessment for their child. They stated that over the last decade such a request was almost always granted, leading to more children being assessed and consequently more being diagnosed.A significant part of the information leading to diagnosis is the child’s narrated history, given by the parents or other caregivers, which was considered as challenging in itself. They speculated that parents have different intentions and skillsets that can affect their abilities to accurately describe their child’s symptoms and function. They experienced that parents and children self-diagnosed ADHD while waiting for an assessment.“Parents that have been waiting for an assessment of their child for a long time, expect to get something back, they will not be so satisfied with, ‘No, it’s not ADHD’”. (I4)As the clinicians often meet the children on just a few limited occasions, they found that parents have a great power to influence the child’s diagnosis. They reflected on the fact that parents might be biased when reporting symptoms based on the common knowledge on which information leads to a diagnosis and what would not.“The most difficult thing with a diagnosis is that it’s the parents who present the function and medical history of their children when they were younger, and I can say that my experience is that a parent can say exactly the right things, so it sounds very much like ADHD. That is not so hard”. (I8)The psychiatrists illuminated that each clinician is influenced by his or her own personal attitudes and experiences in the process of prescribing or not. They struggled with not letting their personal opinions influence their professional clinical decisions. As an example, they shared that when it came to their own children, they would be less likely to agree to ADHD medication compared to what they suggested to patients. On the other hand, it could be tempting to consider medication for their own children when they saw them struggling with homework.They argued that to which extent a clinician explains the symptoms of a child to be biological or rooted in environmental and other factors, can eventually bias the decision to prescribe or not. Being more biologically oriented was considered to make the process fast and simple, to “just press play” and to prescribe medication.The clinicians described that choosing to prescribe medication contrary to the unit´s culture/tradition, led to more work since they had to do all tasks themselves such as follow-ups. This curbed the desire of doctors to follow their own opinion, and instead made them to assimilate into the current unit culture.“There are experienced, senior nurses who manage this independently and decide on increasing the dose in a way I would not have done, and that´s …, well, that’s where the local culture plays in”. (I9)The psychiatrists shared how they would try to tune in to the child, and his or her circumstances in school, when seeing the potential benefits of trying ADHD medication. They intuitively wanted to help and support the child and argued that it is often worth a try, to see if medication could support the child to better function in school and in getting better grades. These intentions made them prone to prescribe ADHD medication earlier in the treatment than suggested in guidelines.“And one feels sorry for the child who sits there, attends secondary school and needs those grades, and then one thinks ’I will prescribe, let´s try ADHD-medication anyway’” (I5)Frustration arose when clinicians recognized an evident ADHD diagnosis in a child waiting for assessment. They could not bypass the regional assessment waiting line, and they felt sorry for the child not being able to start with ADHD medication right away. They were eager to help the child immediately, so clinicians described that they might in such cases prescribe potentially effective off-label medications like bupropion which would not require a confirmed ADHD diagnosis.“I prescribe the medication anyway as my goal is to make the child to be able to manage their homework or to be able to follow at least half of a lesson”. (I8)The psychiatrists said that adaptations often are needed not only in school, but also in the home environment, and that the choice to prescribe today or to wait is made in the minute, when seeing the patient. They experienced that parental support varies to a significant degree. Some parents were considered to have capacities to adapt in such a way that a diagnosis is made too late, compared to some children receiving diagnosis prematurely due to parent’s lack of ability to support their child. The clinicians said that the longer time they had worked within CAMHS, the more they valued and placed emphasis on efforts to support parents in optimizing the child´s sleep, diet and physical activity, and to enhance family lifestyle and relations before prescribing medication.“But I think in general we should be more open and honest, maybe not as strict, as for example regarding requirements for getting a gastric bypass surgery, that one first needs to lose many pounds, but a bit like it: that the family has to try out some things before ADHD medication is considered”. (I6)The psychiatrists described that their unit previously had more focus on teaching parental strategies, but lately psychoeducation for parents had been cancelled due to lack of nurses. They wished to be able to see the families more often and at longer appointments to get to know them better. The clinicians described that the prescription of ADHD medication could correlate inversely with how well parents managed to put necessary support and adjustments in place. Although the clinicians talked to parents about the importance of relational and communicational adaptations, they experienced that they lacked tools and structure to help the families to successfully implement a change and to do follow-ups. Prescribing medicine before these changes were made was perceived as problematic.“Families come after they have received psychoeducational interventions, but many of these families can have difficulties to implement the training in everyday life”. (I1)The clinicians experienced they belonged to a local unit culture with a history and dynamics that influenced how ADHD medications were prescribed. They wished that the assessment of the child´s symptoms and function, prior to giving a diagnosis, was consistent with regional and national guidelines in every CAMHS. Such an alignment had not been implemented according to the clinicians.The clinicians spoke about how they perceived that the four pediatric psychiatric clinics in the region worked in significantly different ways regarding both assessment and treatment of ADHD, and how they had been “raised” in that local tradition.“It’s so obvious, if you are resident in /city X/ you are trained to follow the guidelines strictly, but if you instead got your training in /city Y/ you would probably work outside the book”. (10)The psychiatrists argued that personal style is something that should be valued in clinical work, but one should at the same time be aware of the potential bias when it comes to how strictly one follows the guidelines. They sensed that the psychiatric field leaves more room to “play outside the book” compared to physical health care. Although following guidelines was seen as important, sometimes being symptom and function oriented was considered even more important.They described variation between units concerning procedures created by the directors or the senior doctors. An example was about units with “fast track assessment” leading to quicker access to effective treatment for ADHD but a risk of neglecting co-morbidity. “Fast track assessment” was supposed to derive from wanting to work in a person-centered way and lead to sidestepping the guidelines that had created bottlenecks. They described units where senior doctors had created a culture of never prescribing medication for ADHD without a very thorough assessment, probably leading to high quality of care, but less children were able to get treatment and waiting lines tended to build up. Another variation experienced by the clinicians was with regard to the degree to which different units and school psychologists emphasized interventions such as trying out adjustments for the child or parental psychoeducation before assessment. They pointed out that some children were assessed too quickly and others, the obvious cases, should have been diagnosed much earlier.“I would guess that if one would compare the different schools, those schools with psychologists delivering more individual interventions for their pupils would send less children with mild to moderate ADHD to CAMHS”. (15)Another mentioned the inconsistent manner in which some regional units, contrary to guidelines, used ADHD medication like methylphenidate as a diagnostic tool. If the medication had an effect at follow-up, an ADHD diagnosis was set. As most people can perceive a positive initial effect with stimulants, the clinicians pointed to a risk of over-diagnosing when medication is used like this. As a contrast, putting the bar of assessment too high, was feared as it can lead to the creation of waiting lists of children in need of effective treatment.The clinicians perceived a difference in the quality of the assessments between private and public units, stating that they believed that private units were more prone to diagnose ADHD compared to regional units. The clinicians described a challenge when needing to follow up the treatment plans and prescriptions, that other doctors had made, that differed from their own personal opinions. It was perceived as especially challenging when they met children with a very complex social background, who were often in foster families, treatment homes or state facilities. These children were often prescribed high doses of stimulants. The clinicians shared that it was important that they personally could see a substantial effect at follow-up, otherwise the medication should be stopped, like with all other medications.“They come to my clinic with a diagnosis made at a private unit. Then we do have to prescribe stimulants, although the condition might be mild. I go through the assessment and think no, but I have to prescribe amphetamine anyway”. (11)The psychiatrists had noticed that both ADHD assessment and treatment are more culturally dependent compared to other conditions in CAMHS, and that the threshold for diagnosis has been significantly lowered during the last decade. They discussed the involvement of the pharmaceutical industry and their campaigns of creating awareness of ADHD in society. They described that since evidence-based interventions and adaptations can only be implemented when a child is diagnosed, then they must diagnose. The clinicians wanted to challenge that positivistic mindset, that if clinicians find the right diagnosis, they find the right treatment.“When I started in psychiatry much more was needed to get an ADHD diagnosis, and I believe that main reason for that change is related to the criterion regarding loss in everyday functioning”. (13)They described how it is deeply rooted in the system, that you cannot prescribe ADHD medication without a diagnosis. The clinicians argued that reasons for them to hesitate when considering making an ADHD diagnosis can be both related to the fact that ADHD medication is classified as narcotic substance and traditionally has been perceived as potentially dangerous, and the fact that there is a demand for stimulants among young people which can see them being sold illegally on school grounds. On the other hand, they reflected on the fact that the time-consuming assessment protocols were not necessary in cases where ADHD was obvious. In their view, only very experienced psychiatrists had the confidence to prescribe the whole repertoire of available medications early in the process. This was perceived as a cultural phenomenon contrary to the issues regarding neuroleptics, which they considered to be prescribed with less hesitation as soon as a diagnose was set, despite known side-effects.“I think they have created some kind of sacred aspect around ADHD medications considering that they are narcotics, classified as narcotics, and so on. And these sacred medications, you see them as something that, well you shouldn’t dare to prescribe them, but only in rare cases, and where everything is in place…” (10)The clinicians illuminated that prescribing patterns of ADHD medication stem from society at large. They pointed out that complex circumstances influence a child’s function and that ADHD diagnosis to some degree is dependent on their surroundings’ motivation and capacity to adapt to the present state of the child.The clinicians argued that the current school system, and sometimes parents, had high demands on the child which will have a significant impact on the child’s everyday function. This was exemplified by the statistical fact that “the later you are born in the school year, the more likely you will have an ADHD diagnosis” (I4). Today, they said, a child in the first years of school is asked to perform complex tasks independently. They shared their experience that these academic goals originate from children with high capacities of executive function, and they thought that 20–50% of children will not be able to reach it, no matter how pedagogics are twisted and turned. The clinicians said that this phenomenon of requiring too much of a child is not only true for the school system, but for society at large, where they noticed a general over-estimation of human capacity. They felt that when the society is “too medicalized, you forget to adapt the world to people”. (I4)“And what does it say about our society and our school system that so many children require stimulants to be able to manage in school?!” (12)The clinicians experienced that a discrepancy between a child’s capacity and the demands by the surrounding society, sometimes could be perceived as symptoms of ADHD. To prescribe ADHD-medication-like stimulants to children in order to momentarily compensate for the child´s lack of capacity and simply help them to pass their exams was seen as an ethical challenge. They wished instead that they could have supported these children in other ways to adapt and hoped that children with a lower level of academic performance will be more accepted by the society in the future.“Sometimes you meet a family that has a 10-year-old who is not performing at his best. They have received an ADHD diagnosis and they have received good adjustments at school because they go to one of the slightly better schools. They have got excellent support, but the kid struggles a bit with math, for example. It´s not A-level and not B-level either, it’s C but “it’s my kid so I think he should be able to get an A”. (I3)The clinicians experienced that adjustments at school to support a child’s function differed to a very large degree and were often dependent on the attitudes of the teachers, the principal and the school’s health-care team. Some schools, they said, do not even require an ADHD diagnosis to provide a support teacher, extra breaks or other support throughout the day. The clinicians felt that if a child has difficulties with concentration and regulating activity, this should initially be addressed and supported mainly by the school. However, they said, most children had to wait for optimal adjustments despite an ADHD diagnosis, sometimes leading to lowered thresholds to prescribe ADHD-medication prematurely. From this point of view, it was argued that variation of prescription of ADHD medication starts in school, not at CAMHS.“For me as a doctor it’s an ethical dilemma having a patient with ADHD symptoms when you as a doctor think that most of all, adjustments in school would be beneficial”. (14)The clinicians described how they sometimes diagnosed a mild form of ADHD and prescribed medication immediately if the school had a reputation of insufficient capacity to implement necessary adjustments and support. After having sent documentation about adjustments needed and after having attended lots of school meetings in vain, they prescribed ADHD medication to compensate for an inadequate school environment.“In the end, it’s me sitting there somehow trying to treat imbalances in the school system”. (13)The psychiatrists experienced a lack of time to get to know the families. They pointed to the fact that their own, and their unit’s, resources were not modified to suit the ever-increasing requests for ADHD assessments. They also received many patients from private clinics that had diagnosed the child with ADHD and that now there was an expectation for them to prescribe medication to children that they had not assessed themselves, without much time to read their medical history. Likewise, the psychiatrists had difficulties in trusting the assessments made by the nurses who met the families regularly and said that they would prescribe less medication if they themselves had time to talk to the parents and if they would be able to do more assessments themselves.“Much today is assessed via the nurse, and thereby in several steps. Parents call and tell the nurse things, the nurse makes her own assessment, then we get a short summary in a note and we then often decide to increase the dose. Was it really necessary to increase that dose is the question?” (I1)This led to a strange feeling of not applying “safety principles” when prescribing ADHD medication. The psychiatrists had a significantly increased workload and could not carry out assessments and follow up treatment in the best way. Lack of time was considered to increase the prescribing of ADHD medication.The clinicians spoke about how children are born into a family system without possibility to choose. Parental economics and geographical location were perceived to influence how much a child’s ADHD symptoms would become a problem or not. They described how children that had a long way to travel to CAMHS, with single mothers and several siblings at home, often with their own psychiatric conditions, just could not take part in the non-pharmaceutical interventions offered. They reflected on the fact that the socio-economic load on a child can be multifactorial and will always contribute to care being unequal, and to the extent a family might be able to implement things they learnt during psychoeducation in their everyday life. When the family´s capacity was judged to be very limited the clinicians prescribed medication earlier in the treatment process.“In our most burdened municipalities where there are lower levels of education, I think that psychiatrists are more inclined to medicate the children”. (I5)This study is, to our knowledge, the first to investigate attitudes and experiences of diagnosing and prescribing medication for ADHD among pediatric psychiatrists in Sweden. The results demonstrate that this part of pediatric psychiatry is surrounded by several areas of concern.The participants described uncertainty and a lack of confidence when meeting children and their families who were seeking care for symptoms they suspected to be ADHD. The psychiatrists were not as convinced as the families were that medication in all cases was the right intervention but experienced pressure, both by parents and other professionals, to prescribe pharmacological treatment. Although all participants were employed by the same organization and are supposed to follow the same protocols regarding assessment, treatment and follow-up, individual tendencies influenced the decision-making whether to prescribe stimulants or not and were fueled by culture and traditions at the local outpatient unit the consultant was working, and by the influence of society at large. This phenomena of inter-variability among psychiatrists’ assessments has been recognized and studied before, being a significant motivation for the development of guidelines, such as DSM, that have emerged to counteract this unreliability . FurtherDiverging attitudes towards the diagnosis and treatment of ADHD has previously been shown among general practitioners in several countries . In settThe recently released guidelines for ADHD from The Swedish National Board of Health and Welfare  state thOn the other hand, the Swedish Patient Act emphasizes that all children should receive equal care, regardless of geographical and socioeconomic factors and that all patients should obtain information on all evidence-based treatment options . Given tThe clinicians acknowledged the rationale behind using protocols, while at the same time pointing to local units not necessarily adhering to them. They shared their experience of CAHMS units having different working cultures, which influenced their way of structuring their work and even nudged their decisions in diagnosing and prescribing related to ADHD. The clinicians highlighted how senior doctors and unit directors significantly influenced the variance between units. Newly employed doctors experienced a need to align with the local unit variation for pragmatic reasons, if not, the workload on them increased. That health care units have their own unique working climate has been demonstrated in previous research and factors such as good balance between independence, engagement, loyalty and acceptance seems to be important for successful units in regards of implementation .Several possible reasons for asymmetric adherence to guidelines, at the different units, were mentioned by the consultants including the personal style, experience and training of the clinician, the surrounding environment, both at the unit and in society at large. This has previously been suggested by Mykletun et al., who currently are studying these factors among clinicians in Norway .According to the interviewed clinicians, one of the reasons behind non-compliance to protocol, both individually and at the unit, is the wish to be autonomous and to be in charge of the assessment, as trusting in someone else’s judgment, someone that they do not know that well, or even disagree with is perceived as challenging. A reluctance from general practitioners to collaborate with specialists about children with ADHD have been shown in earlier studies . The cliThe informants also revealed a mistrust regarding nurses’ assessments, despite them having regular contact, over time, with the families, to among other things follow up the effectiveness of prescribed medicines. As teamwork is a core competence, acknowledged by the national assembly of medical doctors and nurses , and by Different ways of organizing care for children seeking help for ADHD have their unique consequences, as stated by the consultants. The “fast track assessment” unit culture potentially enables evidence-based care earlier and indeed to more patients than a more “slow assessment unit”. On the other hand, it might increase the risk of over inclusion, over treatment and missing co-morbidity. According to the recent Swedish guidelines from the national board of health and welfare early interventions should be put in place before the patient has been assessed for a diagnosis . PatientThe pediatric psychiatrists in the present study underlined their experience of interdependence with the school. According to them, one of the reasons for the variation in ADHD assessment and treatment is rooted in variation in how schools take care of children with special needs. This finding is not new and have been demonstrated before to be an underlying factor in ADHD assessment and treatment . Based oTo agree on a common definition of “normal” function of a child and, deriving from that, what to expect and require from a child was recognized as an area of concern by the pediatric psychiatrists in the present study. This topic is not new. As the limits between ADHD and normality are diffuse, not only the child but also the psycho-social environment should be examined . It coulThe between-country and within-country variations in ADHD diagnosis and medication rates are large and have been described previously . Yet, thOnly psychiatrists employed in public health care within the region were invited to the study. Since psychiatrists employed at private clinics assess many children with ADHD symptomology it would be interesting to illuminate their experiences as well. None of the pediatric psychiatrists at the in-patient unit participated, which is a limitation.In this study, the participating pediatric psychiatrists described how they balanced clinical guidelines with personal attitudes and demands from the patient’s family, different local unit cultures, and society at large in a complex interplay. The study adds information about how attitudes may lead to variation in diagnostics and therapy in children with ADHD. In order to increase adherence to evidence-based medicine and promote equal health-care utilization, these findings indicate that collaboration with schools and other caregivers, as well as promoting teamwork, is of particular importance and should be the focus of future research.


Since 1980, when Attention Deficit/Hyperactivity Disorder (ADHD) replaced Hyperkinetic Disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (This failure raises important questions that require new modes of enquiry. What role might psychosocial circumstances play? How does the belief that ADHD is a disease effect institutional practice? What unintended consequences for individuals and societies might arise from popularizing the idea that these common behaviors are potential diseases? For this Research Topic “ADHD: Science and Society” we invited authors to probe beyond bio-deterministic models and explore these multi-layered questions.The articles, draw attention to the impact of personal and professional interests, power issues, assumptions of the DSM, and to processes like reification, throwing light on how these have encouraged diagnosis and medication prescriptions.Mills reveals how ADHD was accepted into the third edition of DSM as the result of careful political maneuvering, not scientific endeavor. In the 1970s psychiatry experienced a crisis of credibility and many insurance companies in the US questioned the lack of specificity in the methods used for assessment and treatment. DSM-III provided a way for standardizing practice that could be used for categorizing presentations and improving the efficiency of reimbursement bureaucracies. Despite these political and economic origins and numerous subsequent criticisms (iticisms –4, the bKoutsoklenis and Honkasilta point out how DSM-5-TR, published in 2022, explicitly and implicitly maintains the essentialist medical scientific metaphor of disorder. For example, it states that “prevalence is higher in special populations such as foster children or correctional settings,” but discussion about the impact of adverse life trajectories is missing. Other social factors like economic disadvantage, social status, and familial care, which Erlandsson et al. discuss in their applied mixed-method systematic review, are also not mentioned. Such textual silence, according to te Meerman et al., is one of the at least four mechanisms that reify the ADHD and portray it as a disease entity that explains rather than just describes inattentive and restless behaviors.Ponnou and Thomé, using comprehensive French general health insurance scheme data, showed that French children and adolescents who are the youngest in their class, as well as children from disadvantaged families, are more likely to be diagnosed with ADHD and prescribed methylphenidate. This resonates with other international studies that have documented that the youngest children in a school year are considerably more likely to be diagnosed with and/or medicated for ADHD than their older classmates (assmates , 6. Nonete Meerman et al., are language choice, logical fallacies, and genetic reductionism. Koutsoklenis and Honkasilta show that DSM-5 engages in genetic reductionism by stating that heritability of ADHD is 74%, without mentioning that this estimate stems from twin studies that cannot separate environmental from genetic influences (Besides such textual silence, other reifying mechanisms described by te Meerman et al. refer to Russel Barkley, an influential ADHD advocate, who compares ADHD to a meat-cleaver: “The back part of your brain is knowledge, the front part is performance. ADHD, like a meat cleaver, just split your brain in half.” The meat-cleaver metaphor arguably has a strong “fear appeal” and reifies the construct of ADHD by removing the agency of individuals. But like all such “neuro” based theories, it lacks any empirical support. Mills deconstructs Barkley's flimsy logic, showing how rhetoric is used to obscure the lack of positive research findings, but that the subsequent dominance of brain-based research and language makes it seem “scientific.”To illustrate how language choice and metaphors can reify the abstract, Schleim it is unlikely that biomarkers for ADHD and many other mental disorders will ever be established: the diagnostic categories are too broad for it to be plausible that DSM definitions neatly match people's behaviors and experiences on the one hand and specific brain anatomy/physiology on the other. Nevertheless, Erlandsson et al. expect that the vast majority of research on inattentive and hyperactive child behaviors will continue to rest on scientifically unjustifiable assumptions about children's attributes. The unequal allocation of resources available in contemporary ADHD research is worrisome, especially considering recent research indicating the potential negative effects of the ADHD label (According to HD label  and its HD label .Collectively, the papers published in this Research Topic edition invite the question: If the science supporting ADHD diagnosis and treatments is weak and has not advanced significantly since 1980; What is driving increased ADHD diagnosis and treatment rates?With the global ‘ADHD therapeutics market' estimated to be worth US$29.56 billion in 2022—and expected to reach US$45.68 billion by 2027 —perhaps te Meerman et al. In addition, the underlying motives of stakeholders and their opposing interests need further investigation. Identifying and hopefully eliminating the impact of any misalignment between parties with a self-interest on the one hand, and the wellbeing of the consumers of ADHD on the other, should be a priority.An example of a possible catalyst of change is the set of guidelines on ADHD psycho-education, described by We hope our Research Topic will provide food for thought and a springboard for academics, scholars, and practitioners to expand their efforts in reimagining this condition in order to prevent further harm being unnecessarily visited on our populations.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


The identification of attention deficit hyperactivity disorder (ADHD) in children, which is increasing every year worldwide, is very important for early diagnosis and treatment. However, since ADHD is not a simple disease that can be diagnosed with a simple test, doctors require a large period of time and substantial effort for accurate diagnosis and treatment. Currently, ADHD classification studies using various datasets and machine learning or deep learning algorithms are actively being conducted for the screening diagnosis of ADHD. However, there has been no study of ADHD classification using only skeleton data. It was hypothesized that the main symptoms of ADHD, such as distraction, hyperactivity, and impulsivity, could be differentiated through skeleton data. Thus, we devised a game system for the screening and diagnosis of children’s ADHD and acquired children’s skeleton data using five Azure Kinect units equipped with depth sensors, while the game was being played. The game for screening diagnosis involves a robot first travelling on a specific path, after which the child must remember the path the robot took and then follow it. The skeleton data used in this study were divided into two categories: standby data, obtained when a child waits while the robot demonstrates the path; and game data, obtained when a child plays the game. The acquired data were classified using the RNN series of GRU, RNN, and LSTM algorithms; a bidirectional layer; and a weighted cross-entropy loss function. Among these, an LSTM algorithm using a bidirectional layer and a weighted cross-entropy loss function obtained a classification accuracy of 97.82%. Attention deficit hyperactivity disorder (ADHD) is a disorder that occurs frequently in childhood and refers to a condition in which attention is continuously insufficient, resulting in distraction, hyperactivity, and impulsivity . ADHD paADHD is a psychiatric disease, not a fracture or cancer that can be diagnosed relatively simply using MRI or CT scan results. Psychiatric diseases are not simple diseases that can be diagnosed with simple tests or symptoms, and therefore, doctors require a large amount of time and effort for diagnosis. Currently, the most commonly used method for diagnosis of ADHD by doctors in hospitals involves aggregating the results of consultations with child patients, consultations with their parents or teachers, and survey results such as the child behavior checklist (CBCL) ,7. In adAs mentioned above, the existing method of diagnosing ADHD by synthesizing the results of counseling and questionnaire results is based on the activity level of children observed by parents or teachers, and thus subjective errors may occur depending on the observer. In order to reduce errors due to subjective judgment, studies are underway to reduce subjective errors by using accelerometers or simulators to objectively measure and judge the activity level of children and to make more accurate diagnoses with objective results.While various studies as above are being conducted, research on machine learning and deep learning has accelerated, and we have started to apply machine learning and deep learning and develop algorithms for classification in various fields in various medical fields ,12. In pIn this study, a game was developed for children to screen for ADHD in a child-friendly environment such as a school without direct intervention from experts. While the children were playing the game, the children’s skeleton data were acquired using five depth sensors. Using the acquired skeleton data and deep learning algorithm, ADHD, ADHD-RISK, and normal were screened with 97% accuracy. ADHD screening evaluation was conducted using several simple models, and among them, it was verified that the LSTM-bidirectional model had the highest accuracy. In particular, ADHD-RISK is a class that has not been seen in other studies and is a taxon that is difficult for doctors to discriminate in actual clinical practice. However, it is important to screen ADHD-RISK that has the potential to develop into ADHD with high accuracy in actual ADHD clinical practice, and this system is expected to be helpful in the future.The detailed structure of this paper is as follows. The Introduction section introduces the existing methods for screening ADHD. The Materials and Methods section introduces the materials used in this study and the methods proposed. The Results section describes the experimental results. The Discussion section describes the discussion in this study. Finally, the Conclusion section presents the conclusion.Various data acquisition systems and artificial intelligence algorithms for the diagnosis of ADHD are being developed. As a first example, various research teams have developed deep learning or machine learning algorithms using the Neuro Bureau ADHD-200 Dataset and have conducted studies on the diagnosis of ADHD. The ADHD-200 Dataset consists of 776 resting-state fMRI and structural MRI data ,19,20,21The team of Peng et al. developed a CNN-based deep learning algorithm to obtain an ADHD diagnosis accuracy of 72.9% . In addiThe second example comprises studies on the diagnosis of ADHD using EEG data ,26,27,28A third related type of study involves the use of continuous performance test (CPT) test results; this test is widely used for the diagnosis of ADHD in hospitals. CPT test results are used as input data for ADHD classification research ,30. UsinThe last related study was conducted by the research team of O’Mahony et al., who classified ADHD using data measured during the TOVA test by having the children under study wear two IMU sensors on their waist and ankle. A classification accuracy of 95.1% was obtained using the SVM-based machine learning algorithm .As mentioned above, various datasets and algorithms are being used and researched for the classification of ADHD. However, studies on the classification of ADHD using skeleton data have not yet been conducted. Skeleton data comprise the subject’s joint movements. After giving children a specific task, we acquired skeleton data and RGB images while the children were performing the task. After all data were acquired, four psychiatrists divided the children into three categories on the basis of the RGB image analysis results and the CBCL and K-ARS results: ADHD, ADHD-RISK, or normal. In this study, it was assumed that there would be a significant difference in the behaviors of children with ADHD, children with ADHD-RISK, and normal children while performing tasks. Using the skeleton data measured on the basis of the above hypothesis as input data, a deep-learning-based algorithm was used to classify the ADHD, ADHD-RISK, and normal groups.In this study, an ADHD diagnosis game was used to acquire skeleton data for children’s ADHD screening diagnosis.The game consists of a total of five stages, comprising two practice games and three main games. In the game, a robot first moves randomly on the nine numbered boards marked on the floor, as shown in As the child follows the path, the characters of the witch or the Wizard of Oz appear on the screen. As shown in As shown in In the sensor system, a calibration procedure was performed to match the coordinate system of each sensor. For this, trajectory data consisting of 3D centroid coordinates of a sphere object with a specific color were used. The trajectory data recognized by each subordinate sensor were used to calculate the rotation matrix using the trajectory data extracted by the master sensor. In addition, the coordinate system of the entire system calibrated with the coordinate system of the master sensor was converted to the world coordinate system set by the user using the Aruco marker. After that, the skeleton data of the target in the capturing area can be extracted from the depth image using Kinect Azure Body Tracking SDK. The skeleton data extracted from each sensor are merged with the skeleton data extracted from the other sensors that recognize objects from different angles to overcome the occlusion problem that occurs in a single sensor. The merging procedure is performed for each joint and includes a method of filtering the noise candidate group using DBSCAN based on the location information of each joint. As a result, the system was able to extract the skeleton data of the object in the capturing area of 3 m × 5 m from the world coordinate system set by the user by using five sensors installed at a height of 2 m. Finally, through the above system, the movement of each waiting stage and game stage acquired continuous movement at 15 frames per second.The beam projector was used to show the path for the main game and the witch or character corresponding to the additional task. Finally, the robot was responsible for explaining and demonstrating the game to the children.For this study, elementary school students from first to sixth grade living in Seoul, South Korea, were recruited. Data were acquired from October 2019 to December 2021 from a total of three elementary schools and one research center. All children participating in the experiment were given parental consent and went through an ethical review process.The children’s skeleton data and RGB image data were saved while the children played the game. The data were largely divided into standby data, which were acquired while the robot explained the game and demonstrated the path the child should follow, and game data, which were acquired while the child played the game. All the children played the game in five stages. Therefore, for each stage, two pieces of data were generated during standby and during the game, resulting in a total of 10 pieces of data. Additionally, the standby data acquired while the robot explained the whole game before the first game was included. In conclusion, each child had six standby data points and five game data points, totaling 11 data points. A total of 596 children participated in this study. By synthesizing the CBCL and K-ARS results performed before the game for this study and the RGB image viewing results among the obtained children’s data, four clinicians divided them into the ADHD, ADHD-RISK, and normal groups.As shown in The RNN-based deep learning algorithm was used to classify the ADHD, ADHD-RISK, and normal groups. The size of the data for each level was different because the standby time and the completion time of the game were different for each level. Therefore, the longest frame among all children’s step-by-step data was defined as the reference size. If each data length was smaller than the standard size, the remaining frames were set to zero. The Azure Kinect devices used in this study can provide data for a total of 32 joints. However, in this study, a total of 18 joints were used, except for the low-accuracy and unstable end point joints, as shown in A total of six standby skeleton data points and a total of five game data points were used as input data. As shown in Moreover, as shown in In formula (1), In this study, classification of ADHD, ADHD-RISK, and normal groups was performed using the RNN model using skeleton data as input data. Three types of RNN models were used: GRU, RNN, and LSTM, and each model used a bidirectional layer and a weighted loss function to improve performance and prevent overfitting. Moreover, in this paper, accuracy, precision, recall, and the F1-score were used to evaluate the model. The formula for each parameter is as shown in the following Formulas (2)–(5):In the above formulas, TP (true positive) is the result of predicting an answer that is actually true as true; FP  is the result of predicting an answer that is actually false as true; FN  is the result of predicting an answer that is actually true as false; and finally, TN (true negative) is the result of predicting an answer that is actually false as false.As can be seen in Thus, in order to improve the performance, we used a bidirectional layer and a weighted loss function in the above model.As a result, as shown in After confirming the above results, we conducted one additional experiment. The skeleton data used in this study were divided into two main categories: the skeleton data of children waiting while the robot explained and demonstrated the game before the game started, and skeleton data obtained while the children directly played the game. We verified which of the above two large categories of data were helpful for the classification of ADHD. This test used models that applied a bidirectional layer and a weighted loss function to each RNN model on the basis of the previous experiment. When only the skeleton data were used during standby, the RNN model obtained the highest accuracy with 96.14%, and when only the skeleton data were used during the game, the GRU model obtained the highest accuracy with 95.39%. The accuracy was similar for standby data and game data, but there was a significant difference in the F1-scores of ADHD and ADHD-RISK. We think that it is more important to screen ADHD-RISK or ADHD than to screen children in the normal group in the ADHD screening diagnosis. This is because, if a child with ADHD is screened as normal, an opportunity for early treatment may be missed . When onWe classified ADHD, ADHD-RISK, and normal groups using only the skeleton data of children acquired through games. Currently, there are no studies using skeleton data among studies for the screening diagnosis of children’s ADHD. All children who participated in the experiment for this study performed the same task in the same limited environment. The advantage of the children’s data collected under these conditions was that they were objective and that high-quality data could be acquired in a much shorter time than the method of acquiring data by wearing an IMU device for a long period of time. This study is expected to serve as a cornerstone for future research on the screening and diagnosis of ADHD in children using skeleton data. Since the data used in this study were time series data, they were compared using an RNN-type model, and as a result, an accuracy of 97.82% was obtained. High accuracy was verified in this study, even when compared with the results of other studies that classified ADHD using various data. The model with the highest accuracy was an LSTM model with a bidirectional layer added, and the confusion matrix obtained through the model is shown in This study used a restricted game environment to observe children’s behavior. During the game, the children’s skeleton data were acquired. ADHD, ADHD-RISK, and normal were classified using the RNN-based deep learning algorithm using the acquired children’s skeleton data. ADHD-RISK was used as a new class in this paper. When doctors diagnose ADHD and normal, the difference between the two taxa is clear, but ADHD-RISK, which lies on the border between ADHD and normal, is difficult to classify. In fact, by classifying ADHD-RISK, which is more needed by doctors in clinical practice, we have developed a system that can help doctors screen for ADHD in future clinical practice.In this study, we classified ADHD, ADHD-RISK, and normality by using children’s skeleton data acquired through a game for the screening and diagnosis of children’s ADHD. The performance of various RNN models was compared, and among them, the LSTM-bidirectional model showed the best results. In the future, we plan to conduct research on performance improvement using various models such as the GCN model optimized for skeleton data. We also intend to analyze which joints affect the model at any point in time using the attention layer. On the basis of the above results, we would like to simplify the skeleton data acquisition system used in this study by utilizing a different number of existing sensors and proposing a new game system that can focus on the major joints in ADHD classification.


This study aimed at identifying brain regions with activation changes and their correlations with neuropsychological functions after treatment with ORADUR-methylphenidate in children with ADHD.Methylphenidate is effective in reducing the clinical symptoms of patients with attention-deficit/hyperactivity disorder (ADHD). ORADURWe recruited drug-naive children with ADHD and age- and sex-matched typically developing (TD) children. They were all scanned with the functional magnetic resonance imaging (fMRI) during the counting Stroop task at baseline, and those with ADHD had the second fMRI assessment after 8-week treatment with ORADUR-methylphenidate. The Rapid Visual Information Processing (RVP) and Conners' Continuous Performance Test (CCPT) were used to assess the attention performance of the ADHD (before and after treatment) and TD groups.d = 2.17) and hyperactivity-impulsivity (Cohen d = 0.98) symptoms. We found less activation in the right inferior frontal gyrus (rIFG) in the pre-treatment ADHD children than TD children and greater treatment-induced activation in the dorsal anterior cingulate cortex (dACC) and the right dorsolateral prefrontal cortex (rDLPFC). There was no significant difference between the post-treatment ADHD and TD groups. However, the treatment-related activations in the dACC, rDLPFC, and rIFG were significantly correlated with CCPT and RVP measures.ORADUR-methylphenidate significantly decreased inattention (Cohen Our findings indicated that ORADUR-methylphenidate increased brain activations in the dACC, rDLPFC, and rIFG in children with ADHD, associated with improved focused attention, reduced impulsivity, and enhanced inhibition control. Activities of these brain regions might be biomarkers for the treatment effectiveness of methylphenidate for ADHD.ClinicalTrials.gov number, NCT02450890 Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with significant functional impairments mediated by executive dysfunctions  have been used to identify the effects of methylphenidate on brain activation in children with ADHD. For example, acute administration of methylphenidate enhanced activations in the right ventrolateral prefrontal region in boys with ADHD, which was correlated with improvement in inhibitory control  and the Conners' Continuous Performance Test (CCPT) outside the scanner was used to examine whether the treatment-related changes in brain activations observed during fMRI were associated with the treatment-related changes in the neuropsychological measures.Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)  score <80; or if they had any prior or current psychotropic medication. Written informed consent was obtained from all participants' parents or legal representatives before performing any protocol-specific procedure.ClinicalTrials.gov number, NCT02450890).The Research Ethics Committee at NTUH approved the informed consent procedures before implementing the current study  children with matched age and sex were enrolled in the control group. Based on K-SADS-E interviews, they had no DSM-5 psychiatric disorder in their lifetime  was a single-item rating of the clinician's assessment of the global severity of ADHD symptoms concerning the clinician's experience with other patients with ADHD. The Chinese version of the CGI-ADHD-S has been widely used in ADHD treatment studies in Taiwan : total hits divided by the sum of total hits and total misses; (2) probability of false alarms (f): total false alarms divided by the sum of total false alarms and total correct rejections; (3) A′: (0.5 + [(h − f) + (h − f)2]/[4 × h × (1 − f)]): a signal detection measure of sensitivity to the target, regardless of response tendency; and (4) mean latency: mean time taken to respond in the correct responses. The RVP has been used in many ADHD research to assess sustained attention and inhibition control  probability of hits , and frequency of all the words across the three conditions were well matched. During fMRI scans, participants were instructed to report the number of words (one to four) by pressing a button, regardless of the word meaning, during fMRI scans. This counting Stroop task has been used in our previous imaging studies  signal.Functional images were interspersed from bottom to top and collected parallel to the AC–PC plane. The scanning has the following parameters: repetition time (TR) = 2000 ms; echo time (TE) = 24 ms; flip angle = 90°; matrix size = 64 × 64; field of view = 25.6 cm; slice thickness = 3 mm; and number of slices = 34. A high-resolution, T1-weighted three-dimensional image was also acquired .The orientation of the 3D image was identical to the functional slices. The task stimuli were administered in a pseudorandom order for all participants to optimize the event-related design.t-tests to examine the treatment-related changes in the number of DSM-5 ADHD symptoms, CGI-ADHD-S, RVP, CCPT, and counting Stroop at week 8 compared with baseline. To avoid the multiple comparison problem, we decided on the significance of each test by employing the Benjamini–Hochberg procedure , medium , and large  effect sizes. In addition, we conducted two-way ANOVA to examine the behavioral improvements in the counting Stroop task . Family-wise error (FWE) rate was controlled at 5%.Cohen's Imaging data analysis was performed using Statistical Parametric Mapping (SPM). The functional images were corrected for the differences in slice-acquisition time to the middle volume and were realigned to the first volume in the scanning session using affine transformations. The exclusion criteria for the motion were 3 mm for displacement and 3° for rotations . Co-regit-tests across all participants to determine whether activation during a contrast was significant  in a whole-brain analysis.Data from each participant were entered into a general linear model using an event-related analysis procedure. Stimuli were treated as individual events for analysis and modeled using a canonical Hemodynamic Response Function (HRF). Parameter estimates from contrasts of the canonical HRF in single-subject models were entered into random-effects analysis using one-sample p < 0.005 uncorrected at the voxel size larger than 10 in a whole-brain analysis. Comparisons between groups were also examined, with all reported areas of activation significant using p < 0.005 uncorrected at the voxel size larger than 10 in a whole-brain analysis.There were three types of events: congruent, incongruent, and control in the counting Stroop task. The present study used the incongruent condition versus congruent condition to explore the neural correlates of inhibitory control within each group . All reported areas of activation were significant using p < 0.05 FWE corrected with an anatomical mask from the WFU PickAtlas toolbox for SPM8, that is., the rIFG, rDLPFC, and dACC.For the significant voxels selected by our hypothesis, the areas of activation were also significant using p < 0.05 level.To examine the correlations between the changes in neuropsychological performances and the changes in brain activation, those clusters showing significant effects of methylphenidate were identified as Regions of Interest (ROIs). We then extracted the beta value  for these ROIs in the ADHD group at pre-treatment and post-treatment for partial correlations with the measures of RVP and CCPT, adjusting for ADHD symptoms . All reported results were significant at n = 5) and personal reasons (n = 1). The imaging data of another 15 participants were not included in the final analyses due to abnormality in structural MRI (n = 1) and poor imaging quality (n = 14), with 28 participants in the final ADHD group. There were no significant differences in age, sex, and FIQ between the ADHD and TD groups . We also found significant reductions in the number of clinical symptoms based on DSM-5 ADHD Criteria, in terms of both inattention  and hyperactivity-impulsivity .We found a significant improvement in the CGI-ADHD-S, indicative of overall symptom severity (t(27) = 0.35, p = 0.73, Cohen's d = 0.07 (t(27) = 0.85, p = 0. 41, Cohen's d = 0.16 (T score), t(27) = 2.98, p = 0.006, Cohen's d = 0.56, with a higher value of perseveration at post-treatment relative to pre-treatment  = 2.01, Mean Squared Error (MSE) < 0.01, p = 0.155, F = 0.93, MSE = 0.01, p = 0.345, F = 4.39, MSE < 0.01, p = 0.020, F = 1.03, MSE = 8333.9, p = 0.344, F = 9.88, MSE = 27767, p = 0.004, However, the main impact of the condition was significant, F = 10.99, MSE = 6910, p < 0.001, The main effect of the condition was also significant, In the present study, the contrast of the incongruent condition versus congruent condition was used to explore the neural correlates of inhibitory control within each group  for these ROIs in the ADHD group at pre-and post-treatment. We then correlated these beta values with neuropsychological performances, partialing out ADHD symptoms  covariates.r = 0.451, p = 0.023, r = 0.477, p = 0.016, r = −0.446, p = 0.026, r = −0.447, p = 0.025, r = −0.465, p = 0.019, Moreover, there was a negative correlation between the activation change of the rDLPFC and the increase of perseveration  inside the scanner and neuropsychological testing  outside the scanner allowed us to examine the pharmacological mechanisms of methylphenidate for improving specific neurocognitive processes of focused attention, impulsivity, and inhibition control in children with ADHD.This is the first study investigating the neural correlates of improved neuropsychological functions after 8-week treatment with ORADUR-methylphenidate in drug-naive children with ADHD. We found that the effect of ORADUR-methylphenidate is most prominent on the rDLPFC and dACC, which are associated with improving impulsivity and focused attention. In addition, ORADUR-methylphenidate may also normalize the activation of the rIFG, enhancing focused attention and inhibitory control.Our findings may expand the understanding of the effects of methylphenidate on cognitive control via the fronto-cingular network (Salehinejad et al.


To evaluate the prevalence of suicidal ideation (SI), plans andattempts, and non-suicidal self-injury (NSSI) among studentswith attention deficit hyperactivity disorder (ADHD).Furthermore, we explored the mediating effects of depression,anxiety, alcohol and substance use on the association betweenADHD and suicidal behaviors and NSSI.n = 1,829) recruited as part of theWorld Mental Health International College Student Initiative.Participants completed validated clinical measures online.Participants were first-year undergraduate students(The prevalence of suicide behaviors and NSSI were significantlyhigher among students with ADHD than those without. Mediationanalyses indicated that ADHD directly and indirectly increasedsuicidal behaviors and NSSI. While ADHD increased suicidalbehaviors and NSSI through depression, ADHD and the co-variatesage and gender also had indirect effects on suicidal behaviorsvia substance use.Specific predictors of risk were identified for students with ADHDwhich may inform the development of more targeted mental healthand suicide prevention strategies across campuses. The mental health of university students is a matter of concern globally, with agrowing body of literature highlighting this group as particularly susceptible topsychopathology . The WorFor many young people the transition into adulthood coincides with the commencementof university which can be a highly stressful experience characterized by majorpsychosocial change. High levels of stress have been associated with first-onsetpsychopathology and the aggravation of pre-existing mental illness inundergraduate students . HoweverThere is a scarcity of literature concerning ADHD prevalence within post-secondaryinstitutions. Preliminary estimates suggest rates range from 2% to 8% .HoweverStudents with ADHD experience higher rates of mental illness .FindingDespite the high prevalence of ADHD and worrisome findings regarding mental healthand suicidality, only a small body of literature examining the relationshipbetween ADHD and suicidality among students exists. Subsequently, the mechanismswhich underlie the association between ADHD and suicidality remain unclear .Some reThe limited pool of existing literature therefore presents mixed findings as towhether ADHD is a distinct risk for suicidality or whether the relationship isattributable to the presence of co-morbid disorders. Previous studies have focusedon North American college students and rely on smaller samples not exceeding 904students . FurtherThe present study aims to address the above concerns and provide further insight intothe associations between ADHD and suicidality. The prevalence of SI, plans andattempts as well as NSSI will be explored. Additionally, the relationship betweenADHD and suicide behaviors, and ADHD and NSSI, will be examined. Finally, we willaccount for the mediating impact of depression, anxiety, substance and alcoholuse, while controlling for age and gender variations.The Student Psychological Intervention Trial (SPIT), which was conductedas part of the WMH-ICS, aims to gather information about studentmental health and monitor this as students’ progress throughuniversity. The current study utilized data collected in September2019 when undergraduate students first commenced college inLetterkenny Institute of Technology (LYIT) in the Republic of Ireland(ROI) and across the four Ulster University (UU) campuses in NI. Thestudy was granted ethical approval from the Ulster University ResearchEthics Committee (REC/19/0072).n = 1,469) and respondents were more likely tobe female  and under the age of 21. All participants were first-yearundergraduate students, over the age of 18 and were residents ofeither NI or the ROI. Consistent with the exclusion criteria of otherWMH-ICS studies, students under the age of 18, those repeatingfirst-year and international students could not participate.One week before registration, all first-year undergraduate studentscommencing degree courses at UU and a subset of those registering atLYIT were invited to partake in the study via email. The invitationemail contained a participant information sheet outlining the study’saims and methods. Following this, trained researchers and volunteersrecruited students on the NI and ROI campuses during welcome meetingsand after the students had registered for their course on campus.Students were provided with a link to the survey and a uniqueparticipant code. Overall 1,829 first-year students completed theonline survey, and each received a university branded sweatshirt. Thesample consisted of mainly Ulster University students. The surnever to very often.Total scores range from 0 to 6, with scores of four or moreindicating probable ADHD. The measure has demonstrated highinternal consistency as well as strong reliability and validityin adult samples  standardized Adult ADHD Self-Report Scale(ASRS-v1.1). The six items are consistent with the DSM-IVcriteria for adult ADHD and measure the frequency of ADHDsymptoms in the previous 6 months. Responses were measured on afive-point scale with options ranging from samples . Moreove samples . In the The Patient Health Questionnaire (PHQ-9) was used to screen fordepression . The PHQThe GAD-7 was used to screen for generalized anxiety disorder. This brThe Alcohol Use Disorders Identification Test (AUDIT) was used toscreen for problematic alcohol use . The meaevery or nearly every day tonever. In the current study, higherscores indicated more problematic substance use. ASSIST has beenfound to be a reliable and valid screening test for drug use was used to screen for substance use. The ASSIST is abrief measure in which participants indicate lifetime frequencyof use of various substances, as well as social and functionalimpairments associated with usage. The six-point scale rangesfrom drug use. In the The self-report version of the Self Injurious Thoughts and BehaviorInterview (SITBI) was used to identify students with a lifetimehistory of SI, plans and attempts, and NSSI . If studWeights were created based on the gender and age characteristics ofthe first-year student population at UU and LYIT. The weightswere applied to the data during analysis to ensure that theresults were representative of the total student population.Mplus v.7.31  was usedThe mediation analyses were conducted in three different stages asoutlined below.Regression models estimated the direct effects betweenindividuals with/without ADHD and the dichotomousdependent variables; lifetime SI, plans andattempts, and lifetime NSSI. The pathways of thecovariates, gender and age, and the mediators were fixed to zero.The covariates, gender, and age were added to the modeland the direct effects were estimated. The pathwaysto and from the mediators remained fixed tozero.The pathways to and from the mediators were freed.Direct effects and indirect effects of ADHD and thecovariates through the mediators were estimated.Direct pathways from ADHD to the mediators were alsoestimated. The mediation model is depicted in Overall, there was a high prevalence of ADHD (27.2%), with 31.8%screening positive at LYIT and 26.1% at UU. The highest lifetimeprevalence rates in all students were for SI (28%), suicide plan(14.3%), and NSSI (13.4%). In a comparison between students withand without ADHD, students with ADHD had rates of suicidalideation that were more than twice as high (44.8% vs. 21.7%),suicide plans which were almost three times higher (26.6% vs.9.8%) and both attempts (13.4% vs. 5.5%) and NSSI (23.4% vs.9.6%) that were almost 2.5 times greater than students withoutADHD .p < .0001). Model 3 was determined tobe significantly superior.A range of model fit indices were assessed to determine theadequacy of the mediation models . TheseiThe direct effects between the independent variable ADHD andthe dependent variables were all significant as shown inOR = 1.594), plan(OR = 1.850), and attempt(OR = 2.359), with those aged 21and over more likely to endorse suicidal behavior.Conversely, age was not a significant predictor ofself-harm.When the covariates gender and age were included in the modelthe effect of ADHD remained significant, with littlechange in the odds ratios for any of the suicidal behavioroutcome variables or self-harm. Gender was not asignificant predictor. Age however predicted suicideideation , plans , attempts , and self-harm .Significant indirect effects were revealed for suicideideation, plans and attempts, with ADHD and theco-variates age and gender having indirect effects viadrug use –6. An ina paths). Alcoholproblems were predicted by age , gender , and ADHD , with males and those under 21 more likely to haveproblems. Drug use was also predicted by age , gender , and ADHD  with males and those 21 and above more likely tohave problems. Anxiety was predicted by gender  and ADHD , with females at agreater risk. While depression was predicted by havingADHD .A number of significant direct effects of ADHD and thecovariates age and gender on mental health and substanceproblems were revealed . Furthermore, high rates of SI (44.5%), plans(26.6%), attempts (13.4%), and NSSI (23.4%) were revealed among those withADHD. The prevalence of suicidal behaviors and NSSI was significantly higherwhen compared to students without ADHD. Additionally, even after adjustingfor comorbid disorders, substance and alcohol use, significant directassociations between ADHD and suicidality and ADHD and NSSI remained.Depression was found to partially mediate the association between ADHD andsuicide behaviors and NSSI. Lastly, ADHD and the co-variates age and genderalso had indirect effects on suicidal behaviors via substance use.The present study found that the prevalence of ADHD among undergraduatestudents was considerably higher (27.2%) than previously reported (2%–8%) byAs a screening tool the ASRS-v1.1 is designed to include room for falsepositives in order to decrease the potential for false negatives.Furthermore, although the ASRS-v1.1 is a well-validated, reliable screeningtool, in participants presenting with mood and substance disorders, thesensitivity, specificity, and classification accuracy of the ASRS-v1.1 isreduced. Subsequently, the likelihood of false positives increases, due tooverlapping symptomology . As moodThe current findings are consistent with previous research that has highlightedstudents with ADHD to be at heightened risk of suicidality . The preThe high rate of suicidal behaviors raises concern as such can adversely impactacademic outcomes, retention, life satisfaction, and cause considerablepsychological distress .FurtherIn accordance with previous literature, current findings demonstrate thatmediating variables only partially accounted for the association betweenADHD and suicide behaviors . ADHD reAnother important finding from the current study is the direct associationbetween ADHD and suicide plans as previous research has indicatedcontrasting findings . The impThe influence of depression in the context of ADHD may place individuals athigh risk for SI, plans, attempts, and NSSI. This finding is in concordancewith findings presented by Interestingly, unlike previous studies, anxiety did not mediate therelationship between ADHD and suicide behaviors . Indeed,Although the current study has its strengths, some limitations should beconsidered. For example, ADHD was screened for using the ASRS-v1.1alone. While the ASRS-v1.1 is a well-validated, reliable screeningtool, a thorough clinical assessment is recommended with historicaldevelopmental corroboration. This is to reduce bias and confirm thatparticipants meet the diagnostic criteria for ADHD and otherconditions can be excluded.Additionally, this study utilized data from a cohort at one timepointonly. As students, particularly those with ADHD, face severalstressors and challenges as they progress through college, it may behelpful to extend the current findings by utilizing longitudinal data.Plans are in place to conduct follow up surveys with this cohort.Future research could examine whether the prevalence of suicidebehaviors change as students with ADHD progress through university andmonitor progression in suicidal behaviors. Additionally, it may bebeneficial to examine if the extent to which mediators influence theassociation between ADHD and suicidality changes over time.Despite the limitations, the present study has enhanced our understanding ofthe relationship between ADHD, suicide behaviors and NSSI, as well as theunderlying mediating mechanisms. A key strength of the current study is theutilization of a large sample and the inclusion of measures for suicideideation, plan, attempt, and NSSI. Many previous studies rely on smallersamples and explore SI exclusively . FurtherMany of the interventions available to students with ADHD focus on improvingorganizational, planning, and time-management skills to alleviate academicimpairment. However, due to the high prevalence of suicidal behaviors andNSSI and considering the mediating effects of depression and substance use,it may be beneficial to integrate evidence-based mental health interventionsinto these pre-existing support frameworks. For example, preliminaryfindings demonstrate that group Cognitive Behavioral Therapy programs showpromise in not only reducing symptoms of impulsivity and inattention but inreducing depression and substance use in students with ADHD . MoreoveThe current study is beneficial in providing baseline information about thehigh prevalence of ADHD and accompanying suicide risk in students upon theirentry into college. Additionally, as depression and substance use aremodifiable risk factors, appropriate strategies and interventions can be putin place to reduce suicide risk among this vulnerable population. Campuswellbeing services may consider screening students for symptoms of ADHD andawareness could be raised about risks presented by this subgroup. Moreover,research like this may help inform the development of more targeted mentalhealth and suicide prevention campaigns, strategies, and interventions aimedspecifically at students with ADHD.