An increasing body of research points to a significant association of obesity to Attention-Deficit/Hyperactivity Disorder (ADHD) and deficits in executive functions. There is also preliminary evidence suggesting that children with ADHD may be at risk of obesity in adulthood.In this article, we discuss the evidence showing that ADHD and/or deficits in executive functions are a barrier to a successful weight control in individuals enrolled in weight loss programs. Impairing symptoms of ADHD or deficits in executive functions may foster dysregulated eating behaviors, such as binge eating, emotionally-induced eating or eating in the absence of hunger, which, in turn, may contribute to unsuccessful weight loss. ADHD-related behaviors or neurocognitive impairment may also hamper a regular and structured physical activity. There is initial research showing that treatment of comorbid ADHD and executive functions training significantly improve the outcome of obesity in individuals with comorbid ADHD or impairment in executive functions.Preliminary evidence suggests that comorbid ADHD and deficits in executive functions are a barrier to a successful weight loss in individuals involved in obesity treatment programs. If further methodologically sound evidence confirms this relationship, screening and effectively managing comorbid ADHD and/or executive functions deficits in individuals with obesity might have the potential to reduce not only the burden of ADHD but also the obesity epidemics. The Dian, IV-TR  defines ADHD is one of the most frequent childhood-onset psychiatric conditions, with an estimated worldwide-pooled prevalence exceeding 5% in school-age children . ImpairiExecutive functions are defined as a set of neurocognitive skills that are necessary to plan, monitor and execute a sequence of goal-directed complex actions and include inhibition, working memory, planning, and sustained attention . BesidesCurrently, the mainstay of treatment, at least for severe cases, is pharmacologic, with psychostimulant medications (methylphenidate and amphetamines) as the first line, and non-stimulants as secondary option ,9. Non-pBecause of its core symptoms as well as associated disorders/conditions, ADHD entails an enormous burden on society in terms of psychological dysfunction, adverse vocational outcomes, stress on families, and societal financial costs. The U.S. annual incremental costs of ADHD have been recently estimated at $143-$266 billion  and highth, 2013, using the following keywords, in multiple combination combination: obesity, BMI, weight, body mass, ADHD, Attention-Deficit/Hyperactivity Disorder, Attention Deficit Disorder, Hyperkinetic Disorder; details of the search strategy and syntax, adapted for each database, as well as of the specific results from each database search, are available from the corresponding author). Given the cross-sectional design of such studies, they cannot allow to infer the causal relationship between obesity and ADHD. Theoretically, it is possible that: 1) ADHD contributes to weight gain; 2) Obesity early in life fosters symptoms of ADHD; 3) Both conditions are the expression of underlying neurobiological and psychopathological dysfunctions. Recent studies have shaded light on the causal relationship between ADHD and obesity, supporting in part the notion that ADHD in childhood may contribute to weight gain later on in life. Cortese et al. [vs. non ADHD comparisons , even after controlling for possible confounders such as socio-economic status (SES) and comorbid psychiatric disorders associated with obesity, i.e., mood, anxiety, and substance use disorders. However, anthropometric data were not collected in childhood, which prevented the authors from determining whether the association between childhood ADHD and weight status at follow-up in adulthood was attributable to weight status in childhood or whether it developed later. Using a dimensional approach  rather than a categorical approach based on the DSM-IV-TR nosography, Fuemmelar et al. [Whereas the comorbidity between ADHD and psychiatric disorders has been extensively explored , the asse et al.  assessedr et al.  found a With regards to executive dysfunctions, there is an emerging literature indicating their possible association with overweigh/obesity. In a recent systematic review  includinSummarizing, there is increasing evidence that both ADHD, at least considering samples of treatment-seeking individuals, and deficits in executive functions, even in the absence of a formal diagnosis of ADHD, may be associated with obesity. Additionally, there is preliminary evidence that ADHD may causally contribute to obesity/overweight. However, an important aspect to note is that the impact of ADHD or executive dysfunction on obesity outcome is still underexplored. In the next section, we discuss the preliminary evidence showing that ADHD or executive dysfunction may represent an important barrier to successful weight loss in patients with obesity during weight loss programs. We also point out the clinical implications of these findings, as well as possible future research directions in this emerging area of investigation.Several possible dysfunctional behavioural pathways associated with either ADHD  or related neuropsychological deficits in executive functions lead to hypothesize that impairing symptoms of impulsivity, inattention or hyperactivity  and/or related neurocognitive impairment may be a barrier to successful weight loss during treatment interventions for individuals with obesity.First, it is possible that impulsivity and deficient neurocognitive inhibitory control foster impulsive and dysregulated eating behaviors, which, in turn, would hamper the success of dietetic regimen. These abnormal eating behaviors include binge eating, “external eating”  and “emotionally-induced eating” , all of which have been related to obesity and overweight ,31.Second, another dysfunction related to impulsivity and deficits in inhibitory control, namely altered reward sensitivity, may also contribute to dysregulated eating behaviors. Indeed, a subset of individuals with ADHD present with a preference for small immediate over larger delayed rewards ,32. ThisThird, it has been noted that attention and related executive functions such as planning and organizational skills are important for a successful adhesion to dietetic regimen and regular physical exercise , both ofThe previous hypotheses of a correlation between ADHD symptoms and/or executive function deficits and abnormal eating start being supported by empirical evidence. With regards to ADHD symptoms, Cortese et al.  found a There is also evidence that deficit in executive dysfunctions are related to abnormal eating behaviors, although causal relationship has not been tested. For example, in a study of 55 women reporting weekly binge eating in the absence of regular compensatory behaviors, Kelly et al.  found a While the correlation of impulsivity and inattention domains to abnormal eating behaviors associated with obesity may be intuitive, one could think that the hyperactive component of ADHD is not involved at all and, actually, it may favour weight loss rather than weight gain. However, it is well known that the motor hyperactivity of ADHD is not constant. Actigraphic measures have shown that motor hyperactivity is modulated by situational variables and may be indistinguishable from normal when there is sufficient stimulation. For example, no significant differences in hyperactivity levels between children with ADHD and healthy comparisons have been detected while watching television, whereas children with ADHD show significantly more hyperactivity during classes at school ; it is iSo, if ADHD or related executive functions deficits foster abnormal eating behaviors contributing to obesity, is there evidence supporting that ADHD and executive dysfunction also represent a barrier to effective and lasting weight loss in individuals with obesity? This starts being reported in the literature, although further and more methodologically sound evidence is needed.In an observational study of 215 adults with obesity in a specialized clinics, Altfas  confirmeIndirect support to the hypothesis that executive function deficit is a barrier to effective weight control is also provided by a longitudinal prospective study by Speranza et al.  who founGiven this preliminary literature, a crucial question is whether treatment of ADHD and/or improvement in executive functions are also effective in decreasing/preventing obesity in children with both conditions. There is initial evidence indicating that the answer may be affirmative.In a study  of 242 iIf further methodologically sound studies confirm that ADHD and/or related executive functions deficits are a barrier to effective weight loss, it would be worthy for the clinicians and professionals involved in the management of obesity to screen for ADHD and impairment in executive functions. We note that professionals involved in the treatment of obesity usually do not have an appropriate knowledge of ADHD and related disorders. A systematic screening and appropriate treatment of ADHD and/or executive functions deficits might not only reduce the burden of ADHD, but also improve the outcome of patients with a past history of weight loss failure. This is particularly relevant in terms of decreasing the stigma associated with obesity. Unfortunately, a common belief manifested not only by the lay public but also by some professionals is that individuals with obesity may fail to succeed at weight-loss programs due to their “laziness” . InattenWe believe that the relationship between ADHD/executive functions and obesity, as well as the impact of neurocognitive impairment on weight loss management, is still in a developing phase. While the cross-sectional relationship between ADHD and obesity starts being well characterized from a clinical descriptive standpoint, further longitudinal studies are needed to better assess the causal relationship. Studies aimed at elucidating common neurobiological and genetics underpinnings are still in their infancy  and neePreliminary evidence suggests that comorbid ADHD and deficits in executive functions are a barrier to a successful weight loss in individuals involved in obesity treatment programs. If further methodologically sound evidence confirms this relationship, screening and effectively managing comorbid ADHD and/or executive functions deficits in individuals with obesity might have the potential to reduce not only the burden of ADHD but also the obesity epidemics.ADHD: Attention-Deficit/Hyperactivity Disorder; BMI: Body mass index; SES: Socioeconomic status.Dr. Cortese has received financial support to attend medical meetings from Eli Lilly & Company (2008) and Shire Pharmaceuticals (2009-2010), and has been co-investigator in studies sponsored by GlaxoSmithKline (2007), Eli Lilly & Company (2008), and Genopharm (2009). He has served as scientific consultant for Shire Pharmaceuticals (2009-2010). Drs. Comencini, Vincenzi, Speranza, and Angriman declare no competing conflict of interest.Dr. Cortese conceived and drafter the manuscript and approved the final version to be submitted; Drs. Comencini, Vincenzi, Speranza, and Angriman critically revised the first draft, contributed to the literature search, and approved the final version to be submitted. All authors read and approved the final manuscript.Dr. Cortese is a post doctoral fellow at the Institute for Pediatric Neuroscience, New York University, New York, NY, USA and at the Child Neuropsychiatry Unit, Verona University, Italy. His research interests focus on ADHD, in particular on the neurobiology and on the evidence-based treatment of ADHD. Dr. Comencini is a resident in child psychiatry at the Child Neuropsychiatry Unit, Verona University, Italy. Her research focuses on the psychopathology of children with obesity. Dr. Vincenzi is a research fellow at the Massachusetts General Hospital, Schizophrenia Clinical and Research Program, Boston, MA, USA. Her research focuses on eating disorders and schizophrenia. Dr. Speranza is a consultant at the Child and Adolescent Psychiatry, Versailles General Hospital. Le Chesnay, France and a researcher at the University of Versailles Saint-Quentin-en-Yvelines, Versailles, France. His research focuses on eating disorders, ADHD, and personality disorders. Dr. Angriman is a consultant at the Child Neurology and Neurorehabilitation Unit, Department of Pediatrics, Central Hospital of Bolzano, Italy. His research focuses on ADHD, obesity, and sleep disorders.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/13/286/prepub


Dear EditorAttention Deficit Hyperactivity Disorder (ADHD) is the most common behavioral disorder in children . PrevailADHD is one of the most common disorders followed by epilepsy that affects the quality of the patients’ life and is an important risk factor of academic achievement . Many rePrevious studies have indicated a strong relationship between epilepsy and neuropsychological disorders such as Electrical Status Epilepticus in Sleep (ESES) and Landau–Kleffner syndrome (LKS)  4). Epi. Epi4). Children with some of the epileptic syndromes such as benign childhood epilepsy with centrotemporal spikes (BCECTS), frontal lobe epilepsy, rolandic epilepsy, complex partial seizures (CPS), and absence seizures may be more likely to be associated with these symptoms. Epidemiological studies have found that children with epilepsy are more susceptible to ADHD than other children are, so that one-third to two-third of such children will be affected by this disorder 5). Inci. Inci5).Other studies have shown that ADHD has a higher risk of incidence in generalized seizures than spasms. In some epileptic syndromes, ADHD is observed as a high risk, so that 67% of the patients with frontal lobe epilepsy and 61% with childhood absence epilepsy had ADHD . ESES isOn the other hand, the results of other studies have indicated the presence of epileptic discharges in some children suffering from ADHD without a history of epilepsy. In consideration of this evidence, a causal relationship between subclinical epileptic waves and occurrence of symptoms is raised  4) 5)  (5) 4) (  (5) 4) Fonseca et al and related research found that Epileptiform Discharges were found in 10% of ADHD patients. The ADHD group showed significantly greater absolute delta and theta powers and also greater absolute beta power and smaller relative alpha 1 and beta powers at some electrodes when compared to the controls ..16).Considering the literature related to this issue, it seems essential to have a logical approach to the use of EEG. On one hand, EEG may contribute to diagnosis of the disease in the patients suffering from ADHD, especially when Deficit Attention is dominant . On the Therefore, it is recommended to perform EEG on patients suffering from ADHD with a high risk in epileptic areas, but not for all patients. According to some resources, the high-risk groups have the following features and symptoms: a history of previous seizures, prenatal events, a history of head trauma, variable behavioral manifestations, and other existing cognitive disorders such as mental retardation as well as a family history of seizures  7). The. The7).


A PCR primer and specific simple sequence repeat marker for rye were used in F5 populations to detect rye chromatin and to amplify a specific chromosome band in six translocation lines . Fragment pSc119.1 cloned from 7-33 had 99% homology with the big ear gene sequence (GenBank AF512607.1) in wheat. The six lines were further characterized via pollen mother cell meiosis analysis for genetic stability, and chromosome C-banding and genomic in situ hybridization for rye chromatin. The results show that line 7-33 was still within the 5R/5A substitution lines and possessed the big ear gene. The other lines all contained small-segment rye chromosome translocations. The results indicated that substitution line hybridization is an effective method for creating small-segment chromosome translocations with useful agronomic traits. Trials for these six wheat-rye translocation lines are justified because they possess many important stably-inherited agronomic characters, including disease resistance and improved yield.Intergeneric crop plant hybrid lines with small-segment chromosome translocations are very useful in plant genetic research and breeding. In this study, to create small-segment chromosome translocations with beneficial agronomic characters, the progeny of wheat-rye substitution lines 5R/5A and 6R/6A were selected from generations F BLASTBasic Local Alignment Search ToolC-bandingcentromeric bandinggDNAgenomic DNAGISHin situ hybridizationgenomic NCBINational Center for Biotechnology InformationPCRpolymerase chain reactionPMCpollen mother cellSSRsimple sequence repeatTriticum aestivum L.) possess genetic traits that, when incorporated into the wheat genome, have improved yield and resistance to various adverse environmental factors. Rye  is closely related to wheat, and is a most useful source of alien genetic material for wheat-breeding. Several rye genes have already been successfully introgressed into the wheat genome, and these varieties are grown widely throughout the world for their disease resistance and other desirable agronomic traits The ability to transfer alien genes that are agronomically desirable from wild relatives into cultivated wheat is very important for the wheat geneticist and breeder Many studies have reported that through the creation of translocation lines, especially from alien chromosome fragments, alien genes or chromosome segments were transferred from wild relatives into common wheat in situ hybridization (GISH) is an efficient and accurate technique that detects all alien chromatin and the translocation breakpoints of interspecies chromosomal rearrangements To identify genes inherited from the rye parent, observation of phenotype can be the simplest and most direct method. For example, Sears 2 to F5. We identified those lines containing incorporated rye germplasm, using a specific molecular marker. In lines containing the amplified rye-specific fragment, stability of inheritance was assessed via PMC meiosis analysis. Rye chromatin was identified with chromosome C-banding and GISH.In this study, we created translocation lines via hybridization of the wheat-rye 5R/5A and 6R/6A substitution lines, and then screened for rye-specific traits favorable for agronomy from hybrid generations FThe wheat-rye 5R/5A and 6R/6A substitution lines, described in detail in previous studies Puccinia graminis) and powdery mildew (Blumeria graminis) was carried out in the greenhouse. The hybrid F2 to F5 generations were tagged for recording observations of plant height (cm), spike length (cm), number of spikelets per ear, number of grains per ear and grain yield per ear (g). All lines were selected according to phenotypic characters such as neck hair, abundant spikelets, disease resistance, and drought tolerance until stable The maternal and paternal parents were crossed by conventional methods. All materials, including Chinese Spring wheat and rye, were grown in single-row plots 1.5 m long with 30 cm row spacing and 5 cm plant spacing within rows. Breeding for disease resistance against stem rust . Recombinant clones were sequenced after a PCR test. Sequencings were performed by Shanghai Sangon Biological Engineering Technology & Services . Sequence alignment was carried out with Basic Local Alignment Search Tool (BLAST) software. Six lines were assayed through simple sequence repeat (SSR) analysis. Primer sequences and chromosome locations are shown in . PCR amp2 to F5 generations.The six lines have some beneficial traits and apparent rye characters, e.g., big ears, disease resistance, grey leaf, and heterozygous advantage . In partC). The rye-specific PCR primers amplified specific bands in the rye and wheat-rye lines, whereas in Chinese Spring wheat neither of the rye-specific PCR primers could amplify any band. These results suggest that pSc119.1 and AF1/AF4 were rye-specific PCR primers, and the six lines were verified to contain rye chromatin. The PCR product of 7-33 was cloned and sequenced (B). A search of GenBank  and BLAST software showed that the DNA sequence of the analyzed fragment had 99.9% similarity to the big ear gene in wheat (GenBank accession number AF512607.1). This result suggests that 7-33 has the big ear gene.The precise identification of translocation lines is an important aspect in the evaluation and utilization of alien genetic material. Specific PCR markers are an easier and reliable means for detecting alien segments in the wheat background A). SCM138 and SCM268 are both located on rye 5RS and amplified a 188 bp and 153 bp fragment, respectively, as specific bands in 7-33 . These results show that the translocation line 7-33 contained rye 5R chromosomes.The SSR markers SCM120, SCM138, and SCM268 were used to identify 5R chromosomes . SCM120 In the six translocation lines, meiotic univalents, heteromorphic bivalents, or multivalents were observed in metaphase. Chromosome bridges, chromosome fragments, and lagging chromosomes appeared in anaphase I and anaphase II. Micronuclei were found in the tetrad phase. The meiotic abnormal phenomena ratio was <2% in all phases of meiosis Table 3,A). GISH indicated that there were two hybridization signals specific for rye chromosomes (B). Together with the results of molecular identification, line 7-33 was designated as a 5R/5A substitution line. The rest of the lines were determined to be small-segment chromosome translocation lines, because no chromosome band patterns changed in the C-banding and because of the presence of a rye-specific hybridization signal in GISH analysis (C–F). However, it could not be determined which of the wheat chromosomes contain these small rye chromosome segments.Compared with the standard C-banding patterns of rye and Chinese Spring wheat, the translocation line 7-33 was missing the 5A chromosome but increased the 5R chromosome (Rye has many useful genes for wheat breeding and some of them have been transferred to wheat T. aestivum–S. cereale addition lines. Li et al. Haynaldia villosa and wheat–Thinopyrum intermedium disomic substitution lines and determined that the translocation lines were produced through exchange due to pairing of homoeologous chromosomes. Li et al. Ren and Zhang 5 generation. This suggests that the crossing of substitution lines can create small-segment chromosome translocation lines with agronomic characteristics of polymeric quality.To create wheat-rye translocation lines possessing superior agronomical characteristics, in the present study, 5R/5A was crossed with 6R/6A. Via a tracing screen of target characteristics and cytogenetic and molecular identification, five chromosome segment translocations and one substitution were obtained in the F2 to F5 were screened for rye characters. This ensured that traits in the translocation lines that had been selected for superior agronomic performance, such as high yield and resistance to stem rust and powdery mildew, were stable in the F5 generation. To avoid painstaking cytological work, we firstly utilized a rye-specific PCR primer to screen the F5 population for desirable rye characters. We found that specific PCR markers, pSc119.1 and AF1/AF4, amplified rye-specific bands in six lines and rye. However, no amplification products were found in Chinese Spring wheat. When amplification products of specific PCR markers for translocation were cloned and sequenced, we found the lines 7-33 to possess the big ear gene. These results document that the 5R or 6R chromosome of rye may carry the big ear gene; the definite location of this gene is still to be determined. The lines were then analyzed for genetic stability through observation of PMC meiosis. Identification of alien chromosomes was made using chromosome C-banding and GISH. This identification procedure enhanced accuracy and reliability, decreased the workload and saved time, and thereby gave the study a clear direction and focus.The present study began with the crossing of the substitution lines 5R/5A and 6R/6A, and in the field the progeny from generations FThe development of small-segment chromosome wheat-rye translocation lines that have beneficial agronomic traits has seldom been achieved In this study wheat-rye chromosome translocation lines were created by crossing substitution lines. Through tracing selection, the translocation lines we produced have superior agronomic characters and improved wheat germplasm. In addition, these lines are useful for studying the mechanisms of alien chromosome introgressions into the receptor chromosome, and the expression of alien segments in receptor plants. Moreover, small-segment chromosome translocation lines can be used to study the mechanisms of gene exchange and gene expansion in species evolution.


High risk behaviors (HRBs) can impact public health. HRB refers to any kind of behavior or reaction that can potentially harm psychological and biological aspects of an individual. These behaviors are hazardous to several areas of human development which include: health, performing duties or tasks commensurate with developmental stage, playing expected social roles, learning the skills, feeling competent and adequate, and preparation for doing tasks . PrevaleAlmost hundred years ago, ADHD was described as a childhood disorder  called hyperactivity. Nearly six decades later, the "minimal brain damage" and "minimal brain dysfunction" were replaced with hyperactivity. With the introduction of attention deficit as the central feature of this disorder, a significant change occurred in the approaches of etiology and diagnosis of ADHD . CurrentPeople with ADHD, suffer from social and interpersonal problems. Inattention and hyperactive/impulsive behavior can cause social problems in this population , thus, PSymptoms of ADHD, in general, and its comorbidity with other disorders  can increase probability of performing HRBs, but these are not the only determinants of high risk behaviors. Overall, ADHD patients have major problems in decision-making, executive functioning and social cognition. Their decision-making in ambiguous situations has the same features of "intuitive-existential" decision-making system . Also, tIn a review of the studies done over a period of 30 years by Uekermann et al. found that ADHD is associated with deficit in social cognition (e.g., face perception, emotional prosody perception . DeficitAlthough our understanding of ADHD and its association with HRBs has increased by the conducted research, there are still questions and issues regarding to hereditary, neuropsychological, developmental, environmental, psychological, social factors of ADHD which should be studied further. Some of the major issues in this regard are listed below.1- The interaction of genetic and environmental factors in the development of ADHD.2- The development of brain networks and circuits associated with ADHD symptoms, impaired executive functions and social cognition of people with ADHD.3- Deficits in executive function as a general capacity and also its components and how executive functions relate to HRBs in children and adults. 4- Studying the effectiveness of drug treatments and psycho-social interventions on executive functions and improving the deficit of social cognition depending on ADHD subtypes and developmental stage of the patients.5- Impact of parenting styles and cultural-social factors on development and maintenance of ADHD symptoms with HRBs, and the impact of ADHD on parental behaviors.6- The role and influence of different situations and emotional states in decision-making of people with ADHD.


This is the second in a series of four empirical studies designed to develop International Classification of Functioning, Disability and Health  core sets for attention deficit hyperactivity disorder (ADHD). The objective of this stage was to gather the opinions from international experts on which ability and disability concepts were considered relevant to functioning in ADHD. An email-based survey was carried out amongst international experts in ADHD. Relevant functional ability and disability concepts were extracted from their responses and linked to the ICF/-CY categories by two independent researchers using a standardised linking procedure. 174 experts from 11 different disciplines and 45 different countries completed the survey. Meaningful concepts identified in their responses were linked to 185 ICF/-CY categories. Of these, 83 categories were identified by at least 5 % of the experts and considered the most relevant to ADHD: 30 of these were related to Body functions , 30 to Activities and Participation , 20 to Environmental factors , and 3 to Body structures . Experts also provided their views on particular abilities related to ADHD, naming characteristics such as high-energy levels, flexibility and resiliency. Gender differences in the expression of ADHD identified by experts pertained mainly to females showing more internalising  and less externalising behaviours (e.g. hyperactivity), leading to a risk of late- and under-diagnosis in females. Results indicate that the impact of ADHD extends beyond the core symptom domains, into all areas of life and across the lifespan. The current study in combination with three additional preparatory studies  will provide the scientific basis to define the ADHD ICF/-CY core sets for multi-purpose use in basic and applied research and every day clinical practice. Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition, defined by patterns of inattention, impulsivity and hyperactivity, which affects approximately 5 % of children , 2 and 2Level 1 chapter: d5 self-careLevel 2 category: d570 looking after one’s healthLevel 3 category: d5702 maintaining one’s healthLevel 4 category: d57022 avoiding risks of abuse of drugs or alcoholThe World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF)  was devePersonal factors are also included in the bio-psycho-social model of functioning, but are not yet classified within the ICF given the large social and cultural variance associated with them . Descripn = 521; Body structures, n = 320; Activities and participation, n = 543; and Environmental factors, n = 270) that together provide an exhaustive classification of an individual’s functioning and as such provides a valuable system for health care and research [The ICF(-CY) contains over 1600 categories , a group of key opinion leaders in ADHD from all WHO regions providing guidance on the project, and by the authors’ personal professional networks. Finally, snowball sampling was applied, as all contacted experts were requested to recommend additional experts to be recruited for the survey. To be considered an “expert” for the purposes of this study, potential participants were required to (1) practice in one or more of the following professions: coach , counsellor, nurse, occupational therapist, physician, physiotherapist, psychologist, psychotherapist, social worker, special educator, or speech and language therapist; (2) have at least 5-year experience in the treatment of individuals with ADHD; (3) be able to read and write in English to complete the survey. Identified experts were contacted via email and received information about the study and a request to participate in the survey. Those who agreed to participate were asked to fill in a reply sheet with information about their work experience (to confirm their eligibility). Experts who were recommended by organisations or expert peers received the reply sheet and the expert survey together in one message. The expert’s eligibility was confirmed in the correspondence with the organisations and the experts who had recommended them (the inclusion criteria of the study were stated in the correspondence). Eligible experts received the survey and the reply sheet as a Word or PDF file via email to fill in and return within 1 month. If necessary, the experts received up to two reminders to return their survey response and reply sheet, and, if requested, they received extended time to respond. Data collection took place between September 2013 and October 2014.The survey was delivered in three parts. Part one contained demographic questions, e.g. age, gender, years of professional experience with ADHD, and the age group of individuals with ADHD they worked with. Part two included six items about the functioning of individuals with ADHD Table . These q“Meaningful concepts” are concise descriptions of specific behaviours, skills or other aspects of functioning that are to be linked to ICF-CY categories. All expert survey responses were analysed to identify the meaningful concepts contained in them. These were then linked to ICF-CY categories following the formal linking rules and procedures determined by the WHO ICF Research Branch , 32. Theĸ = 0.71 (SE = 0.006) with a confidence interval of 0.70–0.72. These indicate substantial agreement.To assure the quality and consistency of results, both the identification of meaningful concepts and the linking to ICF-CY categories were conducted by two independent researchers (ES and SM) both of whom had received extensive linking training by the ICF research branch prior to the project, and who worked in parallel. These researchers compared their linking results and consensus discussions were used to resolve disagreements. Where consensus could not be reached, a third researcher  was available to make the final decision. However, this option was only rarely used because disagreements were almost all resolved by discussion. Initial agreement between the two researchers (prior to consensus in case of disagreement) was 69 % for the second-level ICF-CY categories and 74 % at the level of ICF-CY chapters. Kappa coefficients and confidence intervals for the second-level categories were 0.68 (SE = 0.005) with a confidence interval of 0.67–0.69 and at ICF-CY chapter level was Frequency analysis was used to analyse the responses to the six ICF(-CY)-based questions of the survey. The absolute number of expert survey responses for each of the ICF-CY categories was identified, along with the corresponding percentages relative to the total number of responses received. ICF-CY categories are presented at the second level. If a concept is linked to a third- or fourth-level ICF-CY category, the corresponding second-level category is reported. Because the ICF-CY is organised hierarchically, aspects of the more specific third- and fourth-level categories are included in the less specific second-level categories. Following the ICF Core Sets development guidelines , a seconn = 304; 74 %). Some, however, did not respond to the invitation (n = 87), others explicitly declined, mostly (n = 9) due to lack of time, but some felt that they were not suited to participate in the expert survey (n = 4). A handful of those invited were excluded because they did not meet the inclusion criteria of the study (n = 6). Of the 304 experts who initially agreed to participate in the expert survey, 130 failed to submit their survey responses before the data collection window closed. The main reasons given for non-response were lack of time, or “no reason”. An overview of recruitment is provided in Fig. Invitations were sent to 410 experts. The majority accepted the invitation to participate (Complete survey responses were received from 174 experts 42 %). Some of those that participated declared more than one profession, e.g. psychologist and psychotherapist. Participating experts represented 11 different professional groups, and 45 different countries from all six of the WHO regions. The representation from each of the professions in each of the WHO regions is detailed in Fig.  %. Some Analysis of the 174 expert survey responses yielded a total of 7615 meaningful concepts. These concepts were translated and summarised into 185 second-level ICF-CY categories, 235 Personal factors , 470 not definable codes , 267 not covered codes , and 55 health condition codes . The not definable codes and not covered codes were mostly identified in the questions that captured the environmental factors of functioning and disability, whereas the health condition codes were mostly applied in questions related to Body functions and Body structures component.n = 30), Activities and Participation (n = 30), Environmental factors (n = 20) and Body structures (n = 3). Table n = 19). The other categories were identified in chapters b2 sensory functions and pain , b7 neuromusculoskeletal- and movement-related functions , and b3 voice and speech functions . Six second-level categories in this component were identified in more than 50 % of the responses. The three most identified categories represent the core symptoms of ADHD, i.e. inattention , impulsivity , and hyperactivity . The three next highest rated categories represent functions related to control and coordination of movement , a variety of executive functions , and functions of regulation and display of experienced emotions . Most of the second-level categories in Body functions were identified in less than 25 % of the responses (n = 21).Of the identified ICF-CY categories, 83 were found in the responses of at least 5 % of the experts (range: 5–85 %), and were included in the list of candidate categories. Categories were identified in each of the four components making up the ICF, i.e. Body functions (tors n = 0 and Bodn = 7), d7 interpersonal interactions and relationships , d1 learning and applying knowledge , d2 general tasks and demands , d5 self-care , d4 mobility , d6 domestic life , and d9 community, social and civic life . One second-level category was identified in more than 50 % of the responses, i.e. d820 school education. This category includes various aspects of following and completing an educational programme, such as attending school regularly, cooperating with other students, taking directions from teachers and organising study tasks. As is the case with Body functions, most of the second-level categories in the activities and participation component were identified in less than 25 % of the responses (n = 22).Absolute and relative frequencies of the second-level categories identified in the activities and participation component are presented in Table n = 7), e1 products and technology , e4 attitudes , e5 services, systems and policies , and e2 natural environment and human-made changes to environment . Two of the 20 second-level categories identified in this component were found in more than 50 % of the responses. The first is e310 immediate family, representing the support provided by parents, partners, siblings and other direct family members. The second is e585 education and training services, systems and policies, involving institutions providing mainstream and special education and related services. Environmental factors indicated by the experts can be either helpful or hindering, such as e110 products or substances for personal consumption, which can be a facilitator in the form of medication, but a barrier when it represents alcohol or other non-medical drugs related to substance abuse. The majority of the second-level categories in this component were again identified in less than 25 % of the responses (n = 16).Table The three second-level categories identified in the body structures component are shown in Table n = 34) by those working with adults as compared to those working with children: d845 acquiring, keeping and terminating a job, d850 remunerative employment and d870 economic self-sufficiency, as were categories d230 carrying out daily routine, and d570 looking after one’s health. In the activities covered by these categories, children are often guided by adults, rather than being responsible for themselves. Two additional categories were identified by experts working with adults, but less frequently than those working with children, i.e. b125 dispositions and intra-personal functions (such as adaptability and energy level) and b134 sleep functions . Finally, one category was identified more often (n = 71) by those working with ADHD children compared to adults, namely e585 education and training services, systems and policies.Additional frequency analysis of the expert survey responses exploring the possible relationship between age groups  and the ICF-CY categories identified in their survey responses showed that the majority of categories identified by specialists were from across the lifespan. A few categories were identified more often (The vast majority of experts (93 %) indicated positive sides to ADHD and named one or more abilities related to the condition. There were some recurring themes. A high level of energy was often mentioned as a strength making individuals with ADHD lively and dynamic, often exciting and fun to have around, and enabling them sometimes to get a lot of things done. Other positive characteristics often mentioned were flexibility, resiliency, perseverance, creativity and a generally optimistic attitude, as well as the ability to multitask and process input from various sources simultaneously. Experts described individuals with ADHD as passionate and having a strong drive for the things that interest and motivate them. This was said to make them persist and work hard on these things with a focus that can exceed that of others, and enables them to inspire and energise those around them. Furthermore, they were described as fast learners, fast thinkers and fast decision makers, unafraid to take risks, and not easily discouraged by obstacles. Towards others they were generally described as being sociable, caring, sensitive to the moods and feelings of others as well as loyal, noble and altruistic. It was generally felt that a requirement for these strengths and abilities to become apparent in ADHD is that individuals receive appropriate support or treatment for their needs. An overview of the abilities and strengths mentioned by the experts can be found in Table A majority of experts (65 %) identified gender differences. Of these more than ¾ reported that they had experienced these differences in their daily practice. The most frequently described difference was that males more often presented with the hyperactive/impulsive subtype and females more often presented with the inattentive subtype of ADHD. More specifically, males appear to present with more externalising behaviour problems, more bullying and aggressive behaviours, more social problems and problems with authority, and a greater tendency towards addictive behaviours and substance abuse. Females were reported to have more internalising problems like anxiety and depression, more often feel stressed and overwhelmed trying to live up to social expectations, have lower self-esteem, and more often show self-injurious behaviour and suicidal attempts. Females were also reported to make greater efforts, and to more succeed to hide their difficulties than males. As a consequence, males with ADHD were reported to be generally more readily recognised and diagnosed, in contrast to females whose symptoms and problems often remain unnoticed and where diagnosis occurs often later in life.The current study aimed to capture an expert perspective on the abilities and disabilities related to ADHD through a worldwide survey of ADHD experts from different professional and cultural backgrounds. The experiences and opinions of such a large and diverse group of ADHD experts have not previously been documented in this extensive way. Therefore, the results provide global and diverse insights into ability and disability related to ADHD.With a large number of ICF-CY categories identified across all of the components, the results support the notion that ADHD impacts on major areas of everyday life. From the Body functions component, nearly two-thirds of the identified categories are from chapter b1 mental functions. This finding is perhaps not surprising as ADHD is a mental health condition and thus is expected to affect primarily mental functions. Likewise, the only category in the Body structure component named by the majority of the experts was s110 structure of brain. However, the fact that no fewer than 19 different mental functions were indicated by at least 5 % of the experts shows that ADHD is experienced to affect a far broader composition of mental functions than the core behavioural domains of inattention (b140), impulsivity (b130) and hyperactivity (b147). Some physical functions were also included in the expert responses, suggesting that there are also physical challenges associated with ADHD. These concerned mostly sensory processing and motor-related functions. In the activities and participation component, all chapters except (d3) communication were represented in the selection. This suggests that activities and participation in all areas of life, ranging from managing oneself and everyday demands to relationships with others, education, employment, and recreation, are affected in ADHD. The same can be said about environmental factors, which are represented by categories from all of its chapters. It is important to note that environmental factors can represent both factors that are hindering (i.e. barriers) or helpful (i.e. facilitators) for the individual. For example, (e585) education and training services, systems and policies could be named by an expert as a facilitator when the school provides adequate support for the specific needs of the student with ADHD. However, the same category might represent a barrier when the school does not acknowledge ADHD or a child’s behavioural problems as a health condition. The same goes for the other categories identified in the Environmental factors component.This study is amongst the first to explore specific strengths and gender differences in ADHD as perceived by experts. Overall, the opinions proposed were too broad and inconsistent to derive meaningful concepts and link ICF categories. Thus, this aspect of the survey data was analysed in an exploratory way. Many experts reported both certain abilities linked to ADHD and phenotypes related to gender in ADHD. Whilst there is accumulating evidence indicating subtle, but important gender differences in ADHD , there in = 470). This can be explained in part by the fact that experts answered the survey questions using their own words and formulations. For the linking, this often presented a challenge since answers were sometimes very brief or ambiguous and, therefore, difficult to properly interpret and link (e.g. single word answers such as “familiarity” or “gadgets”). These types of answers were most commonly responses to the questions related to supportive and hindering Environmental factors. In other cases, answers were formulated in such general terms that no one specific ICF-CY category could be identified to represent them (e.g. “supportive environment” or “behaviour problems”). These were again often in response to the questions that captured the Environmental factors of functioning and impairment. However, a closer look at the not definable codes did reveal a few recurring themes. For example, a large proportion of the codes represent the level of structure and routine present in the environment.The survey did present some challenges. For example, there were many meaningful concepts in the expert responses for which no appropriate ICF-CY category could be identified. This resulted in a large number of not definable codes , whilst higher levels of structure were considered facilitators for individuals with ADHD (e.g. “clear structure” and “daily routine”).Another frequently recurring theme was distractions and overstimulation in the environment. These were named by experts as significant barriers to the functioning of individuals with ADHD . Finally, many of the not definable codes represented social and behavioural problems, such as “social awkwardness” and “behavioural control”.Another challenge in the interpretation of findings is the fact that categories in the Environmental factors component in the ICF(-CY) are formulated in a very general way. For example, the chapter (e3) support and relationships include categories that describe only the people or relationships that may represent facilitators or barriers for the individual, such as (e310) immediate family and (e355) health professionals. Unfortunately, the categories do not include any indication of how (relationships with) these people can be helpful or hindering to the individual. The same is true for (e115) products and technology for personal use in daily living, which includes no further description of these products and technologies or how they may be helpful or hindering to the person. This makes it difficult to draw any conclusions extending beyond saying that certain products and technologies used in daily life are helpful for individuals with ADHD. More detailed descriptions and further specifications of categories in the Environmental factor component in the ICF(-CY) would be helpful to create a more complete picture of how an individual’s level of functioning is shaped in relation to the environment. Challenges like these remind us that the current first edition of the ICF(-CY) originates rather from the field of physical than mental health and there is the potential for considerable improvement in relation to the assessment of functioning in the context of mental health problems.Whilst the current study provides a unique, global, multidisciplinary expert perspective on abilities and disabilities associated with ADHD, it cannot be assumed that it is complete, exhaustive or representative for all experts around the world. Even though experts included in the study represented a broad range of different professions and all six of the WHO regions, some professions had only limited representation and some were not represented in all regions. Moreover, the response rate of experts who were invited to participate in this study was modest. Therefore, it seems likely that the identified categories reflect at least in part the composition of those experts who were included. In part the composition of the sample reflects the fact that certain professions either do not exist in some parts of the world, or are not involved in the assessment and treatment of ADHD. For example nurses are not involved in ADHD treatment in India (SEARO region). Similarly, the diagnosis of ADHD is not yet known or not generally accepted or prioritised in some countries within certain regions, such as the Middle East (e.g. Afghanistan) and Africa (e.g. Ghana).The requirement for experts to be able to communicate in English will also have limited those who were able to take part in the study. Several experts were identified and invited to participate in the study, but declined due to not having sufficient English language skills required for completing the survey. This was mostly commonly an issue in regions where English is not commonly used in communication, e.g. South American countries in the AMRO region and Far-Eastern countries in the WPRO region. Specific efforts were, however, made to include at least some experts from these countries and regions in this study. The fact that an email survey was used to survey the experts represented a limitation in itself, both in terms of global reach (many low- and middle-income countries do not have easy access to internet), and because it was not possible to know whether experts interpreted the questions as intended. Extreme care was taken to formulate the survey questions in such a way as to facilitate participation of a broad range of participants. Finally, a technical limitation to the study resulted in 4 experts being unable to provide their responses to the survey due to problems opening and working with the files sent to them via email. However, due to the small number of participants being affected by these problems this is unlikely to have affected the study validity.It is important to see the findings of the current study within the context of the larger project. This is the second study in a total of four that will together inform the development of the ICF Core Sets for ADHD. The first, the comprehensive scoping literature review, aimed to capture the research perspective of ability and disability related to ADHD, and was published earlier . The cur


The aim of the aricle is to study the relationship between attachment, parental rearing behavior, and (infant and current) ADHD symptoms with emotion processing and alexithymia in adults with ADHD.n = 26) and a control group (n = 26). Comparisons were performed between the pooled ADHD groups and the control group, and between the ADHD subtype groups regarding all emotion processing and alexithymia, and attachment-related measures.Attachment, parental behavior, and ADHD variables were tested for predictive value regarding emotion processing and alexithymia in the total sample, the pooled ADHD groups (with inattentive type and combined type, each with Emotion processing/alexithymia parameters were mainly predicted by early or current attachment-related features, and, to a lesser extent, by childhood or current ADHD symptoms, primarily in the ADHD groups.The findings suggest partly specific and possibly causal relationships between attachment-related features and current emotion processing/alexithymia in adults with ADHD. The results confirm the necessity for further study of the multiple interactions between infant and parental ADHD symptoms, aversive parenting, and attachment with respect to emotional functioning in adult ADHD. The prevalence of ADHD in adulthood is estimated at approximately 4 % , 2. Coreolerance . Despiteolerance . Howeverolerance ).However, emotion dysregulation as the central feature of impaired emotion processing in ADHD may have other roots than ADHD-associated dysfunction of attention processes. Attachment, that is, how early mother–child bonding shapes interpersonal behavior in future relationships, has shown to have essential impact on current and future emotion regulation in neurobiological and developmental respect . Also inIn a previous study with adults with ADHD, we found associations between recalled parental, particularly maternal, ADHD and recalled adverse rearing behaviors on the one hand, and emotion dysregulation and current attachment problems on the other hand .To draw on these findings, the present study focused primarily on possible associations between attachment-relevant experiences in childhood, current attachment features, and infant/current ADHD symptoms on the one side, and current emotion processing facets/alexithymia on the other side.Emotion processing, comprising emotion identification, regulation, and response , has shoacceptance of own emotions and, to a lesser extent, for experience of being flooded with emotions [experiences of emotion regulation and self-control. This result was in line with the abovementioned finding that alexithymia may be associated with basic emotion processing deficits rather than higher-order emotion regulation dysfunction.In an earlier study on alexithymia, emotion processing, and social anxiety in adults with ADHD, we found close associations between the construct of alexithymia and other emotion processing features. Significant correlations with alexithymia were detected particularly for emotions . No suchBecause of the limited research on emotion processing and alexithymia in adults with ADHD we aimed to target these features in the present study. Possible relationships between attachment and emotion processing were studied in the main subtypes of ADHD, i.e., combined and predominantly inattentive types, vs. control subjects; Finzi-Dottan et al.  found thTherefore, assuming different qualities in early child–parent interactions, we expected distinct attachment-relevant experiences and styles and thus different emotion processing features in subtype groups. Moreover, we hypothesized that the ADHD group and the control group would differ significantly in some of the emotion processing, alexithymia, and attachment variables. Above all, we expected that emotion processing and alexithymia were markedly and significantly predicted by attachment measures and (attachment-related) parental rearing behavior. Since we found a significant impact of childhood ADHD symptoms on trauma severity in traumatized adults with ADHD in a recent study , we addeSeventy-eight German adults were included in the study: 26 patients with ADHD-combined type, 26 patients with ADHD-predominantly inattentive type, and 26 healthy controls. Patients with ADHD were randomly recruited from our outpatient unit for adults with ADHD. These patients were distinct from those we had recruited for the abovementioned similar study . The conr = 0.85) and an excellent internal consistency (α = 0.91). WURS-k scores at the cutoff of 30 indicate childhood ADHD with a sensitivity of 85 % and a specificity of 76 %. Current ADHD symptoms, i.e., the domains of inattentiveness, hyperactivity, and impulsivity, were examined by means of the ADHD Diagnostic Checklist (ADHD-DC) and the ADHD Self-Rating Scale (ADHD-SR) [To assess childhood ADHD symptoms retrospectively we used the short version of the Wender Utah Rating Scale (German WURS-k) . WURS-k ADHD-SR) . These tADHD ratings were performed in the control group as well, but did not reveal any full ADHD diagnoses. Moreover, the SCID I/II  for comoSkala zum Erleben von Emotionen, which can best translated as Experience of Emotions Scale (EES) [acceptance of own emotions, experiencing being flooded with emotions, experiencing lack of emotions, experiencing body-related symbolization of emotions, experiencing imaginative symbolization of emotions, experiencing emotion regulation, and experiencing self-control. The EES allows for the assessment of a person’s attitudes toward her or his emotions. It has shown good internal consistency, excellent retest reliability, and sufficient convergent and divergent validity. We excluded the two (body-related and imaginative) symbolization-of-emotions measures and the subscale experiencing lack of emotions. The four most suitable EES subscales to serve as dependent variables, covering important facets of emotion processing, were acceptance of own emotions, experiencing being flooded with emotions, experiencing emotion regulation, and experiencing self-control.We assessed emotion processing using two self-report instruments. First, we applied the German le (EES) . This inSecond, we used the 20-item Toronto Alexithymia Scale (TAS-20), which examines difficulties in differentiating and describing emotions . The TASBeziehungsspezifische Bindungsskalen für Erwachsene, which can be translated as Relationship-Specific Attachment Scale for Adults (RASA), a questionnaire for the assessment of current attachment styles with regard to the mother and the intimate partner [secure vs. anxious and dependent vs. independent. The instrument has shown to have excellent specificity regarding the attachment partner (mother or intimate partner), good reliability and efficiency, and good convergent and divergent validity.First, attachment features were assessed by using the German  partner . The RASα = 0.72–0.79) and good convergent and divergent validity.Second, we applied the German version of the Adult Attachment Scale (AAS), a self-report instrument, which reflects attachment-related attitudes, to measure to what extent a person feels (1) comfortable with closeness and intimacy, (2) comfortable being dependent on others, and (3) anxious about rejection or abandonment . The AASTo study recalled parenting, we used the German version (FEE) of the Questionnaire of Recalled Parental Rearing Behavior (QRPRB) , originap < 0.01.Statistical analyses were performed with SPSS version 22.0 for Mac. We calculated ANOVAs and two-tailed t-tests for independent samples for group comparisons of interval scale data, the Kruskal–Wallis test and Chi-Square tests for group comparisons of nominal scale data, and linear regression models with backward elimination of variables, with emotion processing and alexithymia measures as dependent variables, and scales on attachment, recalled parenting, and (infant and current) ADHD symptoms as independent variables. Moreover, sex, age, education, and group entered the regression analyses as independent co-variables, in order to control for any impact on the dependent variables. Because of multiple comparisons the level of statistical significance was set at acceptance of own emotions was explained by a regression model, comprising secure (vs. anxious) attachment in relation to partner, education, and group  and measures reflecting recalled parental rejection and punishment (QRPRB)  , fitted best to Experiencing emotion regulation in the entire sample emerged as predicted best by a set with several attachment parameters, recalled parental behavior variables, ADHD symptoms in childhood and adulthood and educational level (51 % of the variance explained)   in relation to mother (RASA), feeling comfortable with closeness and intimacy (AAS), current hyperactivity (ADHD-SR), current impulsivity (ADHD-SR), and current ADHD symptomatology in total (ADHD-SR).Experiencing self-control was strongly predicted by childhood and current ADHD symptoms, and by two attachment-associated variables and methylphenidate medication. These seven variables explained 49 % of the variance of the dependent variable  in the whole sample by secure (vs. anxious) in relation to partner (RASA), anxiety about rejection and abandonment (AAS), and emotional warmth of father (QRPRB) (see Table feeling comfortable with closeness and intimacy (AAS) and emotional warmth of mother (QRPRB)  with non-significant differences between ADHD subgroups for all comparisons, and significant differences between the ADHD subgroups and the control group for most comparisons. Significant differences (at p < 0.01) between ADHD patients and controls were found for acceptance of own emotions, experiencing being flooded with emotions, but not for experiencing emotion regulation and experiencing self-control. Acceptance of own emotions was significantly lower , and experiencing being flooded with emotions was significantly higher  in the pooled ADHD group. Moreover, ADHD and control groups differed significantly in secure (vs. anxious) in relation to the mother or the partner, respectively (RASA), but not in dependent (vs. independent) in relation to the mother or the partner, respectively. Furthermore, significant group differences emerged with respect to all three AAS variables  and in the TAS-20 total score.Post-hoc Student–Newman–Keuls analyses for multiple comparisons revealed subsets , alexithymia (TAS-20), attachment, , or recalled parenting (QRPRB), respectively.The present study sought to investigate the impact of parenting behaviors, attachment features, and (infant and current) ADHD symptoms on emotion processing and alexithymia in the whole study sample, the pooled ADHD group (that is the combination of subtype groups) and the control group. Moreover, the study was concerned with differences in recalled parental rearing behavior, attachment traits, emotion processing, and alexithymia between the pooled ADHD group and a healthy control group, and between the ADHD subtype groups.As our main finding, emotion processing and alexithymia measures in the whole sample and particularly in the pooled ADHD group, but not in the control group, were predicted, in part, by attachment-related variables, and, to a lesser extent, by childhood and current ADHD symptoms and other variables.acceptance of own emotions on the other. Furthermore, the impact of the covariate education on the acceptance of own emotions was more pronounced with respect to the pooled ADHD group than regarding the total sample—possibly because of a weak self-esteem of the ADHD patients related to lower graduation. Notably, ADHD symptoms did not have any impact on the acceptance of own emotions.On closer examination, the acceptance of own emotions was predicted primarily by features of anxious and dependent attachment and recalled parental rejection and punishment in the pooled ADHD group, to a lesser extent in the total group, but not in the control group. This suggests an ADHD-specific relationship between attachment-related facets including early aversive parental behavior on the one hand and Experiencing being flooded with emotions was associated with several attachment-related measures, both in the pooled ADHD group and the total group. However, also ADHD symptoms in childhood and, with respect to the pooled ADHD group, current symptoms of inattention, had an impact on the feeling to be flooded with emotions. Again, the relationship between attachment features and the emotion processing measure appeared to be closer in the ADHD group than in the whole sample, and no such relation was found in the control group, which also might indicate an ADHD-specific association.Experiencing emotion regulation was also predicted by both attachment and ADHD parameters. However, the impact of attachment on emotion regulation did not stand out as ADHD-specific, which is in accordance with findings that suggest a general association between the two domains. Empirical research has demonstrated overall that children who have secure attachment histories with their mothers regulate their emotions more effectively than do children with insecure histories [istories .experiencing self-control emerged to be predominantly explained by current ADHD symptomatology, which was the case in the pooled ADHD group as well as in the whole sample, but not in the control group. In the pooled ADHD group, furthermore, childhood ADHD symptoms and methylphenidate medication had an impact on experiencing self-control.The prediction of Alexithymia as a dependent variable was exclusively explained by attachment parameters and attachment-related measures , but not by ADHD symptoms, in the total sample as well as in the ADHD group, but not in the control group. This might, once more, indicate a specific relationship between attachment and alexithymia in adults with ADHD. However, despite missing associations between ADHD symptoms and alexithymia in this study, impaired cognitive and particularly verbal abilities generally may contribute to alexithymia in ADHD.acceptance of own emotions was significantly lower, and experiencing being flooded with emotions was significantly higher in the pooled ADHD group than in the control group. Increased experiencing being flooded with emotions in the ADHD group corresponds to Wender’s abovementioned additional symptom domains of ADHD  [Per group comparison, we expectedly found significant differences between the pooled ADHD group and the control group with respect to the most of the emotion processing/alexithymia and attachment-related measures. In terms of emotion processing, particularly lerance) . Empiriclerance) . This filerance) , 30.experiencing emotion regulation and experiencing self-control. This finding might be owed to a leveling between groups through lower introspection or awareness of deficits and thus exaggeration of these rather meta-cognitive/mentalizing-dependent aspects and skills in the ADHD patients. On the other hand, the unexpected effect may be explained by overstatement of own emotion regulation and self-control capabilities as a defense strategy to protect self-esteem against critical or challenging phrasing in the questionnaire concerning profound deficits in ADHD.Since most patients with ADHD report an everyday struggle for control in various situations and efforts to regulate their emotions, it was counterintuitive for us that we did not find any significant group differences with regard to Alexithymia, measured by the TAS-20 total score, was significantly higher in the ADHD group. This finding contrasts with our results from an earlier study, which yielded TAS-20 scores in adults with ADHD that were similar to values in general population samples .fearful attachment style as the main domain (44.4 %), followed by preoccupied (27.2 %) and dismissive (9.9 %) styles. However, the preoccupied attachment style, which is also denoted as an enmeshed or ambivalent style, typically involves dependent behavior in relationships [With respect to attachment-related features, the pooled ADHD group and the control group differed significantly in all variables concerning recalled parental rearing behavior and in the actual attachment measures (including secure/anxious attachment in relation to the mother and the partner)—except dependent/independent attachment style in relation to the mother and the partner, respectively. The finding of significantly less attachment security/more attachment anxiety in the ADHD subtype groups is supported, in part, by the results of Koemans et al. . The autionships –34, a trHowever, we did not find any differences between the two ADHD subtype groups regarding emotion processing, alexithymia, and attachment-related measures. This was an unexpected result because, following the findings of Finzi-Dottan et al.  and MaedThe present study has several limitations. For one thing, the control group was not well matched. Second, the study exclusively relied on subjective report and recall in adults with ADHD, so it cannot be ruled out that the lack of objective information biased the evaluation to considerable degree. Third, the WURS-k, which was used to assess overall ADHD symptoms in childhood, cannot distinguish between the main ADHD symptom domains. Therefore, information whether infant and current ADHD symptoms have comparable impact on EP was not accessible.However, the results do suggest that (adverse) parental rearing behavior and attachment features and, to a lesser extent, childhood and current ADHD symptomatology might, in part, specifically underlie emotion processing and alexithymia in adults with ADHD. Counterintuitively, the pooled ADHD group and the control group did not show any difference concerning experiencing emotion regulation and self-control, and regarding a dependent attachment style. Moreover, the two ADHD subtype groups did not differ in any of the emotion processing/alexithymia and attachment-related features. The results corroborate the necessity for further study of the multiple interactions between infant and parental ADHD symptoms, aversive parenting, and attachment with respect to emotional functioning in adult ADHD.


Only one patient had received medication for ADHD. T1-weighted brain scans were acquired and processed in a voxel-based analysis using permutation-based statistics. A sub-sample of both groups  also performed a Sternberg working memory task whilst acquiring fMRI data. Areas of structural difference were used as a region of interest to evaluate the implications that structural abnormalities found in the ADHD group might have on working memory function. There was lower grey matter volume bilaterally in adolescence ADHD participants in the caudate (p < 0.05 FWE corrected across the whole brain) at age 20–24. Working memory was poorer in adolescence ADHD participants, with associated failure to show normal load-dependent caudate activation. Young adults diagnosed with ADHD in adolescence have structural and functional deficits in the caudate associated with abnormal working memory function. These findings are not secondary to stimulant treatment, and emphasise the importance of taking a wider perspective on ADHD outcomes than simply whether or not a particular patient meets diagnostic criteria at any given point in time.When adolescents with ADHD enter adulthood, some no longer meet disorder diagnostic criteria but it is unknown if biological and cognitive abnormalities persist. We tested the hypothesis that people diagnosed with ADHD during adolescence present residual brain abnormalities both in brain structure and in working memory brain function. 83 young adults (aged 20–24 years) from the Northern Finland 1986 Birth Cohort were classified as diagnosed with ADHD in adolescence (adolescence ADHD,  Attention deficit/hyperactivity disorder (ADHD) –4 was inAlthough the precise neural and pathophysiological substrates of ADHD remain unknown, there is evidence that indicates abnormalities in fronto-striatal and limbic pathways –16. HoweA variety of different outcome measures are important when considering the long-term prognosis of children diagnosed with ADHD. Relevant and important follow-up outcomes include whether or not individuals continue to meet diagnostic criteria for ADHD, the number and severity of ADHD symptoms they retain, the presence of comorbid psychiatric illness, social and occupational outcomes, and neurological and neuropsychological outcomes, including brain structure and function and associated cognitive performance or deficit , 17–20. This study aims to investigate young adult brain structural and functional (in terms of working memory) outcomes of people diagnosed with ADHD during adolescence using a general population-based methodology. The general population-based nature of our study helps us examine ADHD with less, or possibly different, selection biases, compared to the average study of ADHD. Clinical practice in Northern Finland at the time our participants were diagnosed with ADHD did not rely on stimulant medication in the treatment; this enabled us to avoid the potentially confounding effects of medication from the results, as only one subject was taking ADHD medication at the time of the scans and no other participants had been treated with stimulants previously. We hypothesised that there would be residual brain structural, brain functional and working memory deficits in young adults who had been diagnosed with ADHD in adolescence.http://kelo.oulu.fi/NFBC). Parents of cohort members were asked to complete the Strengths and Weaknesses of ADHD Symptoms and Normal Behaviours (SWAN) questionnaire [Fifty two young adults who had been diagnosed with DSM-IV ADHD at age 16–17 (henceforth “adolescence ADHD”) and 34 young adult controls without ADHD gave written consent and took part in the study, which was approved by the ethical committee of the Northern Ostrobothnia Hospital District, Finland. All participants were members of The Northern Finland 1986 Birth Cohort (NFBC1986) and were all aged 20–24 at the time of the study. We have previously published details of how adolescents with ADHD were identified within the birth cohort in a general population-based approach , and we ionnaire  at age 1ionnaire –28, 31. Cohort members with ADHD at age 16–18 (adolescence ADHD), and a sample of the controls without ADHD identified at age 16–18, were, several years later, invited to participate in the current study performed in 2007–2010 at Oulu University Hospital, Finland. Of the 105 adolescence ADHD individuals, and therefore eligible to participate in this study, 52 (50 %) were scanned, along with 34 controls. Out of the 52 scanned adolescence ADHD participants, 3 participants were excluded due to one having developed comorbid bipolar disorder, another schizophrenia and another a clinically significant head injury (a skull fracture) by the time of the study. The final study size for the structural MRI was 49 young adult participants with adolescence ADHD.The exclusion criteria used for both groups were mental retardation according to the Finnish Hospital Discharge Register or previous studies on this cohort; autism-spectrum disorders; speech development disorder with evident cognitive sequelae; psychotic disorder, or serious neurological conditions such as epilepsy, serious head injury or multiple sclerosis.On the day of the MRI scan, participants were evaluated with a clinical assessment, including urine drug screen, SCID  and, in addition, an in-house developed interview to rate the severity of ADHD symptoms in detail. This interview used both DSM-IV and ICD-10 ADHD criteria, allowing scoring on a list of 9 attention, 5 hyperactivity and 4 impulsivity symptoms. Diagnostic assessment was made according to DSM-IV criteria. Clinical answers to the incidence of the 9 inattentive, 5 hyperactivity and 4 impulsivity symptoms were labelled according to frequency of the symptoms and were defined as never/rarely, sometimes, often and very often. Scores ranging from 0 to 3 were attached to this frequency scale. Any score of two or three (often or very often) was deemed to be a positive clinical correlate of that symptom.All participants were scanned using GE Signa EchoSpeed HDx 1.5 Tesla MRI scanner in Oulu University Hospital. T1-weighted images were acquired with inversion recovery (IR)-prepared (“BRAVO”) 3D Fast Spoiled Gradient Echo (FSPGR) sequence using the following parameters: TR 12.4 ms, TE 5.2 ms, FA of 20°, FOV 24 cm × 24 cm, 256 × 256 acquisition matrix, 1 mm slice thickness, half k-space coverage in the phase encoding direction . Structural data were analysed with FSL-VBM, a voxel-based morphometry style pipeline analysis –40. We up < 0.05, family-wise error corrected for multiple comparisons across voxels using the threshold-free cluster-enhancement (TFCE) option in the randomise permutation-testing tool in FSL, which results in fundamentally voxelwise statistics whilst also taking into consideration the size of clusters of significant contiguous groups of voxels. To help interpret the importance of any structural deficits, we planned to utilise the group difference results of the structural analysis to create a region of interest in which we could examine whether there were also functional brain imaging abnormalities in the adolescence ADHD group (see below).For the between-group comparisons, between-group statistics were performed using a permutation-based inference tool for nonparametric statistical thresholding in FSL’s randomise Monte Carlo permutation toolkit using 5000 permutations , with agA random sub-sample of approximately two-thirds of the individuals participating in the structural scans also undertook fMRI scans on the same day using the same scanner as the structural scan using an EPI GRE sequence . We ran this sequence in the two separate runs. The first 4 volumes were removed from each run because of T1 equilibrium effects. Finite resources prevented us from conducting fMRI on all participants.We employed a Sternberg task of working memory  during tThere were four different levels of difficulty, corresponding to four different loads of three, four, five and six letters, interspersed pseudo-randomly across the entire task. The task was divided in two runs, each with thirty-six trials, given a total of seventy-two trials for the whole task. The total duration per run was 10.3 min.We excluded participants with low levels of accuracy from the fMRI analysis to ensure that the subjects whom we did analyse were genuinely and successfully utilising working memory. We applied an accuracy rate that required an accuracy rate of at least 75 % correct trials , so any Functional analyses were performed using the “Analysis Group at the Oxford Centre for Functional MRI of the Brain” (FMRIB) software library (FSL) tools , 44–46. FSL’s FMRI expert analysis tool (FEAT)  was usedDemographics are detailed in Tables p < 0.05 FWE corrected, controlled for age at time of scan, sex, and handedness; Figs. There were significant differences in two clusters located in the left and right caudate, respectively, that had lower grey matter volume in the adolescence ADHD group when compared to controls (n = 21) was 62.76 (SD 4.43) and for the control group (n = 23) it was 66.87 (SD 2.32) , showing that even when only considering participants who were engaging in the task largely successfully, the adolescence ADHD group performed worse than controls. There were very few missing answers, with no differences between groups; the ADHD group had on average 0.67 (SD 1.06) missing answers and the controls had 0.17 (SD 0.49), p = 0.19.There were 11 participants out of 32 who scored below 75 % of the total score in the adolescence ADHD group and one subject out of 24 in the control group; these participants were all excluded from the fMRI analysis. The total score for the remaining adolescence ADHD group ; the ADHD group, however, failed to showed increased activation at higher working memory loads . In both left and right ROIs, there was a group difference of marginal significance in the strength of the linear association across loads . A summary measure of right caudate load-dependent activation  predicted memory performance in controls  but not in patients .We used the left and right caudate regions in which we had observed structural brain differences as masks in which to investigate functional group differences. For each run, we extracted the percent signal change for each load from each participant with FSL-featquery; for each load we then, for each participant, averaged across the two runs and plotted the group differences Fig. . This int = 1.1, df = 29, p = 0.3); or in left caudate volume  t = 0.44, df = 47, p = 0.66) or in right caudate volume ; and there were no differences in fMRI caudate measures: left caudate load-dependent activation current ADHD mean score 0.08, SD 0.07; former mean score −0.03 SD 0.18, t = 1.0, df = 19, p = 0.34; right caudate activation current ADHD mean score 0.05, SD 0.07; former mean score −0.01, SD = 0.18; t = 0.58, df = 19, p = 0.57).To assess whether the group difference was driven by large abnormalities in the small group who continued to meet diagnostic criteria, we compare memory performance and brain structural and functional measures in the current ADHD versus former ADHD participants. There were no differences in memory score  or functional measures . There were no associations between current GAF and brain structural  or functional measures . There were no associations between the number of symptoms in adolescence and the adult structural or functional measures .Within the adolescence ADHD sample, there were no associations between current number of symptoms and brain structural measures  recognised that adults require less symptoms to meet diagnostic criteria than children. The percentage of patients who continued to meet DSM-IV diagnostic criteria in our study is similar to the meta-analysis of Faraone and colleagues , but smaThe structural abnormalities we found provide strong evidence that the caudate is abnormal in ADHD. Previously there has been inconsistent evidence of the structural deficits observed in the caudate for non-medicated people with ADHD. While some groups have established a decrease in caudate volume in children with ADHD , 11 otheWorking memory impairments were present in adulthood in people diagnosed with ADHD in adolescence, even if formal diagnostic criteria are no longer met. The group differences we observed in working memory were not simply secondary to the ADHD group failing to engage in the task, as even when we excluded poor performers and limited to the analysis to participants who were scoring correct answers on the vast majority of trials, correct answers were still significantly less than in controls.Consistent with the working memory performance abnormalities observed in adults diagnosed with ADHD in adolescence, we also showed that caudate activation during task performance was abnormal. Whilst we found load-dependent working memory activation in both left and right caudate in controls, there was no load-dependent activation in the adolescence ADHD group. Load-dependent activation in the right caudate predicted working memory performance in controls but not in patients.The caudate has long been implicated in a working memory network that supplies support functions related to the prefrontal cortex , 51. SpeThere are aspects of our work that are both strengths and limitations: as the participants were recruited from the general population they will differ in certain respects from patients with severe ADHD recruited from specialist clinics. As both the adolescence ADHD group and controls were drawn from the same population-based birth cohort, they are matched in place of birth, and age, and will have been exposed to many similar environmental influences. Our control group was representative of the general population in being balanced in representation from males and females, whereas adolescence ADHD participants were mainly male. However, group differences in brain structure and cognitive performance persisted after controlling for gender. Our study shows that there are important residual deficits in young adults diagnosed with ADHD during adolescence in caudate volume, in working memory performance and associated caudate functional activity. The current work also benefits from a population sample that is, save for one participant, ADHD stimulant medication naïve, proving that the results are not driven by stimulant medication treatment: we are not aware of any similar studies previously published. The sample size of 83 participants (49 with an adolescence diagnosis of ADHD) is modest by the standards of epidemiology and some other research methods; however, a previous study with a smaller sample size (12 patients and 12 controls) was able to demonstrate that medicated patients with ADHD in childhood that persisted to adulthood had widespread fronto-parietal deficits as measured with fMRI during response inhibition . We did Although people diagnosed with ADHD in adolescence may recover clinically sufficiently to no longer meet diagnostic criteria, they may continue to manifest abnormalities in caudate structure and function and working memory performance in early adulthood. The results emphasize the importance of taking a wider perspective on ADHD outcomes than simply whether or not a particular patient meets diagnostic criteria at any given point in time.


Knowledge and use of self-presentational tactics is an important social skill. We examined understanding of the function of three different self-presentational tactics  in 11 8–12-year-old boys with attention-deficit/hyperactivity disorder (ADHD) and 11 matched comparison children. Children were given six different self-presentation stories, two for each one of the three different tactics. After each story, they were asked to evaluate the effects of the self-presentational tactic used. Children with ADHD rated self-promotion and blasting as more positive and more effective—and ingratiation as less positive and less effective—than children in the control group. This implicates that children with ADHD prefer simple and direct self-presentational strategies (like self-promotion), and, therefore, may not as easily understand more subtle strategies (like ingratiation). They also seem to be more inclined to use negatively connoted strategies (like blasting). We suggest that this limited understanding of self-presentational strategies in children with ADHD may explain some of their problems in social interactions. Therefore, social skill interventions in children with ADHD should incorporate elements focusing on use and understanding of different self-presentational strategies. Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent neurobehavioural disorder that occurs in 3–7% of children. The aetiology of ADHD is believed to be multifactorial including genetic, biological and neuropsychological factors. ADHD comprises two separate domains of symptoms: inattention and hyperactivity–impulsivity. Based on these two domains, the Diagnostic and Statistical Manual of Mental Disorders  and ingratiation and blasting as indirect self-presentational strategies : self-promotion is directly linked to the desired social outcome . By contrast, the self-enhancing function of blasting works indirectly . Also, when people use ingratiation, the desired social outcome (being perceived as likable) is achieved indirectly through a positive social evaluation (due to other-enhancing comments). In addition, self-promotion and blasting can be viewed as rather obvious self-presentational tactics because of their apparent self-enhancing function. By contrast, ingratiation can be considered as a rather sophisticated and less obvious tactic.Other well-known self-presentational tactics used to convey a positive self-image include modesty , excuses (denying responsibility for negative events) and disclaimers (explain negative events before they occur).In typically developing children, use and understanding of impression management tactics  develop during middle childhood at around 8 years of age  took part in this study. Eleven boys with ADHD were recruited through a practice of a child psychiatrist, and 11 boys without ADHD were recruited through after-school child-care centres. All participants with ADHD met DSM-IV criteria for ADHD . The boys without ADHD were between 96 and 152 months . The two groups did not differ in age, t(20) = .31, p = .76. Parents received full information about the study. Informed parental consent was obtained for all children who participated in the experiment. Boys in the age-matched control group were excluded if they showed clinically significant scores on the ADHD-Rating Scale-IV . The self-presentation stories had a similar format as the ones used by Watling and Banerjee . ChildreStory content and the self-presentation tactic statement used were counterbalanced. Stories were presented in a fixed order. However, the self-presentation statement used in each story varied between children. Children always heard stories with protagonists matching their own gender, that is, all protagonists were boys.The protagonist was a child, who has just moved to a new school and wanted another character to select him for some team activity. To this end, the protagonist uttered either an ingratiating statement , or a self-promotion statement , or a blasting statement .inclusion judgement; rated on a four-point scale: definitely will not, probably will not, probably will and definitely will, scored 0–3); and (2) how nice the other character would think the protagonist was .After each story, participants had to evaluate the self-presentational tactic used by the protagonist . In line with Watling and Banerjee , childreFor each pair of stories using the same self-presentation tactic , the inclusion and character judgement scores were summed across the two stories. Therefore, for each self-presentation tactic, children received a score from 0 to 6 for the inclusion judgement as well as for the character judgement. Higher scores indicated a greater likelihood of being selected for the team or being judged as nice.justification). Children's answers were coded into one of five categories, following the coding scheme of Watling and Banerjee .Social outcome: Reference to a concrete goal or purpose of the protagonist's statement .Others' feelings: Reference to others' feelings Truth: Reference to the “true” state of affairs, that is, characterizing the protagonist's statement as a description of reality Residual: Any other response In addition, children were asked to justify why the protagonist said what he did .t-tests with re-sampling methods were used because of their robustness against small samples. By bootstrap analysis with 1000 replicates, the bounds for the 95% confidence interval were determined. Significance was determined if the confidence interval did not include zero.All analyses were realized on the SPSS program, version 22.0, with a 5% level of significance. Owing to the small sample size, Table inclusion question was analysed with a 3 × 2 mixed design analysis of covariance (ANCOVA), with the self-presentational tactic  as the within-participants factor, group (ADHD vs. control) as a between-participants factor and age as a covariate. Age was used as a covariate, because we did not expect age differences based on previous research; Watling and Banerjee  = 10.31, MSE = .391, p = .005, with children in the ADHD group offering higher inclusion judgements than children in the control group. The main effect was further qualified by a significant group × tactic interaction, F = 12.27, MSE = .389, p < .001. There was no significant main effect of tactic. Moreover, there was no significant effect of or interaction with age.This ANCOVA revealed a significant main effect of group, M = 2.45, SD = .41) than by the ADHD group , t(20) = 2.07, p = .052, d = .89. By contrast, self-promotion was rated as more effective by the ADHD group  than by the control group , t(20) = 2.52, p < .05, d = 1.07. In fact, control children viewed ingratiation  as more effective than self-promotion , t(10) = 6.17, p < .001, d = 2.47, whereas children with ADHD did not differentially evaluate these two strategies, t(10) = .12, p>.05. The sharpest group difference was evident on the blasting tactic: children with ADHD rated this strategy as far more effective  than children in the control group , t(20) = 6.23, p < .001, d = 2.68. This suggests that children with ADHD evaluate the different interpersonal consequences of different self-presentational tactics in a different way.The significant interaction between group and tactic was due to a different evaluation of all three tactics in the two experimental groups: in terms of the likelihood of being included in the team, ingratiation was rated as more effective by the control group  = 12.29, MSE = .304, p = .002, with children in the ADHD group giving higher character judgements than children in the control group. There was also a significant main effect of tactic, F = 4.08, MSE = .244, p < .05, with children in both groups giving the highest character judgements in the ingratiation stories and the lowest character judgements in the blasting stories. In addition, there was a significant group × tactic interaction, F = 12.46, MSE = .244, p < .001. There was no significant effect of or interaction with age.Performance on the t-tests showed significant (or approaching significant) differences between the two experimental groups for each self-presentational tactic on the character judgement. Similar to performance on the inclusion question, ingratiation was rated more positively  by the control group than by the ADHD group. However, this difference was not significant, t(20) = 1.75, p < .10, d = .75. By contrast, self-promotion, t(20) = 3.50, p = .002, d = 1.49, and blasting, t(20) = 5.16, p < .001, d = 2.20, were rated more positively by the ADHD group than by the control group  = 80.22, MSE = .81, p < .001 , for the number of social outcome justifications, F = 13.36, MSE = 1.77, p = .002  and for the number of others' feelings justifications given, F = 6.13, MSE = .13, p = .023 . That is, children with ADHD offered more social outcome justifications and fewer social evaluation justifications than children in the control group. In contrast to the control group, they did not refer to others' feelings. However, four children with ADHD, but none in the control group, referred to “truth” as an explanation for the protagonist's behaviour; though this effect was not statistically significant.Children's justifications of the protagonist's self-presentational statement also varied in the two experimental groups Table . A multiThe main goal of this study was to examine how children with ADHD evaluate different self-presentational tactics , and it was found that children with ADHD show a distinctive pattern of self-presentational understanding. They consistently rated self-promotion and blasting as more positive—and ingratiation as less positive -—than children in the control group. This effect was evident on an inclusion judgement (“How likely is it that the protagonist will be selected for the team?”) as well as on a character judgement (“How nice will Max think that the protagonist is?”). Nevertheless, similar to Watling and Banerjee , Exp. 1,In a similar vein, when asked to justify the protagonist's statement, children with ADHD used less sophisticated explanations. While children in the control group offered mainly social evaluation justifications, children with ADHD gave mainly social outcome justifications for the different strategies, suggesting that they focus on immediate, but superficial effects of self-presentational behaviour. Owing to their working memory and inhibition problems, children with ADHD may not thoroughly reflect on possible effects, and may instead respond impulsively by selecting any plausible strategy that could work. This may prevent them from understanding how different self-presentational tactics create different impressions. In other words, children with ADHD may simply take each self-presentational strategy as one of the various, but equally plausible, means for obtaining a desired goal .In sum, our study shows that children with ADHD rate simple, obvious tactics (like self-promotion and blasting) as more effective than control children; children in the control group viewed these tactics, especially blasting, as quite ineffective strategies. This differential evaluation of self-presentational strategies may be a consequence of the working memory impairments  should be combined with observational measures of self-presentational behaviour in everyday peer interactions; as the latter may be more sensitive to performance deficits.Further research might also focus on use and understanding of self-presentational tactics in the different ADHD subtypes, because, as suggested by Wheeler and Carlson , skill (Concerning treatment approaches in children with ADHD, our findings tentatively suggest that interventions designed to improve the understanding of more subtle and indirect self-presentational tactics should be pursued. The more so as childhood social skill deficiencies and peer-relationship difficulties have been linked to later adjustment problems, delinquency and psychopathology (e.g., Cowen, Pederson, Babigian, Izzo, & Trost,