After controlling for the other informant, parent-ratings of ADHD symptoms in both early and late adolescence significantly predicted academic and occupational failure, criminal convictions and traffic-related injuries, while self-ratings of ADHD symptoms only in late adolescence predicted substance use disorder and academic failure. Our findings suggest that both parent- and self-ratings of ADHD symptoms in adolescence provides valuable information on risk of future adverse socioeconomic and health outcomes, however, self-ratings are not valuable once parent-ratings have been taken into account in predicting most outcomes. Thus, clinicians and researchers should prioritize parent-ratings over self-ratings. There is scarcity of research investigating the validity of self-report of attention deficit hyperactivity disorder (ADHD) symptoms compared to other informants, such as parents. This study aimed to compare the predictive associations of ADHD symptoms rated by parents and their children across adolescence on a range of adverse socioeconomic and health outcomes in early adulthood. Parent- and self-rated ADHD symptoms were assessed in 2960 individuals in early (13–14 years) and late adolescence (16–17 years). Logistic regression analyses were used to compare the associations between parent- and self-rated ADHD symptoms at both time points and adverse life outcomes in young adulthood obtained from Swedish national registries. Both parent- and self-ratings of ADHD symptoms were associated with increased risk for adverse outcomes, although associations of parent-ratings were more often statistically significant and were generally stronger  contains supplementary material, which is available to authorized users. Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that can have debilitating effects on individuals throughout the lifespan. Clinical and population-based studies have repeatedly shown that both ADHD diagnoses and elevated ADHD symptoms are associated with increased risk of experiencing serious life outcomes, such as educational and occupational difficulties, traffic injuries, criminal convictions and other psychiatric disorders –5. DevelChildhood ADHD has an estimated prevalence of 5.3% (95% CI: 5.0–5.6%) worldwide and often persists into adulthood where the prevalence rate is around 2.5% (95% CI: 2.1–3.1%) . While pd = 0.60) than self-ratings  [There is scarcity of research that has studied how well parent- and self-ratings of ADHD symptoms in adolescence predict adverse socioeconomic and health outcomes in adulthood. This is an essential issue to investigate, as prevention of serious outcomes later in life is an important task for clinicians working with ADHD. Results from a study using a clinical adolescent ADHD sample found that low academic achievers, compared to high academic achievers, displayed more ADHD symptoms, although group differences were larger for parent-ratings  . Another = 0.26) . The stu = 0.26) . A majorProspective studies have shown that ADHD in childhood predicts later adverse life outcomes , 11, 12,In this longitudinal, population-based study, we aimed to examine the predictive associations of parent- and self-ratings of ADHD symptoms in adolescence on assessments of adverse socioeconomic and health outcomes from Swedish national registries. We aimed to (1) compare how well parent- and self-ratings of ADHD symptoms assessed in early and late adolescence predict academic, occupational, social and psychiatric outcomes in young adulthood and (2) examine whether parent- and self-ratings of ADHD symptoms independently predict these outcomes over and above the other informant, to examine whether the source informants provide any unique information. We predicted that parent-ratings of ADHD symptoms would more strongly predict adverse life outcomes than self-ratings based on previous research suggesting that parent-report of ADHD in adolescence has greater construct and concurrent validity.N = 12; obtained from the Cause of Death Register) or emigrated  before or during year 2009, when registries were last updated, were excluded from analyses.This study used data from the Twin Study of Child and Adolescent Development . The tarIndividuals and one of their parents were assessed at two separate time points via mailed questionnaires; at age 13–14 years, 1063 (73%) parents and 2263 (78%) adolescents responded, and at age 16–17 years, 1067 (74%) parents and 2369 (82%) adolescents responded, with a majority of parent-rated information supplied by mothers. Informed consent was appropriately obtained and each wave of data collection was approved separately by the ethics committee of Karolinska Institutet, Stockholm, Sweden.r) between parent- and self-rated symptoms was 0.36 (p < 0.001) at 13–14 years and 0.37 (p < 0.001) at 16–17 years of age, which is consistent with previous research [p < 0.001) and for self-ratings over time was 0.56 (p < 0.001).Parent-ratings consisted of 11 items from the Attention problem (AP) Scale of the Child Behavior Checklist (CBCL) and self-ratings consisted of nine items from the same AP Scale from the Youth Self-Report form (YSR) , 17. Theresearch , 21. TheData on life outcomes were derived through linkage of nationwide population-based registers in Sweden; unique personal identification numbers enabled accurate linkage . The NatThe academic variable was operationalized as not completing 2 or more years of higher (post-secondary) education, which was coded as a binary outcome , and was obtained from the Education Register .The occupational outcome was operationalized as receiving unemployment benefits, which was coded as a binary variable , and was obtained from the Longitudinal Integration Database for Health Insurance and Social Studies. Unemployment was indexed by having received any benefits for being unemployed at least once for a period of at least 3 years during or after the age of 20 years (year 2006), which is the age at which you can claim unemployment benefits.Criminality was identified through the National Crime Register. Convictions were obtained for substance-related crimes  and violent crimes . Criminality was indexed by any substance-related or violent criminal conviction during or after the age of 17 and 18 years  and was coded as a binary variable .Unintentional injuries were defined as any serious transport injuries, identified as emergency hospital visits due to transport-related trauma  via the NPR, which has previously been associated to ADHD in a large population-based study . The outThe psychiatric outcomes we studied were suicide attempt, SUDs and ADHD. We specifically chose to study suicide attempt and SUDs as we aimed to examine serious psychiatric outcomes, capturing both externalizing (SUD) and internalizing (suicide attempt) conditions that have previously been associated with ADHD , 25.Suicide attempt was defined as any record of a suicide attempt from the NPR  during or after the age of 18 years. Suicide attempt was coded as a binary variable .SUD was indexed as a diagnosis of any SUD from the NPR  during or after 18 years. SUD was coded as a binary variable .Individuals with a diagnosis of ADHD were identified from the NPR  by having at least 1 record of in-patient  or out-patient (from year 2001 onwards) care for ADHD. We also classified individuals treated with ADHD medication between 2005 and 2009 as patients with ADHD. These criteria have previously been validated as indicators of an ADHD diagnosis .As only 22 (0.9%) individuals met criteria for ADHD, we did not include ADHD diagnosis as an outcome variable due to insufficient power. The prevalence of having been diagnosed with ADHD in our sample is much lower than in the general population (5.3%). This can be explained by the lack of data on out-patient diagnoses before year 2001 (participants were 15–16 years) and prescribed drugs before year 2005 (participants were 19–20 years). As ADHD is often first diagnosed in childhood, it is likely we have failed to identify individuals that only received a diagnosis in childhood.We ran logistic regression models to examine how well parent- and self-ratings could predict life outcomes in young adulthood. We adjusted the standard errors for the clustered data structure  using a cluster-robust sandwich estimator. The models were run separately for each informant source (parent- and self-ratings), age group (13–14 and 16–17) and life outcome. We also ran models where both informant-ratings were fitted as predictors in one model, to examine the unique predictive value of parent- and self-ratings after controlling for the other informant. Odds ratios (ORs) are used to quantify the strength of the associations and are presented along with 95% confidence intervals. Area under the receiver operating characteristic curve (AU-ROC) is used to quantify the discriminative accuracy of parent- and self-ratings of ADHD symptoms on the outcomes. We additionally investigated the discriminative accuracy of models including both parent- and self-ratings of ADHD symptoms.th centile to investigate whether the pattern of results were similar when we used a cut-off which corresponds to the estimated prevalence of ADHD (~5%).We further dichotomized the ADHD symptom variables using cut-offs at the 90th centile and displayed the odds of experiencing life outcomes if individuals were over or under the 90th centile Figs. , 2. We aN = 722 at time 1, N = 594 at time 2) and parent-ratings , we ran sensitivity analyses to examine whether differences in data missingness influenced any differences observed in the associations between self- and parent-rated ADHD symptoms and the outcomes. We re-ran the logistic regression models only including cases where neither self- nor parent-ratings were missing. To examine the potential effects of sex, we ran sensitivity analyses on males and females separately.As there were differences in the amount of missing data for self- . Self-rated ADHD symptoms did not significantly predict any outcomes in early adulthood when controlling for parent-ratings , when controlling for self-ratings. Self-ratings of ADHD symptoms at 16–17 years significantly predicted not completing higher education and SUD (OR = 1.06–1.13) over and above parent-ratings Table .The pattern of results did not change when we excluded cases that had missing values of either parent- or self-ratings (Table S1) or when analyses were run on males and females separately (Table S2 and S3). However, higher self-ratings of ADHD symptoms in late adolescence uniquely predicted less unemployment while controlling for parent-ratings only in males. Further, both parent- and self-rated ADHD symptoms showed slightly higher predictive values on life outcomes in males than in females.Parent-ratings showed similar associations with the outcomes with and without the two additional ADHD rating scale items, suggesting that differences between parent- and self-rated symptoms in their associations with life outcomes is not explained by differences in rating scale items (Table S4). There was, however, one exception; parent-ratings no longer significantly predicted unemployment over and above self-ratings when parent- and self-rating scales included the same items.We ran additional sensitivity analyses where we dichotomized the ADHD symptom variables using cut-offs at the 95th centile to explore the odds of experiencing life events for individuals over or under the 95th centile. The overall pattern of results remained the same when we used the 5% cut-off as when the 10% cut-off was used (Table S5).In this longitudinal, population-based study, we found that both parent- and self-ratings of ADHD symptoms rated in adolescence predicted several important adverse life outcomes in early adulthood. In general, the associations between ADHD symptoms and outcomes were stronger in late compared to early adolescence, and parent-ratings of ADHD symptoms predicted several outcomes over and above self-ratings in both early and late adolescence. The findings suggest that clinicians can rely on both informant sources in adolescence for predicting risk of future adverse socioeconomic and health outcomes, although some caution should be placed on self-ratings of ADHD in early adolescence.Past research has repeatedly shown that ADHD symptoms rated by parents in childhood are associated with adverse life outcomes, and our current results extend these findings to show that both parent- and self-rated symptoms in adolescence were significantly associated with adverse outcomes. For clinicians, these findings suggest that both informant sources in adolescence may provide valuable information for risk of serious outcomes in adulthood. However, we found that the discriminatory accuracy of both parent- and self-rated ADHD symptoms were low, suggesting that neither can be used to accurately discriminate between adolescents who will experience adverse outcomes from those who will not. Although the response rate of our twin study is high, non-responders are more likely to be male and have higher rates of ADHD symptoms in childhood , 29. GivParent-ratings of ADHD symptoms rated in early and late adolescence were generally more strongly associated with the life outcomes compared to self-ratings, although it should be noted that the confidence intervals of the ORs overlapped for most outcomes, suggesting that the difference between parent- and self-ratings in their predictive strength did not significantly differ. Further, parent-ratings predicted several outcomes over and above self-ratings, and the discriminative accuracy did not significantly improve when self-ratings were added to the models compared to when only parent-ratings were used. Our findings suggest that despite parent- and self-ratings of ADHD symptoms only showing modest correlations (0.36–0.37), self-ratings do not have added value beyond parent-ratings for most life outcomes. While multi-informant approaches  are commonly used based on the belief that each informant provides unique and valuable information, our results suggests that self-ratings are not valuable once parent-ratings have been taken into account in predicting most outcomes, except for SUDs. One possible explanation for the finding that self-ratings significantly predicted SUDs beyond parent-ratings may be that individuals more likely base their ratings of ADHD symptoms on aspects of behavior related to substance use, which parents may not have as much insight into. Our findings are consistent with other lines of research suggesting that parent-ratings have higher concurrent and construct validity than self-ratings in adolescence –32 and yBoth parent- and self-rated ADHD symptoms showed an increase from early to late adolescence in the number of statistically significant associations and also in the effect sizes of the associations with the life outcomes. This overall increase in predictive value is not likely explained by a decrease in endorsed ADHD symptoms with age as parent-rated, but not self-rated, symptoms decreased only slightly (from 1.38 to 1.18). Instead, the findings may reflect the shorter time interval in the predictions with increasing age, or that both parents and adolescents become more accurate in their descriptions of the adolescent’s ADHD symptomatology with age, although this second explanation is unlikely. Future work is needed to extend our findings and examine the predictive validity of parent- and self-rated ADHD in young adulthood. This would be informative in order to explore whether the predictive value of self-ratings increases at a specific point in development from adolescence to adulthood. This could be of great value for both clinicians and researchers when having to decide at which age self-report should be used as the main reporting source of ADHD symptoms.Sensitivity analyses revealed that differences in results between parent- and self-ratings of ADHD were overall not influenced by (1) differences in missing values or (2) differences in items included in the two rating scales. When we re-ran analyses for sex separately, we found that the pattern of results remained the same, although both parent- and self-rated ADHD symptoms in males showed slightly stronger associations with life outcomes than in females. The stronger associations might reflect that boys tend to display more externalizing features of ADHD than girls , 34, whiIt should be acknowledged that this study used a population-based sample, and therefore findings may not generalize to individuals with clinically diagnosed ADHD. Even though behavioral, clinical and etiological research converge in suggesting that ADHD symptoms are the extreme of a normal continuum of behavior in the general population , 36, it In conclusion, we found that both parent- and self-ratings of ADHD symptoms in adolescence were significantly associated with adverse socioeconomic and health outcomes in early adulthood. Parent-ratings of ADHD from early to late adolescence were better predictors of serious outcomes, although self-ratings in late adolescence significantly predicted not having a higher educational degree and SUD over and above parent-ratings. Our findings suggest that both informant-ratings of ADHD in adolescence provide valuable prognostic information on risk of future adverse life outcomes. However, clinicians should prioritize parent-ratings over self-rating, especially in younger adolescents.Supplementary material 1 (DOCX 30 kb)Below is the link to the electronic supplementary material.


Attention deficit/hyperactivity disorder (ADHD) is associated with socioeconomic status (SES), in that children who grow up in low SES families are at an increased risk of ADHD symptoms and diagnosis. The current study explores whether different levels of ADHD symptoms are associated with prior changes in the SES facet of financial difficulty.n = 6416). A multilevel mixed-effects linear regression model with an unstructured covariance matrix was used to test whether different patterns of financial difficulty were associated with subsequent changes in ADHD symptoms.Using the Avon Longitudinal Study of Parents and Children (ALSPAC), we examined symptoms of ADHD measured by the Strengths and Difficulties Questionnaire (SDQ) hyperactivity subscale in relation to parent-reported changes in financial difficulty, grouped into four repeated measures at four time points across childhood; (p < 0.001). Increasing or decreasing financial difficulty predicted mean symptom scores lower than those of the in difficulty group and higher than the no difficulty group.Families who had no financial difficulty had children with a lower average ADHD symptom score than groups who experienced financial difficulty. Children whose families stayed in financial difficulty had higher mean ADHD symptom scores than all other groups  contains supplementary material, which is available to authorized users. The aetiology of attention deficit/hyperactivity disorder (ADHD) is complex and multifaceted. Current theory suggests that multiple small common and rare genetic variants influence any individuals’ levels of inattention, hyperactivity and impulsivity, which when severely rise comprise the syndrome of ADHD . EvidencA diagnosis of ADHD is associated with an increased risk of negative outcomes for the individual across many domains including problems with social function and occupation, poor academic outcomes, driving and car accidents and increased use of services . The preOther studies have found associations between SES across childhood and mental health –11. TheySome have suggested the ADHD–SES association is likely due to social selection: adolescents with ADHD are less likely to have good educational outcomes and this could determine low SES circumstances for them. As ADHD is highly heritable, the offspring of these individuals, genetically predisposed to ADHD, will be born into socioeconomically disadvantaged circumstances , 15. OthThe current study aims to explore whether recent changes in FD are associated with different levels of ADHD symptoms following this change. If changing financial difficulties are associated with later changes in ADHD symptoms, it would suggest that factors associated with such socioeconomic disadvantage may play a causal role in aetiology of ADHD, rather than being due to social selection. Increasing family FD followed by higher levels of hyperactivity and inattention would suggest factors associated with SES are on the causal pathway.We utilised data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to examine symptoms of ADHD in children, grouped by change in FD between two measures, four times across childhood. This allowed us to address our question of interest: whether changes in FD are associated with subsequent differences in levels of ADHD symptoms.ALSPAC is a longitudinal birth cohort in the UK that initially aimed to recruit all pregnant women living in the county of Avon with estimated delivery dates between 1st April 1991 and 31st December 1992 , 18. 14,This study included all children who had at least partial data on the measures required to address our research questions, i.e. at least two consecutive FD measures and one ADHD symptom measure. The ALSPAC study website contains details of all the cohort data that is available through a fully searchable data dictionary . EthicalThe financial difficulties measure was constructed of a series of five questions. The mother was asked to rate on a scale from zero to three how difficult it is currently to afford food, clothes, heating, rent/mortgage and other things considered essential for the child, with higher scores indicating more difficulty. We chose this as our exposure as it was the SES measure most highly predictive of ADHD in a previous study with the ALSPAC cohort , and becFor the main analysis, and because the majority of participants reported no FD, we dichotomised this measure into no FD (score of 0) vs any FD (score of 1 or more) at each time point that the measure was reported. Sensitivity analyses used thresholds of ≥ 5 and ≥ 10 (out of 15) to represent thresholds corresponding to those experiencing moderate and severe FD respectively.Symptoms of ADHD were measured using the parent-report version of the hyperactivity subscale of the Strengths and Difficulties Questionnaire (SDQ) . This scWe included a range of covariates. These included child age at completion of the measures of financial difficulty and hyperactivity in months from the child’s birth date to the date the parent reported filling in the questionnaire. Child gender and birthweight (in grams) were also included, as were whether the child resided in a family with more than three biological children or not (large family size), and whether or not parents of the study child had experienced depression in the first 2 years of the child’s life based on a score of 13 or more on the Edinburgh Postnatal Depression Scale.Covariates related to SES were also included:Housing tenure: mothers reported during pregnancy whether they lived in social or council housing, privately rented or owned/mortgaged a property.Parental employment. Maternal and paternal employment during pregnancy were categorised into unemployed, stay at home parent or in education, and employed.Weekly income, self-reported by mothers in £100 bands from £100 or less to £400 or more when the child was aged 33 months.Maternal education. Mothers reported during pregnancy on their highest educational attainment. This was categorised into not completing GCSE (the UK’s exams to mark the end of mandatory schooling), GCSE, or higher education than GCSE.Marital status during pregnancy. This was categorised as single, cohabiting or married.Parity (number of times the mother had given birth prior to the birth of the study child) was also included as a covariate.FD change group if they had complete data for all five FD measurement occasions.We defined four groups of FD change, each calculated from two consecutive FD measurements. Participants who were below the threshold for FD at both the first and second measurement occasion were classed as being in “No difficulty”. “Decreasing difficulty” participants were above the threshold for FD  at the first measurement occasion, and below it at the second (i.e. no longer in difficulty). “Increasing difficulty” participants were below the FD threshold at the first measurement occasion and above it at the subsequent occasion, and participants who were above the threshold and in FD at both measurement occasions were categorised as “In difficulty”. Each individual, therefore, had up to four data points across childhood for FD change period and a different length of time to outcome.Each FD change period was analysed in relation to the nearest subsequent measurement of the outcome, SDQ hyperactivity in ALSPAC. These are outlined in Table A multilevel mixed-effects linear regression model with an unstructured covariance matrix was used to test whether children in different FD change groups have different subsequent levels of ADHD symptoms using the “xtmixed” command in Stata 13. As we had repeated measures for each child in the study, this mixed model took these into account with random effects for repeated measures (level 1) within children (level 2), with the other variables being included as fixed effects. These fixed-effects coefficients are equivalent to and can be interpreted as standard regression coefficients.To determine which covariates were significantly predictive of SDQ score across the four time points, in addition to FD change and child age at SDQ score measurement, we first ran the full model including all variables outlined above to determine which covariates were statistically significant (at the 0.05 threshold), re-ran the model with only the significant covariates and then introduced the other covariates individually; any further significant covariates were added to the model. We used likelihood ratio tests to determine whether these covariates improved the model fit alongside the Akaike information criterion (AIC) values.We conducted a sensitivity analysis utilising two more stringent thresholds for FD of ≥ 5 and ≥ 10 (out of 15) to evaluate whether any findings are replicated or indeed are more pronounced using more stringent criteria. We then repeated the models using different FD change groups as the reference category to determine how each differed from the others. We used observed data only and did not impute missing data as those of low SES and with children who have higher scores on the SDQ are more likely to have missing data or drop-out from ALSPAC, and are thus not at missing at random .n observations = 19,574). This reflects the drop-out in ALSPAC and higher proportion of uncompleted measures as the children age, however the sample was still substantial. Descriptive statistics for the repeated measures model are described in Table Available data for the sample varied by measurement occasion, however the mixed effects model included data from 6416 individuals  but not from each other  and those in the Decreasing group had a mean score of 3.29 SDQ points . The changing FD groups were significantly different from the No difficulty group and the In difficulty group (p < 0.001). Post hoc analyses found no significant interaction between gender and FD change group. The age of the child when FD were measured had a significant influence on SDQ hyperactivity score (p < 0.001 for both measurement time points). Higher income and maternal education, smaller family size and absence of maternal depression were associated with lower hyperactivity scores. Lower birthweight was associated with higher hyperactivity scores. Although parity, marital status and housing tenure contributed to model fit, they were not significantly associated with the outcome.The average SDQ hyperactivity score for males  was 0.77 points higher than for females  had similar coefficient values. This may be due to the limited range of measurement occasions: depending on when a family’s circumstances change and the amount of time before there is a change in the child’s behaviour, children will have different patterns of change. One limitation of the study was that all measures were reported by one individual, the mother. Utilising teacher-reported ADHD symptoms may address this; however these were only available on two occasions across childhood in ALSPAC.The longitudinal design of the study was a strength, and repeated measures allowed us to draw conclusions across childhood rather than only at individual time points. In addition, using a variety of thresholds to define FD allowed us to test whether the association was robust when more stringent thresholds for defining low SES were used, and the results showed that if anything those that are more disadvantaged have higher symptom levels. Finally, we found that including the age of the child when FD was measured in the model had effects in different directions at the earlier and later time point. This finding was intriguing and should be further explored in other studies.One study recently reported that poverty longitudinally predicted increased externalising behaviour problems, including hyperactivity, across early to middle childhood, supporting our findings . Our finThis study indicates that increasing financial difficulty has a negative impact on symptoms of ADHD, and that higher SES is associated with lower levels of ADHD symptoms. However, as the mechanisms by which this association operates have not been elicited, further research needs to determine mediators of the aetiological mechanisms before consideration of implications for policy and practice, especially with studies beginning to emerge that demonstrate that experiences of severe socio-emotional deprivation may be associated with persistent ADHD . If thisOur findings could not provide conclusive evidence around whether FD changes are in addition to or interact with the complex genetic heritability of ADHD. Recent research exploring interaction between genotypes and environmental exposures is beginning to allow us to tease apart the interrelation between these factors . It may This study demonstrated an association between financial difficulty and childhood symptoms of ADHD that was robust to changes in the threshold used to define FD and timing of the measurements. Our findings add to the building evidence that SES may influence the severity and/or impairment associated with the symptoms of ADHD.Below is the link to the electronic supplementary material.Supplementary material 1 (DOCX 26 KB)


Attention deficit hyperactivity disorder (ADHD) is one of the most common mental disorders observed in childhood and adolescence. Its key symptoms — reduced attention, poor control of impulses as well as increased motor activity — are associated with decreased executive functions performance, finally affecting academic achievement. Although drug treatments usually show some effect, alternative treatments are continually being sought, due to lack of commitment and possible side effects. Cognitive trainings are frequently used with the objectives of increasing executive function performance. However, since transfer effects are limited and novelty and diversity are frequently ignored, interventions combining physical and cognitive demands targeting a broader range of cognitive processes are demanded.The aim of the study is to examine the effects of a cognitively and physically demanding exergame on executive functions of children with ADHD. In a randomised clinical trial, 66 girls and boys diagnosed with ADHD (age 8–12) will be assigned either to an 8-week exergame intervention group (three training sessions per week à 30 min) or a waiting-list control group. Before and afterwards, the executive function performance (computer-based tests), the sport motor performance and ADHD symptoms will be assessed.The current study will offer insights into the effectiveness of a combination of cognitive and physical training using exergaming. Positive effects on the executive functions, sport motor performance and ADHD symptoms are hypothesized. Beneficial effects would mean a large degree of scalability (simple and cost-effective) and high utility for patients with ADHD.DRKS00010171 KEK BE 393/15 ;  Children and adolescents with attention deficit hyperactivity disorder (ADHD) display an increased risk of suffering from long-term academic, work-related and social impairments, which are linked to the key symptoms of ADHD: impaired attention, hyperactivity and lack of control of impulses . ADHD isAlthough a large proportion of the symptoms can be reduced by medication, the main method of treatment , medicatinhibition, working memory and cognitive flexibility [Pronounced ADHD symptoms  are negatively correlated with the executive function performance –22. Execxibility . The exexibility , which exibility  as well xibility . PromotiThe positive influence of increased physical exercise on a wide range of areas of cognition has been repeatedly demonstrated for all age groups , 28. In The few existing intervention studies mostly reveal positive effects on cognitive performance –41, wherThe effectiveness of cognitive training programmes has increasingly been studied in children with ADHD in recent years . This waJust as there have been promising developments towards making cognitive training programmes as multifaceted as possible, the idea that highly varied, cognitively demanding sports activities offer an additional benefit for the executive functions  is increAn innovative combination of physical and cognitive training that takes into account the recommendations of Moreau and Conway  can be aThe aim of this study is to evaluate the influence of an exergame intervention, which is characterised by both high physical and high cognitive demands, on the executive functions of children with ADHD. We expect that exergaming will have a positive impact on the executive functions, the sport motor performance, the symptoms of ADHD and on quality of life.As the primary outcome, we hypothesize that exergaming will positively affect executive function performance compared to controls. More specifically, we expect that the demanding exergame activity that will be carried out over a period of 8 weeks will have a beneficial effect on the key areas—inhibition, working memory and cognitive flexibility—and that we will be able to detect a significant effect (significance level α = .05) with small to moderate effect sizes.As secondary outcomes, we hypothesize that sport motor performance will be significantly improved by the planned intervention . As a further secondary outcome, the influence of the intervention on the symptoms of ADHD will be examined. Based on studies into physical training programmes for children and adolescents with ADHD , we hypoThe present study will be carried out using a randomised study design with a waiting-list control group in Bern, Switzerland. Each participant in the study will take part in the study for a total of nine weeks, being assigned either to the exergame intervention or to the passive waiting-list control group.In total, 66 children with ADHD between the ages of 8 and 12 years should be examined. Any child that has been diagnosed with the ADHD is eligible to take part in the study. Beyond this, the participants and legal guardians must examine the information relating to the study and give their informed consent to take part in the study. As the well-being of the participants is the main priority, people whose mental or physical integrity might be threatened by the study must not take part in it. For safety reasons, people suffering from a neurological disorder, Tourette syndrome or an epileptic disorder will not be allowed to take part. To recruit the study participants, we will collaborate with elpos Schweiz (an association for parents and caregivers of children and adults with ADHD). The sample size of 66 participants was calculated using G*Power  for a geThe planned exergame intervention for the experimental group will be carried out using the XBOX Kinect. This device is able to project the player and his or her movements on the screen by means of a camera. It therefore offers the possibility of immersing oneself directly in all sorts of different virtual worlds. The level of physical activity can be increased playfully, and a continuous adjustment to the corresponding level of performance allows the executive functions to be trained. A physically demanding exergame with a strong cognitive component is “Shape UP” . It is available as a commercial game and resorts to various different elements of endurance, strength and mobility, as well as coordination, working memory, inhibition, attention, speed of action and action planning. In an initial pilot study involving school children, acute effects on cognitive flexibility were noted . In ordephysical activity level. By measuring the acceleration in three-dimensional space, it is for example possible to calculate step counts and MET levels. Participants will be asked to wear the devices at night too, if possible, to obtain data on sleep duration.Baseline (T1): At the beginning of the study, the participants will be fitted with an accelerometer (Actigraph GT9X), which they are expected to wear during the entire study, to monitor their executive functions: working memory, cognitive flexibility and inhibition, are based on three standardised tests. They are specifically designed for the age group in question and have proven their age adequacy and sensitivity to changes in executive function performance in previous studies [e.g. Sport motor performance will be measured using the German Motor Test Battery 6–18, which includes eight test items measuring endurance and coordination [ADHD symptoms will be ascertained using the German version [Quality of life will be measured using the Inventory of Quality of Life in Children and Adolescents [background variables will be determined using questionnaires and will include the following: age, sex, height, weight, socioeconomic status [Pre-intervention measurement (T2): The executive functions, sport motor performance, ADHD symptoms, quality of life and background variables will be measured 7 days after handing over the accelerometer. The measures used to determine the ies e.g. , 65: wories e.g. , in whicies e.g. , 68, agaies e.g.  will be ies e.g. , 65, 70 dination . Beyond dination . The Shudination  will be  version  of the C version . These wlescents . This quc status , exercisc status , and pubc status , completIntervention phase (T3): The children in the experimental group will train three times a week for approx. 30 min over a period of 8 weeks. The frequency of training and the accuracy will be recorded by the XBOX Kinect and using a Training Diary. In addition, the exercise activity will be recorded by an accelerometer (over a period of 8 weeks) and the heart rate will be recorded by a cardio belt (only during intervention sessions).: At these two times  the tests and questionnaires on the executive functions, quality of life, sport motor performance, attention and behaviour used at T2 will be performed once again.Post-intervention measurement (T4) and follow-up (T5)The study is divided up into five phases T1-T5). These are discussed in chronological order below  will be tested as to their statistical properties and analysed accordingly. Normally distributed background and control variables will be compared between the groups  using the two-sample t-test.The diary entries as well as the execution data obtained from the XBOX and the heart rate during training sessions will be used to provide information about the focus and the frequency of the training as well as about the level of physical exertion during exergaming. These scores will be presented as descriptive summaries. The frequency of exercises  during the intervention period will then be compared between the groups and analysed using an independent t-test to determine any differences between groups. Provided no significant differences are found, the repeated measures ANOVAs can be performed. If, on the other hand, significant differences are found, an ANCOVA should be carried out on the baseline data to check the differences. In this case, the pre-intervention scores will serve as covariates, and the post-intervention scores will be introduced as dependent variables.In order to test the hypotheses, the primary and secondary outcome variables will be analysed using repeated measures ANOVAs, if applicable. To determine whether a repeated measures ANOVA is applicable, the pre-intervention scores will be tested using an independent p < .05 for all analyses. The results will be reported in accordance with the CONSORT guidelines for clinical trials [The significance level will be set at l trials .The submitted research project has been approved by the ethics committee of the canton of Bern, Switzerland (KEK-NR. 393/15). In addition, the research project has been registered with the Swiss National Clinical Trial Port and the German Register of Clinical Trials (DRKS00010171). After verifying that they are eligible for the study, the participants and their parents will receive adequate verbal information about the study. They will be given enough time to consider their participation and the informed consent information will be sent to them. After at least another seven days, the researcher will visit the families and they will go through the written consent form together. Children above the age of 11 years will be appropriately informed in writing in addition to the oral information. Participation in the study can be terminated at any time without stating the reasons and without detriment to the participant.The existing empirical evidence indicates that physical activity can have a positive effect on cognitive performance, physical activity and the symptoms of ADHD , 42. In Various different studies have been able to demonstrate that both physical and cognitive training programmes can have a positive effect on the executive functions e.g. , 44, 45.From the point of view of society as a whole, fewer and fewer people are engaging in sports and more and more are failing to meet the recommended daily time spent in physical activity . PhysicaA few limitations need to be mentioned, which might affect the results of the study. First of all, a waiting-list control group is planned, ensuring an economic procedure in view of the low level of available empirical evidence. Should the results be favourable, an exergame intervention would have to be compared with a cognitive training and with a regular physical training programme. The planned exergame intervention is a physical training programme with a high cognitive component. The product in question is commercially available so that the entertainment factor is large and the graphics are appealing. Unfortunately, the exergame was not produced and adapted for the specific use in the current study. As a consequence, the cognitive engagement is greater in some of the game’s levels and lower in others. The cognitive engagement of a cognitive training and an optimal challenge point might not be reached all the time.One of the strengths of the study is its high ecological validity. Children and adolescents with ADHD often play video games. It would therefore seem to be easy to implement active video games at home, and this is being investigated by an increasing number of studies . FurtherRecruitment for the trial started in March 2016 and is estimated to be completed by June 2017.


Attention deficit hyperactivity disorder (ADHD) is a common neuropsychiatric disorder among the children. The burden of ADHD or its associated factors in Uganda are not known. The objective of this study was to determine the prevalence and the associated factors of ADHD among children attending the neurology and psychiatry clinics at Mulago National Referral Hospital.Using the disruptive behavior scale (45 items), we investigated the presence of ADHD symptoms among children attending Mulago Hospital. Questionnaires were administered to the primary care-takers of the study participants to gather information on the factors associated with ADHD. All children were subject to a clinical examination. Children presumed to have ADHD, using the aforementioned rating scale were further assessed by a child psychiatrist to confirm the diagnosis and associated co-morbid conditions.The estimated prevalence of DSM-IV ADHD symptoms was 11%. Children aged less than 10 years were four times likely to have ADHD . The demographic factors independently associated with ADHD were age less than 10 years, male gender, history of maternal abnormal vaginal discharge during pregnancy, and no formal education or the highest level of education being primary school.The prevalence of ADHD among children attending the pediatric neurology and psychiatry clinics is high in our settings and is associated with delayed milestones. Early identification and addressing the co-morbid conditions associated with ADHD such as epilepsy, autism spectrum of disorder, conduct disorder, opposition defiant disorder and intellectual disability in our setting is needed. Attention deficit and hyperactivity disorder (ADHD) is a common psychiatric manifestation of childhood diseases . ADHD isThe present study was therefore conducted; (a) to determine the prevalence of ADHD among children attending the neurology and psychiatry clinics at Mulago Hospital, and (b) to identify the factors associated with ADHD among children attending Mulago National Referral Hospital.This was an analytical cross-sectional study of children attending the Mulago National Referral Hospital.The study was done at the pediatric neurology and psychiatry clinics of Mulago National Referral Hospital, the largest hospital in Uganda. It is a teaching hospital of Makerere University College of Health Sciences. The pediatric neurology clinic is an outpatient’s specialized clinic and operates every Thursday from 9:00 a.m. to 3:00 p.m. except on public holidays. The pediatric neurology clinic receives referred patients from all over the country with neurologic complications. About 20 children are seen on each clinic day. The team of health workers during clinic days includes a pediatric neurologist, two senior house officers/residents, a medical officer, two nursing officers and a records clerk. Medications prescribed from the clinic are dispensed at the clinic pharmacy when available. Patients diagnosed with ADHD are sent to the psychiatry clinic to get further assessment from a child psychiatrist and then get the necessary treatment and specific medications.The child psychiatry clinic at Mulago Hospital is under the Department of Psychiatry and Mental Health. It is also a specialized centre for all mental disorders in the country. It operates as an outpatient’s specialized mental clinic on Tuesdays and Thursdays between 9:00 a.m. and 3:00 p.m. except on public holidays.On every clinic day, about 10 children are attended to by a team of health workers including a child psychiatrist, a child psychologist, two psychiatric senior house officers/residents, two clinical officers, two nursing officers and two records clerks. Prescribed drugs are dispensed from the psychiatry clinic pharmacy when available.The sample size was calculated using the formula:  the USA  where ADThe disruptive behavior disorders rating scale (DBRS) was completed for each study participant to identify the children who were likely to have ADHD symptoms. The scale consists of 45 items representing symptoms of disruptive behavior disorders including; conduct disorder, oppositional defiant disorder and ADHD. All 45 screening items were scored in the present study. Each symptom is rated on a four-point scale indicating the occurrence and severity or symptoms; 0 , 1 (just a little) 2 (pretty much) and 3 (very much). The scales were scored using the scoring method described by Pelham . AccordiThe diagnosis of ADHD was confirmed by the child psychiatrist using the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) version 6.0, a tool based on DSM IV criteria for diagnosis of psychiatric conditions . The co-Study subjects were children aged between 4 and 18 years attending the Mulago National Referral Hospital, neurology and psychiatry clinics between 7th August 2014 and 4th June 2015. The inclusion criteria included; children aged between 4 and 18 years attending the neurology and psychiatry outpatient clinics. All children enrolled into the study had to be a companied by adult caregivers who consented for their participation in the study. Children whose caregivers during the clinic visit did not know much about the children’ illness and symptoms were excluded from the study.Study participants were approached, screened and consecutively enrolled from the outpatient clinic days until the required sample size was obtained. Identification and screening of the participants were systematically done by the study team in the reception areas. The guardians/parents were approached by the study team for consent to participate in the study. Among study participants age eight or older without severe intellectual disability, assent was sought to participate in the study. The PI or research assistant interviewed the caretakers of study participants or the study participants (those who gave assent) using pretested questionnaire written in English, but administered in the language best understood by the parent/guardian. A structured self-administered questionnaire was used to collect information from the parents of children, as well as older children, who presented to paediatric outpatient clinics during the study period. In a few cases in which the parents were illiterate, the questionnaire was administered by study investigators. Parents were asked to recall symptoms, from a list of criteria for the diagnosis of ADHD, exhibited by their children either at home or at school. We used the DSM-IV-TR diagnostic criteria for ADHD. The responses were recorded in English. The physical examination of the study participant was done by the PI or the research assistant. A medical screening of each study participant, including height, weight, temperature and a review of systems, was conducted by the study pediatricians to identify any existent health problems that required immediate medical treatment. Neurological and mental status examinations were done in detail by study pediatricians. Abnormalities of movement and coordination such as tremors, chorea, athetosis, dystonia, gait and ataxia were also assessed. Children who were identified  with symptoms consistent with ADHD were referred to a psychiatrist for further diagnostic assessment and appropriate treatment including long term management. All children with ADHD were confirmed by a child psychiatrist.All questionnaires were cross-checked for completeness, sorted, coded and entered into the computer using Epidata version 2.1 packages. The raw data was securely stored to maintain confidentiality. Data was analyzed with the help of a statistician using Stata version 12.0 software .A total of 520 children were screened for the study. Of these, 188 participants were excluded from the study as follows: 173 participants were not in the age bracket for the inclusion criteria, 10 participants had missing data, and 5 participants lacked the caretaker’s consent to participate in the study. Therefore, 332 participants were recruited and enrolled to participate in the study. Among these study participants with ADHD, 56% were from psychiatry clinic while 44% were from neurology clinic. Two children were receiving phenobarbitone while 18 were receiving benzodiazepines for their epilepsy.The prevalence of ADHD in this sample is 11.7% (39/332), with a prevalence of 12.1% amongst participants who attended neurology clinic and a prevalence of 11.5% amongst participants who attended psychiatry clinic. A prevalence of 14.9% was noted among male study participants compared to a prevalence of 7.6% among female study participants.Eighty-two percent of the participants with ADHD were less than 10 years old and it was noted that those below the age of 10 years old were four times more likely to have ADHD . Similarly, 82% participants who came in with their mothers as next of kin were two times more likely to have ADHD . Seventy-one percent of the study participants with ADHD had a history of delayed milestones as identified by the study pediatricians. Among these study participants, delayed milestones was significantly associated with ADHD (p = 0.001) , male gender of the participant (p 0.017), and maternal abnormal vaginal discharge during pregnancy (p 0.004). The study participant’s medical history of epilepsy (p 0.015) was associated with ADHD. A participant who is younger than age 10 was four times more likely to have ADHD . A male participant was three times more likely to have ADHD than female participants . Children born to a mother with history of abnormal vaginal discharge during pregnancy were four times more likely to have ADHD . A participant with a caretaker who had no formal education or had primary education as the highest level of education was three times more likely to have ADHD  (Table Children with ADHD were further screened for other comorbidities. The frequency of these co-morbidities associated with ADHD were epilepsy (25.71%), autism spectrum disorders (14.29%), conduct disorder (8.57%) and intellectual disability (8.57%).Some participants with ADHD had more than one co-morbid condition. The most common combination was epilepsy and conducts disorder 17.14%), and oppositional defiant disorder (ODD) and conduct disorder (CD) (11.43%), and epilepsy and intellectual disability (ID) (5.71%)  attending the neurology and psychiatry clinics. Reported studies on ADHD among children have been done on different age groups. Biederman et al observed a decline in ADHD symptoms with increasing age among different age groups of children with ADHD over a period of 4 years . This poThis study also found that abnormal vaginal discharge during first trimester of maternal pregnancy was significantly associated with ADHD. This finding could be explained by a possibility of the fetus being exposed to perinatal infections like TORCHES . In this study, systematic screening for these maternal viral infections in the first trimester of pregnancy was not done. Mann Joshua et al. observed that school aged children born to mothers with a history of genitourinary infections were more likely to have ADHD. The study also observed that these mothers reported symptoms of abnormal vaginal discharge and urinary tract infections during their pregnancies . This coThis study found that a child whose primary caretaker had either no education or had primary education as their highest level of education was significantly associated with ADHD. This could be explained by the possibility that the caretaker of this child may have had undiagnosed ADHD in childhood which negatively impacted on their educational attainment. Biederman et al. in an overview of ADHD noted that 5–66% of children with ADHD persist with the disorder to adulthood and that parents of children with ADHD were likely to have ADHD . Sixty-fThis study also found that epilepsy was significantly protective against ADHD. This is a surprising finding because scientifically, epilepsy is thought to possibly increase the likelihood of having ADHD. Koneski et al.  in a revLarson et al. in a meta-analysis to determine patterns of comorbidity among children aged 6–17 years in the United States of America observed that children with ADHD had at least one co-morbid condition like learning disability, conduct disorder and anxiety disorder . SpencerThis study had the following limitations: recall bias for mothers, especially regarding vaginal discharge and delayed milestones. It is especially difficult to establish an ADHD diagnosis in children younger than age 4 or 5 years, because their characteristic behavior is much more variable than that of older children. However, in this study only a few children were less than 5 years. We did not describe comorbidities like tic or anxiety disorders. The associated factors that were found to be significant in this study would require more exploration so that more information to be obtained from caretakers of study participants to ascertain their true associations, given that this was cross-sectional survey and it may not clearly explain these associations from our results.Despite these limitations, this study is important because it is the first study in Uganda that estimated the prevalence and the associated factors of ADHD among children. Also, study participants who were presumed to be having ADHD using the DBRS were re-assessed by the child psychiatrist to confirm the diagnosis based of ADHD and its co-morbidities.The prevalence of ADHD in our setting was similar to that in other parts of the world though higher than the prevalence previously reported in other African study samples. ADHD was associated with delayed milestones. There is need for additional studies regarding ADHD in this region. Early detection and instituting proper care is important to reduce the impact of ADHD on education of these young children. Untreated ADHD also poses a tremendous amount of psychological and social burden to the individual and the community.


Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most well-established and at the same time controversial disorders to the extreme of being placed in doubt. In the first of two parts, the established position is critically reviewed, beginning with showing fallacious reasoning on which the diagnosis is based, lacking clinical proof. Similarly, a certain rhetoric and metaphysics in genetic and neurobiological research is highlighted, where, for example, a meager accumulation of data is offered as robust conclusions, and correlates and correlations as causes and bases. However, that may be, the controversy is silenced in a dialog of the deaf between “defenders” and “critics.” with no way out in sight in empirical and scientific terms. A new meta-scientific position is necessary to analyze the science of ADHD itself and its social uses. In this respect, the second part introduces Aristotle’s four causes, material, formal, efficient, final, as an instrument of enquiry. According to this analysis, ADHD is not the pretended clinical entity as presented, but a practical entity providing a variety of functions. The implications would be rather different from the usual. The established concept presents ADHD as a neurodevelopment disorder with a highly inheritable genetic origin which begins in infancy and frequently continues into adulthood. This concept forms part of the beginning of most articles on ADHD, as an already familiar its rhetoric. The truth is that there is also extensive literature questioning the clinical medical-scientific validity of ADHD. The controversy may be reduced to two opposite positions: the standard, which states its well-established existence, such that denying it would be like denying that the Earth is round, and the critical, which denies its clinical entity, such that those who argue for it would only be pathologizing normal behaviors and problems. A third position, apparently between them, is limited to criticizing overdiagnosis and overmedication, but is still a variant of the standard concept.However, the even authors arguing the standard concept recognize the controversy concerning its clinical entity, perhaps just another aspect of does exist. However, those who argue for ADHD cannot do so only with ambiguous rhetoric and questionable implicit assumptions. The question here would be why they are as genuinely convinced as they are of such a controversial position.Although the controversy is incessant, it does not seem to go any further in the usual terms of whether ADHD exists or not. The critical position cannot just deny its existence under the assumption that it is an “invention” of the pharmaceutical industry or the bio-power that be or whatever. Not because it is an invention would it no longer constitute a factual, practical, and institutional reality. The question would be what what ADHD is, and epistemological scope asking how science itself knows and molds what has ended up as the actual “ADHD.”The controversy cannot be resolved in empirical scientific terms, on the plane of facts, as if the facts spoke for themselves, which is where it now stands. A metascientific, philosophical assessment is required, with an ontological scope asking rhetoric and metaphysics that sustain it. If the rhetoric suggests more persuasive than truthful reasoning, metaphysics refers here to implicit assumptions about genetics and the brain which go beyond what genomics and brain connectomics really permit. The article has two parts. The first concentrates on revealing the rhetoric and metaphysics of ADHD neuroscience. The second develops the metascientific approach beyond the usual controversy – whether or not it exists – attempting instead to understand what it is that exists and how it came to be that way.This approach is based on a critical position (not ingenuous) concerning the impressive neuroscientific evidence claimed as support for the established concept. Such an approach is unthinkable for those who assume the standard concept, given their amazement that anyone would deny it. Without denying their data, light will be shed on the rhetoric and metaphysics on which it is largely based. Its three basic pillars, diagnosis, genetics, and neurobiology, are specifically reviewed.Instead of uncritically assuming the standard ADHD concept as if scientific evidence required it, we review its consistency, focusing on the Everything begins and has its basis in the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders DSM; . For theThe strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.The Critical Psychiatry Network, an organization of critical psychiatrists who focus on a biomedical approach in psychiatry, has promoted a campaign under the slogan, “No more psychiatric labels” for abolition of the DSM/ICD, also on the basis of its lack of validity .New England Journal of Medicine says about psychiatric diagnoses:The DSM may have improved reliability with regard to consistency among those who apply it, but validity is something else: its correctness and robustness for making a diagnosis. A Marcia Angell, ex-director of the If nearly all physicians agreed that freckles were a sign of cancer, the diagnosis would be “reliable,” but not valid. The problem with the DSM is that in all of its editions, it has simply reflected the opinions of its writers .back its validity  then he has ADHD. According to the begging the question fallacy it is already known that the child has ADHD because he/she “often fails to give close attention to details,” “often fidgets with or taps hands or squirms in seat,” and so on. The child does not pay attention and fidgets because he/she has ADHD and he/she has ADHD because he does not pay attention and fidgets. The symptoms are the guarantee of the diagnostic category, which in turn is invoked to explain the symptoms in an endless loop  reduces hyperactivity, the hyperactivity is a symptom and ADHD is a disorder, also commonly occurs. But one does not follow the other, not logically and not empirically, since stimulants produce the same effect whether you have ADHD or not.The truth is that the diagnosis of ADHD is established, but based on fallacious reasoning, typically two : the Affess loop , p. 128.The diagnosis is based on fallacious reasoning, not on clinical tests as would be expected in view of how sure the affirmations are. Based on DSM/ICD diagnosis, a series of objective, complementary, and supposedly confirmatory tests are being studied. Among the most objective is the Test of Variables of Attention (TOVA), a continuous performance test (CPT) . The TOVwith ADHD or without ADHD, not as a diagnostic test itself. These tests can be useful for evaluating attention skills, precision or reaction times, which may be relevant in themselves without presupposing ADHD. They measure what they measure, but it could not be said that the ADHD is measured.The problem of ecological validity can be reduced with virtual reality tests. However, up to now support is limited . VirtualOn the basis of the self-interested consensus that may be assumed from declared conflicts of interest and sponsorship of commissioned work , inconsiBeyond the diagnosis, one fundamental aspect of the ADHD rhetoric is its consideration as a highly inheritable genetic disorder . If the real molecular genetic evidence and the persistence in their affirmation. We refer here to reviews by authors who are not precisely critical of the genetic perspective, but as scientists are compelled to recognize what there is, not without their rhetoric. Thus Cortese, after reviewing the convergence of different approaches (none conclusive), refers to the future, “It is expected that future research will reveal similarly exciting convergent findings”  are not analyses of causes, and therefore do not permit understanding what caused a disorder in an individual  involved in executive functions. Another hypothesis is that individuals with ADHD may have weaker connectivity in DMN when at rest, suggesting immaturity and atypical development. The two networks, DMN/CCN, seem to work in opposite directions in attentional tasks, “As attentional demands increase, activation of the CCN increases, whereas DMN activation decreases; conversely, during periods of internally focused cognitions, activation in the CCN is reduced, and DMN activation increases” , p. 558.Four considerations must be made before or instead of taking the neurodevelopment brain-centered perspective automatically, by default, as if there were no other option.In the first place, the neurodevelopment approach leads to establishing a dichotomy between typical, normal or mature development and atypical, abnormal or immature development defining a psychiatric disorder . This diIn fact, as a second consideration, the supposed “neuronal bases” for ADHD do not consist of anything but correlations and correlates. They are “associations,” which however, implicitly suggest neuronal causes as “bases” , p. 532,not the cause of driving taxis or playing the piano or the violin. The explanation which As a third consideration, in a discussion of causal directions, it would be more coherent, both in conceptual terms based on brain plasticity and empirical terms related to correlations and correlates found, to argue for the opposite hypothesis, that behaviors themselves are the causes of the correlates or neuron “alterations” found. It would be more coherent to understand cerebral variations as “dependent variables” of the activities that organisms carry out in their environment than as causal “independent variables.” The brain changes and adapts in line with an organism’s activities depending on the requirements of the environment. The neuron correlates or brain “alterations” of the taxi drivers and musicians are brain-training, can maximize blood oxygenation directly in certain areas of the brain , not reconstructive (explanatory) of what there is. After all, ADHD does exist. It is real. Negationist critics must recognize that ADHD does exist, since we are even discussing it, though it may be to argue and deny it. The question now is to see what it is that exists, the way it is real.A critical review of the standard conception of ADHD has underlined the tautological  reasoning and assumptions implicit in the causal-explanatory role of the genome and the brain (metaphysics) which impregnate it. It is understood that this conception cannot be taken uncritically as a starting point. Although this review may seem “demolishing,” it is not everything. Up to here the criticism has been radical approach of this type related to the fundamental nature of something, and whole considering the different sides and dimensions of the problem, is found in Aristotle’s four causes.In this respect, we recur to an ontological metascientific and metatheoretical approach, beyond the facts and terms of the controversy itself. A new Physics and Metaphysics, in which he deals with causes are aition, in plural aitia, which is where etiology comes from. Aition has a wider sense than cause in English or Spanish. Aristotle’s causes refer to explanatory factors or principles that approach “why-questions” in order to explain why something exists the way it is .The four Aristotelian causes are related to each other in such a way that it is practically impossible to discuss one without assuming the others. However, for analytical and explanatory reasons, it is advisable to go one by one. Specifically, it is important to begin with the material cause. Not in vain, the material cause is the comportment which is not reduced to a few behaviors.The material cause of ADHD would be the behaviors by which, in fact, it is defined. It refers to some behaviors of children with problems in certain tasks and in certain school, family, and social contexts. These behaviors, typically inattention, hyperactivity or impulsivity, become conspicuous and end up by defining a syndrome and the child itself, but in themselves are not problematic or pathological (“symptoms”), nor do they exhaust what the child is. Such behaviors attract attention and become problematic in terms of norms and values . But theunifying structure of embodied affective (and cognitive) engagement with the world, as the most general term to refer to all-encompassing changes,” , in agreement with The formal cause of ADHD would be the Cartesian scenario what in fact individuals are doing in the real world scenario where they execute their life. After all, neither the intentions are given any place in the brain  in the USA and the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom, and associations such as Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) which support their practices. These institutes and associations in turn are based on scientific research. So it is really scientific research which molds ADHD  by which certain behaviors of children or adults  take the form of a diagnostic category . The efficient cause has to do rather with the actions of “actors” , than wilds ADHD .did have ADHD. In fact, those behaviors really do exist and are observable. The child is from now on observed and defined by ADHD behaviors. Everything else, other behavior, circumstances, contexts or history, remain outside of the description. The clinician believes he has described an objective reality, but he has also created it this way by selecting some behaviors in detriment to others and elevating them to the category of “symptoms.”Clinicians epitomize the efficient cause as “official” providers of the diagnosis. Typically, children referred to them by schools are taken to the doctor by their parents and are given the diagnosis and a prescription . What haCharcot effect here  described by Charcot  reinfluences the patient’s understanding, adopting the explanations and definitions offered. The creation of the category itself was already a process of “selection” of the most conspicuous and operative symptoms to which the problem and the individual  are reduced, as the Charcot effect suggests , it would make no sense to talk about the efficient cause. But neither because it is not natural is it less real and easier to change. The genome and the brain may be more plastic than the scientific practices themselves with their institutionalization, patterns of reasoning and self-confirmatory methods.Summarizing, the efficient cause of ADHD would be found in scientific, clinical, educational, and family practices that imprecision: a case of the strength of vague concepts . Based on this dichotomy, an infinity of topics (“variables”) are chosen to observe possible neurocognitive correlates and genetic and behavioral associations. When a “difference” is found, as Hawthorne says, “the observed difference is only relatively value-free, having been arrived at through several value-valenced choices. The slip from “difference” to “dysfunction,” which is an ethical term, intensifies the valuation.” Positive results reinforce the decisions and in any case, as they say, more studies are necessary, strengthening the feedback loop , p. 136.Attention-Deficit/Hyperactivity Disorder harmonizes a variety of scientific, medical, educational and family interests besides pharmaceutical industry profits (the most openly shameless and rightly denounced). The only party harmed seems to be the children, with the unintentional effect of “accidental intolerance” of the traits and ADHD-associated behaviors , p.142.Briefly, the final cause of ADHD would be in harmonizing the interests of a variety of actors and institutions, not just the pharmaceutical industry. The particular feedback loop between science and society in which normative values become naturalized and legitimated in research, which is valued and supported by society, has been shown. Perhaps the children are the least benefited due to the resulting “accidental intolerance.” Individual differences become dysfunctions, disorder or mental illness.An argument has been developed in three steps. First, the evidence claimed which sustains ADHD was reviewed. It was shown that the diagnosis is based on fallacious reasoning (tautologies), for lack of clinical proof. At this point, the lack of specific genetic and neurobiological evidence should not be surprising, in spite of the enormous amount of literature pointing in that direction. The fact that the science of ADHD seems to be going on the right path is probably due more to the rhetoric and metaphysics of its literature than to accumulated scientific findings. Rhetoric in use seems to convert ambiguous meager data into conclusions presented as “convergent evidence,” where the overused expressions “complex” or “heterogeneous” disorder really means that its causes are unknown, even if assumed to be genetic and neurobiological. Implicit metaphysical assumptions are found for example, in correlates and correlations taken as neural “causes” or “bases.”Second, a new metascientific approach to the science of ADHD was proposed, supposing that a mere critical review leaves the controversy between “defenders” and “critics” the same as it was, in a dialog of the deaf. More so, criticism, as demolishing as it is, still recognizes the sense, persuasion, and good faith, not ignorance or simple interests, of the defenders. How are they not going to be convinced if the science they profess directs their path, sheds light on the subject and offers the method? The fact is that the science itself may have blind points and self-confirming methods, without even going down the right path. The new metascientific approach proposed is Aristotle’s four causes, material, formal, efficient, and final, as an instrument of enquiry.material of which ADHD is made would be some specific behaviors which can be problematic in certain contexts and tasks. These behaviors are easily taken as the form of the “ADHD” diagnostic category according to diagnostic criteria in use . The efficient cause with regard to what, or better, who makes ADHD the way it is may be found on one hand in the clinicians who make the diagnosis and on the other in scientific research which has molded the established concept. The final cause refers to a variety of functions which ADHD meets, not in spite of its scientific-clinical vagueness. On the contrary, it would be precisely due to its imprecision which makes it useful in a variety of contexts. The positive science-society feedback loop which surreptitiously combines facts and values as the reason for its success in harmonizing varied interests has been shown.Third, the enquiry was carried out using Aristotle’s four causes. In addition to a clarifying view, this metascientific focus offers an alternative to the understanding of “ADHD” beyond the dominant biomedical model and its simple denial. According to this analysis, the natural kind, out there, ready for its research as a scientific object, “ADHD” would be a practical kind, constructed on the scientific and clinical practices themselves, fulfilling a variety of functions, who knows for whom or at what cost. Beyond the positivist science framework , the “number one recommendation” would be to “establish a pragmatist framework that carefully uses facts and values in all decisions and actions relevant to ADHD” . More precisely, such “training” would be by parents and teachers with a view to promoting the skills children require. Training by parents using common games involving attention and following rules  as well as behavioral principles , would “remove” children from (risk of receiving the diagnoses of) “ADHD” . A studyWe must supplement the pragmatic interest in action possibilities [afforded by different languages inherent in social practices ] with a hermeneutic interest in interpreting the person and her suffering in her life situation as it presents itself in its “facticity” , p. 645.The author himself conceived, wrote, reviewed and approved the article.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.