Low BW was associated with a lower prevalence of overweight than normal and high BW . Overweight was observed significantly more often in boys with ADHD  even after adjustment for BW and other variables  and after controlling for ADHD type, stimulant treatment and selected comorbid disorders. Independently to applied analysis, obesity was not associated with ADHD. Lower birth weight is over twice more often observed in boys with ADHD than in control group. Although this phenomenon may reduce the rate of overweight in the studied group, ADHD remains strongly associated with increased prevalence of overweight.Population studies indicate a strong relationship between birth weight (BW) and body size in later life. However, BW as a variable was never accounted for in studies on the relationship between attention-deficit/hyperactivity disorder (ADHD) and overweight. This study aims to assess the relationship between ADHD and overweight with control of birth weight and other confounding factors. Prevalence of overweight was compared in clinical sample of 219 boys with ADHD and 396 boys without ADHD, aged 6–18 years. The following factors were controlled: BW, parents income and education level, place of residence, ADHD type, selected comorbid disorders and stimulant treatment. Overweight and obesity were diagnosed according to the criteria proposed by the International Obesity Task Force. Logistic regression analysis was used to estimate the association between ADHD and the prevalence of overweight and obesity. Boys with ADHD differed significantly from the control group in distribution of low BW (8.2 vs. 3.0 %,  Increasing attention has been devoted to comorbidity between attention-deficit/hyperactivity disorder (ADHD) and overweight/obesity in the last few years. Studies suggest that ADHD may be a risk factor of excess body weight –3. ReseaVariables related to growth and body weight have to be controlled during a research on relationship between ADHD and obesity. These known factors include: (1) treatment with stimulants (that may cause a decrease in body weight and slow down growth) , 31–36, High birth weight increases the risk of obesity and excess fatness, according to numerous studies , 53–57. Taking into account the above considerations, one can hypothesize that the higher incidence of obesity in children, adolescents and adults with ADHD is associated with low birth weight, which is more frequently observed in this group. This would suggest that the relationship of ADHD to obesity can be explained, at least in part, by fetal programming hypothesis or the fetal insulin hypothesis.The aim of our study was to assess the relationship between ADHD and prevalence of overweight and obesity in boys with control of their birth weight, subtype of ADHD, comorbid associated disorders, medication status and indices of socioeconomic status.The study has been approved by the Ethics Committee of the Poznan University of Medical Sciences (Decision Number 855/05), and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Study was also consistent with national law. The research received financial support from the Polish Ministry of Science and Higher Education (Grant Number NN303 0175 33). The subjects and their legal guardians were fully informed about research procedures and gave a written consent to participate in the study.The research was carried out in Poland in the years 2005–2008. The examined group of children and adolescents with ADHD was recruited among patients of psychiatric hospitals and of university outpatient clinics. The study enrolled only boys because ADHD is diagnosed much less frequently in girls than in boys, thus the chances of gathering a representative clinical group of girls were small. The range of age of studied boys (6–18 years) was defined by the minimum age of patients diagnosed with ADHD in Poland and age they reach adulthood in accordance with Polish law. This wide age range gave the opportunity to assess the overweight and obesity rates in both populations—children and adolescents. Only boys without significant cognitive deficits (IQ ≥ 85) were enrolled to the study, for which the consent to participate in the study was obtained.Participants had to have met the criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR)  for one Exclusion criteria included: psychiatric disorders comorbid with ADHD, such as depression, anxiety disorder, bipolar affective disorder, anorexia or bulimia; endocrine disorders, such as diabetes, thyroid disease; which may, independently of ADHD, affect the body weight of the patients.In this study we wanted to evaluate the association of birth weight with subsequent body weight of studied boys. Body weight at birth is strongly associated with the term of birth. Infants born prematurely have low birth weight and those postterm-born high birth weight. The term of birth, regardless of birth weight, is a factor associated with subsequent developmental disorders. Therefore, to examine the association of birth weight with subsequent obesity in boys with ADHD, undisturbed by the birth term, we decided to exclude boys preterm born (before 37 weeks of pregnancy) and postterm born (born after 42 weeks of pregnancy) from the study.Birth weight and detailed information about delivery were obtained from medical registries. Then the subjects were categorized, according to guidelines of Centres for Disease Control , into thThe data about subjects’ socioeconomic status (SES) and health were collected using a questionnaire for parents, specially developed for the study. SES was assessed on the basis of two indices: parents’ income and education level. Parents were asked to assess their income level. Based on data from the report of Central Statistical Office, which includes average salaries in Poland in 2005–2008 , we consSubjects were divided according to place of residence into two categories: those living in a large cities with more than 500,000 inhabitants, and those from smaller towns and rural areas. We have chosen this criteria because in Poland university centers and psychiatric clinics are found mainly in cities exceeding 500,000 inhabitants. In smaller towns and rural areas, the opportunity to benefit from the aid of children’s psychiatrist, and hence, obtaining a diagnosis of ADHD is limited. Furthermore, population density of the place of residence is an important factor associated with the development and rate of body fat. We were aware that boys inhabiting large cities could be more prone to overweight, because of their more sedentary lifestyle. This could falsify our results by strengthening the relationship between ADHD and overweight.currently medicated patients included subjects who received stimulants at the time of the study, while the group of not currently medicated subjects included all the children who did not receive stimulants at the time.Data about ADHD treatment came from medical registries maintained in outpatient clinics. However, data about treatment history, used medications, their doses and time of administration were not available for the whole sample. Therefore, the group of Measurements of body height were carried out by trained medical staff with the use of an anthropometer  with measurement accuracy of ±1 mm. Measurements were made according to the standard technique –94. Bodyz scores.BMI was calculated on the basis of height and body weight. Body height and BMI were later adjusted for sex and weight on the basis of World Health Organization (WHO) growth charts  and presInternational Obesity Task Force (IOTF) recommendation  was usedFor the control group, we have used the data collected for the purpose of our second study on the prevalence of overweight in children and adolescents in Poland. Both studies were conducted simultaneously. First, we have gathered the data from boys and girls aged 6–18 years; the recruitment was conducted in primary and secondary schools. Children were included in the study only after submission of the written consent of their parents or legal guardians. The research included anthropometric assessment of height and body weight , questionnaires and medical registries for collection of demographic, socioeconomic and perinatal data, as well as data concerning health of the subjects. Assessment of mental health was based on parents’ responses to the following questions: (1) ‘Has a doctor or health professional ever told you that your child has attention deficit disorder, attention-deficit/hyperactive disorder that is Attention Deficit Disorder (ADD) or ADHD?’ (2) ‘Has a doctor or health professional ever told you that your child has psychiatric disorders?’ (3) ‘Has a doctor or health professional ever told you that your child has oppositional defiant disorder, conduct disorder, emotional problems, such as depression or anxiety disorder?’ Similar questions were used in earlier studies for identification of individuals with and without ADHD , 98, 99.Boys aged 6–18 years, term-born, inhabiting a region of the same urbanization level as the examined boys with ADHD, without endocrine diseases, whose parents had answered ‘no’ to the above questions, and for whom complete data were collected, were assigned as the control group. Differences between boys with ADHD and those of normal development, selected based on above-mentioned criteria, were analyzed in the study.t test was used for comparisons of boys currently medicated and not medicated as well as for comparisons of children with ADHD and the control group in terms of z scores for height and BMI, birth weight and parents’ education. χ2 test was used for assessment of differences in prevalence of underweight, overweight and obesity as well as of categories of birth weight, age and education of parents, place of residence and parents’ income level. Then it was determined if variables that differed between both examined groups were associated with higher prevalence of overweight. χ2 test was also used for this purpose.Two-tailed Stepwise logistic regression with quasi-Newton estimation method was used to assess the probability of overweight/obesity and to control for other factors. The analysis was carried out for the whole sample and then separately: for patients with combined type of ADHD; for patients with comorbid oppositional defiant disorder and conduct disorder; as well as for patients not treated pharmacologically at the time. In all cases, two types of models were used: unadjusted and adjusted for all the variables, which statistically significantly differed boys with ADHD and control group.We also evaluated an association between ADHD as a single factor and prevalence of overweight in the subgroup selected with inclusion criteria: normal or high birth weight, average income level, family with one parent with higher education, place of residence in large cities , not taking stimulants at the time of the research and without associated oppositional defiant disorder and conduct disorder.p < 0.05. Statistical analyses were conducted with Statistica 10 software. Height and BMI were transformed into z scores with WHO AnthroPlus software.In all the analyses, results were considered statistically significant at significance level Consent to the research was obtained for 296 boys with diagnosed ADHD. The following boys were excluded from the group: 6 boys with depression, 11 boys with anxiety disorder, 24 preterm-born boys, 28 postterm-born ones, and 8 boys for whom incomplete data were collected. Among the initial number of 784 boys applying for the control group, the following ones were excluded: 82 boys—due to the risk of mental disorders, 167 preterm-born boys and 5 postterm-born boys, and 7 individuals with hormonal disturbances. One hundred twenty-seven individuals were excluded due to incomplete data.n = 161, 73.5 %). Most of the group  had at least one additional disorder, and the most prevalent ones were learning disorders  and oppositional defiant disorder . Less than half of the sample  was treated with stimulants at the time of the research. Boys not currently medicated and currently medicated did not differ in terms of BMI, prevalence of underweight, overweight and obesity as well as other controlled variables . In the both groups, mother’s age at the time of childbirth was most often in the range of 25–35 years . Compared groups differed in terms of the other controlled variables. In the both groups, families with one parent with higher education were the most numerous, though a higher percentage of both parents with higher education class was observed in boys’ with ADHD families in comparison with control group . More boys with ADHD lived in large cities with above 500,000 citizens . More parents of boys with ADHD were declared above-average income, compared to the control group .Boys with ADHD and control group were at the same age: mean age for boys with ADHD was 11.2 years ± 2.7, and for boys from control group 10.8 years ± 2.8 . However, categorization into low, normal and high birth weight demonstrated that boys with ADHD over twice more often had low birth weight .No statistically significant differences between means of birth weight were found . After distinguishing body weight categories with the method recommended by IOTF, significantly higher percentage of overweight/obesity (as one category) was noted in boys with ADHD  when compared to the control group. More detailed analysis revealed that the prevalence of overweight was over twice higher in boys with ADHD , while the prevalence of obesity in the both groups was similar . The compared groups did not differ in terms of prevalence of underweight .z scores for BMI. Analyses were conducted for the whole sample, without division into the group of boys with ADHD and control group. z scores for BMI of the subjects with low birth weight was −0.01. For boys with normal birth weight, z score for BMI was 0.36 and for those with high birth weight was 0.40. Differences between mean BMI were examined for two groups: boys with low birth weight and boys with normal or high birth weight. The differences were not statistically significant . Overweight was not observed in boys with low birth weight, while the prevalence of overweight in boys with normal and high birth weight was, respectively, 12.1 and 12.5 %. The difference in the prevalence of overweight between the two groups of boys: boys with low birth weight and boys with normal or high birth weight, was statistically significant . Obesity was diagnosed in 6.7 % of boys with low birth weight, 5.3 % of boys with normal birth weight and 5.4 % of boys with high birth weight. The difference in obesity rate between boys with low birth weight and the rest of the sample was not statistically significant .We investigated if birth weight was associated with t = −0.25, p = 0.80) in z scores for BMI between currently medicated (z = 0.41) and untreated boys with ADHD (z = 0.36). Underweight occurred in 2.53 % of currently medicated boys and in 2.14 % of boys untreated . Overweight was found in 16.46 % of boys currently medicated and in 17.86 % of untreated boys . Obesity occurred in 6.33 % of boys currently medicated and in 4.29 % of untreated . Differences between groups were not statistically significant.There were no statistically significant differences  and the other variables included in the model was not statistically significant.Logistic regression was used to assess the association between ADHD and overweight. ADHD was statistically significantly related to higher rate of overweight, when ADHD was treated as a single factor and in models taking into consideration the influence of birth weight, place of residence, parents’ education and income level [unadjusted model OR (odds ratio) = 2.31, 95 % CI 1.40–3.81, n = 161), (2) boys with ADHD with exclusion of individuals with associated oppositional defiant disorder and conduct disorder (n = 149), and (3) boys not treated with stimulants at the time (n = 140), to control the influence of these characteristics in the group of boys with ADHD. Control group was the reference in all the models. Values of OR for ADHD factor differed between the models , however, ADHD still remained the only variable that was statistically significantly related to overweight   boys with only combined type of the disorder .Additionally, the association of ADHD and overweight was assessed in the subgroup created on the basis of normal or high birth weight, average income level, one parent with higher education, living in a large city, not receiving stimulants at the time of the research and without associated oppositional defiant disorder and conduct disorder. The analysis included 24 patients with ADHD and 139 boys of control group. Overweight was observed in 7 (29.17 %) boys with ADHD and in 11 (7.91 %) subjects without ADHD. Logistic regression analysis revealed that ADHD remained a factor that was statistically significantly associated with higher rate of overweight, and OR in thus selected group increased to 4.79 , which define the cut-off point for overweight as the 85th percentile and 95th percentile for obesity e.g., , 101, otOur study indicates that ADHD is significantly associated with higher prevalence of overweight, but not obesity in boys. ADHD, depending on assumed model (with control of confounding variables) was associated with increased prevalence of overweight in boys from 2.17 to 2.71 times. This agrees with the results of Erhart et al. , which sSeveral factors, which could have influenced our results, were controlled in the study. For us, the most interesting variable to examine was the birth weight, so far never taken into consideration in studies on the relationship between ADHD and overweight/obesity. We observed that low birth weight was over twice more frequent in boys with ADHD than in the control group, which agrees with available data , 51, 52.ADHD remained the only factor related to overweight after adjusting for several other variables, which are usually associated with the level of BMI, i.e., place of residence , 37–41 aEarlier studies found that depression and anxiety disorder may increase prevalence of overweight/obesity in individuals with ADHD , 14, 37.The relationship between ADHD and overweight remained significant when children with full-blown ADHD (combined type) or those not treated with stimulants at the time were selected for the analyses. Earlier papers demonstrated a decrease in body weight and inhibition of growth due to treatment –36, 104.n = 24, reference group n = 139).An additional analysis was conducted to examine how ADHD increases the risk of overweight in a group thoroughly selected in terms of controlled variables. Since low birth weight could have decreased the obtained indexes, only the data concerning boys with normal and high birth weight were used in the analysis. Additional inclusion criteria were average income level, average level of education of parents, inhabiting large urban agglomerations, no comorbid oppositional defiant disorder and conduct disorder, and not receiving stimulants at the time of the research. Such a selection enabled the assessment of ‘pure’ association of ADHD and the prevalence of overweight. We demonstrated that the diagnosis of ADHD is associated with nearly five-time higher risk of overweight than it is in case of healthy children. However, the result should be approached with caution due to the small number of individuals meeting the criteria for inclusion in the selected homogeneous group , even though previous work showed the influence of stimulant treatment on the growth of children with ADHD , 31–36.Some limitations refer to the criteria of inclusion. We did not use information gathered from the teachers to confirm diagnosis of ADHD in the sample. Teachers were requested to fill out the questionnaires on ADHD symptoms, but unfortunately most of them did not return the questionnaire. It was not possible also to give more precise psychiatric diagnosis of the control group. We believe that the questions, similar to those of earlier large population studies , 60, 61,The assessment of socioeconomic status was made only on the basis of two separate indicators: assessment of the income and education level of parents. Hence, our methods did not allow a completely objective and accurate assessment of SES. In our opinion, however, they provide an important insight on the quality of condition of the children’s growth and the differences in this area between the studied boys with ADHD and a control group.We did not evaluate the sexual maturation stage, while other studies indicated a significant relationship between increased prevalence of overweight and the onset of puberty . FinallyWe left out a few factors, which might explain the relations between ADHD and overweight in the present study. Apart from common genetic background of ADHD and obesity , 30, thePresented research proved that ADHD is significantly related to increased frequency of overweight in boys irrespective of birth weight, as well as of income level and education of parents, place of residence, ADHD type, medication status and selected comorbid disorders. Low birth weight is twice more frequent in boys with ADHD than in control group, though fetal programing or the fetal insulin hypothesis fails to explain association between ADHD and overweight. Low birth weight may decrease the prevalence of overweight in the group, therefore this factor should be under control in future studies.


Specialist services for the treatment of attention deficit hyperactivity disorder (ADHD) in adulthood in Hong Kong are yet to be developed. This study aims to explore the experiences of adolescents and young adults with ADHD in accessing treatment and services, coping with ADHD-related impairment, and their expectations of future treatment in Hong Kong.Qualitative interviews were conducted with a semi-structured guide. Forty young adult patients aged between 16 and 23 were included in the study. The interview recordings were transcribed verbatim and anonymised. Data were analysed with a thematic approach based on key principles of Grounded Theory.Four meta-themes were developed: Accessing ADHD diagnosis and treatment services; ADHD-related impairment; Experience of ADHD treatments; and Attitudes and expectations of future ADHD treatment. The role of parents and schools were highly significant in accessing services for patients diagnosed with ADHD in childhood. In general, ADHD affected every aspect of patients' lives including academic outcome, employment, family and social relationships. Medications were the principal treatment for ADHD amongst the interviewees and were reported to be generally effective. Half of the patients received non-pharmacological treatments in childhood but these effects were reported to be temporary. There was general consensus that the needs of patients with ADHD could not be met by the current service. In particular, there is a lack of specialist service for adults with ADHD, follow-up by different clinicians, and insufficient provision of non-pharmacological treatments.The findings suggest that further development of specialist ADHD services and non-pharmacological options for young adults are essential to meet their diverse needs with a holistic approach. Attention deficit hyperactivity disorder (ADHD) is a common childhood-onset neurodevelopmental condition with a global prevalence between 5.9 and 7.1%, characterised by inattention, hyperactivity and impulsiveness . ADHD ofADHD can cause significant disruption to the lives of patients and their families. A previous study reported that delayed diagnosis, (after the age of 16), may cause more severe impairment, a sense of failure and missed potential in many areas of life . Adults In Hong Kong’s mental health services in particular, a rapid increase in the number of psychiatric outpatients since 1996 has been reported to adversely affect the quality of care ,13. FactPatients under 18 years with ADHD in Hong Kong can be referred to public mental health services at paediatric clinics and child and adolescent psychiatric clinics under the Hospital Authority. Referrals can be made by various professionals such as school personnel, general practitioners, private psychiatrists, and psychologists from non-governmental organisations, child assessment centres and student health services from the Department of Health. The waiting time for the first appointment depends on patients’ conditions and emergency, ranging from several months to over a year. The major treatments for ADHD in Hong Kong are medication and psychotherapy. Medications include stimulants such as methylphenidate while non-stimulants include atomoxetine, imipramine and clonidine. Non-pharmacological treatments which predominantly focus on children with ADHD include psychoeducation, parent management training, simulated classroom behavioural training, impulse control and social skills training, executive function (EF) based training on homework; and self-management organised by hospitals, non-governmental organisations and primary schools.In Hong Kong, schools and parents play a significant role in facilitating access to mental health services for children with ADHD. However, previous studies suggest that diagnosis and treatment of ADHD may be influenced by the parents’ decision to seek care and their awareness and knowledge about ADHD -17. The To our knowledge, no qualitative research has been carried out to explore the healthcare and treatment related experiences of adolescents and young adults with ADHD in Hong Kong and mainland China. This research is important as it opens up dialogue between service providers and users, enabling patients to express their needs and experiences, and identifies the gaps in current mental health services for ADHD. The study aimed to explore patients’ experiences: a) in accessing services; b) of pharmacological and non-pharmacological treatments; c) of ADHD-related impairments; and d) to ascertain their expectations of future services.Qualitative interviews were used to explore patients’ experiences and opinions towards ADHD treatment in Hong Kong. According to a previous study, qualitative health research contributed to inform mental health policy and generated a better understanding of patients’ experiences and their active management of the disorder . Such reEthics approval was obtained from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB Number: UW13-197). Data collection was conducted between June 2013 and January 2014. Participants were eligible if they were diagnosed with ADHD in Hong Kong, were 16 years old or above, and had previous or current experience of pharmacological treatment for at least three months. Patients were excluded if they were unable to participate in a face-to-face interview. A total of 40 patients with ADHD were recruited and they were categorised into the following subgroups:Group 1: Twenty patients aged between 16 and 17 years diagnosed with and receiving pharmacological treatment for ADHD in Hong KongGroup 2: Twenty patients aged 18 years or above diagnosed with and receiving pharmacological treatment for ADHD in Hong KongThrough this grouping method, this study was able explore patients’ expectation towards transition and future treatment in participants aged between 16 and 17 years. Recruitment of a separate group aged 18 years or above would enhance our understanding of the circumstances surrounding continued treatment in the child and adolescent psychiatry setting and the possible arrangement for future care. We adapted and translated interview questions from our earlier study conducted in the United Kingdom (UK)  so they bullied me” P29) while some encountered difficulty in forming friendships.The impact of ADHD on social life also appeared to be considerable. Constant interrupting behaviours affected relationships with classmates and teachers . A few participants recalled that carelessness and poor attention hindered work performance .Some adult patients encountered difficulties with employment . Other impairments included difficulties with time management . Patients also expressed feelings of inferiority because of ADHD . Several participants were not diagnosed until late adolescence, and experienced the affects early on .Similarly, ADHD disrupted family relationships “The medication helps to keep me controlled. Helps me focus on my homework” P18). For some, however, medication was ineffective (“I did not notice a difference” P50). Indeed, growing up was found to reduce symptom severity and it was easier to be attentive and self-controlled . On the other hand, patients also experienced common side effects of ADHD medication such as reduced appetite, poor sleep quality, lethargy and antisocial feelings . Many patients were worried that medication would damage their health but generally accepted doctors’ clinical decisions (“I worry that it will cause harm to body but doctor said it won’t” P51).Overall, ADHD medication was effective and satisfactory. Medication increased attention span and reduced hyperactivity levels, which enabled the management of daily activities, particularly studying and working . Most, however, were not sure how effective treatment was (“I was quite mature when I was a child. Others were playing games happily but I thought it was stupid…and I think the improvement was not notable. Why waste time on it?” P25). A few said that non-pharmacological treatment together with medication would be more effective .About half of participants reported taking part in ADHD group training offered at the hospital when they were primary school students. At the training, groups of children with ADHD played games and attended classes that discussed school curriculum, emotional control or social skills . Some stated that doctors did not offer such treatments while others were not even aware non-pharmacological treatments were available (“I don’t even know this [treatment] exists. Doctors didn’t tell me” P51).Some patients had no previous non-pharmacological treatment, explaining they had no such need (“She [doctor] understands your problems and knows how to solve it” P34). A few patients did not have specific impressions because they saw different doctors and were asked similar routine questions . In general, doctors were the major treatment decision-makers, particularly when they were children , although they took on this responsibility as they matured (“The doctor will ask me the effect after medications and then I can make decision” P31).In general, the relationship between patient and doctor was acceptable (“The doctor was different at each consultation…I think it’s difficult to understand the patient’s need” P52). Also, the prolonged waiting time for each consultation was frustrating (“Waiting time should be shortened…I was waiting for an hour” P42). As patients reached adolescence and adulthood, psychological treatments were insufficient. A few said they received psychological services only occasionally, such as counselling by a psychologist . Indeed, a few said that the quality of follow-up was poor as doctors spent five to ten minutes asking them routine questions .Being seen by a different doctor at each consultation made follow-up intermittent and impeded build-up of rapport . More assistance or services were requested to meet the psychological needs of patients with ADHD. Some urged that more be done to raise public awareness and understanding of ADHD as they related their experiences of discrimination or being teased . There was hope that public education would address the misconceptions and increase understanding of ADHD .Suggestions were made for more investment in mental health services to alleviate pressure on the public health system (“I knew she [teacher] was busy but I just wanted some help. Was that so hard?” P17), while parents tried to control their behaviour with punitive measures . Suggestions were made that doctors should explain ADHD better, particularly during childhood, to help patients understand their condition and work with other professionals to address their issues .Appropriate guidelines and training on how to manage ADHD children should be available to teachers and parents. Some patients did not receive any support from teachers (“The main purpose is getting the medicines” P33). Patients were ambivalent regarding transition into adult services. They thought that child and adolescent psychiatry would be most appropriate because doctors were better acquainted with their cases but the transition was subject to doctor’s arrangement . It showed that patients hoped to have more regular follow-up regarding their conditions. A few said that doctors in adult psychiatry might be more experienced to deal with problems encountered in adulthood. Indeed, most patients hoped that non-pharmacological options, such as counselling, or small groups to learn to control emotions, practise social skills and share experiences, would be available in adulthood .Most patients preferred to continue treatment from current institutions because of familiarity with services (The findings showed that patients diagnosed with ADHD in childhood as expected had very limited involvement in accessing related services. This was normally arranged by significant others, namely parents and schools who have close interaction with the children. Previous studies confirm that parents and teachers were influential in the decision-making of treatment management ,32. In oIn general, the impairment of most concern was related to academic issues since the onset of ADHD often occurred around school age . The proOverall, patients were satisfied with previous or current treatments. Similar to a previous study in the UK, medications were the main treatment for ADHD . Our patAnother issue arising from treatment experiences was the relationship between patients and doctors, which directly affected the quality of care. Efforts by health professionals were often valued but patients were critical of frequent changes of the doctor in charge of their cases, which affected communication and rapport. Doubts were raised about the effectiveness of consultations that were conducted in a cursory manner in ten to fifteen minutes. Explanations about ADHD and managing the condition were deemed inadequate, particularly for children. More insight into their condition might change attitudes and improve drug compliance .Due to the lack of specialist services for young adults with ADHD, treatment was continued in child and adolescent psychiatry as doctors viewed this to be the most appropriate option. Suggestions were made to some patients that they transfer to adult psychiatry for continuous care. Others were worried that doctors in the ADHD adult psychiatry service might not have an in-depth understanding of their problems due to a lack of experience. In view of the above findings, there is a significant gap in specialist services for ADHD in adulthood, which warrants further development.The findings also illustrate current problems regarding insufficient public awareness and understanding of ADHD, and inadequate promotion of existing guidelines and training available to parents and teachers. The public perceives the classification ‘mental illness’ as a very violent and dangerous condition, resulting in stigmatism and discrimination . In thisAs for future treatment in adulthood, most patients expected follow-up would continue at current mental health services where their cases were known. Although most were open-minded about transitioning to adult services, there was uncertainty and a lack of confidence on the effectiveness of treatment in the current adult service. These factors heighten the necessity for developing specialist services to address the gaps in continuity of care for young adults with ADHD. Figure There were several limitations to the study. First, the sample size was small although it was deemed sufficient for qualitative study since generalising the findings was not the objective. With a small sample size of 40 participants, themes were not quantitatively derived. Moreover, the generalisability of the findings are limited and the participants to this study appear to be well managed based on the overall ‘mild’ self-reported symptoms and impairment severity. Indeed, participants’ experiences may be influenced by other comorbidities which were not accounted for in this study. In this study, we used the ASRS to rate their symptoms and impairments. Notably, the ASRS was developed as a screener for ADHD and the validity of the ASRS for capturing symptom burden rather than for indicating diagnosis is unknown. Second, the response rate was very low at the start of participant recruitment, which was conducted through telephone calls according to a patient list. With the recruitment strategy at the child psychiatric ADHD clinic, however, the response rate of 71% was much better. Patients were more inclined to participate in the research while waiting for their consultation. Additionally, many patients were unable to recall details of initial access to the services because they had little involvement in the process. Therefore, data collection in this section was insufficient.This study suggests that future research should focus on the perspectives of parents, teachers, social workers, ADHD clinicians or other related parties in diagnosing and managing adults with ADHD current treatment modalities for ADHD and the transition of care of young adult patients in Hong Kong. Patients’ experiences of accessing private versus public services can be further investigated, as the organisation and quality of services are quite distinct. Further, the study included several patients who were diagnosed with ADHD in late adolescence and adulthood. Future study comparing the experience between patients diagnosed in childhood and adulthood in Hong Kong is useful when developing services.Several implications for practice and policy can be drawn from the study through the four themes identified. First, the findings highlight the need to raise public awareness and understanding of ADHD to develop appropriate perceptions and attitudes among the general public. Increased public awareness of ADHD may help to minimise delayed diagnosis and reduce the impact of impairment. Since parents and teachers are in close daily contact with children with ADHD, appropriate guidelines, training and support are essential to facilitate communication. Therefore, awareness and promotion of these programmes are equally important. Additionally, this study underscores the need and increasing interest for more non-pharmacological treatment. Medication as the sole treatment for ADHD is prevalent as patients reach adulthood yet it is deficient in meeting their psychological needs. Consequently, there is a pressing need to develop specialist services to offer better and more specific support to young adults with ADHD. Importantly, the four identified themes suggest that individuals may be vulnerable to suboptimal care and these themes are important aspects to understand in the process of health system improvement.This study explores adolescents and young adults’ experiences of ADHD impairment, access to services, treatment, and their expectations of future treatment. Further improvements are required to meet the needs of adult patients such as more non-pharmacological treatment, and increasing public awareness and understanding of ADHD. Appropriate training for parents and teachers would be strategic in helping children with ADHD. As previous studies have shown, ADHD remains challenging in late adolescence and adulthood. These support the findings that specialist services for ADHD in adulthood are necessary as current adult psychiatry services may not meet patients’ needs. Further research is required to further understand the perspectives of involved parties such as parents, teachers, social care, and health care professionals to assess the unmet needs of those affected with ADHD, and to develop a multidisciplinary approach to their care.


Background: Attention deficit-hyperactivity disorder (ADHD) is the most common neuro-developmental disorder in childhood. Its pharmacologic treatment mostly includes methylphenidate, yet many parents seek alternative, “natural,” therapeutic options, commonly omega-3 fatty acids. Previous studies of supplementation with fish oil or long-chain omega-3 fatty acids to children with ADHD yielded mixed results. The use of alpha-linolenic acid (ALA), a medium-chained, plant-based omega-3 fatty acid (18:3 n-3), has not been sufficiently examined in this population.Methods: Forty untreated children with ADHD, aged 6–16 years, were randomized to receive either 2 g/day of oil containing 1 g ALA or placebo, for 8 weeks. Before and after supplementation, the children underwent a physician assessment of ADHD symptoms and a computerized continuous performance functions test. The children’s parents and teachers filled out Conners’ and DSM questionnaires.Results: Seventeen (42.5%) children completed the study, eight in the supplementation group, nine in the placebo group. Main drop-out reasons were capsule size, poor compliance, and a sense of lack of effect. No significant difference was found in any of the measured variables tested before and after supplementation, in both study groups. No between-group difference was found in the changes of the various measures of ADHD symptoms throughout the study period.Conclusion: Supplementation of 2 g/day of oil containing 1 g ALA did not significantly reduce symptoms in children with ADHD. Future studies in this field should consider an alternative method to deliver the oil, a higher dose, and a larger sample size. Attention-deficit hyperactivity disorder (ADHD) is a childhood onset disorder with a relatively high global prevalence, ranging from 2.2–17.8% . ADHD isThe pharmacologic treatment of ADHD mostly includes methylphenidate . SurprisSeveral trials of supplementation with fish oil or long-chain omega-3 fatty acids [mostly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] to children with ADHD have been conducted, and yielded mixed results. Systematic reviews and meta-analyses on this topic summarized that there is currently no consensus that omega-3 fatty acids influence ADHD symptoms . One posFewer trials examined the effect of the plant-based alpha-linolenic acid (ALA), the parent medium-chain omega-3 fatty acid, on ADHD symptoms. In one published study, 200 mg ALA administered as flaxseed oil together with vitamin C were given to children with ADHD . The autThe aim of the current study was to examine if supplementation with an ALA-rich sage oil can improve symptoms in children and adolescents diagnosed with ADHD.The study population included 40 children and adolescents aged 6–16 years, recently diagnosed with ADHD, who were drug naïve and untreated, from two ambulatory ADHD specialty clinics in Israel. Exclusion criteria were refusal to undergo any or all of the testing procedures or to take the designated supplement; a history of chronic health conditions other than ADHD; or use of any chronic medications or dietary supplements, specifically methylphenidate or fatty acid/fish oil supplements. The study was approved by the Institutional Review Board of Hadassah Medical Center, Jerusalem, Israel, conducted according to the Declaration of Helsinki, and registered in a clinical trials registry before recruitment (#NCT00874536). At least one parent signed an informed consent form, and each participant verbally agreed to participate.The study participants were randomized 1:1 to receive either 2 g/day of sage oil or an identical appearing lactose placebo in gel capsules. Participants were instructed to consume two gel capsules daily. The composition of sage oil varies slightly by crop year, and is 50–54% ALA, 20–23% oleic acid, 16–18% linoleic acid, 6–7% palmitic acid, and 2–3% stearic acid . This coBoth types of capsules were supplied in identical amounts in solid plastic bottles. The bottles were numbered consecutively and coded by a person uninvolved in the study, and each participant received three bottles that contained all pills necessary for the study duration. Each ADHD clinic received half of the bottles, numbered consecutively. The children that agreed to participate in the study received their designated bottles in consecutive order. All study participants, parents, teachers, and study personnel were blinded to the allocation until completion of all data collection.The primary outcomes at study end were ADHD symptoms, as assessed by validated questionnaires and a computerized continuous performance test . Each child met the criteria for ADHD according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR criteria , as asseThe diagnostic procedure included an interview with the child and parents, filing of DSM-based ADHD diagnostic questionnaires, and a medical and neurological examination. Parents and teachers filled the appropriate Conners’ rating scales ,b.We used the MOXO-CPT, which is a standardized computerized test designed to diagnose ADHD-related symptoms . The totThe MOXO-CPT measures four performance indices: attention, timing, impulsivity, and hyperactivity. The attention index corresponds to the number of correct space bar keystrokes in response to a target stimulus. This index is considered a pure measure of sustained attention, because it measures correct responses independently of the response time. The timing index is the number of correct responses given quickly, still within the period that the target stimulus is present on screen. The impulsivity index is the number of responses performed following a non-target stimulus. The hyperactivity index is the total number of commission responses that are not coded as impulsive responses . Other measures of the MOXO-CPT are described in detail elsewhere .The same assessment tools were used after 8 weeks of supplementation in both groups. At this final assessment visit, missing pills in the bottles were counted, to assess adherence.U Test. The between-group differences in the changes of questionnaire scores and CPT results were also compared by the Mann–Whitney U Test. Proportions were compared using Fisher’s exact test. Statistical significance was defined as a two-sided p-value <0.05.The differences in questionnaire scores and CPT results between baseline to end-of-study values within each group were compared by the Wilcoxon signed-ranks test. The differences in clinical data, questionnaire scores, and CPT results between study groups at baseline and at trial end were compared by the Mann–Whitney n=7), a subjective sense of lack of effect (n = 4), loss of contact (n = 5), or lack of interest to perform the second assessment (n = 7). None of the participants complained about the most common intolerance to fish oils, namely a “fishy” smell and aftertaste.Twenty children were included in each group, and received their designated supplement. After 8 weeks, only 17 participants remained in the study, and underwent the post-supplementation assessment: nine in placebo group  and eight in the oil group . Reasons for dropout were difficulty to take the capsules due to size or taste  and 13 (range 6–17), p = 0.47].Scores of DSM-criteria questionnaires also did not differ between placebo and omega-3 groups. Respective scores at baseline were 11 (range 6–17) and 13 (range 6–17), Table 3 presents data from the MOXO-CPT that the children undertook before and after the supplementation period. There were no significant differences between study groups at baseline or at trial end in any of the tested parameters. Additionally, there were no significant between-group differences in the changes from pre- to post- supplementation values in any of the measures.The aim of this study was to examine if supplementation with an oil rich in ALA can improve behavior and function in children and adolescents with ADHD. Using several validated questionnaires and a CPT, we found no evidence for a significant effect in any direction. Although we did identify significantly higher post-supplementation scores in the parent Conners’ questionnaires in the omega group, these were attributed to baseline differences; there were no significant differences between the changes in these questionnaire scores between groups. A decrease in the parent Conners’ DSM-IV questionnaire score was seen in the placebo group only, with no other index of improvement in any other measure in this group. We believe that this does not truly reflect clinical improvement, and is probably a random finding resulting from multiple comparisons.Several previous studies of fish oil/long chain omega-3 supplementation to children with ADHD have been performed, with recent meta-analyses showing no significant clinical effect . It shouper se. Collectively, there is still a wide gap in our knowledge regarding the effects of omega-3 fatty acids in ADHD, which is even greater in the field of plant-based ALA. The main reasons are the large variations in the types of fatty acids used , in their dosages, in the proportions between EPA and DHA, and in the different characteristics and numbers of participants in each study.To our knowledge, only two studies that utilized plant-based omega-3 fatty acids in ADHD were published to-date . Both usa priori chose a wide age range and included participants from both sexes in order to increase generalizability, yet eventually this might have been a drawback. Lastly, the dose used might have still been too low to increase the amount of brain EPA and DHA. While this dose has been shown to elevate omega-3 fatty acids concentrations in red blood cells in adults (We recognize that our trial has several limitations. Firstly, we had a relatively small sample size with a high dropout rate, attributed both to the reported inconvenience of consuming 2 g of oil per day, and to the subjective feeling of a lack of effect by the participants or their parents. Recruiting a larger sample size of newly diagnosed, non-medicated children for such a trial may be a challenge, as many parents do request an immediate and efficient treatment once their child is initially diagnosed with ADHD. Secondly, we chose a wide age range of 6.5–16 years, which might have caused a wide variation in test results, especially in the computerized test. Baseline data of the DSM questionnaire also showed a wide range of disturbance, as reflected by the range of DSM scores seen. We n adults , we woulThe strengths of the study were its randomized, placebo-controlled design; the choice of non-medicated, otherwise healthy children; and the concomitant use of several validated tools that directly assessed the child, as well as parent and teacher perceptions of his behavior.In summary, in this study, supplementation of 1 g/day of ALA using an ALA-rich oil to children and adolescents with ADHD did not improve any behavioral measure, as tested by several validated questionnaires and a computerized CPT. We do acknowledge that a major limitation to the trial was the relatively small sample size, attributed to a relatively high dropout rate. Nevertheless, our findings are in concert with many other studies which used both ALA and long-chain omega-3 fatty acids. Given the high dropout rate, and in light of previous research and anticipated effect size, we recommend recruiting much larger numbers of participants, and possibly using a higher ALA dose in future similar studies.Gal Dubnov-Raz contributed to study design, conductance, data analysis, and drafted the first manuscript. Zaher Khoury contributed to study conductance and data analysis. Ilana Wright and Itai Berger contributed to study design, conductance, and data analysis. Raanan Raz contributed to study design and data analysis. All authors contributed significantly to the manuscript text, and approved its final version.The Associate Editor Yael Leitner declares that, despite being affiliated to the same institution as author Gal Dubnov-Raz, the review process was handled objectively and no conflict of interest exists. Itai Berger serves on the scientific advisory board of Neuro-Tech Solutions Ltd. All other authors declare no conflicts of interest.


Bartonella species among rodents and their associated ectoparasites  in several regions across Thailand. A total of 619 rodents and 554 pooled ectoparasites  were collected from 8 provinces within 4 regions of Thailand. Bandicota indica (279), Rattus rattus (163), and R. exulans (96) were the most prevalent species of rats collected in this study. Real-time PCR assay targeting Bartonella-specific ssrA gene was used for screening and each positive sample was confirmed by PCR using nuoG gene. The prevalence of Bartonella DNA in rodent (around 17%) was recorded in all regions. The highest prevalence of Bartonella species was found in B. savilei and R. rattus with the rate of 35.7% (5/14) and 32.5% (53/163), respectively. High prevalence of Bartonella-positive rodent was also found in B. indica , and R. norvegicus . In contrast, the prevalence of Bartonella species in ectoparasites collected from the rats varied significantly according to types of ectoparasites. A high prevalence of Bartonella DNA was found in louse pools  and flea pools , while a low prevalence was found in pools of mites  and ticks . Prevalence of Bartonella DNA in ectoparasites collected from Bartonella-positive rodents (19.4%) was significantly higher comparing to ectoparasites from Bartonella-negative rodents (8.7%). The phylogenetic analysis of 41 gltA sequences of 16 Bartonella isolates from rodent blood and 25 Bartonella-positive ectoparasites revealed a wide range of diversity among Bartonella species with a majority of sequences (61.0%) belonging to Bartonella elizabethae complex , while the remaining sequences were identical to B. phoceensis , B. coopersplainensis , and one previously unidentified Bartonella species .Our study highlights the surveillance of  Bartonella bacteria are new emerging pathogens causing diseases in humans and animals , with eite type  and miteBandicota indica , Rattus rattus  and R. exulans  were the rodent species with highest rates of Bartonella prevalence  and R. rattus (32.5%) followed by R. sabanus (16.7%), B. indica (15.1%), R. norvegicus (12.5%), and R. exulans (3.1%). Rats of B. indica and R. rattus were heavily infested with a variety of ectoparasites  accounting for 84.3% of all ectoparasites collected from rodents in this study  and Hoplopleura spp. (38.9%), fleas were identified as Xenopsylla cheopis, and ticks were identified as Haemaphysalis spp. Mites collected from rats were more diverse than other types of ectoparasites. Three to five mites were selected from each pool and morphologically identified to genus (subgenus), and species if possible. They were all identified as trombiculid mites . The most predominant genera were as follows: Gahrliepia (39.9%), Leptotrombidium (34.3%), Ascoschoengastia (14.6%), Blankaartia (5.4%), Schoengastia (4.0%), Helenicula (1.5%) and Lorillatum (0.3%). Two major genera collected from rats were further identified to subgenus. The results showed that within the genus Gahrliepia, subgenus Walchia was the most prevalent followed by Schoengastiella, and then Gahrliepia. Almost all mites in Leptotrombidium genus belonged to subgenus Leptotrombidium.The lice were identified as Bartonella DNA was detected in lice  and fleas . High prevalence of Bartonella DNA was detected in 17/28 louse pools (60.7%) collected from R. rattus and 13/45 flea pools collected from R. exulans. Mites and ticks were mostly collected from B. indica and R. rattus and only 1.7% (5/287) of mite pools and 3.5% (6/170) of tick pools were positive for Bartonella DNA. Among Bartonella-positive trombiculid mites, 3 pools were Leptotrombidium genus, 1 pool was Ascoschoengastia genus, and the last pool did not have slide for morphological identification.Among the tested ectoparasites, a high prevalence of Bartonella isolates were successfully cultured from 26 individual rodent blood samples. Bartonella species detected from rats and ectoparasites based on sequences and phylogenetic analyses of 318 bp gltA amplicon are presented in Bartonella gltA sequences of Bartonella species detected in this study are summarized in Bartonella-positive samples clustered into 8 different cladograms as described below. The majority of identified sequences (25/41 sequences) fell within B. elizabethae species complex. Within this B. elizabethae complex group (25 sequences), 15 B. rattimassiliensis were detected from 9 rats, 5 louse pools, and 1 mite pool sharing 96.5–100% identity with strain 16115 (AY515125) and strain THNA5-R09 (JX158360). Eight sequences of B. tribocorum were detected from 2 rats and 6 flea pools sharing 99.3–100% identity with strain IBS506 (AJ005494) and strain THSKR-020 (JX158363). One sequence of B. queenslandensis was detected from a flea pool sharing 99.6% identity with strain AUST/NH5 (EU111799). One sequence of undescribed Bartonella species within B. elizabethae complex was detected from a flea pool (#F1644) with a percent identity ranging from 96.8 to 97.1% to B. tribocorum strain IBS506 (AJ005494) and strain THSKR-020 (JX158363). The rest of the detected Bartonella sequences (16 sequences) were identified into eight B. coopersplainsensis which were detected from 5 rats, 2 tick pools, and 1 louse pool sharing 99.0–100% identity with strain AUST/NH20 (EU111803). Seven B. phoceensis were detected solely from ectoparasites: 5 in louse pools, 1 in a mite pool, and 1 in a tick pool sharing 98.4–100% identity with B. phoceensis strain 16120 (AY515126) and B. phoceensis strain BR07 (GU056197). Interestingly, one sequence obtained from Bartonella-positive louse pool (#L1026) was distantly related to the rest of the Bartonella species (66.3–68.2% identity) detected in this study, however, it was similar to some new strains of Bartonella species strain BCF03 (GU056190) and strain BR10 (GU056200) obtained from Taiwan with 99.3% identity  were detected from R. rattus, while two B. tribocorum were detected from R. norvegicus only. However, no specific pattern has been observed among ectoparasites. For example, two different Bartonella species (B. rattimassiliensis and B. phoceensis) were detected in mite pools  were detected in flea pools (Xenopsylla cheopis), 4 species ) were detected in louse pools (Polyplax spp. and Hoplopleura spp.), and 2 species (B. phoceensis and B. coopersplainsensis) were detected in tick pools .In this study, we found that the distribution of te pools , 3 speciBartonella DNA prevalence in ectoparasites collected from Bartonella-positive and Bartonella-negative rats was investigated and presented in Bartonella-positive rats, 20/103 (19.4%) ectoparasite pools were positive for Bartonella species. In contrast, only 27/309 (8.7%) ectoparasite pools were positive from Bartonella-negative rats. Of these Bartonella-positive ectoparasites, louse pools possessed the highest prevalence of 65% (13/20) and 46.7% (7/15) for positive and negative rats, respectively  were higher significantly  comparing to ectoparasites from negative rats (8.7%).The difference of ectively . In geneBartonella species among rodents and their associated ectoparasites  in several regions across Thailand. The data demonstrated the high prevalence of Bartonella DNA in rats and their associated ectoparasites, especially in lice and fleas, as well as the finding of a diverse range of Bartonella species circulated among them. Previous studies have shown the high prevalence of Bartonella species among rats captured from Chiang Rai province (8.7%) [et al. was higher  than what we found , the proportion of rodent species are relatively the same except that B. indica was the highest number trapped in our study , while Bai et al. reported R. rattus as the most prevalent species investigated in their study . Given the higher rate of Bartonella-positive detected in R. rattus comparing to B. indica rat, the high Bartonella prevalence reported in Bai’s study can be explain by rodent species composition. Similarly, high prevalence (41.3%) of Bartonella was reported in rodents and shrews in Taiwan with the highest prevalence was found in R. norvegicus (52.7%) [Our study highlights the surveillance of e (8.7%)  and frome (8.7%) . Althoug (52.7%) .Bartonella DNA was detected in all types of ectoparasites  collected from rats in this study, the prevalence varied substantially between ectoparasite types. The highest rate was found in lice and fleas that were in agreement with the study conducted in Taiwan [Bartonella DNA was found in lower prevalence in ticks and mite pools in both studies, Kabeya et al. reported high prevalence in mites (82.9%) collected from rats in Thailand and all Bartonella species detected from mites were identified into B. tamiae based on their DNA sequences [Polyplax and Hoplopleura lice are more likely specific to Rattus rats or to some other relative rat species [Bartonella community.Although n Taiwan . Though equences . Althoug species , 38, theBartonella species were isolated from whole blood of rats and shrews, including B. rattimassiliensis, B. grahamii, B. elizabethae, B. tribocorum, B. coopersplainensis, B. phoceensis, B. queenslandensis, and unknown genogroup [B. rattimassiliensis, B. tribocorum, B. coopersplainensis, were isolated from rats in our study. Bartonella species found in rodent-associated ectoparasites were more diverse with seven different species found, including species isolated from their rat hosts. In this study, gltA gene sequence was used to identify Bartonella species, although ssrA gene was also sequenced and analyzed. We found that both genes were effective to identify Bartonella at the genus level; however, gltA gene sequence was found to be more suitable for species identification than ssrA gene sequence since the gltA sequence has expressed a higher range of variation comparing to the ssrA. Moreover, the availability of gltA reference sequences for Bartonella species in available databases is much higher than for ssrA genes that makes it a reliable and accurate tool for Bartonella species identification. Additionally, phylogenetic trees constructed from Bartonella culture isolates using both ssrA and gltA genes created quite similar phylogenetic tree topologies as shown in A diverse range of enogroup , 35, 36.et al. [B. tamiae, previously isolated from Thai febrile illness patients, in mites and tick pools collected from rats in Thailand. Two dominant mite genus most infected with B. tamiae were Leptotrombidium (66.7%) and Schoengastia (78.6%), therefore, the author suggested the role of mite as potential vector for B. tamiae transmission to human patients. In this study, Bartonella DNA was also detected from mites of Leptotrombidium and Ascoschoengastia genera, although B. tamiae was not found in our study. Our finding supports the role of trombiculid mite as a vector for Bartonella transmission. Because of the difficulty of mite species identification, the mite species in each pool was determined based on 3–5 mites selected from each pool and mounted on a glass slide as mentioned in materials and methods.Kabeya et al.  reportedBartonella positive ectoparasites from Bartonella-positive rats was higher than in Bartonella-negative rats suggesting that this environment promotes the occurrence of horizontal transmission of Bartonella bacteria during the bite/feeding of vectors on rats. However, in order to prove infection route, transmission studies from an infected vector to naïve hosts/rats should be done in a controlled laboratory environment. Seasonal dynamics of Bartonella infection in natural populations of rats can also obscure a correlation between prevalence in rats and ectoparasites.From our study, we found that Bandicota and Rattus rats are the most common reservoir hosts for Bartonella infection in Southeast Asia which raises a question about the potentially important role of these rodent-borne agents as sources of febrile illness in human populations in Thailand. Detection of Bartonella DNA similar to B. tamiae, isolated from three febrile patients [Bartonella species, previously identified from rodent hosts, from Thai patients’ blood and supported by analysis of history of the patients having an exposure to rats during the 2 weeks before the illness [Bartonella species identified in these human cases included B. elizabethae, B. rattimassiliensis, and B. tribocorum, and the last two of these species were also detected in rodents, mites, fleas, and lice reported in this study.patients , and fropatients  imply a  illness . BartoneResearch was conducted in compliance with the Animal Welfare Act and other federal statutes and regulations relating to animals and experiments involving animals and adheres to principles stated in the Guide for the Care and Use of Laboratory Animals, NRC Publication, 2011 edition. The opinions or assertions contained herein are the private views of the author, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense.S1 FigssrA and gltA genes were able to discriminate all samples into two major clusters (C1 and C2), although some different branching patterns of sequences in C1 group  were noticed.The GenBank accession numbers are shown for each reference sequences. Trees constructed from (TIF)Click here for additional data file.S1 FileBartonella DNA detection in flea pools classified by gender (Table B) and in tick pools classified by stage and gender (Table C)Detail information of ectoparasites collected from rodents in this study (Table A).(DOCX)Click here for additional data file.


Nicotine use has been reported to ameliorate symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). Furthermore, adults with ADHD have a relatively high prevalence of cigarette smoking and greater difficulty abstaining from smoking. Overall, though, there is scant literature investigating the beliefs, perceptions and experiences of smokers with ADHD regarding smoking cessation and withdrawal.n = 20) fulfilling criteria for ADHD and a past or current dependence from nicotine were recruited from the in- and outpatient clinic of the Zurich University Psychiatric Hospital and the Psychiatric Services Aargau (Switzerland). We conducted in-depth interviews to explore their motivations to quit, past experiences with and expectations about quitting using a purposeful sampling plan. The sample was selected to provide diversity in relation to level of nicotine dependence, participation in a smoking-cessation program, gender, age, martial status and social class. Mayring’s qualitative content analysis approach was used to evaluate findings.Our participants  health concerns, 2) the feeling of being addicted, and 3) social factors. Most participants favored a smoking cessation program specifically designed for individuals with ADHD because they thought ADHD complicated their nicotine withdrawal and that an ADHD-specific smoking cessation program should address specific symptoms of this disorder.Since treatment initiation and adherence associate closely with perception, we hope these findings will result in better cessation interventions for the vulnerable subgroup of smokers with ADHD. Adults diagnosed with Attention- Deficit/Hyperactivity Disorder (ADHD) exhibit significantly higher rates of harmful use of or dependence on nicotine than persons without this neuropsychiatric disorder, with comorbidity rates as high as 35 to 55 % in United States samples , 2. SimiPatients with ADHD suffer from symptoms of inattention and hyperactivity-impulsivity that result in a diverse range of psychosocial impairments . Small, More recent research on ADHD and smoking has investigated the link between specific ADHD subtypes  and certain clinical characteristics, including levels of nicotine use, withdrawal symptoms, abstinence rates, treatment readiness, and treatment response , 15, 16.smoking as attempt of self-medication and smoking as a social behavior. Participants viewed the use of nicotine rather positively—considering it a therapeutic aid—and they reported positive effects on psychopathological symptoms (relieving “inner tension”), cognitive, and social functioning. In the present study, we expand this work by focusing specifically on beliefs, perceptions and experiences of smokers with ADHD regarding smoking cessation and withdrawal.In a previous study published in the same journal we explored how patients with adult ADHD, who currently smoked, viewed the relationship (or link) between nicotine use and ADHD . We idenIn the general population, non-ADHD smokers attribute cigarette smoking to beneficial psychological, physiological and social effects , 19; expEspecially in light of the lack of evidence-based guidelines for the treatment of comorbid ADHD and SUD , these qData were collected during a series of qualitative interviews with adult smokers with ADHD in treatment either at the ADHD consultation service at the Centre for Addiction Disorders, an outpatient facility of the Zurich University Hospital (12) or the Psychiatric Services Canton Aargau (8).A mixed method of purposeful sampling and saturation sampling principles was used. The sample was selected to provide diversity in relation to (1) level of nicotine dependence (very low to very high); (2) clinical experience (previous in- and outpatient treatment episodes), including comorbidity , age (25–54), martial status , social class  and immigration status . We also sampled for participants who had participated in the smoking cessation program (8) and for those who had not (12).Zurich participants were recruited from a larger sample of 134 participants who had participated in an epidemiological study of the association between ADHD and tobacco use . DependiPrior being interviewed, eight out of these 12 subjects recruited had participated in a smoking cessation program that was modeled after recommendations by Cornuz et al.  and the Additionally, we interviewed eight subjects from the Psychiatric Services Aargau who had not participated in a cessation program to obtain a greater variation of themes and motives.Subjects who declined specifically named barriers to participation in a few instances. Lack of time was the most common reason why potential participants declined inclusion in this study. Additionally, three potential participants agreed to be interviewed, but missed their appointment. Attempts to contact these subjects again were not successful.Interviews explored the following topics: 1) past experiences with smoking cessation and withdrawal, including strategies used; 2) motivations, expectations, and reasons for participating in a cessation program; 3) thoughts about an “optimal” smoking cessation intervention; and 4) perceptions about a smoking cessation program specifically designed for adults with ADHD.Prior to inclusion, all participants had a complete evaluation of their ADHD in accordance with current diagnostic recommendations  using thAdditionally, researchers had access to a complete clinical chart on each subject, including biographical data and comorbid psychiatric diagnosis according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Nicotine dependence was assessed using the six-item Fagerstrom Test for Nicotine Dependence (FTND) , and absverbatim. Interviews were conducted by two researchers (AF/RN), and participants chose the interview locations so they felt free to fully express their own views and perceptions …”Mrs. F.“Around four – to five times…”Mrs. G.Most participants, regardless of whether they had participated in the smoking cessation program, had attempted to quit smoking several times in the past. Only three subjects had never tried to stop smoking.“I stopped once for 6 months, that is a long time ago when I was 22. The last time I made it for four days.”Mrs. J.“…the only longer period…where I had the feeling of being out of the woods…was for one month…”Mr. K.“…The longest period was one year of not smoking…”Mrs. G.Cessation efforts had resulted in a diverse length of abstinence ranging from days to years.“…nothing big…well, the first three days more psychologically, that I was thinking about it. But physically I did not notice anything…certainly more nervous though”Mrs. H.“…I experienced no withdrawal symptoms, maybe a little restlessness…”Mrs. E.Some participants considered smoking cessation relatively easy, with only minor complications:“…and stopping is so tedious, it fills your mind all day and all night, that you are always thinking about it…you always think you must not smoke, it becomes the primary objective. And then I get in to panic that will go on until life’s end…it is exhausting…”Mrs. J.“I noticed then, that it needs, after such a long time, I am now 53 years old, and I got used to a lot of this stuff and then I noticed the motivation is there, but it is really tough to pull it through…”Mr. A.The majority of participants, however, experienced attempts to quit as highly stressful and described severe difficulties during those attempts, regardless of whether they had made a conscious decision to quit or they were forced to quit by external circumstances.“Nervousness, restlessness, the permanent back and forth, not knowing what it is all about [starts laughing]…I forgot to go get groceries, and I just noticed it at night, and then I forgot it again, because I was so busy, and then I had to get out again…back then…I started sweating and it was difficult to concentrate, but no sleeplessness…”Mrs. F.“…I started to cry because of little things, although I am usually not someone who starts crying, that was bad, tragic…and the irritability, I could not bear anything, I had to cry the entire time and was furious…”Mrs. G.“…one time I had sleep issues, the other times I did not have that. And then the devil in your body. That was the worst for me. Always: now a cigarette, a cigarette, that would be good now, simply, such a chase, now you have to have one…”Mrs. G.“…the first few days were nasty…it was a physical malaise and…also psychologically. I am not easy to talk to, on the edge and bad tempered…”Mr. K.Most often, subjects had experienced symptoms of irritability, nervousness, and restlessness, sometimes accompanied by difficulty sleeping or symptoms of depression and anxiety.“…I noticed that I got depressed and aggressive and that something was missing…and than I started to drink more, and that was a direct consequence. That is why I knew it was alright to drink a bit more…”Mr. A.Some participants who experienced these difficulties described the use of other psychotropic substances to cope:“ …for a time I drank more coffee…”Mrs. E.“…I had a much increased appetite for candy and sweets, what I usually don’t have…”Mr. K.Others noticed a change in their caffeine use or eating:“… I was totally shocked when I stopped [without counseling], what happened back then…when I gain weight that is a huge problem. I can not accept that, I don't want to be 4–5 kg more than I am now, and I don't want to be a nervous wreck. I can not afford that with my children. The last time I tried to quit I almost had a nervous breakdown, and that was shocking.”Mrs. G.Less frequently, other side effects were noted; for example, a perceived increase in weight:“… I get even more erratic and aimless, I walk the entire house and don’t remember what I had planned to do, why and where, I just jump around…”Mrs. J.“… It amplified [symptoms]…my strategies to calm myself down were not working anymore…”Mr. I.Notably, almost all participants who experienced difficulties associated these symptoms with immediate nicotine withdrawal. Since symptoms of ADHD can be difficult to differentiate from nicotine withdrawal symptoms, participants where further asked to elaborate on this issue. The question of whether smoking cessation had a lasting influence on symptoms of ADHD was addressed by half of the participants. While one participant denied that symptoms of ADHD had gotten worse, all others were convinced that smoking cessation had resulted in a worsening of ADHD symptoms even after immediate physical symptoms of withdrawal had subdued.“Actually I didn’t have big problems, during that time, I mean the biggest problem I had was my partner, because he smokes and we were together for such a long time, and then I was smoking with him and that was a problem…”Mrs. C.Independent of withdrawal symptoms, some participants viewed external social factors as the most problematic experience after ceasing the use of cigarettes.“…what helped me was Zyban® and sports…”Mrs. G.“… before that I tried acupuncture, twice with permanent needles, once just with regular needles…did not help…”Mrs. F.“I was working with a magneopath and I was smoking 24 cigarettes a day back then, and then one week only two cigarettes, that was a good experience…”Mrs. D.Only a minority of participants had tried to quit smoking without treatment, conventional or otherwise. Subjects had used medications  as well as alternative methods like acupuncture (two) and magentopathy (one) in various combinations. While pharmaceutical support was experienced as somewhat helpful in attenuating symptoms of withdrawal, acupuncture was not considered helpful and “magnetopathy” was thought to have a positive but transient influence:“…I did do a lot of sports, but at the end of the day, I did not find it difficult…”Mrs. C.Many subjects emphasized that in previous attempts to cease smoking an intensive physical exercise program was very helpful.Easy Way to Stop Smoking , that helped, but I permanently had a piece of wood in my mouth, but it also calmed me…”Mrs. E.“I had a time when I was not smoking for 15 months… I read a book by Alan Carr, that really helped me and I sill believe if I had the money that I would like to take one of those courses.Mrs. C.Other measures included the use of licorice for oral stimulation and reading Allen Carr’s  Smoking  in orderAll subjects addressed the issue of motivation, often spontaneously as part of their initial narrative, regardless of whether they had decided to participate in the cessation program. We identified three themes regarding motivation, but there was significant overlap between themes, and eight participants described more than one motivational factor.health concerns. Subjects were afraid of serious negative consequences to their personal wellbeing from smoking. Additionally, many subjects described perceived negative effects on their physical resilience.“…from my point of view the damage (of smoking) is mostly physical in nature, it puts a limitation on your life, on your fitness, and in the long term all these damages to your health, yes…”Mr. B.“…now it is really, the exercise, the new kinesthesia which you get when you say no, I don’t want to give up now, because that just does not fit together, I cannot work out 5 hours per week and then smoke 10 cigarettes per day, that does not work and this is where I draw the line…”Mr. B.“It all starts with your health, that it is somehow harmful, and that you also feel it, I mean I was not smoking for one year and I know how it is not to be smoking, how you feel with that…”Mrs. G.The most commonly expressed theme was feeling of being addicted, a limitation they described as a lack of personal freedom.“[disadvantages] are for me more of psychological nature, rather than physical, because I go to the doctor on a regular basis to get a check up, I also get lung X-rays frequently and then I am always relieved that I can continue to smoke. It is more the lack of freedom… that I am dependent on these cigarettes…”Mrs. D.“…and the really bad thing is this addiction, I find this worse than all the damages to health. Just because you must have one, it is not your will that is deciding, now I am gonna have a smoke and now not, it is not like eating chocolate, you really must [smoke] …”Mrs. C.An equally important motivational factor for many individuals was the social factors were also frequently mentioned. Immediate family members, relatives and significant others were important external motivational influences. Many participants felt a moral obligation to avoid harming their offspring. Subjects of both genders described previous phases of abstinence during pregnancy and caring for children.“… I mean when I first stopped smoking my motivation was my family, my two kids, my two babies at home, that was enough back then…”Mr. B.“…[I stopped smoking] during pregnancy and lactation…it was clear to me that I would have had remorse…”Mrs. H.“During the last pregnancy… I stopped smoking for two to three weeks…I made sure that I did not inhale…”Mrs. F.As expected, “Today it is also partially difficult, where can you go, without getting looked at…”Mrs. F.Interestingly, two subjects specifically viewed themselves as socially excluded or even harassed by non-smokers and felt that these feelings had contributed to their decision to quit smoking.“I don’t see a benefit, you know every reasonable human sees first, that it costs a lot of money, which you could use otherwise…”Mrs. J.“…and also the cost, that is something…”Mrs. F.Less surprisingly, financial stress was another frequently mentioned external social factor.“maybe something more like an inpatient program, a little bit like a vacation program, with occupational therapy, and when I have a crisis, someone is right there for me. I have been thinking about entering a clinic…for a smoking cessation program, and then I think this is a bit too much [for smoking], everybody else can do without it, but maybe it would be something for me… if there would be care 24/7.”Mrs. D.“and what I would immediately do is to go somewhere for two or three weeks like a heroin addict. I think it is kind of sad, that something like this does not exist for smokers, because I have seen this with my brother who is a heroin addict. I don't see a difference between us [smokers] and heroin-addicted humans. In my perception I am chasing after a cigarette just as he is chasing after an injection, just another form, same thing. It’s a kind of pity that there is no place where I can have a controlled withdrawal…”Mrs. G.Our study participants offered their own suggestions for the design of smoking cessation programs. Interestingly, many subjects viewed an inpatient treatment setting in a “specialized” hospital as desirable and were ready to participate in such treatment even for several weeks. They associated inpatient treatment with less severe withdrawal symptoms because of continuous access to health care professionals and protection against relapse.“… I believe something would have to be changed inside my head [laughs]. I do have the feeling that, I don’t know if it is possible, to participate in a week long “sleeping regimen” in a hospital…Mrs. J.“Or something without side effects, that doesn’t bother and doesn't stress me…and I have to add, that I have something in my head that I would like to try, which has fascinated me for a long time…hypnosis…”Mrs. G.Other subjects suggested even more extreme methods, ranging from a “sleep regimen” to being abandoned on a distant island. Furthermore, several participants were interested in hypnosis.“…the best idea would be to find the switch in your brain, where you can just turn it off…”Mrs. F.“…and of course you wish that someone just has a solution for you…”Mrs. E.“I haven’t given up on it yet, I really want to quit, but, it is still incomprehensible for me, how I am supposed to do that, how I can outsmart myself. Last time it just did not happen, I am still waiting, it sounds stupid, for an inspiration, for something that I suddenly can manage it with.”Mrs. F.There was some overlap in this theme with the desire for a “quick fix” or miracle cure, something fast, with no symptoms of withdrawal.“…I believe that if it is done in a group of other persons who are affected, that say we all want to stop now, and are motivating each other or can talk about difficulties, than it might create good feelings, that one is not alone with this.”Mr. K.Some participants suggested that a group setting might be more beneficial than individual counseling.“…Education, ah, ‘shock therapy,’ although some say it is not helpful, but it supported me a lot, back when a friend of mine was diagnosed with lung cancer and my family practitioner told me that I have chronic ‘smokers cough’ and what that all means and what kind of lung diseases there are, that really alarmed me… you tend to block these things out of your mind…”Mrs. C.“…Coaching could be more intensive and more demanding. I think there should be more pressure from the side of the therapist…and maybe even some financial commitment, defining targets and stages, and also rewards and penalties…”Mr. B.Interestingly some subjects felt that financial penalties or a vivid description of the harmful consequences of tobacco use might lead to success.“…In my case it would need psychiatric support, it can be done together with the treatment of ADHD, because it fits there. Because there are some studies that say nicotine helps people with ADHD, and because of that it is another hazard, and it is also an extra step for people with ADHD, because it is not just an addiction, but almost medicine.”Mr. L.One participant, who was aware of his dual-diagnosis, explained that he viewed psychiatric treatment for his ADHD as the primary strategy to stop smoking.“…I am not sure about it, because there are many people out there, who more or less have it, and who have lived with it without knowing…and that is why…”Mrs. G.“…I could not say, but I see in everybody how difficult it is [to stop smoking].”Mrs. H.While four subjects were reluctant to comment, one participant opposed a program designed for adults with ADHD. Another subject similarly noted that there were many smokers without ADHD who had difficulty quitting.“…the major difference I see is that people with ADHD have a harder time quitting smoking than people without ADHD…and with me I am just scared to change, the inhibition threshold increases because you are chaotic and [when you stop] I am afraid that the chaos just increases, and that is why you wait for a more quiet moment in life…and I think these are the kind of things that people with no ADHD would not think.”Mrs. C.“…the form of consultation [for smokers with ADHD] should be fundamentally different. That you really look if someone can keep the attention focused on the course, that you also support more in case of failure, and that you keep at it, and keep at it, because for smokers with ADHD it is not necessarily a motivational problem… And the topic of compensation is more important, because of the strong inner tension that most experience, that is something that contributes to smoking…”Mrs. E.“I could imagine that it is more important to involve family and friends in smokers with ADHD, compared to other participants, because this way there would be a bit more control, responsibility, support through children, whatever…I think the social community is more important in patients with ADHD than in others…”Mr. B.The other study subjects supported specific counseling for individuals with ADHD, as they felt that people with ADHD have unique smoking patterns. They felt that a specifically designed program should expect a worsening of ADHD symptoms during nicotine withdrawal, help develop coping strategies for these symptoms, consider inattentive symptoms and symptoms of “inner tension,” deliver support during “failures,” engage participants more actively, and involve family members.“…ADHD people are usually more nervous, and they are always sped up, and so on, and the most people with ADHD I know smoke, and smoke a lot, and you have to specifically reach out to these people and also the ones who do not know that they might suffer from that illness, because many people with ADHD that I know, they don’t know that they have it, so it starts earlier on…I only learned about my diagnosis when I was 50 years old…”Mr. A.One participant suggested that screening for ADHD in smokers should be done more routinely, pointing out that he was diagnosed only at a later age.“… I have a lot of experience with ADHD…someone who does not have this sort of experience, who has ADHD and has to fight with addiction, they might need more alternatives… what are these alternatives, and you have to look how it really is with ADHD, and with this inner tension, because you will definitely need something. It should not just be about smoking. The program should be about addiction. I know different people with ADHD and they all have their problems and different strategies to approach them. So we need to know about alternatives, and many individuals with ADHD really have to fight addiction and dependence. Many smoke cannabis like crazy to calm down, others use cocaine…”Mr. A.Another subject was convinced that a cessation program should not focus on the use of tobacco, but on substance misuse in general.This study describes the views and experiences of adults with ADHD regarding smoking cessation and withdrawal, their expectations and motivations for participation in a smoking cessation program, and their ideas about optimal support during the withdrawal process.The vast majority of study participants had a long history of tobacco use. Sixteen subjects were rated “highly” or “very highly” dependent on nicotine according to the FTND, and many reported several previous attempts to quit smoking. Subjects had frequently relapsed after short periods of abstinence, and they described symptoms of irritability, nervousness, restlessness, insomnia, depression, anxiety, and weight gain during withdrawal. These self-reported symptoms do not significantly differ from previously reported self- and observer-rated withdrawal symptoms of self-quitters in non-clinical samples , 42.Some data indicate that adult smokers with ADHD experience worse withdrawal symptoms, depressive mood swings, somatic symptoms, and craving after stopping nicotine use, compared to smokers without ADHD –45. For Our study subjects described a wide variety of smoking intervention and self-help strategies that they had used in previous cessation attempts, including both evidence- and non-evidence-based approaches. Several had tried acupuncture, “magnetophathy,” and homeopathy. Similarly, a recent population-based study of 988 Swiss smokers found a high preference for non-evidence-based treatment strategies, including acupuncture and hypnosis, although both treatments are in few instances prescribed by physicians . The authealth concerns, was named by the majority of the participants and was expressed most frequently. Subjects were afraid of serious future deteriorations in their health status and of negative health consequences in general. The second motive, the feeling of being addicted, was associated with a lack of personal freedom and independence. The third motive, social factors, was mentioned as frequently as the second motive, and it involved themes such as family ties, perceived social undesirability, and financial considerations. These findings are in accord with the extensive literature on factors associated with the desire to quit smoking in smokers without comorbid ADHD [We identified three interrelated motives to quit smoking, though there was some overlap between motives and the majority of our participants gave multifactorial explanations. The first motive, bid ADHD –52. For bid ADHD . A recenbid ADHD .desire for a “quick fix” was common, similar to a desire for finding a “switch in the brain” or a “miracle solution.” Subjects who voiced this motive also suggested a wide variety of measures, including intensive inpatient treatment, financial penalties for non-compliance, non-evidence-based treatment strategies , or even the fantasy of abandonment in a distant location.As demonstrated by their views about an optimal smoking cessation program, participants had some misconceptions about nicotine dependence. For example, subjects did not understand its status as a substance use disorder; some thought an optimal treatment program would allow them to immediately and permanently abstain from smoking without experiencing any symptoms of withdrawal. The motive of a Other findings in this context were more heterogeneous. Some participants thought group therapy should be part of an optimal treatment program, and another participant suggested that focusing primarily on treating ADHD would best change smoking patterns. Furthermore, none of our study subjects spontaneously expressed interest in a long-term nicotine maintenance approach, instead focusing on complete abstinence, even though by the end of the smoking cessation program no subjects were able to maintain abstinence, and half of the participants had returned to their initial pattern of tobacco use. This finding is consistent with previous reports that smokers prefer cessation to nicotine maintenance, and that some smokers even perceive nicotine replacement as harmful , 55.Finally we explored perceptions about a smoking cessation program specifically designed for adults with ADHD. The majority of subjects felt a need for this type of specific counseling, as they considered their ADHD symptoms a significant complication during nicotine withdrawal. Most commonly, subjects called for a treatment protocol that would take into account worsened ADHD symptoms and prepare them with coping strategies specific for these symptoms.This study has certain limitations: AF, a clinical psychologist, who also provided counseling as part of the smoking cessation program, conducted all interviews with SCP participants. This may have influenced participant responses on SCP. However, we also included twelve subjects from different locations, who had not participated in the SCP, broadening the sample of participant views. Furthermore data on nicotine consumption patterns are self-reported; relying on an active reconstruction process called recall, and may have resulted in a recall bias.In summary, adults smokers with ADHD had made several attempts to quit (often using non-evidence-based treatments), experienced those efforts as highly stressful, felt intense symptoms of withdrawal, and relapsed early and frequently. Subjects also frequently noted a perceived worsening of ADHD symptoms with phases of prolonged nicotine abstinence. Their motives to quit smoking were very similar to smokers without ADHD, including health concerns, the feeling of being addicted, and social factors. The majority of subjects who participated in the smoking cessation program viewed it as helpful, and they highlighted the benefits of both structure and counseling. Additionally, many participants in this study favored a smoking cessation program specifically for individuals with ADHD. Many believed that nicotine withdrawal was complicated by symptoms of ADHD and that an ADHD-specific smoking cessation program should address specific symptoms of this disorder. Ultimately, considering that both the initiation of psychiatric services and adherence to those services are closely associated with personal attitudes and beliefs, we offer these findings in the hope that future cessation interventions for smokers with ADHD might better serve this vulnerable subgroup , 57.ADHD, Attention-Deficit/Hyperactivity Disorder; ADHS-SB, Attention-Deficit/Hyperactivity Self-Report Scale; FTND, Fagerstrom Test for Nicotine Dependence; ICD-10, 10th revision of the International Statistical Classification of Diseases and Related Health Problems; SUD, substance use disorder; WRAADDS, Wender-Reimherr Adult Attention Deficits Disorders Scale; WRI, Wender-Reimherr Interview; WURS-k, Wender Utah Rating Scale