Investigate diagnostic stability, daily life functioning and social situation in womendiagnosed with ADHD and/or ASD in childhood.M = 27, 4 years old) with semi-structuredinterviews and questionnaires, close relatives were interviewed.Prospective 17 to 20-year follow-up study of 100 girls of whom 92 diagnosed inchildhood with main DSM-IV ADHD or ASD, and 60 comparison girls. Ninety and 54 of thesewomen were examined (At follow-up, 89% of women with ADHD or ASD in childhood still met the criteria foreither of these diagnoses. Very few women were “in remission.” In 34% the main diagnosisshifted from ADHD to ASD. Women with ADHD and ASD had significantly more disability andunfavorable social situation than comparison women.Women with ADHD and/or ASD in childhood had impairing problems 17 to 20 years later.Early ADHD changed to ASD in adulthood in some cases. Nearly all with ASD met criteriafor ADHD as adults. Diagnostic and Statistical Manual ofMental Disorders  and autism spectrum disorder (ASD) areheterogeneous neurodevelopmental disorders (NDDs) with onset early in life. ADHD is defined byimpairing symptoms of inattention (ADHD-I), impulsivity/hyperactivity (ADHD-H), or acombination of both (ADHD-C) according to the The main symptoms of both ADHD and ASD lead to substantial impairments in many importantdomains of functioning.Until recently, most ADHD and ASD research has focused on boys and men . As a coDuring the past decade, several studies focusing on females have been carried outparticularly with regard to ADHD . A serieStudies on the stability and developmental trajectories of ASD diagnoses in females with ASDare few .HoweverWhile in the past considered to be easily separable disorders, it is now clear that ASD andADHD are often comorbid with each other, share many genetic factors and show similarfunctional and structural brain characteristics and cognitive profiles .Together with other NDDs  and Tic Disorders (TD)) ASD and ADHD are sometimesgrouped under the acronym of ESSENCE  .The prevalence of ASD with ADHD for children in clinical studies have been estimated at 53%to 78%  and in oADHD affects about 5% to 7% of the general population of children  with 1.6Studies focusing on the ADHD symptoms and its effect on women’s psychosocial lives,compared to women without ADHD are few. However adverse outcomes have been reported foryoung women with ADHD in academic, occupational and social areas . TeenageASD has a population prevalence of about 1% to 1.5%  with a mStudies focusing on the ASD symptoms and its effect on women’s psychosocial lives, comparedto women without ASD is rare. However two reports have shown greater risk for negativesexual experiences compared to women without ASD .There arSimilarities between causes of missed or delayed diagnoses in ADHD and in ASD have beenfound . SeveralThe aim was to study diagnostic stability in ADHD and ASD according to DSM-IV establishedin childhood/adolescence into early adulthood in a clinical group of women. Another aim wasto compare the main diagnoses examined according to the DSM-IV and DSM-5. Further, to studyoverall function level and psychosocial situation compared to a group of women without thesediagnoses.The present follow-up study occurred at Time two (T2) after the original diagnostic studyat Time one (T1). It was carried out, as part of a larger prospective longitudinal follow-upstudy of 100 Swedish girls with ESSENCE, the vast majority was diagnosed with ADHD and/orASD in childhood/adolescence, 17 to 20 years after diagnosis . IncludeM = 13.0,SD3.4) than those with ASD  (p < .001).Between 1999 and 2001, 100 girls aged between 3 and 18 years were assessed for socialimpairment and/or attention problems at the Child Neuropsychiatry Clinic, QueenSilvia’s Children and Youth Hospital, Gothenburg, Sweden. The investigation wasmulti-professional and was performed by experienced clinicians. Of the 100 girlsparticipating at T1, 46 received a main diagnosis of ADHD, and 46 a main diagnosis ofASD  of whom the vast majority also had “comorbid” diagnosis ofADHD. Of the remaining eight, three were diagnosed with TD and five with other maindiagnoses (OMD). Although the inclusion criterion of the study was the absence of ID,12 girls (10 with ASD) were found to meet the criteria for ID despite havingoriginally been screened ID negative (see reference ). All din =60) were selected and matched for age (±2 months) with 60 randomly selectedschoolgirls from the register of a pediatric outpatient clinic in a community in theGöteborg region. Exclusion criteria for the community girls included serious medicalillness, ID or having a sibling or parent with a known NDD. Three of 60 communitygirls were excluded after full assessment at T1. The final community group composedtherefore of 57 girls. Among the 60 matched clinic girls ADHD was received in 34 andof them 32% also had autistic trait. Twenty girls received an ASD diagnosis of the 60matched clinic girls.All clinic girls 7 to 16 years of age with a tested FSIQ ≥ 80 when they were ≤18 years of age were invited to participate in a follow-up assessment(T2). Ten of them declined participation. Four further women declined a personalinterview but granted permission for a proxy interview with a close relative. Fivewere not able to participate on their own due to communicative disabilities  but were seen and gave permission themselves or through their legalguardian, for an interview with a close relative . Three womenwanted to participate themselves but did not agree to the participation of a relative.We thus received information from both the woman and her relatives in 78 cases, fromthe woman only in three and from a relative only, in nine cases.MClinG and Non-MClinG, 54 and 36, respectively . All clinic women with ID wereincluded in the Non- MClinG.All the 90 women in FClinG were included at T2 and were distributed betweenvely see . In the In the MComG 54 of the 57 women participated at follow-up, three were not reachableor declined participation. Two of the women agreed to participate but declinedparticipation of a relative. Altogether, information was obtained from both woman andher relative in 52 cases and from the woman only, in two cases. These 54 women wereincluded in the MComG . After fThe Central Ethical Review board of the University of Gothenburg has approved the study. All the 144 participating women or their legal guardians,provided written or orally informed consent to participate. Special arrangements wererequired to ensure that potential participants were fully informed. After the formalinvitation was sent, a second simplified version of the letter, was sent as a supplement.Oral information was also provided to ensure that all participants understood what theinterview/assessment would entail.Appendix1). Most of the clinic women were interviewed during one single session,lasting 4 to 8 hr, but some required two or more sessions. The women in the FClinG wereall assessed by one of three physicians  clinically experienced in the assessment and treatment of NDD. All interviews wereconducted in Swedish and all instruments used were translated and previously used inseveral Swedish studies.All the 144 women were examined with the same instruments according to their ability toparticipate. The interview included 16 instruments for the women and eight instruments forthe first degree relative , andfour in restricted/repetitive behavior and interest domain (RRBI). In DSM-5 this ismodified into three items in the SOC and four in the RRBI domain. To ensure that allcriteria were examined, in addition to what emerged during the interview with thewoman and her relative, data from the instruments below were used.Data were collected using a semi-structured interview schedule including 114questions, in all women who were able to participate by their own. The topics coveredin this interview 11 domains. In the actual study we used data from following topics:housing, relations, studies, economy and work/daily activity. We also asked aboutviolence, physically, mentally and/or sexually  and ifso, by whom. This type of interview has earlier been used in follow-up studies at ourcenter. However our research team added some “female-oriented” questions specificallydeveloped for this study.In the examination process of ADHD, results obtained on the Wender-Reimherr AdultAttention Deficit Disorder Scale (WRAADS) a self-report questionnaire completed by thewoman, and the Wender Riktad ADHD Symtom Skala (WRASS)-scale, a Swedish version of theTargeted Attention Deficit Disorder Rating Scale (TADDS) completed by her relativewere used. The WRAADS is based on the Utah Criteria  for ADHDThe Autism Symptoms Self-Report (ASSERT) were used in the diagnostic process ofautism, completed by both the woman and her relative . The oriThe Asperger Syndrome Diagnostic Interview (ASDI)—parent version completed byrelatives was included in the assessment . ASDI isFunctional level was assessed by the first degree relative with the Adaptive BehaviorAssessment System, second edition (ABAS II) . ABAS IIThe woman’s Global Assessment of Functioning (GAF) score  was estiProblems related to perception/sensory reactions were investigated from the RRBIDSM-5 criteria of ASD and question eight in the ASSERT form; “Do you feel thatyou/your relative are too sensitive or not at all sensitive to for example, sound,touch, different materials, pain, temperature or smell?.” We reviewed the reportsabout sensory reactions at T1 in the medical records and in the Autism BehaviorChecklist (ABC), perception domain in this follow-up study .The DSM-IV criteria were applied to establish diagnoses at both T1 and T2, forexamining the diagnostic stability. DSM-5 was used for comparison at T2 between the maindiagnoses according to variability in criteria across the two manuals. Diagnosesaccording to DSM-IV and DSM-5 were assigned when both symptoms and impairment criteriawere met. Exclusionary criteria were disregarded, as in T1, using the DSM-IV. “Maindiagnosis” was used to define the problems considered most handicapping at the time ofassessment. If the woman was on medication with stimulants at T2, the diagnosis of ADHDwas considered met if clinical interview did not contradict this. ADHD Not OtherwiseSpecified (ADHD NOS) was defined if five symptom criteria according to DSM-IV or four toDSM-5 were met in one of the three ADHD subtypes together with impairment.Only full ADHD syndrome is included in the ADHD analyses. PDD NOS was diagnosed if fourto five criteria for AD were met, including at least one criterion from the socialinteraction domain. Autistic traits was “diagnosed” if two to three criteria werefullfilled for AD. Remission for the main diagnoses assigned at T1 was defined if fullsymptom criteria were not met at T2 and with a calculated functional GAF score>70.All collected information from the FClinG was evaluated conjointly by the two authors, and from the MComG by KA and SL. Diagnoses of four ambiguous cases werediscussed in detail with one of the senior authors (CG). The interviewers were not blindto baseline ascertainment group.However the majority of young women in the MClinG were assessed by the two interviewer,who did not have met any of the young women earlier and were mostly blind for their maindiagnoses.T-testswere used for comparisons between groups. Chi-square test were used for groupcomparisons of proportions. All analyses were two- tailed and a p-valueof less than .05 was considered statistically significant.Statistical analyses were calculated with IBM SPSS version 23 software. Continuousvariables are presented with means and standard deviations, and Results across the two main diagnostic categories, ADHD and ASD , diagnosSD4.4). There was a significant difference (p = .001)in mean age between women diagnosed with ADHD and ASD as main diagnoses at T1, 29.5(SD3.4) and 25.5 (SD4.5). No important difference wasfound in the distribution of the main diagnoses ADHD and ASD at T1 between the 90 clinicwomen at T2 and those 10 who were lost to follow up (p = .726).At T2 the women in the FClinG were between 19 and 37 years of age, mean age of 27.5 women diagnosed at T1 with ADHD or ASD still met thediagnostic criteria for either of these main diagnoses and 19/41 (46%) of women withADHD remained in the ADHD group, and four (10%) fulfilled fewer criteria (ADHD-NOS).Four of the 41 women (10%) were in remission . The comp =.061) and 23% met criteria for ADHD with autistic traits. Twenty two percent from theoriginal ADHD group met an ADHD diagnosis only at T2. All together 54% of the womenreceiving an ADHD at T2 (10 from ADHD group and two from ASD group) also had autistictraits. The combined subtype was diagnosed in 73% with a main diagnosis of ADHD atfollow-up. Only three women met ADHD-I.Fourteen women (34%) with a previously main ADHD diagnosis at T1 changed to ASD at T2.Seven of them had also autistic traits at T1 . In the ADHD groupwithout autistic traits at T1 23% met the criteria for ASD at T2 (At T2 eight more women met a main diagnosis of ADHD according to DSM-5.At follow-up 88% of women with a main diagnosis of ASD in childhood in the FClinGretained in the ASD group. The vast majority 35/37 (95%) of them fullfilled AD . AD persAt T2, seven fewer women were diagnosed with ASD in accordance to DSM-5 than to DSM-VIand met instead the full criteria for ADHD with autistic traits. The diagnosticdifference was mainly due to more women (67 and 56 women respectively) with the requiredcriteria in RRBI met in DSM-IV than in DSM-5 (one criteria respectively 2).Three of seven women retained their diagnoses at T2; one women with TD, one with MildIntellectual Disability, one with LD NOS. One woman with ADHD NOS changed to ADHD-H atT2. One with Sleep Disorder at T1 was later diagnosed with Restless Legs Syndrome butwas now in remission. One woman with Intermittent Explosive Disorder at T1, wasdiagnosed with ASD and co- occurred ADHD- C at T2.ADHD persisted in 14/31 (45%) of women in the MClinG and ASD in 15/18 (83%). The samepattern was seen in the FClinG for these main diagnoses. The diagnostic distributionbetween the main ADHD and ASD differed strongly from the original assessment at T1 . The sixAt follow-up, two women in the MComG met DSM-IV criteria for ASD, three met criteria forADHD. These five women were excluded from the MComG in the follow-up analyses, leaving 49individuals.p < .001). The same pattern was seen in the MClinG betweenthe two main diagnostic groups (ADHD 25% vs. ASD 96%). All women with ADHD and perceptualproblems at T2 also had autistic traits. In the entire ASD group at T1 93% reportedsensory reactions leading to a high consistency for sensory problems from T1 to T2 (81%).Fifteen women with main ADHD, reported no sensory problems. In the 14 cases with a changefrom ADHD at T1 to ASD at T2, 78% already had reported sensory problems at the firstassessment time. Very few women in the matched community group reported perceptualproblems compared to two of three in the collapsed ADHD + ASD group (p =.001).Based on diagnosis in the FClinG of 90 women at T2 sensory reactions were reportedsignificantly less often in the women with a main diagnosis of ADHD compared to ASD and with ASD (n = 42) diagnosed at T1 was measured to study the outcomeat T2. The ADHD and the ASD group did not differ significantly in FSIQ (p= .270) measured at T1 . However the functional ability waslower in the ASD group (nine women with ID) compared to the ADHD group on ABAS-II, with asignificant difference for practical index (p = .002). Nearly all womenwith ASD also had “comorbid” ADHD.The level of functioning in daily life in all women with ADHD p = .08) with lowerscores for the ASD group. Strongly significant differences were found on the results fromABAS-II between the collapsed ASD and ADHD group and the MComG group with neitherdiagnosis.As described in M = 49,SD11) compared to the ADHD group  (p = .001). The collapsed group of ADHD + ASDdiffered significantly in comparison to the MComG in the GAF scores. The six women inremission scored highest on the GAF (M = 78).The global functioning (GAF) score differed between the two diagnostic groups withsignificantly lower GAF scores in the MClinG with ASD (p = .006). Allbut one of these clinic women were diagnosed with ASD. Living with a partner were reported in 77% of women in the MComG and, in 41% of the MClinG with NDD(p = .002). The majority of women who never had a relationshiplasting more than 3 months is found in the ASD group.As described in p = .083) found in comparison betweenthe ADHD group and the ASD group in children that they had, most children lived withmothers in the ADHD group. One of two women with ADHD had performed 1 to 2 abortions andonly women with ADHD had went through more than one abortion (p =.038).There was a statistical trend (p = .002) compared to 14% in the MComG.In the MClinG 50% respectively 40% stated that they felt socially isolated, asignificant difference  with ADHD and ASD reported that theyhad received some type of support during their schooling.p = .002) (There were major significant differences in how to provide for oneself between theMClinG and the MComG ( = .002) . Fiftyfop = .004) as well as physical andmental abuse (p < .001). The mental and physical abuse in the ADHDand ASD groups were mainly carried out by family members or peers and women with ADHDreported the highest degree of exposure.A high rate of being exposed to sexual abuse were self-reported in all study groups.However rape was significantly more frequently reported in the collapsed MClinG withmain ADHD and ASD compared to MComG . Our findingscorrespond to a meta-analysis, which indicated that AD was stable in 76% over time and PDDNOS was less stable (35%), however all these studies included young children . OtheroOur finding of 46% of diagnostic stability from T1 to T2 for a full ADHD diagnosis and10% for ADHD NOS  is in line with the two major female ADHDlongitudinal studies . In the To our knowledge, we have not found any longitudinal study in females with ASD. The malefollow- up study in AS  reportedThe combined subtype had the highest persistence (48%) of the ADHD conditions and wasalso the most common subtype both in the main ADHD group and in ASD with co-occurrenceADHD. The persistence for ADHD-I was only 15%. The Berkley Girls Study mentioned aboveconcluded that a comparatively larger proportion of girls with ADHD-C retain theirdiagnosis compared to ADHD-I . These fThe high change from ADHD to ASD in one of three women from the original study toassessment two was not expected, even though half of them had autistic traits already atT1. For some of these women there had been suspicion about ASD at the first assessmenttime. We found coexisting ASD and ADHD, in 83% and several women with ADHD also had autistictraits (54%). These symptoms partly overshadow each other and cause diagnosticdifficulties . These rThere was a trend toward more severe ASD diagnosis over time with an increase in thenumber of girls fulfilling all 4 DSM-IV SOC criteria at T2 compared to T1. Our findingsfor adult women expand on those from the ALSPAC birth cohort study that found anescalation of ASD across adolescence that was greater in females compared to males .Nearly all women with ASD in the FClinG had perception/sensory problems at T2 and allwith reported perceptual problems at the first assessment retained their sensory problemsat T2. Sensory reactions were not reported in the main ADHD group without autistic traits,but most of the women with ADHD and autistic traits reported such problems. The findingsare consistent with previous work showing that the majority of all children with ASD havehad sensory problems remaining into adulthood . ConstanIn the MClinG of women the significantly larger general impairment of functional levelcompared to the women in the MComG, remained from the first assessment at T1 . This paIn this study the FClinG women with a main ADHD diagnosis or co- existent ADHD in T1 wereoffered treatment with stimulants and psychoeducation, after the study, during theirupbringing. In our previous report we found that one-third of these women today hadongoing treatment with stimulants . In prevThe MClinG women with ADHD and/or ASD differed significantly from the women in the MComGin multiple domains. The important differences found in our study in social situation,educational level, source of income and personal security in life have earlier beendescribed for mostly clinically referred women with ADHD . A populStudies regarding exposure to sexual abuse in adulthood appear to be sparse. There aresome recent work who has pointed out the increased risk of sexual victimization that womenwith ADHD and ASD are exposed to . The bacNearly half of the women with ADHD or ASD reported an experience of involuntary socialisolation, whereas this was infrequently reported in the MComG. Social difficulties are acore symptom of autism, and social problems in a person with ADHD may reflect socialmaladjustment due to impulsivity and inattention toward social codes . HoweverWhile the vast majority of women in the MComG supported themselves with a salary/studygrant, a fourth of those with ADHD and more than half of the women with ASD had some typeof social welfare grant. A partial explanation in addition to their disabling symptoms,might be the large difference in completed education. It is currently challenging to behired in Sweden without schooling beyond elementary school. Secondary school appears to benecessary. Becoming dependent on income through social insurance, early in life, means alife in relative poverty, this too being a factor contributing to poorer physical andmental health .Large and significant differences were seen when regarding exposure to physical or mentalabuse from peers, partners or strangers. Other work by Although the number of participants in our study is relatively small, one of thestrengths is that it had a clinical approach from the beginning. At T1 the group was wellcharacterized and examined with rigorous diagnostic criteria. At T2 the information wasobtained from the women, their first degree relative, and questionnaires as well asthrough observations by the researchers during the interviews. This procedure haspreviously been deemed necessary to obtain a complete picture of the current situation. TheparAvailable data was the decisive factor for the number of participants and for example,the wide age span, which is a limitation to the study with regard to the changes indiagnostic status observed and presented.Clinical samples generally include more severe cases than population samples, and due toknown referral bias especially among girls, they may not fully provide the whole pictureregarding the transition into adulthood among girls with ASD and/or ADHD . ThecomThe fact that one of the researchers, who was responsible for the assessments in T1, alsoparticipated in the evaluations in T2 can be seen as a weakness. The interviews were notblinded. To avoid bias as much as possible, the majority of the women and their relativesin the matched groups, were examined by colleagues who did not participate in T1. Whenconducting the study it was a strength, that good knowledge of the families facilitatedthe contact. It also made it easier to adapt the assessments where the women could notparticipate in the interviews (according to severe autism with ID and/or languagedisabilities) and the parent became the source of information. This fact most likely alsocontributed to the high retention in participation.Diagnoses are to be considered as the best estimates of the condition. As in clinicalwork, it is difficult to get distinct responses from persons with neuropsychiatricsymptomatology, and disabilities are often underreported . In the Most of the women with ADHD and/or ASD diagnosed in childhood/adolescence, still met thecriteria in early adult life for these. A “transition” from ADHD in childhood to ASD inadulthood occurred in some cases, both from the ADHD-C and ADHD-I childhood groups.Co-occurrence of ADHD and ASD was extremely common. Perceptual/sensory problems occurred inalmost everyone with ASD and frequently in women with ADHD and autistic traits. Dailyadaptive functioning were impaired in both matched clinic diagnostic groups, however evenmore so practically in the full ASD group. The low GAF scores in both groups indicate theburden of impairments and the need for support. Further, findings indicate an increased riskof violence and sexual abuse/exploitation compared to peers in the community.It seems important that when ADHD or ASD is suspected in a girl or an adult woman, thepresence of coexisting ADHD and ASD should always be investigated. Clinicians should alsoplan for continued support that takes into account potential changes in the symptom profileand social situation that may occur in early adulthood.Further research should be done to better understand the consequences of living with ADHDand/or ASD in adulthood. With better knowledge, medical care, community, educationalinstitutions and employers would be better at detecting the unmet needs of these women andprovide more functional support.Click here for additional data file.Supplemental material, sj-docx-1-jad-10.1177_10870547231158751 for Girls With Socialand/or Attention Deficit Re-Examined in Young Adulthood: Prospective Study of DiagnosticStability, Daily Life Functioning and Social Situation by Svenny Kopp, Karin SusannaAsztély, Sara Landberg, Margda Waern, Stefan Bergman and Christopher Gillberg in Journalof Attention Disorders


Ruminococcus_gauvreauii_group, Bacteroides, Bifidobacterium, and Blautia significantly increased, whereas that of Lactobacillus, Romboutsia, Facklamia, and Turicibacter significantly declined in the KD group compared with the ND group. The gut microbiota in the KD group of SHR mainly participated in amino acid metabolism- and sugar metabolism-related pathways. KD might alleviate behavioral disorders in ADHD by regulating gut microbiota. This study provides novel insights for the use of KD in treating ADHD.Attention deficit hyperactivity disorder (ADHD) is a common mental behavioral disorder in children. Alterations in gut microbiota composition are associated with neurological disorders. We aimed to investigate whether a ketogenic diet (KD) can be an alternative therapy for ADHD by altering the gut microbiota. Male spontaneously hypertensive rats (SHR) and Wistar Kyoto (WKY) rats were randomly allocated to the normal diet (ND), methylphenidate (MPH), and KD groups. SHR in groups KD and MPH exhibited a significant increase in behavioral characteristics of ADHD, such as distance moved and immobility time. KD and MPH treatment led to a significant elevation in concentrations of 5-HT, AC, cAMP, and NE of brain tissue and the expression of DRD1, DAT, PKA, DARPP32, and cAMP at the protein level in WKY rats and SHR. KD and MPH significantly increased the richness and diversity of gut microbiota in SHR. The abundance of  Attention deficit hyperactivity disorder (ADHD) is a mental disorder of childhood that manifests as persistent inattention, hyperactivity, and impairment of social and academic functions . The patFaecalibacterium is significantly reduced in patients with ADHD [Gut microbiota is important for health and immunity and is linked to neurological disorders such as Alzheimer’s disease, autism, Parkinson’s disease, and ADHD , 7. The ith ADHD . Evidencith ADHD . Recentlith ADHD . Evidencith ADHD . HoweverThe ketogenic diet (KD) contains high fat, low carbohydrate, and moderate protein . KD can The behavioral characteristics of spontaneously hypertensive rats (SHR) are similar to those of ADHD, and SHR is the most widely studied animal model of ADHD . In thisad libitum.Four-week-old male SHR and Wistar Kyoto (WKY) rats were purchased from Nanjing Junke Bioengineering Company. Rats were kept in specific pathogen-free rooms at 20°C–22°C, 12-h light/12-h dark, and relative humidity of 60%–70% and fed The experimental design is illustrated in On weeks 0, 1, 2, 3, and 4, rats were subjected to the open field test. At week 4 (day 28), feces and brain tissues were collected. The rats were euthanized by injecting 1% pentobarbital (50 mg/kg) intraperitoneally. Feces and brain tissues were stored at −80°C until use. This study was approved by the Ethics Committee of The Second Affiliated Hospital of Xi’an Jiaotong University.Open field tests are used to analyze movement, anxiety, and grooming in rodents . ChangesThe levels of 5-HT , adenylate cyclase , cyclic adenosine monophosphate , and NE  in brain tissue were measured using ELISA kits  in accordance with the manufacturer’s instructions. The absorbance value of each well was tested at 450 nm using a Microplate Reader .−ΔΔCt method was utilized to detect the relative mRNA expression of dopamine receptor D1 (DRD1), dopamine transporter (DAT), PKA, DARPP32, and cAMP. The primer sequences are shown in Total RNA was isolated from brain tissues using TRIzol reagent . After the detection of RNA quality and purity, the Reverse Transcription kit  was employed to reverse-transcribe RNA into cDNA. qRT-PCR was conducted using the SYBR Green PCR kit  on Applied Biosystems Q6 real-time PCR system . The reaction conditions were as follows: 95°C for 10 min followed by 40 cycles of 95°C for 15 s and 60°C for 60 s. GAPDH was taken as the internal reference. The 2Total protein was extracted from the brain tissues of WKY rats and SHR using RIPA lysis buffer . The concentration of total protein was measured with a BCA kit . Approximately 20 μg of protein was isolated through 10% SDS-PAGE and transferred to polyvinylidene fluoride membranes. The membranes were stained with Ponceau (Acros Organics) to confirm successful protein transfer. Whereafter, the membranes were blocked with TBST solution containing 5% milk at room temperature for 3 h, and then incubated with primary antibodies against DRD1 , DAT , PKA , DARPP32 , cAMP , and GAPDH  overnight at 4°C. Subsequently, the membranes were washed with 1% TBST solution, incubated with goat anti-mouse IgG H&L (HRP)  at room temperature for 1.5 h. In the end, after washing three times with 1% TBST solution, blots were exposed to an ECL luminescence kit . Image J (v5.2.1) was employed to analyze the bands.5′-ACTCCTACGGGAGGCAGCAG-3′) and 798R (5′-GGACTACHVGGGTWTCTAAT-3′). The PCR product was extracted with 2% agarose gel electrophoresis and purified with AxyPrep DNA Gel Extraction Kit  in accordance with the manufacturer’s instructions. The PCR product was quantified with QuantiFluor-ST . Finally, the Illumina MiSeq PE300 platform was used for 16S rDNA sequencing.Total DNA from feces was isolated using QIAamp 96 PowerFecal QIAcube HT Kit (Qiagen). DNA quality was examined by 1% agarose gel electrophoresis and DNA concentration was measured with a NanoDrop 2000 . The V3–V4 region of the 16S rDNA gene was PCR amplified using primers 338F (The paired-end raw reads were filtered with Trimmomatic (version 0.35). The filtered reads were merged using Flash (version 1.2.11). To obtain clean tags, raw tags were percolated by QIIME (version 1.9.1). The sequences were allocated to operational taxonomic units (OTUs) using UCLUST (Version 1.2.22). OTUs clustering were conducted with a 97% similarity threshold using UPARSE software (version 7.0.1090). The Silva database (Release138) was used to divide OTUs into taxa. Alpha diversity , and principal component analysis (PCA) were carried out with QIIME (version 1.9.1). Venn diagram was utilized to exhibit the number of microbiota in different groups using R (version 1.6.16). Linear discriminant analysis (LDA) effect size (LEfSe) was used for differential abundance analysis of bacteria between groups. Functional prediction of bacterial communities was performed using PICRUSt.post hoc test. p < 0.05 was deemed to be statistically significant.Statistical analyses were conducted with GraphPad Prism 9.0, and the data was exhibited as mean ± standard deviation (SD). Comparisons between more than two groups were performed by one-way ANOVA followed by Tukey’s To evaluate the effect of KD on behaviors of ADHD, the open field test was used to determine the total distance moved and immobility time in SHR. Expectedly, as a first-line drug in the treatment of ADHD, MPH significantly improved behavioral indicators of ADHD in SHR, as evidenced by shorter total distance and longer immobility duration compared with the ND group . SimilarTo investigate the effect of KD on brain nervous system, we determined the effect of KD on the expression of neurotransmitters, including biogenic amines 5-HT and NE, and their downstream G protein effectors and second messengers, such as AC and cAMP, respectively . ELISA aIn addition, we also measured the expression of DA-related genes using WB and qRT-PCR, such as DA transporter (DAT), DA receptors (DRD1 and DARPP32), as well as downstream targets of DARPP32, including cAMP and PKA. WB analysis revealed that compared with the ND group, KD and MPH significantly upregulated the protein expression of DA-related genes  in WKY rats and SHR . HoweverStudies have shown that the imbalance of gut microbiota is closely associated with ADHD . TherefoTo examine the effect of KD on the structure of gut microbiota in SHR, the composition of gut microbiota in each group was investigated at the phylum, family, and genus levels. At the phylum level , in bothAt the family level , in the Romboutsia, Turicibacter, Corynebacterium, and Facklamia increased and that of Streptococcus, UCG-005, and Clostridium_sensu_stricto_1 decreased in SHR, compared with WKY rats. In SHR, the abundance of Romboutsia, Turicibacter, and Facklamia decreased in the KD group compared with the ND group. In stark contrast to the ND group, microbial diversity clearly enhanced after KD or MPH treatment, which is consistent with the results shown in At the genus level , in the H test was used to determine differences in the proportions of gut microbiota between ND, MPH, and KD groups. The results showed that the abundance of Lactobacillus, Romboutsia, Turicibacter, Facklamia, and Corynebacterium was significantly reduced, whereas that of Ruminococcus_gauvreauii_group, Bacteroides, Bifidobacterium, Parabacteroides, and Blautia was significantly increased in the KD group compared with the ND group . KD increased the richness and diversity of the gut microbiota in SHR at the phylum, family, and genus levels. Importantly, we identified a large number of microbiotas with significantly differential abundance after KD treatment at multiple levels. We found that gut microbiota between ND and KD groups in SHR were mainly involved in amino acid metabolism- and glucose metabolism-related pathways.DA, 5-HT, and NE are important neurotransmitters of the nervous system related with the development of ADHD. A disorder in one or more links of the neurotransmitter network can lead to the disordering of the entire network, and ultimately, to the occurrence of ADHD. In our study, the concentrations of 5-HT, NE, AC, and cAMP of SHR in the KD group were strikingly higher than that in the ND group. These results are consistent with previous two studies , 24. MorPatients with ADHD have an imbalance in the composition and proportion of intestinal flora. Gut microbiota plays a central part in ADHD by affecting the synthesis and metabolism of neurotransmitters, such as DA, 5-HT, and NE, as well as their precursors . Prehn-kRuminococcus_gauvreauii_group, Bacteroides, and Bifidobacterium increased in the KD group relative to the ND group in SHR. Bifidobacterium produces gamma-aminobutyric acid (GABA), which is the primary repressive neurotransmitter in the human cerebral cortex. GABA levels in children with ADHD is reportedly low and negatively correlated with impulsive behavior [Bifidobacterium also participates in the DA neural reward system, suggesting that Bifidobacterium is a potential biomarker for ADHD [Ruminococcus, Blautia, and Bacteroides can produce short-chain fatty acids (SCFAs) [Bacteroides reportedly correlate with levels of hyperactivity and impulsivity in ADHD [Changes in intestinal flora can affect the development and function of the nervous system through the gut–brain axis, and then lead to the occurrence and development of ADHD . In thisbehavior . Bifidobfor ADHD , 32. Rum (SCFAs) . SCFAs h (SCFAs) . Supplem (SCFAs) . Evidenc (SCFAs) . Bactero in ADHD . TherefoS-adenosyl-L-methionine supplementation significantly improves ADHD [In our study, KD treatment increased the relative abundance of amino acid metabolism-related pathways compared with the ND group in SHR. Patients with ADHD reportedly have lower levels of amino acids, including tryptophan (precursor of serotonin) and tyrosine (precursor of catecholamines) , 39. Stuves ADHD . Althougves ADHD , 45. Unfves ADHD . Beela aves ADHD . TherefoRuminococcus_gauvreauii_group, Bacteroides, Bifidobacterium, and Blautia at the genus level. KD-induced gut microbiota were enriched in amino acid metabolism- and sugar-related pathways. These results give novel insights into the mechanism of KD in ADHD treatment.In conclusion, KD improved typical behavioral performance of ADHD with hyperactivity and impulsivity in SHR. Additionally, KD significantly activated the DRD1/cAMP/PKA/DARPP32 pathway in SHR. The richness and diversity of gut microbiota were altered in SHR after KD treatment, with significant changes in S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S1 Raw image(PDF)Click here for additional data file.


Attention deficit/hyperactivity disorder (ADHD) is common in alcohol use disorder (AUD). Continuous performance tests (CPTs) allow to measure ADHD related deficits in a laboratory setting. Most studies on this topic focused on CPTs measuring inattention or impulsivity, disregarding hyperactivity as one of the core symptoms of ADHD.N = 47 in three groups  with questionnaires on ADHD core symptoms, executive functioning (EF), mind wandering, and quality of life (QoL). N = 46  were examined with a CPT (QbTest®) that also measures motor activity objectively.We examined Inattention and impulsivity were significantly increased in AUD vs. ADHD and in AUD vs. ADHD + AUD. Hyperactivity was significantly higher in ADHD + AUD vs. ADHD and ADHD + AUD vs. AUD, but not in ADHD vs. AUD. EF was lower in both ADHD groups vs. AUD. Mind wandering was increased in both ADHD groups vs. AUD. QoL was significantly lower in ADHD + AUD compared to AUD. In contrast, results of the QbTest were not significantly different between groups.®. Hyperactivity appears to be a relevant symptom in ADHD + AUD, suggesting a possible pathway from ADHD to AUD. The lower QoL in ADHD + AUD emphasizes the need for routine screening, diagnostic procedures and treatment strategies for this patient group.Questionnaires are more useful in assessing ADHD core symptoms than the QbTest Attention deficit/hyperactivity disorder (ADHD) has a prevalence rate of 7.1% in children and adolescents . AdolescIn adults with alcohol use disorder (AUD), comorbid ADHD is common with prevalence rates between 16 and 21% –7. HowevInternational expert consensus recommends routine screening for ADHD in patients with substance use disorders (SUDs) , althougThe high prevalence of ADHD in AUD –7 and loSensitive methods objectively measuring ADHD symptoms could therefore aid in clinical and scientific settings.Continuous performance tests (CPTs) to measure ADHD symptoms have not been studied extensively in the comorbidity of SUD with ADHD , but hypOur study aimed to investigate whether objective measurements or self-rating scales on inattention, impulsivity, and hyperactivity would show differences between patients with ADHD, AUD, and ADHD + AUD.Participants were 18–64 years old and patients in treatment at the Central Institute of Mental Health .Alcohol use disorder was diagnosed by trained masters- or medical-degreed personnel according to ICD-10 alcohol dependence ; particiAttention deficit/hyperactivity disorder was diagnosed by trained masters- or medical-degreed personnel according to clinical guidelines , based oFor the groups AUD or ADHD, individuals with a diagnosis of a mental disorder within the last year or intake of psychotropic medication within the last 3 days were excluded. Stable medication with fluoxetine was considered acceptable in one participant in the ADHD group (self-reports only). Participants in the ADHD group were allowed to take prescribed stimulants, but not the day when the QbTest was conducted.Psychiatric comorbidity did not lead to an exclusion for the ADHD + AUD group, as psychiatric comorbidity in individuals with ADHD and SUD is remarkably high , 16–18.Participants in the AUD group had to screen negative for ADHD in three different questionnaires: Wender Utah Rating Scale , ADHD seParticipants in the ADHD group had to screen negative (cut-off <8) for AUD in the Alcohol Use Disorder Identification Test .•Cocaine/amphetamine/opioid dependence lifetime•Lifetime diagnosis of delusional disorders, schizophrenia, or bipolar disorder•Severe physical illnessThe Ethics Committee of the Medical Faculty Mannheim, Heidelberg University, Germany approved the study beforehand . All participants provided written informed consent and the study was in accordance with the Declaration of Helsinki.® provides raw scores for motor activity, inattention and impulsivity. From these raw scores, the cardinal parameters Qb-activity, Qb-inattention, and Qb-impulsivity are derived by performing a principal component analysis. These parameters are transformed into normally distributed Q-scores implicating information about the difference between the individual raw score compared to scores of a gender- and age-controlled group  consists of 18 items (DSM criteria for ADHD). A total score as well as sub-scores on hyperactivity, impulsivity, and inattention can be calculated , 24.The 30 items of the Barratt Impulsivity Scale (BIS-11) assess trait impulsivity  .The 16 items of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) measure quality of life (QoL) as the degree of enjoyment and satisfaction experienced in various areas of daily functioning .Executive functioning (EF) summarizes a set of advanced cognitive abilities that allow cognitive, emotional, and motor control to create goals, create plans to achieve the goals and stick to the plan until the goals are achieved. Higher scores in the 75 items Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) mean more EF deficits .Unintentional mind wandering is common in ADHD and higher frequency of mind wandering is associated with increased functional impairment and related to lower EF . The Minp-value < 0.05 was used as significance level for all calculations.Data were analyzed with IBM SPSS Statistics for Windows, Version 27.0. The distribution of gender was compared using Fisher’s exact test. An analysis of variance (ANOVA) was calculated to compare the mean age between groups. Since cardinal Qb-parameters were already controlled for sex and age, we applied an ANOVA, using Bonferroni correction for multiple testing. A one-way analysis of covariance (ANCOVA) was conducted on the questionnaire scores controlling for age and gender, using a Bonferroni correction for multiple testing. A N = 47 participants  and were included in this analysis. For the QbTest®, we included N = 46 .Complete data on the self-report scales were available for Age and gender were significantly different between groups, see post-hoc correction showed no statistically significant differences between groups for all QbTest results , mind wandering, and EF were significantly different in ADHD vs. AUD and in ADHD + AUD vs. AUD, but not in ADHD + AUD vs. ADHD.One-way analysis of covariance with Bonferroni In contrast, hyperactivity was significantly increased in ADHD + AUD vs. ADHD, and in ADHD + AUD vs. AUD , while tTo our knowledge, this is the first study directly comparing individuals with AUD and/or ADHD objectively measuring hyperactivity and other core ADHD symptoms .ADHD + AUD showed increased hyperactivity in self-reports. Other ADHD related deficits also showed differences for ADHD groups (ADHD + AUD or ADHD) vs. AUD. However, we found no group differences for the QbTest parameters.Substance use disorder and ADHD show comparable inattentive and impulsive behavior in CPTs, but hyperactivity was identified as a promising parameter to distinguish ADHD from SUD . One stu®  research – often lead to a temporary decrease in symptoms including hyperactivity . FunctioLarger samples might be needed to detect group differences in ADHD related deficits , 31 due Of note, self-report questionnaires already showed significant and group specific differences at the given sample size.Hyperactivity decreases during adolescence . In adulOur results show that individuals with ADHD (with or without AUD) are more impulsive than individuals with AUD only. Decades of research have linked AUD to increased impulsivity . ImpulsiAlthough impulsivity and alcohol consumption in adolescence negatively affect each other leading to early AUD , 50, 51,Attention deficit/hyperactivity disorder or ADHD + AUD had more deficits in EF compared to AUD, which is in line with recent findings . EF defiMind wandering (MW) was increased in ADHD (with or without AUD) compared to AUD. MW is associated with lower EF, lower QoL and more severe ADHD , 57, andAttention deficit/hyperactivity disorder or AUD is associated with low QoL , 61 but In conclusion, self-report scales on core symptoms of ADHD as well as on ADHD related deficits showed significant and specific group differences between ADHD, AUD, and ADHD + AUD, while a CPT did not show any differences between groups.Hyperactivity was confirmed to be a relevant symptom in ADHD + AUD, suggesting a possible pathway from ADHD to AUD. The lower QoL in ADHD + AUD compared to AUD emphasizes the need for routine ADHD screening, diagnostic procedures and treatment strategies in patients with AUD.mathias.luderer@kgu.de.The datasets presented in this article are not readily available because the data contain information that would compromise research participant consent. We will provide data upon direct request by research colleagues following current data protection guidelines. Requests to access the datasets should be directed to ML, The studies involving human participants were reviewed and approved by the Ethics Committee of the Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany. The patients/participants provided their written informed consent to participate in this study.ML and ES designed the study. ML, JS, and SG collected the sample. ML performed the literature review, conducted the analyses together with JS, and wrote the initial version of this manuscript. All authors contributed to the article and approved the submitted version.