Statistically controlling for age, we found decreased alpha diversity in the urine bacteria of the ADHD group, as evidenced by reduced Shannon and Simpson indices (p < 0.05), and significant differences in beta diversity between the two groups (p < 0.001). The phyla Firmicutes and Actinobacteriota, as well as the genera Ralstonia and Afipia, were relatively more abundant in the ADHD group. The phylum Proteobacteria and the genera Corynebacterium and Peptoniphilus were more abundant in the control group. Notably, the genus Afipia exhibited significant correlations with the Child Behavior Checklist Attention Problems score and DSM-oriented ADHD subscale. This study is the first to propose the urine microbiome as a potential biomarker for pediatric ADHD.While interest in developing the human microbiome as a biomarker for attention-deficit hyperactivity disorder (ADHD) is increasing, there has been limited exploration in utilizing urine samples. In this study, we analysed urine microbiome profiles by extracting 16S ribosomal DNA from purified bacteria-derived extracellular membrane vesicles obtained from urine samples. Sequencing libraries were constructed by amplifying V3–V4 hypervariable regions sequenced using Illumina MiSeq. Profiles of male Korean children and adolescents with ADHD ( Attention-deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity observed in multiple environments . ADHD isRecently, a large number of studies have been exploring the effect of the gut microbiome on psychiatric pathology. As such, the potential use of the human microbiome as a biomarker of various disorders, including mental disorders, is being actively researched. The microbiota–gut–brain axis is the foundation for bidirectional communication between the gut microbiota and the central nervous system. The gut microbiome is associated with various processes such as neuroinflammation, stress axis activation, neurotransmission, blood–brain barrier formation, myelination, and microglial maturation ,8. MajorHowever, recent studies utilizing next generation sequencing have revealed that the human body contains microbiota not limited to the gut, but also within the genitourinary tract. The urine microbiome, namely “urobiome,” is emerging as an increasingly meaningful branch of the human microbiome, consisting of microorganisms from the lower urinary tract and genital tract . Most reRegarding psychiatric pathologies, recent studies have indicated that gut microbiota affects neurotransmitters , organic acids, and metabolite distributions in the urine. Altered gut microbiota affect the integrity of the gut barrier, leading to variations in the bacterial metabolite absorption and excretion of neurotransmitter precursors into urine . This maTogether, these findings open the discussion of a possible bladder–gut–brain axis taking part in the pathophysiology of ADHD, integrating the interaction between the gastrointestinal and urinary tract microbiome to examine the effects the microbiome or its by-products have on neural processing. Further investigation must be undertaken on whether this axis could involve the same mechanisms of bidirectional communication via neurotransmitter release, immune system stimulation, etc., as the microbiota–gut–brain axis .As opposed to stool samples, urine samples are more convenient to study because the collection is relatively simple, causes less aversion for the subjects, and can be efficiently obtained in large amounts. Moreover, since gram-negative bacteria secrete extracellular membrane vesicles (EVs) to communicate with human host cells, genetic material derived from bacteria-derived EVs indicate specific microbiota that are metabolically or pathologically active ,36,37. TThe urobiome profiles of patients with ADHD have not been reported to date. To fill this gap, we investigated whether bacteria-derived EVs in urine are also useful to rapidly identify microbiota profiles in patients with ADHD. In this study, we investigated and identified the urobiome profiles of Korean boys with ADHD by comparing them with those of healthy male controls. Specifically, the urine microbiota of each participant was analyzed by extracting 16S ribosomal DNA (rDNA) from purified EVs found in urine samples by using 16S next-generation sequencing (NGS).A total of 33 boys with ADHD were enrolled in the study from January to April 2022 at a child and adolescent psychiatry clinic in a tertiary university hospital in Seoul, Korea. Inclusion criteria were as follows: (1) an age range from 6 to 16 years; (2) a diagnosis of ADHD according to the DSM-V criteria using Mini-International Neuropsychiatric Interview-Kid (MINI-Kid) , which ig for 10 min at 4 °C, and the supernatant was passed through a 0.22 μm membrane filter to eliminate any foreign particles and quantified based on protein concentration. Isolated EVs from each sample (1 μg of protein) were boiled at 100 °C for 40 min and centrifuged at 13,000× g for 30 min. Bacterial DNA was extracted from the collected supernatants using a DNA extraction kit  following the manufacturer’s instructions. Isolated DNA was quantified using the QIAxpert system .Each urine sample was centrifuged at 10,000× Metagenomic analysis of the 16S rRNA gene amplicon was conducted. It was preferred over whole genome sequencing because the 16S rRNA gene is universal in bacteria and can be measured for comparison among all bacteria, while whole genomes of bacteria are of varying sizes and gene duplication, transfer, deletion, fusion, and splitting are common ,44. ThirPaired-end 16S rRNA gene sequences were analyzed via Quantitative Insights into Microbial Ecology (QIIME2 v2021. 4) . AdapterDemographic characteristics, including age, baseline Child Behavior Checklist (CBCL) subscale scores, and ADHD-RS scores, were analyzed using SPSS 26.0.0.2. Alpha diversity metrics were assessed using the phyloseq  package n = 28) of the participants with ADHD were of the combined presentation, with the remaining 15.2% being of the predominantly inattentive presentation. Hence, we decided that the ADHD group was homogeneous enough in ADHD subtypes to continue analyses as one whole group.We analyzed urine samples from 72 individuals, including 33 boys with ADHD and 39 healthy adults. Patients with ADHD had a mean age of 9.5 ± 2.5 , and the healthy individuals had a mean age of 21.4 ± 1.3 . The baseline CBCL attention problem subscale, DSM-oriented ADHD t-scores, and ADHD-RS scores of patients with ADHD are displayed in p = 0.012; Simpson index, p = 0.046), the Chao1 index and OTUs did not , an enzyme in the phenylalanine (a dopamine precursor) pathway, in the microbiome of individuals with ADHD. The abundance of CDT was negatively correlated with reward-anticipation responses across the whole brain [While we believe that EVs extracted from urine represent microbiota from a more variable source of systems , it is isymptoms . Howeverulsivity . Some stabundant ,13,14,16le brain . Actinobateriota were found to be significantly more abundant in individuals with ADHD. However, on average, the specific genus Bifidobacterium comprised only 0.05% of the microbiota of the ADHD group and was found to be significantly lower than that of the controls (p = 0.002). Our results are also notably different from those of other studies that have examined the gut microbiome of individuals with ADHD. Since this is the first study to identify and report urobiome characteristics in individuals with ADHD, these discrepancies should be analyzed carefully. This may imply that the microbiome of the urine and gut are substantially different and cannot be compared with each other in the first place, or that a microbiome from a source other than the gut plays a key role in the characteristic urobiome of patients with ADHD. Despite the largely varying results among studies on the microbiome in patients with ADHD, microbiome studies on other neurodevelopmental disorders, such as ASD, show promising potential in this field, with results from multiple studies converging to point towards certain microbiota as biomarkers or possible treatment targets [Our results partly agree with the study by Aarts et al., at the phylum level, as  targets ,54,55,56Afipia had significant correlations with the CBCL attention problems subscale and DSM-oriented ADHD subscale t-scores, but not with the ADHD-RS scores. Although the ADHD-RS is the current gold standard questionnaire used to make ADHD diagnoses, the correlation seen in the CBCL attention problems subscale is still notable. To the best of our knowledge, no previous studies have determined the effect of the genus Afipia and its function on the central nervous system. Therefore, we could not exclude the possibility that this genus could play a pathogenic role in individuals with ADHD. Given that the genus is mainly associated with infections [Our correlation results showed that the abundance of the genus fections , there iOur study had several limitations. First, we could not obtain an age-matched sample and thus had to conduct the analyses under the assumption that the urobiome of males would not change substantially with age, while also statistically controlling for age as a covariate in our analyses. Our results should be interpreted with care in terms of clinical implications as it is a limited primary investigation on this topic. Future studies with direct comparisons between ADHD individuals and their age-matched controls within each sex are required for a more accurate analysis. Second, we did not control for certain lifestyles, such as engagement in sexual interests, that may contribute to the microbiome obtained from midstream urine. While the risk of contamination in midstream urine samples in men is lower than in women due to anatomic differences , the posTo the best of our knowledge, our study is the first to show that the urobiome of Korean children with ADHD is significantly different from that of healthy individuals. We demonstrate that bacteria-derived EVs in the urine can be a reliable source of urine micro with ADHD from healthy children. Although this portrays the potential use of urine samples as a biomarker for pediatric ADHD, further research is needed in order to implement our findings directly to clinical usage.


Bartonella and as a proxy indicator of the potential risk of Bartonella transmission from nature to humans. They offer a valuable early warning for human infection. Nevertheless, geographical variations in the impact of the host on the occurrence of Bartonella infection are underestimated. This study was designed to investigate the infection characteristics of Bartonella and explore its species diversity in wild small mammals in western Yunnan Province, China.Small mammals serve as the main reservoir for Bartonella infection, and the Bartonella species were identified by phylogenetic analysis. The factors associated with Bartonella infection in small mammals were analyzed by the Chi-square Test.Wild small mammals were captured from Yulong, Jianchuan, and Lianghe counties in western Yunnan Province between 2015 and 2016. Real-time quantitative PCR (qPCR) was used to detect Bartonella in small mammals was 47.85% (768/1605). Lianghe County had the highest Bartonella infection rate, with 56.27% of the samples tested positive, followed by a rate of 50.91% was tested in Yulong County, and 39.97% in Jianchuan County (p < 0.001). Bartonella was detected positive in a total 25 small mammal species, with infection rates ranging from 2.17% to 100%. Niviventer fulvescens had the highest Bartonella infection rate. In comparison with the dominant small mammal species, Eothenomys mileyus had the lowest Bartonella infection rate than that in Apodemus chevrieri, Rattus tanezumi, and Apodemus draco (p < 0.001). Male small mammals had a higher infection rate than females (p < 0.05). The prevalence of Bartonella in small mammals during the summer season was higher compared to the other three seasons (p < 0.001). Woodland landscape had the highest Bartonella infection rate (p < 0.001). Bartonella rochalimae, B. japonica, B. tribocorum, B. washoensis, B. sylvatica, and B. rattimassiliensis were obtained from infected small mammals.The prevalence of Bartonella was detected with various Bartonella species in small mammals in Yulong, Jianchuan, and Lianghe counties of western Yunnan Province. These findings hold significant scientific clues, providing valuable reference points for further research of Bartonella natural foci in Yunnan or other analogues environments.This study showed a high prevalence of  PreviouEuropean , 20% to European , and 9.3European . AdditioEuropean . These fBartonella, can carry up to 20 Bartonella species, but the infection rate is varied by region. Of the 20 Bartonella species, Bartonella henselae, B. tribocorum, B. rochalimae, B. elizabethae, B. grahamii, B. washoensis, B. tamiae, and B. vinsonii subsp. arupensis have been responsible for hazarding human health  with a 24.86% positive rate. However, there was no prevalence of Bartonella in Lianghe county  was used to detect Bartonella in small mammals, and phylogenetic analysis was performed to identify the diversity of Bartonella species. Additionally, the study examined the relationship between associated factors and Bartonella infection in small mammals. This effort is essential to gain a more profound insight into the complex interactions between Bartonella, its host species, and the environment, which in turn can inform strategies for disease prevention and management.Small mammals, as one of the most abundant species in nature, can harboring various pathogens or viruses. Rodent-borne diseases can easily be transmitted to humans when they come into contact with infected small mammals in nature. Therefore, small mammals can act as effective sentinels of natural disease transmission to humans. Especially rodents, as the main hosts of n health , 9, 16.  decades . In Jianive rate . Yang ete county . Still, Province , even th22.1Bartonella natural reservoir because the diverse climates and rich vegetation growths benefit small mammals and ectoparasites to survive and reproduce, contributing to unneglected concerns for the residents and travelers.The study was carried out in three counties in western Yunnan Province. Yulong and Jianchuan counties are located in the middle of the Hengduan mountain but are separated by low-lying valleys. Yulong county has a low-latitude highland South Asian monsoon climate. Jianchuan county has a low-latitude highland monsoon climate and is concentrated growing pine forests. Lianghe county is located in the southwestern of the Hengduan Mountain and is characterized by the south subtropical monsoon climate. The three counties could be a potential The study was carried out in four seasons, including winter (which started from December in 2015), spring (Mar in 2016), summer (July to August in 2016), and autumn (October in 2016).2.2Small mammals were captured by dead traps (15 × 8 cm). The species were identified by key morphology characteristics of small mammals, spleen or liver tissue of them have been collected under the aseptic condition and stored at −40°C. The type of landscapes was recorded in the fieldwork. In each county, landscapes where small mammals were most likely to be captured were selected based on the annual small mammals monitoring data, including bush, cultivation, and woodland. The details of small mammals captured and tissue collected were described in previous publication . The samDeoxyribonucleic acid (DNA) from the spleen and liver of small mammals was extracted by the BioTeke Whole blood genomic DNA Kit , according to the manufacturer’s instruction and then stored at −40°C until subsequent molecular laboratory.2.3260/A280 was between 1.8 to 2.1, it was selected as the detection template. Real-time Quantitative Polymerase Chain Reaction (qPCR) was performed to amplify the ssrA gene sequence according to previous study  contains the following components: 0.8 μL each of outer primers F and R, 0.4 μL of the probe, 10 μL of HR qPCR Master Mix , and 3 μL of the template. The qPCR condition consisted of pre-denaturation at 94°C for 5 min, denaturation at 94°C for 15 s, and annealing at 60°C for 45 s, followed by 40 cycles. The plasmid standards were used to draw the standard curve. The amplified products were determined according to the standard curve and limit of detection (Cq = 35), if the Cq <35 was positive.Bartonella positive. Following 10%–15% of the positive samples from each county, which included positive samples from different areas and landscapes whenever possible, were randomly selected to sequence in both directions .The sequencing of positive samples was generated by conventional PCR according to the above reaction conditions. The amplified products were collected and electrophoresed in 1.5% agarose gel containing Gelview  and visualized under the Gel imaging system . The amplified products (269 bp) were confirmed as 2.47.1 version). Reference complete or partial sequences encoding ssrA of Bartonella were retrieved from GenBank by the Blast program of the National Center for Biotechnology Information.7.0 version). Phylogenetic trees were constructed by the Neighbor-joining method after 1,000 bootstrapped replicates.Sequences of successfully detected were edited and trimmed by DNASTAR  and other species (≤ 10%) according to the constituent ratio. The 4.0.2 version). The Bartonella infection in different genera, species, county, and season were compared using Chi-square Test. p values less than 0.05 were considered statistical significance.The number of positive were summarized and counted across different species, genus, area, and season using the “tidyverse” package in R software . The small mammals captured were allowed and no painful.33.1Rodentia, 7 species of Insectivora, and one species of Scandentia. In total, Apodemus chevrieri was the dominant species, which accounted for 29.35% (471/1605), followed by Eothenomys miletus was 19.00% (305/1605) and Apodemus draco was 9.78% (157/1605). In Yulong county, the dominant species were A. chevrieri (33.64%), E. miletus (16.55%), and A. draco (16.00%). In Jianchuan county, the dominant species were A. chevrieri (44.14%), E. miletus (31.94%), and A. draco (10.65%). In Lianghe county, Rattus tanezumi (24.57%) was the dominant species, followed by Rattus rattus (19.90%), Mus pahari (10.81%), and Niviventer fulvescens (10.07%). The distribution of wild small mammals across the three counties is shown in A total of 1,605 wild small mammal specimens were taken across the three counties , covering 30 different species. There are 22 species of Bartonella detection. The overall prevalence of Bartonella in wild small mammals was 47.85% (768/1605). The result of partial samples of qPCR and agarose gel electrophoresis are shown in Bartonella was detected varied from 2.17 to 100% by different species. The prevalence of Bartonella was highest in N. fulvescens  and was lowest in Tupaia belangeri . Although Eothenomys eleusis, Soriculus leucops, Vernaya fulva, and Bandicota indica had a high prevalence (>60%), the sample size was too small to represent. Seven small mammal species were captured in all three counties, and Bartonella was detected in four of them, including Crocidura dracula, E. mileyus, Niviventer andersoni, and Niviventer confucianus, with E. mileyus had the highest infection rate , followed by N. confucianus . The infection rates of C. dracula and N. andersoni were more than 50%, but the sample size was too small to represent. Among the dominant small mammal species across the different counties, A. chevrieri had a prevalence of 65.95% (n = 185), followed by A. draco at 65.91% (n = 88), and E. mileyus at 38.46% (n = 91) in Yulong county. In Jianchuan county, A. chevrieri had a prevalence of 46.50% (n = 286), followed by A. draco at 37.68% (n = 69), and E. mileyus at 37.20% (n = 207). However, in Lianghe, N. fulvescens had a prevalence of 85.37% (n = 41), followed by M. pahari at 54.55% (n = 44), R. tanezumi at 57.00% (n = 100), and R. rattus at 54.32% (n = 81), the prevalence of Bartonella in the dominant small mammal species across different areas is shown in Twenty-five various small mammal species were shown positive for Bartonella was detected in 14 of these species. Among the four seasons, summer exhibited the highest infection rate for Bartonella in small mammals , followed by spring  and autumn , while winter had the lowest rate . A. chevrieri, A. draco had a higher infection rate in spring and summer, E. mileyus had a higher infection rate in summer and winter. In addition, R. rattus had higher Bartonella infection in autumn and winter , followed by the genus of Niviventer  and Apodemus . The Soriculus genus had 75% Bartonella prevalence, but the sample was too small to represent. The prevalence of Bartonella distribution of small mammal species and small mammal genera by regions or season are shown in Eighteen small mammal species were captured in all four seasons, and Shown in . A total3.2Bartonella infection in small mammals across the different species, E. mileyus had the lowest Bartonella infection rate than that in A. chevrieri, R. tanezumi, A. draco (p < 0.001). Still, the other three species  had no significant differences from one another. Small mammals that were male had higher infection rate than females (p < 0.05). Comparing the prevalence of Bartonella in small mammals from the three counties, the prevalence of Bartonella in small mammals from Lianghe county had the highest infection rate, followed by those in Yulong, the lowest infection was in Jianchuan (p < 0.001). Among the four seasons, Bartonella infection of small mammals in summer had the highest infection than that in other three seasons (p = 0.001). In addition, Bartonella infection in small mammals in woodland had the highest infection than that in bush and cultivation (p = 0.001). The relationship between the associated factors and the infection of Bartonella in small mammals is shown in Comparing 3.3Bartonella tribocorum, where LH-1-068 and LH-1-115 were homologous up to 100%, JC-3-051, LH-1-012, LH-1-079, LH-1-098, LH-1-103, LH-3-015, LH-3-088, LH-3-198, and LH-4-139 (9 samples) were also shared more than 98% identity with Bartonella elizabethae, LH-3-058 shared 96% with B. tribocorum, but shared a higher identity with Bartonella rattimassiliensis at 99.6%. 31 samples  shared more than 96% identity to Bartonella rochalimae, where LH-3-206 were homologous up to 100%. 18 samples  shared more than 99% identity to B. japonica. YL-3-230, LH-1-094, and YL-1-011 (3 samples) shared more than 98% identity to Bartonella taylorii, and LH-1-094 also shared 97.2% identity to Bartonella sylvatica. YL-1-094 shared 96.8% identity with Bartonella grahamii, but shared a higher identity with B. washoensis at 98%.Out of 768 positive samples , 96 positive sample were randomly selected for further sequence analysis. 33 samples  shared more than 96% identity to ssrA gene sequence homologies of 96 sample sequences and 27 reference sequences of Bartonella is shown in Bartonella strains detected in small mammals belonged to multiple clusters, including B. rochalimae, Bartonella japonica, B. tribocorum, B. sylvatica, B. rattimassiliensis, and Bartonella washoensis. Bartonella species in small mammals from Lianghe county belonged to five different strains, and it was more diverse than the strains of Bartonella identified from Yulong and Jianchuan counties, where only two and one strains were separately detected. The majority of sequences were ascribable to B. japonica. Among these positive samples, A. chevrieri, E. mileyus, and A. draco were detected with Bartonella japonica, R. rattus with B. rattimassiliensis, Dremomys pernyi with B. washoensis, M. Pahari with B. sylvatica, N. fulvescens with B. tribocorum, in addition, R. tanezumi was detected with both B. tribocorum and B. rochalimae. Sequence details from this study are shown in The phylogenetic tree constructed with 4Bartonella has gained recognition as an emerging zoonotic pathogen. It has been detected in various small mammals in China, particular exhibiting a high infection rate in the northern and southwestern regions , followed by Rattus norvegicus (20.7%) , followed by A. latronum. Small mammals that survive in different areas determine the possibility of species carrying Bartonella. In this study, a slightly higher Bartonella infection was detected in male small mammals compared to females. This finding was similar to the previous study and could be attributed to the more vigorous activity of male small mammals, which can elevate their chances for exposure to pathogens and enhance the potential roles serving as a host for transmission to other small mammals  . In this mammals .Bartonella infection in the two areas were different, and this could be due to variations in the number of dominant small mammal species infected with Bartonella, suggesting differences in how small mammals adapt to the pathogens in similar environments. In addition, the dominant small mammal species in Lianghe county also differed from those in Yulong and Jianchuan counties, with higher infection rates in R. tanezumi. This finding was in line with previous studies that showed R. tanezumi was the main host for Bartonella , which could improve the representativeness of the composition and distribution of small mammals in western Yunnan Province. Second, only 96 out of the 768 positive samples were sequenced due to inadequate research project funding, but the randomly selected samples included different counties and landscapes whenever possible. The above selection criteria could be biased, but the sequencing results of positive samples should be as representative as possible. As a result, there might be an insufficient number of 5Bartonella was detected in Yulong, Jianchuan, and Lianghe counties of western Yunnan Province. Six Bartonella species  were obtained, with B. japonica being the main species. The rates of Bartonella infection were influenced by small mammal species, the gender of small mammals, geographical areas, seasons, and landscapes. Therefore, ongoing surveillance for Bartonella infection in small mammals is crucial, and efforts to identify Bartonella species should be maximized to prevent human infections caused by infected small mammals.A high prevalence of The original contributions presented in the study are included in the article/The animal study was approved by Medical Ethics Committee of Dali University. The study was conducted in accordance with the local legislation and institutional requirements.Y-YL: Data curation, Formal analysis, Software, Visualization, Writing – original draft, Writing – review & editing. DY: Data curation, Formal analysis, Methodology, Software, Visualization, Writing – original draft. H-ZZ: Data curation, Formal analysis, Methodology, Writing – original draft. Z-XL: Investigation, Writing – original draft. R-DH: Investigation, Methodology, Writing – original draft. MH: Investigation, Writing – original draft. ZQ-A: Methodology, Writing – original draft. J-JZ: Methodology, Writing – original draft. J-XY: Conceptualization, Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Writing – review & editing.


We sought to identify distinct risk factors for hyperuricemia in native Tibetan and immigrant Han populations in Tibet, China.Three cohorts of male participants aged between 20 and 40 years were enrolled in this study. Biochemical parameters including serum uric acid (UA), fasting plasma glucose, insulin, lactate dehydrogenase (LDH), thyroxin, blood cell count, aminotransferase, and lipid profiles were analyzed. The association of risk factors with UA levels was evaluated using a multivariable line regression model. The effect of UA level on the biochemical parameters between the Hans and Tibetans was evaluated by two-way ANOVA.P<0.05) and LDH (P<0.01) levels, in contrast with lower levels of triglycerides (P<0.05), total cholesterol (P<0.01), and low-density lipoprotein-cholesterol (P<0.01) than Hans in normal UA populations. Biochemistry analysis revealed lower albumin levels (P<0.001) and higher levels of all aminotransaminase and especially alkaline phosphatase (P<0.01) in Tibetans than in Hans in both populations. Compared with Hans, Tibetans had lower serum levels of urea, creatinine, and electrolytes in the normal UA population, which were further exacerbated in the high UA population. Tibetans had comparable white blood cell counts as Hans in both normal and high UA populations. In contrast, the red blood cell count and hemoglobin concentration were much lower in Tibetans than in Hans under high UA conditions.The prevalence of hyperuricemia (≥420 μmol/L) was 24.8% (62/250) in the Hans, similar to 23.8% (29/136) in the Tibetans. In the regression analysis, the risk factors that were significantly associated with UA in Hans did not apply to Tibetans. Tibetans had higher fasting insulin (The distinctive biochemistry between Tibetans and Hans may underlie the different etiologies of hyperuricemia in Tibet, China.  In addition, hyperuricemia is significantly associated with the prevalence of metabolic syndrome (MS) , 2. The n region .Nowadays, with the development of economy and tourism, more inlanders would settle in Chinese Tibet area. The above surveys raised a great concern that Han inlanders accumulated increasing levels of UA if they assimilated into the high altitude as Tibetan highlanders. It has been reported that the clinical indices of Hans were increasingly similar to those of Tibetans with their plateau living . TibetanA high-altitude environment features sustained hypobaric hypoxia . Acute hHowever, most of the related studies in Tibetans were on middle-aged or old populations who had already assimilated to high altitudes for many years and may have developed other confounding diseases. Considering that hypoxic research on healthy individuals at high altitudes may be translated into hypoxemic critically ill patients in a hospital setting , we carrAll study protocols were approved by the ethics committee of the Chinese PLA General Hospital  and were in accordance with established national and institutional ethical guidelines. The study was clearly described to all participants who signed informed consent forms before the collection of blood and personal information. Healthy adults aged 18-60 years old who had lived in the Tibetan region for > 1 year were included in the study. Participants with major operation, tumor, severe lung, heart, digestive, or endocrine diseases were excluded.A comprehensive questionnaire, including questions on demographics, medical history, and lifestyle risk factors, was administered by the staff at local health stations according to a standard protocol. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using a standardized automatic electronic sphygmomanometer (Omron HEM-770A). Body weight (BW) and height were measured, and body mass index (BMI) was calculated as weight/height2 (kg/m2).From April 2018 to October 2022, we recruited three groups of healthy male adults (18-60 years old) from both the Han and Tibetan populations in the Chinese Tibetan region Table 1.Fasting venous blood (8 ml) was collected in EDTA-K2 tubes. Hematological parameters were determined immediately using an automated hematology analyzer . Blood samples were separated by centrifugation at 4,000 rpm for 10 min within 4 h and then stored at -80°C (Group A) or subjected to automatic analysis of a few biochemical indicators  immediately in Tibetan Peoples’ Hospital (Group B) or Naqu Peoples’ Hospital (Group C).®XP, Siemens, Germany). Insulin was detected using a chemiluminescence immunoassay analyzer . Tissue nonspecific alkaline phosphatase (ALP) was detected using colorimetry .Plasma samples in Group A were transported and assayed in the Department of Laboratory Medicine of Chinese PLA General Hospital (Beijing) (Group A), including UA, glucose, lactate dehydrogenase (LDH), albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ-glutamyl transferase (GGT), total bilirubin (TBIL), and direct bilirubin (DBIL); renal parameters, including creatinine, urea, and cystatin C; and lipid parameters, including triglyceride (TRIG), total cholesterol (TCHOL), high-density lipoprotein cholesterol (HDL-CH), low-density lipoprotein- cholesterol (LDL-CH), and electrolytes, using an automatic biochemical immunity analyzer . The remaining plasma (1.5 ml) was used for hormone assays. The thyroxin concentration was determined using an automated chemiluminescence immunoassay analyzer  distance were used to describe variables that did not meet the normal distribution. GraphPad Prism 9.0  was used for data analysis. The two ethnic populations in Group A (Lhasa and Nyingchi) were subjected to multiple line regression analysis to estimate the associations between the major indices and UA levels, including age, altitude, BMI, and biochemical parameters. Where the dependent variable was affected by UA level and ethnicity, the data were analyzed using two-way ANOVA. When the main effect or interaction was significant, r) between the red blood cell (RBC) profile and UA level using Pearson’s analysis. A two-sided P<0.05 was considered statistically significant. Multivariate line regression was used to analyze the associations between RBCs indices and UA levels in the two populations.Group B (Lhasa) was subjected to the calculation of the correlation coefficients (t test was used for intergroup comparisons.Group C (Naqu) was used for the comparison of demography, RBCs profile, and blood cell count between Hans and Tibetans. The Mann–Whitney U test or unpaired The three groups of populations covered the ages 20-30 (Group A), 30-40 (Group B), and 19-20 (Group C) years old. Tibetans were older than Hans in the former two populations, whereas they were younger than Hans in Group C Table 1.vs. 29 (18-41), P=0.032]. However, there was no difference in age between the subgroups (vs. 3.7 (1.3-6.3), P=0.53].The survey of Group A was based on a sample drawn from a larger population. We first enrolled 250 Hans and 136 native Tibetans for general physical examinations. The incidence of hyperuricemia was 24.8% in the total Han population (62/250) with a median (IQR) age (years) of 24 (21-28) and 23.8% in the total native Tibetan population (29/136) with a median (IQR) age of 31 (19-46). From the above population, we matched samples with similar ages and backgrounds into Group A for the following thorough biochemistry analysis, in which the Hans (n=85) were still younger than the Tibetans (years) (n=64) . The incidence of hyperuricemia was 44.3% in the Hans and 32.7% in the Tibetan.In Group B, the Hans (n=70) were also younger than Tibetans (n=156) , more meat in diet and water intake, more tap water over purified water, and less exercise . Nonetheless, Tibetans had fewer signs of acute and chronic altitude sickness.In Group C, the Hans (n=46) were slightly older than native Tibetans (n=65)  and LDH (P<0.01) levels were higher in Tibetans than in Hans in normal UA populations  mmol/L, P<0.001] but not in the Tibetans  compared with the respective ethnic groups in Group A with normal UA levels. However, the glucose levels were comparable between the two ethnicities in Group C)  Group C) Table 3.In both groups of our populations, the level of total cholesterol was 3.21-4.48mmol/L (124-173mg/dl), LDL cholesterol was between 1.85-2.51mmol/L (77-97mg/dl), both were much lower than the total cholesterol (224.0 ± 42.9 mg/dl) and LDL cholesterol (145.3 ± 39.3 mg/dl) from an Italian population, respectively. However, the level of HDL-cholesterol was between 1.00-1.18mmol/L (37-44 mg/dl) and TG was between 0.86-2.24 mmol/L (55-143mg/dl), similar to those from the same Italian population with HDL (55.6 ± 15.6 mg/dl) and TG [96 (69-137) mg/dl], respectively .Surprisingly, in Group A Table 3.In Groups A and B, although the total protein levels were similar between the Han and Tibetan populations, they were increased by high UA levels in both populations 3IIC, D.In Group A, UA levels were comparable between the Hans and Tibetans in both the normal and high UA populations Table 3.Creatine kinase (CK) and its MB isoenzyme (CK-MB) are the most commonly used serological biomarkers for the diagnosis of myocardial infarction. In Group A, CK did not differ between Tibetans and Hans regardless of the UA level . In the Regardless of the UA level, thyroid-stimulating hormone (TSH), triiodothyronine (T3), and free T3 levels were not altered between the Hans and Tibetans in Group A Figure 5In Group A, all serum electrolyte levels were much lower in Tibetans than in Hans in the normal and high UA populations Figure 6In Group B, Tibetans had similar counts of blood cells as Hans, except that they had fewer lymphocyte counts but more eosinophil counts than Hans Figure 712/L, [Hb] 137179 g/L), they were indistinguishable between the two populations under normal UA conditions. Both were differentially increased between Tibetans and Hans under high UA conditions, resulting in higher levels in Hans than in Tibetans  and lower platelet-larger cell ratio (P-LCR) % than Hans Table 3,Interestingly, in Group B, although the UA levels correlated with RDW-SD and RDW-CV significantly in Tibetans Table S1Although the prevalence of hyperuricemia is much higher in Tibet than in other places in China, immigrant Hans have accumulated a high incidence of hyperuricemia in Tibet. When we compared the incidence of hyperuricemia between native Tibetans and immigrant Hans at the three altitudes in the Tibetan region, we found a similarly high prevalence of hyperuricemia between the two ethnicities but with distinct biochemical mechanisms. Hyperuricemia is closely associated with obesity and metabolic disturbances such as insulin resistance, dyslipidemia, hypertension, and kidney disease in lowlanders  and highIn our study, the high prevalence of hyperuricemia in high-altitude-adapted native Tibetans reached at the similar level as the patients with Acute Coronary Syndrome, e.g., acute Heart Failure (35.8%) , which cde novo synthesis, and salvage pathways  to maintain energy levels . Under nSerum alkaline phosphatase (ALP) is a traditional indirect marker of cholestasis. ATP, adenosine diphosphate (ADP), and AMP can be metabolized to adenosine by two different enzyme systems. Ecto-5-nucleotidase (CD73) converts AMP to adenosine  and tissAt the cellular level, the response to hypoxia results in the promotion of glycolytic capacity, increased glycolytic flux, and lactate efflux in cells . LDH is Accordingly, compared with Hans, Tibetans had higher insulin levels in the normal UA population and higher fasting glucose levels in the high UA population in our study Figure 1Accumulating evidence suggests that hyperuricemia is associated with impaired glucose metabolism  and insuIn hypoxia-tolerant systems, a shift away from fatty acid oxidation toward a more oxygen-efficient hypometabolic pathway with the downregulation of ATP demand is a common strategy . In ratsIn the catabolic state of insulin resistance, AST and ALT are responsible for transferring amino acid groups to produce essential intermediate products in the gluconeogenesis pathway. ALT, frequently referred to as glutamic pyruvate transaminase, catalyzes the reversible transamination of alanine and α-ketoglutarate into glutamate and pyruvate . TherefoSaliva ALT and glutamic oxaloacetic transaminase levels increase after hypobaric hypoxia in healthy military aircrews . HypoxiaGlutathione (GSH) is the principal intracellular antioxidant buffer against oxidative stress in the form of reduced GSH and oxidized GSH (GSSG) . A favorPPARA  in the kidney. Glucose then passes into the interstitial fluid and peritubular capillary via the glucose transporter maintained by Na+/K+ ATPase in the proximal tubule  adaption and ethnicity would provide more information for managing the critical illness.Although we recruited both sexes in the beginning, for the limitation of the page space, we only present the data from the male population here. The results including the female population would reflect the biochemistry of hyperuricemia at the overall level of population. Because of the religious faith, it is not easy to collect the blood samples from a larger crowd in Tibetan areas, the limitation of insufficient effect due to the small sample size should be considered. In the multiple line regression analysis, other demographic factors such as the economic status, education, and profession may also be the potential confounding factors but were not included in this study. Another limitation was that routine blood tests, including white blood cell count, red RBCs, and [Hb], were not conducted in Group A.The risk factors associated with MS for hyperuricemia in immigrant Han individuals did not apply to native Tibetans on the Chinese Tibetan Plateau. However, the higher ALP activity in Tibetans than in Hans may be involved in purine metabolism by mediating the degradation of nucleotides. Moreover, heightened glycolysis, worsened glucose intolerance, increased aminotransferase activity, and reduced UA excretion may underlie hyperuricemia in native Tibetans.The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.The studies involving humans were approved by Chinese PLA General Hospital . The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.X-WR conceived the project, recruited the populations, and collected samples and clinical data. KC, JW, Z-LY, and TJ helped collect and detect the samples. Q-HZ statistically analyzed and interpreted the data and wrote the draft of the manuscript. All the authors have read and approved the final manuscript.


To observe the serum levels of 25 hydroxyvitamin D [25 (OH) D] in healthy school-age children and children with attention deficit hyperactivity disorder (ADHD) and to analyze the effects of serum 25 (OH) D on the symptoms of attention deficit and hyperactivity in school-age children with ADHD.According to the Diagnostic and Statistical Manual of Mental Disorders DSM-IV diagnostic criteria for ADHD in children, 80 healthy children aged 6 years or less than 10 years old and children diagnosed with ADHD in the Department of Rehabilitation Medicine, Department of Pediatrics and Department of Physical Examination of our hospital were randomly selected as research subjects. The serum 25 (OH) D level, attention deficit hyperactivity  score and Conners child behavior (PSQ) index were observed and compared between the 2 groups. In addition, the children with ADHD whose serum 25 (OH) D was lower than normal were treated with supplemental VitD3, and the changes in serum 25 (OH) D, SNAP-IV parental score and PSQ index of ADHD children were observed and compared.r = −0.3479, P = .0034) and negatively correlated with PSQ index . After vitamin D3 (VitD3) supplementation in 69 children with serum 25(OH)D levels lower than the normal ADHD group, it was found that the SNAP-IV score  and PSQ index  of 34 children with ADHD were negatively correlated with the increase in serum 25(OH)D. The SNAP-IV score and PSQ index of the other 35 children with ADHD showed no correlation with the increase in serum 25 (OH) D (P > .05).Serum 25(OH)D was insufficient or deficient in 26 healthy children, but the SNAP-IV score and PSQ index were normal. Serum 25(OH)D was lower than normal in 69 patients in the ADHD group, which was negatively correlated with SNAP-IV score (Serum 25(OH)D levels lower than normal are more common in school-age children, and levels lower than normal are not the key pathogenic factor of ADHD in school-age children, but serum 25(OH)D levels lower than normal may be the upregulation factor of attention deficit and hyperactivity disorder expression in some school-age children with ADHD. The lower level of serum 25(OH)D may be closely related to the severity of ADHD symptoms in some children. According to statistics, the prevalence rate of ADHD in school-age children is 3–10%, 2–18% of children worldwide are affected,,3 and 30–50% of children will have symptoms lasting to adulthood and the rest of their lives. ADHD in school-age children seriously affects their health, study and life, leading to family and social disharmony. Therefore, an in-depth understanding of the pathogenesis of ADHD is particularly critical for the treatment of ADHD in school-age children.Attention deficit hyperactivity disorder (ADHD), a persistent neurodevelopmental disorder, has become an important public health problem. ADHD in childhood manifests as serious age-inappropriate impulsivity, hyperactivity and inattention.–8 but a unified pathogenesis theory has not yet been formed; therefore, it is particularly critical to study the mechanism of ADHD as a whole and as a system. At present, domestic and foreign scholars have used drugs  and comprehensive rehabilitation treatment  for children with ADHD, with limited efficacy.,10 Especially for school-age children with ADHD, the above drug treatment easily affects the growth and development of children, and the general acceptance of parents is low. Behavioral therapy and rehabilitation training courses are longer, and children and parents have difficulty adhering to them. Therefore, it is urgent to find a treatment that is easy for children and parents to accept and adhere to.The exact etiology of ADHD remains unclear. Polygene mutation, micronutrient imbalance, intestinal flora disorder, serotonin (5-HT) and catecholaminergic signaling pathway abnormalities have been confirmed to be related to the onset of ADHD, and VitD supplementation is also used to treat mental disorders. However, is serum 25 hydroxyvitamin D [25 (OH) D] lower than normal level a pathogenic factor for ADHD of school age? Moreover, the correlation between the lower level of serum 25(OH)D and the severity of attention deficit and hyperactivity in children needs further study.Dietary nutrition has been increasingly recognized in psychological and behavioral health. We can obtain vitamins, minerals, amino acids, polyunsaturated fatty acids and other nutrients from the diet. However, partial and picky eating is common among school-age children, which directly leads to micronutrient imbalance and affects the internal environment of the body. Studies have shown that the imbalance of vitamin D (VitD) is related to ADHD,Based on the above reasons, we observed the serum 25(OH)D levels in healthy school-age children and ADHD children, analyzed the influence of serum 25(OH)D levels lower than normal on hyperactivity and attention deficits in ADHD children, and analyzed the effects of vitamin D3 supplementation on 25-hydroxyvitamin D levels and hyperactivity symptoms. 80 healthy children and 80 children diagnosed with ADHD in the Department of Rehabilitation Medicine, Department of Pediatrics and Department of Physical Examination of our hospital from June 2019 to December 2022 were randomly selected as research subjects. The children in both groups were more than or equal to 6 years old and less than or equal to 10 years old. Serum 25 (OH) D levels, attention deficit hyperactivity scores of Swanson, Nolan, and Pelham, version IV scale, Swanson, Nolan, and Pelham, version IV (SNAP-IV) (Parent edition) and Conners parental symptom questionnaire, PSQ (Parent edition) were observed and compared between the 2 groups. In addition, children in the ADHD group whose serum 25 (OH) D was lower than normal were treated with supplemental VitD3, and the changes in serum 25 (OH) D, SNAP-IV parental score and PSQ index of ADHD children were observed and compared. ADHD was diagnosed by specially trained and qualified physicians from the Department of Rehabilitation Medicine or the Department of Pediatrics of our hospital. The SNAP-IV and PSQ were evaluated by qualified rehabilitation therapists for children. This study was approved by the Ethics Committee of Ganzhou People’s Hospital (TY-ZKY2021-003-01).According to the diagnostic criteria for ADHD in children in the Diagnostic Statistical Manual of Mental Disorders DSM-IV,Inclusion criteria: Did not meet the diagnostic criteria of ADHD in DSM-IV; the children were more than or equal to 6 years old and less than or equal to 10 years old; 70 ≤ WPPSI-IV score ≤ 110; mother tongue is Mandarin Chinese; no supplements of vitamin D and other health products in recent 1 month; and the family members or guardians of the children were informed of this study, agreed and signed the consent form.Exclusion criteria: Attention deficit and/or hyperactive impulse items in the SNAP-IV rating scale (parent version) ≥ 4; and people with physical diseases, neurological and mental disorders now or in the past.Inclusion criteria: Meeting the diagnostic criteria for ADHD in DSM-IV; the children were more than or equal to 6 years old and less than or equal to 10 years old; 70 scores ≤ WPPSI-IV score ≤ 110; mother tongue is Mandarin Chinese; have not used any ADHD drugs, and have not supplemented any health products such as vitamin D in recent 1 month; and the family members or guardians of the children were informed of this study, agreed and signed the consent form.Exclusion criteria: Conduct disorder, mood disorder and psychosis; mental retardation, pervasive developmental disorder; obvious physical and neurological diseases; and coagulation dysfunction using any central stimulants, tomoxetine, antipsychotics, or antidepressants. 2 specially trained therapists from the Department of Rehabilitation Medicine who have obtained the intelligence assessment qualification of Wechsler will conduct the intelligence quotient (IQ) test according to the standard methods stipulated in the test manual. The scale includes 4 indexes of speech comprehension, perceptual reasoning, working memory and processing speed, among which verbal comprehension and perceptual reasoning are the general ability index and working memory and processing speed are the cognitive efficiency index. The Wechsler Intelligence Scale for Children, Version V has 10 core subtests for building blocks, similarity, number memorization, picture concept, decoding, vocabulary, letters, numbers, matrix reasoning, comprehension and coincidence retrieval. The higher the score, the higher the intelligence. According to the WSC-V measure, IQ ≥ 120, 110-119, 90-109, 80-89, and 70-80 were classified as excellent, upper middle, medium, lower middle, and critical, respectively. Children with IQ scores less than 70 and greater than 110 were excluded from the study.Using the Wechsler Intelligence Scale for Children, Version V,Professionals guide parents to complete the Conners Parent Assessment Questionnaire (PSQ). The scale includes 48 items in 5 subscales . A four-level scoring method  was adopted. 0 score: no such problem; 1. Occasionally a little or slightly present; 2 points: frequent or more serious; 3 points: very common or very serious. The score of the project was added and divided by the number of items to obtain the hyperactivity index. A hyperactivity index of 0.75 to 1.5 indicates mild hyperactivity, 1.5 to 2.25 indicates obvious hyperactivity, and a hyperactivity index ≥ 2.25 indicates severe hyperactivity. which included 3 subscales and 26 items. They were divided into the attention inattention scale (items 1–9), hyperactivity/impulsivity scale (items 10–18), and oppositional disobedience scale (items 19–26). Each item was scored according to 4 levels from 0 to 3: 0 points: none; 1 point: a little bit; 2 points: not a lot; and 3 points: a lot. The score value is calculated by adding the scores of each item and dividing by the number of items. A score of 0–1 is normal; a score of 1.1–1.5 hints at an edge; a score of 1.6–2 indicates moderate; and a score of 2 or above indicates serious. The higher the score, the more severe the ADHD symptoms.The Chinese version of Swanson, Nolan, and Pelham, Version IV scale, SNAP-IV (Parent edition) revised by Zhou Jinbo was adopted,: 2 mL of fasting venous blood was collected in the morning, and the serum was isolated and stored at −70°C. Chemiluminescence immunoassay was used to detect the level of 25(OH)D in the serum, which was divided into 3 horizontal segments: adequate level (20–100 ng/mL); insufficient level (15–19.9 ng/mL); and deficient level (<15 ng/mL). We defined < 20 ng/mL as below normal.25(OH)D detectiont test was used for comparison. The χ2 test was used for enumeration data, and Pearson correlation analysis was used for correlation analysis. P < .05 was considered statistically significant.The SPSS 15.0 statistical software package was used for data analysis. Measurement data conforming to a normal distribution were expressed as P > .05), indicating comparability  D was lower than the normal level in 26 cases, but the SNAP-IV score and PSQ index were normal. The other 54 children had normal levels of serum 25(OH)D. The serum 25(OH)D level, SNAP-IV score and PSQ index of the healthy children group were not statistically significant (P < .01). The serum 25(OH)D level in the remaining 11 patients was at an adequate level, and there was no correlation with the SNAP-IV score and PSQ index (P > .05) (Table The serum 25(OH)D level in 69 patients in the ADHD group was lower than the normal level, and a level lower than the normal level was negatively correlated with the SNAP-IV score and PSQ index P < .0. The serP < .01), and the difference was more significant before and 45 days after supplementation (P < .0001). These results indicated that the intervention of VitD3 supplementation could improve the symptoms of attention deficit and hyperactivity in some school-age ADHD children with serum 25 (OH) D lower than the normal level, and the therapeutic effect tended to be more significant with the extension of treatment time (Table Sixty-nine children with ADHD whose serum 25(OH)D levels were lower than normal were treated with VitD3 supplementation (daily VitD31000IU), and serum 25(OH)D levels were observed before supplementation and 15 and 45 days after supplementation. There were significant differences in serum 25(OH)D levels at 3 stages by one-way analysis of variance. There were significant differences before and after 15 days of supplementation and after 15 and 45 days of supplementation (P < .01). These 34 cases were included in the continuous improvement group. The SNAP-IV score and PSQ index of the other 35 ADHD children showed no correlation with the increase in serum 25 (OH) D (P > .05), and we included these 34 patients in the uncertain effect group (Table Through VitD3 supplementation in 69 children with ADHD whose serum 25 (OH) D was lower than the normal level, we further found that the SNAP-IV score and PSQ index were negatively correlated with the increase in serum 25 (OH) D in 34 children with ADHD , norepinephrine (NE) and 5-HT can regulate cognitive functions such as attention, motivation, consciousness, executive function, sensory gating, social behavior and impulsiveness.,25 Kesby found that VitD deficiency during development could lead to disorders of a variety of neurotransmitter systems in the brains of newborn rats, including 5-HT, DA, and NE. In this study, some children in both groups had serum 25(OH)D levels lower than the normal level , indicating that serum 25(OH)D levels lower than the normal level are not the key pathogenic factor of ADHD in school-age children. Why do only children with ADHD express hyperactivity and attention deficits? In summary, we conclude that insufficient or deficient serum 25(OH)D is not the key pathogenic factor for ADHD in school-age children. It is possible that the body may have an imbalance in neurotransmitter secretion when the diet environment changes on the basis of genetic variation and gene mutation, and the expression of attention deficit and hyperactivity in ADHD children is easily upregulated.Experimental studies in mice confirmed that the 5-serotonin transporter-associated promoter region involved in the transcriptional regulation and transport of 5-HT was prone to genetic variation, including insertion and loss of 44 base pairs, forming alleles of 2 different lengths, l (long) and s (short) genes. ADHD individuals with the 5-serotonin transporter-associated promoter region s allele are especially sensitive to environmental changes.P < .01). After supplementing VitD3 1000 IU/d for these 69 children with ADHD, it was found that after supplementing VitD3 15 and 45 days, in 34 cases, the SNAP-IV score and PSQ index were negatively correlated with the increase in serum 25 (OH) D (P < .01), and the symptoms of attention deficit and hyperactivity showed continuous improvement (continuous improvement group). The SNAP-IV score and PSQ index of the other 35 children showed no correlation with the increase in serum 25 (OH) D (P > .05), and there was no improvement in the symptoms of attention deficit and hyperactivity (uncertain efficacy group). There were significant differences in serum 25 (OH) D levels in 69 children before VitD supplementation and 15 and 45 days after VitD supplementation (P < .01), and the difference was more significant before and 45 days after supplementation (P < .0001), indicating that the lower level of serum 25 (OH) D than the normal level may be the upregulating factor for the expression of attention deficit and hyperactivity in some school-age children with ADHD, and the lower level of serum 25 (OH) D than the normal level may be closely related to the severity of attention deficit and hyperactivity in some children. The intervention of VitD3 supplementation can improve the symptoms of attention deficit and hyperactivity in some school-age ADHD children with serum 25 (OH) D lower than the normal level, and the therapeutic effect tends to be more significant with the extension of treatment time.Our research group showed that the degree of serum 25(OH)D lower than the normal level in 69 children with ADHD was negatively correlated with the SNAP-IV score and PSQ index (P > .05). There was no correlation between the level of serum 25(OH)D deficiency and the severity of ADHD symptoms in 35 children with ADHD (P > .05). What is the reason? Domestic and foreign research results on micronutrients other than VitD suggest that the imbalance of vitamin A (VitA), VitD, vitamin B2 (VitB2), vitamin B6 (VitB6), vitamin B12 (VitB12), folic acid, iron, zinc, magnesium, copper and other micronutrients are also correlated with ADHD,,28 and DA is the most active neurotransmitter among catecholamines. Three dopaminergic pathways in the brain have been proven to be related to the pathogenesis of ADHD: mesolimbic, mesocortal and substantia nigrostriatum pathways. Therefore, we speculate that school-age children with ADHD may have different genetic variations, gene mutations or different neurotransmitter pathway disorders . When picky eating leads to the deficiency of micronutrients  D was at a sufficient level, showing no correlation with SNAP-IV score and PSQ index . To further study the different neurotransmitter pathways  disorders in school-age children with ADHD of different types caused by different genetic variations and gene mutations and downregulation of attention-deficit and hyperactivate-like micronutrients  in school-age children with ADHD.We thank the children and their parents for participating in our study.Conceptualization: Juan Yang.Data curation: Juan Yang, Ruijuan Qiu, Xiaoqin Fu.Methodology: Juan Yang, Ruijuan Qiu, Xiaoqin Fu.Project administration: Huozhong Yuan.Writing – original draft: Juan Yang.Writing – review & editing: Huozhong Yuan.


Attention-Deficit / Hyperactivity Disorder (ADHD) is prevalent at a higher rate in correctional settings than in the general population. Treatment of ADHD in this environment is challenging as stimulants, the most common treatment for ADHD, require cautious prescribing in the context of frequent substance use disorders (SUD) and diversion in the institutional setting. In addition, both pharmacological and non-pharmacological treatment approaches require significant staff resources. The aim of this scoping review is to map and summarize all literature addressing treatment of ADHD specifically in correctional settings, synthesize the evidence supporting various approaches, and highlight areas for future research. Due to the limited number of primary research studies addressing this question directly, we chose a scoping review methodology that would allow us to explore what kinds of studies and literature exist and include all types of articles directly related to our question.Five-hundred sixty-five relevant articles were screened. Thirty-two articles were included in the final review. Eleven of the articles reported primary research. Five of these articles were based on three randomized controlled trials. Among randomized controlled trials on the effect of stimulants, inclusion criteria, outcome measures and effectiveness varied widely. Non-male and non-white populations were under-represented. Among review articles and recommendations opinion was inconsistent, with some recommending stimulants as first-line treatment and others recommending they be avoided altogether. The effect of non-stimulant medications was examined in 2 small studies. The only non-pharmacological treatment examined was dialectical behavior therapy, and only feasibility was reported. Four articles provided practice recommendations from consensus or expert opinion. Two of these recommended stimulants as first-line treatment, and two recommended stimulants as treatment of last resort.We found a diverse but shallow literature addressing our research question. Primary research in the corrections setting is limited and varies in inclusion criteria, outcomes studied, and effectiveness. Recommendations on treatment are inconsistent. Future research should address methods of diagnosis, the role of non-stimulants, non-pharmacological interventions, non-male and non-white people who are incarcerated (PWAI), and effects of treatment method on patients, staff and other PWAI. Better research and guidance on treating ADHD has potential to improve health of PWAI, the institutional environment, and resource utilization. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by inattention, hyperactivity, or impulsivity that interferes with daily functioning, interpersonal activity, and academic achievement. Although most commonly diagnosed in childhood, ADHD can continue into adulthood. Diagnosis of ADHD is extremely challenging and subjective. As of 2013, the major method used by practitioners to diagnose ADHD is based on DSM-5 criteria. For adults 17 years and older, diagnosis requires at least 5 symptoms of either inattention or hyperactivity lasting at least 6 months. In addition, the symptoms must have been present since before age 12, present in at least two different settings, not caused by other disorders, and interfere with the individual’s quality of life , are likely to play a role in the observed higher prevalence in correctional facilities  ide ide1. ThThe search was conducted in the following databases: Ovid MEDLINE Epub ahead of print 1946–2021), APA PsychInfo, Pubmed, Web of Science, Embase, and Sociological Abstracts. We did not conduct a search of the grey literature. Relevant studies were identified as those that involved the following: (a) adult populations in correctional settings and (b) the treatment of (c) ADHD. All types of research papers from any year were included. Articles were reviewed using the Covidence web platform. Both researchers screened the titles and abstracts of the 565 articles resulting from the initial search to determine inclusion for full review. Inclusion criteria for this step were kept broad to identify as many relevant articles as possible. Of these articles, 128 were selected and underwent a full-text review by one researcher (CB) to further determine relevance to the research question. Thirty of these articles fit the scope of our research goals and an additional 2 relevant articles that were published after the date of the initial search were included in the final report. Figure 946–2021,The outcome of our final review is summarized in Tables Success of treatment will inevitably depend on the reliability of the diagnostic method. We found diverse approaches to diagnosis in the primary research studies reported. Among these studies, 6 used a clinical interview, 4 used the ASRS, 3 used WURS, 1 used CCPT, 1 used the brief-BAARS, 1 used the self-rated Barkley ADHD scale, and 3 were unclear/unspecified regarding what diagnosis or screening method was used. The UK expert consensus statement suggests the specific use of CHAT in youth followed by SNAP-IV / Conners’ CBRS, and the brief-BAARS in adults followed by an interview with CAADID, DIVA-2, or ACE+ , highlighting a lack of racial diversity in the current literature (Asherson et al., We found that the scientific knowledge base related to ADHD treatment in correctional settings has only a small number of primary studies. These studies are made up of small samples that are overwhelmingly white males, primarily focused on stimulants as treatment, diverse in methodology and outcomes, short in follow-up and inconsistent in results. We identified articles offering narrative review, expert opinion, and recommendations. These vary widely in their guidance. This presents a challenging foundation on which to base policy and clinical practice guidance for clinicians caring for people in correctional facilities.Although not the subject of this scoping review, there is a substantial knowledge base that draws on primary research on ADHD treatment outside of the correctional facility context. This evidence is relevant to the treatment of ADHD in PWAI, but the degree to which it can be extrapolated is uncertain. People in correctional facilities have higher rates of comorbidity with SUD and mental illness than people with ADHD in the general population. In addition, patterns of socialization, interaction with facility staff and policies, prevalence of violence, and drug market dynamics within institutions will all play a role in both the need for, and the effectiveness of, ADHD treatment.The unique and complex factors surrounding ADHD diagnosis and treatment in correctional facilities require specific and relevant treatment research to inform policy and clinical practice. We suggest that the current knowledge base is not adequate for this purpose. Our study sheds light on the critical need for research conducted among PWAI, as well as clinicians and institution staff. This research needs to be guided by stakeholder input including people who have experience living with ADHD in situations of incarceration, clinicians who have experience making treatment decisions with these patients, and facility staff who have experience with the socialization and security of PWAI within institutions. A research agenda should include consensus-based treatments; use consistent diagnostic criteria, treatment protocols and outcome measures; and include demographically representative populations of PWAI.Our study has not captured grey literature. It has not provided quantitative synthesis of data, nor has it provided systematic assessment of reliability of the literature. However, the number of studies and participants, and the methodological diversity among these, renders more systematic synthesis inappropriate. Our scoping review approach to this question was well suited to mapping the characteristics of the knowledge base, and for qualitatively exploring the range of methods and findings.The current literature on ADHD treatments in correctional settings is diverse and contentious. Additional high quality research is needed to improve health outcomes for individuals with ADHD experiencing incarceration.


Adult attention-deficit/hyperactivity disorder (ADHD) is often associated with risky decision-making behavior. However, current research studies are often limited by the ability to adequately reflect daily behavior in a laboratory setting. Over the lifespan impairments in cognitive functions appear to improve, whereas affective functions become more severe. We assume that risk behavior in ADHD arises predominantly from deficits in affective processes. This study will therefore aim to investigate whether a dysfunction in affective pathways causes an abnormal risky decision-making (DM) behavior in adult ADHD.Twenty-eight participants with ADHD and twenty-eight healthy controls completed a battery of questionnaires regarding clinical symptoms, self-assessment of behavior and emotional competence. Furthermore, skin conductance responses were measured during the performance in a modified version of the Balloon Analogue Risk Task. A linear mixed-effects model analysis was used to analyze emotional arousal prior to a decision and after feedback display.t = −2.63, p < 0.001) and after feedback display . Although risky behavior was greater in HC than in ADHD, we found a significant interaction effect of group and anticipatory skin conductance responses regarding the response behavior . Post hoc analyses revealed a positive correlation between anticipatory skin conductance responses and reaction time in HC, whereas this correlation was negative in ADHD. Self-assessment results were in line with the objective measurements.Results showed higher emotional arousal in ADHD participants before decision-making (β = −0.12, SE = 0.05, We found altered changes in physiological activity during a risky decision-making task. The results confirm the assumption of an aberrant relationship between bodily response and risky behavior in adult ADHD. However, further research is needed with respect to age and gender when considering physiological activities. Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder with a prevalence of 5% worldwide . ADHD prcold functions) and the intuitive-affective functions (hot functions)  . The mosnctions) .hot function driven behavioral impairments, further research on affective functioning is needed. Additionally, based on the prefrontal recovery hypothesis  whereas changes that precede a decision are described as anticipatory SCR (aSCR). Although SCRs represent emotional arousal, it cannot be clearly assessed whether an rSCR follows a positive or negative feedback  . When emfeedback . It has feedback . In addifeedback . Regardifeedback . Thus, ifeedback .There are only a few studies which have investigated the relationship between electrodermal activity and risky DM behavior in adult ADHD. However, results indicated an altered psychophysiological activity in the context of behavioral impairment in adult ADHD . FurtherThe aim of the present study was to investigate whether a dysfunction in affective pathways is associated with an altered risky DM behavior in adult ADHD. To address this, we analyzed SCRs as well as the relationship between aSCRs and task-behavior. Therefore, we used a modified version of the Balloon Analogue Risk Task (BART) to demand hot function-guided risky decision behavior . The BARn = 30 HC and n = 29 patients with ADHD] were recruited for the current study and met the following inclusion criteria: aged between 18 and 60 years, fluent German language skills, no neurological diseases, no depressive disorder, no borderline personality disorder, or other psychiatric disorder with psychosis. The patient group was recruited from the outpatient clinic of the Department of Psychiatry and Psychotherapy of the University Hospital Bonn and met the full DSM-V criteria  were excluded from the subsequent analyses due to missing measurement data, acute suicidality, or extreme outlier values. The study was approved by the Ethics Committee of the Medical Faculty of the University of Bonn (122/21) and all participants gave oral and written informed consent.Fifty-nine participants . Results indicate the same propensity of risk engagement in ADHD and HC. The ANOVA for the self-assessment of emotional competence  revealed a significant difference between ADHD and HC , indicating a higher emotional competence in HC  did not reveal a significant difference of group [n HC see .The present study investigated whether there is a potential causal relationship of affective pathways and abnormal risky DM behavior in adult ADHD. Therefore, different phases of hot function-guided DM were analyzed and compared between adult ADHD and HC on the basis of behavior, physiological activity, and self-assessment.Results showed higher emotional arousal in ADHD indicated by elevated SCRs preceding a DM. These findings are consistent with the observation of hyperactivity of the autonomic nervous system being increasingly associated with motoric hyperactivity and impulsive behavior in ADHD. These results were suggested to reflect an over-activation of autonomic functions . It is dRegarding the available effect of somatic markers at this point, high aSCRs would be expected to be associated with high risk behaviors, as the somatic response will increase with increased risk engagement in order to avoid disadvantageous behavior . HoweverThus, in order to investigate how the somatic response influences behavior we analyzed the relation of aSCRs and RT. Results showed that risk engagement in HC coincides with increased aSCR, representing the correlation of disadvantageous behavior and higher SCRs . In turnTo understand further aspects of hot function-guided DM, SCRs in response to feedback were also investigated. In this context, the somatic response reflects the evaluation and emotional arousal toward feedback. Results of the rSCRs indicate that feedback is evaluated more emotionally arousing for ADHD than to HC. We could also identify that the feedback of loss is more arousing than gain across both groups. The high rSCRs are also consistent with findings of previous studies on reward sensitivity in ADHD. It was shown that hyperarousal during feedback is associated with weaker inhibitory abilities . FurtherRisk engagement was also investigated by self-assessment using the domain of probability of risk engagement of the DOSPERT questionnaire. Results showed no differences in the self-awareness of risky DM behavior. Contrary to the postulated daily behavior in ADHD, self-assessment does not seem to be perceived as an altered behavior. However, it should be noted that in the current study only the subdomain “probability of risk engagement” was used for a group comparison. Thus, a general evaluation of risky DM based on the DOSPERT results is limited. As questionnaires mostly comprise a subjective and consciously driven self-assessment, it can be assumed that on a conscious level, there are smaller differences in the risk-engagement between HC and ADHD. Consequently, it can be assumed that more unconscious, emotional-motivational driven processes, thus control the increased risky DM behavior in ADHD that is postulated in daily life. This is further supported by the self-assessment of emotional competence using the EKF questionnaire. Results indicated an impaired ability of emotional regulation, perception, understanding, and expression in ADHD that are important requirements for a proper hot function-guided decision . MoreoveOverall, the measurement of SCRs has been shown to be a robust method to easily detect subconscious emotional arousal in anticipation and evaluation of DM. It yields a continuous measure that is related to activity in the sympathetic branch of the autonomic nervous system . HoweverIn conclusion, the present study is the first to investigate hot functions as underlying mechanisms for risky DM in adult ADHD. Results show significantly higher arousal before a DM and after feedback display in ADHD. However, ADHD participants were unable to use this physiological information to modify behavior. This finding is also confirmed by self-reports that showed a weaker ability in the perception of arousal and emotion in ADHD, whereas self-reported risk behavior was not altered compared to HC. Further research is needed to investigate how emotional processing can be influenced or improved in ADHD. However, our research underlines the importance of considering emotional therapeutic technics in the work with patients with ADHD.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of the Medical Faculty of the University of Bonn. The patients/participants provided their written informed consent to participate in this study.EH, SL, and PH contributed to the conception and design of the study. EH, FK, and AH acquired the data and performed data analyses. PH designed the paradigm and performed data analyses. EH, MB, BH, CD, SL, and AP contributed to data interpretation and discussion of results. BA recruited patients with ADHD for study participation. EH wrote the first draft of the manuscript. All authors read and approved the submitted version.


Treatment of the ADHD types  in children has rarely been studied separately, although their prognostic courses differ widely. In addition, data show that improvements in hyperactivity/impulsivity are hard to achieve. Thus, we focused on treatments tailored to hyperactivity/impulsivity. We examined meta-analyses and systematic reviews within the inter- and intra-individual treatments and found that psychoeducation and training for parents, school-based interventions, reinforcement strategies, and neurofeedback consistently showed small to moderate effect sizes in reducing hyperactivity/impulsivity in children. Conversely, emotional self-regulation, social skills, and cognitive trainings showed unsatisfactory results. In summary, we found that the quality of usual care can be surpassed when the designated interventions are purposefully combined into a multimodal treatment program. Inattention is defined by forgetfulness, distractibility, and careless mistakes. Moreover, concerned persons commonly seem to have difficulties listening when they are spoken to, finishing what they started, and organizing themselves as expected. They also often avoid or refuse to do their homework and frequently lose their toys and belongings;Hyperactivity is characterized as fidgeting and not being able to sit still, respectively, by running and climbing around in inadequate situations. Moreover, hyperactive children may not be able to play in a quiet way or, at least not over an extended time span. Moreover, excessive motor activity often cannot be managed by the social environment and direct orders;Impulsivity is regarded as interrupting others or not being able to hold back answers, thus bursting into other people’s conversations. Impulsive children talk excessively and often change the conversation subject. Consequently, these children are very impatient, and they find it difficult to wait their turn.Attention deficit hyperactivity disorder (ADHD) is one of the most common mental disorders in childhood ,2. ADHD The prevalence of ADHD is age-dependent and varies with the diagnostic criteria and sources of information used to assess symptomatology. In childhood and adolescence, the prevalence found in international epidemiological studies is around 5.3% worldwide, with no significant differences internationally . For aduIn population samples, the prevalence ratio between boys and girls varies around 3:1, whereas in clinical samples, the prevalence ratio between boys and girls varies around 6:1 . ScahillMoreover, prevalence estimates for ADHD types vary considerably across studies, and no consensus has yet been found on which type is more prevalent. Depending on the study, the prevalence rates for the hyperactive and impulsive type range from 0.7% to 2.77%, while the prevalence rates for the inattentive type range from 0.3% to 3.2% ,12,13,14The conditions for the development of ADHD are extremely diverse as multiple interacting factors are involved in the pathogenesis of ADHD. Genetic predispositions and pre-, peri-, and early-postnatal environmental influences that affect structural and functional brain development play a central role .Research on molecular genetics has shown that particularly dopamine and serotonin seem to be involved in the pathogenesis of ADHD. Heightened dopamine transporter concentration and reduced dopamine concentration in the synaptic gap have been found to be associated with ADHD symptoms . FurtherIn addition, parental ADHD was linked to a higher likelihood of being diagnosed with the combined ADHD type and a lower chance of being diagnosed with the inattentive type alone . Apart fIntriguingly, Tully et al.  have fouMoreover, ADHD is frequently paired with cognitive and executive deficits that are related to diffuse brain abnormalities. The anterior cingulate gyrus and the dorsolateral prefrontal cortex are significantly smaller in ADHD patients. These changes are thought to explain deficits in purposeful behavior. In addition, activity in the frontostriatal region is similarly impaired in these individuals, as shown by fMRI measurements. An understanding of these pathophysiological mechanisms is crucial so that interventions can be targeted to them ,22.Additionally, a range of psychosocial factors are commonly discussed in the literature, which have been shown to moderate the intensity of children’s hyperactive and impulsive behaviors. In general, a genetic disposition is considered the main causative variable of ADHD. However, unfavorable conditions in the family and school can lead to an increase in negative interactions in the environment, which, in turn, can amplify symptoms of ADHD. Moreover, the family is the first environment in which children learn rules and boundaries. In families where this process is not successful, the adoption of rules becomes progressively more problematic throughout life and leads to increasingly harsher consequences . In thisThe criteria of the ICD-11 or the DSM-5 classification systems must be fulfilled to diagnose ADHD. Both classification systems specify three types, namely the predominantly inattentive type, the predominantly hyperactive/impulsive type, and the combined type. According to the American Psychiatric Association ).Moreover, to complete the view of a multimodal approach in the following subsection, the transcendent effect of goal setting is discussed. Naturally, this effect needs to be subtracted from the positive impact of any other applied method. Furthermore, the combination of some effective methods will not result in an arithmetic addition of all effect sizes but rather in a slight increase in the overall effect since all methods operate largely on similar mechanisms and patterns and, hence, possess an overlying effect. Nonetheless, the general scientific evidence provides a clear consensus on the fact that a multimodal treatment approach to hyperactivity/impulsivity symptoms in ADHD represents the procedure of choice see ,66)..66]).Setting up therapy goals represents a key element of behavior change interventions, yet it remains unclear when goal setting is optimally effective. In this regard, Epton et al.  have perRostain et al.  found thKersting et al.  found thFiks et al.  demonstrThe evidence presented in this review is largely based on meta-analyses as well as on some comprehensive studies that evaluated the effects of therapeutic methods for treating children suffering from the hyperactive and impulsive type of ADHD. The methods studied were divided into inter- and intra-individual interventions, depending on whether the children themselves or their psychosocial environment were the main target of the intervention. The strength of this paper is the robustness of the underlying methodology of the reviewed studies, which have been mostly based on randomized controlled trial designs. This step ensures a bias reduction that may, in turn, affect the interpretation of results. However, there exists a range of limitations within this review that must be addressed. First, only a minority of studies included drew their conclusions from blinded ratings, which uniformly revealed smaller effect sizes compared to the results of non-blinded studies. Second, treatment as usual has frequently been used as a control group, which does not allow for the same comparative value as against a multimodal approach as a control group. In this regard, the control groups of the cited studies have been very heterogeneous, hence impeding the comparison between study results. Third, many studies have computed their results from limited group sizes, which, in turn, decreases the power of the applied tests substantially. Fourth, many studies reported an overrepresentation of comorbidities within their samples, which, in turn, possesses an undermining effect on the evaluated effect sizes. Fifth, the transferability of the effects to everyday life is unclear; this shortcoming is particularly apparent in the case of cognitive training. Besides these points, all studies suffer to some extent from a selection of information bias. However, the studies included in this review do not show any signs of a lowered quality in this regard compared to the general standards within psychosocial research (see ). EspeciFirst and foremost, this review takes a unique stand on the diagnosis of ADHD by segregating the predominantly inattentive and predominantly hyperactive/impulsive types of ADHD in terms of treatment implementation. Even though the types have their rightful place within the overarching diagnosis of ADHD, this review draws attention to their diverse developmental trajectories. Consequently, these types should be conceptually considered differently in the clinical practice and require specific and distinctive treatment plans. Furthermore, this review provides solid arguments that an adaptive, integrative, and modular treatment approach represents the state-of-the-art treatment paradigm for the management of the ADHD hyperactive and impulsive type. Moreover, inter-individual and intra-individual interventions are considered as equally important. Beyond that, this paper mainly focuses on the effects of psychosocial interventions on the dimensions of hyperactivity and impulsivity in children.Moreover, it is noteworthy that psychopharmaceutical treatments for the impulsivity dimension of ADHD have their rightful place and can serve as stand-alone treatments. In short, psychopharmaceuticals can also complement, enhance, or enable psychosocial treatments . SantoshConsequently, more attention has been focused in recent years on the establishment of an evidence base for effective psychosocial treatments for ADHD . Back inFurthermore, children with a diagnosis of ADHD tend to have multiple comorbid conditions, such as anxiety, depression, and oppositional defiant behavior, as well as relationship difficulties, so a multimodal treatment approach appears to be the most beneficial and fitting. Thus, in children with milder symptoms, behavioral interventions seem to be the first line of choice, especially for safety and user preference reasons ,93. Overall, our findings are consistent with clinical guidelines that recommend treating more severe hyperactivity and impulsivity in children with psychostimulants while offering multimodal psychosocial treatment to the children, their parents, and teachers. In contrast, for low to moderate symptom severity, a predominantly multimodal psychosocial treatment approach should be offered, using psychostimulants only when interventions do not result in clinically significant symptom reductions ,30,69,93Clinical practice guidelines widely recommend that children and adolescents with mild to moderate hyperactivity and impulsivity should primarily be offered psychosocial treatment, while the parents should be provided with a group-based parent training program ,30. In tFirst, the evidence suggests that purely psychosocial interventions for hyperactivity/impulsivity symptoms in ADHD can have positive effects in children, although considerable heterogeneity in effect sizes was found between studies. The clinical significance and the transfer of the effects into everyday life are also still unclear, as the available data often contradict each other. On that account, steps need to be taken to continuously improve psychosocial treatment outcomes for ADHD. To ensure this, emotion regulation processes such as reward and punishment and the balance between proactive and reactive behavioral interventions need to be more prominent and closely linked to the instrumental processes of psychosocial treatment. In this context, future research should investigate further into what works, for whom, and in which circumstances (see ).Second, considering that this review is essentially about the treatment of hyperactivity and impulsivity in the scope of ADHD disorder, a review of current treatment options for inattention would be the work of choice to complement the present paper. Another way to complement the current gap in this research is to further explore the efficacy and effectiveness of state-of-the-art treatment options for adults. Ideally, these include the development and testing of standardized instruments to describe interventions, agreements on gold standard outcome measures to assess ADHD behavior, and the testing of a range of potential moderators alongside intervention studies (see ).