Adults with ADHD showed decreased scores regarding awareness of the arrival of bills, knowledge of own income, having a reserve fund for unexpected expenses, the ability to state long-term financial goals, own preferences for estate management, understanding of assets, legal action for debt, access to financial advice/counseling, and the ability to compare medical insurance plans as compared with adults without ADHD . However, no effect of income was found. In conclusion, adults with ADHD have difficulties with many aspects of everyday financial knowledge and skills, which might result in a plethora of personal and legal consequences. It is, therefore, of the utmost importance that professionals who support adults with ADHD proactively ask about everyday financial functioning so that assessment, financial support, and coaching can be provided.Adequate financial capability is crucial in everyday life. This capability might, however, not be given to adults with ADHD. The present study aims to determine strengths and weaknesses regarding everyday financial knowledge and judgment skills in adults with ADHD. In addition, the impact of income is explored. Forty-five adults with ADHD (M Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that has a prevalence of approximately 3.4% in adulthood . NumerouIn our everyday lives, we make numerous financial decisions , and an adequate capability to make financial decisions is crucial for independent living, leisure-time activities, and social relations. Financial incapability can, therefore, have far-reaching personal and legal consequences and may lead to financial insecurity, debt, placement under financial guardianship, poverty, reduced social and societal participation, and diminished opportunities for leisure-time activities. Financial capability includes both financial competence and financial performance . FinanciSurprisingly, the financial capability of adults with ADHD is a topic that has received little attention so far. Indeed, our previous study  was the To deal with financial difficulties, general education programs aimed at improving financial knowledge and skills are often offered and are considered to be an antidote to dealing with financial issues and financial complexity by many policymakers . A recenThe present study has a non-experimental, cross-sectional design. Adults with ADHD were recruited via the Department of Psychiatry and Psychotherapy at the University of Duisburg-Essen, Germany. All adults with ADHD were diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition . Adults Data were collected between 2014 and 2016. Participants were assessed individually by research assistants who were all extensively trained. The use of a detailed assessment and scoring manual guaranteed consistent assessment and scoring.age = 36.6, SDage = 10.2, range 19–61 years) and 47 adults without ADHD  were used for analyses.All participants were requested to complete the Wender Utah Rating Scale—Childhood WURS-K ,30), whi, whi30])The following demographic information was collected on all participants: age (in years), years of education, sex , and work status .The FCAI  is a staAnnual gross income of participants was rated on a six-point scale: (1) <EUR 15,000, (2) EUR 15,000–EUR 25,000, (3) EUR 25,000–EUR 35,000, (4) EUR 35,000–EUR 45,000, (5) EUR 45,000–EUR 55,000, and (6) >EUR 55,000.Symptoms of ADHD were assessed with the WURS-K and ADHD-SR. The WURS-K is a self-report questionnaire that consists of 25 items focused on childhood symptoms of ADHD, which are rated on a 5-point scale ranging from 0 , 1 , 2 , 3 , to 4 . The WURS-K was found to have high internal consistency (r = 0.91), inter-rater reliability (r = 0.90), and good convergent validity (r = 0.94) ,30. CurrThe Statistical Package for the Social Sciences, version 28.0. IBM, New York, NY, USA, was used for analyses. Not all continuous variables  were normally distributed. Therefore, Mann–Whitney U tests were used for group comparison. Chi-square tests were used to compare adults with and without ADHD on categorical variables.To determine whether adults with and without ADHD showed different scores on the items of the FCAI, which are measured on an ordinal level, Mann–Whitney U tests were used for comparison. Subsequently, all participants were allocated to one of two income groups: (1) people with a relatively low income  or (2) people with a relatively high income . To explore to what extent income affects scores on the items of the FCAI, Mann–Whitney U tests were used to compare people with a relatively low and a relatively high income. The latter analysis was conducted in groups of adults with and without ADHD separately.p-value of 0.05/38 = 0.001 was, therefore, considered significant. Finally, participants with missing data were excluded pairwise, i.e., a participant was omitted from the analysis of item 1 and included in the analysis of item 2 if they had a missing value for item 1 but not for item 2.Effect sizes (Cohen’s d) were calculated for all comparisons of scores on FCAI items and interpreted as small (d = 0.2), medium (d = 0.5), and large (d = 0.8) . To corrThe clinical and descriptive characteristics of both groups are presented in Adults with ADHD showed poorer scores on several items of the FCAI as compared with adults without ADHD . Signifin = thirty-one; adults without ADHD n = twenty-one); or a relatively high-income group . Within the group of adults with ADHD, no significant differences were found between the relatively low and relatively high-income groups  of adults with ADHD had to deal with legal action for debt in the last five years, while this was only the case in 2% (n = 1) of adults without ADHD.The present study aimed to determine strengths and weaknesses regarding everyday financial knowledge and judgment skills in adults with ADHD. The results of our study show that adults with ADHD have difficulties with several aspects of everyday finances as compared with adults without ADHD, findings that are in line with previous studies that focused on financial difficulties in adults with ADHD ,20,21,23Currently, it is unclear what the underlying cause of these reduced financial performances in adults with ADHD is. It is, of course, likely that the cognitive and affective symptoms that accompany ADHD play a role. Indeed, according to the dual-pathway model of decision-making, both motivational/affective and deliberative/analytic processing of information are involved in the decision-making process, including financial decision-making ,33,34. Sn = 15) of adults with ADHD would like for someone else to make their financial decisions or that they require assistance when making financial decisions, compared with 2% (n = 1) of adults without ADHD. Furthermore, of the adults with ADHD who require financial assistance or would like for someone else to take over their financial decisions, 47% (n = 7) have had to deal with legal action for debt in the last five years. These findings are disturbing, as the results of the present study also show that adults with ADHD more often state that they have less access to these services than adults without ADHD. The latter finding might indicate that adults with ADHD are less aware or have less knowledge about financial constructs, services, protocols, etc., and where to find them—an assumption that would be in line with the finding that adults with ADHD have decreased knowledge of what assets are and have difficulties naming their major assets compared with adults without ADHD. This assumption is, however, not supported by the data since adults with and without ADHD scored similarly on items such as knowledge of programs/services offering financial support, understanding banking protocols, and understanding credit. The discrepancy between the financial support adults with ADHD receive or would like to have and their actual access to financial services thus requires further investigation to determine its underlying cause.The results of the present study further indicate that adults with ADHD more often state that they would like for someone else to make their financial decisions or that they need assistance when making financial decisions . When exploring the exact answers of adults with and without ADHD regarding this item, it becomes clear that no fewer than 33%  has good content and concurrent validity , and theWithin the context of the present study, several limitations/weaknesses must also be considered. First, even though the FCAI assesses a large number of aspects of everyday financial skills, there are still many aspects of everyday financial capability that were not considered in the present study. For example, the ability to compare financial products  other than insurance, knowledge about taxes, and the ability to detect financial deception or fraud were not examined. Since aspects such as these can also negatively influence everyday financial functioning, they require further exploration in future studies. A second limitation is that the researchers of the present study were aware of the diagnoses of the participants, which might have resulted in an observer bias. Even though a standardized protocol was used for assessment and scoring, which should have minimized this effect, it cannot be excluded. Third, a larger sample size is needed to reproduce our findings and provide more reliable results. Indeed, a posthoc power analysis  reveThe results of the present study show that adults with ADHD have difficulties with many aspects of everyday financial knowledge and skills. These financial difficulties might result in a plethora of personal and legal consequences, such as financial insecurity, debts, placement under financial guardianship, poverty, reduced social and societal participation, and diminished opportunities for leisure-time activities. These findings are alarming, as no fewer than one-third of adults with ADHD state that they would like assistance or support with making financial decisions, 27% have had to deal with legal action for debt in the last five years, and adults with ADHD indicate that they have less access to financial assistance than adults without ADHD. It is, therefore, of the utmost importance that professionals who support adults with ADHD not only focus on the symptoms and treatment but also proactively ask about everyday functioning, including everyday financial functioning. Only in this way can an assessment of financial knowledge and skills be conducted with tests such as the FCAI, and tailored financial support and coaching be provided.


Pain perception is important in children with attention deficit hyperactivity disorder (ADHD) since they are more likely to experience painful events due to increased accident rates. The aim of this study is to contribute to the literature concerning the relationship between ADHD diagnosis, methylphenidate (MPH) therapy, and pain thresholds, since findings regarding the change in pain perception in children with ADHD are scarce and inconsistent.Children aged 8–13 years constituted both the ADHD group (n = 82) and the healthy controls (n = 41). The ADHD group was divided into two subgroups, ADHD without MPH  and ADHD with MPH . The Conners’ Parent Rating Scale–Revised: Short Form was employed to assess ADHD, a visual analog scale was applied to evaluate chronic pain severity, and a manual pressure algometer was used to assess pain thresholds.P < 0.05). However, lower regional pain thresholds were observed in the ADHD group without MPH compared to both the healthy control and ADHD with MPH groups. Although pain thresholds in the ADHD with MPH group were regionally lower than in the healthy controls, low pain thresholds were found in fewer regions compared to the ADHD without MPH group.Children with ADHD had lower pain thresholds than the healthy controls (Children with ADHD are more sensitive to pain sensation, and MPH may help normalize these individuals’ pain experiences by raising pain thresholds. Families and clinicians must be aware of situations that may cause pain in children with ADHD. In addition, these children’s low threshold for pain may lead them to experience it more intensely. Attention deficit hyperactivity disorder (ADHD) in pediatric cases is characterized by hyperactivity, impulsivity, and/or inattention and affects 5% of children worldwide. The symptoms impact on cognitive, educational, behavioral, and emotional functioning . ChildreDespite being one of the most extensively researched psychiatric disorders, the mechanism underlying the symptoms of ADHD is not completely understood . NumerouStimulants used to treat ADHD, such as methylphenidate (MPH) and amphetamine, help improve attention, concentration, and impulse control by increasing levels of neurotransmitters such as dopamine and norepinephrine in the brain . MethylpAccumulating data suggest that dopamine is also implicated in pain processing , 22. ManThe dopaminergic anomalies exhibited by individuals with ADHD are likely to result in altered pain perception. Pain sensitivity in children with ADHD is one of the least frequently studied aspects of the condition. However, this may be particularly important to these children, as they are more likely to experience painful events due to their higher accident rates .A limited number of studies have examined pain perception in children with ADHD. Scherder et al. evaluated the pain perception of children and adolescents with ADHD, their unaffected siblings, and healthy controls using the children’s pain inventory . Those aResearch has also investigated pain in adults with ADHD and revealed a decrease in pain thresholds. In one study, in which pain sensitivity was evaluated psychophysically, the ADHD participants without methylphenidate (MPH) had a considerably lower cold pain threshold and cold tolerance compared to controls. Both the cold threshold and tolerance of ADHD patients treated with MPH increased significantly in comparison to those who did not receive medication. That study suggests that individuals with ADHD are more sensitive to pain and that MPH may have antinociceptive qualities . Recent The purpose of this study is to contribute to the literature concerning the relationship between ADHD diagnosis, MPH therapy, and pain thresholds, since findings regarding the change in pain perception in children with ADHD are both scarce and inconsistent. In terms of deficits in dopaminergic pathways in ADHD and the mechanism of action of MPH in these pathways, we hypothesized that the pain threshold would be lower in patients with ADHD and would differ between the MPH, non-MPH, and healthy control groups.This cross-sectional study was conducted in accordance with the Declaration of Helsinki and in line with the Strengthening the Reporting of Cross-Sectional Studies (STROBE) statement. The research was conducted between December 30, 2020 and March 30, 2021 at the University of Health Sciences, Konya City Hospital, Türkiye. Ethical approval was obtained from the Necmettin Erbakan University Ethics Committee (no. 14567952-050/1725).Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) [The participants consisted of children aged 8–13. The ADHD group was selected from individuals with ADHD symptoms who presented to the child and adolescent psychiatry clinic, while the healthy control group was established from individuals presenting to the general pediatric outpatient clinic. Children with ADHD were identified on the basis of clinical assessments using the  (DSM-5) . Diagnos (DSM-5) . MembersThe ADHD group was further divided into ADHD without MPH  and ADHD with MPH  subgroups. The healthy control group consisted of children admitted to the general pediatric outpatient clinic who participated in the study on a voluntary basis. These had no psychiatric, endocrinological, neurological, rheumatological, or oncological diseases and were not using medication.The study sample size was calculated via G*Power - Universität Düsseldorf software. In a previous study  the respThe Conners’ Parent Rating Scale–Revised: Short Form (CPRS-R:S) is frequently used to investigate ADHD symptoms in children. On this four-point Likert-type scale ranging from 0  to 3 (very true), the parent is asked to assess how much each of the 27 items has represented a problem for their child . The TurA visual analog scale (VAS) (0–100 mm) was used to examine the severity of pain, with 0 denoting “no pain” and 100 “the most severe pain possible.” The VAS is recognized as an easily applied and reliable scale for assessing the severity of pain in children aged ≥ 8 years . A 30-se2. Algometry has previously been shown to be reliable in measuring PPTs in children [2/s until the participants felt the first sensation of pain (PPT). A maximum pressure of 22 kg/cm2 was applied for all the participants. PPTs were measured bilaterally from eight reference areas using the algometer, the mid-frontal line, supraspinatus origin, trapezius middle fiber midpoint, and deltoid midpoint, 2 cm distal to the lateral epicondyle, the midclavicular line intersected with thoracal 2, the great trochanter region, and the proximal medial tibial point  method using a manual pressure algometer (Baseline Dolorimeter®) was employed to assess pain thresholds. The investigator placed the algometer on the site to be examined and pressed against that site in a vertical direction while increasing the force at a constant rate of 1 kg/cmchildren . The parChildren and their parents provided written consent to participation in the study. After the participants’ diagnoses had been evaluated, comorbidities were assessed using K-SADS-PL, and the CPRS-R:S was applied. The clinician then asked about the presence of chronic pain (defined as persisting for more than three months), and the average pain intensity. The algologist, one of the two authors of this study, who was blinded to the study groups, measured PPTs using a manual algometer.Statistical analyses were performed using SPSS version 28.0 software . There were no missing data for any variable. The Shapiro–Wilk test was used to evaluate the distribution of the data. Descriptive data are presented as frequencies (n) and percentages (%) for categorical variables, as median values with 25–75% percentiles for non-normally distributed numerical variables, and as means plus standard deviation for normally distributed numerical variables. The chi-square test was used to compare categorical variables between independent groups, while the Mann–Whitney U test was used to compare linear variables between independent groups. Correlation between numerical variables was assessed using Spearman’s and Pearson’s correlation analysis. p < 0.05 was considered statistically significant. The statistical differences between all ADHD patients and healthy controls in terms of PPT values were analyzed with Student’s T test in the trochanter area and the Mann-Whitney U test elsewhere.Three-group comparisons were analyzed using ANOVA for normally distributed numerical variables, and with the Kruskal Wallis test for non-normally distributed numerical variables. Bonferroni correction was applied to avoid possible type-1 errors, and p < 0.016 was considered statistically significant. At evaluation of normality before the comparison of the healthy control, ADHD with MPH, and ADHD without MPH groups, only PPT values in the trochanter region met the normality criteria, but these did not meet the homogeneity of variance. Post hoc analysis was therefore performed with the Game-Howell test, since the Welch value was 0.017. Three-group comparisons in other areas of measurement domains were analyzed with the Kruskal-Wallis test, and Bonferroni correction was applied for within-group comparisons.The relationship between the CPRS:S score and PPT values in the frontal, trapezius, supraspinatus, deltoid, tibia, lateral epicondyle, and thoracal 2 regions in the patients with ADHD was analyzed by means of Spearman’s test, while values in the trochanter region were analyzed using Pearson’s test. In the ADHD with MPH group, the relationship between CPRS:S scores and PPT values in the thoracal 2 and deltoid areas were analyzed using Spearman’s test, while values in the frontal, trapezius, supraspinatus, lateral epicondyle, trochanter, and tibial areas were analyzed with Pearson’s test. In the ADHD without MPH group, the relationship between CPRS: S scores and all PPT values was analyzed using Spearman’s test.One hundred twenty-three individuals were included in the study, with 41 age- and gender-matched participants in each group. The average age was 10 (8.0-12.25) years. Each group consisted of 11 (26.8%) girls and 30 (73.2%) boys. Mean CPRS-R:S scores were 42.11 ± 18.72 for all ADHD patients, 47.34 ± 18.38 in the ADHD without MPH group, and 36.87 ± 17.77 in the ADHD with MPH group.Chronic pain was present in 34 (41.46%) of all ADHD patients, in 19 (46.34%) members of the ADHD without MPH group, 15 (36.58%) of the ADHD with MPH group, and 19 (46.34%) of the healthy control group. No statistically significant difference was observed between the three groups in terms of the presence of chronic pain (p = 0.743).Pain severity was 50 (30.0–50.0) mm in both the ADHD without MPH and ADHD with MPH groups, compared to 40.0 (40.0–50.0) mm in the healthy control group. No statistically significant difference in pain severity was observed between the two ADHD groups (p = 0.907).The analysis results of between all ADHD patients and the healthy controls in terms of PPT values are given in Table Measurements and comparisons between the three groups’ PPT values are given in Table No relationships were determined between CPRS:S scores and PPT values in the frontal, trapezius, supraspinatus, deltoid, trochanter, tibia, lateral epicondyle, or thoracal 2 regions in the ADHD patients . No relationships were observed between CPRS:S scores and PPT values in the thoracal 2, deltoid, frontal, trapezius, supraspinatus, lateral epicondyle, trochanter, or tibia areas in the ADHD with MPH group . Finally, no relationships were found between CPRS:S scores and PPT values in the frontal, trapezius, supraspinatus, thoracal 2, deltoid, lateral epicondyle, trochanter, or tibia areas in the ADHD without MPH group .This study compared the presence and perception of chronic pain, and pain thresholds using the pressure pain test in children with ADHD and healthy controls and examined the relation of MPH treatment on these parameters. The presence of chronic pain and pain perception were similar between the groups. Children with ADHD had lower pain thresholds than the healthy controls. However, lower regional pain thresholds were observed in the ADHD group without MPH compared to both the healthy control and ADHD with MPH groups. Although the pain thresholds of the ADHD with MPH group were regionally lower than those of the healthy controls, low pain thresholds were observed in fewer regions compared to the ADHD without MPH group.To the best of our knowledge, this study is the first to evaluate both chronic pain perception and pain thresholds in children with ADHD using the pressure pain test applied to eight parts of the body. This study contributes to the literature by showing that pain thresholds are low in children with ADHD and supports previous research focusing on adults , 30. SimScarce and inconsistent findings have been reported regarding changes in pain perception in children with ADHD. Among the previous studies evaluating pain perception in ADHD, Scherder et al. found no difference in pain perception compared to controls, a finding consistent with the present study . A diffeDeficits in time perception , emotionThe low pain threshold in ADHD may be co-present with the etiological consequences of the disorder. First, dysfunction of the locus coeruleus (LC) has been described in ADHD through a defect in the number of noradrenergic receptors . A deficThe model of the vigilance regulation in ADHD  interprets patients’ hyperactivity and sensory input seeking as an autoregulatory attempt to balance wakefulness by creating a stimulating environment. Hypoarousal in ADHD has mainly been demonstrated by means of skin conductance and electroencephalography . The lowIn the present study, the pain thresholds of the ADHD with MPH group were higher than those of the group not receiving MPH. The analgesic effect of MPH treatment has been reported in several chronic pain conditions , 57. In The particular strengths of this study are that pain thresholds were measured using induced pain, and that the clinician who measured this was blinded to the study groups. Research has emphasized that MPH affects pain perception and thresholds in ADHD, and this effect should be evaluated , 29. TheHowever, this study also has a number of limitations. Pain threshold and pain perception are distinct concepts. This study evaluated pain perception in chronic pain and pain thresholds with induced pain. Investigating pain perception during induced pain may lead to a better understanding of these pain-related variables. Using physiological measures  to assess sensitization to induced pain may yield a better understanding of pain perception changes in children with ADHD. Pain thresholds may vary due to exposure to external events, such as harsh parental discipline and peer bullying . ExperieThe findings of this study show that children with ADHD have a low pain threshold, and that MPH may raise this. Experimental investigation of the dopaminergic and opioid systems in the brain will provide a better understanding of pain changes in ADHD. Families and clinicians must be aware of situations that may cause pain in children with ADHD. These patients’ low threshold for pain may lead them to experience more pain. Finally, the fact that children with ADHD do not report pain to painful stimuli does not necessarily mean that they do not experience it.


Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition that presents distinct challenges for African children due to a complex interplay of social, economic and cultural factors. This review examines the various obstacles faced by children with ADHD in Africa, focusing on the lack of awareness and stigma surrounding the disorder, limited access to mental health services, educational system constraints, economic limitations and cultural beliefs and practices. The review underscores the significance of public awareness campaigns and educational initiatives to dispel myths and misconceptions surrounding ADHD. These efforts should target the general public, educators, healthcare professionals, religious leaders and traditional healers. Crucial to addressing this issue is strengthening mental health services, especially in rural and underserved areas, through increased funding and the availability of trained mental health professionals specialised in ADHD diagnosis and treatment. Integrating mental health services into primary healthcare systems is proposed to enhance accessibility for children with ADHD. By training primary care providers to recognise ADHD symptoms and provide initial support and referrals, early identification and intervention can be facilitated. Addressing the affordability and accessibility of ADHD treatment is a priority, with policy recommendations including subsidising medications and therapies and providing financial assistance to families in need. A call for collaborative efforts between governments, nongovernmental organisations and pharmaceutical companies is advocated to ensure that ADHD treatment is affordable and widely available. HighlightsCultural beliefs, stigma and limited access to mental health services often result in the underdiagnosis or misdiagnosis of children with attention-deficit/hyperactivity disorder (ADHD).Understanding these disparities is crucial for developing targeted interventions to ensure that children with ADHD receive appropriate care and support.Potential solutions, such as telemedicine, community-based care models and partnerships with nongovernmental organisations can help bridge the gap and ensure more equitable access to care for children with ADHD across the continent.1. It is characterised by impairing inattention, disorganisation and/or hyperactivity-impulsivity, as defined in the DSM-52. ADHD’s features include challenges in attentional endurance, motor hyperactivity and heightened impulsivity, while its aetiology is complex, stemming from multiple genetic and environmental factors2.Attention-deficit/hyperactivity disorder (ADHD) significantly impacts the lives of many children and adolescents worldwide3. However, specific African populations exhibit varying rates, ranging from 1.5% in the general populace to 100% in special populations of children with apparent organic brain injury3. Despite these ongoing investigations, research on ADHD in Africa remains limited, and unique challenges persist in understanding its prevalence, risk factors and cultural implications. Understanding ADHD in Africa is vital to providing equitable care for affected children, as untreated ADHD can lead to various complications affecting academic performance, social skills, self-esteem, and overall well-being.Recent recognition of the importance of understanding and addressing ADHD in Africa has led to studies exploring its prevalence and impact on the continent. Globally, ADHD affects around 6% of children and adolescents and 3% of adultsThis review explores the current knowledge regarding ADHD in Africa, focusing on its prevalence, risk factors, comorbidities and cultural aspects influencing its manifestation and management. By meticulously examining the available literature, including studies from diverse African countries, we aim to comprehensively understand ADHD within the African context and identify potential avenues for improving equitable and effective care for affected children. Additionally, this review will highlight the importance of cultural factors in shaping the presentation and treatment of ADHD in African communities.Synthesising existing research on ADHD in Africa will contribute to collective efforts to enhance mental healthcare for children with ADHD across the continent. By identifying gaps in knowledge and understanding, we hope to nurture future research endeavours that can lead to tailored interventions, promoting positive outcomes for children with ADHD and enhancing their overall well-being in African communities.Focus on ADHD prevalence among children and adolescents in African countries.Inclusion of community-based studies, clinical studies and epidemiological surveys.Publication in peer-reviewed journals and availability in English.Presentation of original data on ADHD prevalence rates, risk factors, or sex-specific analysis.Publication between 2000 and May 2023 to capture recent developments in the field.This study is a narrative review. A comprehensive literature search was conducted to achieve this objective, encompassing electronic databases such as PubMed, PsycINFO and Google Scholar Table . The seaFocused solely on adult populations or individuals outside the specified age range.Were reviews, commentaries, or conference abstracts without original data.Need more data or methodological limitations affecting the validity of results.On the other hand, studies were excluded from the review if they:The data extracted from the selected studies were synthesised using a narrative synthesis approach to provide an overview of ADHD prevalence in Africa. This method summarised the findings and identified common themes and patterns across the studies. The synthesis focused on prevalence rates and sex-specific differences and identified risk factors for ADHD in the context of African communities.By conducting this comprehensive review, we aim to shed light on the prevalence and risk factors associated with ADHD in Africa while also exploring the influence of sex and cultural factors on presenting and managing the disorder in African children and adolescents. The findings from this review will contribute to a better understanding of ADHD in the African context and potentially inform targeted interventions and strategies to address the disorder in the region.In the context of Africa, with a total of 54 countries, our study’s findings highlight the heterogeneous nature of ADHD prevalence, which carries significant implications for public health initiatives and clinical practices in the region. The observed variation in prevalence rates across different regions and periods indicates that ADHD is not uniformly distributed throughout Africa but is influenced by a complex interplay of cultural factors, healthcare access and diagnostic practices.et al. in Ethiopia and Kashala et al. in Kinshasa, the Democratic Republic of the Congo, reported discrepant prevalence rates of 1.49 and 6%, respectively5. These disparities exemplify the need for caution when generalising ADHD prevalence in Africa. Cultural norms surrounding child behaviour and attention and varying healthcare infrastructure and resources in different regions might impact how ADHD symptoms are perceived, recognised and diagnosed.Early studies conducted by Ashenafi et al. revealed interesting patterns, with men exhibiting a higher prevalence of 7.1 compared to 4.9% in women5. This echoes global trends and emphasises the importance of investigating sex-specific risk factors and biological mechanisms that may contribute to this disparity. Societal expectations surrounding sex roles could also affect how ADHD symptoms are manifested and interpreted in males versus females.A sex-specific analysis of ADHD prevalence conducted by Kashala et al. and Farahat et al. reported 8 and 6.9% prevalence rates7. These studies suggest a rising prevalence of ADHD in specific African countries, possibly indicating increased recognition of the disorder and improved access to healthcare services. However, further research is needed to understand the factors contributing to this trend and determine if it reflects a substantial rise in the disorder’s incidence or enhanced awareness and detection.Subsequent studies conducted in Nigeria and Egypt by Ofovwe et al.8 on adolescent students reported a prevalence of 9.4%, suggesting a potential rise in ADHD prevalence among this age group. In contrast, studies in South Africa by Coetzee et al. and Hogan et al. reported significantly higher prevalence rates of 36 and 12.4%, respectively10. These figures warrant attention from policymakers and public health authorities to understand the underlying reasons for such high rates. Disparities in healthcare access, socioeconomic conditions and ADHD awareness may be contributing factors.Recent studies in the last decade have added complexity to the ADHD prevalence landscape in Africa. Research by Bishry et al.11 provided a pooled estimate of ADHD prevalence at 7.47% among children and adolescents in Africa. This analysis consolidates data from multiple studies, offering a more robust perspective on the regional disorder’s burden. However, the sex-specific analysis revealing a higher prevalence among males calls for further exploration of cultural, social and biological determinants contributing to this difference.The systematic review and meta-analysis by Ayano The consistent finding across the reviewed studies of males having a higher risk of developing ADHD than females, with a threefold increased likelihood, aligns with global trends. Understanding the sex-specific risk factors for ADHD in Africa is crucial for tailoring interventions and providing targeted support to those affected. Further research is needed to elucidate the underlying mechanisms contributing to this sex-based variation.et al.12 highlighted that children under 10 were four times more likely to have ADHD. This emphasises identifying and addressing ADHD symptoms during early childhood to minimise potential cognitive and psychosocial development impacts. Early detection and intervention programs can facilitate timely access to appropriate resources and therapeutic interventions, improving long-term outcomes for affected children.The findings regarding age as a crucial factor in ADHD prevalence underscore the significance of early intervention and support. The study by Wamulugwa 14. Limited or no education among primary caregivers is associated with a higher risk of ADHD development. This finding highlights the importance of educational support and awareness programs targeting caregivers in vulnerable communities. Providing accessible and culturally sensitive education on ADHD symptoms, management strategies and available resources can empower caregivers to recognise early signs of ADHD and seek appropriate assistance for their children.Illiteracy among primary caregivers emerged as a notable risk factor for ADHD in African children, consistently supported by various studieset al., Lola et al., and Olashore et al.17. Factors such as living with a single parent, parental mental health disorders and nonmaternal child care influence ADHD prevalence. These findings emphasise the need for a holistic approach to understanding ADHD in Africa. Addressing family-related risk factors, promoting mental health support for parents and implementing family-based interventions can be crucial in mitigating the impact of ADHD on affected children and fostering a supportive environment for their well-being.Family-related factors also play a significant role in ADHD cases, as highlighted by various researchers, including van Dyk Managing ADHD can be challenging in any part of the world, but specific difficulties are faced in Africa due to various factors, including limited resources and cultural perspectives Table 18. This information gap leads to widespread misconceptions and a stigma surrounding the condition, making life challenging for individuals with ADHD19. Many individuals, including parents, educators and community members, remain unfamiliar with the neurobiological underpinnings of the disorder18. As a result, they often misinterpret the symptoms, viewing them as mere manifestations of misbehaviour, a lack of discipline, or deliberate defiance20. Such misunderstandings give rise to harsh judgments, criticism and, occasionally, punitive actions against children and adults with ADHD, exacerbating their difficulties and significantly impacting their overall well-being21. Consequently, affected individuals may internalise negative stereotypes about themselves, leading to feelings of shame and diminished self-esteem22. Consequently, they may avoid seeking assistance or treatment, fearing further marginalisation and censure22.African communities are confronted with a lack of awareness and understanding concerning ADHD23. Seeking professional help may be perceived as a sign of weakness or failure, discouraging families from pursuing intervention23. Consequently, individuals with ADHD may not receive timely diagnosis and access to effective treatments, significantly impacting their educational and occupational prospects22.The consequences of this stigmatisation have far-reaching effects on individuals with ADHD and their families, creating formidable barriers to accessing the necessary support. Families often deny the existence of ADHD, hoping that the symptoms will fade over time or attributing the behaviours to other causes24. Consequently, the child’s academic struggles may intensify, impeding their educational progress24. Moreover, undiagnosed and untreated ADHD can cause difficulties in concentration, task completion and positive peer relationships, further compromising academic performance24.The implications of this lack of awareness and stigma on a child’s education are equally profound. Educators and teachers, often uninformed about ADHD, may misinterpret the behaviours as deliberate disruptions, leading to disciplinary measures rather than providing appropriate support25. Given that social support is crucial for mental well-being, the community’s lack of understanding and acceptance can contribute to heightened psychological distress for those grappling with ADHD25.The social consequences of stigma can be equally devastating. Individuals with ADHD may withdraw from social interactions to avoid judgment or ridicule, leading to feelings of isolation and loneliness26. This scarcity of resources also extends to the availability of qualified professionals, particularly child psychologists and psychiatrists specialising in ADHD, thereby creating challenges in the early identification and intervention of children with the condition27. The dearth of trained mental health professionals with expertise in ADHD poses considerable obstacles for families seeking assistance for their children. Consequently, numerous children with ADHD may remain undiagnosed or receive inaccurate diagnoses, prolonging their struggles and impeding their developmental progress11.In several African countries, a significant impediment to the effective management of ADHD emerges from limited access to mental health services. Insufficient funding and inadequate attention to mental health contribute to the compromised state of mental health services in these regions, resulting in a lack of comprehensive care for those in need28. Early identification and access to evidence-based interventions, such as behavioural therapy and medication, are essential for effectively managing ADHD and enabling these children to realise their full potential29. Moreover, the repercussions of limited access to mental health services extend beyond childhood and can have enduring effects on individuals’ lives. The unmet mental health needs of children with ADHD may persist into adulthood, significantly influencing their personal and professional trajectories29.Without timely intervention and appropriate treatment, children with ADHD confront difficulties in academic performance, behavioural challenges and social interactions30 adequately. A prominent obstacle is the prevalence of large class sizes in many schools30. The overcrowded classrooms hinder teachers from providing personalised attention to each student, leaving those with ADHD without the requisite support30. Consequently, these children may need help to keep up with the fast-paced instruction and become disengaged from the learning process.In certain African countries, the education system encounters significant challenges that impede its ability to support and accommodate children with ADHD31. Consequently, the academic performance and overall well-being of students with ADHD may suffer.Moreover, limited resources present another barrier to effectively addressing the needs of students with ADHD. The demand for educational materials, specialised tools and support staff makes it challenging for teachers to implement effective strategies for these students32. The lack of awareness and understanding can lead to misconceptions about the condition, resulting in students with ADHD being misunderstood and their behaviours inaccurately attributed to a lack of effort or discipline. Regrettably, in some instances, disciplinary measures may be taken against these students, further exacerbating their struggles and hindering their access to appropriate support.Compounding the issue is the inadequate training of teachers concerning neurodevelopmental disorders like ADHD32. Their specific needs may not be recognised, and they may not receive the necessary accommodations or interventions. Consequently, these children may experience discouragement and isolation, sensing that they are left behind and unsupported in their academic journey.Due to these challenges, students with ADHD risk being overlooked within the education system33. However, in regions where a significant portion of the population lives in poverty, such as African low-income communities, families may encounter difficulties affording the necessary treatments or accessing healthcare facilities in urban areas34.In Africa, the management of ADHD is often complicated by economic challenges. The treatment of ADHD typically involves a range of therapies, medications and interventions, many of which can be financially demanding35. Behavioural therapies, counselling sessions and specialised educational interventions play vital roles in ADHD management, but they often come with significant expenses36. Additionally, the medications prescribed to manage ADHD symptoms may be prohibitively expensive, limiting accessibility for many financially stretched families37.The cost of managing ADHD can substantially burden families already struggling to meet their basic needs37. The impracticality and high cost of travelling to urban centres for ADHD treatment, particularly in regions with inadequate transportation infrastructure, pose significant barriers. Consequently, many families may find themselves compelled to forgo seeking professional help for their children with ADHD, leaving these individuals without the necessary support to manage their condition effectively.Families residing in remote or rural areas face additional challenges, as access to specialised healthcare facilities is often limitedThe economic constraints experienced by families in low-income communities can have far-reaching consequences for children with ADHD. The lack of access to appropriate treatments and interventions may result in difficulties with academic performance, social interactions and overall well-being. Furthermore, their educational and vocational opportunities may be curtailed, leading to long-term implications for their prospects and economic mobility.38. In certain cultures, behaviours characteristic of ADHD, such as hyperactivity, impulsivity and inattentiveness, may be attributed to spiritual possession or witchcraft rather than being recognised as neurodevelopmental symptoms39. This misunderstanding can stigmatise and discriminate against individuals with ADHD, as they may be unfairly regarded as ʻpossessedʼ or ʻcursedʼ.Cultural beliefs and practices hold significant sway over the perception and treatment of ADHD within Africa40. The reluctance to seek professional help due to cultural beliefs can lead to delays in diagnosis and intervention, exacerbating the challenges faced by individuals with ADHD and impeding their ability to lead fulfilling lives40.The misattribution of ADHD behaviours to spiritual causes can have profound and detrimental consequences. People with ADHD may face ridicule, ostracism, or even be subjected to harmful traditional treatments, such as exorcism rituals, instead of receiving appropriate medical care23. Parents may experience feelings of shame or fear of social repercussions, leading them to conceal their child’s condition and avoid seeking support. This culture of secrecy can further isolate the child and hinder their access to necessary resources and understanding from their community23.Furthermore, the stigma associated with mental health conditions like ADHD can extend beyond the affected individuals to their familiesOver the years, efforts to address ADHD in Africa have gained momentum, with various stakeholders working to enhance awareness, diagnosis, treatment and support for individuals impacted by the disorder. Collaboration with international organisations, such as the WHO and UNICEF, has further accelerated progress in the field of ADHD in Africa. By forging partnerships with global entities, African countries gain access to valuable resources, knowledge and best practices that can be adapted to suit local contexts. This collaborative approach fosters a dynamic exchange of ideas and expertise, contributing to a comprehensive and sustainable approach to ADHD management. However, prioritising public awareness campaigns and educational programs is crucial to address the challenges surrounding ADHD in Africa Table 41. It is crucial to include educators in awareness initiatives by organising workshops, training programs and seminars to equip them with the knowledge and skills to recognise ADHD symptoms in their students. This enables early identification and timely interventions and support in the classroom setting. Similarly, healthcare professionals, including primary care providers and specialists, diagnose and treat ADHD42. Ensuring they are well informed about the latest research, diagnostic criteria and evidence-based treatments is crucial. Continuing medical education programs focused on ADHD can be organised to keep healthcare providers up-to-date with the best practices for managing the condition effectively. Moreover, religious leaders and traditional healers are highly respected figures in African communities43, so their influence can be significant. By involving them in awareness campaigns, they can become advocates for understanding and supporting individuals with ADHD. Providing them with accurate information about the neurodevelopmental nature of ADHD can help dispel misconceptions and reduce the stigma surrounding the condition. In turn, they can be crucial in encouraging community acceptance and support for those affected.Educators play a vital role in the lives of children with ADHD as they spend a significant amount of time with them in schoolsIn addition to raising awareness about ADHD, strengthening mental health services in Africa is paramount to addressing the challenges associated with ADHD management effectively. Adequate funding should be allocated to mental health programs and facilities, with special attention given to rural and underserved areas. Investing in these regions ensures that individuals with ADHD can access the necessary support and treatment options regardless of location. In addition, expanding the availability of trained mental health professionals, such as child psychologists and child psychiatrists, is critical to improving the diagnosis and treatment of ADHD. These specialists possess the expertise to accurately diagnose ADHD and develop tailored treatment plans based on each child’s unique needs. Ensuring sufficient qualified professionals can reduce waiting times for assessments and interventions, allowing children with ADHD to receive timely and appropriate care.Integrating mental health services into primary healthcare systems is another essential step. Since primary care providers are often the first point of contact for families seeking medical assistance, training them to recognise ADHD symptoms is vital. Equipping them with knowledge and resources to offer initial support and referrals can lead to early identification and intervention for children with ADHD. This integrated approach can bring mental health services closer to the communities, making it more convenient for families to seek help.Addressing the affordability and accessibility of ADHD treatment is critical to ensuring that individuals with the condition receive the support they need, regardless of their economic circumstances. In Africa, where many families face diverse economic challenges and limited access to healthcare resources, the cost of managing ADHD can pose a significant burden. Policy measures must be implemented to make necessary treatments and interventions more affordable and accessible. One key policy intervention is the subsidisation of medications and therapies for ADHD. Medications like stimulants, often prescribed to manage ADHD symptoms, can be costly for many families. By implementing subsidies or price controls on these medications, governments can reduce the financial strain on families and increase access to essential treatment. Pharmaceutical companies can also play a role in ensuring affordability by working with governments to offer discounted or lower-cost medications for ADHD management. In addition to medication subsidies, therapies and interventions for ADHD should be made more affordable. Behavioural therapies, counselling and educational support are crucial components of comprehensive ADHD management, but their costs can be prohibitive for many families. Governments can partner with nongovernmental organisations (NGOs) to establish subsidised or free therapy programs for children with ADHD. These programs can be implemented in schools or community centres, making them easily accessible to affected individuals and their families.Financial assistance programs can be instrumental in supporting families with limited resources. Governments and NGOs can create targeted financial aid programs to help families cover the costs of ADHD treatment. These programs can be means-tested to ensure that the families most in need receive the support they require. Such initiatives can significantly reduce the financial burden on families, encouraging them to seek timely and appropriate treatment for their children.Furthermore, telemedicine and digital health platforms can play a role in improving the accessibility of ADHD treatment, especially in remote or underserved areas. Telemedicine enables healthcare professionals to provide virtual consultations, allowing individuals with ADHD to access expert advice and support regardless of their geographic location.One of the strengths of this study lies in its comprehensive and diligent review of the existing literature on ADHD in Africa. By critically analysing available studies, the research provides valuable insights into the unique challenges faced in delivering equitable care to children with ADHD in the region. This inclusive examination allows a deeper understanding of the multifaceted factors influencing ADHD care, paving the way for informed and targeted interventions. Despite the study’s strengths, it is important to acknowledge the existing limitations, primarily stemming from the current state of data availability. The scarcity of studies on ADHD in Africa poses challenges in making conclusive comparisons across different countries. Nevertheless, the study makes the most of the available data and presents a comprehensive analysis within this context, providing valuable insights that can inform future research and policy development.Managing ADHD in Africa is a complex challenge influenced by social, economic and cultural factors. Limited awareness and stigma hinder timely support for affected individuals. Access to mental health services in rural areas delays ADHD diagnosis and treatment. The education system’s inability to accommodate neurodevelopmental disorders worsens students’ ADHD difficulties. Economic constraints in African communities make essential ADHD treatments unaffordable. Cultural beliefs lead to misunderstandings and inappropriate treatment. To address these challenges, prioritise public awareness campaigns and education to dispel misconceptions and reduce stigma. Strengthen mental health services and train professionals in ADHD diagnosis and treatment for early intervention. Improve affordability and accessibility through subsidies, financial aid and stakeholder collaboration. Integrate appropriate traditional healing practices to foster cultural acceptance. These measures require concerted efforts from governments, healthcare professionals, educators, communities and stakeholders. Further research, resource allocation and advocacy are vital to support children with ADHD and unlock their potential for a brighter future.Ethical approval is not applicable for this review.Informed consent is not applicable for this review.No funding was received for this review.N.A.: conceptualization. All authors contributed in writing of first and final drafts.All authors declare no conflicts of interest.Name of the registry: not applicable.Unique identifying number or registration ID: not applicable.Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable.Nicholas Aderinto.No new dataset were generated for this review.Not commissioned, externally peer-reviewed.


Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that is prevalent in children worldwide. We evaluated the potential relationship between birth weight and ADHD using newly released data from the National Survey of Children’s Health 2019–2020.This population-based survey study used parent recollection data that were collected and submitted by 50 states and the District of Columbia to the National Survey of Children’s Health database from the National Survey of Children’s Health database. Those aged < 3 years and without birth weight or ADHD records were excluded. Children were stratified according to ADHD diagnosis and birth weight: very low birth weight , low birth weight , and normal birth weight . Multivariable logistic regression was applied to examine the causal association between birth weight and ADHD while controlling for child and household characteristics.The final sample consisted of 60,358 children, of whom 6,314 (9.0%) were reported to have an ADHD diagnosis. The prevalence of ADHD was 8.7% in NBW children, 11.5% in LBW, and 14.4% in VLBW. Compared with NBW children, LBW children , and VLBW children  had a significantly higher risk of ADHD after adjusting all variables. These associations persisted in the male subgroups.This study found that LBW and VLBW children were at a higher risk of ADHD. FOXP2, SORCS3, and DUSP6 have been reported (Attention-deficit hyperactivity disorder (ADHD), characterized by a non-episodic pattern of inattentive, hyperactive, or impulsive symptoms, is one of the most prevalent developmental disorders among young children and adolescents . Approxireported . Despitereported . Numeroureported .Children with LBW seem to have more cognitive and psychiatric symptoms such as anxiety and depression . A meta-This study examined the relationship between LBW and very low birth weight (VLBW) and later outcomes of ADHD in 3–17-year-old children by analyzing cross-sectional data from the National Survey of Children’s Health (NSCH) survey cycles 2019 and 2020, which are nationally representative and population-based. Then, we performed subgroup analysis to explore the potential effect of children’s characteristic and postnatal and social factors like adverse childhood events and family resilience on the association between birth weight and ADHD.Combined 2019–2020 data from the NSCH database were used in this cross-sectional survey . The NSCBirth weight was assessed as a continuous variable. However, in the released data, the birth weight of the population was truncated by 72 and 155 ounces , respectively, where children born under 2,041 g were considered 2,041 g and over 4,394 as 4,394 g. Therefore, to avoid uncertainty, an association between ADHD and birth weight was estimated using birth weight data between 73 and 154 ounces .The International Peace Maternity and Child Hospital Institutional Review Board deemed the study exempt from review and waived the informed consent requirement because the data used were publicly available and the study did not involve human participants. We followed the strengthening the reporting of observational studies in epidemiology (STROBE) reporting guidelines.The primary outcome of interest was the diagnosis of ADHD in children. The ADHD diagnosis was identified using the following two NSCH questions:1.“Has a doctor or other healthcare provider ever told you that this child has Attention-Deficit Disorder or attention-deficit hyperactivity disorder, that is, ADD or ADHD?”2.“Does this child currently have the condition?”Attention-deficit hyperactivity disorder (ADHD) was confirmed if the parents or caregivers responded “yes” to the two questions above, where the children were deemed as currently having ADHD.The covariates in the model included child and household characteristics. Child characteristics included sex, age, and race/ethnicity. According to the survey questions, the children were grouped into preschool children (3–5 years of age), school-aged children (6–12 years of age), and adolescent children (13–17 years of age). Race/ethnicity was classified as white, Hispanic, African-American, Asian, or other.1 the proportion of missing values is less than 2% in most cases. The elimination of these values did not change the estimated prevalence and only slightly affected the weighted population counts.Caregivers’ characteristics included poverty/income level and health insurance status. Poverty/income levels were 0–99%, 100–199%, 200–399%, and 400% or above federal poverty level. The NSCH prepares nine questions on ACEs, including parental separation/divorce, parental death, witnessing household violence, witnessing neighborhood violence, household mental illness, household incarceration, household substance abuse, racial/ethnic mistreatment, and economic hardships. In this study, ACEs were categorized into three groups: no ACE, one ACE, and two or more ACEs. Family resilience includes family members: (1) discussing what to do, (2) working together to solve the problem, (3) knowing they have whom they can draw strength from, and (4) staying hopeful even in difficult times when the family faces problems. Families with 0–1 item, 2–3 items, and all four items were labeled as some/none of the time, most of the time, and all of the time, respectively. The household smoking status was determined by “Does anyone living in this child’s household use cigarettes, cigars, or pipe tobacco?” as “Yes” or “No.” When necessary, a missing category for the covariates was added. According to the official guidelines for data analysis,The 2019–2020 combined dataset consisted of two individual survey rounds (2019 and 2020 NSCH). Only items with the same unique household identifier (HHID) across both datasets are included in the DRC-produced combined dataset. Information on the process of the datasets combination and weight adjustments is available in the “Guide to Analysis of Multi-Year NSCH Data” . Each reThe weighting process was designed to estimate national- and state-level prevalence for a variety of child and family health measures with an effective and representative sample size . In the P-values were 2-sided, and P < 0.05 was statistically significant.After the sample weighting process, estimates of the population characteristics were reported with 95% CI, based on Wald’s method. Categorical variables were reported as frequencies and percentages. Additional information is available on the DRC website (see text footnote 1). All Based on logistic regression models, we estimated the odds ratios (ORs) with 95% CIs of birth weight vs. ADHD. The main analyses examined the association between birth weight (LBW and VLBW groups separately) and ADHD, using normal birth weight (NBW) children as the reference group. In light of previous research, we considered multiple confounding factors using three models. Model 1 was unadjusted, while Model 2 was adjusted for sociodemographic characteristics such as age, race, ethnicity, poverty/income level, and health insurance status. Additionally, Model 3 was adjusted for the variables in Model 2 plus preterm birth to estimate the independent effect of birth weight on ADHD. Restricted cubic spline with 3 knots was applied to flexibly model and visualize the relation of predicted birth weight and ORs of ADHD. Furthermore, we performed the exploratory subgroup analysis where the population was stratified by preterm birth, age, sex, and race of the child, household smoking exposure, ACEs and family resilience based on interaction analysis and previous research. The widths of the CI was not adjusted for multiple testing, therefore, the results might not be used to statistical inference. Specifically, children were divided by ACEs status and family resilience to control the influence of the postnatal environment. All analyses were performed using the “survey” package in R 4.0.6.The exposure and outcome variables for 60,358 children aged 3–17 years from the combined 2019–2020 NSCH sample, which included 72,210 children, were obtained. In our sample, 6,314 or 9.0%  were diagnosed with ADHD currently. Moreover, 796 or 1.3%  were reported to have VLBW, and 4,373 or 7.9%  were reported to have LBW . The larP < 0.05) , preterm birth , sex , race, household poverty level, exposure to secondhand smoke, and ACEs  were associated with the birth weight of children ( < 0.05) .Thereafter, we assessed the association between birth weight and ADHD and discovered that VLBW was associated with a higher risk of the disorder , and a similar trend was noted for LBW  . After aP = 0.005]  increase in birth weight was associated with a one percent reduction in the odds of ADHD  . In addi= 0.005] . In thisExplorative stratified analyses by preterm birth, age, race, exposure to secondhand smoke, insurance status, ACEs, and family resilience were performed .In this nationwide population-based survey study, we found that birth weight and both LBW and VLBW were significantly associated with ADHD compared to NBW after adjusting for preterm birth and other covariates.N = 12,991) found that mothers of children with ADHD were more likely to be delivered early, irrespective of the sex of the child, while low birth weight, post-term pregnancy, small for gestational age infants, fetal distress, and low Apgar scores were not identified as risk factors  were not more likely to be born prematurely than controls  in a US case-control study (n = ∼1.17 million), and found that among individuals born at term (week 37–41 of gestation), the risk of ADHD increased with decreasing Z scores of birth weight by gestational age. Therefore, there is a distinctive and pervasive pattern of neurodevelopmental morbidity associated with birth weight at term. In our research, after adjusting for maternal age, maternal education, marital status, year of childbirth, sex, and all pregnancy/labor/newborn factors, especially preterm birth, we indicated that lower birth weight may independently increase the risk for ADHD . Furthermore, the association remained in LBW  but not in VLBW. The potential reason might be that VLBW limited sample size . In our study, preterm was not associated with ADHD after adjusting for all the variables . However, this might be due to the lack of analysis on the cause and extent of preterm births because of limited information . Further research is needed to address this issue.Previous studies have indicated that birth weight may correlate with ADHD. Aarnoudse-Moens et al.  conducte factors . However factors . Similarol study . To elimol study . Furtherol study  used datSeveral hypotheses have indicated that environmental adversities during the fetal and postnatal periods, as well as parental genetic factors and pathological issues, such as hypothalamic-pituitary-adrenal (HPA) axis dysregulation and perinatal systemic inflammation, are causally related to neural disorders such as ADHD and other psychiatric and developmental disorders –25. PrevFinally, this study also provided the current national prevalence of ADHD, where 9.0% of US children had ADHD, which is close to prior estimates of the national prevalence of ADHD of 9.6% in 2017–2018 and 9.4% in 2016 from the NSCH data , 32.This study utilized a nationally open-access representative sample to analyze and provide generalizable results for preschool-aged children in the US. The NSCH has been updated since 2015, using several methods, such as an address-based sampling frame, to decrease sample bias and include accommodation to improve the response rate. With a large NSCH dataset, several variables were adjusted for confounding factors, thus avoiding the limitations of many previous studies and providing a relatively solid result with large sample size.However, this study has some limitations. First, ADHD diagnosis and severity information were collected from caregivers’ reports, which could not be confirmed with a healthcare provider and were inevitably subject to potential caregiver bias. And the bias might lead to the inconsistent results in stratified analysis of children with and without ACE. In addition, both inherited and environmental factors contribute to ADHD , 34; howIn summary, our study results indicate that LBW/VLBW children, compared to the NBW group, were associated with subsequent ADHD diagnosis in 3–17-year-old children in the US. This study provides the latest nationally representative estimates of multiple ADHD diagnoses across the pediatric population in the US. Further investigations are necessary to elucidate the mechanisms underlying the association between LBW/VLBW infants and the risk of ADHD, as well as the interactions of birth weight with postnatal and environmental factors such as ACEs and family resilience to explore how other independent variables, particularly those having a biological basis, may work together with birth weight to impact ADHD in children.http://www.childhealthdata.org/NSCH.Publicly available datasets were analyzed in this study. This data can be found here: The studies involving human participants were reviewed and approved by the International Peace Maternity and Child Hospital Institutional Review Board. They deemed the study exempt from review and waived the informed consent requirement because the data used were publicly available, and the study did not involve human participants. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.MN, LL, and ZL: study design. MN, QS, WL, XD, SQ, TW, BL, and DY: data analyses and interpretation. MN and LL: manuscript drafting. ZL, QZ, JZ, and MN: critical revision of the manuscript. All authors contributed to the work approved the final version of the manuscript.


This study aimed to examine potential disparities in hematologic inflammation parameters between children diagnosed with attention deficit hyperactivity disorder (ADHD) and their healthy counterparts and to determine whether atomoxetine treatment induced any alterations in inflammation indicators. This case–control study involved 43 children aged 6–13 years, 22 diagnosed with ADHD for the first time, and 21 healthy children. In all children, complete blood count and albumin, C-reactive protein (CRP), thyroid stimulating hormone (TSH), free thyroxine (free T4), folate, vitamin B12, aspartate aminotransferase (AST), alanine transaminase (ALT), creatinine and urea values were performed. Children with ADHD were started on atomoxetine treatment, and one month later, the blood test was repeated for those who commenced treatment. Neutrophil (p = 0.005), platelet (PLT) (p = 0.002), neutrophil/lymphocyte ratio (NLR) (p = 0.001), platelet/lymphocyte ratio (PLR) (p < 0.001), systemic immune /inflammation index (SII) (p < 0.001) and pan-immune-inflammation value (PIV) (p = 0.025) parameters were found to be significantly higher than the control group, while the lymphocyte value (p = 0.001) was found to be significantly lower. In those in the ADHD group, lymphocyte (p = 0.041) and albumin (p = 0.027) values increased significantly after treatment. The results of this study show the increase in inflammation in drug-naive ADHD patients and the partial improvement after treatment. However, there is a need to evaluate inflammation in larger samples after longer-term treatments and follow-ups. The prevalence of ADHD tends to decrease with age, but it persists into adulthood in approximately two-thirds of cases3. Although studies conducted in different parts of the world have reported significantly different results, the worldwide-pooled prevalence of ADHD is estimated to be 5.29%4.ADHD is a neurodevelopmental disorder primarily observed in childhood, characterized by symptoms such as inattention, excessive activity, and impulsivity that are inconsistent with typical developmental patterns6. Moreover, investigations exploring the connection between ADHD and peripheral inflammation have highlighted the potential role of neuroinflammation in the pathophysiology of ADHD. Animal studies have also provided evidence suggesting a relationship between exposure to inflammation and the development of ADHD6.Inflammation has been found to be associated with neuropsychiatric disorders not only in adults but also in children and adolescents. Studies have shown that markers of inflammation increase in various neuropsychiatric conditions in these age groups7. NLR from systemic inflammation indicators and PLR from chronic inflammation indicators; increases in psychiatric disorders such as ADHD, schizophrenia, bipolar and obsessive–compulsive disorder11. Similarly, it has been shown that the monocyte/ lymphocyte ratio (MLR) is high in psychiatric disorders10.Leukocytes, neutrophils, and platelets play an essential role in inflammation. CRP and albumin also respond to inflammation as acute-phase reactants7. Similar to CRP, SII ((platelet count x neutrophil count)/lymphocyte count) is a superior indicator of inflammation than NLR, PLR, and MLR. Nitric oxide, arginase, and reactive oxygen species released in the presence of high SII may play a role in the development of ADHD by inhibiting activated T cells12. It has been found that PIV ((platelet count x neutrophil count x monocyte count)/lymphocyte count) is high in obsessive–compulsive disorder13.In addition to NLR, PLR, and MLR, it has been reported that CRP/Albumin ratio (CAR), Red Cell Distribution Width (RDW), and Mean Platelet volume (MPV) are high in schizophrenia patients15. Conversely, the lymphocyte level is lower in individuals with ADHD9. Additionally, there is a suggested relationship between ADHD and decreased levels of albumin16. These findings further support the potential involvement of these specific hematologic parameters, such as neutrophils, platelets, lymphocytes, and albumin, in the pathophysiology of ADHD.Indeed, some studies have reported elevated levels of neutrophils alone and platelets (PLT) alone in individuals with ADHD compared to control groups17.The treatment options for ADHD include pharmacological interventions, behavioral therapy, or a combination. One of the pharmacological treatment options is atomoxetine, a selective norepinephrine (NE) reuptake inhibitor. Atomoxetine is an approved medication for ADHD in children, adolescents, and adults. Although the precise mechanism of action of atomoxetine remains unknown, it is known to inhibit the reuptake of dopamine in specific brain regions while preventing NE reuptake. Notably, atomoxetine significantly improves ADHD symptoms within a few weeks of treatment. Moreover, atomoxetine has shown effectiveness in addressing symptoms associated with comorbidities often observed in individuals with ADHDBased on the provided references, there is limited information about direct or indirect evidence explicitly addressing the effect of atomoxetine on inflammatory markers in individuals with ADHD. Further research explicitly investigating this aspect is needed to determine the impact of atomoxetine on inflammatory markers in the context of ADHD treatment.The primary objective of this study was to examine potential differences in hematologic inflammation parameters between children diagnosed with ADHD and healthy children without any complaints. Additionally, the study aimed to determine if these parameters could serve as diagnostic markers for ADHD. Furthermore, the study investigated whether atomoxetine treatment impacted the inflammation indicators.Ethical approval for the study was obtained from the Fırat University Non-Interventional Research Ethics Committee, dated December 1, 2022, with the reference number 2022/14-05. Since all participants in the study were under the age of 18, written consent was obtained from their families, indicating their agreement to participate in the study. Furthermore, all procedures adhered to the principles outlined in the Declaration of Helsinki and complied with relevant local laws and regulations.This case–control study was conducted at the Kahta District State Hospital in the Southeastern Anatolia Region of Turkey, from January 1, 2023, to May 1, 2023. The study included two groups, the case and the control groups, with similar sociodemographic characteristics. The case group consisted of children aged 6–13 years who presented at the Child and Adolescent Psychiatry Outpatient Clinic and received a first-time diagnosis of ADHD based on the diagnostic criteria outlined in the DSM-V. In contrast, the control group comprised children without complaints, acute or chronic illness, or concurrent medication use who attended the Healthy Child Outpatient Clinic for routine screening blood tests.18. When calculating the sample size, when 0.5 effect size, 5% margin of error, and 80% power were accepted, it was planned to include 38 children, 19 for the case group and 19 for the control group.G*Power version 3.1.9.2 program was used to calculate the sample size in the study. For sample calculation, Önder et al. study was referenced17. The maximum daily dose of atomoxetine administered to any treated child did not exceed 80 mg.All blood samples were collected via venous blood sampling. Following a 12-h fasting period, a comprehensive set of blood tests, including CBC, albumin, CRP, TSH, free T4, folate, vitamin B12, AST, ALT, creatinine, and urea values, were conducted in all participating children. For children diagnosed with ADHD, atomoxetine treatment was initiated as a single daily dose in the morning. The initial atomoxetine dose was set at 0.5 mg per kg per day for the first week, followed by a maintenance dose of 1.2 mg per day after one week4 of the 48 ADHD patients examined at the Child and Adolescent Psychiatry Outpatient Clinic were not included in the study because their parents did not have consent. Among the remaining patients, those with additional psychiatric diagnoses of autism spectrum disorder (3), mental retardation (1), obsessive–compulsive disorder (2), oppositional defiant disorder (2), and depression (1) were excluded from the study.In order to evaluate the comorbidities of the ADHD patients and the control group, they were examined by a specialist pediatrician at the pediatric outpatient clinic at their first admission and 1-month follow-up. Among ADHD patients, those with anemia (2), upper respiratory tract infection (2), epilepsy (1), hyperthyroidism (1), and celiac disease (1) were not included in the study. After one month of atomoxetine treatment, the children underwent a follow-up visit for evaluation, and blood tests were repeated. 4 ADHD patients who did not come to follow-up at the 1-month follow-up and 2 ADHD patients with upper respiratory tract infections were excluded from the study. Flow-chart illustration of the study’s sample was shown in Fig. Statistical analyses were conducted using the SPSS software package  version 22. Descriptive statistics were presented as n and % for categorical data, and mean ± standard deviation (mean ± SD) or median with interquartile range  for continuous data. Categorical variables were compared between groups using the Pearson chi-square test, and the Shapiro–Wilk test was used to assess the normality of continuous variables. Paired groups were compared using the Mann–Whitney U test, and values before and after treatment were compared using the Wilcoxon signed-rank test. Receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic value of various parameters in diagnosing ADHD. The statistical significance level for all analyses was set at p < 0.05.A total of 43 children participated in the study, with 22 children in the ADHD group and 21 children in the healthy control group. In the ADHD group, 36.4% were girls, and 63.6% were boys. In the control group, 47.6% were girls, and 52.4% were boys. There was no significant difference in gender distribution between the two groups (p = 0.712). The median age of the children in the ADHD group was 8.3 years (range: 7.0–9.3), with a mean age of 8.6 ± 2.2 years. In the control group, the median age was 5.0 years (3.4–13.6), with a mean age of 7.8 ± 5.1 years. There was no significant difference in age between the two groups (p = 0.307) , PLT p = 0.002), NLR (p = 0.001), PLR (p < 0.001), SII (p < 0.001), and PIV (p = 0.025) compared to the control group. Conversely, the lymphocyte value was significantly lower in the ADHD group (p = 0.001). No significant difference was detected between the two groups in the other blood parameters compared  and albumin values (p = 0.027). No significant difference was detected in the other blood parameters examined. Table .Table 3CROC analysis was conducted to assess the predictive ability of various values for ADHD diagnosis, and cut-off values were determined. The results indicated that neutrophil, lymphocyte, PLT, NLR, PLR, SII, and PIV parameters had a significant diagnostic value for ADHD Table .Table 4T13.In contrast to some studies suggesting that increased inflammatory response does not play a role in ADHD, the present study demonstrated that neutrophils, PLT, NLR, PLR, SII, and PIV levels were significantly higher in children with ADHD compared to the control group, while lymphocyte levels were significantly lower. ROC analysis revealed that these parameters had significant diagnostic values for ADHD, as indicated by the determined cut-off values. These findings are consistent with a study conducted by Abus et al., which reported higher SII and PIV levels in patients with obsessive–compulsive disorder compared to the control group1. On the other hand, Aksu & Dağ reported a high MPV value in children with ADHD, particularly in boys, which contrasts the present study's findings 19]. Additionally, Avcil suggested in their study that the NLR ratio increased in ADHD and that the extent of NLR elevation played a role in the inflammatory pathophysiology of ADHD9.The findings of Akıncı & Uzun, which showed significantly higher neutrophil, PLT, and NLR levels in the ADHD group compared to the healthy group, are consistent with the results of the present study. However, unlike the present study, Akıncı & Uzun also observed elevated PDW, MPV, and WBC values in the ADHD group8. Similarly, Kirlioglu et al. reported higher PLR and MLR values in bipolar patients and elevated NLR and MLR values in manic patients10. These studies support the notion that inflammation markers, as reflected by NLR, PLR, and MLR, may play a role in the pathophysiology of these psychiatric conditions.The study conducted by Özdin et al. demonstrated higher NLR, PLR, and MLR values and lower lymphocyte numbers in patients with bipolar disorder and schizophrenia compared to the control group. Moreover, they observed increased platelet numbers in patients with bipolar disorder and elevated neutrophil numbers in patients with schizophrenia20.The study conducted by Ceyhun&Gürbüzer reported no significant difference in PDW between children in the ADHD group and the control group, which is consistent with the present study's findings. However, they mentioned that, unlike the present study, the SII ratio did not differ between the two groups14.Similarly, the present study, in line with the study by Topal et al., found elevated neutrophil levels in children with ADHD, indicating consistency between the two studies. However, no significant difference in vitamin B12 and folate levels was observed in the present study, which differs from the findings of Topal et al.Regarding examining CAR ratios in ADHD, the present study did not find a significant difference between children with ADHD and the control group of healthy children. It is essential to consider these variations in findings across studies and continue conducting further research to understand the role of inflammation markers and related factors in ADHD and other psychiatric conditions.15.In the present study, no significant differences were found in MPV, PDW, and PCT levels between the ADHD group and the control group. However, Akbayram et al. reported high values for MPV, PDW, and PCT in children with ADHD, which contrasts with the present study's findings19.Additionally, while Aksu & Dag reported gender-related differences in inflammatory marker levels in their study, no significant differences based on gender were observed for any parameter in the present study21. While Lu et al. suggested that there might be low albumin levels in ADHD, this present study found no significant difference in albumin levels between children with ADHD and the healthy control group16.Unlike C-reactive protein (CRP), albumin, an acute-phase reactant, decreases during inflammation22. Therefore, the observed increase in albumin and lymphocyte levels may be attributed to a direct mechanism of action independent of the drug's clinical effects.However, a significant increase in albumin and lymphocyte levels was observed in the blood analysis conducted one month after treatment, compared to the pre-treatment blood analysis of children diagnosed with ADHD. This increase in albumin and lymphocyte levels could indicate a decrease in inflammation, the effectiveness of atomoxetine, or an improvement in ADHD symptoms. Consequently, albumin and lymphocyte levels can be considered parameters for ADHD prognosis. It is important to note that atomoxetine is highly bound to plasma albumin, with a binding rate of 99%13. Similarly, Akıncı & Uzun found elevated neutrophil, PLT, and NLR levels in the ADHD group, supporting the results of the present study1. Avcil also suggested an increased NLR ratio in ADHD, indicating a potential role of inflammation in the pathophysiology of the disorder9.The results of the present study are consistent with some previous studies. For example, Abus et al. reported higher SII and PIV levels in patients with obsessive–compulsive disorder, which aligns with the findings of the present study19.However, there are also discrepancies between the present study and previous research. For instance, Aksu & Dağ reported elevated mean platelet volume (MPV), platelet distribution width (PDW), and white blood cell (WBC) values in the ADHD group, which were not observed in the present study. Aksu & Dağ also found gender-related differences in inflammatory marker levels, which were not significant in the present studyThe inter-study differences in inflammation markers in ADHD may be attributed to various factors, including sample characteristics, study design, and measurement methods. The present study provides evidence of altered inflammatory markers in children with ADHD, supporting the involvement of inflammation in the disorder. The clinical significance of changes in these markers, such as the increase in albumin and lymphocyte levels after treatment, highlights their potential as prognostic indicators.The fact that this study was conducted with a relatively small number of participants stands out as a major limitation. However, a purer patient group was obtained due to the exclusion of comorbid organic and mental illnesses of ADHD patients by the child psychiatrist and pediatrician. Evaluating inflammation markers only after one month will not be sufficient to evaluate the treatment of chronic diseases such as ADHD. Therefore, evaluating inflammation markers in the third and sixth months would be appropriate. The follow-up period may be extended in future studies. Additionally, it is a limitation that scales that evaluate disease severity, such as the Conners rating scale, are not used to evaluate response to treatment in ADHD patients.In this study, inflammation markers were higher in drug-naive ADHD patients than healthy controls. In addition, the improvement in lymphocyte and albumin values after atomoxetine treatment may be valuable in showing the decrease in the severity of inflammation. However, it would be more meaningful to evaluate ADHD patients after longer-term treatment and follow-up.