The results showed that the ADHD and subthreshold ADHD groups exhibited similar patterns of the impaired executive function of attention  and reduced cognitive control capacity, and no significant difference was found between the two groups. These findings suggest that although children with subthreshold ADHD have not met the full criteria of ADHD, they showed reduced efficiency in cognitive control and attention function, similar to children with ADHD.Subthreshold Attention-Deficit/Hyperactivity Disorder (ADHD) is defined as a neurobiological condition with some core inattentive or hyperactive/impulsive symptoms of ADHD which do not meet the full diagnosis clinically. Although it has been well documented that deficits in cognitive control, a high-level cognitive construct closely related to attention, are frequently found among children with ADHD, whether subthreshold ADHD is also associated with similar deficits remains unclear. In this study, we examined the attention functions and the cognitive control capacity (CCC) in children with ADHD ( Attention deficit hyperactivity disorder (ADHD) is a prevalent psychological disorder in childhood. It is characterized by inattention, short attention time, hyperactivity, and impulsivity that are not commensurate with age and developmental level. This disorder is often accompanied by learning difficulties, behavior disorders and maladjustment . In receDiagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases. Although this diagnostic method has been validated , attention is supported by large-scale brain networks composed of different brain regions with specific anatomical regions and biochemical mechanisms . AlertinDeficit in the executive function of attention is usually reflected by a reduction in the efficiency of conflict processing, i.e., an augment of conflict effect in the Stroop task, the flanker task, and the Simon tasks. Conflict processing is a special case of uncertainty reduction in cognitive control, and the conflict effect can be considered as the speed of processing 1 bit of information by cognitive control . BesidesThe current study examined, from the perspectives of the multi-level attention networks and the CCC, whether children with subthreshold ADHD have alternations of cognitive control similar to those of children with clinically diagnosed ADHD. Three groups of participants were included in our research: children with (full) ADHD, children with subthreshold ADHD, and typically developing peers (TD) as controls. Each participant completed an Attention Network Test-Interaction (ANT-I)  to evaluA total of 8,156 students (age ranged from 6 to 13 years) in Grades 1–5 from six primary schools and first-year students from six junior high schools in Huangpu District, Guangzhou, China participated in the initial screening of this study. Then 135 of them participated in the formal experiment, 109 of which were included as the final sample. This study received ethical approval from the Human Research Ethics Committee of South China Normal University, Guangzhou, China.Swanson, Nolan, and Pelham Rating Scale (SNAP-IV for parents) (Conners Abbreviated Symptom Questionnaire (ASQ) , hyperactivity/impulsivity (nine items), and opposition/defiance (eight items). Symptom severity is rated on a 4-point scale in each item (the severer the higher score), and the score in each subset is totaled. The ASQ is a 10-item questionnaire, and each item is rated on a 4-point scale. Higher total scores in both questionnaires indicate more severe symptoms.A two-step screening procedure was adopted to identify children with ADHD and subthreshold ADHD. In the first step, the parents of the students were invited to complete an online two-part survey as a preliminary identification. In the screening, we used two tools to assess the children’s behavioral performance, namely the Chinese version of parents)  and Connre (ASQ) . The SNAn = 1010), a total of 7,146 children had valid data in the first step . Among them, 671  met the diagnosis for ADHD or subthreshold ADHD based on parental reports. Then the headteacher of each of the 671 children was invited to participate in the second screening step via a phone interview to further verify the diagnostic information. The teachers were also required to complete both SNAP-IV and ASQ, and to provide demographic information and physical and mental health status of the children. In this step, only children who met both parent’s and teacher’s rated criteria were included for further study.After excluding children failing to fill out the questionnaire carefully and those with physical and mental diseases according to the reports from their parents (DSM-IV (SNAP-IV: (1) he or she scores at least two points in at least six of the nine items of the attention deficit factors, and/or at least six of the nine items of the hyperactivity-impulsivity factors; (2) these symptoms exist in at least two environments  before age 7, and have an obvious impact on his or her communication, study and life. To improve the effectiveness of screening, a cut-off point of 10 in the ASQ survey was included as an additional criterion for the diagnosis of ADHD. Children who met the criteria of both SNAP-IV and ASQ were classified as the ADHD group. Children who were diagnosed with ADHD but not intervened were also defined as ADHD in this study. A participant was diagnosed with subthreshold ADHD if he or she scored at least two points in 3–5 items concerning the attention deficit factors and/or impulsive hyperactivity factors of SNAP-IV, but did not meet the full criteria for ADHD .Diagnosis of ADHD and subthreshold ADHD was performed for the remaining children based on the reports in the second step of the screening. According to DSM-IV , one meefor ADHD . A cut-o2(1) = 15.87, p < 0.001; subthreshold ADHD: 75.5% vs. 24.5%, χ2(1) = 31.98, p < 0.001]. Three groups of children, i.e., ADHD, subthreshold ADHD, and TD, were randomly recruited from this subject pool, with 45 children in each group . We further reassured that the 45 children in the TD group did not meet the diagnostic criteria from their headteachers via phone interviews. The final sample only included the children having valid data in the two computerized tasks (ANT-I and MFT-M), and there were 39 subjects in the ADHD group, 34 in the subthreshold ADHD group, and 36 in the TD group . Demographic and diagnostic information of the participants in each group of the final sample was reported in The above screening identified 149 children with ADHD , 229 children with subthreshold ADHD . The number of participants considered as TD was 6,475. The proportions of boys with ADHD and subthreshold ADHD were significantly higher than those of girls , with the difference being significant between the TD and ADHD groups , between the TD and subthreshold ADHD groups (χ2 = 3.93 p = 0.047), but not between the ADHD and subthreshold ADHD groups .Descriptive statistics of the demographic information were reported in F2,129 = 191.39, p < 0.001, η2 = 0.788, BF10 > 1,000), with the differences being significant between all pairs of groups . The hyperactivity/impulsivity factor was significantly different between groups , with the difference being significant between all pairs of groups .Descriptive statistics of the diagnostic information were reported in F2,103 = 2.98, p = 0.055, η2 = 0.055, 1/3 < BF10 = 1.135 < 3), with the ADHD group showing a significant greater alerting effect than the TD group  and no significant difference between the subthreshold ADHD and the other two groups . Simple effect analysis showed that the between-group difference was significant for the RT in the without alerting signal conditions , with the significantly shorter RT in the ADHD group compared to the other two groups , but with no significant difference between the subthreshold ADHD and TD groups . In contrast, the between-group difference was not significant for the RT in the with alerting signal conditions . These results suggest that the between-group difference of the alerting effect in RT was mainly driven by the difference in the without alerting signal conditions. In addition, the main effect of sex and the sex × group interaction were not significant for the alerting effect in RT , indicating that the sex difference was not a significant confounding factor of the between-group difference of the alerting effect in RT. The alerting effect in response accuracy was not significantly different between groups , indicating that the between-group difference of the alerting effect in RT was not driven by the difference in speed-accuracy trade-off.The attentional effects in RT and response accuracy in each group were presented in F2,103 < 1, η2 = 0.002, BF10 = 0.094 < 1/3; F2,129 = 2.24, p = 0.111, η2 = 0.042, 1/3 < BF10 = 0.597 < 3).For the orienting effect, no significant between-group difference was found in neither RT , with both ADHD and subthreshold ADHD groups showing a significantly greater conflict effect  than the TD group , but not between ADHD and subthreshold ADHD groups . Simple effect analysis showed that the between-group difference was significant for the RT in the congruent conditions , with the difference being significant between the ADHD and the other two groups , but not significant between the subthreshold ADHD and TD groups . The between-group difference was also significant for the RT in the incongruent conditions , with the difference being significant between the ADHD and TD groups , but not significant between the subthreshold ADHD and the other two groups . These results suggest that the between-group difference of the conflict effect in RT was driven by the difference in both congruent and incongruent conditions. In addition, the main effect of sex and the sex × group interaction was not significant for the conflict effect in RT , indicating that the sex difference was not a significant confounding factor of the between-group difference of the conflict effect in RT. The conflict effect in response accuracy was not significantly different between groups , indicating that the between-group difference of the conflict effect in RT was not driven by the difference in speed-accuracy trade-off.For the conflict effect in RT , the betF2,103 = 3.05, p = 0.052, η2 = 0.056, 1/3 < BF10 = 1.144 < 3). Post hoc analysis showed that the ADHD group was significantly slower than the subthreshold ADHD  and the TD  groups. However, there was no significant difference between the subthreshold ADHD and TD groups . In addition, the main effect of sex and the sex × group interaction was not significant for the alerting effect in RT , indicating that the sex difference was not a significant confounding factor of the between-group difference of the overall RT.For the overall RT in the ANT-I , the betF2,103 = 3.51, p = 0.034, η2 = 0.064, 1/3 < BF10 = 1.918 < 3), with both ADHD and subthreshold ADHD groups showing a significant lower CCC than the TD group . But no significant difference was found between the ADHD and subthreshold ADHD groups . In addition, the main effect of sex and the sex × group interaction were not significant on the alerting effect in RT , indicating that the sex difference was not a significant confounding factor of the between-group difference in the CCC.The estimated CCC of each group was presented in f) of participants with deficits in any of the following: (1) alerting function ; (2) orienting function ; (3) executive control function ; (4) CCC .The ADHD and subthreshold ADHD groups did not significantly differ in the frequency , and a significant positive correlation between the alerting effect in RT and the hyperactivity/impulsivity score . However, for children in the ADHD and subthreshold ADHD groups, no significant correlation between any attention effect/CCC and the SNAP-IV factors was revealed in any group.With the ADHD syndrome viewed as a continuously distributed trait, our correlation analyses across all participants  revealedr31 = −0.367, p = 0.036, 1/3 < BF10 = 1.08 < 3), and in the subthreshold ADHD group , but not in the ADHD group . This correlation was significantly more negative in the subthreshold ADHD group compared to the ADHD group , but not significantly different between the ADHD and TD groups , or between the subthreshold ADHD and TD groups .For the correlation between the CCC and attentional functions , the CCCps < 0.001, BF10 > 1,000), and also for the subthreshold ADHD vs. TD classifications , but not for ADHD versus subthreshold ADHD based on any feature set . The attentional effects and CCC combined feature set significantly improved the accuracy of the subthreshold ADHD versus TD classification compared to classification based on attentional effects or CCC solely , but not significantly improved the accuracy of the ADHD versus TD classification .The prediction accuracy of all classification analyses was reported in ps < 0.001, BF10 > 1,000). For the ADHD-to-subthreshold-ADHD cross-classification, the combined feature set significantly improved the accuracy compared to accuracy based on attentional effects or CCC solely . For the subthreshold-ADHD-to-ADHD cross-classification, the combined feature set also significantly improved the accuracy compared to the accuracy based on the CCC solely , but did not significantly increase the accuracy compared to the accuracy based on the attentional effects solely .The prediction accuracies of all cross-classifications  were sigstatus quo of ADHD in China (n = 293) who were identified as typically developing peers according to the teachers’ report, which may also lead to the omission of some cases of ADHD or subthreshold ADHD. Second, our study used online and phone surveys that may have lower reliability compared to the traditional written notice and questionnaire, and therefore some potential children with ADHD or subthreshold ADHD may have been left out. Third, some parents might have been afraid of the intervention of ADHD and had concealed information about their children. In addition, the symptoms of children with subthreshold ADHD might be ignored by their teachers who usually face large groups of students. After all, their symptoms are less obvious than those of ADHD children. Therefore, the proportion of children with subthreshold ADHD identified based on teachers’ interviews may be lower than that based on parents’ assessment.The result of the identification of children with ADHD and subthreshold ADHD in our study was in line with the epidemiological status of the general population but with a lower detection rate. Furthermore, the proportions of boys with ADHD and subthreshold ADHD were significantly higher than those of girls, which was in line with the epidemiological in China  and the in China . Howeverin China . The 3.2Similar but distinct patterns of multi-level alternations of attentional functions in RT were observed in the ADHD and subthreshold ADHD groups. Specifically, significantly enlarged conflict effects were shown in both ADHD and subthreshold ADHD groups and no difference between these two groups was observed. The frequencies of participants with deficits in the executive control of attention were also very similar (about 38%) between these two groups. These findings together suggest that the subthreshold ADHD children may suffer from similar impairment in executive control of attention as in the ADHD children. In addition, no change of the orienting effect was observed in either ADHD or subthreshold ADHD groups compared to the TD group. These results are consistent with previous research findings on children with ADHD  and chilThe association between the lower-level alerting function and the CCC may be important for the functioning of cognitive control. A significant negative correlation between the alerting effect and the CCC has been observed in the TD group , indicating that children with higher capacity may also have a higher sensitivity to detect the coming information, and therefore may depend less on additional alerting signals. This negative correlation was also observed in the subthreshold ADHD group, suggesting this association has not been affected when the severity of ADHD does not reach the clinical criteria. However, this association was lacking in the ADHD group, suggesting that the ADHD children may have to recruit cognitive resources constantly to maintain alertness to the task-relevant information, and need the assistance of additional alerting signals. This background process may compete with the foreground control of information processing, and therefore lead to reduced CCC.The results of our classification analysis further demonstrate that measuring both attentional functions and capacity of cognitive control is important for evaluating the alternations of cognitive control associated with ADHD and subthreshold ADHD. Attention effects and the CCC can be used to successfully differentiate children with ADHD and subthreshold ADHD from their typically developing peers, but they could not differentiate ADHD children from subthreshold ADHD children, demonstrating the ADHD and subthreshold ADHD groups may share a similar composite pattern of alternations in cognitive control. In addition, our results of the cross-classifications further demonstrate that the two groups are similar in the composite pattern of the attentional effects and the capacity of cognitive control. In addition, combining attentional effects and CCC could significantly improve the performance of the subthreshold ADHD versus TD classification, indicating the importance of a comprehensive evaluation of the cognitive control abilities in children with ADHD-related symptoms even when the severity does not reach the clinical diagnosis. It is worth noting that, the classification accuracies were only 60–70%, although they are significantly higher than the chance level. This makes us question the capability of these neuropsychological measures in adding diagnostic efficiency to ADHD and subthreshold ADHD as biomarkers.It is important to note that, although we have found that children with subthreshold ADHD have reduced cognitive control efficiency, we are not claiming that all those children have cognitive deficits. According to previous studies on the neurocognitive heterogeneity in ADHD, only approximately 33–50% of the children with diagnosed ADHD exhibit impairments in executive functioning . With a This study may advance our understanding of the cognitive function of children with subthreshold ADHD, such as identifying the rationality and necessity of defining subthreshold ADHD from the perspective of attention and cognitive control, and expanding the research scope of ADHD. In family education, school education and clinical intervention, the symptoms and other coexisting psychological and behavioral problems associated with subthreshold ADHD should not be ignored. In terms of prevention, education and intervention, children with subthreshold ADHD deserve due attention as children with full diagnosed ADHD.However, this research has some limitations. On one hand, for identifying children with ADHD and subthreshold ADHD from the population, no diagnostic interviews were conducted with their parents. The parents’ assessment in the survey was not free from subjectivity, and we got less information from the survey than interviews. In addition, as for the ADHD, only the reports of symptoms were utilized for the diagnosis of the subthreshold ADHD, due to the restriction of resources in our study. It would be better to also include the impairment criteria via diagnostic interviews for the subthreshold group for a more comprehensive diagnosis. On the other hand, this study did not divide ADHD and subthreshold ADHD into subtypes . Deficits in attention network and cognitive control vary across these subtypes, which might have affected the accuracy of the research results . At presThe 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 Human Research Ethics Committee of South China Normal University. Written informed consent to participate in this study was provided by each participant’s legal guardian/next of kin.CC designed the experiments. CC, ZL, and YP collected the data. TW, CC, and ZL analyzed the data. TW, XL, ZL, and CC discussed the results and contributed to the writing of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


P < 0.01). fNIRS management platform can effectively identify ADHD patients with high recognition accuracy. The intelligent management platform can significantly reduce the number of physical examination personnel, prolong the diagnosis and treatment time, reduce a lot of repetitive work, and improve the efficiency of diagnosis and treatment. At the same time, this technology also provides great help for better research and improvement of ADHD patients and provides a reference for the information intelligent construction of modern hospitals.Chronic diseases are gradually becoming the main threat to human health. By designing an efficient hospital management platform to quickly identify the corresponding chronic diseases, it can effectively reduce the labor cost, improve the accuracy of disease identification, and improve treatment efficiency. ADHD is a common behavioral disorder in school-age children, and it is also one of the most common chronic health problems in this period. The internationally recognized prevalence of ADHD is 3%–9%. ADHD often brings adverse effects on children's life and studying and at the same time increases difficulties for their families. Therefore, this paper designs an intelligent management platform for public hospitals based on a deep learning algorithm, evaluates the current situation and influencing factors of ADHD children through the child adaptive behavior scale and the family function assessment scale, and designs its intelligent platform by using a new technology of fNIRS. According to the nonlinearity and unsteadiness of the fNIRS signal, this paper proposes a motion noise removal method based on EMD algorithm methods: to automatically identify children with ADHD and improve the cognitive function of children with ADHD by intervention technology. The data are from the outpatients of the Department of Child Psychology of the First People's Hospital of Tianshui City in Gansu Province in 2018. The results showed that there were significant differences in the adaptive behavior scale (CABS) and fad scores between the two groups. In the seven dimensions of family function, there were significant differences between the two groups ( Childhood ADHD is a typical behavior disorder of school-age children, and it is also one of the most common chronic health problems. They usually show obvious difficulty in concentration, short attention duration, and hyperactivity. It is not age-appropriate. More impulsive adult children will also affect their personal development, cause problems in daily work and life, interpersonal communication, and other aspects, and are more likely to become irritable, insecure, depressed, and even depressed. In addition, children are prone to drug abuse in adulthood, and the risk of antisocial personality disorder and behavior disorder is much higher than that of normal children. The risk of persistent emotional and destructive behavior disorder will also increase. Studying and mastering the image recognition method of ADHD patients based on deep learning has a positive impact on improving the problem behavior of ADHD children.Many children with ADHD perform poorly at school, disobey their parents and teachers, disrupt the classroom, feel tired at school, and disobey because of symptoms. Their classmates will also exclude them, and their interpersonal relationships will be in trouble. It will also bring a lot of trouble and burden to the family. The relationship between parents and children is the most important type of relationship in the family. The disharmony between parents and children can lead to the development of ADHD children's bad behavior. The path can affect children's behavior through direct influence, such as the demonstration effect of parents' behavior, and indirect influence, such as the method of raising children or the interaction between parents and children.J L studied the association of ADHD spectrum disorder symptoms with social function, mental health, quality of life, and sleep in children with and without ADHD. ADHD was assessed through community-based screening and case confirmation using the child IV diagnostic interview schedule. Social interaction questionnaire was used to identify ASD symptoms, but there was no specific data [g believes that traditional research studies on ADHD in children and adolescents mainly focus on the genetic and neurobiological aspects of the disease, but the role of family relationship has not been systematically studied. There is increasing evidence that the quality of parent relationship is correlated with ADHD symptoms in children. However, there is a lack of necessary experimental data [l believes that the parallel phenomenon found in the study of attachment and attention deficit hyperactivity disorder indicates that there is a connection between the two structures. However, several articles on this tie have investigated all children with a possible expression of ADHD but have not found enough evidence to prove the link between ADHD and attachment. This study attempts to gather evidence that there may be a link between two aspects of ADHD in children with inattention. However, in the study of the impact of attachment on the disease, ADHD as a whole construction is not clear. Contrary to previous studies, only considering the types of inattention can completely alleviate this relationship by externalizing behavior problems. It is better to analyze it in the longitudinal study, but it lacks the content of numerical analysis [s said the study assessed possible correlations between behavioral profiles, quality of life and perceptions of social support, and parenting styles adopted by 26 mothers of children and adolescents with ADHD diagnosed by the same neurologist. The pattern characterized by negative behavior is related to the higher frequency of behavior problems and is related to the decrease of caregivers' adaptive function index, but some discussions are not accurate [The incidence rate of ADHD is increasing every year, which not only has a negative impact on children's physical and mental health but also has an overall impact on the overall quality of the nation and the future development of the country, which has brought many adverse effects to families, schools, and society. Green fic data . Gonzaletal data . Weyers analysis . Franke accurate .The innovation of this paper is to master the behavior and family situation of ADHD patients based on the evaluation scale. Using fNIRS, a new technology to establish a hospital intelligent management platform accurately identifies ADHD patients, intervenes ADHD children's families, comprehensively and deeply understands the parent-child relationship problems faced by ADHD children and their families, and explores ways to solve the problems. Through fNIRS technology, we can better master the information of patients, reduce the cost of human resources, and accelerate the construction of hospital automation. It has a positive effect on improving the diagnosis mode of disease.Deep learning is a new direction in the field of machine learning. Its main purpose is to create a processing mechanism similar to the human brain. A neural network simulates the human brain for analysis and data processing  , 6. The n inputs and one output. The formula for calculating source data isx =  is the input data, h =  is the network weight, a is the bias, and f  is the nonlinear activation function [The artificial neural network is composed of a large number of interconnected neurons , 12. Amofunction . The inpfunction , 14. Thex = . hjia represents the weight parameter between the ith neuron of layer a and the jth neuron of layer a + 1. rja represents the results of the activation value of the output of the jth neuron in the network layer a which are as follows:The artificial neural network model is composed of the input layer, hidden layer, and output layer. The early artificial neural network is also called multilayer perceptron, sa is the number of neurons in the hidden layer of layer a as follows.jth neuron in layer a is the same as that in layer a:Because, in neural networks, the initial value of the hidden layer activation is usually used as the output of the next layer, the input value of the activation function of the x = . After that, the forward propagation process of the multilayer feed-forward network is analyzed.Input data is x, y) is determined as follows:h and a are the weight parameters of the network, which is a sample fh,a(x). The original value y obtained from the direct propagation of the network is the actual value corresponding to the sample X, {(x(1), y(1),…, xm), M is the number of samples).The backpropagation algorithm is usually used in the process of training artificial neural networks , 16. TheImage recognition is to recognize and classify the research objects according to their characteristics , 20. ForThe first part is to get the information about the image. The second part is image preprocessing. The preprocessing process includes the use of appropriate technical means to eliminate the noise and distortion of the original image, weaken the irrelevant features, and enhance the recognition system's more concerned function. If there are multiple recognition targets in the original image, it is necessary to use image segmentation technology to segment the original image into multiple images containing only one recognition target. The third part is the removal of objects. In order to ensure the accuracy of recognition, according to the predeveloped extraction principle, the features that have a greater impact on classification and recognition are selected.In fact, it is impossible to understand and analyze all problems only through clear boundaries. Fuzzy theory is introduced here to imitate human thinking. The process of identifying the method can be summarized as follows: calculate the degree of belonging of the sample to a specific category, that is, the degree of belonging to complete the model classification. The method of identifying template fuzzy sets can be simplified to the method of identifying the principle of maximum membership degree and the closest method of identifying the principle according to different principles.f be the domain of the object to be identified, H1H2⌃…Hn is an n-dimensional fuzzy set on f, and f0 ∈ F is an identified object element, if any:Let h, and the expected pattern is also a fuzzy subset contained in universe H. In this case, special treatment is needed: let B and C be two fuzzy sets in the universe H, and H =  is a finite set definition:In practical application, it may be found that the object to be identified is a fuzzy subset contained in universe R is a positive real number. Let m  be the relative Minkowski distance of fuzzy sets B and C. If r = 1, thenP=22, then M  is called relative Euclid distance:If n fuzzy sets on universe h, R  be some closeness degree of fuzzy sets C and B, if there is I such thatLet The etiology and influencing factors of ADHD are mainly divided into three aspects: genetic factors, perinatal status and family, and psychological and social factors.Genetic factors are the key and important factors in the whole etiology. If the parents of children have different degrees of physical defects, chromosome abnormalities, mental disorders, etc., they will affect the children's brain development to varying degrees, resulting in hyperactivity.If the mother of a child has abnormal reactions during pregnancy, premature delivery, or even poor nutrition, it will increase the prevalence of ADHD.Family, psychological, and social factors play a very important role in ADHD. Family is the first environment for children's growth or life. What kind of mentality they have and what kind of interests they have all come from the influence of family.From January 2018 to October 2018, 200 children with ADHD aged 3–12 years were investigated. 178 valid questionnaires were collected, with an effective recovery rate of 89%. In the experimental group, there were 100 cases in total, and 93 cases received the effective questionnaire, with an effective recovery rate of 93%. All the patients were diagnosed by child psychiatrists through outpatient consultation, scale evaluation, behavior observation, nervous system examination, and other auxiliary examinations, and the generalized developmental disorder, mental retardation, and other major mental diseases were excluded. In the control group, 100 children aged 3–12 were selected from other departments in the same period, excluding mental diseases such as ADHD, nervous system diseases, mental retardation, physical diseases, learning difficulties, and emotional disorders. Finally, 85 valid questionnaires were collected, and the effective recovery rate was 85%. The survey plan was reviewed and approved by the ethics committee of the First People's Hospital of Tianshui city. The questionnaire survey of all subjects was carried out with the informed consent of their guardians, and the questionnaire was filled in by their guardians. The age and gender distribution of ADHD in children showed that ADHD was more common in children aged 6–9. Among them, 28 cases were 3–5 years old, accounting for 30.11%; 46 cases were 6–9 years old, accounting for 49.46%; 79 cases were male, accounting for 84.95%; and 14 cases were female, accounting for 15.05%. The results are shown in t-test, as shown in From the score of CABS, the score of the control group was higher than that of ADHD children. The difference in scores of the other six dimensions and 4 factors was statistically significant except for the difference in sensory movement and spatial-temporal trend between the two groups by The family environment is an important environment for children with ADHD to grow up in, and it is also an important factor leading to or aggravating ADHD symptoms. The relationship between family members, interaction, behavior thoughts and attitudes, and cultural literacy has little effect on the employment and growth of ADHD children. Only by establishing a harmonious and equal relationship between parents and children can we optimize the family environment and alleviate the symptoms of ADHD children. On the positive side, try more appropriate ways to raise children and give them more care and support. The scale contains some descriptions of families. Please read each project carefully and base on the last two months. Among the four possible answers, circle the number that best describes your family. For this reason, the survey scores are shown in P < 0.01), and the R value of the complex correlation coefficient was between 0.341 and 0.669. Among them, the self-control factor and adaptive quotient factor are dependent variable models, which are statistically significant with the partial regression coefficient of three dimensions of family function.The independent function factor score, cognitive function factor score, social self-control factor score, and adaptive ability quotient (ADQ) in ADHD children's adaptive behavior scale were taken as the dependent variables, respectively, and the scores of 7 dimensions of the family function scale were 7 independent variables, and four multivariate regression models were constructed. The results are shown in The intelligent management platform is made according to the situation and quantity of children with ADHD. The system should provide the flexibility of operation as much as possible under the guidance of users. Authority management is an important guarantee of system flexibility; a user-friendly interface should fully reflect the people-oriented design concept and create a relaxed and pleasant experience for office users; try to use the simplest working method to realize the most powerful function, so as to provide a convenient system update and expansion according to the development requirements of measurement business. The successful operation of the system ensures a high exchange of measurement data, improves the scalability and maintainability of the system, and facilitates the collection and reading of the required situation and quantity of children with ADHD. fNIRS, as a noninvasive optical brain imaging technology, is very suitable for young children and other groups by virtue of its advantages of high ecological efficiency, portability, and long-time collection. It successfully describes the attenuation of light intensity as the function of the concentration of color cluster, molar extinction coefficient, differential path factor, and light source-detector distance, such asThrough the comprehensive analysis and judgment of the rehabilitation of ADHD children, it is found that, in general, the rehabilitation of ADHD children is based on drug treatment. However, through a lot of practice and experience analysis, it is found that ADHD children are still faced with complex factors in the process of treatment, which are related to medical, social, psychological, ethical, and other aspects. With the continuous improvement of social work mechanisms and working methods, social work is becoming more and more important, more and more attention has been paid to the importance of work, and its role in solving the problems of children with ADHD is also playing an increasingly important role. The in-depth development and comprehensive application of social work children with ADHD are mainly characterized by lack of attention to affairs, low level of understanding of things, and lagging development of language and movement. In graduate school, they left places where they socialized, walked, or fought in class, and they did not have clear goals. In physical education class, these hyperactive children have poor body coordination and awkward posture. According to the questionnaire, the scores of children's ADHD adaptive behavior, such as sensory motor, are shown in It can be seen from ADHD children's family function problems are more common, which will directly affect the formation of harmonious family relationships between parents and children. The relationship between parents and children is not only the earliest social relationship in the process of children's growth but also the most important relationship in the family relationship. Communication is all the communication between parents and children. Through these communication behaviors, all the information such as cognition, attitude, and emotion between parents and children can be transferred to each other. This survey scale contains some descriptions of families. The family function assessment scale is shown in It can be seen from ADHD usually occurs in childhood and often lasts until adolescence or even adulthood. About 5–8% of school-age children suffer from ADHD. These children with ADHD are difficult to control their own behavior or maintain attention, which has a very negative impact on their academic performance and social function. This disease increases the risk of other diseases, even if they are not directly associated with ADHD. Therefore, it is very important to explore an effective biological index for early diagnosis and intervention. In order to recognize ADHD children based on brain activity measured by fNIRS, we applied the hemodynamic response amplitude of the n-back task to the MVPA method. The signals collected by fNIRS do not fully represent brain functional activities and are often polluted by physiological system noise and the head movement-induced motion noise. Before the subsequent statistical analysis, these noises must be regressed. fNIRS is not so sensitive to motion noise, but head movement will still cause disturbance of fNIRS signals, such as sharp wave or baseline drift. A variety of methods have been developed to reduce the impact of motion noise, and then signal processing methods are used to detect and remove the motion noise, as shown in It can be seen from After preprocessing the fNIRS data, we calculated the average hemodynamic response of each channel of each subject under 1-back condition. The average value of each channel was taken as the feature extracted from each subject, based on the multivariable relationship between brain activity and behavior data. The higher the accuracy of the task, the faster the reaction, and the stronger the brain activity in the brain area. There is a correlation between brain activity and behavior data of the two groups under each condition. The error bar represents the 95% confidence interval of the bootstrap ratio. Based on multivariate pattern analysis, ADHD children and healthy control children were distinguished with very high classification accuracy, as shown in In the fNIRS system, the common optical receiver probes include photomultiplier, photodiode, and avalanche photodiode. PMT is very sensitive to light, but it is limited to large volume, is sensitive to the magnetic field, and cannot be exposed to ambient light. PD has a high dynamic range, small volume, fast reaction speed, and no magnetic field sensitivity and can be exposed to ambient light. But because there is no amplifier in PD, it is necessary to design a low noise amplifier circuit to amplify the PD signal. APD has advantages similar to PD. In addition, the hemodynamic response patterns of the brain located in the lateral prefrontal lobe, middle and lower part of the prefrontal lobe, the right posterior prefrontal lobe, and the right temporal lobe have a strong ability to distinguish. The recognition pathway, especially the right lateral frontal lobe, is shown in This paper studies the time spent between ADHD children, parents, and children. It is a key person in early childhood education and development, and the parent-child interaction model also has some impact on the future path of interpersonal interaction, because once the behavior pattern of ADHD children is formed, it is difficult to change. Therefore, it is more important for ADHD children to maintain or promote a good parent-child interaction model. However, the existing research results show that the pressure and interaction between parents and children in ADHD families are not optimistic. Therefore, rapid identification of chronic diseases is of great significance for the intelligent construction of medical institutions and the exploration of a good parent-child interaction model between ADHD children and their parents. In this paper, the behavior and family status of ADHD children were investigated by questionnaire, and the current situation of ADHD children was studied by specific experiments. According to the questionnaire survey, most ADHD children have the above defects in their behavior and family status. I hope to inspire parents of other autistic children and to enhance their understanding of special education professionals, social workers, and children. The public should understand the real situation of family interaction, and ADHD children should provide appropriate support from now on.t-test. The scores of language development, self-care, personal orientation, social responsibility, social self-control factor, labor skills, economic life, independent function, and cognitive function were all less than 0.01. The results showed that there were significant differences in the scores of ADHD children and normal children, and the scores of several dimensions of ADHD children were higher than those of ADHD children. Among them, the adaptive quotient of normal children was 108.06, and the adaptive quotient of children was 92.63, indicating that the adaptive ability of normal children was significantly higher than that of ADHD children. A study on the related factors of ADHD children in 2017 showed that there were significant differences between the ADHD group and control group in seven dimensions: sensory movement, self-care, personal orientation, social responsibility, social self-control factor, independent function factor, and ADQ (P < 0.01). Interestingly, no significant difference in sensorimotor dimension was found between the two groups. This study is aimed at children in Western China. At present, domestic ADHD research is mostly concentrated in the developed areas of Eastern China. The analysis results show that there are differences in influencing factors of ADHD among children in eastern and western China, and differences in geographical culture and family education concepts are the reasons for these differences. Among them, the personal orientation dimension and ADHD showed the strongest negative correlation.The scores of the dimensions of the Adaptive Behavior Scale (CABS) in children with ADHD and normal children were obtained by a two-sample This study first compares the children with ADHD and the normal children with the critical value of the family function by analyzing the scores of two groups of children on the family function scale (FAD). And then we analyze the critical value of the family function score between the children with ADHD and the normal children and evaluate their family function.t-test. The results showed that there were significant differences in all dimensions of family functional health between the two groups except sensory movement and temporal and spatial orientation (P < 0.05). The family functional status of children in the normal group was better than that of children with ADHD, especially in the three dimensions of emotional response, emotional intervention, and behavioral control.The results showed that the scores of six dimensions of family functional health in children with ADHD were higher than the critical value, indicating that family function in children with ADHD was in an unhealthy state in six dimensions of problem-solving, communication, role, emotional response, emotional intervention, and behavior control, while the scores of six dimensions of family functional health in normal children group were not above the critical value, but in a relatively healthy state. Meanwhile, the children with ADHD and normal children scored in each dimension of family function by a two-sample Based on the deep learning algorithm, an intelligent disease recognition algorithm is designed, which has good international adaptability and scientificity . ForeignThe sample size of the study is small, and the sample size of ADHD girls is small. The difference between boys and girls in ADHD children's adaptive behavior is large, and the adverse relationship caused by feedback to the family is also different. The number of samples will be expanded in future research, and the weight of influencing factors between different genders will be more accurately determined.


Introduction: Belatacept is a common immunosuppressive therapy used after kidney transplantation (KT) to avoid calcineurin-inhibitor (CNI) use and its related toxicities. It is unclear whether its use exposes KT recipients (KTx) to a greater risk of infection or a poorer response to vaccines. Areas covered: We reviewed PubMed and the Cochrane database. We then summarized the mechanisms and impacts of belatacept use on the risk of infection, particularly opportunistic, in two settings, i.e., de novo KTx and conversion from CNIs. We also focused on COVID-19 infection risk and response to SARS-CoV-2 vaccination in patients whose maintenance immunosuppression relies on belatacept. Expert opinion: When belatacept is used de novo, or after drug conversion the safety profile regarding the risk of infection remains good. However, there is an increased risk of opportunistic infections, mainly CMV disease and Pneumocystis pneumonia, particularly in those with a low eGFR, in older people, in those receiving steroid-based therapy, or those that have an early conversion from CNI to belatacept . Thus, we recommend, if possible, delaying conversion from CNI to belatacept until at least six months post-transplantation. Optimal timing seems to be eight months post-transplantation. In addition, KTx receiving belatacept respond poorly to SARS-CoV-2 vaccination. For decades, calcineurin inhibitors (CNIs: cyclosporine A [CsA] or tacrolimus) have become the cornerstone of immunosuppressive therapy after kidney transplantation (KTx). However, these drugs are known to be nephrotoxic and can cause acute and/or chronic toxicity on the kidney graft ,2, as weCNIs act on the first signal: thus, inhibition of the second signal is a promising approach. Thus, the more clinically relevant co-stimulation pathway that is targeted after organ transplantation, is the interaction between the clusters of differentiation (CD) CD28 and CD80 B7-1)/86 (B7-2)  months, and the mean time of follow-up after belatacept conversion was 20.1 ± 13 months. Most patients, i.e., 332 (79.3%), were converted to belatacept at >six months post-transplantation. As compared to the initial cohort, our monocentric cohort of 173 patients differed regarding the following criteria: patients were converted to belatacept later after post-KTx , i.e., 92.5% patients were converted after 6-months vs. 61.4% before, p < 0.001. Rate of lymphopenia at conversion was lower . Regarding the immunosuppressive regimen before conversion to belatacept: in our monocentric cohort, less patients received steroids  and CsA , and more patients received tacrolimus . Additionally, mean eGFR at conversion was higher . OIs occurred in 42 (9.3%) patients after converting to belatacept at a mean time of 14 ± 12 months post-conversion. Amongst OI patients, eight (19%) presented with two OI episodes during the follow-up.These results were assessed in a more recent study that merged the cohort of Bertrand et al. . The cumulative incidence of OIs was 6.5 OIs/100 p–y. In multivariate analyses, only an eGFR of <25 mL/min/1.73 m2 at conversion was significantly and independently associated with the development of OIs (hazard ratio (HR) = 4.7 (2.2–10.3); p < 0.001). The HR of steroid use at conversion to predict OIs was 2.1 (0.8–5.2) but did not reach statistical significance (p = 0.121) %, 89.7 %, and 85.7 % among patients treated with a belatacept-based regimen compared to 100.0%, 98.0 %, and 91.7 % among patients treated with a tacrolimus-based regimen. After adjustment for the patients’ characteristics and donor type, the hazard ratio for a poor outcome in CMV high-risk recipients treated with a belatacept-based regimen was 1.63  compared to patients treated with a tacrolimus-based regimen, which was mostly driven by a higher risk of graft loss. The risk of a poor outcome did not differ based on immunosuppression regimen in CMV low-risk patients . Similarly, there were no significant differences in patients’ survival between belatacept-based and tacrolimus-based regimens in both CMV high- and low-risk patients. CMV high-risk patients treated with a belatacept-based regimen were more likely to develop CMV viremia during the first two years posttransplant with a 2-year cumulative incidence of CMV viremia of 50.0 [49.5–50.5]% among the belatacept-based regimen compared to 34.4 [33.7–35.1]% among the tacrolimus-based regimen  compared to patients in the tacrolimus group (1.6%) (p = 0.001). This resulted in a greater use of second-line antiviral drugs in those receiving a belatacept-based regimen (20% of viremic patients) compared to those on a tacrolimus-based regimen (5%) (p < 0.001) , CMV viremia  and BK viremia  did not significantly differ from their counterparts ) than with CNI therapy (three patients [3%]). Infections mostly consisted of mild or moderate skin or oral infections. None were classified as serious or resulted in discontinuation of the study drug . At threGupta et al. reported on 53 patients of which three (5.7%) developed Cryptococcus . In the The two studies by Bertrand et al. focused on OIs. Therefore, there is no information regarding mild to moderate fungal infections. In the first study, nine patients developed Pneumocystis pneumonia and one patient developed Aspergillus fumigatus colitis . In the There is a trend towards more fungal infections in belatacept-treated patients in a conversion setting, but these infections are mostly of mild to moderate severity and have only very rarely necessitated treatment to be stopped. Severe fungal infections are rare, apart from Pneumocystis pneumonia, which we discuss below. To our knowledge, no study has specifically focused on fungal infections associated with belatacept. Published studies have not described the characteristics of the patients that have developed fungal infections (excepted for Pneumocystis).Overall, fungal infections are not a major issue for patients on a belatacept immunosuppressive regimen, excepted for Pneumocystis pneumonia.Belatacept and Pneumocystis Jiroveci Infection could be seen in Pneumocystis pneumonia  = 1.62), 2.85% with CNI/mTORi (HR = 2.45), and 14.7% with belatacept/MPA (HR = 13.1). Five belatacept-treated patients developed tuberculosis, of whom one died [Viana et al. reported on tuberculosis infection after kidney transplantation amongst 11,453 KT procedures within 16 years. Regarding maintenance immunosuppression 52% were receiving CNI/azathioprine (AZA); 34% received CNI/MPA, 7% received CNI/mTORi, and 0.3% belatacept/MPA  in combination with belatacept (Bela/Tacshort), or by a longer course of tacrolimus (up to nine months post-transplantation) combined with belatacept (Bela/Taclong) or tacrolimus/MPA. In that study, eGFR at four years was superior in belatacept-treated subjects compared to those that were receiving tacrolimus/MPA at post-transplantation, i.e., a mean difference of 15 mL/min. In terms of acute cellular-rejection rate, when a three-month course of tacrolimus was combined with belatacept (Bela/Tacshort), the rejection rate was significantly reduced, although not to the same level previously seen with standard tacrolimus-based therapy. Only when the tacrolimus taper was extended to nine months (Bela/Taclong) was rejection controlled to a level comparable to that seen with standard tacrolimus dosing.p = 0.02) This was probably due to the significantly higher rate of rejection and the subsequent administration of antithymocyte globulins with high doses of steroids to treat rejection episodes rather than a result of the initial immunosuppression regimen itself. BKV nephropathy was a rare event with no significant differences across the treatment groups. In addition, there were no differences with regard to serious infections that required hospitalization [In terms of safety, there were no significant differences in the rates of CMV or BKV viremias when comparing belatacept-based CNI-free and tacrolimus-based treatments. However, Adams et al. found a significantly higher rate of detectable CMV viremia in the belatacept-based CNI-free treatment compared to the other treatments, i.e., 27.8% vs. 14.2%  in a specific population of KTx at high immunological risk and with a high medically complex profile . The rationale of this protocol was to combine the benefits of belatacept and reduced CNI exposure to minimize the risk of acute rejection. There were 19 patients; of these, 12 experienced viral (including CMV and EBV reactivation) or bacterial infections (incidence 0.062 episode/month of exposure considering a cumulative exposure time to belatacept of 257 months). Infection episodes were more common in early  versus late-converted KTx. One patient in the later conversion group experienced acute cholangitis secondary to biliary obstruction of the transplanted liver, with severe sepsis leading to graft failure. Hospitalization was needed in only 7/19 patients with significant clinical symptoms, and all recovered after appropriate therapy without belatacept interruption . rminated .The study by Adams et al. shows that the adjunct of low-dose tacrolimus combined with belatacept, given in the first year post-transplantation, was associated with a huge drop in acute-rejection rate without increasing the risk of infection. More importantly, because of the higher rate of acute rejection in the belatacept-CNI free group, there were more cases of CMV-positive DNAemia in this group than in the tacrolimus group .Gallo et al. showed that adding low-dose tacrolimus after a rescue conversion to belatacept in highly medically complex transplant patients was a feasible option and helped prevent acute rejection and improved graft function without substantially increasing infectious complications . Even thBelatacept-treated patients respond poorly to SARS-CoV-2 vaccination. We still recommend three doses of mRNA-based vaccine. Hence, belatacept-treated KTx should maintain enhanced barrier measures. Vaccination of household members could also confer indirect protection to KTx. For those that do not develop anti-SARS-CoV-2 antibodies after three vaccine injections, we recommend casirivimab/imdevimab as prophylaxis, given by monthly injection.Response to vaccination is, in general, a concern for belatacept-treated patients; further studies are thus needed to understand the underlying mechanisms that can explain the poor results observed.Infected SARS-CoV-2 belatacept-treated patients tend to need more hospitalizations, both overall and in ICUs, and mortality is greater compared to CNI-treated patients. Regarding the available data, at present, with the COVID-19 infection, we do not recommend postponing belatacept injections or switching to another immunosuppressive regimen. Instead, we recommend organizing a dedicated infection-control protocol with stringent barrier precautions for patients that require regular outpatient infusions during the COVID-19 pandemic.Although belatacept-based therapy has many clinical benefits, there are concerns regarding its safety in terms of acute cellular rejection and risk of infection. This systematic review suggests that even though there are issues that can affect the safety profile, it is still acceptable with regards to its benefits to avoid declining GFR and reduced graft survival, and/or an increased risk of cardiovascular disease. In addition, the studies that have raised concerns about the safety profile of using belatacept as a rescue treatment have been retrospective and uncontrolled. Hence, at present, the only way to use second-signal blockers in the setting of kidney transplantation is to use belatacept.Pneumocystis pneumonia). The right timing to perform a conversion seems to be eight months post-transplantation.The main risk factors for developing an adverse event are early conversion from CNI to belatacept, a low GFR at conversion, older-recipient age, and steroid use. We recommend converting patients from CNI to belatacept at least six months after transplantation. Indeed, patients converted before six months have a significantly higher risk of developing an opportunistic infection (especially CMV disease and Pneumocystis jiroveci infections for three months in low-to-mild risk patients and for six months in high-risk patients.If patients need to be converted within the first six months after transplantation, we recommend maintaining prophylaxis to prevent CMV and Even though PTLD is still a concern for patients treated with belatacept, there is not an increased risk for PTLD in EBV-seropositive KTx as compared to CNI-treated KTx.Thus, there is a need for prospectively controlled studies that can assess the risk of OIs when belatacept is given to KTx as rescue therapy.


Do not go gentle into that good night,Old age should burn and rave at close of day;Rage, rage against the dying of the light.Though wise men at their end know dark is right,Because their works had forked no lightning theyDo not go gentle into that good night.Good men, the last wave by, crying how brightTheir frail deeds might have danced in a green bay,Rage, rage against the dying of the light.Wild men who caught and sang the sun in flight,And learn, too late, they grieved it on its way,Do not go gentle into that good night.Grave men, near death, who see with blinding sightBlind eyes could blaze like meteors and be gay,Rage, rage against the dying of the light.And you, my father, there on the sad height,Curse, bless, me now with your fierce tears, I pray.Do not go gentle into that good night.Rage, rage against the dying of the light.Dylan ThomasThe Poems of Dylan Thomas, New Directions Publishing 1971.This poem is in the public domain. Dylan Thomas was born in Wales, United Kingdom, in 1914 and died much too young in 1953. He was in New York City on his fourth trip to America. One of the better-known 20th century poets, Thomas is often pigeonholed as a Romantic or Post-Romantic. He didn’t generally mix with those in the Imagist movement (such as William Carlos Williams) or the Beats (such as Alan Ginsburg), many of whom were his contemporaries, but he could be characterized as being in their periphery because of his love of wordplay.Thomas drank to excess and probably enjoyed a drug or two. His life was hard scrabble: he was peripatetic and always short of cash, even as he was becoming a recognized writer and poet. Words and writing were his passion from a young age. In fact, he was drawn to literature through nursery rhymes that he heard as an infant; he came to understand those words even before he could read, which isn’t surprising given that his father was a teacher with an English literature degree from University College, Aberystwyth. But Thomas wasn’t only a poet. He also wrote short stories and film scripts, with many of his works published when he was just a teenager.Conquest of a Germ (1944), dedicated to the researchers and doctors who discovered sulfonamides, which at the time revolutionized treatment of many infectious diseases and preceded penicillin.During World War II, Thomas was able to avoid combat due to a medical condition characterized as an “unreliable” lung. Instead, he wrote several screenplays for the British Broadcasting System while continuing to drink excessively. One film of interest to us healthcare providers is Do Not Go Gentle Into That Good Night is a typical example, capturing you with its images, rhythms, and rhymes. It is best read aloud to savor the wordplay and reveal a deeper meaning. Unlike a sonnet, this writing is a villanelle—a 19-line poem with five stanzas comprised of three lines each and concluding with a quatrain (a four-line phrase). Two rhymes are used repeatedly throughout the poem: “Rage, rage against the dying of the light” and “Do not go gentle into that good night.” Searching for deeper allegory, it helps to know that Thomas’ father was said to be gravely ill when the poem was crafted (1947). The reference to a closing of the day and coming nightfall seems related to the graying pall of a dying father, with an admonition to struggle against a seeming fate.Unlike his screenplays, Thomas’ poems are lyrical mashups with plentiful entertaining wordplay. As we continue to struggle with today’s pandemic and the toll it has taken, Thomas’ poem encourages us to think about the cyclical process of life and death, especially our efforts to staunch premature death while recognizing when dying becomes an unavoidable passage that should be nurtured. Dylan Thomas’ death was not a peaceful one. He raged against a setting sun and the dying of light. Continuing to drink right up to the end, he had been given narcotics in the setting of what might have been pneumonia, sepsis, and an alcohol-induced encephalopathy. Just after turning 39 years old, after a day at a favorite New York pub, he fell into a coma from which he never awoke. His poetry lives on for us to study, reflect on, and enjoy.


Both maternal prepregnancy body mass index (BMI) and gestational weight gain (GWG) influence maternal and pediatric outcomes. We sought to clarify the impact of prepregnancy BMI-specific GWG and its patterns on the risk of low birth weight (LBW) or macrosomia using data from a large nationwide study in Japan.n = 98,052) used data from the Japan Environment and Children’s Study (JECS). The outcome variables in this study were LBW and macrosomia. We stratified the subjects into groups according to prepregnancy BMI.This cohort study (GWG from pre-pregnancy to the first trimester had a small effect on the risk of LBW and macrosomia. From the first to second trimesters, insufficient GWG was associated with the risk of LBW, and from the second trimester to delivery, a GWG of less than 2 kg was associated with the risk of LBW. These associations were commonly observed in all prepregnancy BMI categories. Irrespective of the GWG from pre-pregnancy to the first trimester, GWG from the first to second trimesters affects LBW and/or macrosomia. Irrespective of the GWG from the first to second trimesters, GWG from the second trimester to delivery affects LBW and/or macrosomia. LBW or macrosomia was associated with the prevalence of a sustained low or high BMI percentile until three years of age, respectively.The present large national cohort study indicates that the risk of LBW or macrosomia is associated with GWG in women in Japan; the significance of this risk depends on the GWG patterns. Both maternal prepregnancy body mass index (BMI) and gestational weight gain (GWG) influence maternal and pediatric outcomes. Several studies have reported that increasing prepregnancy body weight (BW) has a linear relationship with birth weight , 2; consAs well as total GWG, GWG across specific time intervals of pregnancy may contribute differently to perinatal outcomes. Weight gain in early pregnancy is reportedly a determinant of infant birth weight and is associated with maternal and neonatal complications , 10; conIn this context, we sought to clarify the impact of prepregnancy BMI-specific GWG and its patterns on the risk of LBW or macrosomia using a large nationwide study in Japan: the Japan Environment and Children’s Study (JECS), which is a nationwide birth cohort study founded by the Ministry of the Environment of Japan. The primary aim of the JECS is to analyze the effect of environmental risk factors on children’s health. This project is being conducted in 15 Regional Centers across Japan . Researchers recruited expectant mothers from these areas between 2011 and 2014, during which approximately 100,000 pregnancies were registered. Additionally, we tracked the infants’ BMI until three years of age to evaluate the relationship between mothers’ GWG and its patterns and their children’s growth.Data from the JECS, a government-funded birth cohort study started in January 2011, were used. This survey investigated the effect of several environmental factors on children’s health . The eliThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Declaration of Helsinki of 1975, as revised in 2008. The JECS protocol was reviewed and approved by the Ministry of the Environment’s Institutional Review Board on Epidemiological Studies and the Ethics Committees of all participating institutions, and the Ethics Committee, University of Yamanashi. Written informed consent was obtained from all participants.The outcome variables in this study were LBW, macrosomia, and moderate and severe hypertensive disorders in pregnancy (HDP). Small for gestational age was defined as a weight below the 10th percentile for the gestational age. LBW has been defined as the first weight recorded within hours of birth of <2500 g. Very LBW is defined as <1500 g and extremely LBW is defined as <1000 g. Macrosomia was defined as ≥4000 g. All data on maternal BW during pregnancy were based on BW at prenatal checkups during the JECS. prepregnancy BMI was self-reported in the questionnaire responses. Maternal BW measured at gestational age 0w0d to 13w6d was considered “BW at first trimester”. All maternal BW measurements from gestational age 14w0d to 27w6d were considered “BW at second trimester”. All maternal BW measurements from gestational age 28w0d until delivery were considered “BW at third trimester”. Weight gain during the total gestational period  and specific intervals are defined in Supplementary Fig. Information on HDP, which was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥ 90 mmHg in this study, was obtained from the Dr0m questionnaire. Since this questionnaire only revealed whether the participant was diagnosed with HDP or not, we analyzed the incidence of HDP without a previous history of hypertension before pregnancy. We also defined severe HDP as systolic blood pressure ≥ 160 mmHg, diastolic blood pressure ≥ 110 mmHg, and/or proteinuria (≥ 2 g/day).2. In some analyses, we stratified the subjects into four groups because of small numbers of outcome events.We calculated prepregnancy BMI from self-reported prepregnancy height and BW, and we stratified the subjects into five groups based on BMI: <18.5, ≥18.5 to <21, ≥21 to <25, ≥25 to <30, and ≥30 kg/mFirst, we performed univariate and multivariate logistic regression analyses on LBW or macrosomia with known basic confounders: when LBW was used as a dependent variable, the independent variables were age, prepregnancy height, and BMI, total GWG, smoking status, gestational week at delivery, birth history, and HDP. When macrosomia was used as a dependent variable, the independent variables were prepregnancy height and BMI, total GWG, gestational week of delivery, and history of macrosomia and diabetes. When HDP was used as a dependent variable, the independent variables were age, prepregnancy height and BMI, total GWG, gestational weeks of delivery, and history of LBW, HDP, diabetes, hypertension, hyperthyroidism, hypothyroidism, systemic lupus erythematosus (SLE), and antiphospholipid antibody syndrome.Next, the associations between the risk of LBW or macrosomia and maternal BW gain were evaluated using a multinomial logistic regression analysis with LBW or macrosomia as the dependent variables. We categorized the independent variable maternal BW gain into six groups during specific time intervals.Furthermore, to assess the associations between the risk of LBW and macrosomia and GWG patterns, we performed a multinomial logistic regression analysis using LBW, macrosomia, or HDP as dependent variables. We used BW gain from prepregnancy to the first trimester and from the first to second trimesters as categorical independent variables.We finally tracked the BMI of children born from the subjects in this study until three years of age. The associations between LBW or macrosomia and the risk of a BMI below the 10th percentile or above the 90th percentile at 1, 1.5, 2, 2.5, and 3 years old were evaluated using a multinomial logistic regression analysis with LBW or macrosomia as dependent variables. The independent variables included the duration of breastfeeding and a parent’s total number of cigarettes smoked per day in the home. Statistical adjustment was performed by conventional confounding factors –16. GrowAll descriptive and statistical analyses were performed using Microsoft Excel 2016  and Easy R . Statistical significance was set at 0.01 or 0.0001, and all statistical tests were two-tailed.n = 15,845) had a BMI < 18.5 kg/m2, 41.1%  had a BMI ≥ 18.5 to <21 kg/m2, 31.9%  had a BMI ≥ 21 to <25 kg/m2, 8.2% (n = 8035) had a BMI ≥ 25 to <30 kg/m2, and 2.5%  had a BMI ≥ 30 kg/m2 .To clarify whether the optimal patterns of maternal BW gain during the gestational period to avoid LBW and macrosomia affects the risk of other maternal adverse events, we assessed the risk of moderate and severe HDP as an example of an adverse maternal event reportedly associated with GWG , 31. In Finally, we analyzed the risk for low (<10th percentile) or high (≥90th percentile) BMI until three years of age in the children born at LBW or macrosomia. Children born at LBW consistently showed a low risk for high BMI values at 1, 1.5, 2, 2.5, and 3 years old, but they had a high risk for low BMI values Fig. . ConversAs observed in western countries including the United States , France 2, which is diagnosed as “obese” by Japanese criteria, insufficient GWG after the second trimester can increase the risk of LBW.The following findings were commonly observed in the present study in all prepregnancy BMI categories: (1) from pre-pregnancy to the first trimester, GWG had a small effect on the risk of LBW or macrosomia, (2) from the first to second trimesters, insufficient GWG was associated with the risk of LBW, and (3) from the second trimester to delivery, a GWG of less than 2 kg was associated with the risk of LBW. Based on our observations, even in subjects with a prepregnancy BMI ≥ 25 kg/m2, which accounted for 10.7% of the total subjects in this study. The IOM guidelines report recommendations for the total GWG and weekly GWG in the second and third trimesters for overweight (BMI ≥ 25 to <30 kg/m2) and obese (BMI ≥ 30 kg/m2) subjects [2 in this study gained 14.1–22.7 kg, which is the recommended total GWG for overweight women, it will result in an increased risk of macrosomia.This study also showed that the GWG pattern significantly affected the risk of LBW and/or macrosomia in women of Japan. Irrespective to GWG from pre-pregnancy to the first trimester, GWG from the first to second trimesters affects LBW and/or macrosomia. Furthermore, irrespective of the GWG from the first to second trimesters, GWG from the second trimester to delivery affects LBW and/or macrosomia. These observations suggest that to minimize the risk of LBW and macrosomia, the appropriate GWG must be determined during multiple intervals of the gestation period. The Japanese Ministry of Health, Labour and Welfare guideline provide two main recommendations for GWG, which are the total GWG and the weekly GWG after 14w0d. However, no specific total GWG and weekly GWG after 14w0d are recommended for subjects with a prepregnancy BMI ≥ 25 kg/msubjects . Howeversubjects . Indeed,A possible mechanism by which GWG patterns are associated with the risk of LBW or macrosomia is epigenetic modifications in nonimprinted genes induced by aspects of the developmental environment ; during In this study, the subjects seem to focus on the total GWG more than the GWG patterns, which may result in insufficient or excessive GWG after the second trimester. However, our observation suggests that in all prepregnancy BMI categories, GWG after the second trimester affects the risk of LBW and/or macrosomia, irrespective of GWG until the second trimester. Thus, if women focus too much on the total GWG, there may be an increased risk of LBW and/or macrosomia for women in Japan.The 3-year follow-up of the children’s BMI suggested that being born at LBW or macrosomia increases the risk of being in the low or high BMI percentiles until 3 years of age, respectively. Importantly, small size at birth per se is well known to be associated with early adiposity rebound, obesity, and metabolic syndrome –49. AlthIn addition to LBW and macrosomia, we assessed the risk of HDP as an adverse event related to both prepregnancy BMI and GWG. Maternal BMI is consistently reported as an independent risk factor for both preeclampsia and gestational hypertension –52. The n = 858) was smaller than the number of LBW (n = 7967) and adequate to gestational age  infants. Therefore, the low number of cases limited the data analysis and ability to draw conclusions. Third, since the present study was a prospective cohort study, it does not demonstrate the effect of an intervention for maternal BW on the outcomes of infants. Fourth, prepregnancy height and BW, smoking history, past history of diseases, and children’s height and BW were self-reported values.This study has some limitations. First, the BW at each trimester was defined as the BW measured at some point within the respective trimester at the JECS checkups. Since the specific timepoint in each trimester was not indicated, the intervals among pre-pregnancy, the first, second, and third trimesters, and delivery varied among individuals (Supplementary Fig. 2, which is diagnosed as obese by the Japanese criteria, insufficient GWG from the second trimester to delivery consistently increases the risk of LBW. The results of this study may serve as a standard for the optimal GWG for women in Japan and possibly for Asian women in general.In conclusion, the present large national cohort study indicates that the risk of LBW or macrosomia is associated with GWG in women in Japan; the significance of this risk depends on the terms of pregnancy and the GWG pattern. The present study also implies that subjects may try to accelerate GWG after the second trimester based on the GWG before the second trimester to attempt to achieve the target total GWG, which consequently affects the risk of LBW and/or macrosomia. In any prepregnancy BMI category including BMI ≥ 25 kg/mSupplementary Information


Background: The symptoms of attention-deficit hyperactivity disorder (ADHD) are known to exacerbate the effect of cognitive-behavioral impairments on emotional burden. Although adults with ADHD frequently experience procrastination and internalizing symptoms such as depression and anxiety, few studies have examined whether the association between procrastination and internalizing symptoms differs by ADHD symptoms.Objective: This study aimed to examine the moderating effect of ADHD symptoms on the association between procrastination and internalizing symptoms.Method: A cross-sectional survey was conducted among 470 adults  using self-reported questionnaires: Adult ADHD Self-Report Scale, General Procrastination Scales, Patient Health Questionnaire-9, and State–Trait Anxiety Inventory.Conclusion: Participants with more substantial ADHD symptoms experienced more procrastination and internalizing symptoms than those with the less substantial ADHD symptoms. Therefore, procrastination constitutes the treatment target for those suffering from ADHD and comorbid internalizing symptoms. Alternatively, there was no enhancing effect of ADHD symptoms on the association between procrastination and internalizing symptoms. It is necessary to examine more precise and valid hypotheses and underlying mechanisms of procrastination in high and low ADHD symptom groups. Attention-deficit hyperactivity disorder (ADHD), which persists in 2.5–5% of adults , is charTo improve internalizing symptoms, it is necessary to approach the associated symptoms of ADHD as well as decreasing the cardinal symptoms . The assProcrastination has two aspects: maladaptive and adaptive. Maladaptive procrastination is defined as “voluntarily delay in an intended course of action despite expecting to be worse off due to the delay” . SeveralProcrastination, which can cause maladaptive problems, frequently appears in ADHD adults’ daily lives . ClinicaThe presence of ADHD tendencies may explain the inconsistent research on the effects of procrastination on psychiatric symptoms. These inconsistent findings show that effects of procrastination differ depending on the presence of ADHD tendencies. For instance, the adaptive aspects of procrastination require executive functional skills such as time management and planning strategies . AdditioTherefore, the current study aimed to investigate the moderating effect of ADHD symptoms on the association between procrastination and internalizing symptoms. Based on the literature regarding ADHD, procrastination, and internalizing symptoms, this study proposed the following three hypotheses: (a) People with ADHD exhibit more procrastination, (b) procrastination is positively correlated with depression and anxiety symptoms, and (c) ADHD symptoms strengthen this correlation.All procedures of this study were approved by the institutional Ethics Review Committee on Research with Human Subjects of the first author’s affiliation (2018-282).r=0.21, r=0.43, r=0.36, r=0.27, r=0.25, which resulted in an estimated sample size of 240. As a reward, respondents received points that could redeem for goods within the system of the survey company.The online questionnaire survey was conducted among participants who had registered on an online survey company in Japan. It was executed during February and March 2019. Before completing the questionnaire, participants read an onscreen explanation about responding without compulsion as an ethical consideration. This study recruited 500 participants who were grouped according to their Adult ADHD Self-Report Scale-v1.1 (ASRS) score. The higher-level ADHD symptoms group (ADHD-H) were those who scored above the cutoff point of the ASRS Part A , while tTo ensure the quality of the online survey, data from 10 of the 500 participants were excluded because their answers showed patterns of straightlining for all scales. Straightlining is defined as giving the same answer for all items in each scale ; it is anever) to 4 (very often) to indicate ADHD symptoms. Responses like “often” and “very often” in all items were regarded as positive ADHD symptomatology. In the case of items 1, 2, and 3, a response of “sometimes” was also considered positive. This study defined ADHD-H as those who showed four or more positive responses for the first six items of the ASRS (Part A), which predicts an adult ADHD diagnosis based on the DSM-IV criteria (α=0.63–0.72) and test–retest reliability (r=0.58–0.77), and the area under the receiver operating characteristics curve (AUC) was 0.90 (Attention-deficit hyperactivity disorder symptom status was assessed using the ASRS . The fircriteria . This scwas 0.90 .extremely uncharacteristic) to 5 (very characteristic). However, the Japanese version of the GPS  according to Self-reported difficulties related to procrastination were determined using the General Procrastination Scale GPS; . The oriS J-GPS;  includesnot at all) to 3 (nearly every day). Higher scores indicate greater severity of depressive symptoms over the past 2weeks. The total score ranges from 0 to 27; scores over 20 indicate clinical severity. Internal consistency of the PHQ-9 has been shown to be high  to 4 . The inventory consists of two subscales (state and trait anxiety) with 20 items each. However, this study used only the trait anxiety items to investigate the frequency anxiety which a person experiences anxiety with the highest stability over time. Higher scores indicate greater severity of anxiety symptoms. The total score ranges from 20 to 80, and the clinical significance level is over 55. The reliability and validity of the Japanese version of the State–Trait Anxiety Inventory were confirmed by α=0.896 in men and α=0.904 in women) and test–retest reliability (r=0.58 in men and r=0.77 in women).The Japanese version of the State–Trait Anxiety Inventory  is scoret tests to examine the first hypothesis. Third, Pearson’s correlation coefficients were calculated between all variables to test the second hypothesis. Finally, two hierarchical multiple regression analyses using depression and anxiety symptoms as outcome variables were conducted to examine the last hypothesis. Four variables  were used as predictors in the first step. In the second step, the interaction variable (ADHD symptom status and procrastination) was added. The interaction term was calculated using ADHD symptom status and the centering procrastination score. It aimed to establish the moderating effect of ASRS Part A on the association between procrastination and symptoms of depression and anxiety. The model fit was assessed using the Akaike information criterion (AIC) and Bayesian information criterion (BIC).All statistical analyses were conducted using IBM SPSS Statistics 26.0 software . The anat test for all variables are presented in t ratio, value of p, and Cohen’s d. The number of participants with clinical-level depression and anxiety in the ADHD-H group was 24 (9.68%) and 90 (36.29%), respectively, and 13 (5.37%) and 43 (17.77%), in the ADHD-L group, respectively.An acceptable level of skewness was observed for all scales, indicating a normal distribution. The descriptive characteristics and Our analyses revealed significant differences between the two groups for all assessments . ParticiHierarchical multiple regression analyses using depressive and anxiety symptoms as outcome variables were conducted using all variables as predictors in the first step and adding the interaction of ADHD symptom status and procrastination as a predictor in the second step. These analyses allowed the examination of whether procrastination predicted internalizing symptom and if this relation is strengthened by ADHD symptom status as a moderator.β=−0.121, B=−1.675, SE=0.651, p=0.010, CI ] and procrastination  had a statistically significant effect on depression after controlling for participants’ sex and age. ADHD symptom status  and procrastination  also had a significant effect on trait anxiety. In contrast, in the second step, the interaction effect of ADHD symptom status and procrastination was not significantly associated with depression  or trait anxiety . This interaction did not improve the prediction of depression  and anxiety symptoms  compared to first step in depression  and anxiety symptoms .The results for depressive symptoms are presented in d (0.83). This result is consistent with a previous study that compared academic procrastination in undergraduate students with or without ADHD symptoms status . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.MO designed and conducted the survey, undertook the statistical analyses, and wrote the draft manuscript. TT, YN, and HK managed the survey and all other issues related to conducting the research. MO, TT, YN, and HK contributed to the critical revision and have approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by grants from the Ibuka fund and JSPS KAKENHI grant Number 202023103.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.