The potential etiological role of early acetaminophen exposure on Autism Spectrum Conditions (ASC) and Attention-Deficit/Hyperactivity Disorder (ADHD) is inconclusive. We aimed to study this association in a collaborative study of six European population-based birth/child cohorts. A total of 73,881 mother–child pairs were included in the study. Prenatal and postnatal (up to 18 months) acetaminophen exposure was assessed through maternal questionnaires or interviews. ASC and ADHD symptoms were assessed at 4–12 years of age using validated instruments. Children were classified as having borderline/clinical symptoms using recommended cutoffs for each instrument. Hospital diagnoses were also available in one cohort. Analyses were adjusted for child and maternal characteristics along with indications for acetaminophen use. Adjusted cohort-specific effect estimates were combined using random-effects meta-analysis. The proportion of children having borderline/clinical symptoms ranged between 0.9 and 12.9% for ASC and between 1.2 and 12.2% for ADHD. Results indicated that children prenatally exposed to acetaminophen were 19% and 21% more likely to subsequently have borderline or clinical ASC  and ADHD symptoms  compared to non-exposed children. Boys and girls showed higher odds for ASC and ADHD symptoms after prenatal exposure, though these associations were slightly stronger among boys. Postnatal exposure to acetaminophen was not associated with ASC or ADHD symptoms. These results replicate previous work and support providing clear information to pregnant women and their partners about potential long-term risks of acetaminophen use.The online version contains supplementary material available at 10.1007/s10654-021-00754-4. Acetaminophen (or paracetamol) is used by 46–56% of pregnant women in developed countries –3. WhilsTwo meta-analyses have investigated the link between prenatal acetaminophen use and ASC and ADHD symptoms , 13. TheFirst, it is unclear whether girls or boys are differentially affected by acetaminophen exposure. A recent study examining biomarkers of prenatal acetaminophen exposure among 996 mother–child pairs observed higher odds for ASC among boys and higher odds for ADHD among girls.  This is In the current study, we aim to examine the association between early acetaminophen exposure and ADHD and ASC symptoms and hospital diagnosis. Furthermore, we also examined postnatal exposure and we present sex-stratified results. To reduce heterogeneity, we used a common set of confounders, the same statistical approach and harmonized the exposure and outcomes measurements across cohorts.We included six European population-based birth cohorts: Avon Longitudinal Study of Parents and Children (ALSPAC), DNBC, Gene and Environment: Prospective Study on Infancy in Italy (GASPII), the Generation R Study, INMA (including four subcohorts), and the Mother–Child Cohort in Crete (RHEA) (Methods S1). Mother–child pairs were recruited from 1991 through 2008. A total of 73,881 children with available data on either prenatal or postnatal exposure to acetaminophen and at least one outcome (ASC or ADHD symptoms) and main covariates were included (60.5% of the children recruited at baseline).Informed consent was obtained from all participants in each cohort and ethical approval was obtained from the local authorized institutional review boards.Regarding prenatal acetaminophen exposure, mothers were interviewed two , three (GASPII) or four (DNBC) times during pregnancy using standardized questionnaires. At each interview, mothers were asked if they had taken medications from the month before becoming pregnant  or beginning of pregnancy (RHEA) through delivery. In ALSPAC and the Generation R Study, mothers completed questionnaires two (ALSPAC) or three (the Generation R Study) times during pregnancy reporting acetaminophen use from the month before becoming pregnant to gestational week 32 of pregnancy. In GASPII, mothers were interviewed at birth and provided retrospective information on acetaminophen use at each trimester. Mothers were classified as ever exposed if they reported having taken any dose of acetaminophen in the defined prenatal exposure period; otherwise they were classified as non-exposed  or completed questionnaires (INMA) about medication use in their children one (RHEA) or two times  in the first 18 months of life of the child. At each interview, mothers were asked if they had given any medication including acetaminophen, to their child. Children were classified as postnatally exposed to acetaminophen if they had taken any dose of acetaminophen at any time up to 18 months of life. Otherwise, they were considered non-exposed   (ALSPAC)In addition to the SDQ-Hyperactivity/Inattention subscale, in the DNBC cohort, diagnoses of ASC and ADHD from national hospital register were also available .25 The ADHD index of the CSRS-R:S has a cut-off for elevated T-scores (65–69) that we used to classify children as presenting borderline/clinical symptoms (T-scores > 65) [To harmonize the continuous scores on ASC and ADHD symptoms, we used questionnaire-specific validated cut-offs to yield proxies for ASC and ADHD symptoms within the borderline/clinical range. Specifically, for the DSM-ADHD Questionnaire scores, we applied established cut-offs consisting of 6 or more symptoms of inattention or hyperactivity to yield proxies for borderline/clinical ADHD symptoms . For CBCes > 65) . The DAWes > 65) . In the es > 65) . Finallyes > 65) . FurtherPotential confounding variables were selected a priori prioritizing availability and consistency. Covariates were factors previously associated with ASC, ADHD and acetaminophen exposure, and include maternal and child characteristics. Maternal characteristics included age at delivery (years), education , pre-pregnancy body-mass index (BMI), alcohol (yes/no), smoking (yes/no) and mental health problems (yes/no) during pregnancy, age at birth (years) and parity , maternal fever (yes/no) and infections (yes/no) during pregnancy. Maternal education was not provided by the DNBC and analyses were adjusted by maternal socio-occupational status based on job titles instead. Child characteristics included sex, age at behavioural assessment (years), cold (yes/no) and respiratory infections (yes/no) in the first 2 years of life. Maternal characteristics were collected during pregnancy except for mental health in INMA, which was collected when children were around 5 years. Child characteristics were collected in the first 18 months of life. Two cohorts adjusted their analysis for cohort-specific covariates. Specifically, analysis in Generation R Study were also adjusted by ethnicity  and analysis in INMA were also adjusted by subcohort .All analyses were performed following the same protocol. We used logistic regression models to assess the association between prenatal and postnatal acetaminophen exposure and ASC or ADHD symptoms (as binary outcomes) within the borderline/clinical range. Separate models were conducted for prenatal and postnatal exposure, and for ASC and ADHD symptoms. Main models were adjusted for the abovementioned covariates and stratified by child sex.Q test and the I2 statistic.Cohort-specific analyses were undertaken at each study centre and pooled using random-effects meta-analysis. Random effects models, which account for unexplained heterogeneity, assume that the effect size varies across the studies because of real differences in the exposure effect and sampling variability . BetweenSince the cohorts included herein differ in the length of follow-up, we performed meta-regression including mean age of the child at outcome assessment as moderator. These analyses allow us to examine potential changes in the association between acetaminophen exposure and ASC and ADHD symptoms over time.Sensitivity analyses included: (a) testing the associations with hospital diagnosis of ASC and ADHD available in the DNBC cohort, (b) testing the associations with ASC symptoms excluding ADHD cases, (c) meta-analyses leaving out one cohort at a time to determine the influence of each cohort, and (d) additional adjustment for gestational age, birthweight (grams), maternal chronic diseases -except psychiatric diseases- (yes/no), maternal use of other drugs (yes/no) and maternal folic acid use (yes/no).https://www.r-project.org/). Logistic regression models to estimate odds ratio (OR) and 95% confidence interval (CI) were fitted using finalfit package . Meta-analyses were conducted using metafor package [Analyses were performed using R 3.5.1  and 1,393 (2%), respectively . Children with ADHD symptoms within the borderline/clinical range were also more likely to be males and have a higher proportion of nulliparous mothers, who smoked during pregnancy and experienced mental health problems during pregnancy compared to children not in the borderline/clinical range (Table S3).Children prenatally exposed to acetaminophen were overall more likely to have older and non-nulliparous mothers with higher education levels and higher pre-pregnancy BMI who report alcohol consumption, smoking and mental health problems during pregnancy (Table S4). Children postnatally exposed to acetaminophen were more likely to have nulliparous mothers, who have higher education levels and report alcohol consumptions during pregnancy (Table S5).Pinteraction = 0.188). When using hospital diagnosis in DNBC, a similar effect size was observed in boys  and girls  (Table S6). Excluding ADHD cases, prenatal acetaminophen exposure was associated with ASC symptoms based on questionnaires in all cohorts  (Table S7). Additional adjustment for other confounders did not change the results meaningfully (Table S8). In leave-one-out analyses results, the association was attenuated but remained positive when omitting DNBC .Children prenatally exposed to acetaminophen were 19% more likely to subsequently have ASC symptoms within the borderline/clinical range than non-exposed children  Fig. , though I2 = 68.37%) (Table S6).Substantial between-study heterogeneity was only observed when examining this association among girls using hospital diagnosis in DNBC .Meta-regression analyses showed that children’s age at outcome assessment did not modified the association between prenatal exposure to acetaminophen and ASC symptoms (Pinteraction = 0.747)  .Meta-regression analyses showed that children’s age at outcome assessment did not modified the association between prenatal exposure to acetaminophen and ADHD symptoms (I2 = 48.4)  .Meta-regression analyses showed that children’s age at outcome assessment did not modified the association between postnatal exposure to acetaminophen and ASC symptoms  .Meta-regression analyses showed that children’s age at outcome assessment did not modified the association between postnatal exposure to acetaminophen and ADHD symptoms  levels, oxidative stress due to inflammation-induced immune activation, changes in neurotransmission and endocrine-disruptive properties of acetaminophen , 35. AceThe abovementioned findings provide biological plausibility and coherence for the current findings. In this regard, other causal criteria supported by the current findings include consistency and temporality . ConsistOur findings need to be interpreted with caution given the limitations of our study. First, ASC and ADHD symptoms were assessed by different instruments in the cohorts. All instruments have been validated for the assessment of these symptoms, but the coverage may slightly differ among the instruments. To overcome this heterogeneity, we used instrument specific cut-offs to evaluate the presence or absence of borderline/clinical symptoms, a strategy that other meta-analysis analysing these outcomes have used , 44. AltOverall, despite the above limitations, the homogeneity of the findings among the different cohorts, the novel assessment of postnatal acetaminophen exposure, and the use of an harmonized definition of exposure and outcome as well as of common statistical approaches overcomes the criticisms of previous meta-analysis , 15.To conclude, our results support previous findings and address part of the weaknesses of previous meta-analyses. Considering all evidences on acetaminophen use and neurodevelopment, we agree with previous recommendations indicating that while acetaminophen should not be suppressed in pregnant women or children, it should be used only when necessary .Supplementary file1 (DOCX 147 kb)Below is the link to the electronic supplementary material.


Importantly, the prevalence of vaccine-related adverse events was also assessed as being higher after the lecture . The increase in self-declared knowledge on vaccinations and perceived need for vaccinations  was lower among participants who rated the lecture less vs. more useful. Importantly, both participants who liked vs. did not like the lecture comparably rated vaccines safer after vs. before the lecture : 16% (0–39%) vs. 18% (2–42%), p = 0.39). Conclusions: An educational lecture on vaccinations positively impacts vaccine confidence in young adult women. Irrespective of the subjective rating of the lecture, all listeners perceived vaccinations to be safer after vs. before the speech.Background: We investigated the impact of a single unstructured educational lecture about vaccinations on the vaccine confidence in volunteer participants. Methods: We conducted a survey-based study during a series of open meetings related to pregnancy and parenting. Before and after the pediatrician’s lecture related to vaccinations, listeners completed the visual analogue scales , evaluating (1) self-declared knowledge on vaccinations and (2) how they perceive the safety and efficacy of this preventive method. Results: In total, 484 women aged 30 ± 4 years participated in the lecture . Participants declared to have more comprehensive knowledge on preventive vaccinations and perceived vaccines to be safer and more useful (the role for the immunity) after vs. before the lecture (median VAS: 10.4 vs. 7.2, 10.8 vs. 8.7, and 11.0 vs. 10.4 cm, all  Despite evidence-based diverse medical and socioeconomic benefits of contemporary vaccination schemes (for both particular persons and the whole populations) , there aIn the current study, we aimed to assess the impact of a single unstructured educational lecture on vaccinations (performed by a pediatrician) on comprehensive opinions regarding this immunization method in volunteer lecture listeners. We hypothesized that the participation in such lectures may positively influence vaccine confidence in the listeners.We conducted a survey-based study during a series of open meetings (Academy: Mother Asks), arranged and conducted for educational and advertising purposes by a commercial company Academy Mother Asks from Poznan, Poland (meeting organizer was not an academic institution) in 11 large Polish cities in 2014. The aim of each educational meeting was to familiarize the volunteers with different topics related to pregnancy, childbirth, and parenting, which were covered by professional educational lectures. Meetings were free of charge for volunteer listeners but included advertising and promotion of commercial services and goods. During each meeting, one educational lecture was related to vaccinations and was performed by a specialist pediatrician with long-term experience in vaccinology. The pediatrician–lecturer received the honorarium for the lecture paid by the organizers. Particular vaccine formulations were not advertised during the meeting.1Participant knowledge on vaccinations (lack of knowledge versus comprehensive knowledge);2Participant opinion on the need for vaccinations ;3Safety of vaccinations (low vs. high);4Incidence of adverse events after vaccinations (rare vs. frequent);5The role of vaccinations for the immunity of a child (non-significant vs. significant);6The role of the disease per se for the immunity of a child (non-significant vs. significant).For the current study, we developed an original Polish-language survey to evaluate the knowledge on vaccinations and the attitudes towards this preventive method before and after the educational lecture. The meeting organizer approved the use of the survey mentioned above for non-commercial scientific purposes and was neither involved in preparing the survey, nor influenced its final content. The survey was completely anonymously  and comprised two parts: the first part included questions about gender, age, place of living, and children; in the second part of the questionnaire, study participants were asked to use 0–15 cm visual analogue scales (VAS) to answer six questions regarding the following topics:English translation of the survey is presented in After the lecture, participants were asked to complete the same questionnaire as before . The additional VAS referred to the subjective rating of the lecture (useless vs. very useful—“how do you assess the usefulness of the issues presented in the lecture”).This study was approved by the Bioethics Committee of Wroclaw Medical University, Wroclaw, Poland.Based on the character of particular questions, the VAS scale results (0–15 cm) showed either normal  or obviously skewed distributions , and are presented as medians with lower and upper quartiles . Hence, for further statistical analyses, we used non-parametric tests. The inter-group differences were tested using the Mann–Whitney U-test for unpaired samples. The VAS results after vs. before the lecture were tested using the signs test. To compare changes in opinion regarding particular aspects of vaccinations in subjects who subjectively rated the lecture better vs. worse, we calculated coefficients delta VAS for particular questions from the survey ). Categorized variables are expressed as numbers and proportions (%) and the inter-group differences were tested using the Chi-square test.Statistical analyses were performed using STATISTICA 13.3 data analysis software .There were only a few male participants in the lecture, therefore we did not include them in further statistical analyses, as the potential analysis of gender-related differences would be unreliable due to significant disproportion between women and men. Finally, 484 women participated in the lecture from January to May 2014, who were included in the statistical analyses presented below. They were aged 30 ± 4 years (median: 29) and the majority had a high education level (88%). As many as 81% of female participants declared active employment and over 90% were city residents. The majority of women (68%) were pregnant at the time of the lecture, while 56% had one or more children. Only 9 (2%) women analyzed in this study were neither pregnant nor had children. Baseline vaccine confidence ) according to socioeconomic data are presented in Lecture listeners declared more comprehensive knowledge on and the need for vaccinations after vs. before the lecture . Moreovep = 0.6). Lecture participants who rated the lecture lower  had lower baseline knowledge on vaccinations (7.1 (4.5–8.5) vs. 7.5 (4.9–9.7) cm, p = 0.03) and perceived this method to be less safe (7.6 (6.2–10.1) vs. 9.8 (7.7–11.6) cm, p < 0.001), less useful  vs. 12.0 (10.3–14.0) cm, p < 0.001), and less efficient  vs. 11.0 (9.7–12.3) cm, p < 0.001). Importantly, lecture listeners who finally evaluated the lecture less useful declared at baseline (before the lecture) that vaccinations are related to lower incidence of adverse reactions as compared with subjects who liked the lecture and assessed it as more useful (7.7 (6.8–10.0) vs. 8.9 (7.3–11.0) cm, p < 0.001).The median evaluation (rating) of the lecture  was 12.2 cm. The 2 groups  did not differ regarding age  vs. 5% (0–20%), p = 0.02; respectively). Importantly, the change in opinion on the safety of vaccinations was comparable in subjects who liked vs. did not like the lecture  vs. 18% (2–42%), p = 0.39). The difference regarding the change in awareness of adverse reactions to vaccines  was of borderline statistical significance (delta VAS: 4% (−5–27%) vs. 9% (−3–36%), p = 0.06).The changes in self-declared knowledge on and the need for vaccinations , expressed as % of baseline VAS (before the lecture)) were significantly lower among participants who perceived the lecture as less vs. more useful (delta VAS: 27% (6–77%) vs. 43% (19–118%), There were two major findings arising from our survey-based study. Firstly, we demonstrated that a single unstructured educational lecture positively impacts vaccine confidence in young adult women (mostly pregnant or with children). Secondly, irrespective of the subjective rating of the lecture, both listeners who rated the lecture higher vs. lower perceived vaccinations as safer after vs. before the lecture.In 2019, the World Health Organization considered vaccine hesitancy as one of the major threats to global health . AlthougDifferent factors influencing the vaccine confidence in particular persons and the whole populations or communities have been the subject of research interest in recent years, including societal, economic, and psychological determinants. ,9,15. ItImportantly, the accumulated evidence demonstrates that for parents the direct contact with a physician (pediatrician) who reliably informs about vaccinations plays a key role in improving comprehensive knowledge on vaccinations and overall vaccine confidence ,22,23,24Our study contributes to previous observations that education is the key determinant of vaccine confidence. We have demonstrated that a simple, single educational intervention (open lecture) positively affects the perception of the safety of vaccinations and their role for public health in young adult women. Such interventions may further decrease the number of vaccine-hesitant individuals ,28,30,31However, attention is drawn to the fact that often a lack of time, overload with work and duties, and a lack of specific training  have negative impacts on HCPs, who are not able to adequately answer all of the parents’ questions or address particular doubts and fears, especially in the face of rapidly changing medical recommendations, as well as with diverse new preparations appearing on the market  . This isa priori and there were probably differences in the time periods devoted to specific topics during each presentation. Secondly, we measured the changes in opinion on vaccination directly after the lecture, and no follow-up was available to assess the long-term effectiveness of such educational interventions. Finally, most women participating in the study were pregnant, and their opinions on preventive vaccinations may vary from the general population.Certain limitations of this study need to be acknowledged. Firstly, the lecture was not structured In a survey-based study, we have demonstrated that a single unstructured educational lecture on vaccinations positively impacts the opinions on this preventive method in young adult women, most of whom were pregnant or had children. Importantly, irrespective of the subjective rating of the lecture, both listeners who rated the lecture higher vs. lower perceived vaccinations as safer after vs. before the lecture. Further studies evaluating individual and social benefits of such educational actions or events (including follow-up) are warranted to precisely evaluate the cost-effectiveness.


Children in foster care have a high prevalence of attention deficit and hyperactivity disorder (ADHD) diagnosis, together with other difficulties in inattentive/hyperactive behaviors, executive and cognitive processes. Early exposure to adversity is a risk factor for developing ADHD via neurodevelopmental pathways. The goal of this research is (a) to study the cognitive and executive performance and inattentive/hyperactive behavior of ADHD-diagnosed children living in foster families in Spain, and (b) to analyze the role of placement variables in their performance. The sample was composed of 102 ADHD-diagnosed children aged 6- to 12-years-old, divided into two groups: 59 children living with non-relative foster families and 43 children not involved with protection services. Children’s executive function–inhibition, working memory, flexibility, attention, intellectual capacity, verbal comprehension, perceptive reasoning, working memory and processing speed were assessed using objective testing measures. At the same time, parents and teachers reported on children’s inattentive, hyperactive and impulsive behaviors. Children in foster care obtained lower scores in the general ability index than the control group after controlling the age at assessment. However, no differences were found in executive processes. Regarding placement factors, children with shorter exposure to adversities in their birth families and more time in foster care showed better executive performance. Professionals should consider the placement history of children in foster care and its influence on their symptomatology and cognitive capacities. Many children in the world are unable to live with their biological family due to various factors, including inadequate parenting style, neglect, and abuse . In SpaiChildren in foster care are exposed to experiences of early adversity, including deprivation of certain experiences needed for normal development and exposure to threatening practices . While iHence, children in foster care are more likely to show symptoms related to ADHD such as impulsivity, overactivity and inattention difficulties ,15,16,17Both inherited, and non-inherited factors contribute to developing ADHD. In addition to some gene variants, low birth weight/prematurity and pre and postnatal exposure to negative influences, including sometimes early exposure to extreme adversity, are considered risk factors for developing ADHD. However, it has not yet been found that any of them can cause ADHD on their own . On one In addition to a higher prevalence of ADHD, children in foster care frequently show difficulties in other aspects of executive function (EF from now on). Research findings, however, are not always homogeneous. Preschool children in foster care performed worse in cognitive flexibility assessed with neuropsychological tasks . OppositPrevious research also has found difficulties in general cognitive function in foster care children ,29,30. CAnother influential factor on the ill development and subsequent recovery of children in foster care is the timing of the adversity. The age when adverse experiences occur can affect brain development, especially in regions with a more protracted trajectory that is more vulnerable to stress exposure . TherefoIn conclusion, higher rates of ADHD symptoms and diagnosis prevalence are common in children in foster care, a neurodevelopmental disorder related to well-known patterns of executive and intellectual impairment. Children in foster care are more likely to have experienced adversities that contribute to developing behavioral and attention regulation difficulties that may exacerbate or mimic ADHD-like symptoms -including post-traumatic stress disorder, language and learning problems, reactive attachment disorder, and mood and anxiety disorders ,38. The The specific goals of this study were (1) to analyze the ADHD symptomatology, EF performance and cognitive profile differences between foster care and a control group of children ADHD-diagnosed in Spain; and (2) to study the relation between the placement history and ADHD symptomatology, EF performance and cognitive profile in the group of children in foster care. Due to the exposure to early experiences of adversity, the accumulation of risk factors and the consequent alterations of the neural substrate, we expect that (1) compared with a control ADHD group, the ADHD-diagnosed foster group will show higher ADHD symptomatology—inattention, hyperactivity and impulsivity, a slight affectation of intellectual performance, and more global impairment in EF—especially in attention and inhibition. We predict that (2) a shorter stay in residential care, earlier age at placement and a longer time in the foster care family will be related to lower ADHD symptomatology, as well as better EF and intellectual performance.M = 8.29, SD = 1.92). Of these, 59 children  were in non-relative foster families, and 43 children  were growing up with their biological families with no relation to child protection services. For the entire sample, 41 children (40.2%) met the criteria for ADHD, predominantly inattentive (ADHD-I), and 61 children (59.8%) met the criteria for ADHD-combined (ADHD-C). Given the scarce number of participants of the original clinical sample diagnosed with predominantly hyperactive/impulsive ADHD (ADHD-H), together with doubts about the temporal validity of the ADHD nominal subtype [Participants were 102 Spanish children  diagnosed with ADHD, aged between 6 and 12 years old  when they entered into residential care, where they stayed an average of 15.5 months (SD = 13.8). Children were placed into foster families at an average age of 6.49 years (SD = 2.00) and, at the time of the study, had been placed for an average of 22.2 months (SD = 10.7). The entire sample of the foster group experienced some type of abuse and/or neglect–according to the information obtained in the children’s files– when they were living with their biological families, although these variables were not included in further analysis.Children in foster care had lived with their biological families until they were an average age of 5.2 years (The foster families were contacted through the program for non-relative foster families of Alacant (Spain). The control group was recruited using a simple random sampling in six public schools of the province of Alacant, assigned to the Children and Youth Mental Health Unit of the General University Hospital of Alacant. One inclusion criterion for the control group was that they lived with their biological family without previous contact with social services. There were several inclusion criteria for both groups: (i) to be aged 6 to 12 years old; (ii) have a prior diagnosis of ADHD by the public mental health system; (iii) have more than six symptoms in the ADHD rating scale-IV  in both M = 5.5, SD = 2). ENFEN has been validated and scored for Spain’s child population. However, the official manual does not report reliability and validity data. Each task is independent of the other—they load in different factors, so removing one task has little effect on the others. In Maldonado [The battery of neuropsychological assessment for executive function in children (ENFEN) is a Spanish battery of tests designed to assess EF performance from 6 to 12 years . It inclaldonado , CronbacFluency task is an indirect measurement of working memory. The child has one minute to produce as many words as possible from both phonemic and semantic categories;Trail Making test assesses flexibility, inhibition, working memory and executive attention. In the gray trial, the child had to draw a line linking numbers from 20 to 1, which appeared randomly on a sheet of paper assessing working memory and executive attention. In the color version, the child must link numbers from 1 to 21, but he/she must switch between yellow and pink colors assessing to larger extent flexibility and inhibition;An inhibition task derived from the Stroop test assesses cognitive inhibition. A paper sheet shows three columns with 13 words in each. The words are color names printed with random color inks, but the color name and the color ink never match. The child must say the color ink of each word.M = 10, SD = 3) that contribute to the computation of a full-scale intelligence quotient, as well as four-factor index scores : verbal comprehension, perceptive reasoning, working memory, and processing speed. Lastly, the general ability index (GAI) and cognitive processing index (CPI) were calculated. The GAI is based on verbal comprehension and perceptive reasoning indices, and the CPI summarizes performance on the working memory and processing speed indices. Administration time was approximately two hours, following the same order for applying the 10 subtests, and raw scores were converted into age-corrected standardized scores.The Wechsler Intelligence Scale for Children Fourth Edition (WISC-IV)  was usedThe ADHD rating scale-IV  is an 18Furthermore, the medical team of the Child and Youth Mental Health Unit carried out semi-structured interviews with the families to test whether the children met the DSM-IV criteria for ADHD . When thThe Foster Care Intervention Program in the Province of Alacant (Spain) implements and supervises psychological intervention with foster families. This service contacted the families that met the inclusion criteria stipulated in the study, achieving the participation of all contacted families. Each family signed their consent and commitment to collaborate in training and research processes to improve the foster care resource. Families did not receive any compensation for participating in this study. The evaluation process of each child was carried out by the same psychologist during three sessions: file study, psychometric evaluation and family interview. Once the Directorate General for Equality and Inclusive Policies and the participating families gave their authorization, the information from the file of the minors was extracted. The retrieved information included: date of birth, date and reason for the declaration of protection order, start date and duration of residential care, start date and duration of family foster care. The foster families and the children were called to the intervention team’s premises, where the psychological evaluation of the children was carried out in a session of approximately two hours. The family interview took place in the family home in the course of one of the follow-up visits.This research was conducted following the ethical principles included in the Declaration of Helsinki in its current form. The approval of the study and its methodology was granted by the institutional review board, the ethics committee of the University of Alacant and Directorate-General of Equality and Inclusive Policies, the agency responsible for the minors in the foster care program. Both foster parents and biological parents from the control group signed a written consent form, approved by the Ethics Committee of the University of Alacant (file number UA-2018-03-08). d for parametric analyses and rank-biserial correlation for nonparametric analyses. A value of Cohen’s d of d = 0.2, d = 0.5 and d = 0.8 correspond to small, medium and large effects, respectively [r = 0.10 is considered a small effect, r = 0.30 a medium effect, and r = 0.50 a large effect [Three different analyses were conducted. The first analysis aimed to contrast the average scores in ADHD symptomatology and intellectual and executive performance for foster care and control groups. Effect size analyses were also conducted, specifically Cohen’s ectively . The sece effect . Furtherps < 0.05). Therefore, nonparametric tests were conducted in those cases.Before conducting the analysis, data distribution was explored. The variables related to ADHD symptoms, ENFEN indexes and age, were all non-normally distributed  nor gender . Likewise, no differences between groups were found in most of the variables , and “general ability index” . In both cases, effect sizes were small to medium. As expected, “hyperactivity/impulsivity symptoms” variable was negatively correlated with “age” . Furthermore, “age” was also correlated with the trail-making subtests  “color trail”  and “gray trail” . Hence, ANCOVAs with “age” as a covariate and Kruskal–Wallis tests were conducted to determine between group differences on these variables controlling for age . ANCOVA revealed significant effects of “group” on “general ability index” after controlling for age, F = 4.486, p = 0.037, η2 = 0.043 . No more differences were found for the rest of the variables.There were no differences between groups neither by age . The only exception was a significant positive relationship between “verbal comprehension index” and “ADHD hyperactivity/impulsivity symptoms” . No more correlations were significant.The possible relationship between ADHD symptoms and EF performance was explored. First, correlational analyses  were conducted with the total sample; then, the analyses were re-run by groups. Similarly, the possible relationship between ADHD symptoms and cognitive profile was also explored. For the total sample, no relationships between ADHD symptoms and EF performance were found  for the foster group, but not for the control group (ps > 0.05). No more correlations were found between ADHD symptoms and EF performance. Regarding the cognitive profile, a significant correlation was found between “ADHD hyperactivity/impulsivity symptoms” (family form) and “processing speed index”  for the foster group, but not for the control group (ps > 0.05). No more correlations were significant.Results by groups were slightly different. “ADHD hyperactivity/impulsivity symptoms” were significantly correlated with “phonemic fluency”  and the trail-making subtests , “gray trail”, and “color trail” . MoreoveF = 0.517, p = 0.763, R2 = 0.05; for ADHD symptoms family form, F = 0.439, p = 0.819, R2 = 0.04). No one of the other models conducted was significant. In other words, placement history variables or ADHD symptoms predicted neither EF performance nor cognitive profile (controlling for children’s age).To conduct the multiple regression analyses, the Z-scores for non-normally distributed variables were calculated. EF and cognitive scores were the dependent variables; ADHD symptoms and placement history were included as the independent variables . The first analysis was a multiple linear regression to predict “verbal comprehension index” based on ADHD symptoms and placement history. The regression equations were not significant . Some pFurthermore, in relation to EF performance, both groups showed low scores in some EF tasks color trail , phonemic fluency (working memory), and Interference (inhibition), but average scores in others semantic fluency (working memory) and gray trail  compared to community controls . A similOur second analysis was focused on the relation between inattentive/hyperactive symptoms, EF performance and cognitive profile. In the foster group, only higher hyperactivity/impulsivity symptoms were related to better phonemic fluency and processing speed. A possible explanation could be that those children in foster care perceived as more hyperactive and impulsive could have a higher processing speed and also perform better in certain tasks, such as phonemic fluency, that push the child to think quickly and to elaborate as many responses as possible. The low number of correlations is consistent with previous research that did not find a relationship between neuropsychological measures of EF and ADHD symptoms , nor betThe second goal was to study the relationship between placement variables and ADHD symptoms, EF performance and cognitive profile. Contrary to previous research that has reported weak relations between early placement variables and executive and intellectual capacity in children in foster care ,28,37 buThis study had a number of limitations. The sample size was small from a statistical point of view. Still, it is similar to previous studies with this type of specific population that is difficult to access. The local sampling of the foster group may limit the generalization of the findings. Still, the group characteristics were similar to the Spanish population of children in foster care regarding age, but not gender , and alsFuture lines of research would include a more global approach to other areas of development, such as emotional development and attachment variables, mental health and school achievement. Other developmental stages, such as adolescence, where the executive and cognitive capacities continue to develop academic and social demands, have increased complexity. Another future line of research would be to add a sample of children in foster care with behaviors mimicking symptoms associated with ADHD but without a diagnosis of ADHD. This could help to disentangle the similarities and differences between primary ADHD and ADHD-like symptoms derived from emotional problems or from the experience of traumatic situations . It woulThe practice implications of this study involve different groups. On one hand, foster parents and professionals must be aware that these children are more likely to present inattention, hyperactivity and impulsive behaviors, which may be a consequence of an alteration of the neurodevelopment associated with the child’s history. Regarding clinical assessment, ADHD diagnostic guidelines should reflect these particular characteristics of children in foster care, recommending that the higher prevalence of ADHD in this group be considered. Furthermore, following the indications of the DSM-V, a differential diagnosis should be performed to rule out that the symptoms are not better explained by other reasons unrelated to ADHD. Although the difficulties shown by these ADHD-diagnosed children in foster care were not predicted by their placement trajectories, the younger entry and longer exposure to a stable and nurturing family were related to better executive performance, pointing to the beneficial effects of protection policies based on out-of-home family care.


Patients with strabismus had more comorbidities than those without (p < 0.05). In summary, this large-scale study found a higher cumulative incidence of ADHD in patients with strabismus, especially in those with esotropia.Strabismus is associated with amblyopia and a lower quality of life. Attention-deficit hyperactivity disorder (ADHD) is common among children and adolescents, and influences their academic, vocational, and social life. Previous studies have suggested an association between strabismus and ADHD. Using data from the Taiwan National Health Insurance Research Database between 2000 and 2010, we performed a large-scale cohort study comparing the incidence, risk factors, and severity of ADHD in children with and without strabismus. A total of 2049 patients <18 years old with newly diagnosed strabismus  were identified, and 8196 age- and sex-matched controls without strabismus were also included. After an average of 6.5 ± 2.9 years of follow-up, the incidence of ADHD per 1000 person-years was 5.39 in the strabismus group  and 3.23 in the control group. The cumulative incidence of ADHD was significantly greater in the esotropia (hazard ratio [HR]: 2.04; 95% confidence interval [CI]:1.36–3.06;  Strabismus is a common ocular alignment disorder that affects 1–5% of children worldwide ,3,4. ExoAttention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder among children and adolescents. Overall, the pooled estimated prevalence is 7.2% in school and community populations . ADHD isIn the past decade, strabismus has been found to be related to mental health problems in both children and adults ,23,24,25The National Health Insurance (NHI) program is a mandatory health insurance program that covers 99% of the 23 million residents in Taiwan. The Taiwan National Health Insurance Research Database (NHIRD) contains the medical records of inpatients, outpatients, emergency care, surgery, and prescription records. We utilized the Taiwan NHIRD to conduct a large cohort study to compare the incidence, risk, and severity of ADHD between children with and without strabismus in Taiwan from 2000 to 2010.This retrospective population-based cohort study used data from the Taiwan NHIRD. In this study, we included patients aged ≤18 years with exotropia or esotropia between 2000 and 2010. Patients with a previous diagnosis of ADHD were excluded. For each included insurant, we recruited four sex-and age-matched controls without a diagnosis of exotropia or esotropia. We also collected data regarding comorbidities such as autism, Tourette syndrome, depression, delayed development, intellectual disability, lower respiratory tract infection, and epilepsy.We used the Longitudinal Health Insurance Database of the NHIRD. This database randomly selected 1,000,000 patients from registered insurants from the NHI program. We defined esotropia in this study as International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 378.0, 378.21, 378.22, 378.35, 378.41, 378.84, and 378.85 and exotropia as ICD-9-CM codes: 378.1, 378.23, 378.24, and 378.42. To avoid errors during data collection and to confirm the accuracy of the diagnosis, only those with the same diagnosis (esotropia or exotropia) occurring at least three times were included. Patients with a diagnosis of both esotropia and exotropia, even when these occurred at different times, were excluded. To rule out the effect of suboptimal visual acuity on the mental development of children, we excluded individuals with a diagnosis of amblyopia . Since this study was designed to determine the incidence per year of ADHD, patients with a diagnosis of ADHD  at baseline were also excluded . Age- anThe primary outcome was the development of ADHD. Diagnosis of ADHD was based on clinical evaluation (DMS-IV-TR) by psychiatrists (ICD-9CM code: 314). All patients were followed-up until the development of ADHD or until they dropped out from the study. The secondary outcome was medical usage in patients with ADHD. Medication usage duration and dosage may reflect the severity of ADHD. Thus, for disease severity analysis, we collected the medical records of these patients, including duration and age at the start of medical treatment.2 test was performed to examine the study and control cohorts in terms of demographic data; The Wilcoxon rank sum test was applied for mean value analysis; and the Kaplan–Meier method was used for survival plot analysis for ADHD development in patients with esotropia or exotropia and control groups. The Cox proportional hazard model was used for multivariate analysis. p < 0.05 was considered statistically significant.We used the SAS statistical package for Windows, version 9.1,  for the study analysis. The Pearson Xp = 0.07).In total, 404 patients with esotropia, 1645 with exotropia, and 8196 age- and sex-matched controls were included in this study. A flowchart of the study is presented in p < 0.05; An analysis of comorbidities found that patients with strabismus had more comorbidities than those in the control group. Comorbidities included autism spectrum disorder, depression, delayed development, intellectual disability, encopresis, prematurity, perinatal infection, lower respiratory tract infection, paralysis, headaches, epilepsy, rheumatic disease, chronic pulmonary disease, asthma, allergic rhinitis, allergic conjunctivitis, and deficiency anemia (All p < 0.001) after adjustment for age, sex, autism, delayed development, intellectual disability, lower respiratory tract infection, paralysis, and prematurity (p < 0.001). Patients with exotropia did not have a higher incidence of ADHD than patients in the control group in crude comparison, but there was a significant difference in multivariate analysis  years in the strabismus group , and exotropia, 9.90 ± 3.06 (4.44–17.91)) and 9.34 ± 2.85 (2.73–16.06) years in the control group. There was no significant difference between the groups.p = 0.53). Among those receiving medical treatment for ADHD, the median duration of treatment was 4.43 months in the strabismus group and 3.54 months in the control group, with no significant difference between groups .To evaluate the severity of ADHD, we further analyzed the use of medical treatment in patients with ADHD. In patients with strabismus (both esotropia and exotropia), 41 (56.9%) were under medical treatment, while 31 (43.1%) were not. In the non-strabismus group, 106 (61.3%) patients were under medical treatment, and 67 (38.7%) were not; there were no significant differences between the strabismus and control groups , and more than half (57.7%) of the children with esotropia were diagnosed under the age of 7, while the most common (43.8%) age distribution was between 8 and 12 years in our exotropia subgroup. Earlier disorders of the eye, including strabismus and cataract, may have a more profound effect on neurodevelopment in children [Previous studies ,26 foundchildren . Besideschildren . Early echildren . In our children . AlthougAlthough the causal relationship between strabismus and ADHD is not fully understood, neuroimaging studies revealed structural brain alterations both in strabismus and ADHD patients ,42,43,44The limitation of the present study mostly originates from the nature of the NHIRD . For exaOur study found a higher cumulative incidence of ADHD in patients with strabismus in a large nationwide database with an average of 6.5 ± 2.9 years of follow-up. The relative risk of ADHD was higher in children with esotropia than in those with exotropia and without strabismus. Further neuroimaging or field survey studies are required to understand the underlying pathomechanisms.


N=234) replicated previous work on parental knowledge mediating the association between ADHD symptoms and RTB, study 2  added peer influence, and study 3  assessed whether parental knowledge mediated the association between ADHD symptoms and homework behavior. Parental knowledge consistently mediated the association between ADHD symptoms on one hand and RTB and homework problems on the other, and also predicted stronger resistance to peer influence. Because parental knowledge was repeatedly linked to ADHD-related problems, it seems promising to include parental knowledge in treatment of ADHD-related problems in adolescents, by improving the parent-child relationship. Future studies should test more directly how improvement of the parent-child relationship can be used to optimize parental knowledge, which in its turn reduces ADHD-related problems.Parents of children with ADHD experience several difficulties while raising their children and report lower levels of knowledge about their children’s life and behaviors. A recent study found that low levels of parental knowledge mediated the association between ADHD symptoms and risk-taking behavior (RTB) in adolescents. The current study aimed to investigate this previous finding further by replicating it, by taking peer influence into account as additional social factor of importance and by extending it and also investigate the role of parental knowledge in the association between ADHD symptoms and homework problems. Three studies were performed: study 1 (The online version of this article (10.1007/s00787-020-01579-4) contains supplementary material, which is available to authorized users. Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity and impulsivity , occurriAn important aspect of parenting is parental knowledge, defined as “knowing where, how and with whom children spend their time” . A longiN=92) and focused only on the relation between ADHD symptoms, parental knowledge and RTB. Here, we report three studies that replicate the pioneering study by Pollak and colleagues and extend it by adding peer influence as additional mediator in the link between ADHD symptoms and RTB, and by investigating the possibility that parental knowledge also mediates the link between ADHD symptoms and other domains of impairment, in this case homework problems. The first study was a conceptual replication study, testing the mediatingN=234) than the original study.The mediating role of parental knowledge in the association between ADHD symptoms and RTB observed by Pollak et al. is highly relevant to treatment – as it suggests to focus treatment of adolescents with ADHD on the increase of parental knowledge. However, the study by Pollak and colleagues is the first to demonstrate this mediation effect, had a relatively small sample size for assessing mediation , now extending the design by investigating (low) resistance to peer influence as an alternative social factor that may result in RTB . This time we used a pre-registered design and methodology, implying that the design and data-analytic approach were determined beforehand, and could not be changed during the course of the study. Pre-registration of studies prevents flexibility in data-analysis, and confirmation of previous findings using pre-registered methods increases confidence in the findings ) aThe current study relied on self-report only which might have caused biased  or socially desirable answers. However, for the central construct of this study—parental knowledge—similar response patterns were observed for self- and other report , and preOn a related note, internal consistency of the RPI was low, although similar to other RPI studies , 51]. T. T51]. TFinally, parental knowledge only partially mediated the link between ADHD symptoms and RTB/homework problems. The effect ratio  indicated that the indirect effect of parental knowledge explained 10.5% and 19.4% of the link between ADHD symptoms and RTB in the first two studies, respectively. This is smaller than the 34.3% that was found by Pollak and colleagues , but is However, apart from these indirect effects, ADHD symptomatology alone has a major contribution in the development of both RTB and homework problems, and treating core symptoms of ADHD should always be an aim in treatment. Nevertheless, the current set of studies and the highly consistent patterns of outcomes highlight the importance of parental knowledge in the interplay between ADHD symptoms and some of the problems related to these symptoms.To sum up, three consecutive studies with large and independent samples demonstrated the importance of parental knowledge in the association between ADHD symptomatology and related domains of impairment. Targeting parental knowledge in treatment of adolescents with ADHD may be a promising way to go.Supplementary materials (DOCX 210 kb)Below is the link to the electronic supplementary material.


Conclusions: By this SEM pathway analysis, there is the correlation between the disruptive, more aggressive subtype of ADHD in children/adolescents and the existence of psychopathological symptomatology of their parents. ADHD + ODD + aggression in children should be classified as an irritable subtype of ADHD, warranting early diagnosis and intensive treatment.Background: Children with attention deficit hyperactivity disorder (ADHD) co-occurring with Oppositional Defiant Disorder (ODD) further present aggressive behavior and may have a depressive parent. A child with co-occurring ADHD and ODD has differentially higher levels of behavioral and emotional difficulties. Little is known about how the irritable subtype of ADHD in children mediates the development of parental symptomatology. This study aims to elucidate the direct or indirect influence of childhood disruptive ADHD with aggressive behavior on their parental symptom using Structural Equation Modeling (SEM). Methods: A total of 231 ADHD children and their parents completed the Swanson, Nolan, and Pelham Version IV questionnaire for symptoms of ADHD, Oppositional Defiant Disorder (ODD) scale for irritable symptoms, Child Behavior Check List (CBCL) for aggression, and Symptom Checklist (SCL) for parental symptom. Results: The three-factor confirmatory factor analysis (CFA) model found symptoms of inattention, hyperactivity/impulsivity, irritable ODD, and aggression were inter-related. Mediational analyses demonstrated ODD mediates symptoms directly predicting the risk of increasing ADHD severity. Disruptive child symptoms (ADHD + ODD + aggression) may increase the risk of depression-related symptoms in the parent. When the child’s aggression increases by one standard deviation (SD), parental psychiatric symptoms increase by 0.235 SD ( Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder, with a reported high prevalence of 5% to 12.76% among children and adolescents ,4. FamilBy the developmental-transactional model, it is reasonable to find the cause-and-effect relationship between ADHD in children and maternal depressive disorder through multiple psychosocial and biological risks . As an eNot every family has a difficult time. When reviewing ADHD symptom severity, we found a clinically heterogenous picture, especially when ADHD is complicated by extensive comorbid conditions . Up to 8Previous studies on psychopathological spectrum disorders have focused more on the symptom profiles of ADHD, ODD, and Conduct Disorder (CD) , not aggStructural equation modeling (SEM) is an appropriate method for analyzing a set of interactive factors simultaneously . TraditiThe authors first hypothesize a bidirectional association between the symptoms of the child and parental symptoms. Following this, we examined the direct effect between ADHD, ODD, aggression, and parental symptoms. This allows us to further examine whether disruptive symptoms in children have a more direct effect on parental depression-related symptoms compared to families with kids that only have ADHD. To discover the relationship between ADHD, ODD, and aggression, the authors also hypothesized ODD is a mediating risk factor that causes children with ADHD to become aggressive and has a significant, direct effect on parental depression-related psychiatric symptoms. With these results, mental health professionals can take steps earlier to manage ODD and develop more intensive parenting programs to prevent further occurrences of conduct disorder in the future.This study recruited patients from the outpatient unit of a major medical center in Taipei, Taiwan. The Mackay Memorial Hospital Institutional Review Board (IRB) approved the design of the study, with IRB No. MMH-I-S-489 under the project “exploring the symptomatology on children with internet addiction and attention deficit hyperactivity disorder and their parent”. After receiving a complete description of the study, participants provided written informed consent in line with the IRB guidelines. A total of 231 children with a clinical diagnosis of ADHD, based on the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV), were recruited in this study. The senior child and adolescence psychiatrist confirmed the clinical diagnosis of ADHD based on the DSM-IV criteria. After obtaining signed consent from the legal guardian, each subject recruited for this study was invited to participate in the following programs and was interviewed to derive the following measures.The Swanson, Nolan, and Pelham version IV scale, Chinese (SNAP-IV-C) consists of the following items: inattention (9 items), hyperactivity/impulsivity (9 items), and oppositional symptoms (8 items). These items reflect the core symptoms of ADHD and ODD, as defined in DSM-IV . The inaWe used the Child Behavior Check List (CBCL) to determine competencies and behavioral/emotional problems of children aged 4–18 years. The questionnaires, completed by the parents, included 118 items to assess specific behavioral and emotional problems. The CBCL was translated into Chinese via a two-stage translation . The intThe ODD score from SNAP plus an aggressive behavior score from CBCL was used to indicate Disruptive Child Symptoms (DCS) and to differentiate general irritable ODD or aggressive symptoms from symptoms of ADHD. We used the Symptom Checklist-90-Revised (SCL-90-R), a 90-item self-report system developed in the 1980s by Derogatis , to determine the parental psychiatric symptom score. The SCL-90-R has previously been proven as a reliable psychometric measurement. The Cronbach α coefficient range of the SCL-90-R is 0.77–0.90, according to the study by Derogatis . The ChiThe nine primary dimensions are somatization, obsessive–compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. We used a five-point scale (0–4) for symptoms, ranging from “not at all” to “extremely”. We chose five parental symptoms  for this SEM analysis to explore the association between parental depressive/anxiety symptoms and disruptive behavior symptoms of children.SEM can be used to evaluate and to explain how the relationships among unobserved variables and their influence on their parental psychiatric symptom. SEM is directly adequate latent pathway analysis to elucidate the hypothesis test. This paper reviews the role of latent variables in multiple regression, factor analysis, and structural equation models. SEM process centers around two steps. One is validating the measurement model: accomplished primarily through confirmatory factor analysis (CFA). Other is fitting the structural model: accomplished primarily through path analysis with latent variables .The first SEM process was using factor loadings to specify the association between an unobservable construct (latent variables) and its theoretically related measures (indicator variables). Multiple linear regression methods were used to determine the relationships among the aforementioned latent variables and were indexed by standardized path coefficients. 2; (2) the comparative fit index, CFI; (3) the Bentler–Bonett [2 (p > 0.05), GFI and CFI greater than 0.95, TLI greater than 0.96, and RMSEA less than 0.06 each indicated a good fit between the data and the hypothesized model [The second step is to use absolute model fit indices determining how well a priori model fits the sample data. The six following indices were used to evaluate model fit: (1) the chi-square test, χr–Bonett  normed fr–Bonett . All theed model . We used the following two models to establish the potential direct effect of a diagnosis of worse ADHD severity with related disruptive child symptoms (ODD and aggression) on the development of parental psychiatric symptoms (SCL-90). Among three latent variables, named ADHD, Disruptive Child Symptoms (DCS), and parental symptom (SCL), we used a three-factor confirmatory factor analysis (CFA) model to explore the existence of bivariate correlations. For the direct effect model of DCS on ADHD and parental symptoms (SCL-90), we used the SEM model to find the relationship. Furthermore, a mediational effect model, analyzed by SEM, was used to elucidate the relationship among ADHD, ODD, and aggression. We used Amos 21.0 and SPSS v.21.0 packages (SPSS Inc.) to perform all statistical analyses .There are some limitations in using the SEM method. The most severe one is that all measurement variables (represented by rectangles) are normally distributed. In other words, the demographic factors, such as gender, marriage status, and socioeconomic status, etc., cannot be put into the structure part to control for their potential influence on the relationships in the modeling.Overall, 231 eligible patients with ADHD were enrolled. In p < 0.001). However, the covariance between perceived ADHD symptoms in children and SCL-90 parental symptoms was not significantly different from zero at the 0.05 significance level . Based on the aforementioned six indices, this model provides a good fit for the data, as suggested by the results of the non-significant chi-square test and the other five indices of good fit . The results of the three-factor CFA, in p < 0.001). In other words, when DCS increased by one standard deviation, ADHD significantly increased by 0.85 standard deviations. This SEM model also provided a very good fit for the data .p < 0.001) and is predictive of aggression in children . On the other hand, children’s aggression had a significant, direct effect on pa-rental somatization, obsessive–compulsive disorder, interpersonal sensitivity, depression, and symptoms of anxiety. More specifically, the standardized direct effect of a child’s aggression on parental symptom was 0.235 (p < 0.001). That is, when aggression in children increased by one standard deviation, parental psychiatric symptoms in-creased by 0.235 standard deviations. The mediation model also provided an excellent fit for the data .The mediational effect model analyzed by SEM is shown in Our study used exploratory SEM to elucidate the association between ADHD, ODD, and aggression in children with parental psychiatric symptoms. We found a potential bi-directive influence between symptoms from children with ADHD and parental depression-related symptoms. This Confirmatory Factor Analysis (CFA) conceptualized ADHD, ODD, and aggression in children interact with parental depression-related symptoms. We have known that adolescents with ADHD have more family-related impairments due to higher ADHD severity and parenting stress . This stp < 0.001). ODD, being a serious intermediate diagnosis, plays a role in increasing the severity of hyperactive/impulsive symptoms of ADHD. The symptoms of ADHD were not significantly associated with parental depression-related symptoms. However, if ADHD co-occurs with ODD and aggressive behavior, the inter-relevance of symptoms of the child and parental depression-related symptoms became significant, 0.23 (p = 0.006). Higher ADHD severity with disruptive behavior problems in children, or so-called the psychopathologic spectrum, could be used to predict the depression- and anxiety-related psychiatric symptoms in their parents, according to this SEM analysis.According to this study result, so-called higher ADHD severity is a form of ADHD in children that co-occurs with disruptive behavior symptoms (ODD and aggression). Importantly, these three behavior symptoms  are inter-correlated with each other, with a ratio of 0.86  need an intensive program combining pharmacotherapy and parenting programs , here ouAnother contribution of our study is the zero-order correlation, which highlighted aggressive behavior as closely correlated with the severity of hyperactivity/impulsivity symptoms  and with ODD (0.587) in children. As other studies have found, the severity of the children’s hyperactivity/impulsivity symptoms, but not inattention in ADHD, influence parenting stress . This SEThis study has the following limitations. First, a symptom-by-symptom checklist (SCL-90) was used to assess parental psychiatric status, rather than directly interviewing parents. Therefore, construction of the subscale seems to be arbitrary in symptom expression. Another limitation is the cross-sectional design, which may not necessarily represent the longitudinal developmental relationship among ADHD, ODD, aggression, and parental depression-related symptoms. In addition, most of the information was from the primary caregiver (mainly mothers), which may lead to sampling deviations. Finally, since the objective of this study was to explore the relationship between symptom severity in children and parental depression-related symptoms, we used the presence of any aggressive behavior in the CBCL, instead of a formal diagnosis of Conduct Disorder, which is a well-known diagnosis of childhood disruptive behavior symptoms. Evaluating aggressive behavior symptoms in the outpatient setting may be particularly challenging for some families because parents may refuse to report their child’s aggression symptoms during interview. Despite these limitations, we still suggest using the CBCL aggression scale as a tool to screen for these high-risk patients .This study used SEM to conceptualize the intergenerational transmission of ADHD in children and parental psychiatric symptoms. We first provide this view to understand how ODD moderately enhances the severity of ADHD symptoms. In summary, this study conceptualized symptoms of ADHD, ODD, and aggression interact with parental depression-related symptoms. It is important and requires low costs to routinely screen ADHD children with ODD and aggressive behavior using the CBCL in a clinical setting. ADHD children on the severe end of the psychopathologic spectrum require a more intensive biopsychosocial model of treatment to help them earlier in clinical psychiatric practice .


Secale cereale L.) is an exceptionally climate-resilient cereal crop, used extensively to produce improved wheat varieties via introgressive hybridization and possessing the entire repertoire of genes necessary to enable hybrid breeding. Rye is allogamous and only recently domesticated, thus giving cultivated ryes access to a diverse and exploitable wild gene pool. To further enhance the agronomic potential of rye, we produced a chromosome-scale annotated assembly of the 7.9-gigabase rye genome and extensively validated its quality by using a suite of molecular genetic resources. We demonstrate applications of this resource with a broad range of investigations. We present findings on cultivated rye’s incomplete genetic isolation from wild relatives, mechanisms of genome structural evolution, pathogen resistance, low-temperature tolerance, fertility control systems for hybrid breeding and the yield benefits of rye–wheat introgressions.Rye ( A chromosome-scale genome assembly of rye inbred line ‘Lo7’ provides insights into its incomplete genetic isolation from wild relatives, mechanisms of genome structural evolution and the yield benefits of rye–wheat introgressions. Secale cereale L.), a member of the grass tribe Triticeae and close relative of wheat (Triticum aestivum L.) and barley (Hordeum vulgare L.), is grown primarily for human consumption and animal feed. Rye is uniquely stress tolerant (biotic and abiotic) and thus shows high yield potential under marginal conditions. This makes rye an important crop along the northern boreal-hemiboreal belt, a climatic zone predicted to expand considerably in Eurasia and North America with anthropogenic global warming1. Currently, rye is produced on 4.1 million ha , 81% of which is in northeastern Europe. More importantly, however, rye chromatin is commonly introgressed into bread wheat varieties to improve yield and thus rye genetic material is present in a far greater proportion of cultivated land area5. Rye is a diploid with a large genome 6, 50% larger than the syntenic diploid barley and bread wheat subgenomes7. Like barley and wheat, rye entered the genomics era very recently. A virtual gene-order was released in 20138 and a shotgun de novo genome survey of the same line became available in 20179. Both resources have been rapidly adopted by researchers and breeders12 but cannot offer equivalent opportunities to the high-quality genome assemblies available for other Triticeae species17.Rye  10x Chromium linked reads, (3) genetic map markers9, (4) three-dimensional chromosome conformation capture sequencing (Hi-C)18 and (5) a Bionano optical genome map  in 90 miRNA families (Supplementary Tables 20. Fluorescence in situ hybridization (FISH) to mitotic rye chromosomes confirmed agreement between in silico predicted and true physical distribution of distinct low- and high-copy probe sequences . Large SVs therefore provide a potential mechanism for localized collinearity loss between the pericentromeric regions of Triticeae species. This collinearity loss provides, in turn, at least one mechanism for effective genetic isolation during speciation24.Megabase-scale inversions are a common feature of structural variation (SV) in the related barley genomeng Hi-C; 23. In thmes Fig. . Among tmes Fig. , providi8 interpreted variation in sequence identity between rye and barley along chromosomes as a possible indicator of ancient species hybridization creating a ‘mosaic’ genome. Genome-wide estimations of fixation indices (Fst) and ABBA-BABA-based D-statistics have reflected varying levels of recent genetic exchange among Secale groups25. We confirmed, using D-statistics, that directional gene flow has occurred between rye groups  statistics between ‘Lo7’ and sequence data from a population of 955 cultivated and wild ryes  but approaches zero at two interstitial positions (~600 and 720 Mb), corroborating incomplete genetic separation between these subgroups.We then produced an analogous analysis for ers Fig. . In contter Fig. , S. sylvers Fig. . On chroPn/Ps) but which shared an allele with the consensus state of the three bread wheat genomes , thus surveying primarily recent mutations within rye lineages .To investigate the effects of incomplete genetic isolation on recent selection pressures exerted on domesticated rye, we examined the ratio of nonsynonymous to synonymous mutations in exonic single nucleotide polymorphisms (SNPs) segregating among ryes , United States Department of Agriculture Regional Performance Nursery (USDA-RPN), International Maize and Wheat Improvement Center (CIMMYT), Wheat and Barley Legacy for Breeding Improvement (WHEALBI); The transfer of rye genetic material into bread wheat can provide substantive yield and stress tolerance benefitsgo’ Fig. 3,4. Due n = 19,677) and USDA  breeding panels showed that 1R introgressions could increase average yields up to ~4.55%  classifier that replicates human assignment with over 97% accuracy . We thenUSDA n = 9,035 bre5% Table –25. The Rye distinguishes itself from other Triticeae through strong allogamy, which facilitates commercial hybrid-rye breeding, as well as conferring resilience to biotic stress and extreme winter-hardiness, qualifying rye as an important plant genetic resource in wheat improvement. Here, we showcase how the high-quality genome assembly sheds light on the genetic control of these specific aspects of rye biology.Rf genes belong to a distinct clade of the pentatricopeptide repeat (PPR) RNA-binding factor family, referred to as Rf-like (RFL)30. Members of the mitochondrial transcription TERmination factor (mTERF) family are probably also involved in male fertility restoration in cereals32. The ‘Lo7’ assembly reveals a PPR-RFL/mTERF hotspot on 4RL coinciding with known Rf loci for two rye CMS systems known as CMS-P  and CMS-C35/restorer-of-fertility (Rf) systems; however, the underlying molecular mechanisms have yet to be elucidated. Known d CMS-C35. We deteRfmulti (Restoration-of-fertility in multiple CMS systems) on wheat chromosome 1BS. Replacement of the wheat Rfmulti locus by its rye ortholog using 1RS.1BL chromosome translocations produces the male-sterile phenotype39. At the syntenic position of Rfmulti, wheat and rye share a PPR-RFL gene cluster7 . Thus, the absence of a TraesCS1B02G071642.1 ortholog in the nonrestorer rye suggest it as an attractive Rfmulti candidate. Current implementations of a wheat–rye Rfmulti CMS system involve 1RS.1BL translocations41, which are typically linked to reduced baking quality27. Efforts to break this linkage may now benefit from marker development and/or genome editing approaches targeting TraesCS1B02G071642.1 (ref. 42).The new assembly also helped to dissect a strong candidate gene for the wheat locus er7 Fig. . Only tw43. We annotated 792 full-length rye NLR genes, finding them enriched in distal chromosomal regions, similar to what has been seen recently in the bread wheat genome44  and rust (Lr10) resistance gene loci from wheat and barley -motif genese44 Fig.  and 30. ley Fig. . All loct in rye . In esse45. A syntenic locus Fr2 comprising a cluster of CBF (C-repeat/DRE-binding factor) genes is present on Triticeae group 5 chromosomes controlling LTT46 in rye47, T. monococcum48, bread wheat50 and barley51. In cold-tolerant varieties, LTT-implicated CBF genes of the Fr2 locus are transcriptionally upregulated53. In ‘Lo7’, the Fr2 locus comprises a cluster of 21 CBF-related genes at 614.3–616.5 Mb on 5R  to other Triticeae crops 5R Fig. .54  in comparison to ‘Lo7’ (low LTT). Four of the Fr2 CBF genes, all members of the same CBF subfamily   equipped with a 532-nm green laser. The gain of the instrument was adjusted so that the peak representing interphase first growth (G1) nuclei of the standard was positioned approximately on channel 100 on a histogram of relative fluorescence intensity when using a 512-channel scale. Five individual plants per test species were sampled and each sample was analysed three times, each time on a different day. A minimum of 5,000 nuclei per sample was analysed and 2C DNA contents in pg were calculated from the means of the G1 peak positions by applying the following formula:We characterized the landscape of 61). Statistical analysis was performed using NCSS 97 statistical software package . One-way analysis of variance and a Bonferroni’s  multiple comparison test were used for analysis of variation in monoploid (1C×) genome size. A significance level α = 0.01 was used.Mean nuclear DNA content (2C) was then calculated for each accession. DNA contents in pg were converted to genome size in bp using the conversion factor 1 pg DNA = 0.978 Gb  (Three-day-old roots of the rye accession were pretreated in 0.002 M 8-hydroxyquinoline at 7 °C for 24 h and fixed in ethanol:acetic acid (3:1 v/v). Chromosome preparation and FISH were performed according to the methods described by Aliyeva-Schnorr et al.able 63) .7 (T. aestivum cv. ‘Chinese Spring’) and barley13 (H. vulgare cv. ‘Morex’) using BLASTn (v.2.9.0+)64 with default parameters. The lowest E-value alignment for each gene against the transcriptome associated with each subject genome (or subgenome) was selected, with the highest bitscore and then longest alignment chosen in the case of a tie. Only reciprocal best matches per (sub)genome were accepted. Relative evolutionary distances between rye, barley and the wheat subgenomes were estimated using the mean percentage identity scores of these filtered matches, calculated in bins of 100 reciprocal matches (in increments of 20 bins). The positions of the bins on the pseudomolecules were taken to be the mean match position of the matches within each bin.HC gene sequences from the ‘Lo7’ gene annotation were aligned to the annotated transcriptomes of bread wheat25 was extended by a 347 further GBS samples from the IPK gene bank  and the five samples used in the Hi-C SV-detection study . The resulting sample set (n = 955) and passport data are listed in Supplementary Table en.novogene.com/) for Illumina library construction and sequencing in multiplex on the NovaSeq platform . Demultiplexing, adapter trimming, read mapping and variant calling correspond to the approach described in Schreiber et al.25, using the new reference for read mapping. The dataset was filtered for a maximum of 30% missing data and a minor allele frequency of 1% resulting in 72,465 SNPs was used  was performed with smartPCA from the EIGENSOFT v.6.0.1 package (github.com/DReichLab/EIG) using least square projection without outlier removal. Seven rye genetic clusters were designated using the ‘kmeans’ R function, with default parameters, using the first three principal components from the PCA as input.The genotyping-by-sequencing (GBS) dataset of 603 samples from Schreiber et al.was used . A neighFst analyses, a more stringent filtering regime requiring read depth ≥ 6, maximum 5% missing data and call quality ≥ 250  was selected . The calculation was performed for every pairwise combination of the following groups: ‘Domesticated-like’ (cluster 3), ‘Wild–S. strictum-like’  and ‘Wild–S. sylvestre-like’ (cluster 4).For IBS and selected . IBS sco7 alleles using the rye-versus-wheat CDS BLAST alignments (see above) and parsing the BLAST alignment strings using the custom script blast_get_alleles_at_position.c (https://github.com/mtrw/tim_bioinfo_tools). Reciprocal best matches were calculated separately for the alignments between the rye CDS set and the set of CDSs from each wheat genome. The ancestral allele was assigned by consensus among the wheat genomes and, if no allele claimed a majority, the variant was omitted from the dataset. Genome-wide D-statistics were calculated according to the four-taxon ABBA-BABA method as described in ref. 67, with the wheat consensus allele as the outgroup and selections of the k-means-assigned clusters selected as the three test populations. Estimator variance was approximated via the block jackknife procedure, with 5 Mb exclusion bins. The effects of the rye-versus-wheat nucleotide differences falling within coding sequences were annotated using SnpEff , with default parameters. Pn/Ps scores (the ratio of counts of nonsynonymous to synonymous differences to wheat in variants segregating in rye) were calculated using the same binning scheme as was used for Fst and IBS (see above). Pn/Ps scores were calculated separately for subgroups of rye clusters representing ‘wild-like’ and ‘domesticated-like’ ryes separately (see main text). Pn/Ps scores were only estimated for bins in which the combined number of rye-segregating variants exceeded nine.To assign ancestral states to variant SNPs segregating in rye, exonic variants identified in the GBS dataset were coupled to their orthologs alleles in the three bread wheat (‘Chinese Spring’)7. Publicly available data were obtained from WHEALBI project resources68 (n = 506), CIMMYT (n = 903) and KSU . GBS libraries were constructed and sequenced for samples from USDA-RPN  and aligned to the combined reference using bwa mem 71 after trimming adapters with cutadapt72. The aligned reads from all panels were filtered for quality using samtools73 . The numbers of reads aligned to 1 Mb nonoverlapping bins on each pseudomolecule were tabulated. The counts were expressed as rpmm ≡ log2(reads mapped to bin per million reads mapped). To control for mappability biases over the genome, the rpmm for each bin was normalized by subtracting the rpmm attained by the ‘Chinese Spring’ sample for the same bin to give the normalized rpmm, r.We assayed for the presence of 1R germplasm in wheat genotypes in silico by mapping various wheat sequence data to a combined reference genome made up of the pseudomolecules of rye line ‘Lo7’ (this study) and wheat cv. ‘Chinese Spring’r across the combined reference genome were inspected and obvious cases of 1R.1A and 1R.1B introgression were distinguished from several other karyotypes, including nonintrogressed samples and ambiguous samples showing a slight overabundance of 1RS reads but less discernible signals of depletion in 1A or 1B (featureA = –log[(mean(r1AI) – mean(r1AN)) × (mean(r1RI) – mean(r1RN))] and featureB = –log[(mean(r1BI) – mean(r1BN)) × (mean(r1RI) – mean(r1RN))]. Whenever the term inside the log was negative (and would thus give an undefined result), the value of the feature was set to the minimum of the defined values for that feature. The quantity mean(r1RI) refers to the average value of r for all bins within the terminal 200 Mb of the normally introgressed (I) end of 1R  arm) and so forth for other chromosomes. This choice of feature definition meant that, wherever little difference in r occurred between 1RS and 1RL, suggesting no presence of rye, the factor mean(r1RI) – mean(r1RN) would pull the feature values close to the origin and differences between r on the long and short arms of 1A or 1B would pull the values of A or B respectively away from the origin, depending upon which introgressions are present. A classifier was developed by training an SVM to distinguish nonintrogressed, 1A.1R-introgressed, 1B.1R-introgressed and ambiguously introgressed samples, using the function ksvm  from the R package kernlab. Classification results are given in Supplementary Table To investigate the possibility of classifying the samples automatically, visual representations of 1A or 1B . We defiTo confirm the common origin of the 1AL.RS and 1BL.1RS introgressions, predicted 1RS carriers were selected to form a combined 1RS panel  to call SNPs. A total of over 3 million SNPs were called with samtools/bcftools v.1.9 . SNPs were filtered on the basis of combined minimum read depth of 25, minor allele frequency of 0.01. A total of >900,000 SNPs were obtained. All IBS percentages were calculated and the square root values of per cent different calls were used to derive a heatmap for all pairwise comparisons .Fr2 region in ‘Puma-SK’ and the introgression in ‘NorstarPuma5A:5R’, whole-genome sequencing was performed using the Chromium 10x Genomics platform. Nuclei were isolated from 30 seedlings and high molecular-weight genomic DNA was extracted from nuclei using phenol chloroform according to the protocol of Zheng et al.74. Genomic DNA was quantified by fluorometry using Qubit 2.0 Broad Range (Thermofisher) and size selection was performed to remove fragments smaller than 40 kb using pulsed field electrophoresis on a Blue Pippin (Sage Science) according to the manufacturer’s specifications. Integrity and size of the size-selected DNA were determined using a Tapestation 2200 (Agilent) and Qubit 2.0 Broad Range (Thermofisher), respectively. Library preparation was performed as per the 10x Genomics Genome Library protocol (https://support.10xgenomics.com/genome-exome/library-prep/doc/user-guide-chromium-genome-reagent-kit-v2-chemistry) and uniquely barcoded libraries were prepared and multiplexed for sequencing by Illumina HiSeq. Demultiplexing and the generation of fastq files were performed using LongRanger v.2.2.0 mkfastq .To characterize the 7 genome assemblies, respectively, using LongRanger WGS . Large-scale structural variants detected by LongRanger were visualized with a combination of Loupe  implemented within the Longranger v.2.2.0 WGS pipeline. For determining the introgression, ‘NorstarPuma5A5R’ reads which did not map to the ‘Chinese Spring’ reference were aligned to the ‘Lo7’ assembly using the LongRanger align pipeline (https://support.10xgenomics.com/genome-exome/software/pipelines/latest/advanced/other-pipelines). Samtools (v.1.9)73 bedcov was used to calculate the genome-wide read coverage across both references. CNV between ‘Puma-SK’ and ‘Lo7’ was detected using a combination of barcode coverage analysis output by the Longranger WGS pipeline and read depth-of-coverage based analysis using CNVnator75 v.0.4 and cn.mops76 v.1.12.0.Sequencing reads from ‘Puma-SK’ and ‘NorstarPuma5A:5R’ were aligned to the rye line ‘Lo7’ and bread wheat cv. ‘Chinese Spring’77. RNA reads from ‘NorstarPuma5A:5R’ and ‘Puma’ were aligned to the ‘Lo7’ reference using Hisat2  and transcripts were quantified with htseq . Differential expression analysis was carried out using DESeq2 .RNA from ‘NorstarPuma5A:5R’ and ‘Puma’ was isolated and sequenced as described above. Sequencing adapters were removed and low-quality reads were trimmed using TrimmomaticFurther information on research design is available in the Nature Research Reporting Any methods, additional references, Nature Research reporting summaries, source data, extended data, supplementary information, acknowledgements, peer review information; details of author contributions and competing interests; and statements of data and code availability are available at 10.1038/s41588-021-00807-0.Supplementary InformationSupplementary NoteReporting SummarySupplementary TablesSupplementary Tables 1–34