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Birgit Amann, MD, discusses the importance of sports for patients with attention-deficit/hyperactivity (ADHD) disorder in building self competence and a sense of accomplishment, as well as respect, discipline, and concentration skill building. 

is a child & adolescent specialist and a psychiatrist in private practice.

Self discipline, respect, and concentration... sports can help build many skills in patients with ADHD. 

The Importance of Sports for Patients with ADHD

Sometimes, on a summer Sunday, I sit outside on my covered porch and contemplate my shade garden. During that time, I also think about my patients, and the lessons that my garden has taught me about them. It may sound strange to compare patients to plants—so let me explain.

Before we became physicians, and even before we started medical school, we were premeds, studying basic biology as well as botany. In Biology 101, we learned about animal habitats and which animals thrive in which habitats, and which would not survive in those same circumstances. Some settings are suitable for some creatures, whereas others are not. Polar bears, for instance, do well in the cold and the snow, whereas tropical birds and butterflies require the opposite conditions. Move those polar bears into the Amazon, and those polar bears will be no more. Many of us learned similar basic biology lessons much sooner, simply from visiting zoos.

Since most of us do not keep polar bears in our backyards, I will not belabor the point and will not pontificate about animals and ecology. Better to talk about gardens, which are more common.

In the popular imagination, gardens need sunshine, as well as good soil, and the right amount of rain, so that roses and so many other beautiful sun-loving flowers can grow. Yet I can look out on my shade garden and see many other lovely flowers which were planted or potted. To my right, are stairsteps covered with caladiums, of many different varieties. I wish I could list each species by name, but I can say with certainty that all their leaves come in a magnificent array of colors, with each leaf shaped like an elongated heart. Some are a dusty red, with green borders, and some are green with red trim. Some have green veins running though reds, whereas others are white, with green stripes, and so on. There are so many permutations to these shade flowers, and so many variations—but they share one thing—they need shade and may wither and die in full sun.

A few feet above those stair steps sits a balcony, surrounded by white fencing, some of which remains in the shade, and some of which continues into the sun. From those railings that rest above the caladiums hang scrolled wire baskets, filled with begonias. Some begonias are off-white, while others are pale pink, and yet more are coral or a deeper red that many might call vermillion. The colors and textures of the begonias play off the translucent shades of the caladiums below, although the shapes and sizes of the begonias are dramatically different from the large, elongated leaves of the caladium. But begonias and caladium have something in common: both prefer shade and cannot tolerate the sun.

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat.

If you will bear with me just a little bit more, let me mention one more garden, straight ahead of me, in full frontal view, shaded by towering pine trees that drop sticky pinecones each fall. By this time of the summer, the hostas are in full bloom, having grown wider and taller each year. They, too, come in many different hues, and many different varieties, even though each of them is some shade of green. A true horticulturist could name each and every one, but I am content to call each of them beautiful, with no need to know more for now. In the sweltering heat of summer, they sprout long stems with pale lilac flowers. In the early spring, those same rows are occupied by pink daffodils that also thrive in the shade, in contrast to their better-known cousins that demand full sun. I adore those sun-loving narcissi also, with their yellow and orange and gold trumpet-shaped crowns, and which proclaim the start of spring.

I could go on and on about each plant, shrub, and flower in my gardens, but let me explain why I am comparing plants to patients.

Patients Who Found Their Place in the Shade

As humans, we have the hubris to believe that we can change nature and impose our wills on biology (hurricanes, wildfires, and floods notwithstanding). Sometimes we can succeed at altering the course of nature, and often, we should—but not always. For sure, human-made irrigation systems made Israel’s deserts bloom, replacing sand with fruit trees to feed the population. Without surgical interventions, children born with club feet could be left with lifelong limps, unable to ambulate fully. And so on and so forth. Yes, modern medicine has worked miracles for many, often offering longer and healthier lives. But how does psychiatry fit into this picture and how does that impact psychopharmacology in particular?

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat—even if it is not an environment that is envied by others.

Let me provide 2 patient examples to dramatize this point. Let me call one “Ms A” and the other “Mr B.” Ms A was already an attorney, albeit one who hated reading and writing—and especially arguing. Yet she chose law on the advice of her parents, who dismissed her wish to become a baker, unmoved by the wonderful creations she made for friends and family. Ms A did well in grade school, high school, and college, well enough to be admitted to law school. Yet her concentration dropped as she studied legal details that held little interest for her. A local doctor diagnosed her with attention-deficit/hyperactivity disorder and started her on stimulants, despite the absence of an early history of attention problems, and apparently without inquiring about her interest in the subjects that she studied. With these pharmaceutical aids, she earned her JD, passed the bar, and was hired by a mid-sized law firm in midtown Manhattan. Although her parents were thrilled by her seeming success, (her analogue to a garden’s sunshine), she was unhappy sitting at a desk, staring at a computer screen, when she wanted to be baking.

Because she was so unhappy, she went to each happy hour after work, and soon enough developed an alcohol use disorder. She started coming in late for work when she was not calling in sick. Luckily, the bar association offered help to their members and referred her to treatment, which by this time included antidepressants as well as anti-craving medications. We also added behavioral activation to encourage her to engage in pleasurable activities (and to increase the odds of overcoming depression, as reported in 

Instead of idling away her after-work hours at local watering holes, she signed up for culinary classes. Her mood brightened enough, and her concentration cleared enough, for her to decide on her own to complete a culinary certificate and to change careers. As she put it, she preferred to “knead dough” rather than to make more dough. No longer sitting in a chair for hours on end, she could wander around a commercial kitchen at will. She decided that she no longer needed the stimulants that were prescribed to push her through an education that she disdained. In short, she found her shade garden where she could not just survive, but thrive—even if it was not the sunny rose garden that her parents recommended.

Mr B’s situation was somewhat different. Always a shy man, Mr B found solace in his college computer classes that required limited human interaction—and that also promised a bright financial future. It came as no surprise that he landed a good-paying coding job after graduation, but it was an unpleasant surprise when he became paranoid while working in a large open space rather than a confined cubicle. Soon enough, he accused coworkers of plotting against him, and engaged in enough arguments to lose the job. He never had frank auditory hallucinations—only barely audible intermittent whispers—but, in hindsight, his evolving symptoms sounded ominous. It was easy enough to find another job, given his high-level coding skills and the high demand for such skills, and it was surprisingly easy to squash those emerging psychiatric symptoms with a low dose of an atypical antipsychotic.

All might have worked well, had he not developed involuntary facial twitches from his new medication. To avert worse consequences in the future, he reluctantly agreed to stop the medication, even though it had brought him so much relief. We substituted cognitive behavioral therapy techniques instead, and watchful waiting. Then, Mr B was literally saved by the pandemic. Everyone in his office was forced to work from home. Without the untenable proximity to his coworkers, his paranoid symptoms abated, even in the absence of medication. The erratic whispers evaporated. Even his productivity improved, and his supervisor commended him. When the company owners spoke about reopening the office, we opted to request accommodation under the Americans with Disabilities Act, which would allow him to work from his family’s home. Better to work from home than to wind up in a hospital setting, should his rudimentary symptoms return and progress to a full-blown schizophrenic break, which could impair his cognition in the future and interfere with his employability. For Mr B, his home office was his shade garden, where he could survive and thrive.

Is there a moral to this story and a special message to psychiatrists? Yes, there is. These 2 cases of 

 demonstrate the interactions between humans and their environments.

I wish I could claim to have discovered the concept of human ecology, but I cannot. This term was coined many decades earlier. Although we discuss the impact of climate change on human well-being, human ecology is not a concept that we typically discuss in contemporary psychiatry, but perhaps this concept deserves consideration. The concept of human ecology traces back to Carl Linnaeus, MD, whose name we heard in those biology and botany premedical courses taken while we were 

 to becoming physicians. Linnaeus is best remembered as a taxonomist who categorized both animals and plants—but he was much more than that. Linnaeus was both a botanist and a physician who probably would have appreciated how gazing at gardens can add insights into treating patients.

is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

1. Park LT, Zarate CA Jr. Depression in the primary care setting. 

Different flowers need different levels of light, water, and shade. What would it mean to treat patients with a similar amount of care? 

Lessons From my Garden About Patient Care


The importance of maternal mental health for fetal development has been the subject of 

 Researchers have also investigated the possibility that other perinatal illnesses, like viral or bacterial infections, could increase the risk of a child later developing psychiatric conditions such as schizophrenia.

Perinatal immunological diseases may have long-term effects, too, especially because the

 There is evidence that activation of the maternal immune system during pregnancy—whether by infection, chronic inflammation, or autoimmune disease—is associated with increased risk of neurodevelopmental disorders in the offspring.

 In the case of the latter, maternal autoantibodies may cross the placenta and alter fetal development through epigenetic changes, brain microglial cell activation, and modulation of synapses.

Previous studies have focused on the association between maternal autoimmune disease and autism spectrum disorders, whereas attention-deficit/hyperactivity disorder (ADHD) has been less studied. Only 1 

 examined the association between any maternal autoimmune disease and ADHD risk in children.

 A recent paper, however, set out to investigate the association between any (and specific) maternal autoimmune disease and ADHD in children, and to incorporate those results into a systematic review and meta-analysis on this topic.

Using the New South Wales (NSW) Perinatal Data Collection, Nielson and colleagues identified all women with full-term, singleton live births from July 2000 to December 2010. Birth data were linked to all hospital admissions for both mother and child, and pharmaceutical data for the child for treatment of ADHD through registers. A child was considered to have ADHD if they had a stimulant prescription for ADHD and/or a hospital diagnosis of ADHD. Children linked to a first ADHD event before age 3 years were excluded. Children were followed to death or at the end of follow-up in December 2014.

Maternal autoimmune disease was determined based on the mother’s hospitalization records. Children whose mother had at least 1 hospitalization for autoimmune disease were considered exposed. Exposed and nonexposed mothers were propensity matched based on age, country of birth, socioeconomic status, place of residency, parity, smoking during pregnancy, and mental health diagnosis. Cox proportional hazard models were used to examine the association of maternal autoimmune disease and ADHD, adjusting for child sex. Analyses were performed for any maternal autoimmune disease and individual conditions with at least 15 cases of ADHD among exposed children.

The authors also performed a systematic search of MEDLINE, Embase, and Web of Science to identify studies on the association between maternal autoimmune disease and ADHD. Studies were assessed for quality using the Newcastle-Ottawa Quality Assessment Scale. Meta-analyses of any (and specific) maternal autoimmune disease with ADHD in the offspring were performed by calculating random-effects pooled hazard ratios (HRs) and inverse-variance weighting.

In the NSW Perinatal Data Collection, 831,718 mothers and children were included, and 12,767 children (1.5%) were exposed to maternal autoimmune disease. Propensity score matching included a cohort of 12,610 exposed children and 50,440 controls. During follow-up, 1094 male (3.4%) and 332 female (1.1%) children were diagnosed with ADHD. After adjustment, any maternal autoimmune disease (HR, 1.30), type 1 diabetes mellitus (HR, 2.23), psoriasis (HR, 1.66), and rheumatic fever or carditis (HR, 1.75) were associated with increased risk of ADHD, and this association was not moderated by child sex (

). When considering mothers diagnosed before or within 180 days of birth (N = 9700), any maternal autoimmune disease (HR, 1.28) and type 1 diabetes mellitus (HR, 1.95) remained significantly associated with ADHD.

Five studies, including the present cohort, were included in the meta-analysis. Two studies estimated the association with any maternal autoimmune disease, and 11 specific conditions were investigated in 2 or more individual studies. In the meta-analyses, any maternal autoimmune disease (HR, 1.20), type 1 diabetes mellitus (HR, 1.53), hyperthyroidism (HR, 1.15), and psoriasis (HR, 1.31) were all associated with increased risk of ADHD.

The authors found an association between any maternal autoimmune disease, type 1 diabetes mellitus, and psoriasis in both the present study and meta-analysis, and an association with hyperthyroidism in the meta-analysis. They noted significant heterogeneity in findings across individual studies, and that nonimmune factors such as glycemic control (in type 1 diabetes) and endocrine aspects of hyperthyroidism may also contribute to associations with ADHD.

Strengths of the present study include the hybrid design, including a large population-based cohort and meta-analysis. Limitations include the lack of outpatient/primary care records for identifying maternal autoimmune disease, absence of data on the clinical status of the mother’s autoimmune disease and associated medications, and absence of data on nonstimulant ADHD medications and severity of ADHD.

Maternal autoimmune disease is associated with increased risk of ADHD in offspring, adding evidence that adverse maternal immune function during pregnancy may alter fetal neurodevelopment. Children of affected mothers may benefit from additional follow-up and support for developmental issues.

is a professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the editorial board and serves as the schizophrenia section chief for 

. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain and Behavior Research Foundation, and the Stanley Medical Research Institute.

1. Stein A, Pearson RM, Goodman SH, et al. 

Effects of perinatal mental disorders on the fetus and child.

Perinatal depression: implications for child mental health.

Maternal infection during pregnancy: increased risk of psychosis in offspring. 

Multifaceted interactions between adaptive immunity and the central nervous system. 

5. Knuesel I, Chicha L, Britschgi M, et al. 

Maternal immune activation and abnormal brain development across CNS disorders

Maternal immune activation: implications for neuropsychiatric disorders.

Maternal inflammation and neurodevelopmental programming: a review of preclinical outcomes and implications for translational psychiatry.

8. Rising Nielsen P, Eriksen Benros M, Dalsgaard S. 

Associations between autoimmune diseases and attention-deficit/hyperactivity disorder: a nationwide study.

9. Nielsen TC, Nassar N, Shand AW, et al. 

Association of maternal autoimmune disease with attention-deficit/hyperactivity disorder in children.

A new research study, based on over 800,000 mothers and children, tests the hypothesis. 

Could Childhood ADHD Have Its Roots in Perinatal Autoimmune Disorders?

It can be difficult to know if treatments for attention-deficit/hyperactivity disorder are having the desired effects. This is in part because clinical procedures commonly rely on self-rated scales and interviews. Could a more objective measurement be added into the mix?

In this Mental Health Minute, Dr Roy discusses the results of 

 on capturing and measuring the effects of ADHD treatments—a study that included a novel objective measurement.

is board certified in internal medicine and pediatrics. He specializes in treating ADHD.

A new combination of subjective and objective measures might finally provide a reliable answer.

Is That ADHD Treatment Working?

 and the importance of its approval by the US Food and Drug Administration. 

is a practicing psychiatrist with a subspecialty in child and adolescent psychiatry, clinical researcher, and president of the Center for Psychiatry and Behavioral Medicine, Inc. in Las Vegas.

This new medication is a huge leap forward for treating attention-deficit/hyperactivity disorder. 

A Welcome Addition to the Child and Adolescent ADHD Armamentarium

Elysa Marco, MD, talks about positive play—how using digital media can enhance specific abilities for kids, especially those with attention-deficit/hyperactivity disorder. 

is a board-certified cognitive and behavioral pediatric neurologist, neuroscience researcher, and author. She specializes in the evaluation and treatment of children with sensory processing disorder, autism, and other neurodevelopmental conditions at Cortica in San Rafael, California.

Kids will find the screens. Health care providers should join them in order to supply the most helpful digital treatments. 

You Can't Beat the Screens

Attention-deficit/hyperactivity disorder (ADHD) is frequently 

 other psychiatric conditions, including psychotic disorders. There is 

 for shared genetic susceptibility to both conditions,

 and first-degree relatives of people with ADHD have twice the risk of having schizophrenia compared with healthy controls.

There is also an added risk of psychosis in patients with comorbid cannabis use. There are overlapping environmental 

 for both disorders, including obstetric complications, preterm birth, and low birth weight.

 There are also abnormalities in overlapping dopaminergic brain circuits in schizophrenia and ADHD.4 However, epidemiologic evidence for the association between psychotic disorders and ADHD remains inconsistent.

 performed a systematic review and meta-analysis of the association between ADHD during childhood and the subsequent risk of developing a psychotic disorder. The authors searched MEDLINE, Scopus, PsycInfo, and Web of Science from inception through November 2015. They included peer-reviewed case-control and cohort studies of children younger than 18 with ADHD (using any recognized diagnostic criteria) with a comparison group.

The primary outcome was occurrence of any psychotic disorder (also using any recognized diagnostic criteria; including schizophrenia, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, delusional disorder, psychotic disorder not otherwise specified, or schizotypal personality disorder) at or after aged 18 years following a diagnosis of ADHD. They excluded studies with attention deficits or impulsivity without any ADHD diagnosis or adult ADHD diagnosis, or psychotic disorders that were diagnosed before or concurrently with ADHD. 

Relevant data—including relative risks (RR), odds ratios (OR), hazard ratios (HR), and 95% confidence intervals—were extracted for each study. An assessment of risk of bias and study quality was performed for each included study. Pooled measures of relative effects (eg, RR, OR, HR) were calculated using random-effects meta-analysis. Egger’s test and funnel plots were used to assess for potential publication bias. Subgroup and meta-regression analyses were performed for study design, sex, treatment, relevant psychiatric comorbidities, and type of outcome, but data were not available regarding substance use comorbidity.

The authors screened 3782 records and assessed 45 full-text articles for eligibility. After review, 15 studies (1 case-control and 14 cohorts) were included in the systematic review and 12 studies (1.85 million unique participants) were included in the meta-analysis. The median prevalence of 

 in the cohort studies was 0.5% for controls and 2.7% for the ADHD population, corresponding to an approximately 5-fold increased risk of subsequent psychotic disorder in children with ADHD (relative effect = 4.74, 95% CI 4.11-5.46).

Findings were similar in subgroup analyses (including schizophrenia versus other psychotic disorders, as well as the presence or absence of follow-up after aged 18 years). In meta-regression analyses, sex, and study quality did not moderate the association. There was no evidence of publication bias.

The authors performed the first meta-analysis of observational studies on the association between ADHD and psychotic disorders. They note that substance use disorder comorbidity is common to both conditions, and that the effects of 

 are also an important consideration, as there is inconsistent evidence on the possible association between chronic psychostimulant treatment and subsequent risk of psychotic disorder. 

There was inadequate data to consider effects of either substance use or psychostimulants in the present meta-analysis, and thus this information is relevant to future studies. They also note that psychotic symptoms and ADHD symptoms may overlap and can be confused and misdiagnosed (

). Strengths of the study included the large sample size and absence of publication bias. Limitations include clinical heterogeneity in the study populations, diagnostic criteria, and outcomes.

“Mr D” is a 21-year-old African American male outpatient at the community mental health center. He has a diagnosis of ADHD, combined type, and as a child, he received remote treatment with an unknown stimulant medication. His sister has depression, but his family history is otherwise unremarkable. At age 19, he was admitted for 1 week to the state psychiatric hospital because he had command auditory hallucinations for self-harm and began banging his head against the wall. He subsequently received a diagnosis of schizophrenia and cannabis use disorder. For the past year, he has been clinically stable on antipsychotic medication without additional psychiatric hospitalizations.

A childhood diagnosis of ADHD increased the risk of subsequent psychotic disorder almost 5-fold, independent of sex and diagnostic outcome (schizophrenia versus other psychotic disorder). Early detection (and management) of psychotic disorders in children with an ADHD diagnosis is essential.

1. Hamshere ML, Stergiakouli E, Langley K, et al. 

Shared polygenic contribution between childhood attention-deficit hyperactivity disorder and adult schizophrenia

Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder

3. Linnet KM, Dalsgaard S, Obel C, et al. 

Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence

4. Howes OD, Kambeitz J, Kim E, et al. The nature of dopamine dysfunction in schizophrenia and what this means for treatment. 

5. Nourredine M, Gering A, Fourneret P, et al. 

Association of attention-deficit/hyperactivity disorder in childhood and adolescence with the risk of subsequent psychotic disorder: a systematic review and meta-analysis

There is evidence for overlapping risk factors and symptomatology between ADHD and psychotic disorders. New research investigates the association between ADHD during childhood and the subsequent risk of developing a psychotic disorder.









Examining the Relationship Between ADHD and Psychotic Disorders

A classification system to identify communication between brain regions brings us closer to predicting and diagnosing attention deficit hyperactivity disorder (ADHD) with better precision than ever before, according to a 

In this Q&A, we speak with lead author of the study, Chris McNorgan, PhD. Dr McNorgan is assistant professor, Department of Psychology at the University at Buffalo, State University of New York, and director of Computational Cognitive Neuroscience Laboratory, in the Department of Psychology at the University at Buffalo — SUNY.

Psychiatric Times (PT): You talk about task-based functional connectivity as a biomarker of ADHD. Can you tell us more about that?

 The challenge with using behavior to diagnose cognitive disorders is that behavior is extremely variable, even within individual patients. Behavioral indicators commonly used to identify ADHD might meet a subjective threshold on one day, but not during a follow-up test, leading to diagnostic instability.

 detects or confirms the presence of a condition of interest by virtue of covarying with the condition: If the biomarker is present, then so is the condition. ADHD is associated with atypical activity patterns, and because the brain does not rewire itself every day, we expected to find persistent differences between ADHD and controls in the connectivity that governs those activity patterns. 

Although a computer is required to represent the complex connectivity patterns that distinguished between controls and ADHD, the high classification accuracy for these machine-learning models establishes that these connectivity patterns provide sufficient evidence to reliably identify ADHD.

PT: What new information does the study provide?

 Ours was not the first study that assumed ADHD can be identified by characteristic functional connectivity. However, the substantial improvement in prediction accuracy over previous studies tells us a few things. First, that task-based functional connectivity within a brain network involved in a task that taxes inhibitory control appears to be more predictive of ADHD than resting state connectivity collected while individuals let their minds wander.

The second finding is more of an analytic innovation, explicitly tying diagnostic accuracy to performance on a relevant behavioral task. The 

 (IGT) was developed under a particular theory about the role of inhibitory processing in ADHD. However, just because it is theoretically tied to ADHD does not make it so. 

Because the classifiers had to identify both IGT performance and ADHD diagnosis from the same set of functional connections, it had to find which connections, if any, were predictive of both. Successfully solving the problem established that performance on the IGT is relevant to ADHD by virtue of the fact that the same functional connections predict both. The study provides a template for similarly linking other diagnostic measures to outcomes.

PT: What can you tell us about the future of machine learning in predicting ADHD with diagnostic accuracy?

 Although task-based connectivity was more diagnostic than resting-state, running an experimental task in an MRI scanner will not be a practical diagnostic tool anytime soon. However, by explicitly linking neuroimaging results to easily administered behavioral tasks, models like this might be used in the future. They may translate a particular behavioral performance profile into a likely connectivity profile confirmed by MRI if need be. These results might inform the choice of intervention. 

ADHD diagnoses have been described as unstable: The same individual may fall above or below threshold at different times. So the fact that childhood ADHD diagnoses were 

 in fMRI scans taken from young adults is remarkable, and I think points to the disorder as something that is deeply ingrained at the neurological level, although it may appear much more transitory at the behavioral level. We do not have information about severity in the participants at the time of the scan, but even if we assumed all of them were symptom-free, their brains are clearly doing something identifiably different.

Finally, these models are remarkably accurate because they make use of many different data points. The optimal precision was calculated based on 4 individual fMRI scans per participant. There may be different subtypes that could be identified by an extension of this paradigm using new tasks. All this points to the general idea that having more information on-hand leads to better evaluations, though the information required to achieve very high accuracy may take a computer to process it.

PT: Did you find anything in your research that was unexpected?

 In hindsight, finding subgroups seems obvious, but we were not looking for different connectivity profiles for high- and low-scorers on the IGT. This was purely for a proof-of-concept, and to make it easier to argue that the classifier had identified activity that was related to inhibitory control. This got us thinking about how this sort of approach might be useful for identifying subpopulations.

PT: Can you tell us about future directions in this research?

 There are a few interesting directions that immediately suggest themselves. Clinical endpoints may be based on subjective self-report. As a surrogate, the 

 must not only be correlated with the condition, but evidence of a causal link must be established between the condition and the biomarker. Research that examines whether and/or which interventions lead to related changes in functional connectivity and in clinical endpoints might establish functional connectivity as a surrogate endpoint. This would allow connectivity to provide additional context for interpreting subjective patient reports.

A second direction would be to link diagnostically predictive connectivity patterns to other commonly used behavioral indicators. We found different connectivity profiles for those with ADHD that scored uncharacteristically high on the IGT, which is commonly used in an experimental setting. This indicates that individuals with ADHD may be differentiated by different patterns of hyper- or hypo-connectivity, and these differences may inform choice of intervention, eg, a drug that targets the hypo-connected circuit. 

 to performance on other tasks more commonly used in a clinical setting may lead to more effective treatment of ADHD in patients who show atypical performance on 1 or more clinically relevant measures.

1. McNorgan C, Judson C, Handzlik, Holden JG. Linking ADHD and Behavioral Assessment Through Identification of Shared Diagnostic Task-Based Functional Connections. 

 2020;11:583005. Accessed April 13, 2021. 

https://www.frontiersin.org/articles/10.3389/fphys.2020.583005/full

New research brings us closer to linking diagnostically predictive connectivity patterns in patients with ADHD.

Advances in Predicting and Diagnosing ADHD

 and there is evidence that activation of the maternal immune system during pregnancy—whether by infection, chronic inflammation, or autoimmune disease—is associated with increased risk of neurodevelopmental disorders in the 

 In the case of the latter, maternal autoantibodies may cross the placenta and alter fetal development through epigenetic changes, brain microglial cell activation, and modulation of 

 Previous studies have focused on the association between maternal autoimmune disease and autism spectrum disorders, whereas attention-deficit/hyperactivity disorder (ADHD) has been less studied. Only 1 previous study examined the association between any maternal autoimmune disease and ADHD risk in 

Nielsen and colleagues aimed to investigate the association between any (and specific) maternal autoimmune disease and ADHD in children, and to incorporate those results into 

a systematic review and meta-analysis on this topic

 Using the New South Wales (NSW) Perinatal Data Collection, they identified all women with full-term, singleton live births from July 2000 to December 2010. Birth data were linked to all hospital admissions for both mother and child, and pharmaceutical data from the child for treatment of ADHD through registers. A child was considered to have ADHD if they had a stimulant prescription for ADHD and/or a hospital diagnosis of ADHD. Children linked to a first ADHD event before age 3 were excluded. Children were followed to death or at the end of follow-up in December 2014.

The authors also performed a systematic search of MEDLINE, Embase, and Web of Science to identify studies on the association between maternal autoimmune disease and ADHD. Included studies were assessed for study quality using the Newcastle-Ottawa Quality Assessment Scale. Meta-analyses of any (and specific) maternal autoimmune disease with ADHD in the offspring were performed by calculating random-effects pooled hazard ratios (HRs) and inverse-variance weighting.

In the NSW Perinatal Data Collection, 831,718 mothers and children were including and 12,767 (1.5%) exposed to maternal autoimmune disease. Propensity score matching including a cohort of 12,610 exposed children and 50,440 controls. During follow-up, 1094 male (3.4%) and 332 female (1.1%) children were diagnosed with ADHD. After adjustment, any maternal autoimmune disease (HR = 1.30), type 1 diabetes mellitus (HR = 2.23), psoriasis (HR = 1.66), and rheumatic fever or carditis (HR = 1.75) were associated with increased risk of ADHD, and this association was not moderate by child sex. When considering mothers diagnosed before or within 180 days of birth (N = 9700), any maternal autoimmune disease (HR = 1.28) and type 1 diabetes mellitus (HR = 1.95) remained significantly associated with ADHD.

Five studies, including the present cohort, were included in the meta-analysis. Two studies estimated the association with any maternal autoimmune disease, and 11 specific conditions were investigated in 2 or more individual studies. In the meta-analyses, any maternal autoimmune disease (HR = 1.20), type 1 diabetes mellitus (HR = 1.53), hyperthyroidism (HR = 1.15), and psoriasis (HR = 1.31), were all associated with increased risk of ADHD.

The authors found an association between any maternal autoimmune disease, type 1 diabetes mellitus, and psoriasis in both the present study and meta-analysis, and an association with hyperthyroidism in the meta-analysis. They noted significant heterogeneity in findings across individual studies, and that non-immune factors such as glycemic control (in type 1 diabetes) and endocrine aspects of hyperthyroidism may also contribute to associations with ADHD.

is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

1. Kipnis J. Multifaceted interactions between adaptive immunity and the central nervous system. 

2. Knuesel I, Chicha L, Britschgi M, et al. Maternal immune activation and abnormal brain development across CNS disorders. 

3. Estes ML, McAllister AK. Maternal immune activation: Implications for neuropsychiatric disorders. 

4. Gumusoglu SB, Stevens HE. Maternal inflammation and neurodevelopmental programming: a review of preclinical outcomes and implications for translational psychiatry. 

5. Nielsen PR, Benros ME, Dalsgaard S. Associations between autoimmune diseases and attention-deficit/hyperactivity disorder: a nationwide study. 

6. Nielsen TC, Nassar N, Shand AW, et al. Association of maternal autoimmune disease with attention-deficit/hyperactivity disorder in children. 

Activation of the maternal immune system during pregnancy is associated with increased risk of neurodevelopmental disorders in children. A recent review and meta-analysis examine the link in ADHD.

Maternal Autoimmune Disease and ADHD Risk in Children

An international group of experts analyzed findings from a large pool of select studies and developed an updated consensus statement with declarations about attention deficit hyperactivity disorder (ADHD). They curated a collection of validated statements, addressing questions on topics ranging from nutrition, neuropsychiatry, and nonpharmacologic treatments. The 

Lead author Stephen V. Faraone, PhD, joins us in this Q&A to talk about the study. Dr Faraone is Distinguished Professor in the Departments of Psychiatry and Neuroscience and Physiology, Psychiatry Research Division, SUNY Upstate Medical University, Syracuse, New York. He is President of the 

Psychiatric Times (PT): What prompted the consensus guidelines and why are they important now?

Despite a large scientific literature about ADHD, much misinformation about ADHD is spread by the internet and other media. This creates 

 and leads to treatment decisions that are not in the best interests of patients. Our consensus provides clinicians, patients, and family members evidence-based results they can use to make informed decisions.

I asked thought leaders from ADHD professional associations from around the world to nominate authors for the project.

PT: Since this is a worldwide consensus statement with 27 countries represented, what sort of differences did you find internationally? How does the United States

compare with other countries in terms of recognition and treatment?

The prevalence of ADHD, the symptoms of the disorder and its outcomes are essentially the same around the world, with some small exceptions. The main difference is in how often ADHD is appropriately diagnosed and treated. Diagnosis and treatment rate are better in countries with well-developed health care systems compared with other countries. The United States has higher rates of diagnosis compared with other high-income countries, although ADHD in adults is underdiagnosed in the United States and around the world.

PT: The article talks about stigma of both patients with ADHD and the health professionals who treat the disorder. Can you tell us more about that?

For patients diagnosed with ADHD, stigma leads to decreased self-esteem, less acceptance by peers, social isolation, and lower self-perceptions of confidence. When treatments are stigmatized, patients and parents are less likely to seek appropriate treatment. Moreover, clinicians are less likely to provide those treatments. This leads to unnecessary distress and disability and costs to society.

PT: The piece came up with 208 empirically supported statements about ADHD. Which ones were most impactful? What new information does the paper provide?

The degree of impact will vary with the reader. Learning about what treatments do and do not work for ADHD can be life changing for patients and families. Learning that ADHD costs societies billions of dollars each year will motivate policy makers to improve access to care. Learning about the medical conditions associated with ADHD will be of much interest to primary care clinicians.

By definition, strong evidence cannot be “new” because it arises from published scientific studies. But I expect that much of this information will be new to most nonprofessional readers and for those professionals that are new to 

PT: Of what clinical relevance is the consensus statement, and does it offer teaching points for readers?

In a nutshell, clinicians will learn that ADHD is a well-defined condition that can be diagnosed at any age; untreated ADHD has many, many serious consequences ranging from school failure in childhood to criminality in adulthood; and the medications for treating ADHD are much more effective than nonmedical treatments for relieving ADHD symptoms.

• ADHD is not an invention of modern society. The syndrome had been reported in medical writings in Europe as early as 1775.

• ADHD is rarely caused by a single genetic or environmental risk factor, but most cases of ADHD are caused by the combined effects of many genetic and environmental risks each having a very small effect.

• Neuroimaging studies find small differences in the structure and functioning of the brain between people with and without ADHD. These differences cannot be used to diagnose ADHD.

I was surprised to learn that ADHD puts people at increased risk for many medical disorders including obesity, asthma, allergies, diabetes mellitus, hypertension, sleep problems, psoriasis, epilepsy, sexually transmitted infections, abnormalities of the eye, immune disorders, and metabolic disorders.

Our next goal is to disseminate the International Consensus Statement as widely as possible. It has been translated into Spanish, French, and German and we also have a summary in Welsh. Colleagues are currently in the process of translating it into Mandarin, Turkish, Portuguese, Arabic, Hindi, Dutch, Japanese, and Italian. These translations will be available at the World Federation of ADHD website.

Readers can learn more about the Consensus Statement from Dr Faraone via Twitter: 

1. Faraone SV, Banaschewski T, Coghill D, et al. The World Federation of ADHD International Consensus Statement: 208 Evidence-based Conclusions about the Disorder. 

 2021;S0149-7634(21)00049-X. Accessed April 4, 2021. 

https://www.sciencedirect.com/science/article/pii/S014976342100049X#abs0010

A collection of validated statements addresses overarching topics ranging from nutrition, neuropsychiatry, and nonpharmacologic treatments.

ADHD