Attention deficit hyperactivity disorder symptoms and disordered eating in the English general population

The use and misuse of the SCOFF screening measure over two decades: a systematic literature review

PURPOSE

The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested.

METHODS

The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors.

RESULTS

180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use.

CONCLUSION

This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested.

LEVEL OF EVIDENCE

Level I.

Attention-deficit hyperactivity disorder is associated with disordered eating in adolescents

AIM

Attention-deficit hyperactivity disorder (ADHD) and disordered eating (DE) are both highly prevalent among adolescents, but their relationship is understudied. This study examines their possible association in a nationally representative sample of adolescents.

METHODS

Participants in the Israeli Youth Health and Nutrition Survey (2015-2016), a cross-sectional, school-based study, completed self-administered questionnaires, including the SCOFF questionnaire, and underwent anthropometric measurements. An affirmative reply to at least two SCOFF items was considered a DE case. Multivariable logistic regression evaluated the ADHD-DE association and the associations between ADHD and individual SCOFF items, controlling for age, sex, socioeconomic status, and body mass index.

RESULTS

Of 4616 participants (12-18 years, 50.2% male), 654 reported an ADHD diagnosis. DE prevalence among ADHD adolescents was significantly higher than the non-ADHD group (50.2% vs. 43.9%, p = 0.003). Controlling for potential covariates, the association between ADHD and DE remained significant (OR = 1.409; 95% CI: 1.170-1.697), as did associations between ADHD and three SCOFF items. No difference in DE prevalence was found between stimulant-treated (n = 287) and untreated (n = 326) adolescents with ADHD.

CONCLUSION

Adolescents with ADHD are more likely to experience DE. As DE can herald an imminent eating disorder, early identification is crucial. Further studies are needed to determine the ADHD-DE relationship's causality.

IMPACT

Disordered eating (DE) and attention-deficit hyperactivity disorder (ADHD) are common among adolescents, and significantly affect health and well-being. This study examined the association between ADHD and DE in adolescents using the SCOFF questionnaire. Following adjustment for sociodemographic variables and BMI z-score, ADHD was associated with a 41% increased odds for DE. This study established the association between ADHD and DE, using a well-known questionnaire, in a large, nationally representative sample of adolescents. Monitoring eating behaviors and attitudes among adolescents with ADHD should be a priority, to minimize the risk of developing an eating disorder and its harmful consequences.

Processed Food-Sweets Patterns and Related Behaviors with Attention Deficit Hyperactivity Disorder among Children: A Case-Control Study

BACKGROUND

Previous studies have focused on the associations between core symptoms and dietary intake in children with attention deficit hyperactivity disorder (ADHD). However, few studies have explored how dietary patterns and behaviors relate to the risk of ADHD. The aim of our study is to explore the associations between dietary patterns and behaviors and the risk of ADHD, which could provide evidence for follow-up and treatments for children with ADHD.

METHODS

We conducted a case-control study, including 102 children diagnosed with ADHD and 102 healthy children. The food frequency questionnaire (FFQ) and the children's eating behavior questionnaire (CEBQ) were used to investigate food consumption and eating behaviors. We applied exploratory factor analysis for constructing dietary patterns, and the factor scores were adopted for log-binomial regression to assess the associations between how dietary patterns and eating behaviors affect the risk of ADHD.

RESULTS

We extracted five dietary patterns with a cumulative contribution rate of 54.63%. Processed food-sweets scores revealed positive associations with an increased risk of ADHD (OR = 1.451, 95% CI: 1.041-2.085). Moreover, processed food-sweets tertile 3 was associated with an increased risk of ADHD (OR = 2.646, 95% CI: 1.213-5.933). In terms of eating behaviors, the group with a higher score relating to a desire to drink was also positively correlated with the risk of ADHD (OR = 2.075, 95% CI: 1.137-3.830).

CONCLUSIONS

In the treatment and follow-up of children with ADHD, dietary intake and eating behaviors should be considered.

Eating behavior-mediated association between attention deficit hyperactivity disorder and body fat mass

Background

Adverse eating behaviors and a high rate of obesity have been identified among children diagnosed with attention deficit hyperactivity disorder (ADHD). In this study, we investigate the relationships between eating behaviors and body fat mass among children with ADHD.

Methods

All participants were recruited from the Children's Health Care Department of the Children's Hospital of Nanjing Medical University from June 2019 to June 2020. ADHD was diagnosed according to the diagnostic criteria of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by psychiatrists. Core ADHD symptoms defined by the DSM-5 were inattention and hyperactivity/impulsivity. The anthropomorphic indices defined by the World Health Organization (WHO) were utilized in this study (body mass index [BMI], underweight, normal body mass, overweight, obesity, short stature). Body fat mass, fat mass percentage (FM%), skeletal muscle mass, skeletal muscle mass percentage (SMM%) were tested via body composition meter, and eating behaviors were assessed by parents using the Chinese version of the Children's Eating Behavior Questionnaire (CEBQ). The CEBQ was comprised of subscales related to food avoidant behaviors (satiety responsiveness, slowness in eating, fussiness, and emotional undereating) and food approach behaviors (food responsiveness, enjoyment of Food, desire to drink, and emotional overeating). The associations among ADHD, obesity and adverse eating behavior were tested through correlation analysis, and a mediating effect model was established to explore the effect of eating behaviors.

Results

A total of 548 participants aged 4-12 years were recruited. Among them, 396 were diagnosed with ADHD, with the remaining 152 enrolled in a control group. Compared with the control group, the ADHD group had higher incidences of overweight (22.5% vs. 14.5%) and obesity (13.4% vs. 8.6%) (p < 0.05). The ADHD group was more likely to display "slowness in eating" (11.01 ± 3.32 vs. 9.74 ± 2.95), "fussiness" (15.61 ± 3.54 vs. 15.03 ± 2.84), "food responsiveness" (11.96 ± 4.81 vs. 9.88 ± 3.71) and "desire to drink" (8.34 ± 3.46 vs. 6.58 ± 2.72) (p < 0.05). Moreover, The FM% of children with ADHD was positively correlated with inattention (β = 0.336, 95% CI: 0.001 to 0.673) and "food responsiveness" (β = 0.509, 95% CI: 0.352 to 0.665) in the multiple linear regression model. The mediation effect model showed that "food responsiveness" accounted for a significant portion (64.2%) of the mediating effect.

Conclusion

Children with ADHD had higher prevalence of overweight and obesity. As an important risk factor, food responsiveness may connect core symptoms of ADHD with obesity.

Associations between inattention and impulsivity ADHD symptoms and disordered eating risk in a community sample of young adults

BACKGROUND

Symptoms of attention deficit hyperactivity disorder (ADHD) and trait impulsivity have been associated with disordered eating but are seldom assessed in community studies, or longitudinally and little is known about the mediating mechanisms.

METHODS

We tested associations between ADHD symptoms and disordered eating cross-sectionally and between trait impulsivity and disordered eating longitudinally. We utilised data from a normative cohort of young adults (642 participants: 65% female, M_age = 23 years). Participants were classified as high risk or low risk for disordered eating using the SCOFF instrument. In the first two steps of both cross-sectional and longitudinal hierarchical logistic regression models, demographics and covariates were entered. For the cross-sectional regression, Adult ADHD self-report scale (ASRS) scores, separated into inattentive and hyperactive/impulsive symptoms, were entered in the third step. In a separate longitudinal model, Barratt impulsivity scale subscales (attentional, motor and non-planning impulsivity) were entered in the third step. Depression, as assessed by the moods and feelings questionnaire (MFQ), was examined as a mediator.

RESULTS

Cross-sectionally, sex, MFQ score and inattentive symptoms predicted disordered eating risk (model R² = 20%). Longitudinally, sex, MFQ score and attentional impulsivity predicted disordered eating risk (model R² = 16%). The relationship between inattentive symptoms and the disordered eating risk was partially mediated by MFQ score, whereas the relationship between attentional impulsivity and the disordered eating risk was fully mediated by MFQ scores.

CONCLUSIONS

These data highlight (1) a specific role for inattentive symptoms of ADHD and (2) the importance of both depression and impulsivity in predicting eating disorder risk.

DNA methylation associated with persistent ADHD suggests TARBP1 as novel candidate

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by age-inappropriate symptoms of inattention and/or hyperactivity and impulsivity. ADHD is highly prevalent in childhood and often persists into adulthood. Both genetic variants and environmental factors play a role in the onset and persistence of ADHD, and epigenetic changes, such as DNA methylation are considered as a link for their interplay. To investigate this, we studied DNA methylation in 37 candidate genes by performing targeted bisulfite sequencing of DNA isolated from whole blood of N = 88 individuals diagnosed with adult ADHD and N = 91 unaffected individuals (mean age 34.2 years). Differentially methylated sites were assessed by generalized linear models testing ADHD status and ADHD symptoms, accounting for a methylation-based smoking score, age, sex, and blood cell count. DNA methylation of single sites within DRD4 and KLDR1 was associated with adult ADHD status, and multiple DNA methylation sites within TARBP1 were associated with ADHD symptoms in adulthood and childhood. Awaiting replication, findings of this pilot study point to TARBP1 as a new candidate gene for ADHD symptoms. Our work also stresses the need for research to further examine the effects of environmental factors, such as nicotine exposure, on epigenetic modifications associated with psychiatric traits.

Negative Affectivity and Emotion Dysregulation as Mediators between ADHD and Disordered Eating: A Systematic Review

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with disordered eating, especially addictive-like eating behavior (i.e., binge eating, food addiction, loss of control overeating). The exact mechanisms underlying this association are unclear. ADHD and addictive-like eating behavior are both associated with negative affectivity and emotion dysregulation, which we hypothesized are mediators of this relationship. The purpose of this systematic review was to review the evidence related to this hypothesis from studies assessing the relationship between childhood or adulthood ADHD symptomatology, negative affectivity, emotion dysregulation and addictive-like eating behavior. The systematic review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations. The literature search was conducted in PubMed and PsycINFO (publication date: January 2015 to August 2020; date of search: 2 September 2020). Out of 403 potentially relevant articles, 41 were retained; 38 publications reported that ADHD and disordered eating or addictive-like eating behavior were significantly associated, including 8 articles that suggested a mediator role of negative affectivity or emotion dysregulation. Sixteen publications reported that the association between ADHD symptomatology and disordered eating or addictive-like eating behavior differed according to gender, eating behavior and ADHD symptoms (hyperactivity, impulsivity and inattention). We discuss the practical implications of these findings and directions future research.