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Ann Johns D, Quirk SE, Pasco JA, Hyde NK, Williams LJ. Parental mental health during preconception years in association with offspring attention deficit hyperactivity disorder (ADHD): a systematic review protocol. BMJ Open 2024; 14:e082958. [PMID: 39122396 PMCID: PMC11331898 DOI: 10.1136/bmjopen-2023-082958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric condition prevalent in both children and adults. With growing awareness of the importance of the preconception period in health, it is essential to understand whether preconception parental mental health and related factors are related to onset of offspring ADHD. This protocol presents the methodology for undertaking a systematic review to investigate associations between parental mental health and/or psychotropic use during the preconception years and offspring ADHD. METHODS AND ANALYSIS Peer-reviewed literature will be identified by searching relevant electronic databases including Medline complete, Embase, PsycINFO and CINAHL; reference lists of eligible articles will be hand searched and grey literature considered. Eligible study designs include population-based and/or clinically based cohort or case-control studies. The primary exposure and outcome of interest is parental history of mental health conditions in the preconception period and offspring ADHD, respectively (ie, according to semistructured interviews/confirmed diagnosis by a relevant health professional or screening instruments). Critical appraisal will be undertaken. A descriptive synthesis will be presented including characteristics of the included studies, critical appraisal scores and a summary of main findings (eg, presented in tables, text and figures). A meta-analysis will be conducted, if possible, and statistical techniques will be employed if heterogeneity is detected. ETHICS AND DISSEMINATION Ethical permissions are not required for this systematic review since the study will only use published data. Findings from this systematic review will be published in a peer-reviewed scientific journal/presented at national and international conferences relevant to the field. PROSPERO REGISTRATION NUMBER CRD42023460379.
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Affiliation(s)
- Ditty Ann Johns
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Shae E Quirk
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Julie A Pasco
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
- University Hospital, Geelong, Victoria, Australia
- Department of Medicine, Western Health, University of Melbourne, St. Albans, Victoria, Australia
- Department of Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Natalie K Hyde
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
- University Hospital, Geelong, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Lana J Williams
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
- University Hospital, Geelong, Victoria, Australia
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Mazurek C, Barry TD, Fisher K. Low neurocognitive performance and problematic contexts: interaction influences in predicting adolescent externalizing behaviors within a community sample. Child Neuropsychol 2024:1-25. [PMID: 39072450 DOI: 10.1080/09297049.2024.2375804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 06/28/2024] [Indexed: 07/30/2024]
Abstract
Research has identified neurocognitive and contextual risk factors of externalizing behaviors. However, fewer studies have examined the interaction among neurocognitive and other risk factors in predicting externalizing behaviors. The goal of the current study was to examine the relation between neurocognitive and contextual factors in predicting externalizing behaviors in a community sample of adolescents. Participants were 84 adolescents, aged 11-17 (M = 13.39, SD = 1.82), recruited as part of a larger study. Separate moderated multiple regression models were utilized in which neurocognitive variables (intellectual functioning, short-term memory/attention, disinhibition) were added as predictors and contextual variables (family dysfunction and parental depression, anxiety, and stress) were added as moderators in step 1, and their interaction was added in step 2. Externalizing behaviors served as criterion variables (hyperactivity/impulsivity and oppositional defiant disorder symptom severity, reactive and proactive aggression). Overall, results suggest that higher levels of problematic contextual factors exacerbate the significant negative associations among neurocognitive functioning and externalizing behaviors. Importantly, this pattern was shown across neurocognitive domains and contextual factors. Findings suggest that contextual factors should be targeted for the treatment or prevention of youth externalizing behaviors, particularly for adolescents with neurocognitive vulnerabilities.
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Affiliation(s)
- Callie Mazurek
- Department of Psychology, Washington State University, Pullman, WA, USA
| | - Tammy D Barry
- Department of Psychology, Washington State University, Pullman, WA, USA
| | - Karin Fisher
- Allina Health Care & Medical Services, Minneapolis, MN, USA
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Barbieri V, Piccoliori G, Engl A, Wiedermann CJ. Parental Mental Health, Gender, and Lifestyle Effects on Post-Pandemic Child and Adolescent Psychosocial Problems: A Cross-Sectional Survey in Northern Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:933. [PMID: 39063509 PMCID: PMC11277222 DOI: 10.3390/ijerph21070933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/06/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND The exacerbation of psychosocial problems among children and adolescents during the coronavirus disease 2019 (COVID-19) pandemic necessitates an assessment of the long-term mental health impact of pandemic interventions. Focusing on both pandemic-related factors and demographic variables, such as gender and daily habits, an analysis was conducted to understand how these elements continue to affect young populations in the post-pandemic era. METHODS In April 2023, a comprehensive online survey was administered to families in South Tyrol, Italy, with children aged 7-19 years, to ensure age and gender representation. The survey included parent ratings and adolescent (11-19 years) self-reports using standardized instruments to measure the symptoms of mental health problems (Strengths and Difficulties Questionnaire, SDQ), anxiety (Screen for Child Anxiety Related Emotional Disorders, SCARED), and depression (Patient Health Questionnaire-2, PHQ-2). Statistical analyses included descriptive statistics, chi-square tests, and unadjusted odds ratios (ORs). RESULTS Of the 4525 valid responses, 1831 were self-reported by adolescents. Notable gender differences in mental health outcomes were identified, along with significant demographic predictors, such as age, single parenthood, parental mental health problems, and immigrant background. Negative effects were associated with reduced family climate and increased screen time, whereas physical activity showed beneficial effects. Proxy reports overestimated adolescents' mental health problems, whereas self-reports tended to underestimate them. CONCLUSIONS Persistent mental health problems and gender disparities highlight the need for a public health approach. This should include accessible support services, resilience building, targeted support for vulnerable families and gender-specific interventions.
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Affiliation(s)
- Verena Barbieri
- Institute of General Practice and Public Health, Claudiana College of Health Professions, 39100 Bolzano, Italy
| | - Giuliano Piccoliori
- Institute of General Practice and Public Health, Claudiana College of Health Professions, 39100 Bolzano, Italy
| | - Adolf Engl
- Institute of General Practice and Public Health, Claudiana College of Health Professions, 39100 Bolzano, Italy
| | - Christian J. Wiedermann
- Institute of General Practice and Public Health, Claudiana College of Health Professions, 39100 Bolzano, Italy
- Department of Public Health, Medical Decision Making and Health Technology Assessment, University of Health Sciences, Medical Informatics and Technology, 6060 Hall, Austria
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Jean FAM, Moulin F, Schwartz AN, Castel L, Montagni I, Macalli M, Notredame CE, Côté SM, Galéra C. Association between ADHD symptoms and illicit stimulants use following 1 year among French university students of the i-Share cohort. Soc Psychiatry Psychiatr Epidemiol 2024; 59:887-897. [PMID: 37268785 DOI: 10.1007/s00127-023-02499-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 05/24/2023] [Indexed: 06/04/2023]
Abstract
PURPOSE Although attention deficit hyperactivity disorder (ADHD) has been associated with illicit stimulants use, less is known about their prospective association in university students. We aimed to examine the association between ADHD symptoms at inclusion and illicit stimulants use following 1 year among university students. METHODS The i-Share cohort recruited French students from February 2013 to July 2020. The study included 4270 participants. The Adult ADHD Self-Report Scale (ASRS) was used to evaluate ADHD symptoms at inclusion. Illicit stimulants use was assessed at inclusion and 1 year after inclusion. Multivariable logistic regressions were conducted to assess the association between ADHD symptoms at inclusion and illicit stimulants use following 1 year. RESULTS High levels of ADHD symptoms at inclusion were associated with a greater probability of illicit stimulants use following 1 year (adjusted OR: 2.42 (1.51-3.8)). The adjusted odds ratio was 2.7 (1.08-7.84) among participants who had used illicit stimulant at least once (continuation) and 2.25 (1.04-4.37) among participants who had never used illicit stimulants at inclusion (initiation). CONCLUSION High levels of ADHD symptoms are a feature that may promote both initiation and continuation of illicit stimulants use among university students. Our findings suggest that university students with high levels of ADHD symptoms may benefit from screening to help identify those at risk of illicit stimulants use.
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Affiliation(s)
- François A M Jean
- Department of Psychiatry, Dr Jean Eric Techer Hospital, Calais, France
- University of Bordeaux, Bordeaux, France
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France
| | - Flore Moulin
- University of Bordeaux, Bordeaux, France
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France
| | - Ashlyn N Schwartz
- University of Bordeaux, Bordeaux, France
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France
- Department of Public Health, University of Tennessee, Knoxville, USA
| | - Laura Castel
- University of Bordeaux, Bordeaux, France
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France
| | - Ilaria Montagni
- University of Bordeaux, Bordeaux, France
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France
| | - Mélissa Macalli
- University of Bordeaux, Bordeaux, France
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France
| | - Charles-Edouard Notredame
- University of Lille, Lille, France
- PSY Lab, Lille Neuroscience & Cognition Centre, INSERM U1172, National Institute of Health and Medical Research (Institut National de la Santé et de la Recherche Médicale-INSERM), Lille, France
- Teaching Hospital of Lille (Centre Hospitalier Universitaire de Lille-CHU de Lille), Lille, France
| | - Sylvana M Côté
- University of Bordeaux, Bordeaux, France
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France
- University of Montreal, Montreal, Canada
| | - Cédric Galéra
- University of Bordeaux, Bordeaux, France.
- Bordeaux Population Heltch Research Center, UMR1219, HEALTHY Team, National Institute of Health and Medical Research (Institut National de La Santé Et de La Recherche Médicale-INSERM), Bordeaux, France.
- Charles Perrens Hospital, Bordeaux, France.
- Pôle Universitaire de Psychiatrie de L'enfant et de L'adolescent, Centre Hospitalier Charles-Perrens, 146Bis, rue Léo-Saignat, 33076, Bordeaux, France.
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Rattay K, Robinson LR. Identifying Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD): a Public Health Concern and Opportunity. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:195-202. [PMID: 38598041 PMCID: PMC11315233 DOI: 10.1007/s11121-024-01667-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders with significant individual and societal negative impacts of the disorder continuing into adulthood (Danielson et al. in Journal of Clinical Child and Adolescent Psychology, in press; Landes and London in Journal of Attention Disorders 25:3-13, 2021). Genetic and environmental risk (e.g., modifiable exposures such as prenatal tobacco exposure and child maltreatment) for ADHD is likely multifactorial (Faraone et al. in Neuroscience & Biobehavioral Reviews 128:789-818, 2021). However, the evidence for potentially modifiable contextual risks is spread across studies with different methodologies and ADHD criteria limiting understanding of the relationship between early risk factors and later childhood ADHD. Using common methodology across six meta-analyses (Bitsko et al. in Prevention Science, 2022; Claussen et al. in Prevention Science 1-23, 2022; Dimitrov et al. in Prevention Science, 2023; Maher et al. in Prevention Science, 2023; Robinson, Bitsko et al. in Prevention Science, 2022; So et al. in Prevention Science, 2022) examining 59 risk factors for childhood ADHD, the papers in this special issue use a public health approach to address prior gaps in the literature. This introductory paper provides examples of comprehensive public health approaches focusing on policy, systems, and environmental changes across socio-ecological contexts to improve health and wellbeing through prevention, early intervention, and support across development using findings from these meta-analyses. Together, the findings from these studies and a commentary by an author independent from the risk studies have the potential to minimize risk conditions, prioritize prevention efforts, and improve the long-term health and wellbeing of children and adults with ADHD.
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Affiliation(s)
- Karyl Rattay
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Lara R Robinson
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention, Atlanta, GA, USA
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Maher BS, Bitsko RH, Claussen AH, O'Masta B, Cerles A, Holbrook JR, Mahmooth Z, Chen-Bowers N, Rojo ALA, Kaminski JW, Rush M. Systematic Review and Meta-analysis of the Relationship Between Exposure to Parental Substance Use and Attention-Deficit/Hyperactivity Disorder in Children. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:291-315. [PMID: 37976008 PMCID: PMC11098969 DOI: 10.1007/s11121-023-01605-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/19/2023]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is characterized by persistent patterns of inattention, hyperactivity, and impulsiveness. Among US children and adolescents aged 3-17 years, 9.4% have a diagnosis of ADHD. Previous research suggests possible links between parental substance use and ADHD among children. We conducted a systematic review and meta-analysis of 86 longitudinal or retrospective studies of prenatal or postnatal alcohol, tobacco, or other parental substance use and substance use disorders and childhood ADHD and its related behavioral dimensions of inattention and hyperactivity-impulsivity. Meta-analyses were grouped by drug class and pre- and postnatal periods with combined sample sizes ranging from 789 to 135,732. Prenatal exposure to alcohol or tobacco and parent substance use disorders were consistently and significantly associated with ADHD among children. Other parental drug use exposures resulted in inconsistent or non-significant findings. Prevention and treatment of parental substance use may have potential for impacts on childhood ADHD.
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Affiliation(s)
- Brion S Maher
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rebecca H Bitsko
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Angelika H Claussen
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Joseph R Holbrook
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Naomi Chen-Bowers
- Office Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop: H 21-11, Atlanta, GA, 30329, USA
| | | | - Jennifer W Kaminski
- Office Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop: H 21-11, Atlanta, GA, 30329, USA.
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Faraone SV. Understanding Environmental Exposures and ADHD: a Pathway Forward. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:337-342. [PMID: 38512443 DOI: 10.1007/s11121-024-01672-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
This commentary addresses a series of articles in Prevention Science about environmental causes of attention deficit hyperactivity disorder (ADHD). It provides an overview of their key findings and places them in a broader context to facilitate their interpretation. Each of the articles included in the special issue is a meta-analysis assessing the association of ADHD with several environmental exposures. Each of the author teams systematically searched for articles and defined eligibility criteria. They assured that the measurement of risk factors preceded the measurement of ADHD. Most of the analyses are based on many studies with many participants in the constituent studies. As is typical of any observational epidemiologic study, the constituent studies could not correct for all possible confounds because some were not measured, and some are unknown. For this reason, these meta-analyses may have documented confounded associations, which calls for cautious interpretations. None of the constituent studies assessed what might be the most important type of confounding, familial, and genetic confounding, which occurs when the environmental exposure being studied is correlated with the genetic risk of the disorder being studied or other familial risk factors. Addressing familial/genetic confounding requires a genetically informed study. Because of these issues, the results presented here are intriguing but require further examination before one can conclude that the reported associations correspond to causal events for ADHD. A pathway forward is suggested by drawing parallels between genomic and exposure research.
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Affiliation(s)
- Stephen V Faraone
- Department of Psychiatry and Behavioral Sciences, Norton College of Medicine, SUNY Upstate Medical University, 750 East Adams St., Syracuse, NY, 13210, USA.
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Dimitrov LV, Kaminski JW, Holbrook JR, Bitsko RH, Yeh M, Courtney JG, O'Masta B, Maher B, Cerles A, McGowan K, Rush M. A Systematic Review and Meta-analysis of Chemical Exposures and Attention-Deficit/Hyperactivity Disorder in Children. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:225-248. [PMID: 38108946 PMCID: PMC11132938 DOI: 10.1007/s11121-023-01601-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 12/19/2023]
Abstract
Exposure to certain chemicals prenatally and in childhood can impact development and may increase risk for attention-deficit/hyperactivity disorder (ADHD). Leveraging a larger set of literature searches conducted to synthesize results from longitudinal studies of potentially modifiable risk factors for childhood ADHD, we present meta-analytic results from 66 studies that examined the associations between early chemical exposures and later ADHD diagnosis or symptoms. Studies were eligible for inclusion if the chemical exposure occurred at least 6 months prior to measurement of ADHD diagnosis or symptomatology. Included papers were published between 1975 and 2019 on exposure to anesthetics (n = 5), cadmium (n = 3), hexachlorobenzene (n = 4), lead (n = 22), mercury (n = 12), organophosphates (n = 7), and polychlorinated biphenyls (n = 13). Analyses are presented for each chemical exposure by type of ADHD outcome reported (categorical vs. continuous), type of ADHD measurement (overall measures of ADHD, ADHD symptoms only, ADHD diagnosis only, inattention only, hyperactivity/impulsivity only), and timing of exposure (prenatal vs. childhood vs. cumulative), whenever at least 3 relevant effect sizes were available. Childhood lead exposure was positively associated with ADHD diagnosis and symptoms in all analyses except for the prenatal analyses (odds ratios (ORs) ranging from 1.60 to 2.62, correlation coefficients (CCs) ranging from 0.14 to 0.16). Other statistically significant associations were limited to organophosphates (CC = 0.11, 95% confidence interval (CI): 0.03-0.19 for continuous measures of ADHD outcomes overall), polychlorinated biphenyls (CC = 0.08, 95% CI: 0.02-0.14 for continuous measures of inattention as the outcome), and both prenatal and childhood mercury exposure (CC = 0.02, 95% CI: 0.00-0.04 for continuous measures of ADHD outcomes overall for either exposure window). Our findings provide further support for negative impacts of prenatal and/or childhood exposure to certain chemicals and raise the possibility that primary prevention and targeted screening could prevent or mitigate ADHD symptomatology. Furthermore, these findings support the need for regular review of regulations as our scientific understanding of the risks posed by these chemicals evolves.
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Affiliation(s)
- Lina V Dimitrov
- Division of Human Development and Disability, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA.
| | - Jennifer W Kaminski
- Division of Human Development and Disability, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joseph R Holbrook
- Division of Human Development and Disability, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rebecca H Bitsko
- Division of Human Development and Disability, National Center On Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael Yeh
- Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joseph G Courtney
- Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Brion Maher
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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So M, Dziuban EJ, Pedati CS, Holbrook JR, Claussen AH, O'Masta B, Maher B, Cerles AA, Mahmooth Z, MacMillan L, Kaminski JW, Rush M. Childhood Physical Health and Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Modifiable Factors. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:316-336. [PMID: 35947281 PMCID: PMC10032176 DOI: 10.1007/s11121-022-01398-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 10/15/2022]
Abstract
Although neurobiologic and genetic factors figure prominently in the development of attention deficit/hyperactivity disorder (ADHD), adverse physical health experiences and conditions encountered during childhood may also play a role. Poor health is known to impact the developing brain with potential lifelong implications for behavioral issues. In attempt to better understand the relationship between childhood physical health and the onset and presence of ADHD symptoms, we summarized international peer-reviewed articles documenting relationships between a select group of childhood diseases or health events (e.g., illnesses, injuries, syndromes) and subsequent ADHD outcomes among children ages 0-17 years. Drawing on a larger two-phase systematic review, 57 longitudinal or retrospective observational studies (1978-2021) of childhood allergies, asthma, eczema, head injury, infection, or sleep problems and later ADHD diagnosis or symptomatology were identified and subjected to meta-analysis. Significant associations were documented between childhood head injuries, infections, and sleep problems with both dichotomous and continuous measures of ADHD, and between allergies with dichotomous measures of ADHD. We did not observe significant associations between asthma or eczema with ADHD outcomes. Heterogeneity detected for multiple associations, primarily among continuously measured outcomes, underscores the potential value of future subgroup analyses and individual studies. Collectively, these findings shed light on the importance of physical health in understanding childhood ADHD. Possible etiologic links between physical health factors and ADHD are discussed, as are implications for prevention efforts by providers, systems, and communities.
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Affiliation(s)
- Marvin So
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-E88, Atlanta, GA, 30341, USA.
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA.
| | - Eric J Dziuban
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Caitlin S Pedati
- Virginia Beach Department of Public Health, Virginia Beach, VA, USA
| | - Joseph R Holbrook
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-E88, Atlanta, GA, 30341, USA
| | - Angelika H Claussen
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-E88, Atlanta, GA, 30341, USA
| | | | - Brion Maher
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Jennifer W Kaminski
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-E88, Atlanta, GA, 30341, USA
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Rost K, Gossmann E, Fegert JM, Ziegenhain U, Köhler-Dauner F. Long-term consequences of childhood emotional abuse in mothers on parental load and child mental health. Acta Psychol (Amst) 2024; 244:104169. [PMID: 38341882 DOI: 10.1016/j.actpsy.2024.104169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Childhood emotional maltreatment can be associated with long-term consequences on mental health. In addition, transgenerational transmission of adverse childhood experiences to the next generation can occur and thus have an impact on the mental health of one's own children. OBJECTIVE The purpose of this study was to examine the role of stress on the association between childhood emotional maltreatment and parental load what is referred to in this study as limitations in parental functioning that affect the resources available to parents to cope with the demands of raising, caring for, and providing for their child. Furthermore the effect of parental load on the mental health of one's own children will be examined. PARTICIPANTS AND SETTING N = 237 mother-child dyads (age mother M = 33.76, SD = 4.07 years; age child M = 11.91 months, SD = 0.89 months) from a longitudinal cohort study were examined at two different measuring points. METHODS Emotional abuse, perceived stress, parental load and child mental health were assessed using self and external report questionnaires. RESULTS The calculation of a mediation showed that the association of emotional abuse and parental load was completely mediated by perceived stress (indirect effect ab = 0.44, 95 %-CI[0.17, 0.78]). In addition, effects of parental load on the child's mental health (β = 0.13, 95%CI [0.07;0.20]), mainly hyperactivity (β = 0.06, 95%CI [0.03;0.11]) and prosocial behavior (β = -0.04, 95%CI [-0.07; -0.01]), were evident. CONCLUSIONS The results of this study provide evidence that the mental health of children can be influenced in the long term by increased parental load.
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Affiliation(s)
- Katharina Rost
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany.
| | - Emily Gossmann
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
| | - Ute Ziegenhain
- Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University, Ulm, Germany
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Neuperdt L, Beyer AK, Junker S, Mauz E, Hölling H, Schlack R. [Parental strain, inattention/hyperactivity symptoms and parent-reported ADHD in children and adolescents: results of the KiGGS study]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:429-438. [PMID: 38536438 PMCID: PMC10995013 DOI: 10.1007/s00103-024-03859-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 02/27/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND A child's attention deficit hyperactivity disorder (ADHD) is associated with strain for the parents. In turn, psychosocial parental strain is associated with higher probabilities for the occurrence of inattention/hyperactivity symptoms (IHS) in their children. The aim of this paper is to assess the association between parental strain, IHS, and a parent-reported ADHD diagnosis of the children. METHODOLOGY Based on data from n = 4596 participants of the KiGGS cohort (wave 2: 2014-2017), the type and extent of parental strain was set in relation to IHS and an ADHD diagnosis of the child in cross-sectional analysis. Frequencies, means, beta coefficients, and odds ratios adjusted for sex, age, socioeconomic status, and migration background are reported. RESULTS In individual consideration, a greater number of parental strains were associated with IHS than with an ADHD diagnosis. In a multivariate analysis, financial worries and parenting problems/conflicts with the children were significant predictors of IHS and an ADHD diagnosis, respectively. In addition, four or more types of parental strain were associated with a higher likelihood of both IHS and an ADHD diagnosis. DISCUSSION Financial and child-rearing strain are relevant to parents of children with IHS and an ADHD diagnosis. Interrelationships between parental stress and a child's IHS or an ADHD diagnosis can be assumed. To relieve their burden, prevention can either aim at improving the situation of ADHD-affected families or at improving the family's handling of the child's ADHD.
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Affiliation(s)
- Laura Neuperdt
- Abteilung Epidemiologie und Gesundheitsmonitoring, Fachgebiet Psychische Gesundheit, Robert Koch-Institut, General-Pape-Str. 62-66, 12101, Berlin, Deutschland
| | - Ann-Kristin Beyer
- Abteilung Epidemiologie und Gesundheitsmonitoring, Fachgebiet Psychische Gesundheit, Robert Koch-Institut, General-Pape-Str. 62-66, 12101, Berlin, Deutschland
| | - Stephan Junker
- Abteilung Epidemiologie und Gesundheitsmonitoring, Fachgebiet Psychische Gesundheit, Robert Koch-Institut, General-Pape-Str. 62-66, 12101, Berlin, Deutschland
| | - Elvira Mauz
- Abteilung Epidemiologie und Gesundheitsmonitoring, Fachgebiet Psychische Gesundheit, Robert Koch-Institut, General-Pape-Str. 62-66, 12101, Berlin, Deutschland
| | - Heike Hölling
- Abteilung Epidemiologie und Gesundheitsmonitoring, Fachgebiet Psychische Gesundheit, Robert Koch-Institut, General-Pape-Str. 62-66, 12101, Berlin, Deutschland
| | - Robert Schlack
- Abteilung Epidemiologie und Gesundheitsmonitoring, Fachgebiet Psychische Gesundheit, Robert Koch-Institut, General-Pape-Str. 62-66, 12101, Berlin, Deutschland.
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12
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Ingeborgrud CB, Oerbeck B, Friis S, Pripp AH, Zeiner P, Aase H, Biele G, Dalsgaard S, Overgaard KR. Do maternal anxiety and depressive symptoms predict anxiety in children with and without ADHD at 8 years? Eur Child Adolesc Psychiatry 2024:10.1007/s00787-024-02374-1. [PMID: 38376613 DOI: 10.1007/s00787-024-02374-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/08/2024] [Indexed: 02/21/2024]
Abstract
Maternal anxiety and depression during pregnancy and early childhood have been associated with child anxiety and attention-deficit/hyperactivity disorder (ADHD). However, previous studies are limited by their short follow-up, few assessments of maternal symptoms, and by not including maternal and child ADHD. The present study aimed to fill these gaps by investigating whether maternal anxiety and depressive symptoms from pregnancy to child age 5 years increase the risk of child anxiety disorders at age 8 years. This study is part of the population-based Norwegian Mother, Father, and Child Cohort Study. Maternal anxiety and depressive symptoms were assessed by the Hopkins Symptom Checklist (SCL) six times from pregnancy through early childhood, and ADHD symptoms by the Adult Self-Report Scale (ASRS). At age 8 years (n = 781), symptoms of anxiety disorders and ADHD were assessed, and disorders classified by the Child Symptom Inventory-4. Logistic regression models estimated the risk of child anxiety depending on maternal symptoms. The mothers of children classified with an anxiety disorder (n = 91) scored significantly higher on the SCL (at all time points) and ASRS compared with the other mothers. In univariable analyses, maternal anxiety and/or depression and ADHD were associated with increased risk of child anxiety (odds ratios = 2.99 and 3.64, respectively), remaining significant in the multivariable analysis adjusted for covariates. Our findings link maternal anxiety, depression, and ADHD during pregnancy and early childhood to child anxiety at age 8 years.
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Affiliation(s)
- Christine Baalsrud Ingeborgrud
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
- Division of Mental Health and Addiction, Child and Adolescent Psychiatry Unit, Institute of Clinical Medicine, University of Oslo, Blindern, 0315, Oslo, Norway.
| | - Beate Oerbeck
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Svein Friis
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Pål Zeiner
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Heidi Aase
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Guido Biele
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Søren Dalsgaard
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Dept. of Child and Adolescent Psychiatry Glostrup, Mental Health Services of the Capital Region, Hellerup, Denmark
- School of Business and Social Sciences, National Centre for Register-Based Research, Aarhus University, Aarhus C, Denmark
| | - Kristin Romvig Overgaard
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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13
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Mahadevan J, Gautam M, Benegal V. Mental health and well-being for the prevention of substance use disorders. Indian J Psychiatry 2024; 66:S272-S282. [PMID: 38445279 PMCID: PMC10911324 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_716_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/16/2023] [Accepted: 12/04/2023] [Indexed: 03/07/2024] Open
Affiliation(s)
- Jayant Mahadevan
- Department of Psychiatry, Centre for Addiction Medicine, NIMHANS, Bangalore, Karnataka, India E-mail:
| | - Manaswi Gautam
- Consultant Psychiatrist, Gautam Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Vivek Benegal
- Department of Psychiatry, Centre for Addiction Medicine, NIMHANS, Bangalore, Karnataka, India E-mail:
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14
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Avalos LA, Chandran A, Churchill ML, Gao X, Ames JL, Nozadi SS, Roubinov D, Brennan PA, Bush NR, Camargo CA, Carroll KN, Cioffi CC, Ferrara A, Goldson B, Hedderson MM, Hipwell AE, Kerver JM, O’Connor TG, Porucznik CA, Shuffrey LC, Talavera-Barber MM, Wright RJ, Zhu Y, Croen LA. Prenatal depression and risk of child autism-related traits among participants in the Environmental influences on Child Health Outcomes program. Autism Res 2023; 16:1825-1835. [PMID: 37526980 PMCID: PMC10857745 DOI: 10.1002/aur.2988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 06/30/2023] [Indexed: 08/03/2023]
Abstract
This study evaluated the association between prenatal depression and offspring autism-related traits. The sample comprised 33 prenatal/pediatric cohorts participating in the Environmental influences on Child Health Outcomes program who contributed information on prenatal depression and autism-related traits. Autism-related traits were assessed continuously and at the diagnostic cut-off using the Social Responsiveness Scale for children up to 12 years of age. Main analyses included 3994 parent-child pairs with prenatal depression diagnoses data; secondary analyses included 1730 parent-child pairs with depression severity data. After confounder adjustment, we observed an increase in autism-related traits among children of individuals with prenatal depression compared to those without (adjusted β = 1.31 95% CI: 0.65, 1.98). Analyses stratified by child sex documented a similar significant association among boys (aβ = 1.34 95%CI: 0.36, 2.32) and girls (aβ = 1.26 95% CI: 0.37, 2.15). Prenatal depression was also associated with increased odds of moderate to severe autism-related traits (adjusted odds ratio: 1.64, 95%CI: 1.09, 2.46), the screening threshold considered high risk of autism spectrum disorder (ASD) diagnosis. Findings highlight the importance of prenatal depression screening and preventive interventions for children of pregnant individuals with depression to support healthy development. Future research is needed to clarify whether these findings reflect overlap in genetic risk for depression and ASD-related traits or another mechanism.
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Affiliation(s)
- Lyndsay A. Avalos
- Division of Research, Kaiser Permanente Northern California, Oakland CA
| | | | | | | | - Jennifer L. Ames
- Division of Research, Kaiser Permanente Northern California, Oakland CA
| | - Sara S. Nozadi
- Department of Pharmaceutical Sciences, Health Sciences Center, University of New Mexico
| | - Danielle Roubinov
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | | | - Nicole R. Bush
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Department of Pediatrics, University of California, San Francisco
| | | | - Kecia N. Carroll
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Assiamira Ferrara
- Division of Research, Kaiser Permanente Northern California, Oakland CA
| | - Brandon Goldson
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Jean M. Kerver
- Departments of Epidemiology & Biostatistics and Pediatrics and Human Development, College of Human Medicine, Michigan State University
| | - Thomas G. O’Connor
- Departments of Psychiatry, Psychology, Neuroscience, Obstetrics and Gynecology, University of Rochester
| | | | - Lauren C. Shuffrey
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| | - Maria M. Talavera-Barber
- Avera McKennan Hospital and University Health Center, Avera Research Institute, Sioux Falls, SD, USA
| | - Rosalind J. Wright
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland CA
| | - Lisa A. Croen
- Division of Research, Kaiser Permanente Northern California, Oakland CA
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15
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Younis EA, Shalaby SES, Abdo SAEF. Screening of attention deficit hyperactivity disorder among preschool children Gharbia Governorate, Egypt. BMC Psychiatry 2023; 23:285. [PMID: 37098572 PMCID: PMC10126573 DOI: 10.1186/s12888-023-04785-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/13/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Children who experience mental health issues, such as attention deficit hyperactivity disorder (ADHD), experience significant distress and impairment at home, at school, and in the community. Without adequate care or prevention, this frequently results in adulthood-long distress and impairment at large societal costs. Determining the prevalence of ADHD cases among preschoolers as well as some associated maternal and child risk factors was the aim of this study. METHODS An analytical cross-sectional study including 1048 preschool children aged 3-6 years was carried out in Tanta City, Gharbia Governorate. From March to April 2022, a proportionate stratified cluster random sample of them was picked. Data were gathered using a predesigned instrument that included sociodemographic information, family history, maternal and child risk factors, and the Arabic version of the ADHD Rating Scale IV questionnaire. RESULTS The prevalence of ADHD among preschoolers was 10.5%. The inattention type was the most common (5.3%), followed by the hyperactivity type (3.4%). There were statistically significant associations regarding positive family history of psychological and neurological symptoms (17.9% positive vs. 9.7% negative), family history of ADHD symptoms (24.5% positive vs. 9.4% negative), active smoking by the mother (21.1% positive vs. 5.3% negative), cesarean section delivery (66.4% positive vs. 53.9% negative), elevated blood pressure during pregnancy (19.1% positive vs. 12.4% negative), and history of taking drugs during pregnancy (43.6% positive vs. 31.7% negative). Significant child risk factors were: exposure to any source containing lead that causes slow poisoning (25.5% positive vs. 12.3% negative), children with cardiac health problems (38.2% positive vs. 16.6% negative), and hours spent by a child in front of the TV or mobile phone (any screens) per day (60.0% of those with positive screening spent more than 2 h/day vs. 45.7% negative). CONCLUSION In the Gharbia governorate, 10.5% of preschoolers suffer from ADHD. Significant maternal risk factors for ADHD included a positive family history of psychiatric and neurological symptoms, a family history of ADHD symptoms, active maternal smoking, caesarean section delivery, increased blood pressure during pregnancy, and a history of drug use during pregnancy. Youngsters who had cardiac health issues and who spent more time each day watching TV or using a mobile device (screen use) were at substantial risk.
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Affiliation(s)
- Eman Ali Younis
- Department of Public Health & Community Medicine, Faculty of Medicine, Tanta University, Tanta, 31257, Egypt.
| | - Safynaz El Saied Shalaby
- Department of Public Health & Community Medicine, Faculty of Medicine, Tanta University, Tanta, 31257, Egypt
| | - Sanaa Abd El-Fatah Abdo
- Department of Public Health & Community Medicine, Faculty of Medicine, Tanta University, Tanta, 31257, Egypt
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16
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Fan Y, Zhao L, Deng Z, Li M, Huang Z, Zhu M, Xu W. Non-linear association between Mediterranean diet and depressive symptom in U.S. adults: A cross-sectional study. Front Psychiatry 2022; 13:936283. [PMID: 35911213 PMCID: PMC9334730 DOI: 10.3389/fpsyt.2022.936283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/27/2022] [Indexed: 11/23/2022] Open
Abstract
The Mediterranean diet (MED), a dietary pattern rich in fruits and vegetables, whole grains, legumes, nuts, fish, and olive oil, has anti-oxidative and anti-inflammatory effects. Although some data suggest that MED adherence is associated with decreased manifestation of depressive symptoms, it remains necessary to further analyze this apparent non-linear association as well as the influence of different factors on the relationship between MED and depression. Here, we investigated associations between the alternate MED (aMED) score and depressive symptom via multivariate logistic regression, weighted generalized additive (GAM) and two-step linear regression models, analyzing data from the 2005-2018 National Health and Nutrition Examination Survey (NHANES). The most important factor relevant to aMED score that contributed to the prevalence of depressive symptom was assessed using random forest. Furthermore, we examined whether the relationship between aMED score and depressive symptom differs by age, race, sex, socioeconomic variables, lifestyle- and health-related variables, and chronic medical conditions, via subgroup analyses. A total of 19,477 participants (20-80 years of age) were included in this cross-sectional study. In crude and adjusted (1-5) multivariate logistic regression models, increased aMED score was noted to associate with non-depressive status, as defined using the Patient Health Questionnaire-9 (P < 0.05). Data analyses via GAM and two-piecewise linear regression revealed a non-linear association between aMED and depressive symptom, which had an inflection point of 3. Random forest results revealed that vegetable score contributes greatest to the relationship between aMED and depressive symptom. Subgroup analyses revealed that aMED score is significantly negatively related with depressive symptom in most different populations (P < 0.05) with the exception of high annual income, diabetes, borderline blood glucose level and Parkinson's disease (PD) (P > 0.05). In conclusion, we observed a non-linear association between aMED score and depressive symptom. Further studies are needed to validate our results.
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Affiliation(s)
- Yaohua Fan
- Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Lijun Zhao
- Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Zhiyuan Deng
- Gaozhou Hospital of Traditional Chinese Medicine, Gaozhou, China
| | - Mengzhu Li
- Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Zifeng Huang
- Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Meiling Zhu
- Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Wenhua Xu
- Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou University of Chinese Medicine, Shenzhen, China
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