Attention Deficit Hyperactivity Disorder (ADHD) and disordered eating behaviour: A systematic review and a framework for future research

Potential mechanisms underlying the association between feeding and eating disorders and autism

There is a reliable association between autism and Feeding and Eating Disorders. Concerningly, where these two conditions co-occur, clinical outcomes of Feeding and Eating Disorders are significantly worse, and treatment less effective, than when the Feeding and Eating Disorders occur in neurotypical individuals. Problematically, the reason for the association between autism and Feeding and Eating Disorders is poorly understood, which constrains advances in clinical care. This paper outlines several possible mechanisms that may underlie the observed association and suggests ways in which they may be empirically tested. Mechanisms are split into those producing an artefactual association, and those reflecting a genuine link between conditions. Artefactual associations may be due to conceptual overlap in both diagnostic criteria and measurement, Feeding and Eating Disorders causing transient autistic traits, or the association being non-specific in nature. A genuine association between autism and Feeding and Eating Disorders may be due to common causal factors, autism directly or indirectly causing Feeding and Eating Disorders, and Feeding and Eating Disorders being a female manifestation of autism.

Attention-deficit/hyperactivity symptoms and loss of control eating in emerging adults: Role of psychological resilience

OBJECTIVE

This study aimed to fill a gap in the literature regarding the role of resilience in the relationship between symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) and loss of control (LOC) eating in a nonclinical sample of emerging adults. Resilience was examined as a potential moderator and as a potential mediator of ADHD symptoms and engagement in LOC eating behaviors. Improved understanding of this relationship may inform clinical intervention and risk screening methodologies for disordered eating behaviors in college students.

METHODS

Participants were undergraduate students (N = 386) from a private university in the northeastern United States. Linear regression analysis examined whether greater ADHD symptoms related to greater LOC eating. Pathway analyses examined resilience as either a moderator or mediator of the relationship between ADHD symptoms and LOC eating.

RESULTS

A direct positive relationship was found between ADHD symptoms and LOC eating (p < .05). Resilience partially mediated this relationship, such that increased ADHD symptoms indirectly related to increased LOC eating through low resilience (p < .05).

CONCLUSION

Findings indicate that undergraduate students with greater ADHD symptoms engaged in more frequent LOC eating, and that low resilience was a partial mediator of this positive relationship.

Overlap of eating disorders and neurodivergence: the role of inhibitory control

BACKGROUND

Difficulties with inhibitory control have been identified in eating disorders (EDs) and neurodevelopmental disorders (NDs; including attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder), and there appear to be parallels between the expression of these impairments. It is theorised that impairments in inhibitory control within NDs may represent a unique vulnerability for eating disorders (EDs), and this same mechanism may contribute to poorer treatment outcomes. This review seeks to determine the state of the literature concerning the role of inhibitory control in the overlap of EDs and neurodivergence.

METHOD

A scoping review was conducted to summarise extant research, and to identify gaps in the existing knowledge base. Scopus, Medline, PsycInfo, Embase, and ProQuest were systematically searched. Studies were included if the study measured traits of ADHD or autism, and symptoms of ED, and required participants to complete a performance task measure of inhibitory control. Where studies included a cohort with both an ND and ED, these results had to be reported separately from cohorts with a singular diagnosis. Studies were required to be published in English, within the last 10 years.

RESULTS

No studies explored the relationship between autism and EDs using behavioural measures of inhibitory control. Four studies exploring the relationship between ADHD and EDs using behavioural measures of inhibitory control met selection criteria. These studies showed a multifaceted relationship between these conditions, with differences emerging between domains of inhibitory control. ADHD symptoms predicted poorer performance on measures of response inhibition in a non-clinical sample; this was not replicated in clinical samples, nor was there a significant association with EDs. Both ADHD and ED symptoms are associated with poor performance on attentional control measures; where these diagnoses were combined, performance was worse than for those with a singular diagnosis of ADHD. This was not replicated when compared to those with only ED diagnoses.

CONCLUSION

Impairments in attentional control may represent a unique vulnerability for the development of an ED and contribute to poor treatment outcomes. Further research is needed to explore the role of inhibitory control in EDs, ADHD and autism, including the use of both self-report and behavioural measures to capture the domains of inhibitory control.

The impacts associated with having ADHD: an umbrella review

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) affects up to 5% of the population and is characterised by symptoms of impulsivity, hyperactivity and inattention. These symptoms are significantly impairing and carry additional risks for children and adults with ADHD, including negative mental health (e.g. depression), physical health (e.g. obesity) and societal outcomes (e.g. imprisonment, divorce). Very few studies have attempted to synthesise these risks in one publication due to the breadth of evidence published on the adverse outcomes of ADHD.

Methods

An umbrella review was performed to identify reviews (systematic, meta-analysis and narrative) that investigate the risks arising from having ADHD. We conducted a narrative synthesis of the findings and conducted a quality review of the included publications.

Results

Upon searching five databases, 16,675 records were identified. Of these, 125 reviews met the criteria for inclusion. A narrative synthesis of these findings highlighted three key domains of risks associated with ADHD: mental health, physical health, social and lifestyle. Most reviews were of good and moderate quality.

Discussion

This review highlights the many risks associated with having ADHD, beyond its three key symptom domains and the impact of the condition on daily functioning.

Registration

International Prospective Register of Systematic Reviews (PROSPERO CRD42023404073).

Recognising and responding to physical and mental health issues in neurodivergent girls and women

People experience life and interact with others in many ways. The term 'neurodivergence' refers to variations from what is considered typical. Research and education into conditions that cooccur with neurodivergence are essential in shaping clinicians' approaches to people who may present with a wide range of symptoms. Neurodivergence may influence a person's style of communication, learning, attitudes, and behaviour, and they often experience inequity and rejection. This review highlights the huge burden of cooccurring conditions carried by neurodivergent women and girls whose medical issues have largely gone under the radar. We suggest how clinicians might increase their awareness of diagnosis and management of their problems with mutual benefit.

A Female-Specific Treatment Group for ADHD-Description of the Programme and Qualitative Analysis of First Experiences

Background: The diagnostics and treatment of attention-deficit/hyperactivity disorder (ADHD) in women remain insufficient. Fluctuations of reproductive hormones during the premenstrual period, postpartum period, and (peri)menopause are neglected, even though they impact ADHD symptoms and associated mood disorders. Therefore, we created a female-specific treatment group for women with ADHD and premenstrual worsening of ADHD and/or mood symptoms. Methods: We describe the group programme and underlying rationale, offering a qualitative analysis of the participants' evaluation. Results: The seven bi-weekly sessions foreground the menstrual cycle and address several ADHD-specific topics in relation to this cyclical pattern. Concurrently, women track their menstrual cycle and (fluctuating) ADHD and mood symptoms with an adjusted premenstrual calendar. In total, 18 women (25-47 years) participated in three consecutive groups. We analysed the evaluation of the last group. Participants experienced the group as a safe and welcoming space. Recognition was valued by all. The topics discussed were deemed valuable, and the structure suited them well. Completing the premenstrual calendar augmented the awareness and recognition of individual cyclical symptoms. A lifespan approach increased self-understanding. Participants took their menstrual cycle more seriously, prioritising self-acceptance and self-care. Conclusions: Exploring a cyclical approach in a group setting seems to be a positive addition to treatment for female ADHD.

The role of irrational beliefs in the relationship between attention deficit hyperactivity disorder (ADHD) symptoms and disordered eating in two general student samples

Attention deficit hyperactivity disorder (ADHD) symptoms are associated with disordered eating and negative mood. The purpose of this study was to examine whether irrational beliefs mediate this relationship along with previously reported mediators such as depression and impulsivity. Irrational beliefs trigger negative automatic thoughts which are believed, in cognitive behavior therapies, to be a source of psychopathology. Challenges brought about by symptoms of ADHD may lead to habitual emotion-eliciting thought patterns which, in turn, could lead to negative mood and disordered eating. Undergraduate students (N = 127) completed online questionnaires assessing ADHD symptoms and disordered eating and several potential mediators including irrational beliefs, depression, impulsivity, interoceptive accuracy, and reward responsiveness. The results, which were replicated in a second study (N = 254), indicated that irrational beliefs and depression mediated the relationship between ADHD symptoms and disordered eating. In the second study, impulsivity due to negative urgency was also a mediator. These findings support the theory that the symptoms of ADHD lead to enhancement of irrational beliefs, depression, and negative urgency which are linked to disordered eating.

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.

A systematic meta-review of systematic reviews on attention deficit hyperactivity disorder

BACKGROUND

There are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.

METHODS

We searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.

RESULTS

The prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.

CONCLUSIONS

Despite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.

Interoceptive accuracy mediates the longitudinal relationship between attention deficit hyperactivity disorder (ADHD) inattentive symptoms and disordered eating in a community sample

Attention deficit hyperactivity disorder (ADHD) symptoms are associated with disordered eating and interoceptive deficits (as assessed by reliance on hunger/satiety cues) have been suggested as a potential mediating influence. The aim of this longitudinal study was to examine whether the association between ADHD symptoms and disordered eating is explained by deficits in specific facets of interoception. We also aimed to provide further evidence on the previously reported association between ADHD symptoms, negative mood and disordered eating. A community-based sample of 345 adult men and women (M age = 33.9, 72.5% women) completed questionnaires assessing disordered eating (restrictive and binge-type), ADHD symptoms, reliance on hunger/ satiety cues, specific facets of interoception (interoceptive accuracy and interoceptive sensibility) and negative mood at two timepoints over a 6-month period. We tested the mediating influence of reliance on hunger/satiety cues, facets of interoception and negative mood on the relationship between ADHD symptoms and disordered eating. Reliance on hunger/satiety cues mediated the relationship between inattentive symptoms of ADHD and both restrictive and binge-type eating. Interoceptive accuracy, but not sensibility mediated the relationship between inattentive ADHD symptoms and binge-type eating. Negative mood mediated the relationship between both ADHD symptom types and restrictive and binge-type eating. The results from this longitudinal study confirm that deficits in interoception and negative mood contribute to the relationship between ADHD symptoms and disordered eating and extend knowledge by highlighting interoceptive accuracy specifically as the most important facet of interoception in the relationship between inattentive symptoms and binge-type eating.

Delayed Mid-Sleep Time Associated With Weight Gain While Controlling for Eating Behaviors and Attention Deficit Hyperactivity Disorder Symptoms During the COVID-19 Pandemic

OBJECTIVE

Society's sleep-wake cycle and eating behaviors have altered and are considered the psychological outcomes of the coronavirus disease-2019 (COVID-19) pandemic. Our aim was to examine the relationship between sleep-wake rhythms, eating behaviors (dieting, oral control, and bulimic behaviors), and attention deficit hyperactivity disorder (ADHD) symptoms with weight gain during the COVID-19 pandemic.

METHODS

The participants were 578 female university students divided into three groups based on weight change during COVID-19 who lost weight, whose weight did not change (nWC), and who gained weight (WG). The participants' information about weight change in the last year and responses to the Pittsburg Sleep Quality Index, Eating Attitudes Test, Adult ADHD Severity Rating Scale, and Wender Utah Rating Scale were collected via an online survey from January 8, 2021 to January 11, 2021.

RESULTS

The sleep-wake phase was more delayed in WGs than in the other two groups. The bulimic behavior score was higher and the oral control behavior score was lower in the WG group than in the nWC group. A hierarchical regression analysis model, in which weight change scores were dependent variables, showed that mid-sleep time in second step (β=4.71, t=2.18, p=0.03), and oral control (β=-0.11, t=-3.24, p=0.001)/bulimic behaviors (β=0.20, t=3.20, p=0.001) in third step were associated with weight change after controlling for both current and childhood ADHD symptoms.

CONCLUSION

Chronotherapeutic approaches that regulate sleep-wake rhythm may facilitate weight control of individuals during stressful periods, such as the COVID-19 outbreak.

[Physical growth and dietary characteristics of children with attention deficit hyperactivity disorder: a cross-sectional study]

OBJECTIVES

To investigate the physical growth and dietary characteristics of children with attention deficit hyperactivity disorder (ADHD), and to analyze their relationship with core symptoms of ADHD.

METHODS

A total of 268 children who were newly diagnosed with ADHD in Children's Hospital of Nanjing Medical University from June to December 2020 were included in the ADHD group, and 102 healthy children who underwent physical examination during the same period were selected as the control group. Physical evaluations and dietary surveys were conducted for both groups. ADHD diagnosis and scoring were performed according to the Diagnostic and Statistical Manual of Mental Disorders (5th edition). Factor analysis, Spearman correlation analysis, and mediation analysis were used to study the relationship between core symptoms of ADHD, dietary patterns, and physical growth.

RESULTS

The rate of overweight/obesity in the ADHD group was significantly higher than that in the control group (35.8% vs 21.6%, P<0.05). Three dietary patterns were extracted from the food frequency questionnaire: vegetarian dietary pattern, traditional dietary pattern, and snack/fast food pattern. The factor score for the snack/fast food pattern in the ADHD group was higher than that in the control group (P<0.05). There was a significant positive correlation between ADHD symptom scores, snack/fast food pattern factor scores, and body fat percentage (P<0.05). The mediation analysis showed that the snack/fast food pattern played a partial mediating role in the relationship between ADHD symptom scores and body fat percentage, with a mediation proportion of 26.66%.

CONCLUSIONS

The rate of overweight/obesity in children with ADHD is higher than that in non-ADHD children. Core symptoms of ADHD are related to dietary patterns and physical growth, with the snack/fast food pattern playing a partial mediating role in the relationship between core symptoms of ADHD and physical growth.

Obtaining long-term recovery: advances in optimizing treatment outcomes in patients with binge-eating disorder

INTRODUCTION

Binge-eating disorder (BED) is a complex and disabling eating disorder (ED) associated with considerable burden and impairments in quality of life and physical/mental health. It has been recognized as a formal ED category since 2013, however BED is still underdetected and undertreated.

AREAS COVERED

This review summarizes the advances in the understanding of the pathophysiology of BED as well as the evidence on the efficacy of the existing treatments. The authors searched Scopus, PubMed, ClinicalTrials.Gov, and ANZCTR with terms including 'assessment' OR 'treatment' OR 'diagnosis' OR 'mechanisms' AND 'binge eating' OR 'binge-eating disorder' for manuscripts published between January 2013 and April 2023.

EXPERT OPINION

Most of the trials on treatments of BED have been in people of high weight with weight loss as an outcome. Nevertheless, less is known about the treatment of this condition in people with body mass index (BMI) within the normal range where weight stabilization may be a more appropriate goal. Moreover, there is a need for an enhanced appreciation of the role of combination treatment to improve overall outcomes. Also, there are important opportunities for future research in understanding the mechanisms of action and effectiveness of BED treatments.

Grazing Is Associated with ADHD Symptoms, Substance Use, and Impulsivity in a Representative Sample of a Large Metropolitan Area in Brazil

Grazing is a clinically relevant eating behaviour, especially when it presents with a sense of loss of control (compulsive grazing). There is evidence that other disordered eating patterns are associated with problematic substance use and impulsivity-related conditions, such as attention-deficit/hyperactivity disorder (ADHD). This overlap contributes to higher psychopathology and treatment complications. Less is known about grazing, and most information originates in high-income countries. Hence, we sought to investigate relationships between grazing, tobacco and alcohol use, ADHD, and impulsivity in a large representative sample from Brazil. Data were collected by trained interviewers from adults (N = 2297) through an in-person household survey based on a stratified and clustered probability sample. We found significant associations between compulsive grazing and problematic alcohol use (OR = 3.02, 95% CI: 1.65, 5.53), ADHD (OR = 8.94, 95% CI: 5.11, 15.63), and smoking (OR = 1.67, 95% CI: 1.12, 2.47), with impulsivity contributing to the first two relationships. The substantial association with ADHD suggests that other executive functions may promote disordered eating, possibly expressed through difficulties in adhering to regular meals. Clinically, these findings highlight the importance of assessing problematic eating patterns, such as compulsive grazing, in those presenting with difficulties with substance use or impulsivity, and vice versa.

Multimodal integrated intervention for children with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common disorders in child and adolescent psychiatry, with a prevalence of more than 5%. Despite extensive research on ADHD in the last 10 to 20 years, effective treat-ments are still lacking. Instead, the concept of ADHD seems to have become broader and more heterogeneous. Therefore, the diagnosis and treatment of ADHD remains challenging for clinicians.

AIM

To investigate the effects of a multimodal integrated intervention for children with ADHD.

METHODS

Between March 2019 and September 2020, a total of 100 children with ADHD who were diagnosed and treated at our hospital were assessed for eligibility, two of whom revoked their consent. A case-control study was conducted in which the children were equally assigned, using a randomized number table, to either a medication group (methylphenidate hydrochloride extended-release tablets and atomoxetine hydrochloride tablets) or a multimodal integrated intervention group (medication + parent training + behavior modification + sensory integration therapy + sand tray therapy), with 49 patients in each group. The clinical endpoint was the efficacy of the different intervention modalities.

RESULTS

The two groups of children with ADHD had comparable patient characteristics (P > 0.05). Multimodal integrated intervention resulted in a significantly higher treatment efficacy (91.84%) than medication alone (75.51%) (P < 0.05). Children who received the multimodal integrated intervention showed lower scores in the Conners Parent Symptom Questionnaire and the Weiss Functional Impairment Rating Scale than those treated with medication alone (P < 0.05). The Sensory Integration Scale scores of children in the multimodal integrated intervention group were higher than those of children in the medication group (P < 0.05). Children who received the multimodal integrated intervention had higher compliance and family satisfaction and a lower incidence of adverse events than those treated with medication alone (P < 0.05).

CONCLUSION

Multimodal integrated intervention effectively alleviated symptoms associated with ADHD in children. It enhanced their memory and attention with high safety and parental satisfaction, demonstrating good potential for clinical promotion.

The association between eating disorders and mental health: an umbrella review

OBJECTIVE

There have been an increasing number of systematic reviews indicating the association between eating disorders (ED), including its risk factors, with mental health problems such as depression, suicide and anxiety. The objective of this study was to conduct an umbrella review of these reviews and provide a top-level synthesis of the current evidence in this area.

METHOD

A systematic search was performed using four databases (MEDLINE Complete, APA PyscInfo, CINAHL Complete and EMBASE). The inclusion criteria were systematic reviews (with or without meta-analysis), published in the English language between January 2015 and November 2022. The quality of the studies was assessed using the Joanna Briggs Institute Critical Appraisal tools for use of JBI Systematic reviews.

RESULTS

A total of 6,537 reviews were identified, of which 18 reviews met the inclusion criteria, including 10 reviews with meta-analysis. The average quality assessment score for the included reviews was moderate. Six reviews investigated the association between ED and three specific mental health problems: (a) depression and anxiety, (b) obsessive-compulsive symptoms and (c) social anxiety. A further 3 reviews focused on the relationship between ED and attention deficit hyperactivity disorder (ADHD) while 2 reviews focused on ED and suicidal-related outcomes. The remaining 7 reviews explored the association between ED and bipolar disorders, personality disorders, and non-suicidal self-injury. Depression, social anxiety and ADHD are likely to have a stronger strength of association with ED relative to other mental health problems.

DISCUSSION

Mental health problems such as depression, social anxiety and ADHD were found to be more prevalent among people suffering from eating disorders. Further research is necessary to understand the mechanism and health impacts of potential comorbidities of ED.

The Relationship Between Eating-Attitudes and Clinical Characteristics, Agouti-Related Peptide, and Other Biochemical Markers in Adult-Attention Deficit Hyperactivity Disorder

OBJECTIVE

In our study, we aimed to evaluate eating-attitudes in adult-ADHD, and to examine its relationship with sociodemographic, clinical, AgRP, and biochemical parameters.

METHOD

The study included 70 adult-patients and 47 healthy-controls. The DIVA2.0, SCID-1 was administered to the participants. Eating-Attitudes Test (EAT), Night-Eating Questionnaire (NEQ), Barratt Impulsivity Scale (BIS-11) were filled by the participants.

RESULTS

We found that psychological state affect eating-attitudes in adult-ADHD (p = .013), emotional eating is more common, nocturnal chronotype is dominant (p < .001), NES is more frequent (p < .001), waist circumference measurement is higher (p = .030), and lipid profile is deteriorated (p < .001). AgRP levels were significantly lower in patients treated with methylphenidate (p = .021). Those who received methylphenidate treatment had less NES than those who did not. Deterioration in eating-attitudes and symptom severity of night eating in ADHD, it was positively correlated with clinical severity of ADHD and impulsivity. In addition, age and increase in night eating symptoms were predictors of deterioration in eating attitudes in adult-ADHD. We found that impaired eating-attitudes and impulsivity severity were also predictors of NES (p = .006, p = .034).

CONCLUSION

The necessity of adult-ADHD treatment has been demonstrated by the deterioration in eating-attitudes and cardiometabolic risk dimensions and the underlying mechanisms.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

ADHD and eating disorders in childhood and adolescence: An updated minireview

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders with overactivity, inattention, and impulsivity as core characteristics. Recent studies suggest that 20 % of children with ADHD also develop eating disorders (EDs), including anorexia nervosa, bulimia nervosa and binge eating disorder. However, little is still known about the association between ADHD and EDs through childhood and adolescence. Therefore, in the present work, we aimed at summarizing the studies investigating ADHD and EDs in childhood and adolescence over the last 10 years.

METHODS

A bibliographic search on PubMed was performed and only studies that considered participants with a clinical diagnosis of ADHD, patients with an additional diagnosis of EDs and patients under 18 years old were included. A total of 7 studies were retrieved and included in the review.

RESULTS

The majority of the reviewed studies (N = 5) found an association between ADHD and EDs, while the remaining, which focused on EDs symptomatology, reported either lower ED symptoms in ADHD sample or no association between ADHD and EDs.

LIMITATIONS

the majority of studies were cross-sectional and therefore did not allow to explore the longitudinal casual relation between ADHD and EDs in the developmental age range considered.

CONCLUSIONS

This review suggests that children and adolescents with ADHD should be monitored for EDs. However, more work is still needed to better understand the clinical implications of the comorbidity between ADHD and EDs and its prospective impact on the life of children and adolescents with ADHD.

The relationship between anorexia nervosa and bulimia nervosa, attention deficit/hyperactivity disorder, and suicidality in college students

OBJECTIVE

This study aimed to assess the association between anorexia nervosa (AN), bulimia nervosa (BN), attention deficit/hyperactivity disorder (ADHD), and associated impairments (e.g., suicidality).

METHODS

A secondary data analysis of the American College Health Association-National College Health Assessment IIc (Fall 2015-Spring 2019) was conducted to assess the prevalence of comorbid anorexia or bulimia + ADHD, symptoms, and impairments among college student (N = 342,432; M_age  = 20.39, SD = 1.88). Logistic regressions were used to compare eating disorder symptomology, treatment utilisation, and suicidality among college students.

RESULTS

Compared to college students without ADHD, college students with ADHD were 18.30× more likely to be diagnosed with anorexia or bulimia and reported greater use of weight loss techniques (p's < 0.001). College students with comorbid anorexia or bulimia + ADHD reported higher rates of dieting to lose weight (aOR = 1.27, 95% CI: 1.12, 1.43, p < 0.001) and treatment utilisation (aOR = 1.30, 95% CI: 1.06, 1.50, p < 0.001) compared to college students with AN or BN only. The highest level of suicidality was reported in college students with the comorbid AN or BN + ADHD.

CONCLUSION

Elevated eating disorder symptoms and comorbidity is found among college students with ADHD. Increased screening and prevention for anorexia and bulimia is needed among young adults with ADHD to enhance care for those with these eating disorders.

Exploring the Link between ADHD and Obesity: A Focus on Temperament

Multiple studies support the relationship between ADHD and overweight/obesity in youth. Different mechanisms may be involved, such as temperamental and psychopathological factors. The aim of this study was to test the hypothesis that specific temperamental and psychopathological dimensions could mediate the relationship between ADHD and obesity. The sample included 100 children and adolescents (78 males and 22 females; age range 6 to 18 years; mean age 9.90 ± 2.5 years). The assessment procedure included Conners' Parent Rating Scale-Long (CPRS-R:L) as the inclusion criterion for ADHD diagnosis, the Child Behavior Checklist (CBCL), a dimensional measure for psychopathology, and the Junior Temperament and Character Inventory, which describes four temperamental dimensions: novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (P). While in the whole ADHD sample, the highest scores were found in NS and the lowest in P, ADHD with overweight/obesity, compared to ADHD with normal weight, showed higher HA and RD, lower NS, and higher CBCL Internalizing scores. These findings suggest that ADHD youth with overweight/obesity present specific temperamental and psychopathological features compared to those without overweight/obesity. If confirmed in larger samples, using a control group without ADHD, these temperamental and psychological features may be helpful for an earlier recognition of ADHD patients at higher risk for obesity, and may represent possible targets for temperament-based preventive interventions and tailored treatment programs. These features should be included in the routine assessment of children and adolescents with ADHD and/or are overweight/obese.

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.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

A phenome-wide association study of polygenic scores for attention deficit hyperactivity disorder across two genetic ancestries in electronic health record data

Testing the association between genetic scores for Attention Deficit Hyperactivity Disorder (ADHD) and health conditions, can help us better understand its complex etiology. Electronic health records linked to genetic data provide an opportunity to test whether genetic scores for ADHD correlate with ADHD and additional health outcomes in a health care context across different age groups. We generated polygenic scores (ADHD-PGS) trained on summary statistics from the latest genome-wide association study of ADHD (N = 55,374) and applied them to genome-wide data from 12,383 unrelated individuals of African-American ancestry and 66,378 unrelated individuals of European ancestry from the Vanderbilt Biobank. Overall, only Tobacco use disorder (TUD) was associated with ADHD-PGS in the African-American ancestry group (Odds ratio [95% confidence intervals] = 1.23[1.16-1.31], p = 9.3 × 10-09 ). Eighty-six phenotypes were associated with ADHD-PGS in the European ancestry individuals, including ADHD (OR[95%CIs] = 1.22[1.16-1.29], p = 3.6 × 10-10 ), and TUD (OR[95%CIs] = 1.22[1.19-1.25], p = 2.8 × 10-46 ). We then stratified outcomes by age (ages 0-11, 12-18, 19-25, 26-40, 41-60, and 61-100). Our results suggest that ADHD polygenic scores are associated with ADHD diagnoses early in life and with an increasing number of health conditions throughout the lifespan (even in the absence of ADHD diagnosis). This study reinforces the utility of applying trait-specific PGSs to biobank data, and performing exploratory sensitivity analyses, to probe relationships among clinical conditions.

Cardiovascular Considerations for Stimulant Class Medications

The cardiovascular (CV) impact of stimulants has been examined for decades, with investigations ranging from small sample targeted studies of heart rate (HR) and blood pressure (BP), to large scale epidemiologic investigations. The preponderance of evidence is reassuring, albeit generally based on healthy samples using variable methodology, excluding those at theoretic high risk (eg, comorbid cardiac illness). Screening for theoretically vulnerable patients are recommended, as well as monitoring for CV symptoms and BP/HR, with shared inquiry/further evaluation if concerned. Future investigations to support the identification of risk are needed, while attention to stimulant-associated CV risk is an opportunity for clinicians to engage in general CV risk identification and intervention.

ADHD co-morbidities: A review of implication of gene × environment effects with dopamine-related genes

ADHD is a major burden in adulthood, where co-morbid conditions such as depression, substance use disorder and obesity often dominate the clinical picture. ADHD has substantial shared heritability with other mental disorders, contributing to comorbidity. However, environmental risk factors exist but their interaction with genetic makeup, especially in relation to comorbid disorders, remains elusive. This review for the first time summarizes present knowledge on gene x environment (GxE) interactions regarding the dopamine system. Hitherto, mainly candidate (GxE) studies were performed, focusing on the genes DRD4, DAT1 and MAOA. Some evidence suggest that the variable number tandem repeats in DRD4 and MAOA may mediate GxE interactions in ADHD generally, and comorbid conditions specifically. Nevertheless, even for these genes, common variants are bound to suggest risk only in the context of gender and specific environments. For other polymorphisms, evidence is contradictory and less convincing. Particularly lacking are longitudinal studies testing the interaction of well-defined environmental with polygenic risk scores reflecting the dopamine system in its entirety.

Utility of an experimental medicine model to evaluate efficacy, side-effects and mechanism of action of novel treatments for obesity and binge-eating disorder

Obesity and Binge Eating Disorder (BED) are prevalent conditions that are associated with increased risk of morbidity and mortality. There is evidence that the use of pharmacotherapy alongside behavioural treatments can improve quality of life and reduce disease risk for patients with these disorders. However, there are few approved drug therapies for obesity, and these are limited by poor efficacy and/or side effects and only one drug has been approved for the treatment of BED. There is considerable potential to use experimental medicine models to identify new drug treatments for obesity and BED, with greater efficacy and an improved side effect profile, at an early stage of development. Here, we present a model developed in our laboratory that incorporates both behavioural and neuroimaging measures which can be used to facilitate drug development for obesity and BED. The results from validation studies conducted to date using our model suggest that it is sensitive to the effects of agents with behavioural, neurophysiological and neuropharmacological mechanisms of action known to be associated with weight loss and reductions in binge eating. Future studies using the model will be valuable to evaluate the potential efficacy and side-effects of new candidate drugs at an early stage in the development pipeline for both obesity and BED.

An exploration of eating behaviours and caregiver mealtime actions of children with Tourette syndrome

Food avoidant behaviours are common concerns amongst individuals with Tourette syndrome, with high levels of food selectivity reported in children and food neophobia and avoidant restrictive eating behaviours in adults. However, less is known about food approach behaviours. The current study aimed to explore differences in food approach and food avoidant eating behaviours in children with Tourette syndrome (TS) and their relationship to caregiver mealtime actions. Thirty-seven caregivers of children with Tourette syndrome were compared with children with Autism Spectrum Disorders, children with Attention-Deficit/Hyperactivity Disorder and a control group. Caregivers completed the Child Eating Behaviour Questionnaire and Parent Mealtime Action Scale-Revised. Caregiver-reported findings revealed that children with Tourette syndrome exhibited more food approach behaviours, specifically greater food responsiveness, emotional overeating and desire to drink, compared to controls. Children from the three neurodiverse groups had similar levels of emotional overeating and food selectivity, which were all significantly higher than the control group. Positive persuasion was uniquely identified as a mealtime strategy adopted by caregivers of children with Tourette syndrome. The results suggest that children with Tourette syndrome are at more risk of showing a broader array of food difficulties than previously reported, including food avoidant and approach behaviours. It is encouraged that clinicians monitor eating behaviour in appointments with children with Tourette syndrome.

The longitudinal association of eating behaviour and ADHD symptoms in school age children: a follow-up study in the RHEA cohort

Previous evidence suggests a link between attention deficit hyperactivity disorder (ADHD) symptoms and disordered eating behaviours; however, the direction of the causal association remains unclear. Building on our previous research, we aimed to examine the longitudinal association between eating behaviours at 4 years, ADHD symptoms at 6 years of age, and the role of body mass index (BMI). We included children from the RHEA mother-child cohort in Greece, followed up at 4 and 6 years (n = 926). Parents completed the Children's Eating Behaviour Questionnaire (CEBQ) to assess children's eating behaviour at 4 years and the ADHD Test (ADHDT) and Child Behaviour Checklist for ages 6-18 (CBCL/6-18) to evaluate ADHD symptoms at 4 and 6 years, respectively, as well as measures of BMI. Longitudinal structural equation modeling (SEM) was carried out to evaluate the associations of all variables between 4 and 6 years. Food responsiveness at 4 years was positively associated with hyperactivity at age 6, whereas emotional overeating was negatively associated with hyperactivity. There was no evidence of an association between eating behaviours of preschoolers and BMI at 6 years, or BMI at 4 years and later ADHD symptoms and vice versa. Findings suggest that food responsiveness is an early marker of ADHD symptoms at 6 years of age. In contrast to our hypothesis there was no significant association between ADHD at age 4 and BMI at age 6.

Lisdexamfetamine and binge-eating disorder: A systematic review and meta-analysis of the preclinical and clinical data with a focus on mechanism of drug action in treating the disorder

Binge-Eating Disorder (BED) is the most common eating disorder in the United States. Lisdexamfetamine (LDX) was approved in 2015 by the FDA for treatment of BED and is the only drug approved for treating the disorder. There has been no systematic evaluation of the published clinical and preclinical evidence for efficacy of LDX in treating BED and the mechanisms responsible for the therapeutic action of the drug. To address this gap, we conducted a systematic review and meta-analysis using PRISMA guidelines. Fourteen clinical and seven preclinical articles were included. There is consistent evidence from clinical studies that LDX is an effective treatment for BED and that the drug reduces the BED symptoms and body weight of patients with the disorder. There is also consistent evidence from preclinical studies that LDX reduces food intake but no consistent evidence for a preferential reduction of palatable food consumption by the drug in rodents. The evidence on mechanism of action is more limited and suggests LDX may reduce binge eating by a combination of effects on appetite/satiety, reward, and cognitive processes, including attention and impulsivity/inhibition, that are mediated by catecholamine and serotonin mechanisms in the brain. There is an urgent need for adequately powered, placebo-controlled, behavioural and neuroimaging studies with LDX (recruiting patients and/or individuals with subclinical BED symptoms) to further investigate the mechanism of action of the drug in treating BED. An improved understanding of the behavioural and neurochemical mechanisms of action of LDX could lead to the development of improved drug therapies to treat BED.

Diagnostic delay in ADHD: Duration of untreated illness and its socio-demographic and clinical predictors in a sample of adult outpatients

AIM

To investigate the Duration of Untreated Illness (DUI) and its socio-demographic and clinical predictors in a sample of adult ADHD outpatients.

METHODS

The DUI of 150 adult outpatients with a confirmed diagnosis of DSM-IV ADHD was calculated. Non-parametric tests were used to evaluate differences in DUI among subgroups and to build a correlation matrix. Subsequently, a multiple linear regression model was performed.

RESULTS

The median DUI was 17 years (interquartile range [IQR] = 14). DUI was longer in employed patients, those with a family history of ADHD, those with a history of major depressive disorder and those who had predominantly inattentive ADHD in childhood. The current age, age at administration of the first proper treatment and education level were correlated with DUI. Current age (63.3% of total variance), family history of ADHD and the presence of a predominantly inattentive type in childhood (together, 2.6% of total variance) were all predictors of DUI.

CONCLUSIONS

Information programmes for caregivers and training for health care professionals should be promoted to foster the early recognition of covert inattentive symptoms and shorten DUI.

The association between adult ADHD and food addiction: A mediation analysis

OBJECTIVES

The aim of this study was to investigate the association between food addiction severity (FA) and ADHD symptomatology. Furthermore, we investigated whether emotional distress, and the mentalization deficits could mediate this relationship.

METHODS

Three hundred eighty-five Italian adults (307 women and 78 men) participated in the study and completed the Italian versions of the Modified Yale Food Addiction Scale version 2.0, the Adult ADHD Self-Report Scale, the Depression Anxiety Stress Scales 21 and the Mentalization Questionnaire.

RESULTS

ADHD symptoms severity and general distress were significantly and independently associated with FA. Emotional distress partly mediated the relationship between FA and ADHD symptoms severity. In addition, mentalization deficits partly mediated this relationship only when evaluating the influence of FA on ADHD symptoms severity.

LIMITATIONS

This is a cross-sectional study and causal interpretations of the relationships among the variables are speculative.

CONCLUSIONS

It is important to assess emotional distress and mentalization deficits in individuals at risk of ADHD and FA because these conditions could increase the risk for the presence of disordered eating patterns.

Eating Problems in Autistic Females and Males: A Co-twin Control Study

This study investigated the association between autism and self-reported eating problems and the influence of gender on the association, in a sample of adolescent and adult twins (N = 192). Autistic traits and autism diagnosis were associated with both total and specific eating problems, including selective eating and sensory sensitivity during mealtimes. Interaction effects indicated a stronger association between autistic traits and total eating problems in females, as well as more difficulties with eating in social contexts among autistic females. In within-pair analyses, where unmeasured confounders including genes and shared environment are implicitly controlled for, the association was lost within monozygotic pairs, which might further indicate a genetic influence on the relationship between autism and eating problems.

Caloric restriction or cafeteria diet from birth to adulthood increases the sensitivity to ephedrine in anxiety and locomotion in Wistar rats

INTRODUCTION

Obesity and undernutrition, consequences of malnutrition, have been linked to the development of mental illnesses. Both states have been linked to increased sensitivity to some drugs, but there are few data for this association considering drugs with noradrenergic-dopaminergic action.

OBJECTIVE

To evaluate the nutritional status of animals treated with either a caloric restriction (CR) or cafeteria (CAF) diet from birth and their behavior after ephedrine application.

METHODS

During the lactation period, 12 litters of Wistar rats (dam + 8 pups) were fed one of three diets: control (n = 4), CR (n = 4), and CAF (n = 4). After weaning, the males were placed in individual boxes and received the same diet as their respective dams. Nutritional assessments were performed after weaning and in adulthood. In adulthood, males received either saline or ephedrine (20 mg/kg) and underwent behavioral tests including the elevated plus-maze, open-field, and food intake tests.

RESULTS

The CR group exhibited higher serum high-density lipoprotein (HDL) levels and lower food and caloric intake, weight gain, and fat mass than the control group. The CAF group exhibited lower food intake and higher fat caloric intake, fat mass, and serum low-density lipoprotein (LDL), triglyceride, total cholesterol, and hepatic lipid levels than the control group. These results indicated that the CR and CAF groups had developed undernutrition and obesity, respectively. In the elevated plus-maze and open-field tests, the CR and CAF groups showed lower anxiety-like behaviors than the control group after ephedrine application. This result indicates that the animal's nutritional status (undernutrition or obesity) can enhance ephedrine sensitivity.

CONCLUSION

The CR group exhibited undernutrition, whereas the CAF group exhibited obesity. Ephedrine altered anxiety and locomotion in animals that received the CR and CAF diets in manner different than that observed in animals receiving the standard diet.

Restrictive eating disorders in children and adolescents: a comparison between clinical and psychopathological profiles

PURPOSE

DSM-5 describe three forms of restrictive and selective eating: Anorexia Nervosa-Restrictive (AN-R), Anorexia Nervosa-Atypical (AN-A), and Avoidant/Restrictive Food Intake Disorder (ARFID). While AN is widely studied, the psychopathological differences among these three diseases are not clear. The aim of this study was to (i) compare the clinical features of AN-R, AN-A, and ARFID, in a clinical sample recruited from a specialized EDs program within a tertiary care children's Hospital; (ii) identifying three specific symptom profiles, to better understand if restrictive ED share a common psychopathological basis.

METHODS

Data were collected retrospectively. Psychometric assessment included: the Children's Depression Inventory (CDI), the Multidimensional Anxiety Scale for Children (MASC), the Child Behavior Checklist (CBCL), and the Eating Disorder Inventory-3 (EDI-3).

RESULTS

A final sample of 346 children and adolescent patients were analyzed: AN-R was the most frequent subtype (55.8%), followed by ARFID (27.2%) and AN-A (17%). Patients with ARFID presented different features from AN-R and AN-A, characterized by lower weight and medical impairment, younger age at onset, and a frequent association with separation anxiety and ADHD symptoms. EDI-3 profiles showed specific different impairment for both AN groups compared to ARFID. However, no differences was detected for items: 'Interpersonal Insecurity', "Interoceptive Deficits", "Emotional Dysregulation", and "Maturity Fears".

CONCLUSIONS

Different ED profiles was found for the three groups, but they share the same general psychopathological vulnerability, which could be at the core of EDs in adolescence.

LEVEL OF EVIDENCE

III. Evidence obtained from case-control analytic studies.

A Systematic Review of Electrophysiological Findings in Binge-Purge Eating Disorders: A Window Into Brain Dynamics

Binge-purge eating disorders (BP-ED), such as bulimia nervosa and binge eating disorder, may share some neurobiological features. Electroencephalography (EEG) is a non-invasive measurement modality that may aid in research and diagnosis of BP-ED. We conducted a systematic review of the literature on EEG findings in BP-ED, seeking to summarize and analyze the current evidence, as well as identify shortcomings and gaps to inform new perspectives for future studies. Following PRISMA Statement recommendations, the PubMed, Embase, and Web of Science databases were searched using terms related to “electroencephalography” and “binge-purge” eating disorders. Of 555 articles retrieved, 15 met predefined inclusion criteria and were included for full-text analysis. Eleven studies investigated EEG by means of event-related potentials (ERP) in BP-ED individuals: 7 using eating disorder-related stimuli (i.e., food, body image) and 4 using non-eating disorder-related stimuli (i.e., facial expressions or auditory clicks). These studies found significant differences in the N200, P200, P300, and LPP components in BP-ED participants compared to controls, indicating that this population exhibits impairments in selective attention, attentional allocation/processing, and allocation of motivational or emotion-based attention. Five studies investigated EEG using frequency analysis; reporting significant differences in beta activity in fronto-temporal and occipito-temporo-parietal areas in BP-ED individuals compared to controls, revealing a dysfunctional brain network. However, the small number of studies, the heterogeneity of samples, study paradigms, stimulus types, and the lack of an adequate assessment of neuropsychological parameters are some limitations of the current literature. Although some EEG data are promising and consistent with neuroimaging and neuropsychological findings in individuals with BP-ED, future studies need to overcome current methodological shortcomings.

Are there causal relationships between attention-deficit/hyperactivity disorder and body mass index? Evidence from multiple genetically informed designs

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) and body mass index (BMI) are associated. However, it remains unclear whether this association reflects causal relationships in either direction or confounding. Here, we implemented genetically informed methods to examine bidirectional causality and potential confounding.

METHODS

Three genetically informed methods were employed: (i) cross-lagged twin-differences analyses to assess bidirectional effects of ADHD symptoms and BMI at ages 8, 12, 14 and 16 years in 2386 pairs of monozygotic twins from the Twins Early Development Study (TEDS); (ii) within- and between-family ADHD and BMI polygenic score (PS) analyses in 3320 pairs of dizygotic TEDS twins; and (iii) two-sample bidirectional Mendelian randomization (MR) using summary statistics from genome-wide association studies (GWAS) on ADHD (N = 55,374) and BMI (N = 806,834).

RESULTS

Mixed results were obtained across the three methods. Twin-difference analyses provided little support for cross-lagged associations between ADHD symptoms and BMI over time. PS analyses were consistent with bidirectional relationships between ADHD and BMI, with plausible time-varying effects from childhood to adolescence. MR findings also suggested bidirectional causal effects between ADHD and BMI. Multivariable MR indicated the presence of substantial confounding in bidirectional relationships.

CONCLUSIONS

The three methods converged to highlight multiple sources of confounding in the association between ADHD and BMI. PS and MR analyses suggested plausible causal relationships in both directions. Possible explanations for mixed causal findings across methods are discussed.

Assessment and Treatment of a Young Adult with Congenital Heart Disease and ADHD

CASE

Phillip is a young man born with hypoplastic left heart syndrome referred to your practice for a range of mental health concerns. He underwent palliation to an extracardiac Fontan in infancy and experienced multiple complications over the next decade including valvular regurgitation and arrhythmias necessitating a pacemaker. Phillip continued to have systolic heart failure with New York Heart Association class II symptoms, managed with 4 medications and anticoagulation.Despite this complex history, Phillip had intact cognitive abilities, achieved typical milestones, and performed well academically in secondary school. His first year of college proved to be more challenging, and Phillip presented to the outpatient psychiatry service with an acute depressive episode. His family history included depression, without known attention-deficit/hyperactivity disorder (ADHD). Treatment, including a selective serotonin reuptake inhibitor, cognitive behavioral therapy, and family support, led to near resolution of his symptoms of depression.In subsequent appointments, Phillip described a long history of inattention and disorganization with onset in childhood. This contributed to the decision to leave college, despite remission of symptoms of depression. Phillip was unable to study for any extended period without "perfect conditions," described as the absence of potential distractions except for background music. Despite attempts to maintain "perfect conditions," Phillip was often off task and "hyperfocusing" on irrelevant topics. Phillip struggled with planning and time management and would misplace items daily. Moreover, although the importance of self-care was well understood, Phillip often forgot to take his cardiac medication or to exercise, and he admitted to inconsistent sleep habits because of losing track of time.Based on a comprehensive psychiatric evaluation including retrospective report from a parent, Phillip was diagnosed with ADHD, coexisting with major depressive disorder, in remission. Significant ADHD symptoms were documented by interview, self-report, and administration of an abbreviated neuropsychological battery.Considering concerns regarding use of stimulants in a patient with congenital heart disease, including death, stroke, and myocardial infarction,1,2 how would you assess the risks-benefits of use of stimulants with Phillip?

REFERENCES

1. Wilens TE, Prince JB, Spencer TJ, et al. Stimulants and sudden death: what is a physician to do? Pediatrics. 2006;118:1215-1219.2. Zito JM, Burcu M. Stimulants and pediatric cardiovascular risk. J Child Adolesc Psychopharmacol. 2017;27:538-545.

Hyperactivity is associated with higher fat-free mass and physical activity in Swedish preschoolers: A cross-sectional study

Aim

We investigated psychological strengths and difficulties in a Swedish population of preschool children and analysed how these behavioural variables were related to body composition, cardiorespiratory fitness, physical activity levels, sedentary behaviour and diet.

Methods

Three hundred and fifteen boys and girls were recruited during 2014‐2015. Body composition was measured using air‐displacement plethysmography, and anthropometric measures were taken. Parents responded to questions about age, sex and educational attainment, diet, physical activity levels and smoking habits, as well as the Strengths and Difficulties Questionnaire (SDQ). Regression models were created to analyse associations between psychological variables, body composition and health behaviours.

Results

Hyperactivity scores were positively related to fat‐free mass (β = 0.20, P = .001) and moderate‐to‐vigorous physical activity (β = 0.16, P = .003) and negatively associated with sedentary behaviours (β = 0.18, P = .001), but showed no statistically significant associations with fat mass.

Conclusion

Our findings suggest that the adverse health consequences of hyperactivity on obesity and obesity‐related health behaviours may be established after the preschool period. Questions about the time frame of contributing and modulating factors in obesity development are discussed.

Life-course effects of early life adversity exposure on eating behavior and metabolism

Environmental variations in early life influence brain development, making individuals more vulnerable to psychiatric and metabolic disorders. Early life stress (ELS) has a strong impact on the development of eating behavior. However, eating is a complex behavior, determined by an interaction between signals of energy homeostasis, neuronal circuits involved in its regulation, and circuits related to rewarding properties of the food. Although mechanisms underlying ELS-induced altered feeding behavior are not completely understood, evidence suggest that the effects of ELS on metabolic, mood, and emotional disorders, as well as reward system dysfunctions can contribute directly or indirectly to altered feeding behavior. The focus of this chapter is to discuss the effects of ELS on eating behavior and metabolism, considering different factors that control appetite such as energy homeostasis, hedonic properties of the food, emotional and cognitive status. After highlighting classic studies on the association between ELS and eating behavior alterations, we discuss how exposure to adversity can interact with genetics characteristics to predict variable outcomes.

Atomoxetine Reduced Binge/Purge Symptoms in a Case of Anorexia Nervosa Binge/Purge Type

ABSTRACT

Psychopharmacologic treatments for eating disorders (EDs) remain unclear, particularly for anorexia nervosa. As in attention-deficit hyperactivity disorder, a dopaminergic mechanism has been implicated in EDs, prompting our use of atomoxetine in an 18-year-old woman with anorexia nervosa, binge/purge type. Atomoxetine is a highly selective norepinephrine reuptake inhibitor with nonaddictive properties and limited effects of appetite suppression. Doses followed those used in a previous trial of atomoxetine in the treatment of binge ED, and response was assessed over 4 months, with significant improvement in ED behaviors and mood. Larger-scale, randomized studies that assess the efficacy of atomoxetine in the treatment of anorexia nervosa, binge/purge type are warranted.

Eating behaviors, depression, and anxiety levels of pre bariatric surgery patients with obesity comorbid with or without Attention deficit and hyperactivity disorder: ADHD or Major Depression? Which is more related with eating behaviors?

OBJECTIVE

A high rate of attention deficit and hyperactivity disorder (ADHD) has been reported in patients undergoing obesity treatment. It is controversial whether ADHD solely or its comorbid disorders account for eating behaviors associated with obesity.

METHODS

After presurgery psychiatric assessment, 100 severely obese patients (50 with ADHD and 50 without ADHD) were administered Adult Attention Deficit Hyperactivity Disorder Self-Report Scale(ASRS), Wender Utah Rating Scale(WURS), Three-Factor Eating Questionnaire(TFEQ), and Beck Depression Inventory(BDI) and Beck Anxiety Inventory(BAI).

RESULTS

Patients with obesity and ADHD had significantly greater emotional eating, susceptibility to hunger, depression, and anxiety but less restraint of eating scores than those without ADHD. Disinhibition of eating scores and presence of Binge Eating Disorder(BED) did not differ significantly between ADHD and non-ADHD groups. Obese patients with major depression had significantly higher ASRS, WURS, TFEQ, BAI scores, disinhibition of eating control, emotional eating, susceptibility to hunger, and diagnosis of BED than nondepressed ones.

CONCLUSIONS

Major depression and anxiety disorder have associations with disinhibition of eating control, emotional eating, susceptibility to hunger and BED, ADHD. Disinhibition of eating and BED did not differ according to the presence of ADHD; thus, depression was associated with eating control on more constructs than ADHD in our study.

Occupational experiences of college students with ADHD: A qualitative study

BACKGROUND

College students with attention deficit hyperactivity disorder (ADHD) face difficulties with occupational performance in many functional domains. Despite the broad literature on academic and psychosocial functions, there is a gap in knowledge regarding how these students experience participation in their various daily functions.

OBJECTIVE

Gaining a deeper understanding of the occupational experiences of college students with ADHD and exploring factors that facilitate or impede their occupational performance.

METHOD

Twenty college students with ADHD were interviewed using the Occupational Performance History Interview (OPHI-II). Qualitative content analysis was employed.

RESULTS

Six themes were found in relation to varied occupational domains: (1) Eating and meal preparation: Too little or too much; (2) Sleep: Not enough to 'recharge batteries'; (3) Medication management: Intense ambivalence; (4) Studying: Too hard, too effortful (5) Work: Need it and love it; and (6) Leisure: Desired yet absent. Each theme contained categories related to factors that influenced performance. Impeding factors included occupational demands, ADHD biological attributes, and personal beliefs. Facilitating factors included self-awareness, executive strategies, adaptive routines, and enabling social context.

CONCLUSIONS

College students with ADHD experience profound difficulties in occupational performance, yet variation occurs across domains, attributable to occupational, biological, psychological, and social factors. Results can inform tailored interventions supporting occupational performance in this population.

Are attention deficit hyperactivity disorder symptoms stable irrespective of recovery from eating disorders? A 1-year follow-up of adult females

OBJECTIVE

To explore the influence of recovery from eating disorders (ED) at 1-year follow-up on self-reported attention deficit hyperactivity disorder (ADHD) symptoms in an unselected group of patients in a specialized ED clinic.

METHODS

Four hundred and eight adult females with an ED were assessed with the World Health Organization adult ADHD Self-Report Scale-Screener, and for comorbid psychiatric symptoms at baseline and 1-year follow-up. Recovery was registered at follow-up.

RESULTS

ADHD symptoms decreased between baseline and follow-up in recovered patients treated for bulimic ED. In not recovered patients, ADHD symptoms were stable. Decreased depressive symptoms were associated to decreased ADHD symptoms at 1-year follow-up.

CONCLUSIONS

Bulimic ED and ADHD are linked together. This link, although not known in every detail, has clinical implications with possible value for bulimic ED patients. Clinical studies exploring implementation of ADHD treatment strategies for Bulimia Nervosa are recommended.

Food Addiction among Female Patients Seeking Treatment for an Eating Disorder: Prevalence and Associated Factors

The concept of "food addiction" (FA) has aroused much focus because of evidence for similarities between overeating and substance use disorders (SUDs). However, few studies have explored this concept among the broad spectrum of eating disorders (ED), especially in anorexia nervosa (AN). This study aimed to assess FA prevalence in ED female patients and to determine its associated factors. We recruited a total of 195 adult women with EDs from an ED treatment center. The prevalence of FA diagnosis (Yale Food Addiction Scale) in the whole ED sample was 83.6%; AN restrictive type (AN-R), 61.5%; AN binge-eating/purging type (AN-BP), 87.9%; bulimia nervosa (BN), 97.6%; and binge-eating disorder (BED), 93.3%. The most frequently met criteria of FA were "clinically significant impairment or distress in relation to food", "craving" and "persistent desire or repeated unsuccessful attempts to cut down". An FA diagnosis was independently associated with three variables: presence of recurrent episodes of binge eating, ED severity, and lower interoceptive awareness. In showing an overlap between ED and FA, this study allows for considering EDs, and AN-R in particular, from an "addictive point of view", and thus for designing therapeutic management that draws from those proposed for addictive disorders.

Study of disturbed eating behaviors in children with attention deficit hyperactivity disorder

Background

There is emergent evidence that disturbed eating behaviors, including emotional eating and obesity, co-occur with attention deficit hyperactivity disorder (ADHD) in children. The hypothesis that disturbed eating behaviors in ADHD children are related to ADHD symptom severity, so we aimed to examine the link between ADHD symptoms and eating behaviors.

Results

Fifty ADHD children were included, and they completed the Emotional Eating scale adapted for children (ESS-C) to evaluate eating in response to emotions. Parents completed the Children’s Eating Behavior Questionnaire (CEBQ) to assess children’s eating behavior. Multivariable regression analysis was used to detect the most independent factor for higher body mass index (BMI) risk. Higher rates of overweight/obesity were detected among ADHD children than among the normal population. Also, higher Conners global index was associated with higher BMI z scores. Both inattentive and combined types were linked to higher BMI, while hyperactive type with lower BMI. Regarding eating behaviors, a positive association between food approach and BMI, and a negative association between food avoidant and BMI z-scores was found. Similarly, there was a noteworthy positive relation between emotional overeating and BMI. Sixty-eight of ADHD children were high emotional eaters, mainly inattentive and combined types. Others, mainly hyperactive type, were low emotional eaters. Only ESS-C total score was confirmed as an independent factor for higher BMI risk.

Conclusion

Our findings provide evidence that emotional overeating and food approach eating behaviors are common among ADHD children with higher BMI associated with them. Future studies for a better understanding of this overlap will enhance potential interventions.

Emotion regulation difficulties, but not negative urgency, are associated with attention-deficit/hyperactivity disorder and eating disorder symptoms in undergraduate students

Eating disorders and attention deficit/hyperactivity disorder (ADHD) are highly comorbid. The majority of research on this comorbidity has focused on impulsivity, which is a shared vulnerability between ADHD and eating disorders characterized by binge eating. Less is known about which shared factors may contribute to the co-occurrence of other eating disorders (i.e., anorexia nervosa, restricting subtype) and ADHD. Furthermore, little research has focused on other potential overlapping vulnerabilities, though deficits in emotion regulation have been implicated as an additional shared vulnerability. The current study (N = 306 undergraduate students) uses path analysis to examine if emotion regulation difficulties and negative urgency (i.e., impulsivity during negative mood state) are unique or shared vulnerabilities for ADHD symptoms (inattention, hyperactivity-impulsivity) and eating disorder symptoms (bulimic symptoms, drive for thinness). Emotion regulation difficulties were uniquely associated with all dimensions of ADHD and eating disorder symptoms, and negative urgency was uniquely associated with global eating disorder symptoms, bulimic symptoms, and drive for thinness. These results suggest that emotion regulation difficulties are a shared vulnerability factor for the development of diverse presentations of ADHD and eating disorder symptoms, and may be an important prevention target. Additionally, our results support a unique relationship between negative urgency and drive for thinness. Future research should examine these associations prospectively and experimentally to determine directionality and inform preventative interventions for ADHD and eating disorders.

Body dissatisfaction and weight control behaviour in children with ADHD: a population-based study

Although attention-deficit/hyperactivity disorder (ADHD) is associated with eating disorders (EDs), it is unclear when ED risk emerges in children with ADHD. We compared differences in body dissatisfaction and weight control behaviour in children with/without ADHD aged 12-13 years concurrently, and when aged 8-9 and 10-11 years, to determine when risk emerges. We also examined differences by ADHD medication status at each age. This study uses waves 1-5 from the Longitudinal Study of Australian Children (n = 2323-2972). ADHD (7.7%) was defined at age 12-13 years by both parent- and teacher-reported SDQ Hyperactivity-Inattention scores > 90th percentile, parent-reported ADHD diagnosis and/or ADHD medication treatment. Children reported body dissatisfaction and weight control behaviour at 8-9, 10-11 and 12-13 years. Children with ADHD had greater odds of body dissatisfaction at ages 8-9 and 12-13 years. Comorbidities drove this relationship at 8-9 but not at 12-13 years [adjusted odds ratio (AOR): 1.6; 95 % CI 1.1-2.4; p = 0.01]. At 12-13 years, children with ADHD had greater odds of both trying to lose and gain weight, regardless of BMI status. Comorbidities drove the risk of trying to lose weight in ADHD but not of trying to gain weight (AOR 2.3; 95% CI 1.1-4.6; p = 0.03), which is likely accounted for by ADHD medication treatment. ADHD moderately increases body dissatisfaction risk in children aged 8-9 and 12-13 years. Clinicians should monitor this and weight control behaviour throughout mid-late childhood, particularly in children with comorbid conditions and those taking ADHD medication, to reduce the likelihood of later ED onset.