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Postema MC, Hoogman M, Ambrosino S, Asherson P, Banaschewski T, Bandeira CE, Baranov A, Bau CH, Baumeister S, Baur-Streubel R, Bellgrove MA, Biederman J, Bralten J, Brandeis D, Brem S, Buitelaar JK, Busatto GF, Castellanos FX, Cercignani M, Chaim-Avancini TM, Chantiluke KC, Christakou A, Coghill D, Conzelmann A, Cubillo AI, Cupertino RB, de Zeeuw P, Doyle AE, Durston S, Earl EA, Epstein JN, Ethofer T, Fair DA, Fallgatter AJ, Faraone SV, Frodl T, Gabel MC, Gogberashvili T, Grevet EH, Haavik J, Harrison NA, Hartman CA, Heslenfeld DJ, Hoekstra PJ, Hohmann S, Høvik MF, Jernigan TL, Kardatzki B, Karkashadze G, Kelly C, Kohls G, Konrad K, Kuntsi J, Lazaro L, Lera-Miguel S, Lesch KP, Louza MR, Lundervold AJ, Malpas CB, Mattos P, McCarthy H, Namazova-Baranova L, Rosa N, Nigg JT, Novotny SE, Weiss EO, Tuura RLO, Oosterlaan J, Oranje B, Paloyelis Y, Pauli P, Picon FA, Plessen KJ, Ramos-Quiroga JA, Reif A, Reneman L, Rosa PG, Rubia K, Schrantee A, Schweren LJ, Seitz J, Shaw P, Silk TJ, Skokauskas N, Vila JCS, Stevens MC, Sudre G, Tamm L, Tovar-Moll F, van Erp TG, Vance A, Vilarroya O, Vives-Gilabert Y, von Polier GG, Walitza S, Yoncheva YN, Zanetti MV, Ziegler GC, Glahn DC, Jahanshad N, Medland SE, Thompson PM, Fisher SE, Franke B, Francks C. Analysis of structural brain asymmetries in attention-deficit/hyperactivity disorder in 39 datasets. J Child Psychol Psychiatry 2021; 62:1202-1219. [PMID: 33748971 PMCID: PMC8455726 DOI: 10.1111/jcpp.13396] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Some studies have suggested alterations of structural brain asymmetry in attention-deficit/hyperactivity disorder (ADHD), but findings have been contradictory and based on small samples. Here, we performed the largest ever analysis of brain left-right asymmetry in ADHD, using 39 datasets of the ENIGMA consortium. METHODS We analyzed asymmetry of subcortical and cerebral cortical structures in up to 1,933 people with ADHD and 1,829 unaffected controls. Asymmetry Indexes (AIs) were calculated per participant for each bilaterally paired measure, and linear mixed effects modeling was applied separately in children, adolescents, adults, and the total sample, to test exhaustively for potential associations of ADHD with structural brain asymmetries. RESULTS There was no evidence for altered caudate nucleus asymmetry in ADHD, in contrast to prior literature. In children, there was less rightward asymmetry of the total hemispheric surface area compared to controls (t = 2.1, p = .04). Lower rightward asymmetry of medial orbitofrontal cortex surface area in ADHD (t = 2.7, p = .01) was similar to a recent finding for autism spectrum disorder. There were also some differences in cortical thickness asymmetry across age groups. In adults with ADHD, globus pallidus asymmetry was altered compared to those without ADHD. However, all effects were small (Cohen's d from -0.18 to 0.18) and would not survive study-wide correction for multiple testing. CONCLUSION Prior studies of altered structural brain asymmetry in ADHD were likely underpowered to detect the small effects reported here. Altered structural asymmetry is unlikely to provide a useful biomarker for ADHD, but may provide neurobiological insights into the trait.
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Affiliation(s)
- Merel C. Postema
- Language and Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands
| | - Martine Hoogman
- Department of Human Genetics, Radboud university medical center, Nijmegen, Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Sara Ambrosino
- NICHE lab, Department of Psychiatry, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Philip Asherson
- Social, Genetic and Developmental Psychiatry Centre; Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Medical Faculty Mannheim / Heidelberg University, Mannheim, Germany
| | - Cibele E. Bandeira
- Adulthood ADHD Outpatient Program (ProDAH), Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Department of Genetics, Institute of Biosciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexandr Baranov
- Research Institute of Pediatrics and child health of Central clinical hospital of the Russian Academy of Sciences of the Ministry of Science and Higher Education of the Russian Federation, Moscow, Russia
| | - Claiton H.D. Bau
- Adulthood ADHD Outpatient Program (ProDAH), Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Department of Genetics, Institute of Biosciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Developmental Psychiatry Program, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Sarah Baumeister
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Medical Faculty Mannheim / Heidelberg University, Mannheim, Germany
| | - Ramona Baur-Streubel
- Department of Biological Psychology, Clinical Psychology and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Mark A. Bellgrove
- Turner Institute for Brain and Mental Health and School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Joseph Biederman
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, USA
| | - Janita Bralten
- Department of Human Genetics, Radboud university medical center, Nijmegen, Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Daniel Brandeis
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
- The Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Silvia Brem
- The Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Jan K. Buitelaar
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands
- Karakter child and adolescent psychiatry University Center, Nijmegen, The Netherlands
| | - Geraldo F. Busatto
- Laboratory of Psychiatric Neuroimaging (LIM-21), Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Francisco X. Castellanos
- Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
- Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| | - Mara Cercignani
- Department of Neuroscience, Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - Tiffany M. Chaim-Avancini
- Laboratory of Psychiatric Neuroimaging (LIM-21), Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Kaylita C. Chantiluke
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anastasia Christakou
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- School of Psychology and Clinical Language Sciences, Centre for Integrative Neuroscience and Neurodynamics, University of Reading, Reading, UK
| | - David Coghill
- Departments of Paediatrics and Psychiatry, University of Melbourne, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - Annette Conzelmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Tübingen, Germany
- PFH – Private University of Applied Sciences, Department of Psychology (Clinical Psychology II), Göttingen, Germany
| | - Ana I. Cubillo
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Renata B. Cupertino
- Adulthood ADHD Outpatient Program (ProDAH), Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Department of Genetics, Institute of Biosciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Patrick de Zeeuw
- NICHE Lab, Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Alysa E. Doyle
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, USA
| | - Sarah Durston
- NICHE Lab, Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Eric A. Earl
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland OR, USA
| | - Jeffery N. Epstein
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas Ethofer
- Clinic for Psychiatry/Psychotherapy Tübingen / Department for Biomedical Magnetic Resonance, Tübingen
| | - Damien A. Fair
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland OR, USA
| | - Andreas J. Fallgatter
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Tuebingen, Germany
- LEAD Graduate School, University of Tuebingen, Germany
| | - Stephen V. Faraone
- Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, New York
| | - Thomas Frodl
- Department of Psychiatry and Psychotherapy, Otto von Guericke University Magdeburg, Germany
- Department of Psychiatry, Trinity College Dublin, Ireland
| | - Matt C. Gabel
- Department of Neuroscience, Brighton and Sussex Medical School, Falmer, Brighton, UK
| | - Tinatin Gogberashvili
- National Medical Research Center for Children’s Health, Laboratory of Neurology and Cognitive Health, Moscow, Russia
| | - Eugenio H. Grevet
- Adulthood ADHD Outpatient Program (ProDAH), Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Department of Genetics, Institute of Biosciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Developmental Psychiatry Program, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Jan Haavik
- K.G. Jebsen Centre for Neuropsychiatric Disorders, Department of Biomedicine, University of Bergen, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Neil A. Harrison
- Department of Neuroscience, Brighton and Sussex Medical School, Falmer, Brighton, UK
- Sussex Partnership NHS Foundation Trust, Swandean, East Sussex, UK
| | - Catharina A. Hartman
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, The Netherlands
| | - Dirk J. Heslenfeld
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter J. Hoekstra
- University of Groningen, University Medical Center Groningen, Department of Child and Adolescent Psychiatry
| | - Sarah Hohmann
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Medical Faculty Mannheim / Heidelberg University, Mannheim, Germany
| | - Marie F. Høvik
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Bernd Kardatzki
- Department of Biomedical Magnetic Resonance, University of Tuebingen, Tuebingen, Germany
| | - Georgii Karkashadze
- Research Institute of Pediatrics and child health of Central clinical hospital of the Russian Academy of Sciences of the Ministry of Science and Higher Education of the Russian Federation, Moscow, Russia
| | - Clare Kelly
- School of Psychology and Department of Psychiatry at the School of Medicine, Trinity College Dublin, Ireland
- Trinity College Institute of Neuroscience, Trinity College Dublin, Ireland
| | - Gregor Kohls
- Child Neuropsychology Section, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital RWTH Aachen, Germany
| | - Kerstin Konrad
- Child Neuropsychology Section, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital RWTH Aachen, Germany
- JARA Institute Molecular Neuroscience and Neuroimaging (INM-11), Institute for Neuroscience and Medicine, Research Center Jülich, Germany
| | - Jonna Kuntsi
- Social, Genetic and Developmental Psychiatry Centre; Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Luisa Lazaro
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Biomedical Network Research Center on Mental Health (CIBERSAM), Barcelona, Spain
- Department of Medicine, University of Barcelona, Spain
| | - Sara Lera-Miguel
- Department of Child and Adolescent Psychiatry and Psychology, Institute of Neurosciencies, Hospital Clínic, Barcelona
| | - Klaus-Peter Lesch
- Division of Molecular Psychiatry, Center of Mental Health, University of Würzburg, Würzburg, Germany
- Laboratory of Psychiatric Neurobiology, Institute of Molecular Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Mario R. Louza
- Institute of Psychiatry, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Astri J. Lundervold
- K.G. Jebsen Centre for Neuropsychiatric Disorders, Department of Biomedicine, University of Bergen, Bergen, Norway
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Charles B Malpas
- Developmental Imaging Group, Murdoch Children’s Research Institute, Melbourne, Australia
- Clinical Outcomes Research Unit (CORe), Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Paulo Mattos
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- Federal University of Rio de Janeiro
| | - Hazel McCarthy
- Department of Psychiatry, Trinity College Dublin, Ireland
- Centre of Advanced Medical Imaging, St James’s Hospital, Dublin, Ireland
| | - Leyla Namazova-Baranova
- Research Institute of Pediatrics and child health of Central clinical hospital of the Russian Academy of Sciences of the Ministry of Science and Higher Education of the Russian Federation, Moscow, Russia
- Russian National Research Medical University Ministry of Health of the Russian Federation, Moscow, Russia
| | - Nicolau Rosa
- Department of Child and Adolescent Psychiatry and Psychology, Institut of Neurosciencies, Hospital Clínic, Barcelona, Spain
| | - Joel T Nigg
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland OR, USA
| | | | - Eileen Oberwelland Weiss
- Translational Neuroscience, Child and Adolescent Psychiatry, University Hospital RWTH Aachen, Aachen, Germany
- Cognitive Neuroscience (INM-3), Institute for Neuroscience and Medicine, Research Center Jülich
| | - Ruth L. O’Gorman Tuura
- Center for MR Research, University Children’s Hospital, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology (ZIHP)
| | - Jaap Oosterlaan
- Clinical Neuropsychology Section, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Emma Children’s Hospital Amsterdam University Medical Centers, University of Amsterdam, Emma Neuroscience Group, department of Pediatrics, Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Bob Oranje
- NICHE Lab, Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Yannis Paloyelis
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paul Pauli
- Department of Psychology (Biological Psychology, Clinical Psychology and Psychotherapy) and Center of Mental Health, University of Würzburg, Würzburg, Germany
| | - Felipe A. Picon
- Adulthood ADHD Outpatient Program (ProDAH), Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Kerstin J. Plessen
- Child and Adolescent Mental Health Centre, Capital Region Copenhagen, Denmark
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University Hospital Lausanne, Switzerland
| | - J. Antoni Ramos-Quiroga
- Department of Psychiatry, Hospital Universitari Vall d’Hebron, Barcelona, Catalonia, Spain
- Group of Psychiatry, Mental Health and Addictions, Vall d’Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain
- Biomedical Network Research Centre on Mental Health (CIBERSAM), Barcelona, Catalonia, Spain
- Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Liesbeth Reneman
- Amsterdam University Medical Center, Academic Medical Center, Amsterdam, the Netherlands
| | - Pedro G.P. Rosa
- Laboratory of Psychiatric Neuroimaging (LIM-21), Department and Institute of Psychiatry, Hospital das Clinicas HCFMUSP, Faculty of Medicine, University of São Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Katya Rubia
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anouk Schrantee
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam; the Netherlands
| | - Lizanne J.S. Schweren
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, The Netherlands
| | - Jochen Seitz
- Child and Adolescent Psychiatry, University Hospital RWTH Aachen, Aachen, Germany
| | - Philip Shaw
- National Human Genome Research Institute and National Institute of Mental health, Bethesda, MD, USA
| | - Tim J. Silk
- Deakin University, School of Psychology, Geelong, Australia
- Murdoch Children’s Research Institute, Developmental Imaging, Melbourne, Australia
| | - Norbert Skokauskas
- Centre for child and adolescent mental health, NTNU, Norway
- Institute of Mental Health, Norwegian University of Science and Technology
| | | | - Michael C. Stevens
- Olin Neuropsychiatry Research Center, Hartford Hospital, Hartford, CT, USA
- Department of Psychiatry, Yale University School of Medicine, USA
| | - Gustavo Sudre
- National Human Genome Research Institute, Bethesda, MD, USA
| | - Leanne Tamm
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, USA
- College of Medicine, University of Cincinnati, USA
| | - Fernanda Tovar-Moll
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- Morphological Sciences Program, Federal University of Rio de Janeiro, Rio de Janeiro
| | - Theo G.M. van Erp
- Clinical Translational Neuroscience Laboratory, Department of Psychiatry and Human Behavior, University of California Irvine, 5251 California Ave, Irvine, CA, 92617, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, 309 Qureshey Research Lab, Irvine, CA, 92697, USA
| | - Alasdair Vance
- Department of Paediatrics, University of Melbourne, Australia
| | - Oscar Vilarroya
- Department of Psychiatry and Forensic Medicine, Universitat Autonoma de Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | | | - Georg G. von Polier
- Child and Adolescent Psychiatry, University Hospital RWTH Aachen, Aachen, Germany
- Brain and Behavior (INM-7), Institute for Neuroscience and Medicine, Research Center Jülich, Germany
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Yuliya N. Yoncheva
- Department of Child and Adolescent Psychiatry, NYU Child Study Center, Hassenfeld Children’s Hospital at NYU Langone
| | - Marcus V. Zanetti
- Department of Psychiatry, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
- Hospital Sírio-Libanês, São Paulo Brazil
| | - Georg C. Ziegler
- Division of Molecular Psychiatry, Center of Mental Health, University of Würzburg, Würzburg, Germany
| | - David C. Glahn
- Olin Neuropsychiatry Research Center, Hartford Hospital, Hartford, CT, USA
- Department of Psychiatry, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115-5724, USA
| | - Neda Jahanshad
- Imaging Genetics Center, Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, Marina del Rey, CA, 90292
| | - Sarah E. Medland
- Psychiatric Genetics, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Paul M. Thompson
- Imaging Genetics Center, Stevens Institute for Neuroimaging & Informatics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Simon E. Fisher
- Language and Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Franke
- Department of Human Genetics, Radboud university medical center, Nijmegen, Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
- Department of Psychiatry, Radboud university medical center, Nijmegen, Netherlands
| | - Clyde Francks
- Language and Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
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