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ADHD  and  the  Need  for  Speed:   How  Demands  for  Speed  Affect  Academic   Performance  in  Children  with  ADHD

E. Mark Mahone, Ph.D., ABPP Director, Department of Neuropsychology Co-Director, Center for Innovation and Leadership in Special Education Kennedy Krieger Institute Professor of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine

NIH  Consensus  Statement  (1998)

Acknowledgements R01 HD068425 R21 MH092693 ¡  5M01 RR00052 ¡  P50HD052121 ¡  Johns Hopkins Brain Science Institute ¡  ¡ 

¡ 

No additional disclosures

CDC  (2011):  Percentage  of  US  Children   (5-­‐‑17)  Ever  Diagnosed  with  ADHD

“Evidence supporting the validity of ADHD includes the long-term developmental course of ADHD over time, cross-national studies revealing similar risk factors, familial aggregation of ADHD (which may be genetic or environmental), and heritability.”

ADHD:  Where  the  Sun  Doesn’t  Shine?

CBS News. April 1, 2013

NBC News. May 16, 2013

New York Times. March 31, 2013

Arns, M., van der Heijden, K.,B., Arnold, E., & Kenemans, J.L. (2013). Geographic variations in the prevalence of ADHD: The sunny perspective. Biological Psychiatry. doi:10.1016/j.biopsych.2013.02.01.

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Getahun, D., Jacobson, S.J., Fassett, M.J., Chen, W., Demisse, K., & Rhoads, G.G. (2013). Recent trends in childhood Attention-deficit/Hyperactivity Disorer. JAMA Pediatrics, 167, 282-288

Do  We  Have  An  ADHD  Epidemic? •  “It  is  no  accident  that  recent  epidemics  have   occurred  mostly  in  the  childhood  disorders.   There  are  two  contribu9ng  factors:   –  ...the  push  by  the  drug  companies  into  a  new  market;   –  …belief  that  provision  of  special  educa9on  services   o@en  requires  that  there  be  a  DSM  diagnosis.”  

Francis & Widiger (2012). Psychiatric diagnoses: Lessons learned from the DSM-IV past and cautions for the DSM-V future. Annual Review of Clinical Psychology, 8, 17-22.

An  ADHD  Epidemic? •  “Over  the  next  few  years,  America  can  count  on  a  major   expansion  of  early  childhood  educa9on.  Unless  we’re  careful,   today’s  preschool  bandwagon  could  lead  straight  to  an   epidemic  of  4-­‐  and  5-­‐year-­‐olds  wrongfully  being  told  that  they   have  ADHD.   •  Introducing  millions  of  3-­‐  to  5-­‐year-­‐olds  to  classrooms  and   pre-­‐academic  demands  means  that  many  more  distracted   kids  will  undoubtedly  catch  the  aRen9on  of  their  teachers.   Many  children  this  age  are  already  in  preschool,  but  making   the  movement  universal  and  embedding  transi9onal-­‐K   programs  in  public  schools  is  bound  to  increase  the  pressure.”   Hinshaw, S.P., & Scheffler, R.M. (2014, Feb. 23). Expand pre-K, not ADHD. NY Times, Op-Ed.

Why  We  Should  Be  Concerned •  Annual  societal  costs  of  over  52  billion  dollars   in  US   •  One-­‐fourth  of  these  costs  are  borne  by  the  US   educa9on  system   –  Educa9on  costs  associated  with  6-­‐fold  increase   over  students  without  ADHD   Robb,  J.  A.,  Sibley,  M.  H.,  Pelham,  Jr,  W.  E.,  Foster,  E.  M.,  Molina,  B.  S.  G.,  Gnagy,  E.  M.,  &  Kuriyan,  A.  B.  (2011).  The   es9mated  annual  cost  of  ADHD  to  the  US  educa9on  system.  School  Mental  Health,  3,  169-­‐177.    

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Why  Study  Neurobiology  of  ADHD? •  Even  when  treated,  many  con9nue  to  have   significant  difficul9es  into  adulthood   –  Injuries   –  Smoking   –  Drug  abuse   –  Obesity   –  Hypertension   –  Depression  and  suicidal  behaviors  

Students  with  ADHD •  More  likely  to  experience:    

–  Learning  problems   –  Missed  school   –  Troublesome  rela9onships  with  family   members  and  peers   –  Mental  and  physical  condi9ons  

•  As  adults,  these  risks  result  in  33%  reduced   earning  and  15%  increase  in  use  of  social   assistance   Fletcher,  J.  M.  (2013).  The  effects  of  childhood  ADHD  on  adult  labor  market   outcomes.  Health  Economics.  Advance  online  publica9on.  doi:10.1002/hec.2907  

Untreated  ADHD:  Economic  Risks •  A  recent  German  study  examined  31,844   individuals  born  in  2010   •  Es9mated  a  life9me  tax  revenue  for  non-­‐ADHD   individual  was  €80,000  ($103,000)  greater  than   for  untreated  individual  with  ADHD   •  From  this  cohort,  es9mated  a  €2.5  billion  tax   revenue  loss  ($3.2  billion)  compared  to  equally-­‐ sized  non-­‐ADHD  cohort     Kotsopolous, N, Connelly, M.P., Sobanski, E., & Postma, M.A. (2013). The fiscal consequences of ADHD in Germany: A quantitative analysis based on differences in educational attainment and lifetime earnings. Journal of Mental Health Policy and Economics, 16, 27-33.

Comorbidity:  Rule  not  Exception •  67%  of  children  with  ADHD  have  comorbid  dx   ToureRe/  Tics   10%   Learning  Disabili9es   46%  

ADHD  

Speech   problems   12%   Anxiety   18%  

Risk for multiple dx (>3) increases with poverty (3.8x greater risk)

ASDs   25%  

Conduct  Disorder   27%  

Depression   14%   Larson et al. (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD. Pediatrics, 127, 462-7.

Efron, D., et al. (2014). Functional status in children with ADHD at age 6-8: A controlled community study. Pediatrics. doi:10.1542/peds.2014-1027

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ADHD  Revisions:  DSM-­‐‑5 •  The  disorder  consists  of:   –  a  characteris9c  paRern  of  behavior  and  cogni9ve   func9oning   –  present  in  different  sepngs   –  gives  rise  to  social  and  educa9onal  or  work   performance  difficul9es  

Will  Rates  of  ADHD  Change   Now  That  the  DSM-­‐‑5  Has   Been  Published?

Age  of  Onset  change:   • 

“several  inaRen9ve  or  hyperac9ve-­‐impulsive  symptoms  were  present   prior  to  age  12”  

DSM-­‐IV:  “some  symptoms  that   cause  impairment  were  present   before  the  age  of  7”  

ADHD  Revisions:  DSM-­‐‑5

ADHD  Revisions:  DSM-­‐‑5

–  In  children  and  young  adolescents,  diagnosis  should  be   based  on  informa9on  obtained  from  parents  and   teachers,  to  establish  pervasiveness  

•  Number  of  InaRen9ve  &  Hyperac9vity/ Impulsivity  symptoms  remain  9  for  each  domain  

 

–  Addi9onal  examples  within  criteria  targeted   toward  symptoms  seen  in  adulthood  

–  “Manifesta9ons  of  the  disorder  must  be  present  in  more  than   one  sepng…  .  Confirma9on  of  substan9al  symptoms  across   sepngs  typically  cannot  be  done  accurately  without   consul9ng  informants  who  have  seen  the  individual  in  those   sepngs.”    

•  For  the  item  o4en  runs  about  or  climbs,  note  specifies  “in   adolescents  or  adults,  may  be  limited  to  feeling  restless”   •  For  the  item  o4en  “on  the  go”  or  acts  as  if  “driven  by  a   motor,”  note  specifies  “uncomfortable  being  s9ll  for   extended  9me,  as  in  restaurants,  mee9ngs;  may  be   experienced  by  others  as  being  restless  or  difficult  to   keep  up  with”  

–  Examina9on  of  the  pa9ent  in  the  clinician’s  office  may  or  may   not  be  informa9ve:    

–  Adult  diagnosis  (age  17  and  up)  possible  with  5   (rather  than  6)  symptoms  

•  “signs  of  the  disorder  may  be  minimal/absent  when  the  individual  is   receiving  frequent  rewards  for  appropriate  behavior,  is  under  close   supervision,  is  in  a  novel  sepng,  is  engaged  in  interes9ng  ac9vi9es,   has  consistent  external  s9mula9on,  or  is  interac9ng  in  1:1  situa9ons   (e.g.,  the  clinician’s  office).”    

DSM-­‐IV   •  C.  “some  impairment   from  symptoms  is   present  in  2  or  more   sepngs  (e.g.,  at  school  or   home  or  work)”   •  D.  “must  be  clear   evidence  of  clinically   significant  impairment  in   social,  academic,  or   occupa9onal   func9oning”  

DSM-­‐5   •  C.  “several  symptoms  (not  

impairment)  are  present  in   2  or  more  sepngs  (e.g.,  at   home,  school,  …  with   friends  or  rela9ves,  or  in   other  ac9vi9es)  

•  D.  “there  is  clear  evidence  

that  symptoms  interfere   with,  or  reduce  the  quality   of,  social,  academic  or   occupa9onal  func9oning”  

Frequency

Impairment  (vs.  Interference)

10 8 6

Age  of  Symptom  Onset 1 DSM-­‐‑IV  &  DSM-­‐‑5 7 DSM-­‐‑5 12 Criterion  not  satisfied

4 2 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Age  of  Onset  (years)

Note.  Only  participants  12  or  older  with  >2  symptoms  of  inaYention  or  hyperactivity/impulsivity   endorsed  by  parent  report  are  represented. McCurdy, M., Hague, C., & Mahone, E.M. (2013). The shift to DSM-5: Implications for diagnosis of attention deficit hyperactivity disorder in clinically referred youth [Abstract]. The Clinical Neuropsychologist, 27, 634.

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The  Developmental  Context  for   Understanding  ADHD

Learning  and  Memory:     The  Actual  Developmental  Course

Weintraub et al. (2013). Neurology.

Changes  in  Educational  Demands

The  Fallacy  of  the  Emerging  Lag

Thomas et al. (2009). J. Speech, Language, & Hearing

Sexual  Dimorphism

Holmes, 1987 GRADE 1

LEARNING TO LEARN & READ

GRADE 4

READING TO LEARN

MIDDLE SCHOOL

LEARNING TO ORGANIZE YOUR LEARNING

HIGH SCHOOL

LEARNING TO LEARN, READ, & ORGANIZE ON YOUR OWN

•  Boys  brains  are  bigger  than  girls  brains,  but…   •  But  girls  mature  earlier   –  At  birth,  girls  3  weeks  ahead  of  boys  in  physical   matura9on   –  1  year  ahead  by  school  entry  (Eme,  1992)  

Eme,  R.  F.  (1992).  Selec9ve  female  afflic9on  in  development  of  disorders  of  childhood:  A   literature  review.  Journal  of  Clinical  Child  Psychology,  21,  354–364.  doi:10.1207/ s15374424jccp2104_5  

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Sex  Differences  in  ADHD •  Male:Female  ra9o  in  ADHD  es9mated  to  be  2:1  (CDC,  2012)  

–  In  a  large  epidemiological  U.S.  study  (n=3907),  8.7%  met  DSM-­‐IV   criteria  for  ADHD  :  51%  boys  and  49%  girls  

Froehlich,  T.  E.,  Lanphear,  B.  P.,  Epstein,  J.  N.,  Barbaresi,  W.  J.,  Katusic,  S.  K.,  &  Kahn,  R.  S.  (2007).   Prevalence,  recogni9on,  and  treatment  of  aRen9on  deficit/hyperac9vity  disorder  in  a  na9onal   sample  of  US  children.  Archives  of  Pediatrics  &  Adolescent  Medicine,  161,  857-­‐864.  

 

•  Girls  more  likely  to  be  inaRen9ve,  less  disrup9ve  behavior     •  ADHD  risk  genes  have  sexually  dimorphic  effects        

Faraone  SV,  Perlis  RH,  Doyle  AE,  et  al.  (2005).  Molecular  gene9cs  of  aRen9on-­‐deficit/hyperac9vity   disorder.  Biological  Psychiatry,  57,  1313-­‐1323.  

Lenroot,  R.K.,  Gogtay,  N.,  Greenstein,  D.  K.,  Molloy  Wells,  E.,  Wallace,  G.  L.,  Clasen,  L.  S.,  …  Giedd,  J.  N.   (2007).  Sexual  dimorphism  of  brain  developmental  trajectories  during  childhood  and  adolescence.   NeuroImage,  36(4),  1065-­‐1073.    

Girls  with  ADHD

Rates  of  ADHD  Diagnosis  and   Medication  Use  by  Birth  Month ADHD diagnosis rates

•  Con9nued  dysfunc9on  a@er  10  years  (Hinshaw  et  al.,  2012)  

Medication usage rates

–  Hyperac9ve  symptoms  iniPally  have  steeper  decline  than  inaRen9on   – 

*

Hinshaw,  S.  P.,  Owens,  E.  B.,  Zalecki,  C.,  Huggins,  S.  P.,  Montenegro-­‐Nevado,  A.  J.,  Schrodek,  E.,  &  Swanson,  E.   N.  (2012).  Prospec9ve  follow-­‐up  of  girls  with  aRen9on-­‐deficit/hyperac9vity  disorder  into  early  adulthood:   Con9nuing  impairment  includes  elevated  risk  for  suicide  aRempts  and  self-­‐injury.  Journal  of  ConsulPng  and   Clinical  Psychology,  80,  1041-­‐1051.    

*

•  Execu9ve  dysfunc9on     – 

Miller,  M.,  Loya,  F.,  &  Hinshaw,  S.  P.  (2013).  Execu9ve  func9ons  in  girls  with  and  without  childhood  ADHD:   Developmental  trajectories  and  associa9ons  with  symptom  change.  Journal  of  Child  Psychology  and   Psychiatry,  54,  1005-­‐1015.  

•  Depression,  suicide     –  – 

Gaub,  M.,  &  Carlson,  C.  L.  (1997).  Gender  differences  in  ADHD:  A  meta-­‐analysis  and  cri9cal  review.  Journal  of   the  American  Academy  of  Child  &  Adolescent  Psychiatry,  36,  1036-­‐1045.   Gershon,  J.  (2002).  A  meta-­‐analy9c  review  of  gender  differences  in  ADHD.  Journal  of  ATenPon  Disorders,  5,   143-­‐154.    

•  Ea9ng  disorders     – 

 

Biederman,  J.,  Ball,  S.  W.,  Monuteaux,  M.  C.,  Surman,  C.  B.,  Johnson,  J.  L.,  &  Zeitlin,  S.  (2007).  Are  girls  with   ADHD  at  risk  for  ea9ng  disorders?  Results  from  a  controlled,  five-­‐year  prospec9ve  study.  Journal  of   Developmental  &  Behavioral  Pediatrics,  28,  302-­‐307.  

Mar

June

Sept

States with September 1 Kindergarten Entrance Cutoffs

Dec

Mar

June

Sept

Dec

States with December 1 or 2 Kindergarten Entrance Cutoffs

Elder,  T.  E.  (2010).  The  importance  of  rela9ve  standards  in  ADHD  diagnoses:  Evidence  based  on   exact  birth  dates.  Journal  of  Health  Economics,  29,  641-­‐656.  

Bruchmuller,  K.,  Margraf,  J.,  &  Schneider,  S.  (2012).  Is  ADHD  diagnosed  in  accord  with  diagnos9c  criteria?   Overdiagnosis  and  influence  of  client  gender  on  diagnosis.  Journal  of  ConsulPng  and  Clinical  Psychology,  80,  128-­‐138.  

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The  Academic  Cost  of       “The  Need  for  Speed”

Is  ADHD  a  “Learning”  Disorder? 12 11

Rapid forgetting

Point A

Point B

9

ADHD Control

8 7

Long Free Raw

List B raw

Short Free Raw

Trial 5 Raw

5

Trial 4 Raw

6

Trial 3 Raw

Mean

10

Trial 2 Raw

¡ 

Given repeated exposure, children with ADHD do not retain information well Something seems to be interfering with new learning

Trial 1 Raw

¡ 

Executive  Function

Cutting, L.E., Koth, C.W., Mahone, E.M., & Denckla, M.B. (2003). Evidence for unexpected “difficulties in learning” in children with Attention Deficit Hyperactivity Disorder (ADHD) without Reading Disabilities (RD). Journal of Learning Disabilities, 36, 259-269.

Executive  Function Perception

Action

ADHD  &  Learning:  Research  Questions •  How can we better understand skills that exist at the interface between ADHD and academic function, especially reading? •  What is the cognitive and academic cost of the apparent “slowing” associated with ADHD?

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“Processing”  Speed  in  ADHD •  As  a  group,  children  with  ADHD  are  “slow”  on  nearly  every   9med  task   –  –  –  – 

Motor  (Cole  et  al.,  2008)   Oculomotor  (Mahone  et  al.,  2009)   Reac9on  9mes  (Wodka  et  al.,  2007)   Processing  Speed  Index  (Jacobson  et  al.,  2011)  

•  Implica9ons  for  all  academic  work   –  Is  it  “processing”  or  responding  speed?   Cole, W., Mostofsky, S.H., Larson, J.C.G., Denckla, M.B., & Mahone, E.M. (2008). Age related change in motor subtle signs among girls and boys with ADHD. Neurology, 71, 1514-1520.

Processing  Speed  (PS)  and     Reading  Fluency •  PS  =  Speed  of  comple9ng  a  task  with  reasonable   accuracy   •  Fluency  =  ability  to  read  words  quickly  with  reasonable   accuracy  

–  Poor  reading  fluency  increases  demands  on  other  processes   (e.g.,  working  memory)  and  affects  comprehension   –  Higher  level  processes  compete  with  decoding  for  9me   limited  resources   –  Can  create  a  cogni9ve  boRleneck  

Jacobson, L.A., Ryan, M., Martin, R.B., Ewen, J., Mostosfky, S.H., Denckla, M.B., & Mahone, E.M. (2011). Verbal working memory influences processing speed and reading fluency in ADHD. Child Neuropsychology, 17, 209-224. Mahone, E.M., Mostofsky, S.H., Lasker, A.G., Zee, D., & Denckla, M.B. (2009). Oculomotor anomalies in ADHD: Evidence for deficits in response preparation and inhibition. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 749-756. Wodka, E.L., Mahone, E.M., Blankner, J.G., Gidley Larson, J.C., Fotedar, S., Denckla, M.B., & Mostofsky, S.H. (2007). Evidence that response inhibition is a primary deficit in ADHD. Journal of Clinical and Experimental Neuropsychology, 29, 345-356.

Napping  and  Cognition

Sleep  as  a  Biomarker  for   Development  in  Young   Children  with  and  without   ADHD n  =  59,  ages  3-­‐5  years   Lam,  J.C.,  Mahone,  E.M.,  Mason,  T.B.A.,  &  Scharf,  S.M.  (2011).  The  effects  of  napping  on  cogni9ve  func9on  in   preschoolers.    Journal  of  Developmental  and  Behavioral  Pediatrics,  32,  90-­‐97.  

Sleep  Problems  and  ADHD

n = 64 (31 control, 33 ADHD) p =.001, η2 = .158 Isaakson et al. (2012). Journal of Psychiatric Research

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Sluggish  Cognitive  Tempo? •  During field trials for the DSM-IV, investigators identified a subset of symptoms that were found to be distinct from both ADHD subtypes described in DSM-III •  This construct was later termed “sluggish cognitive tempo”

Sluggish  Cognitive  Tempo •  •  •  •  •  •  •  • 

Daydreaming Difficulty sustaining attention Decreased orientation Confusion Drowsiness Lethargy Physical underactivity Slow processing speed

Teacher Data (n = 143) Jacobson et al. (2012)

Sluggish  Cognitive  Tempo •  It remains unclear whether SCT is related to the Inattentive subtype of ADHD, or a whether it constitutes a different disorder altogether –  Anxiety –  Depression –  Language –  Something else? Murphy-Bowman, McCurdy, Jacobson, Pritchard, & Mahone (2013). INS

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SCT,  Age,  Speed,   &  Mood

METHODS Participants: • 559 children referred for assessment at a large outpatient neuropsychology clinic (65% male), 271 children < 10 years, 288 ≥10 years. • Total Sample: Age M=10.37(SD=2.75, range: 6-16); 57.8% Caucasian

Measures: • Vanderbilt Parent Rating Scale (VPRS, Wolraich et al., 2003): anxiety and depression symptom scales • Sluggish Cognitive Tempo Scale (SCT; Penny et al., 2009) • ADHD Rating Scale-IV (ADHDRS-IV, DuPaul et al., 1998): Inattention (IA) and Hyperactivity/Impulsivity (HI) scales • WISC-IV Processing Speed Index (PSI; Wechsler, 2004)

Components  of  Reaction  Time

Geist, M., Jacobson, L., McCurdy, M., Correa, C., & Mahone, E.M. (2012). Sluggish cognitive tempo: Associations with processing speed, age, and emotional symptomatology [Abstract]. Journal of the International Neuropsychological Society, 19(S1), 183.

Figure 1. Association between Processing Speed Index and SCT

Figure 2. Associations Between SCT and Depression

Depression Rating Total

Whelan,  R.  (2008).  Effec9ve  analysis  of  reac9on  9me  data.  The  Psychological  Record,  58(3),  475-­‐482.  

Components  of  Reaction  Time

Borella,  E.,  de  Ribaupierre,  A.,  Cornoldi,  C.,  &  Chicherio,  C.  (2013).  Beyond  interference  control  impairment   in  ADHD:  Evidence  from  increased  intraindividual  variability  in  the  color-­‐stroop  test.  Child  Neuropsychology,   19,  495-­‐515.  

Simple  Reaction  Time:  Ex-­‐‑Gaussian  Analysis

ADHD,  Speed,  and  Reading •  “Processing” speed highly salient – Variability a sign of dysfunction

Mu: F(1,66) = 0.10, p = .75, η2 = .002

n = 67

Tau: F(1,66) = 7.31, p = .009, η2 = .101

(37 ADHD, 28 control) ages 9-14 years

Jacobson,  L.,  Ryan,  M.,  Denckla,  M.,  Mostofsky,  S.,  &  Mahone,  E.M.   (2013).  Performance  lapses  in  children  with  ADHD  contribute  to  poor   reading  fluency.  Archives  of  Clinical  Neuropsychology.  doi:  10.1093/ arclin/act048  

R2

= .19

•  Slowing and inefficiency impede reading fluency – Create secondary “attention” problems – Increases the load on other systems – Creates a “bottleneck” – Increases demand for working memory

•  What are the brain anomalies contributing to “slowing”

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“Working”  Memory  Reduced  in  ADHD •  Working memory is the temporary retention of information that was just experienced but no longer exists –  Can be stored for short periods of time –  Manipulation or rehearsal –  Central to dual-tasking

•  Working memory may be necessary to guide controlled behavior –  Increased working memory load may negatively affect performance

Are  We  Creating  AYention  Problems? 55 50 45 % Commission Errors

40

Controls ADHD

35 30 25 20 Simple

Working Memory

Wodka, E.L., Mahone, E.M., Blanker, J., Larson, J., Fotedar, S., Denckla, M.B., & Mostosfky, S.H. (2008). Evidence that response inhibition is a primary deficit in ADHD. Journal of Clinical and Experimental Neuropsychology, 29, 345-356.

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The  Brain’s  White  MaYer  Facilitates  Speed

White  MaYer  in  Preschoolers  with  ADHD

•  White matter can be measured in the brain •  Fiber track disturbances addressed with diffusion tensor imaging (DTI) –  Fractional anisotropy (FA) reflects directionality of water diffusion through tissue –  FA higher in more organized white matter –  Myelinated tracts restrict diffusion

•  Children ages 4-5 years (25 with ADHD [14 male], 26 controls [15 male]) •  Voxel-wise analyses of group differences examining normalized fractional anisotropy (FA) and mean diffusivity (MD) images performed. Initial clusterforming threshold of t=2.5 •  Three large clusters of reduced MD in ADHD

•  L region spanning from pre-central (BA4) to medial frontal gyrus (BA 6/8) •  bilateral posterior thalamus/pulvinar •  bilateral superior cerebellar peduncle

Mahone, E.M., Peterson, D., Crocetti, D., Slifer, K., Denckla, M.B., & Mostofsky, S.H. (2013). Abnormal frontal white matter diffusivity in preschool children with ADHD. Attention Deficit and Hyperactivity Disorders, 5(2), 186-187.

White  MaYer  Disruption  in  ADHD

Processing  Speed  and  Rapid  Naming

R

Visual-Verbal Connection: aka “see-it/say-it” Arcuate and/or inferior longitudinal fasciculus? R

Increased FA in ADHD compared to controls Statistical parametric maps are at a threshold of p