A Capacity Audit of Medical Geneticists and Genetic Counsellors in South Africa, 2024: A National Crisis.

Community genetic services were introduced in South Africa almost seven decades ago, with medical geneticists and genetic counsellors being formally recognized for the past 30 years. Initial training platforms were established at academic centres countrywide, and posts for relevant healthcare professionals, including medical geneticists and genetic counsellors were created in the public sector. Despite these early advances, the number of these specialists required to address the rising burden of congenital disorders in the country remains far below required targets established by the National Department of Health. The aim of this study was to analyse the retrospective, current and projected number of medical geneticists and genetic counsellors in South Africa. The results indicate the number of practicing medical geneticists (n = 13) and genetic counsellors (n = 28) are currently at 10% and 5% of capacity targets, respectively. There is unequal distribution of these specialists between the public and private healthcare sectors, and geographical maldistribution. An alarming trend of emigration is particularly prevalent among newly qualified genetic counsellors. With the proportion of congenital disorders expected to continue to rise in coming years, together with the increasing proportion of ageing South Africans, it is imperative that health workforce planning addresses the ever-widening gap between the supply, demand and unmet need for these crucial specialists in South Africa.

A continuous aggregated accumulation model of recognition judgments.

In recognition, remember-responses are understood to be based on recollection, and know-responses are understood to be based on familiarity. Two kinds of models have been proposed for the process by which recognition decisions are made. In single-process models, familiarity and recollection are integrated, and there is a single criterion for recognition. In dual-process models, familiarity and recollection are segregated, and there are separate criteria for remember and know-judgments. Recent process models can account for the distribution of remember and know-responses (under a range of different assumptions) but do not address the time course of the recognition process. Paradoxical findings, indicating that familiarity is available faster than recollection but remember-responses are on average faster than know-responses, cannot be convincingly explained by any existing dual-process model. We propose a new model that resolves this paradox by analyzing in detail the time course of recollection and familiarity. Know-responses based on the high familiarity of the test item are faster than remember-responses based on recollection. However, low-familiarity, low-recollection responses are slow and are also categorized by participants as know-responses. Hence, the average know-response time is slower than average remember-response time because know-responses include both fast high-familiarity responses and slow low-familiarity, low-recollection responses. A 12-parameter quantitative model that describes the relationship among the effects of confidence, accuracy, and remember and know categorization on accuracy and reaction time provided the best fit between expected reaction time and observed reaction time among the models tested. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

One-year follow-up of clinical convergence measures in children enrolled in the Convergence Insufficiency Treatment Trial-Attention and Reading Trial.

PURPOSE: To assess the long-term stability of clinical measures of convergence (near point of convergence [NPC] and positive fusional vergence [PFV]) in participants enrolled in the Convergence Insufficiency Treatment Trial-Attention and Reading Trial (CITT-ART) who received 16 weeks of office-based vergence/accommodative therapy. METHODS: A total of 310 children, 9-14 years old, with symptomatic convergence insufficiency were enrolled in CITT-ART. Some 270 completed both their 16-week primary outcome visit followed by a 1-year follow-up visit. Of those 270, 181 (67%) were randomised to the vergence/accommodative therapy. Of the 181 in the vergence/accommodative group, 121 (67%) reported not receiving any additional treatment after the 16-week primary outcome visit. The mean change in NPC, PFV and percentages of children classified by the predetermined success criteria of convergence (normal NPC [<6 cm] and/or improved by ≥4 cm; normal PFV [passing Sheard's criterion and base-out break >15Δ] and/or improved by ≥10Δ) were compared at the 16-week primary outcome visit and 1 year later. RESULTS: Of the 121 who returned for their 1-year follow-up visit, there was no significant change in mean adjusted NPC (reduction of -0.2 cm; 95% CI: -1.0 to 0.5 cm) at 1 year. There was a statistically significant decrease in mean-adjusted PFV (-4.7∆; 95% CI: -6.5 to -2.8Δ) at 1 year. There were similar percentages of participants classified as 'normal' (p = 0.30), 'normal and/or improved' (p > 0.50) and 'normal and improved' (p > 0.14) based on NPC and PFV at the 1-year visit compared with the 16-week primary outcome visit. CONCLUSION: The improvements in NPC and PFV following 16 weeks of vergence/accommodative therapy (with no reported additional treatment thereafter) in children with symptomatic convergence insufficiency persisted 1-year post-treatment.

Ruthenium complexes with triazenide ligands bearing an N-heterocyclic moiety, and their catalytic properties in the reduction of nitroarenes.

A series of ruthenium complexes of formulae [RuCl(triazenide)(p-cymene)] have been synthesized using as ligand a triazenide monofunctionalized with an N-heterocyclic moiety. Nuclear magnetic resonance, high resolution mass spectrometry and X-ray diffraction were used to characterize the triazenide ligands and their complexes. In addition, these ruthenium complexes catalyzed the reduction of nitrobenzene to aniline in the presence of sodium borohydride and ethanol as solvent at room temperature. Notably, complex 5 was especially active in the reduction of nitroarenes substituted at the aromatic ring with electron-withdrawing or electron-donating fuctional groups affording the desired arylamines in good to excellent yields (80-100%). The role of the N-heterocyclic moiety on catalysis was explored.

The role of adrenergic neurotransmitter reuptake inhibitors in the ADHD armamentarium.

INTRODUCTION: Adrenergic neurotransmitter reuptake inhibitors are gaining attention in treatment for attention-deficit hyperactivity disorder (ADHD). Due to their effects on norepinephrine, dopamine, and serotonin neurotransmission, they benefit both ADHD and comorbid disorders and have some other advantages including longer duration of action and fewer adverse effects compared to stimulants. There is continued interest in these agents with novel mechanisms of action in treatment of ADHD. AREAS COVERED: The authors conducted a PubMed literature search using the following key words: 'ADHD' AND 'adrenergic reuptake inhibitors' OR 'nonstimulants' OR 'atomoxetine' OR 'Viloxazine' OR 'Dasotraline' OR 'Centanafadine' OR 'PDC-1421' OR 'Reboxetine' OR 'Edivoxetine' OR 'Bupropion' OR 'Venlafaxine' OR 'Duloxetine.' They reviewed FDA fact sheets of available medications for safety/tolerability studies and reviewed published clinical studies of these medications for treatment of ADHD. EXPERT OPINION: Adrenergic neurotransmitter reuptake inhibitors fit the diverse needs of children and adolescents with ADHD with 1) poor tolerability to stimulants (e.g. due to growth suppression, insomnia, rebound irritability, co-morbid depression, anxiety and tic disorders, substance abuse or diversion concerns), 2) cardiac risks, and/or 3) need for extended duration of action. Their differences in receptor affinities and modulating effects support the unique benefits of individual agents.

Challenging the Diagnostic Value of Theta/Beta Ratio: Insights From an EEG Subtyping Meta-Analytical Approach in ADHD.

The frequently reported high theta/beta ratio (TBR) in the electroencephalograms (EEGs) of children with attention-deficit/hyperactivity disorder (ADHD) has been suggested to include at least two distinct neurophysiological subgroups, a subgroup with high TBR and one with slow alpha peak frequency, overlapping the theta range. We combined three large ADHD cohorts recorded under standardized procedures and used a meta-analytical approach to leverage the large sample size (N = 417; age range: 6-18 years), classify these EEG subtypes and investigate their behavioral correlates to clarify their brain-behavior relationships. To control for the fact that slow alpha might contribute to theta power, three distinct EEG subgroups (non-slow-alpha TBR (NSAT) subgroup, slow alpha peak frequency (SAF) subgroup, not applicable (NA) subgroup) were determined, based on a halfway cut-off in age- and sex-normalized theta and alpha, informed by previous literature. For the meta-analysis, Cohen's d was calculated to assess the differences between EEG subgroups for baseline effects, using means and standard deviations of baseline inattention and hyperactivity-impulsivity scores. Non-significant, small Grand Mean effect sizes (-0.212 < d < 0.218) were obtained when comparing baseline behavioral scores between the EEG subgroups. This study could not confirm any association of EEG subtype with behavioral traits. This confirms previous findings suggesting that TBR has no diagnostic value for ADHD. TBR could, however, serve as an aid to stratify patients between neurofeedback protocols based on baseline TBR. A free online tool was made available for clinicians to calculate age- and sex-corrected TBR decile scores (Brainmarker-IV) for stratification of neurofeedback protocols.

Developing the Diagnostic Interview for Adolescents and Adults with Mild/Moderate Intellectual Disabilities: An interview schedule of mental disorders (DIAAID).

Introduction: Young people with intellectual disabilities (ID) are at an increased risk for experiencing mental health issues compared to their peers without disabilities. Further, there are limited resources available to help accurately assess mental health disorders and that are accessible for adolescents with ID. Method: This paper describes the iterative development and pilot testing of the Diagnostic Interview for Adolescents and Adults with Intellectual Disabilities (DIAAID). The authors utilized Evidence Center Design and Universal Design principals to develop the DIAAID; a multi-informant diagnostic interview. Results: The DIAAID development resulted in the creation of 15 adolescents disorder interviews and 24 caregiver disorder interviews. Preliminary results suggest that the DIAAID is a feasible and accessible diagnostic interview for adolescents with ID and their caregivers. Discussion: Lessons learned from DIAAID implementation and future areas research are discussed.

Evaluating mineral biomarkers as mediators and moderators of behavioural improvements in a randomised controlled trial of multinutrients for children with attention-deficit/hyperactivity disorder.

Essential minerals are cofactors for synthesis of neurotransmitters supporting cognition and mood. An 8-week fully-blind randomised controlled trial of multinutrients for attention-deficit/hyperactivity disorder (ADHD) demonstrated three times as many children (age 6-12) had significantly improved behaviour ('treatment responders') on multinutrients (54 %) compared with placebo (18 %). The aim of this secondary study was to evaluate changes in fasted plasma and urinary mineral concentrations following the intervention and their role as mediators and moderators of treatment response. Fourteen essential or trace minerals were measured in plasma and/or urine at baseline and week eight from eighty-six participants (forty-nine multinutrients, thirty-seven placebos). Two-sample t tests/Mann-Whitney U tests compared 8-week change between treatment and placebo groups, which were also evaluated as potential mediators. Baseline levels were evaluated as potential moderators, using logistic regression models with clinical treatment response as the outcome. After 8 weeks, plasma boron, Cr (in females only), Li, Mo, Se and vanadium and urinary iodine, Li and Se increased more with multinutrients than placebo, while plasma phosphorus decreased. These changes did not mediate treatment response. However, baseline urinary Li trended towards moderation: participants with lower baseline urinary Li were more likely to respond to multinutrients (P = 0·058). Additionally, participants with higher baseline Fe were more likely to be treatment responders regardless of the treatment group (P = 0·036.) These results show that multinutrient treatment response among children with ADHD is independent of their baseline plasma mineral levels, while baseline urinary Li levels show potential as a non-invasive biomarker of treatment response requiring further study.

Problems most concerning to parents of children with ADHD and emotional dysregulation in a randomized controlled trial of multinutrients: MADDY secondary analysis.

OBJECTIVE: With dual focus on structured, objective quantification of parent observations of child's behavior and identifying behaviors most amenable to change, this report examines Parent Target Problems (PTP) as a secondary outcome in a randomized clinical trial (RCT) of children with attention-deficit/ hyperactivity disorder (ADHD) in which one primary outcome, Clinical Global Impression-Improvement, showed a significant advantage of multinutrients over placebo and the other, Likert-type parent ratings, showed significant improvement in both groups, without significant difference between them. METHOD: In a multisite 8-week RCT of broad-spectrum micronutrients ("multinutrients"), parents of children ages 6-12 (N = 126, 73% male, 88% white) with ADHD and emotional dysregulation nominated their child's most concerning problem(s) at baseline and quantified them by frequency, duration, impairment, and consequences. At subsequent visits, parents re-quantified the problem(s). Blinded child psychiatrists independently reviewed the PTPs and rated change at two timepoints compared to baseline. PTPs were grouped into 9 categories. Mean ratings were compared between active and placebo groups and explored by category. RESULTS: By week 8, a significant separation favored multinutrients: 38% of the multinutrient group were "definitely improved" or better, compared to 25% of the placebo group, and ratings of "no change" or "worse" occurred in 35% with placebo versus 23% with multinutrients (p = 0.04). Inattention (72.2%) and emotional dysregulation (69.1%) were the most frequently reported PTP categories. Inattention and internalizing symptoms improved more with multinutrients than placebo (p = 0.01, d = 0.55; p = 0.03, d = 0.80, respectively). The multinutrient advantage was not significant for 7 other symptoms, including hyperactivity/impulsivity, aggression, autistic symptoms, or emotional dysregulation/irritable oppositionality. CONCLUSIONS: This secondary analysis found that the multinutrients, compared to placebo, were associated with improvements in parental concerns overall, and in two domains specifically: inattention and internalizing symptoms (anxiety/depression), but not in seven domains: hyperactivity/impulsivity, aggression, autistic symptoms or physiological symptoms, peer relationships or emotional dysregulation/irritable oppositionality.

Assessment of Iron-Based Spin-Orbit Coupling Effects in Pt-Fe Heterobimetallic Lantern Complexes via 57Fe Mössbauer Spectroscopy.

A series of heterobimetallic lantern complexes, [PtFe(SOCR)4(pyX)] where R = Me, X = H (1), X = NH2 (2), X = SMe (3); R = Ph, X = H (4), X = NH2 (5), X = SMe (6), have been prepared and characterized spectroscopically. Compounds 1, 4, and 5 are reported herein for the first time. The high-spin iron(II) sites of 1-6 have been investigated using 57Fe Mössbauer spectroscopy. Although the isomer shift of these species is nearly identical, their quadrupole splitting exhibits a much larger variation. Moreover, the zero-field Mössbauer spectra of 3-5 show surprising changes over time which are likely indicative of small structural distortions. The field dependent Mössbauer study of 1 and 6 revealed a zero field splitting (ZFS) characterized by a relatively large and positive D value. The combined Density Functional Theory (DFT) and ab initio Complete Active Space Self-Consistent Field (CASSCF) investigation of 1-6 indicates that their ground state is best described using a linear combination of {|xz⟩, |yz⟩} states. Our theoretical analysis suggests that the ZFSs and magnitude of the quadrupole splitting of 1-6 are determined by the spin-orbit coupling of the three lowest orbital states which have a T2g parentage.

Impact of electrophysiologists at daily multidisciplinary report in a paediatric cardiac care unit.

BACKGROUND: Paediatric cardiac electrophysiologists are essential in CHD inpatient care, but their involvement is typically limited to consultation with individual patients. In our integrated heart centre, an electrophysiologist reviews all cardiac inpatient telemetry over the preceding 24 hours and participates in daily multidisciplinary morning report. This study investigates the impact of the strategy of consistent, formalised electrophysiologist presence at multidisciplinary morning report. METHODS: This is a single-centre, prospective, observational study of electrophysiologist participation in patient encounters during heart centre multidisciplinary morning report from 10/20/2021 to 10/31/2022. Multidisciplinary morning report includes discussion of all intensive care and non-intensive care cardiac patients. An encounter was defined as reporting on one patient for one day. Electrophysiologists were initially blinded to observations. RESULTS: Two electrophysiologists were observed over 215 days encompassing 6413 patient encounters. Electrophysiologists made comments on 581(9.1%) encounters in 234 unique patients with diverse diagnoses, equating to a median of 3[interquartile range:1-4] encounters per day. These included identifications of arrhythmias and describing electrocardiographic findings. Recommendation to change management occurred in 282(48.5%) encounters, most commonly regarding medications (n = 142, 24.4%) or pacemaker management (n = 48, 8.3%). Of the 581 encounters, there were 61(10.5%) in which they corrected another physician's interpretation of rhythm or electrocardiogram. CONCLUSION: Routine electrophysiologist involvement in multidisciplinary morning report provides significant, frequent, and timely input in patient management by identifying precise rhythm-related diagnoses and allowing nuanced, patient-specific medication and pacemaker management of all cardiac patients, not just those consulted. Electrophysiologist presence at multidisciplinary morning report is a vital resource and this practice should be considered at integrated paediatric cardiac centres.

Ultrafast Au(III)-Mediated Arylation of Cysteine.

Through mechanistic work and rational design, we have developed the fastest organometallic abiotic Cys bioconjugation. As a result, the developed organometallic Au(III) bioconjugation reagents enable selective labeling of Cys moieties down to picomolar concentrations and allow for the rapid construction of complex heterostructures from peptides, proteins, and oligonucleotides. This work showcases how organometallic chemistry can be interfaced with biomolecules and lead to a range of reactivities that are largely unmatched by classical organic chemistry tools.

Demographic and Clinical Factors Associated With Health-Related Quality-of-Life Profiles Among Prostate Cancer Survivors.

PURPOSE: Our purpose was to describe the prevalence and predictors of symptom and function clusters related to physical, emotional, and social components of general health-related quality of life (HRQOL) in a population-based sample of prostate cancer (PCa) survivors. METHODS: Participants (N = 1,162) completed a baseline survey at a median of 9 months after diagnosis to ascertain the co-occurrence of eight symptom and functional domains that are common across all cancers and not treatment-specific. We used latent profile analysis (LPA) to identify subgroup profiles of survivors with low, moderate, or high HRQOL levels. Multinomial logistic regression models were used to identify clinical and sociodemographic factors associated with survivors' membership in the low versus moderate or high HRQOL profile. RESULTS: The LPA identified 16% of survivors who were categorized in the low HRQOL profile at baseline, indicative of the highest symptom burden and lowest functioning. Factors related to survivors' membership in the low versus higher HRQOL profile groups included less than age 65 years at diagnosis, identifying as non-Hispanic Black race, not working, being a former versus never smoker, systemic therapy, less companionship, more comorbidities, lower health care financial well-being, or less spirituality. Several factors remained associated with remaining in the low versus higher HRQOL profiles on the follow-up survey (n = 699), including younger age, Black race, comorbidity, and lower financial and spiritual well-being. CONCLUSION: About one of six PCa survivors experienced elevated physical and psychosocial symptoms that were independent of local curative therapy, but with younger age, race, comorbidity, and lower financial and spiritual well-being as stable risk factors for poor HRQOL over time.

Circum-Antarctic bottom water formation mediated by tides and topographic waves.

The downslope plumes of dense shelf water (DSW) are critical for the formation of Antarctic Bottom Water (AABW), and thus to the exchange of heat and carbon between surface and abyssal ocean. Previous studies have shown that tides and overflow-forced topographic Rossby waves (TRWs) may have strong impact on the downslope transport of DSW, but it remains unclear how the combined action of these two processes influence the descent processes of DSW, and of the resulting AABW properties. Here, with a synthesis of historical in situ observations and a set of numerical model experiments, we show that tides and TRWs play comparable roles in AABW formation: they both act to accelerate DSW descent to the abyss, leading to the formation of colder and denser AABW. Yet, tides have little impact on AABW formation unless the continental slope is steep enough to suppress TRW generation. We further characterize the dynamical regimes of dense overflows around the entire Antarctic continent based on the relative importance of TRWs versus tides. These findings highlight the pervasive role of high-frequency processes, which are not well represented in the present climate models, in the formation of AABW, and thus in the global overturning circulation.

Rilparencel (Renal Autologous Cell Therapy-REACT®) for Chronic Kidney Disease and Type 1 and Type 2 Diabetes: Phase 2 Trial Design Evaluating Bilateral Kidney Dosing and Redosing Triggers.

INTRODUCTION: Autologous cell-based therapies (CBT) to treat chronic kidney disease (CKD) with diabetes are novel and can potentially preserve renal function and decelerate disease progression. CBT dosing schedules are in early development and may benefit from individual bilateral organ dosing and kidney-dependent function to improve efficacy and durability. The objective of this open-label, phase 2 randomized controlled trial (RCT) is to evaluate participants' responses to rilparencel (Renal Autologous Cell Therapy-REACT®) following bilateral percutaneous kidney injections into the kidney cortex with a prescribed dosing schedule versus redosing based on biomarker triggers. METHODS: Eligible participants with type 1 or 2 diabetes and CKD, eGFR 20-50 mL/min/1.73 m2, urine albumin-to-creatinine ratio (UACR) 30-5,000 mg/g, hemoglobin >10 g/dL, and glycosylated hemoglobin <10% were enrolled. After a percutaneous kidney biopsy and bioprocessing ex vivo expansion of selected renal cells, participants were randomized 1:1 into two cohorts determined by the dosing scheme. Cohort 1 receives 2 cell injections, one in each kidney 3 months apart, and cohort 2 receives one injection and the second dose only if there is a sustained eGFR decline of ≥20 mL/min/1.73 m2 and/or UACR increase of ≥30% and ≥30 mg/g, confirmed by re-testing. CONCLUSION: The trial is fully enrolled with fifty-three participants. Cell injections and follow-up clinical visits are ongoing. This multicenter phase 2 RCT is designed to investigate the efficacy and safety of rilparencel with bilateral kidney dosing and compare two injection schedules with the potential of preserving or improving kidney function and delaying kidney disease progression among patients with stages 3a-4 CKD with diabetes.

High Salinity Shelf Water production rates in Terra Nova Bay, Ross Sea from high-resolution salinity observations.

High Salinity Shelf Water (HSSW) formed in the Ross Sea of Antarctica is a precursor to Antarctic Bottom Water (AABW), a water mass that constitutes the bottom limb of the global overturning circulation. HSSW production rates are poorly constrained, as in-situ observations are scarce. Here, we present high-vertical-and-temporal-resolution salinity time series collected in austral winter 2017 from a mooring in Terra Nova Bay (TNB), one of two major sites of HSSW production in the Ross Sea. We calculate an annual-average HSSW production rate of ~0.4 Sv (106 m3 s-1), which we use to ground truth additional estimates across 2012-2021 made from parametrized net surface heat fluxes. We find sub-seasonal and interannual variability on the order of [Formula: see text] [Formula: see text], with a strong dependence on variability in open-water area that suggests a sensitivity of TNB HSSW production rates to changes in the local wind regime and offshore sea ice pack.

A diffusion decision model analysis of the cognitive effects of neurofeedback for ADHD.

OBJECTIVE: To examine cognitive effects of neurofeedback (NF) for attention-deficit hyperactivity disorder (ADHD) as a secondary outcome of a randomized clinical trial. METHOD: In a double-blind randomized clinical trial (NCT02251743), 133 7-10-year olds with ADHD received either 38 sessions of NF (n = 78) or control treatment (n = 55) and performed an integrated visual and auditory continuous performance test at baseline, mid- and end-treatment. We used the diffusion decision model to decompose integrated visual and auditory continuous performance test performance at each assessment into cognitive components: efficiency of integrating stimulus information (v), context sensitivity (cv), response cautiousness (a), response bias (z/a), and nondecision time for perceptual encoding and response execution (Ter). Based on prior findings, we tested whether the components known to be deficient improved with NF and explored whether other cognitive components improved using linear mixed modeling. RESULTS: Before NF, children with ADHD showed main deficits in integrating stimulus information (v), which led to less accurate and slower responses than healthy controls (p = .008). The NF group showed significantly more improvement in integrating auditory stimulus information (v) than control treatment (significant group-by-time-by-modality effect: p = .044). CONCLUSIONS: NF seems to improve v, deficient in ADHD. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The stability and persistence of symptoms in childhood-onset ADHD.

The course of childhood-onset attention deficit hyperactivity disorder (ADHD) varies across individuals; some will experience persistent symptoms while others' symptoms fluctuate or remit. We describe the longitudinal course of ADHD symptoms and associated clinical characteristics in adolescents with childhood-onset ADHD. Participants (aged 6-12 at baseline) from the Longitudinal Assessment of Manic Symptoms (LAMS) study who met DSM criteria for ADHD prior to age 12 were evaluated annually with the Kiddie Schedule for Affective Disorders and Schizophrenia for eight years. At each timepoint, participants were categorized as meeting ADHD criteria, subthreshold criteria, or not having ADHD. Stability of course was defined by whether participants experienced consistent ADHD symptoms, fluctuating symptoms, or remission. The persistence of the symptoms was defined by symptom status at the final two follow-ups (stable ADHD, stable remission, stable partial remission, unstable). Of 685 baseline participants, 431 had childhood-onset ADHD and at least two follow-ups. Half had a consistent course of ADHD, nearly 40% had a remitting course, and the remaining participants had a fluctuating course. More than half of participants met criteria for ADHD at the end of their participation; about 30% demonstrated stable full remission, 15% had unstable symptoms, and one had stable partial remission. Participants with a persistent course and stable ADHD outcome reported the highest number of symptoms and were most impaired. This work builds on earlier studies that describe fluctuating symptoms in young people with childhood-onset ADHD. Results emphasize the importance of ongoing monitoring and detailed assessment of factors likely to influence course and outcome to help young people with childhood-onset ADHD.